Health Alliance Medical Plans, Inc.
2023 POS 2500 Elite Gold
Member Responsibility
Member Benefits Participating (In-Network) Non-Participating (Out-of-Network
(OON))
Plan Year Deductible Medical Individual $2,500 $5,000
Embedded Family $5,000 $10,000
Pharmacy Individual Not Applicable Not Applicable
Family Not Applicable Not Applicable
Dental Per Member $120 Not Applicable
Plan Year Out-of-Pocket Maximum (OOPM)
Combined medical and pharmacy
expenses including deductible,
coinsurance & copayments.
Dental OOPM goes toward medical
OOPM
Contract Year Maximum Benefits
Ambulatory Patient Services
Medical/Pharmacy Individual $6,000 $17,500
Family $12,000 $35,000
Pediatric Dental Individual $350 Not Applicable
Family $700 Not Applicable
Cardiac Rehabilitation Services 36 OP sessions w/in 6 month of event combined in-net and OON
Outpatient Rehabilitation Services 60 visits per condition per plan year combined in-net and OON
Habilitative Services 60 visits per condition per plan year combined in-net and OON
Acupuncture Treatment 15 visits per plan year combined in-net and OON
Chiropractic Services 25 visits per plan year combined in-net and OON
Adult Vision Exam Once every 12 months.
Pediatric Vision Exam Once every 12 months combined in-net and OON
Pediatric Vision Materials Once every 12 months combined in-net and OON
Pediatric Dental Exam Once every 6 months combined in-net and OON
Pediatric Vision Therapy 12 visits for treatment of Convergence Insufficiency per plan year
Vision Exam *$20 per exam Not Covered
Virtual Visits *$0 visits 1-3, then $25 per visit Not Covered
Emergency Services
Primary Care Physician Office Visits *$25 per visit 50%
Specialty Care Physician Office Visits *$50 per visit 50%
Chiropractic Services *$50 per visit In Network Benefit Applies
Acupuncture *$25 per visit In Network Benefit Applies
Urgent Care Visits *$50 per visit In Network Benefit Applies
Allergy Treatment and Testing 15% 50%
Emergency Department Visits 15% In Network Benefit Applies
Emergency Ambulance Transportation 15% In Network Benefit Applies
Rehabilitative and Habilitative Services
Outpatient Rehabilitation Services (PT, OT, ST) 15% 50%
Inpatient Rehabilitation/Skilled Nursing Facility 15% 50%
Home Health 15% 50%
Diagnostic Services
Mental Health/Substance Use Treatment
MRI and CT Scans 15% 50%
Laboratory and X-rays 15% 50%
Outpatient Office Visits *$25 per visit 50%
Inpatient Services 15% 50%
Outpatient Surgery/Procedures Facility Fee 15%
Outpatient Surgery/Procedures Physician/Surgeon Services 15%
Inpatient Hospitalization Facility Fees 15%
Inpatient Physician/Surgeon Fees 15%