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In-Network |
Out-of-Network |
| Deductibles |
Total in-network and out-of-network deductibles:
$1,500 per employee
$3,000 per family |
|
HSA |
The University of Minnesota allocation
which may be used to offset deductible expenses:
$1,000 for an employee
$2,000 for a family |
| Emergency Care |
90% after deductible |
70% after deductible |
| Urgent Care |
90% after deductible |
70% after deductible |
| Network Hospital - General |
90% after deductible |
70% after deductible |
| Network Hospital - Mental Health/Chemical Dependency |
90% after deductible |
70% after deductible |
| In-Network Health Care Services |
| Preventive Care |
100% coverage |
70% after deductible |
| Physician |
90% after deductible |
70% after deductible |
| Eye and Hearing Exam (nonroutine) |
90% after deductible |
70% after deductible |
| Outpatient/surgery |
90% after deductible |
70% after deductible |
| Outpatient Mental Health/Chemical Dependency |
90% after deductible |
70% after deductible |
| Chiropractic Care |
90% after deductible |
70% after deductible |
| Physical, Speech, Occupational Therapy |
90% after deductible |
70% after deductible |
| Home Health Care |
90% after deductible |
70% after deductible |
| Prosthetics, Durable Medical Equipment |
90% after deductible |
70% after deductible |
| Out-of-Network Care |
|
70% of reasonable and customary charges after the deductible |
| National Coverage |
Available in-network through UnitedHealthcare Options PPO network |
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| Annual Out-of-Pocket Maximum |
| In-Network and Out-of-Network Total Annual |
$2,500 per person
$5,000 per family
Note: Out-of-pocket maximum includes the deductible |
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Lifetime Maximum |
$5 million per person |
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