If you need immediate medical attention Emergency room care 10% coinsurance Covered as In-Network --------none-------- Emergency medical transportation 10% coinsurance 30% coinsurance --------none-------- Urgent care 10% coinsurance 30% coinsurance --------none-------- If you have a hospital stay Facility fee (e.g., hospital room) 10% coinsurance 30% coinsurance --------none-------- Physician/surgeon fees 10% coinsurance 30% coinsurance --------none-------- If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit 10% coinsurance Other Outpatient 10% coinsurance Office Visit 30% coinsurance Other Outpatient 30% coinsurance Office Visit --------none-------- Other Outpatient --------none-------- Inpatient services 10% coinsurance 30% coinsurance $500 per admission penalty applies if pre-authorization is not obtained. If you are pregnant Office visits 10% coinsurance 30% coinsurance Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Your doctor’s charges for delivery are part of prenatal and postnatal care. Failure to obtain pre-authorization if inpatient stay exceeds 48 hours for normal delivery and 96 hours after a cesarean delivery may result in or reduced benefits. $500 per admission penalty applies if pre-authorization is not obtained. Applies to inpatient facility. Other cost shares may apply depending on the services provided. Childbirth/delivery professional services 10% coinsurance 30% coinsurance Childbirth/delivery facility services 10% coinsurance 30% coinsurance If you need help recovering or have other special health needs Home health care 10% coinsurance 30% coinsurance 80 days limit/benefit period. Rehabilitation services 10% coinsurance 30% coinsurance *See Therapy Services section Coverage is limited to 60 visits per calendar year for Cardiac Rehabilitation, Occupational, Physical Habilitation services 10% coinsurance 30% coinsurance
About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) The overall $900 The overall $900 The overall $900 coinsurance 10% coinsurance 10% coinsurance 10% Hospital (facility) coinsurance 10% Hospital (facility) coinsurance 10% Hospital (facility) coinsurance 10% Other coinsurance 10% Other coinsurance 10% Other coinsurance 10% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $12,840 Total Example Cost $7,460 Total Example Cost $2,010 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $900 Deductibles $900 Deductibles $900 Copayments $0 Copayments $792 Copayments $0 Coinsurance $900 Coinsurance $108 Coinsurance $193 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $60 Limits or exclusions $55 Limits or exclusions $0 The total Peg would pay is $1,860 The total Joe would pay is $1,855 The total Mia would pay is $1,093