Page 7 - Enrollment Guide Example
P. 7
[Carrier] [Carrier] [Carrier] [Carrier]
[Plan 1] [Plan 2] [Plan 3] [Plan 4]
In-Network In-Network In-Network In-Network
Mental Health
Inpatient 80% after ded 80% after ded 90% after ded 100% after ded
Limitations None None None None
Outpatient— $20 copay $20 copay 90% after ded 100% after ded
ofice visit
Limitations None None None None
Substance Abuse
Inpatient 80% after ded 80% after ded 90% after ded 100% after ded
Limitations None None None None
Outpatient— $20 copay $20 copay 90% after ded 100% after ded
ofice visits
Limitations None None None None
Other
Skilled nursing care 80% after ded 80% after ded 90% after ded 100% after ded
(no limits)
Home healthcare (no 80% after ded 80% after ded 90% after ded 100% after ded
limits)
Hospice care 80% after ded 80% after ded 90% after ded 100% after ded
Durable medical 80% after ded 80% after ded 90% after ded 100% after ded
equipment
Prosthetic devices 80% after ded 80% after ded 90% after ded 100% after ded
Chiropractic Care—30 visits
80% after ded 80% after ded 90% after ded 100% after ded
Outpatient Therapies
Physical therapy $20 copay $25 copay 90% after ded 100% after ded
Limitations No limits No limits No limits No limits
Speech therapy $20 copay $25 copay 90% after ded 100% after ded
Limitations No limits No limits No limits No limits
Occupational therapy $20 copay $25 copay 90% after ded 100% after ded
Limitations No limits No limits No limits No limits
Transplants (Some transplants must be performed in hospitals with approved [Carrier] Human Organ Transplant programs)
80% after ded 80% after ded 90% after ded 100% after ded
For out-of-network coverage details, please refer to your summary plan description (SPD) or an oficial plan
document.
7
[Plan 1] [Plan 2] [Plan 3] [Plan 4]
In-Network In-Network In-Network In-Network
Mental Health
Inpatient 80% after ded 80% after ded 90% after ded 100% after ded
Limitations None None None None
Outpatient— $20 copay $20 copay 90% after ded 100% after ded
ofice visit
Limitations None None None None
Substance Abuse
Inpatient 80% after ded 80% after ded 90% after ded 100% after ded
Limitations None None None None
Outpatient— $20 copay $20 copay 90% after ded 100% after ded
ofice visits
Limitations None None None None
Other
Skilled nursing care 80% after ded 80% after ded 90% after ded 100% after ded
(no limits)
Home healthcare (no 80% after ded 80% after ded 90% after ded 100% after ded
limits)
Hospice care 80% after ded 80% after ded 90% after ded 100% after ded
Durable medical 80% after ded 80% after ded 90% after ded 100% after ded
equipment
Prosthetic devices 80% after ded 80% after ded 90% after ded 100% after ded
Chiropractic Care—30 visits
80% after ded 80% after ded 90% after ded 100% after ded
Outpatient Therapies
Physical therapy $20 copay $25 copay 90% after ded 100% after ded
Limitations No limits No limits No limits No limits
Speech therapy $20 copay $25 copay 90% after ded 100% after ded
Limitations No limits No limits No limits No limits
Occupational therapy $20 copay $25 copay 90% after ded 100% after ded
Limitations No limits No limits No limits No limits
Transplants (Some transplants must be performed in hospitals with approved [Carrier] Human Organ Transplant programs)
80% after ded 80% after ded 90% after ded 100% after ded
For out-of-network coverage details, please refer to your summary plan description (SPD) or an oficial plan
document.
7
