Page 17 - Benefits Summary 2018-2019 b_Neat

What You Will Pay
Common Limitations, Exceptions, & Other
Medical Event Services You May Need In-Network Provider Out-of-Network Provider Important Information
(You will pay the least) (You will pay the most)
Coverage is limited to 60 visits annual
max. (The limit is not applicable to
Home health care 30% coinsurance Not covered
mental health and substance use
disorder conditions.)
Coverage is limited to an annual max
of 20 visits for Physical therapy and
$50 copay/visit for Physical,
Speech, Hearing & Occupational 20 visits for Speech, Hearing &
Occupational therapy and 20 visits
therapy**
If you need help Rehabilitation services Not covered annual max for Chiropractic care
recovering or have other $50 copay/visit for Chiropractic services.
special health needs care**
**Deductible does not apply Limits are not applicable to mental
health conditions for Physical, Speech
and Occupational therapies.
Habilitation services Not covered Not covered None
Coverage is limited to 60 days annual
Skilled nursing care 30% coinsurance Not covered
max.
Durable medical equipment 30% coinsurance Not covered None
Hospice services 30% coinsurance Not covered None
Children's eye exam Not covered Not covered None
If your child needs dental
or eye care Children's glasses Not covered Not covered None
Children's dental check-up Not covered Not covered None

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