Innovation Health medical plans for Virginia 1– 50 at-a-glance
Plans effective January 1, 2015
HMO plans
Deductible
(ded)
Out-of-pocket
individual
limit individual PCP office Specialist Emergency Inpatient Laboratory
2x family Coinsurance 2x family
visit
office visit room
hospital outpatient X-ray
Diagnostic
imaging
Pharmacy
VA Innovation Health
Gold HMO 500A
$0
0%
$5,000
$30
$50
$300
$500/admit
$15
$50
$300
T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Gold HMO 80%
$0
20%
$5,000
$30
$50
$300
20%
$15
$50
$300
T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Gold HMO 1000 100%
$1,000
0%
$5,000
$30
$50
$300
0%
$0
$50
$300
T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Silver HMO 2000 100%
$2,000
0%
$6,350
$45
$75
$350
0%
$20
$75
$350
T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Silver HMO 2000 80%
$2,000
40%
$6,350
$40
$60
20%
20%
20%
20%
20%
T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Silver HMO 2000 60%
$2,000
20%
$6,350
$40
40%
40%
40%
40%
40%
40%
T1A: $3, T1: $15\$50\$100\$300
Innovation Health is the brand name used for products and services provided by Innovation Health Insurance Company and Innovation Health Plan, Inc. Health benefits
and health insurance plans are offered and/or underwritten by Innovation Health Insurance Company and Innovation Health Plan, Inc. Innovation Health Insurance
Company and Innovation Health Plan, Inc. are affiliates of Inova and of Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management
services to Innovation Health.
Refer to page 5 for notes.
71.02.101.1-IH A (8/14)
innovation-health.com
Open HMO plans
Deductible
(ded)
Out-of-pocket
individual
limit individual PCP office
2x family Coinsurance 2x family
visit
Specialist Emergency Inpatient Laboratory
office visit room
hospital outpatient X-ray
Diagnostic
imaging
Pharmacy
VA Innovation Health
Gold Open HMO 500A
$0
0%
$5,000
$30
$50
$300
$500/admit
$15
$50
$300
T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Gold Open HMO
1000 100%
$1,000
0%
$5,000
$30
$50
$300
0%
$0
$50
$300
T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Silver Open HMO
2000 100%
$2,000
0%
$6,350
$45
$75
$350
0%
$20
$75
$350
T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Silver Open HMO 2000
90% HSA
$2,000
10%
$6,350
10% after ded
10% after ded 10% after ded 10% after
ded
10% after ded
10%
after
ded
10% after ded T1A: $3, T1: $15\$50\$100\$300
aft ded
VA Innovation Health
Bronze Open HMO
3000 HSA
$3,000
0%
$6,350
$40 after ded
$60 after ded
$300 after
ded
$500/d, days $15 after ded
1 – 5
$60
after
ded
$300 after
ded
VA Innovation Health
Bronze Open HMO
4500 HSA
$4,500
0%
$6,350
0% after ded
0% after ded
0% after ded
0% after ded 0% after ded
0% after 0% after ded
ded
T1A: $3, T1: $15\$50\$100\$300
aft ded
VA Innovation Health
Gold Open HMO 80% SS
$0
20%
$5,000
Designated: $15; $50
nondesignated:
$30
$300
20%
$15
$50
$300
T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Silver Open HMO 2000
75% SS
$2,000
25%
$6,350
Designated: $20; $60
nondesignated:
$40
25% after ded 25% after
ded
25% after ded
25%
after
ded
25% after ded T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Silver Open HMO 2000
60% SS
$2,000
40%
$6,350
Designated: $20; 40% after ded 40% after ded 40% after
nondesignated:
ded
$40
40% after ded
40%
after
ded
40% after ded T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Platinum Open
HMO 300A
$0
0%
$6,000
$15
$30
$300
$300/admit
$0
$0
$200
T1A: $3, T1: $10\$30\$60\$300
VA Innovation Health
Platinum Open
HMO 80%
$0
20%
$6,000
$15
$30
$300
20%
$0
$0
$200
T1A: $3, T1: $10\$30\$60\$300
VA Innovation Health
Gold Open HMO
500 80%
$500
20%
$6,350
$25
$50
$300
20% after
ded
20%
20%
20% after ded T1A: $3, T1: $10\$40\$75\$300
VA Innovation Health
Gold Open HMO
1000 80%
$1,000
20%
$6,350
$30
$50
$300
20% after
ded
20%
20%
20% after ded T1A: $3, T1: $10\$40\$75\$300
VA Innovation Health
Silver Open HMO 2000
100% SJ
$2,000
0%
$6,350
$20
$50 after ded
$300 after
ded
$250/admit
after ded
$0 after ded
$0 after
ded
$500 after
ded
Refer to page 5 for notes.
2
T1A: $3, T1: $15\$50\$100\$300
aft ded
T1A: $3,
T1: $10/$40/$75/$225/$300
PPO plans
Deductible
(ded)
Out-of-pocket
individual
limit individual PCP office
2x family Coinsurance 2x family
visit
Specialist
office visit
Emergency Inpatient Laboratory
room
hospital outpatient X-ray
VA Innovation Health
Bronze PPO 3000 HSA
$3,000
0%
$6,350
$40 after ded
$60 after ded
$300 after
ded
$500/d, days $15 after ded
1 – 5 after
ded
$60
$ 300 after
after ded ded
T1A: $3, T1: $15\$50\$100\$300
after ded
VA Innovation Health
Bronze PPO 4500
100/50 HSA
$4,500
0%
$6,350
0% after ded
0% after ded
0% after ded
0% after ded 0% after ded
0% after 0% after ded
ded
T1A: $3, T1: $15\$50\$100\$300
after ded
VA Innovation Health
Gold PPO 100/50 500A
$0
0%
$5,000
$30
$50
$300
$500/admit
$50
$300
T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Gold PPO 1000 100/50
$1,000
0%
$6,350
$30
$50
$300
0% after ded $0
$50
$300
T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Gold PPO 1000 80/50
$1,000
20%
$6,350
$30
$50
$300
20% after
ded
20%
20%
20%
T1A: $3, T1: $10\$40\$75\$300
VA Innovation Health
Gold PPO 500 80/50
$500
20%
$6,350
$25
$50
$300
20% after
ded
20%
20%
20% after ded T1A: $3, T1: $10\$40\$75\$300
VA Innovation Health
Gold PPO 80/50 SS
$0
20%
$5,000
Designated: $15; $50
nondesignated:
$30
$300
20%
$15
$50
$300
T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Platinum PPO
100/50 300A
$0
0%
$6,000
$15
$30
$300
$300/admit
$0
$0
$200
T1A: $3, T1: $10\$30\$60\$300
VA Innovation Health
Platinum PPO 80/50
$0
20%
$6,000
$15
$30
$300
20%
20%
20%
20%
T1A: $3, T1: $10\$30\$60\$300
VA Innovation Health
$2,000
Silver PPO 2000 100/50
0%
$6,350
$45
$75
$350
0% after ded $20
$75
$350
T1A: $3, T1: $15\$50\$100\$300
VA Innovation Health
Silver PPO 2000
100/50 SJ
$2,000
0%
$6,350
$25
$50 after ded
$300 after
ded
$250/admit
after ded
$0 after ded
$0 after
ded
$500 after
ded
T1A: $3,
T1: $10/$40/$75/$225/$300
aft ded
VA Innovation Health
Silver PPO 2000
60/50 SS
$2,000
40%
$6,350
Designated: $20; 40% after ded
nondesignated:
$40
40% after ded 40% after
ded
40% after ded
40%
40% after ded T1A: $3, T1: $15\$50\$100\$300
after ded
VA Innovation Health
Silver PPO 2000
75/50 SS
$2,000
25%
$6,350
Designated: $20; $60
nondesignated:
$40
25% after ded 25% after
ded
25% after ded
25%
25% after ded T1A: $3, T1: $15\$50\$100\$300
after ded
VA Innovation Health
Silver PPO 2000
90/50 HSA
$2,000
10%
$6,350
10% after ded
10% after ded 10% after
ded
10% after ded
10%
10% after ded T1A: $3, T1: $15\$50\$100\$300
after ded
after ded
Refer to page 5 for notes.
10% after ded
$15
Diagnostic
imaging
Pharmacy
3
Indemnity plan
VA Innovation Health Silver
Indemnity 2000 80%
Refer to page 5 for notes.
4
Deductible
(ded)
individual
2x family Coinsurance
Out-of-pocket
limit individual PCP office
2x family
visit
Specialist
office visit
Emergency Inpatient
room
hospital
$2,000
$6,000
20% after ded
20% after ded
20%
20% after ded
Laboratory
outpatient
20% after ded 20% after ded
X-ray
Diagnostic
imaging
20%
20% after ded
after ded
Pharmacy
20%\20%\20%\20%
after ded
Notes
This is a partial description of benefits available;
for more information, refer to the specific Summary
of Benefits and Coverage (SBC). The dollar amount
copayments indicate what the member is required
to pay. The coinsurance percentage amounts
indicate what Innovation Health is required to
pay. Some benefits are subject to limitations or
visit maximums. Members or providers may be
required to precertify, or obtain prior approval
for certain services, such as non-emergency
hospital care. We cover the cost of care differently
based on whether health care providers, such as
doctors and hospitals, are in-network/designated
or out-of-network.
This way of paying out-of-network doctors and
hospitals applies when members choose to get care
out of network. When they have no choice (for
example: emergency room visit after a car accident),
we will pay the bill as if they received care in network.
Members pay the plan’s copayments, coinsurance
and deductibles for the in-network/designated level
of benefits. Contact Innovation Health if a provider
asks for more. Members are not responsible for any
charges above the plan’s “recognized” amount for
emergency services beyond the copayments,
coinsurance and deductibles.
To learn how we pay out-of-network benefits
visit www.innovation-health.com. Type “how
Innovation Health pays” in the search box. Members
can avoid these extra costs by getting care from our
broad network of health care providers. Go to
www.innovation-health.com and click on “Find
a Doctor”. Existing members may sign on to their
Plan Benefits Navigator SM member website
powered by Aetna Navigator®.
5
This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location.
Health benefits and health insurance plans contain exclusions and limitations. Providers are independent contractors and not agents of Innovation Health or Aetna. Provider
participation may change without notice. Innovation Health or Aetna do not provide care or guarantee access to health services. Not all health and dental services are covered.
See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. Information is believed to
be accurate as of the production date; however, it is subject to change. For more information about Innovation Health plans, refer to innovation-health.com.
innovation-health.com
©2014 Innovation Health Plan, Inc.
71.02.101.1-IH A (8/14)