Page 34 - Washington Nationals 2023 Benefits Guide -10.26.22_Neat

PPO

On the chart below, you'll see what your plan pays for specific services. You may be responsible for a facility fee, clinic charge or similar fee or charge (in
addition to any professional fees) if your office visit or service is provided at a location that qualifies as a hospital department or a satellite building of a
hospital.
Minor League Baseball Health & Welfare Plan
Field Personnel and International Scouts - Option 2 Effective 01/01/2023
Benefit Network Out-of-Network
General Provisions
Benefit Period(1) Calendar
Deductible (per benefit period)
Individual $250 $500
Family $500 $1,000
Plan Pays – payment based on the plan allowance 90% after deductible 80% after deductible
Out of Pocket Limit (Includes deductible. Once met, plan pays
100% coinsurance (excluding applicable copays) for the rest of
the benefit period)
Individual $750 $1,500
Family $2,000 $4,000

Total Maximum Out-of-Pocket (includes deductible,
coinsurance, copays and other qualified medical expenses,
Network only)(2) Once met, the plan pays 100% of covered
services for the rest of the benefit period.
Individual
Family $6,350 N/A
$12,700 N/A

Office/Clinic/Urgent Care Visits
Retail Clinic Visits 100% after $20 copayment 80% after deductible
Primary Care Provider Office Visits 100% after $20 copayment 80% after deductible
Specialist Office Visits 100% after $20 copayment 80% after deductible
Urgent Care Center Visits 100% after $20 copayment 80% after deductible
Telemedicine Services(3) 100% after $20 copayment Not Covered
Preventive Care
Routine Adult
Physical exams 100% (deductible does not apply) Not Covered
Adult immunizations 100% (deductible does not apply) 80% after deductible
Colorectal cancer screening (includes colonoscopy; 100% (deductible does not apply) 80% after deductible
sigmoidoscopy; barium enema; blood occult)
Routine gynecological exams 100% (deductible does not apply) 100% (deductible does not apply)
Routine Pap Smear 100% (deductible does not apply) 100% (deductible does not apply)
Mammograms, annual routine 100% (deductible does not apply) 100% (deductible does not apply)
Diagnostic services and procedures 100% (deductible does not apply) 80% after deductible
Routine Pediatric
Physical exams 100% (deductible does not apply) 80% after deductible
Pediatric immunizations 100% (deductible does not apply) 80% (deductible does not apply)
Diagnostic services and procedures 100% (deductible does not apply) 80% after deductible
Hospital and Medical/Surgical Expenses (including maternity)
Hospital Inpatient 90% after deductible 80% after deductible
Hospital Outpatient 90% after deductible 80% after deductible
Maternity (non-preventive facility & professional services) 90% after deductible 80% after deductible
Medical/Surgical (except office visits) 90% after deductible 80% after deductible
Second surgical opinion 90% after deductible 80% after deductible
Emergency Services
Emergency Room Services 90% after $50 copayment (waived if admitted)
Ambulance 90% (deductible does not apply)

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