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.) 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) or a congenital abnormality. 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. 50% penalty for no out-of-network precertification. 50% penalty for failure to precertify out-of-network inpatient hospice services.
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
Durable medical equipment 20% coinsurance
50% coinsurance
20% coinsurance/inpatient services 20% coinsurance/outpatient services
50% coinsurance/inpatient services 50% coinsurance/outpatient services
Hospice services
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