Page 107 - Cover Letter and Evaluation for Paul Dorroh
P. 107
Your Medicare Health Plan Details https://www.medicare.gov/find-a-plan/results/planresults/plan-details.as...
Outpatient hospital coverage
In-Network: $40-275 per visit
Out-of-Network: 40% per visit
Doctor visits Primary:
In-Network: $9 per visit
Out-of-Network: $50 per visit
Specialist:
In-Network: $40 per visit
Out-of-Network: $50 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: $9-40 per visit (always covered)
Diagnostic procedures/lab Diagnostic tests and procedures:
services/imaging In-Network: 20%
Out-of-Network: 40%
Lab services:
In-Network: $25
Out-of-Network: 40%
Diagnostic radiology services (e.g., MRI):
In-Network: $225
Out-of-Network: 40%
Outpatient x-rays:
In-Network: $39
Out-of-Network: 40%
Mental health services
In-Network: $300 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: $39
Out-of-Network: $50
Outpatient individual therapy visit with a psychiatrist:
In-Network: $39
Out-of-Network: $50
Outpatient group therapy visit:
In-Network: $39
Out-of-Network: $50
Outpatient individual therapy visit:
In-Network: $39
Out-of-Network: $50
Skilled Nursing Facility
In-Network: $0 for days 1 through 20
$145 for days 21 through 100
Out-of-Network: 40% per stay
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