Page 69 - Appendices for Eric Hartman
P. 69
HOSPITAL SERVICES
Inpatient hospital In-network: $150 per day for Limits apply
coverage days 1 through 3
$0 per day for days 4 through
90
$0 per day for days 91 and
beyond
Out-of-network: 20% per stay
Outpatient hospital In-network: $165 copay per Limits apply
coverage visit
Out-of-network: 25%
coinsurance per visit
SKILLED NURSING FACILITY
Skilled nursing facility In-network: $0 per day for Limits apply
days 1 through 20
$100 per day for days 21
through 51
$0 per day for days 52
through 100
Out-of-network: 30% per stay
PREVENTIVE SERVICES
Health care to prevent illness or detect illness at an early stage, when treatment is likely
to work best (like Pap tests, u shots, and screening mammograms).
Learn more about your costs for preventive services
Preventive services In-network: $0 copay Limits apply
Out-of-network: 30%
coinsurance
