Page 67 - Benefits Summary 2018-2019
P. 67
What You Will Pay
Common Services You May Need Limitations, Exceptions, & Other
Medical Event In-Network Provider Out-of-Network Provider Important Information
(You will pay the least) (You will pay the most)
Office visits No charge 30% coinsurance Depending on the type of services, a
Childbirth/delivery No charge 30% coinsurance copayment, coinsurance or deductible
If you are pregnant professional services may apply. Maternity care may
include tests and services described
Childbirth/delivery facility No charge 30% coinsurance elsewhere in the SBC (i.e.
services
ultrasound).
$250 penalty for no precertification.
Coverage is limited to 60 visits annual
Home health care No charge 30% coinsurance max. (The limit is not applicable to
mental health and substance use
disorder conditions.)
$250 penalty for failure to precertify
speech therapy. Coverage is limited to
an annual max of 20 visits for Physical
No charge/visit for Physical, 30% coinsurance/visit for
Speech, Hearing & Physical, Speech, Hearing & therapy and 20 visits for Speech,
Hearing & Occupational therapy and
If you need help Rehabilitation services Occupational therapy Occupational therapy 20 visits annual max for Chiropractic
recovering or have other care services.
special health needs No charge/visit for Chiropractic 30% coinsurance/visit for
care services Chiropractic care
Limits are not applicable to mental
health conditions for Physical, Speech
and Occupational therapies.
Habilitation services Not covered Not covered None
$250 penalty for no precertification.
Skilled nursing care No charge 30% coinsurance Coverage is limited to 60 days annual
max.
Durable medical equipment No charge 30% coinsurance $250 penalty for no precertification.
Hospice services No charge 30% coinsurance $250 penalty for no precertification.
Children's eye exam Not covered None
If your child needs dental
or eye care Children's glasses Not covered None
Children's dental check-up Not covered Not covered None
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