HSA Blue Plan

Medical Plan Schedule of Benefits
	In-Network (Blue Preferred)	Out-of-Network
OCCC Health Savings Account Contribution	$1,000 per Plan Year
Annual Deductible Individual Family	$3,200 $6,400	$6,000 $12,000
Coinsurance	100% after deductible	60% After Deductible
Out of Pocket Maximum Individual Family	$3,200 $6,400	$8,000 $14,000
Office Visits Primary Care Specialist Telemedicine/Virtual Visit	Covered at 100% After Deductible	Covered at 60% After Deductible
Chiropractic Care Limited to 60 visits per year combined with Physical and Occupational Therapy	Covered at 100% After Deductible	Covered at 60% After Deductible
Preventive Care	Covered at 100%; No copay	Covered at 60% After Deductible
Outpatient Physical Therapy/ Occupational TherapyLimited to 60 visits per year combined with Muscle Manipulations	Covered at 100% After Deductible	Covered at 60% After Deductible
Emergency Room True Emergency Non-Emergency Urgent Care	Covered at 100% After Deductible Covered at 100% After Deductible Covered at 100% After Deductible	Covered at 100% After Deductible Covered at 100% After Deductible Covered at 60% After Deductible
Lab and X-Ray	Covered at 100%; No copay	Covered at 60% After Deductible
Inpatient Hospitalization	Covered at 100% After Deductible	Covered at 60% After Deductible
Outpatient Surgery	Covered at 100% After Deductible	Covered at 60% After Deductible
Prescription Drugs	30-Day Supply	90-Day Supply (Mail Order)
Generic Preferred Brand Non-Preferred Brand Specialty	Covered at 100% after deductible	Covered at 100% after deductible

Health Savings Accounts (HSAs) are a great way to save money and budget for qualified medical expenses. HSAs are tax-advantaged savings accounts that accompany high deductible health plans (HDHPs). HDHPs offer lower monthly premiums in exchange for a higher deductible (the amount you pay before insurance kicks in).

WHAT ARE THE BENEFITS OF AN HSA?

There are many benefits of using an HSA, including the following:

• It saves you money. HDHPs have lower monthly premiums, meaning less money is being taken out of your paycheck.
• It is portable. The money in your HSA is carried over from year to year and is yours to keep, even if you leave the company.
• It is a tax-saver. HSA contributions are made with pre-tax dollars. Since your taxable income is decreased by your contributions, you’ll pay less in taxes.
• Additional Retirement Savings. After age 65, funds can be withdrawn for any purpose without penalty (only income tax is assessed).
• Investment Opportunities. Once you have a balance of $1,000 in your HSA account, you can self-direct investments that can potentially grow your savings for healthcare or retirement.

ANNUAL CONTRIBUTIONS AND LIMITS

	Employee Only	Family
IRS Annual Max Contribution	$4,150	$8,300
Catch-Up Contribution (Members 55+)	Additional $1,000 per year

ARE YOU ELIGIBLE FOR AN HSA?

If you enroll in the qualified High Deductible Health Plan (HDHP), you are eligible to participate in the HSA plan, with the exception of the following guidelines:

• You cannot be covered by any other non-HSAcompatible health plan, including Medicare Parts A and B
• You cannot be covered by TriCare
• You cannot have accessed your VA medical benefits in the past 90 days (to contribute to an HSA)
• You cannot be claimed as a dependent on another person’s tax return

HOW DOES AN HSA PLAN WORK?

The elections you make to the Health Savings Account are automatically taken from each paycheck throughout the year and deposited in your HSA account. You can also contribute to your account anytime throughout the year by completing an online transfer from your bank account in the HSA Bank member portal.

When you have an eligible expense, HSA Bank offers convenient options to pay for current or future healthcare expenses. To pay for a service or make a purchase, you need to have the available funds in your account.

• Use Your HSA Debit Card
• Use Online Bill Pay – Pay a provider directly from your HSA account.
• Write a Check – You can order a book of 50 checks to pay for routine and point-of-sale purchases. claims or file a manual claim.

Access your HSA Account online at www.hsabank.com or download the HSA Bank Mobile App from the Apple App Store or Google Play.