AFFORDABLE CHOICE PLAN COMPARISON Surgical and Hospitalization Benefits PLAN 1 PLAN 2 PLAN 3 PLAN 4
PLAN 5
Inpatient Hospital Confinement (31 day maximum per confinement)
$500
$1,000
$1,500
$2,000
$2,000
12-23 Hours: 25% Inpatient 24-47 Hours: 50% Inpatient 48 Hours: 75% Inpatient
Observation Unit
ICU Confinement (31 day maximum per confinement)
$1,000/day
$2,250/day
$3,000/day
$4,000/day
$3,000/day
Hospital Benefits
$1,000,000 Calendar Year Limit
First Day Hospitalization Benefit (For the first Inpatient Day per calendar year) Emergency Room (Max 1 day per calendar year)
$500
$1,000
$1,500
$2,000
$2,000
$200
$300
$400
$500
$250
Urgent Care (Max 2 days per calendar year)
$200
$300
$400
$500
$250
1 Unit of Surgical Schedule
2 Units of Surgical Schedule
3 Units of Surgical Schedule
3 Units of Surgical Schedule
1 Unit of Surgical Schedule
Surgery Benefit
Ambulatory/Outpatient Facility Benefit
$1,000
$2,000
$3,000
$4,000
$1,000
Surgical Benefits
Maximum $50,000 benefit per calendar year
20% (1 unit) of the eligible surgical schedule
20% (2 unit) of the eligible surgical schedule
20% (3 unit) of the eligible surgical schedule
20% (3 unit) of the eligible surgical schedule
20% (1 unit) of the eligible surgical schedule 20% (1 unit) of the eligible surgical schedule
Assistant Surgeon Benefit
25% (1 unit) of the eligible surgical schedule
25% (2 unit) of the eligible surgical schedule
25% (3 unit) of the eligible surgical schedule
25% (3 unit) of the eligible surgical schedule
Anesthesiologist Benefit
Doctor's Visits (4 days maximum per calendar year for plans 1-4) Prescription Benefit (CY stands for Calendar year maximum)
$75
$125
$175
$225
N/A
$25 ; $250/CY $50 ; $500/CY $75 ; $750/CY $100; $1,000/CY
N/A
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