Page 31 - Benefits Summary 2018-2019

Benefits In-Network Out-of-Network
Inpatient hospital services
 $300 in-network per admission deductible is
separate and in addition to the plan deductible. You pay $300 per admission You pay $600 per admission
Plan deductible only applies to the Professional deductible, deductible,
Services. Then Then
 $600 out-of-network per admission deductible Plan pays 100% You pay 30%
is separate and in addition to the plan Plan pays 70%
deductible. Plan deductible only applies to the
Professional Services.
Inpatient Professional Services After the plan deductible is met, After the plan deductible is met,
 For services performed by Surgeons, You pay 0% You pay 30%
Radiologists, Pathologists, Anesthesiologists, Plan pays 100% Plan pays 70%
and Hospital Based Physician
After the plan deductible is met, After the plan deductible is met,
Outpatient hospital services You pay 0% You pay 30%
Plan pays 100% Plan pays 70%
Outpatient professional services After the plan deductible is met, After the plan deductible is met,
 For services performed by Surgeons, You pay 0% You pay 30%
Radiologists, Pathologists, Anesthesiologists Plan pays 100% Plan pays 70%
After the plan deductible is met, After the plan deductible is met,
Skilled nursing facility care
 60 days per plan year maximum You pay 0% You pay 30%
Plan pays 100% Plan pays 70%
After the plan deductible is met, After the plan deductible is met,
Hospice care You pay 0% You pay 30%
Plan pays 100% Plan pays 70%
Home health care After the plan deductible is met, After the plan deductible is met,
 60 visits per plan year maximum You pay 0% You pay 30%
 The limit is not applicable to mental health and Plan pays 100% Plan pays 70%
substance use disorder conditions.
Mental Health and Substance Use Disorder
You pay $600 per admission
You pay $300 per admission
Inpatient mental health deductible, deductible,
 Includes Residential Treatment then you pay 30%, Plan pays
then Plan pays 100%
70%
Outpatient mental health – Physician’s Office After the plan deductible is met,
 Includes Individual, Intensive Outpatient, You pay $50 per visit copay, You pay 30%
Behavioral Telehealth Consultation, and Group then plan pays 100% Plan pays 70%
Therapy
Outpatient mental health – all other services
 Includes Partial Hospitalization Plan pays 100%, After the plan deductible is met,
 Includes Individual, Intensive Outpatient, no copay,no deductible You pay 30%
Behavioral Telehealth Consultation, and Group Plan pays 70%
Therapy
You pay $600 per admission
You pay $300 per admission
Inpatient substance use disorder deductible, deductible,
 Includes Residential Treatment then you pay 30%, Plan pays
then Plan pays 100%
70%
Outpatient substance use disorder – Physician’s
Office You pay $50 per visit copay, After the plan deductible is met,
 Includes Individual, Intensive Outpatient, then plan pays 100% You pay 30%
Behavioral Telehealth Consultation, and Group Plan pays 70%
Therapy

11/1/2018
ASO
Open Access Plus - OAP High 11-2018 - 7899546. Version# 12

3 of 8 ©Cigna 2018