Page 57 - APPENDICES for Diane Falten

HOSPITAL SERVICES

Inpatient hospital In-network: $350 per day for Limits apply
coverage days 1 through 5
$0 per day for days 6 through

90
$0 per day for days 91 and
beyond
Out-of-network: $500 per day
for days 1 through 7
$0 per day for days 8 through
90

Outpatient hospital In-network: $45-350 copay Limits apply
coverage per visit
Out-of-network: 30%
coinsurance per visit

SKILLED NURSING FACILITY

Skilled nursing facility In-network: $0 per day for Limits apply

days 1 through 20
$188 per day for days 21
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
Out-of-network: $0 copay or
30% coinsurance