Page 75 - Appendices to Jane Miller's evaluation

SKILLED NURSING FACILITY

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$184 per day for days 21 through 53
$0 per day for days 54 through 100
Out-of-network: $225 per day for days 1 through 45

$0 per day for days 46 through 100

Limits apply

PREVENTIVE SERVICES

Preventive services
In-network: $0 copay
Out-of-network: 0-40% coinsurance

AMBULANCE

Ground ambulance
In-network: $250 copay
Out-of-network: $250 copay

THERAPY SERVICES

Occupational therapy visit
In-network: $20 copay

Out-of-network: $70 copay

Limits apply

Physical therapy & speech & language therapy visit
In-network: $20 copay
Out-of-network: $70 copay

Limits apply