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.

• Compare to other Medical Mutual of Ohio plans.

• Compare to all carriers in Ohio.

	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