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Health Investor HMO

Like the Traditional HMOs the State offers, with the Health Investor HMOs you must use network providers to receive benefits; no benefits are paid when you use non-network providers unless it's a medical emergency. Emergency room expenses are subject to the deductible. The Health Investor HMOs are provided by many of the same health plans who offer the Traditional HMO to State employees - in the same geographical areas. Check the personal Benefit Statement you'll receive in late September to see which HMOs are available to you. Here are the highlights of how the Health Investor HMO work.

Plan Highlights

 

Health Investor HMO

Covers care received

network only

You meet annual deductible

  • Individual coverage
  • Family coverage

$1,250
$2,500

With family coverage, you must meet the family deductible before anything but preventive care is covered

What you pay for care received after deductible

  • Medical care
  • Prescription drug
    • generic and preferred brand
    • non-preferred brand

20%

30%
50%

Annual out-of-pocket maximum (after deductible)

  • Individual
  • Family

$3,000
$6,000

after your out-of-pocket costs reach these maximums, for the rest of the calendar year the plan pays 100% for covered care in most cases, up to allowable costs

Preventive care: some routine physical exams, health screenings and immunizations

Same as Traditional HMOs; no deductible required

  • routine annual physicals
  • screenings at published intervals

While the Health Investor HMO cover all the same services and supplies as their Traditional HMO counterparts, there are some key differences. Under the Health Investor HMO:

  • If you contribute toward the cost of your coverage, your monthly insurance premiums are lower.
  • If you or your covered dependents do not have other medical coverage*, you may open a Health Savings Account and make pre-tax contributions to it. You can use the HSA to pay out-of-pocket expenses like your deductible and coinsurance - now or in the future.
  • For specific preventive care services, there's no deductible.
  • Except for preventive care, you must meet the deductible before benefits begin for medical care or prescription drugs.
  • If you have family coverage, you and your dependents must meet the family deductible before the plan pays benefits for any of you as individuals. If you have an HSA, you can use available funds for eligible expenses while you're meeting the deductible.

*For purposes of determining whether you may open a Health Savings Account, "other coverage" includes coverage through your spouse's employer's plan, Medicare, Medicaid, a Healthcare Flexible Spending Account that covers medical expenses (like the State's Medical Reimbursement Account), or any other medical plan.