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Medical Mutual of Ohio – SuperMed One HSA 5000 – Ohio

A comparison of the SuperMed One HSA 5000 offered by MMOH is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
Network See Provider See Provider
Application SuperMed One HSA 5000 Application SuperMed One HSA 5000 Application
Brochure SuperMed One HSA 5000 Brochure SuperMed One HSA 5000 Brochure
Copay N/A N/A
Office Visit 100% after deductible 50% after deductible
Deductible Individual: $5,000, Family: $10,000 Individual: $10,000, Family: $20,000
Coinsurance 100% 50%
Coinsurance Limit See OOP Maximum See OOP Maximum
Out-of-Pocket Maximum N/A (Excluding the deductible) Single: $4,000, Family: $8,000
Lifetime Maximum $2,500,000 $2,500,000
Prescription Drugs 100% after deductible 50% after deductible (Home Delivery Not Covered).
Emergency Room 100% after deductible 100% after deductible (50% after deductible if it is a non-emergency)
Adult Preventative Care 100% after deductible $500 maximum per benefit period covered at 50% after deductible.
Child Preventative Care $500 maximum per benefit period covered at 100% after deductible. $500 maximum per benefit period covered at 50% after deductible.
Lab / X-Ray 100% after deductible 50% after deductible.
Maternity Not Covered Not Covered
Physical Therapy 20 visits per benefit period covered at 100% after deductible. 20 visits per benefit period covered at 50% after deductible.
Skilled Nursing $10,000 maximum per benefit period covered at 100% after deductible. $10,000 maximum per benefit period covered at 50% after deductible.
Home Health Care 60 visits per benefit period covered at 100% after deductible. 60 visits per benefit period covered at 50% after deductible.
Mental Health
  • Inpatient: 30 days per benefit period, 100% after deductible.
  • Outpatient: 20 visits per benefit period, 50% after deductible.
  • Inpatient: 30 days per benefit period, 50% after deductible.
  • Outpatient: 20 visits per benefit period, 50% after deductible.
  • Hospital Care 100% after deductible 50% after deductible.
    Optional Benefits see brochure see brochure
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