Page 20 - 2021-2022 New Hire Benefits
P. 20
Inpatient Hospital Services In-network member pays Out-of-network member pays
Inpatient hospital services, $500 copayment/day up to $2,000 20% coinsurance
including room and board per year after plan deductible
Skilled nursing and $500 copayment/day up to $2,000 20% coinsurance
rehabilitation facilities per year after plan deductible
up to 90 days per year
Outpatient Hospital Services In-network member pays Out-of-network member pays
and Home Care
20% coinsurance
Hospital outpatient facilities $300 copayment/visit
after plan deductible
20% coinsurance
Ambulatory surgical center $300 copayment/visit
after plan deductible
Home health services No charge 25% coinsurance
up to 100 visits per year after $50 bene t deductible
Outpatient Rehabilitative In-network member pays Out-of-network member pays
Services
Rehabilitative Services
up to 40 visits per year
includes services combined for $30 copayment/visit 20% coinsurance
after plan deductible
physical, speech and occupational
therapy
Chiropractic services $45 copayment/visit 20% coinsurance
up to 20 visits per year after plan deductible
Mental Health and Substance In-network member pays Out-of-network member pays
Abuse
Inpatient mental health $500 copayment/day up to $2,000 20% coinsurance
services per year after plan deductible
Inpatient alcohol and $500 copayment/day up to $2,000 20% coinsurance
substance abuse treatment per year after plan deductible
Outpatient mental health,
alcohol and substance abuse $30 copayment/visit 20% coinsurance
treatment after plan deductible
o ice visits and home services
Outpatient mental health,
alcohol and substance abuse 20% coinsurance
treatment No charge after plan deductible
intensive outpatient treatment and
partial hospitalization
Supplies In-network member pays Out-of-network member pays
Durable medical equipment 50% coinsurance
including prosthetics and 50% coinsurance after plan deductible
disposable medical supplies
CICI FlexPOS and Combined/BS LG (01/2021) E ective Date: 7/2021
FlexPOS-CNT-30129705
CT P01656449 / MA P01756450 -129705
FlexPOS-CNT-30-45-300-500D-01
Bene t ID: Lo
