Common Medical Event Services You May Need Your Cost If You Use a Network Provider Your Cost If You Use an Provider Limitations & Exceptions If you have a hospital stay Facility fee (e.g., hospital room) Preferred 10% coinsurance. All other Facilities 20% coinsurance 40% coinsurance after calendar year deductible Pre-authorization required for care. Physician/surgeon fee Preferred 10% coinsurance. All other Facility 20% coinsurance 40% coinsurance calendar year deductible ––––––––––– None ––––––––––– If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $25 copay per visit 40% coinsurance after calendar year deductible ––––––––––– None ––––––––––– Mental/Behavioral health inpatient services 10% coinsurance 40% coinsurance after calendar year deductible Pre-authorization required for care. Substance use disorder outpatient services $25 copay per visit 40% coinsurance after calendar year deductible ––––––––––– None ––––––––––– Substance use disorder inpatient services 10% coinsurance 40% coinsurance after calendar year deductible Pre-authorization required for care. If you are pregnant Prenatal and postnatal care No charge 40% coinsurance after calendar year deductible ––––––––––– None ––––––––––– Delivery and all inpatient services 0% coinsurance 40% coinsurance after calendar year deductible Includes outpatient postnatal care. Pre-authorization required for out-of-network care.
Common Medical Event Services You May Need Your Cost If You Use a Network Provider Your Cost If You Use an Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care 0% coinsurance 40% coinsurance after calendar year deductible Pre-authorization required for care. Rehabilitation services $25 copay per visit 40% coinsurance after calendar year deductible ––––––––––– None ––––––––––– Habilitation services $25 copay per visit 40% coinsurance after calendar year deductible Benefit limitations may apply. Skilled nursing care 0% coinsurance 40% coinsurance after calendar year deductible Coverage is limited to 100 days per calendar year. Pre-authorization required for out-of-network care. Durable medical equipment 0% coinsurance 40% coinsurance after calendar year deductible ––––––––––– None ––––––––––– Hospice service 0% coinsurance 40% coinsurance after calendar year deductible Pre-authorization required for care. If your child needs dental or eye care Eye exam No charge 40% coinsurance after calendar year deductible Coverage is limited to 1 routine eye exam per calendar year. Glasses Not covered Not covered Not covered. Dental Not covered Not covered Not covered. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Long-term care Private-duty nursing Dental care (Adult & Child) Non-emergency care when traveling outside the Routine foot care Glasses (Child) U.S. Weight loss programs Other Covered Services (This isn't a complete list. your policy or plan document for other covered services and your costs for these services.) Acupuncture Hearing aids - Coverage is limited to 1 hearing aid Infertility treatment - Benefit limitations may apply. Bariatric surgery to a maximum of $1,400 per 36 months up to age Routine eye care (Adult) - Coverage is limited to 1 Chiropractic care 19. routine eye exam per calendar year.
Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don't include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren't specific to a particular geographic area or health plan. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited. Does the Coverage Example predict Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you'll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides. The patient's condition was not an excluded or preexisting condition. my own care needs? Are there other costs I should All services and treatments started and ended in the same coverage period. are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. No. Treatments shown are just examples. The care you would receive for this condition could be different, based on your doctor's advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. consider when comparing Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you'll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.