Page 215 - Washington Nationals 2023 Benefits Guide -10.26.22_Neat

What You Will Pay

Common Medical Services You May Need Network Provider Out-of-Network Limitations, Exceptions, & Other
Event (You will pay the Provider (You will Important Information
least) pay the most)
If you need help Home health care 20% coinsurance 40% coinsurance Precertification may be required.
recovering or have Rehabilitation services 20% coinsurance 40% coinsurance Combined network and out-of-network:
other special health 70 combined physical medicine,
needs occupational therapy, and speech
therapy visits per benefit period. Limit
does not apply to Therapy Services
prescribed for the treatment of Mental
Health or Substance Abuse.
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.
Precertification may be required.
Durable medical equipment 20% coinsurance 40% coinsurance Precertification may be required.
Hospice services 20% coinsurance 40% coinsurance Precertification may be required.
If your child needs Children’s eye exam Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
dental or eye care Children’s glasses Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
Children’s dental check-up Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−

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