Page 68 - Cover letter and evaluation for Peter Smith
P. 68
11/27/2017 Your Medicare Health Plan Details
Outpatient hospital coverage
In-Network: $45-275 per visit
Out-of-Network: 40% per visit
Doctor visits Primary:
In-Network: $5 per visit
Out-of-Network: 40% per visit
Specialist:
In-Network: $45 per visit
Out-of-Network: 40% per visit
Preventive care
In-Network: $0 copay
Out-of-Network: 0-40%
Emergency care/Urgent care Emergency: $80 per visit (always covered)
Urgent care: $5-60 per visit (always covered)
Diagnostic procedures/lab Diagnostic tests and procedures:
services/imaging In-Network: $40
Out-of-Network: 40%
Lab services:
In-Network: $0 copay
Out-of-Network: 40%
Diagnostic radiology services (e.g., MRI):
In-Network: 20%
Out-of-Network: 40%
Outpatient x-rays:
In-Network: $40
Out-of-Network: 40%
Mental health services
In-Network: $324 for days 1 through 5
$0 for days 6 through 90
Out-of-Network: 40% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network: $40
Out-of-Network: 40%
Outpatient individual therapy visit with a psychiatrist:
In-Network: $40
Out-of-Network: 40%
Outpatient group therapy visit:
In-Network: $40
Out-of-Network: 40%
Outpatient individual therapy visit:
In-Network: $40
Out-of-Network: 40%
Skilled Nursing Facility
In-Network: $0 for days 1 through 20
$167 for days 21 through 100
Out-of-Network: 40% per stay
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=055&sgmntid=0#plan_benefits 2/5
