Page 46 - 2023 Hickory Crawdads - Benefits Guide_Neat

What You Will Pay
Common Medical Services You May Need Limitations, Exceptions, & Other
Event Network Provider (You Out-of-Network Provider Important Information
will pay the least) (You will pay the most)
If you need help Home health care 20% coinsurance 40% coinsurance Combined network and out-of-
recovering or have network: 100 visits per benefit period,
other special combined with visiting nurse.
health needs Precertification may be required.
Rehabilitation services 20% coinsurance 40% coinsurance Precertification may be required.
Habilitation services Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
Skilled nursing care 20% coinsurance 40% coinsurance Combined network and out-of-
network: 100 days per benefit period.
Precertification may be required.
Failure to precertify will result in
benefits payable being reduced by
$250.
Durable medical equipment 20% coinsurance 40% coinsurance Precertification may be required.
Hospice services No charge No charge Precertification may be required.
Deductible does not apply. Deductible does not apply.
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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