The HSA Quarterly Health Statement: A Brief Overview

The HSA Quarterly Health Statement: A Brief Overview
As an Anthem member, you receive a quarterly health statement. The health statement gives you a comprehensive view
of how you’re spending your health care dollars.
Below is a sample quarterly health statement for the Lumenos® with Health Savings Account (HSA) plan, along with an
overview of the information that’s provided in the statement.
1 Summary of Annual Benefit
Maximum Contribution Allowed: Reminds
HSA STANDARD
Anthem, FOH13-MB,OH25A-203
1351 WM Howard Taft
Cincinnati, OH 45206
SAMPLE
Your Quarterly Health Plan Status
For the period from January 1, 2011 to March 31, 2011
Account Holder:
Joe Consumer
Health Program ID:
WEP9998817749004
JOE CONSUMER
300 MAIN STREET
ALEXANDRIA, VA 22314
Group:
9999wf99r9
Coverage Type:
Single
Date Prepared:
04/11/2011
You can also view this statement online.
Log on to anthem.com for more details
1
Summary of Annual Benefit
For Coverage Effective 01/01/2011
Maximum Contribution Allowed for Tax Year 2011: $
Annual Out-of-Pocket Maximum Amounts:
In-Network:
Out-of-Network:
6,150.00
Your Annual Deductible*:
$
3,000.00
Amount accumulated towards Annual
Out-of-Pocket Maximum:
In-Network:
Out-of-Network:
$
$
250.00
0,000.00
$ 6,000.00
$ 12,000.00
*Your deductible is the annual amount you pay before you reach the
coinsurance portion of the plan.
2
Plan Status (Benefit Year to Date)
Amount paid to satisfy deductible:
$
250.00
Log on to anthem.com for your most up-to-date HSA balance information.
3
Summary of How Your Health Care Dollars Were Spent (Benefit Year to Date)
Service Type
Preventive care
Non-preventive care
Medical expenses
Brand name drugs
Generic drugs
RX expenses
Total expenses
$
$
$
$
$
$
$
Amount
600
250.00
175.00
425.00
50.00
25.00
75.00
500.00
500
300
200
100
Preventive care
Non-preventive care
Brand name drugs
Generic drugs
Total expenses
3 Summary of How Your Health Care Dollars
24934381200
Were Spent
This section provides a quick snapshot of how
your health care dollars were applied towards
general categories of types of services received
year to date.
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Your Annual Deductible: This is the amount
you must pay, from your HSA or out-of-pocket,
before your insurance begins to cover any of
your expenses.
Annual Out-of-Pocket Maximum: This
is the maximum amount you will pay out
of pocket for the year for network and
out-of-network medical (e.g., doctor and
hospital visits) and prescription expenses.
Once you have reached this amount, you
won’t have to pay anything for covered
services for the remainder of the plan year.
2 Plan Status
Amount paid to satisfy deductible: The
amount you’ve paid (year to date) toward
meeting your annual deductible.
400
0
you of how much you’re allowed to contribute
to your HSA during the course of the year, as
determined by the IRS.
Amount accumulated toward Annual
Out-of-Pocket Maximum: Shows the amount
you’ve spent (year to date) toward reaching
your Out-of-Pocket Maximum.
The HSA Quarterly Health Statement: A Brief Overview
Below is a sample of additional components you will find on a quarterly health statement for the Lumenos with
Health Savings Account (HSA) plan, along with an overview of the information the statement provides you.
4 Summary of Recent Health Plan Activity
HSA STANDARD
SAMPLE
Your Quarterly Health Plan Status
For the period from January 1, 2011 to March 31, 2011
4
Summary of Recent Health Plan Activity (01/01/20 to 03/31/2011)
Claim Activity
Total Member Responsibility for Claims:
5
$
Amount Saved by Choosing
Participating Network Providers:
250.00
$
240.11
Health Plan Activity Details (01/01/20 to 03/31/2011)
Posted
Date
Member
Name
Description
Claim Number
Amount
(+/-)
Plan Paid*
Your
Resp **
03/07/11
03/09/11
Joe Consumer
Smith, John MD
XXXXXXXXX
$175.00
$0.00
02/23/11
02/26/11
Joe Consumer
Allenville Pediatrics
XXXXXXXXX
$250.00
$250.00
$0.00
02/23/11
02/26/11
Joe Consumer
Pharmacy
XXXXXXXXX
$50.00
$0.00
$50.00
03/26/11
03/31/11
Joe Consumer
Pharmacy
XXXXXXXXX
$25.00
ToTAl This Period
$175.00
$0.00
$25.00
$250.00
$250.00
* Is the amount paid toward coinsurance, preventive care and/or covered medical expenses.
** Is the amount you owe. The doctor or facility will bill you for this amount.
6
Amount Saved by Choosing Participating
Network Providers: Shows the amount you
saved, this quarter, by visiting providers in the
Blue Cross Blue Shield network.
5 Health Plan Activities Details
The following transactions were processed during the statement period. Additional detail is available at anthem.com.
Once you log in, click on “Plans and Benefits” to view transactions.
Service
Date
Total Member Responsibility for Claims:
Shows the amount you’ve paid from your HSA or
out-of-pocket for services received this quarter.
This section shows a breakdown of the claims
received throughout the quarter, including
the amount billed, how much was covered
by traditional health coverage and how
much you’re responsible for paying. If you’re
responsible for any expenses, you’ll receive a bill
for services from your provider.
Making the Most of My Plan
Diagnosis codes from your doctors show that you had a heart attack in the past. For most people, a type of medication
called a beta blocker can lower your chances of having another heart attack. We encourage you to communicate with
your doctor about this suggestion to see if a beta blocker is right for you.
It is currently recommended that people obtain certain blood tests 3 months after starting Lipitor. These tests will
re-check your cholesterol and liver function. We have not received a bill from a laboratory that shows you have had
these tests. We recommend that you communicate with your doctor about the suggestion (55).
6 Making the Most of My Plan
This section provides personalized tips on ways
you can improve your health and/or take better
advantage of the benefits offered through your
health plan.
Using generic drugs reduces the amount you pay for your prescriptions. Recently, you filled a prescription for Proventil
and paid a discounted price of $65.00. Albuterol is a generic form of Proventil. If you use Albuterol, your estimated
discount cost would be only $7. By switching, you could save $395 per year. Talk to your doctor about whether you can
make this switch and start saving money.
Using generic drugs reduces the amount you pay for your prescriptions. Recently, you filled a prescription for Proventil
and paid a discounted price of $65.00. Albuterol is a generic form of Proventil. If you use Albuterol, your estimated
discount cost would be only $7. By switching, you could save $395 per year. Talk to your doctor about whether you can
make this switch and start saving money.
24934381200
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18049ANMENABS 11/10
For additional information, please contact Member Services.
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance
Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company
(HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not
underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of
Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (“BCBSWi”), which underwrites or administers the PPO and indemnity policies; Compcare Health Services
Insurance Corporation (“Compcare”), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association.
® ANTHEM and LUMENOS are registered trademarks of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.