AFFORDABLE CHOICE PLAN COMPARISON Surgical and Hospitalization Benefits PLAN 1 PLAN 2
Inpatient Hospital Confinement (Per Inpatient Day)
$500
$1,000
12-23 Hours: 25% Inpatient ($125 - $250) 24-47 Hours: 50% Inpatient ($250 - $500) 48 Hours: 75% Inpatient ($375 - $750)
Observation Unit
Hospital Admission Benefits (For the first Inpatient Day per calendar year)
$500
$1,000
Emergency Room (Per day; 1/CY)
$200
$300
Urgent Care (Per day; 2/CY)
$200
$300
Surgery Benefit (Maximum $50,000 benefit per calendar year)
1 X Medicare Fee Schedule
2 X Medicare Fee Schedule
Ambulatory Surgical Benefit
$1,000
$2,000
Daily Assistant Surgeon Benefit
Pays 20% of the eligible surgical benefit
Daily Anesthesiologist Benefit
Pays 25% of the eligible surgical benefit
Doctor's Visits
$75 per day ; 4/CY
$125 per day ; 4/CY
Prescription Benefit (Per Day)
$25 ; $250/CY
$50 ; $500/CY
Outpatient Medical Benefits
Wellness Benefit: (1/CY, 30 day waiting period)
$100
Preventative Services: (Per service)
$250 $250
$300 $300
Pap PSA
Laboratory Services: (Per day)
$200 $50
$300 $50
Surgical Pathology Other Laboratory Services
Therapy Services: (Per day for physical, occupational, speech) Radiology Services: (per day: MRI/PET scan/ CT scan/mammogram/other radiology tests)
$50
$75
$300/$300/ $300/$250/$200
$600/$600/ $600/$300/$250
Calendar year limit for all Outpatient Benefits
$4,000
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