Page 14 - 2021-2022 New Hire Benefits

Outpatient Hospital Services In-network member pays
and Home Care
Ambulatory surgical center $300 copayment/visit

Home health services No charge
up to 100 visits per year

Outpatient Rehabilitative In-network member pays
Services

Rehabilitative Services
up to 40 visits per year
includes services combined for $30 copayment/visit
physical, speech, and occupational
therapy

Chiropractic services $45 copayment/visit
up to 20 visits per year

Mental Health and Substance In-network member pays
Abuse

Inpatient mental health $500 copayment/day up to $2,000 per year
services
Inpatient alcohol and $500 copayment/day up to $2,000 per year
substance abuse treatment
Outpatient mental health,
alcohol and substance abuse $30 copayment/visit
treatment
o ice visits and home services
Outpatient mental health,
alcohol and substance abuse
treatment $30 copayment/visit
intensive outpatient treatment and
partial hospitalization
Supplies In-network member pays

Durable medical equipment
including prosthetics and 50% coinsurance
disposable medical supplies
Arti cial Limbs
includes associated supplies and 20% coinsurance
equipment
Diabetic equipment and 20% coinsurance
supplies
Modi ed food products and
specialized formula pharmacy 50% coinsurance
tier

CCI/HMO/BS LG (01/2021) E ective Date: 7/2021
Choice_HMO-OA-129630
CT H00154139 / MA H01254140 -129630
Choice HMO-OA-CNT-30-45-300-500D-01
Bene t ID: Lk