Page 90 - 2022 Washington Nationals Flipbook

What You Will Pay

Common Medical Services You May Need Network Provider Out-of-Network Limitations, Exceptions, and Other
Event (You will pay the Provider (You will Important Information

If you need help Home health care least) pay the most) Precertification may be required.
recovering or have Rehabilitation services Combined network and out-of-network:
other special health 20% coinsurance 40% coinsurance 70 combined physical medicine, speech,
needs and occupational therapy visits per
20% coinsurance 40% coinsurance benefit period.
Precertification may be required.
Habilitation services Not covered Not covered ----------------------None-------------------
Skilled nursing care 20% coinsurance 40% coinsurance Out-of-network: 100 days per benefit
period.
If your child needs Durable medical equipment 20% coinsurance 40% coinsurance Precertification may be required.
dental or eye care Hospice service 20% coinsurance 40% coinsurance Precertification may be required.
Precertification may be required.
Children’s Eye exam Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
Children’s Glasses Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
Children’s Dental check-up Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−

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