5000 HSA — Cigna Choice Fund PPO

In-Network Benefits

Eligibility & Enrollment

• Issue ages: 18–64. Dependent children covered to age 26 regardless of student, marital, or financial dependency status.
• State availability: 46 states. Not available in Idaho, North Dakota, South Dakota, or Washington.
• Required membership: Elevate Wellness national association membership is required and added during enrollment.
• Eligibility classes: Active employees working 30+ hours per week, accepted business owners, or self-employed members with documented self-employment income.
• Waiting period: 30 consecutive days as an active eligible member before coverage starts.
• Effective date: 1st of the month following approval. Enrollment deadline is the 20th of the prior month.
• Rate lock: 12 months from effective date.
• Dependent definition: Spouse (including same-sex spouses and qualifying domestic partners with 12-month cohabitation and joint ownership), children to age 26, totally disabled adult children if dependent on covered member.

Visit Limits & Service Caps

Services Not Covered (Exclusions)

The following are excluded from plan coverage. This list is sourced from the Triad Benefits Summary of Benefits and Coverage (SBC) and the master Plan Document. Limitations and exceptions may apply — refer to the full plan document for legal descriptions.

1. Infertility services (including IVF, IUI, fertility drugs, and assisted reproductive technology)
2. Surrogacy-related services
3. Impotence / erectile dysfunction treatment
4. Sterilization reversal
5. Abortion (elective)
6. Gender affirming care
7. Obesity treatment, including bariatric surgery and medically-supervised weight loss programs
8. Contraceptive materials, devices, and injections (preventive services for women per ACA mandate are covered)
9. Electroconvulsive Therapy (ECT)
10. Massage therapy
11. Biofeedback
12. Hearing aids for adults (covered for under-18 with medical necessity at $1,500/aid, $3,000/pair, every 5 years)
13. Orthopedic shoes (except for diabetics — limited to 1 pair per calendar year)
14. Routine eyeglasses and contact lenses for children (one children's eye exam every 24 months is covered)
15. Routine dental check-ups for children and adults
16. Orthodontia, periodontal disease treatment, and dentures
17. Acupuncture (not covered as a primary benefit; may be considered under limited circumstances)
18. Specialty drug 90-day supply (specialty drugs only covered as 30-day supply)
19. Pregnancy of a dependent daughter (covered only for spouse and employee, not for dependent children)
20. Non-human organ and tissue transplantation
21. Transplantation of the stomach, small intestine, and/or colon
22. Home health aide services, food or home-delivered meals, dietician, homemaker, or maintenance services
23. Outpatient private duty nursing on a 24-hour-shift basis
24. Experimental and/or investigational treatments (per plan definition — services not approved by FDA, under Phase I/II clinical trials, or not within accepted medical practice)
25. Services received outside the United States, except in case of Medical Emergency
26. Services provided by a member of the patient's immediate family
27. Cosmetic surgery or services (except reconstruction following a covered surgery or accidental injury)
28. Services not Medically Necessary as determined by the Claims Administrator
29. Charges not pre-certified when pre-certification is required (50% benefit reduction, max $2,500 penalty)