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Arizona Health Insurance > Celtic Insurance Company > CelticSaver HSA Plan Benefits

Celtic Insurance Company

Quote & Apply - Electronic Application

CelticSaver HSA Plan
Features/Benefits Specifics
Eligibility Ages 6 months - 641⁄2 years
Plan Type PPO** or Managed Indemnity
Annual Plan Deductibles & Coinsurance

Individual
$1,500 (80/20 of the next $18,000)
$2,600 (80/20 of the next $12,000)
$1,500 (100%)
$2,600 (100%)
$5,000 (100%)

 Family
$3,000 (80/20 of the next $36,000)
$5,150 (80/20 of the next $24,000)
$3,000 (100%)
$5,150 (100%)
$10,000 (100%)
Lifetime Maximum $7,000,000
Non-Preventive office visits to Network Provider Covered after deductible subject to coinsurance.
Emergency Room Deductible
(in addition to annual plan deductible)		 $250 per visit (waived if admitted to hospital).
Prescription Drugs Covered after deductible subject to coinsurance.
Preventive Care Eligible expenses for medical services and supplies incurred for preventive care in an asymptomatic individual are covered up to $300 per person, per calendar year, which includes up to $50 for routine eye exams.
Psychiatric Care*** Inpatient annual maximum of $2,500 per person, per calendar year. Outpatient annual maximum of $1,000 per person, per calendar year. Lifetime maximum of $10,000 per person for inpatient and outpatient combined.
Manipulative Therapy*** $500 maximum per person, per calendar year.
Hospital Average semi-private room rate. Intensive care at 4 times the average semi-private room rate.
Home Health Care 30 visits per person, per calendar year.
Rehabilitation Facility Inpatient—up to 30 days confinement per person, per calendar year.
Rehabilitation Therapy Outpatient—up to 30 visits per person, per calendar year.
Extended Care Facility Up to 12 days of confinement per person, per calendar year.
Transplants Covered up to amount negotiated by network if Transplant Network used; capped at $100,000 per procedure if insured goes out of network.
Ambulance $3,000 maximum per person, per calendar year, for emergency air or ground ambulance service.
Value-Added Benefits Specifics
Non-tobacco Rates and Preferred Rates Applicants and/or their spouses who have not used tobacco in the past 12 months will receive additional premium savings. Plus, Preferred Rates are available for qualifying applicants.
Rx Discounts Use your Celtic ID card at more than 50,000 participating pharmacies nationwide and receive discounts on prescription drug purchases.

* The Primary Applicant cannot be claimed as a dependent on any tax return.
** If PPO plan is chosen, out-of-network eligible charges reduced additional 20%.
*** Benefit will vary by state.

Medical Service Charges – Charges for the following medical services are eligible expenses:

  • nonsurgical professional services by a physician or nurse;
  • radiologist or laboratory charges for X-ray or radiation therapy, diagnosis or treatment;
  • up to 30 visits per person, per calendar year of home health care by a home health care agency, but only if a hospital, skilled nursing or extended care facility confinement would otherwise be needed and the visit is prescribed by a physician;
  • non-surgical treatment for tonsils, adenoids or hernia and surgical treatment for tonsils, adenoids or hernia after coverage is in force for 6 months;
  • one screening by low-dose mammography, per calendar year beginning at age 35;
  • emergency air or ground transportation in an ambulance to the nearest hospital up to $3,000;
  • if a tubal ligation is performed during a pregnancy or complication of pregnancy, then those charges will be considered as eligible expenses. Tubal ligations and vasectomies performed as outpatient surgery are covered after 12 months of continuous coverage;
  • one cytologic screening per calendar year for women age 18 and older;
  • coverage for one prostate cancer screening per calendar year for an insured person age 50 and over.

 

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