What You Will Pay
Out-of-Network Provider (You will pay the most)
Payment of all Out-Of-Network professional services will be limited to 135% of the Medicare fee schedule. Payment of all Out- Of-Network facility services will
Common Medical Event
Limitations, Exceptions, & Other Important Information
Network Provider (You will pay the least)
Services You May Need
be limited to 175% of the Medicare fee schedule
Facility fee (e.g., hospital room)
20% coinsurance
40% coinsurance
Pre-notification is recommended
If you have a hospital stay
Physician/surgeon fees
20% coinsurance
40% coinsurance
None.
If you need mental health, behavioral health, or substance abuse services
Outpatient services
20% coinsurance
40% coinsurance
None
Inpatient services
20% coinsurance
40% coinsurance
Pre-notification is recommended.
Cost sharing does not apply for preventive services. Depending on the type of services, a coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Pre-notification is recommended for vaginal deliveries requiring more than a 48 hour stay and for cesarean section deliveries requiring more than a 96 hour stay. Pre-notification is recommended. Limited to 120 visits/calendar year Physical and occupational therapy: limited to a combined maximum of 30 visits of office and outpatient facility services per calendar year. Speech therapy: limited to 30 visit maximum per calendar year.
Office visits
20% coinsurance
40% coinsurance
Childbirth/delivery professional services
20% coinsurance
40% coinsurance
If you are pregnant
Childbirth/delivery facility services
20% coinsurance
40% coinsurance
Home health care
20% coinsurance
40% coinsurance
If you need help recovering or have other special health needs
Rehabilitation services
20% coinsurance
40% coinsurance
Habilitation services
20% coinsurance
40% coinsurance
Skilled nursing care
20% coinsurance
40% coinsurance
30 days/calendar year
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