Page 12 - Franklin Madison 2022 Benefits Guide

Medical Comparison Chart

HSA OAP OAP Enhanced OAP 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
90% after
Inpatient deductible 70% after 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
Physician 90% after 70% after 90% after 70% after 80% after 60% after
Services deductible deductible deductible deductible deductible deductible
Mental Health & Substance Abuse
90% after
90% after
80% after
Inpatient deductible 70% after deductible 70% after deductible 60% after
deductible
deductible
deductible
90% after
Outpatient deductible 70% after $40 copay 70% after $40 copay 60% after
deductible
deductible
deductible
Outpatient Rehabilitation
Speech (20 visit 90% after 70% after 70% after 60% after
maximum per deductible deductible $25 copay deductible $30 copay deductible
year)
Occupational
(20 visit 90% after 70% after $25 copay 70% after $30 copay 60% after
maximum per deductible deductible deductible deductible
year)
Physical (20 visit 90% after 70% after 70% after 60% after
maximum per deductible deductible $25 copay deductible $30 copay deductible
year)
Chiropractic
Therapy (20 90% after 70% after $25 copay 70% after $30 copay 60% after
visit maximum deductible deductible deductible deductible
per year)

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