Page 12 - Aegion Value Plan SPDs

Medical Care HSA Plan

Hearing Aid Services
(Hearing Aids Benefit Maximum — $2,000 every 5 years.
Cochlear implants do not have limits.)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Home Health Care / Home Infusion Therapy
(Private Duty Nursing is only covered in the home and is
limited to $10,000 each calendar year ($50,000 lifetime
maximum) for Network and Out-of-Network combined.)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Hospice Care
(No limit per lifetime)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Hospital Inpatient Care
Please refer to Health Care Management –
Precertification Section.
(Includes semiprivate room, Hospital-billed Physician
charges, general nursing services, operating and special
care rooms, medications, medical supplies, and diagnostic
and therapy services. For well newborn care, the
Deductible is applied to mother’s claim only. Includes
hearing/vision screenings rendered in Inpatient setting.)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance
Hospital Inpatient Physical Medicine Rehabilitation
(Limited to 60 days each calendar year for Network and
Out-of Network combined.)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Hospital Outpatient Care
(Includes pre-surgical and pre-admission testing.)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Immunizations (Routine) See “Preventive Care”.

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