HSA Plan
The Village of Ashwaubenon offers an HSA medical plan to all eligible employees and their eligible dependents. The medical plan is administered by UMR (www.UMR.com) or call 1-800-207-3172. For UMR Care Management call 1-800-494-4502 OptumRx administers the pharmacy drug plan. Optum can be contacted at (www.Optumrx.com) or call the number on the back of your ID.
For complete benefit details, please refer to the following documents:
Documents
HSA Medical Plan Benefit Summary
The purpose of this benefits summary is to highlight the major aspects of your HSA medical benefits and to provide you with a quick reference tool. A full description of the benefit plan can be found in the Summary Plan Descriptions (SPD), which takes precedence over this benefits summary. SPDs are also posted on the Village’s intranet. Please take time to review the SPD to understand your benefit choices and options.
| Medical Plan Coverage | In-Network Benefits | Out of Network Benefits |
|---|---|---|
| Annual Deductible | $2,000 Single/$4,000 Family | $4,000 Single/$8,000 Family |
| Maximum Out of Pocket (includes deductible, coinsurance and copays) | $6,550 Single/$13,100 Family (Ind Max $6550) | $10,000 Single/$20,000 Family (Ind Max $10,000) |
| Primary Care Provider | 90% after deductible | 70% after deductible |
| Specialist Provider | 90% after deductible | 70% after deductible |
| Preventive Care Visits | Covered at 100% | 70% after deductible |
| Maternity | 90% after deductible | 70% after deductible |
| Inpatient Hospitalization | 90% after deductible | 70% after deductible |
| Outpatient / Ambulatory Surgery | 90% after deductible | 70% after deductible |
| Emergency Room | 90% after deductible | 90% after PPO deductible |
| Ambulance Ground or Air | 90% after deductible | 90% after PPO deductible |
| Urgent Care | 90% after deductible | 70% after deductible |
| Inpatient Mental Health, Alcohol and Substance Abuse | 90% after deductible | 70% after deductible |
| All Therapies (PT, OT, Speech) | 90% after deductible | 70% after deductible |
| Chiropractic Services | 90% after deductible | 70% after deductible |
| Outpatient Labs and X-rays | 90% after deductible | 70% after deductible |
| MRI (Nuclear Medicine, Other High Tech) | 90% after deductible | 70% after deductible |
Eligibility for Medical Plan
Eligible Employees
An eligible Employee is a person who is classified by the employer on both payroll and personnel records as an Employee who regularly works full-time 30 or more hours per week, but for purposes of this Plan, it does not include the following classifications of workers except as determined by the employer in its sole discretion:
- Leased Employees
- Independent Contractors as defined in this Plan
- Consultants who are paid on other than a regular wage or salary basis by the employer.
- Members of the employer’s Board of Directors, owners, partners or officers, unless engaged in the conduct of the business on a full-time, regular basis.
Eligible Dependents
If you are an Eligible Employee, you may elect to cover your eligible Dependents. An eligible “Dependent” is defined to mean:
- Your legal spouse, provided he or she is not covered as an Employee under this Plan. For purposes of eligibility under this Plan, a legal spouse does not include a Common-Law Marriage spouse. Documentation on a Covered Person’s marital status may be required by the Plan Administrator.
- A Dependent Child until December 31 in the year they attain age 26.
A “Child” is defined to mean:
- A natural biological Child
- A stepchild
- A legally adopted Child or Child legally Placed for Adoption
- A Child under Your (or Your spouse’s) Legal Guardianship as ordered by a court
- A grandchild, as long as the Employee’s covered Dependent is the parent of the grandchild. Coverage for the grandchild will end when the Employee’s covered Dependent (the parent of the grandchild) is no longer eligible under this Plan or when the Dependent (the parent of the grandchild) reaches 18 years of age, whichever occurs first.
- Totally Disabled Dependent Child over age 26
This is a general outline of the Eligibility Coverage. A full description of Eligibility Coverage can be found in the Summary Plan Descriptions (SPD), which takes precedence over this Eligibility Summary.
UMR Member Benefits Portal
Go to www.UMR.com or call UMR customer service at 1-800-207-3172 if you need to:
- Find an In-Network Provider
- Print a temporary ID card or request additional ID cards
- Have a hospital stay pre-authorized (this is required)
- File a claim
- Check the status of a claim and view your claim history
- Print an Explanation of Benefits (EOB)
- Get answers to coverage and benefit level questions
- Obtain answers to claims or eligibility level questions
UMR Mobile App
UMR Plan Advisor
The UMR plan advisors can guide and support you in making the right decisions when you need to see a doctor or have questions about your benefit plan. The advisors are available 7:00 AM to 7:00 PM central time at 1-800-207-3172.
Call the plan advisors for help with:
- Explanation of a claim for a recent treatment or procedure
- Find out if a doctor or facility is In-Network
- Get help finding a primary care physician and making an appointment
- Learn whether you’re due for routine care or preventive screenings
- Hear messages about timely health topics
MyHealthcare Cost Estimator Tool
Like anything else, it pays to shop around. Your costs may depend on what doctor you see and where you go for care. Search for treatments or procedures from local providers. You can view estimates, including your out of pocket costs and what your plan will pay. Choose a provider and get a final estimate. For more information about the Cost Estimator Tool, please read the following:
UMR Care Management
UMR Care Management is a staff of experienced nurses who will help you get the most out of your health plan benefits. For more information, please read the following:
Explanation of Benefits (EOB)
The EOB is a summary of your processed healthcare claims.
10 Ways to Control Healthcare Costs
What are Deductible, Coinsurance, Copay, Out of Pocket Maximum?
Deductible is the amount you must pay before your plan pays for specified services. Deductibles are usually an annual set amount. A deductible may apply to all services or just a portion of your benefits.
Coinsurance is a set percentage of costs that are covered by your plan after your deductible has been paid. Your plan pays a higher percentage.
Copay means that amount shown in the benefit schedule which is your responsibility for charges Incurred for the doctor’s office visits, prescription drugs or other services as listed in the benefit schedule.
Out of Pocket Maximum is the amount you pay out of your pocket for a particular health care service during a particular period of time. An out-of-pocket maximum limits the amount you must pay during a particular period of time (usually a calendar year).