What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information 50% penalty for no out-of-network precertification. Coverage is limited to 120 days annual max. 16 hour maximum per day (The limit is not applicable to mental health and substance use disorder conditions.) 50% penalty for failure to precertify out-of-network speech therapy services. Coverage is limited to annual max of: 90 days for Rehabilitation services; 36 days for Cardiac rehab services; 20 days for Chiropractic care services Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Services are covered when Medically Necessary to treat a mental health condition (e.g. autism). 50% penalty for failure to precertify out-of-network speech therapy services. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. 50% penalty for no out-of-network precertification. Coverage is limited to 90 days annual max.
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Home health care
20% coinsurance
50% coinsurance
Rehabilitation services
20% coinsurance/visit
50% coinsurance/visit
If you need help recovering or have other special health needs
Habilitation services
20% coinsurance/visit
50% coinsurance/visit
Skilled nursing care
20% coinsurance
50% coinsurance
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