Page 11 - Franklin Madison 2021 Benefits Guide

Medical Comparison Chart

Consumer Choice with HSA POS Enhanced POS Basic
Beneit In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Providers
Providers
Providers
Providers
Providers
Providers
Hospital Care
70% after
Inpatient 90% after deductible 90% after 70% after 80% after 60% after
deductible
deductible
deductible
deductible
deductible
Outpatient 90% after 70% after 90% after 70% after 80% after 60% after
Surgery deductible deductible deductible deductible deductible deductible
Maternity
Hospital 90% after 70% after 90% after 70% after 80% after 60% after
Services deductible deductible deductible deductible deductible deductible
100% after $40 100% after $40
Physician 90% after 70% after copay on irst 70% after copay on irst 60% after
Services deductible deductible visit; 90% after deductible visit; 80% after deductible
deductible deductible
Mental Health & Substance Abuse
70% after
70% after
Inpatient 90% after deductible 90% after deductible 80% after 60% after
deductible
deductible
deductible
deductible
70% after
70% after
Outpatient 90% after deductible $25 copay deductible $30 copay 60% after
deductible
deductible
Outpatient Rehabilitation
Physical,
Speech,
Occupational 100% after 100% after
& Chiropractic 90% after 70% after applicable per 70% after applicable per 60% after
Therapy (60 deductible deductible visit copay deductible visit copay deductible
visit maximum
for all services
combined per
year)

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