Page 32 - 2021-2022 New Hire Benefits
P. 32

Sudden and Unexpected Care            In-network member pays              Out-of-network member pays

        Urgent care or other walk-in          0% coinsurance                      Same as In-network bene t
        clinic                                after plan deductible

                                              0% coinsurance
        Emergency room                                                            Same as In-network bene t
                                              after plan deductible
                                              0% coinsurance
        Ambulance                                                                 Same as In-network bene t
                                              after plan deductible
        Inpatient Hospital Services           In-network member pays              Out-of-network member pays
        Inpatient hospital services,          0% coinsurance                      30% coinsurance
        including room and board              after plan deductible               after plan deductible

        Skilled nursing and                   0% coinsurance                      30% coinsurance
        rehabilitation facilities             after plan deductible               after plan deductible
        up to 60 days per year
        Outpatient Hospital Services
        and Home Care                         In-network member pays              Out-of-network member pays
                                              0% coinsurance                      30% coinsurance
        Hospital outpatient facilities
                                              after plan deductible               after plan deductible
                                              0% coinsurance                      30% coinsurance
        Ambulatory surgical center
                                              after plan deductible               after plan deductible
        Home health services                  0% coinsurance                      25% coinsurance
        up to 100 visits per year             after plan deductible               after plan deductible

        Outpatient Rehabilitative
        Services                              In-network member pays              Out-of-network member pays

        Rehabilitative Services
        up to 20 visits per year              $30 copayment/visit                 30% coinsurance
        includes services combined for        after plan deductible               after plan deductible
        physical, speech and occupational
        therapy
        Chiropractic services                 $45 copayment/visit                 30% coinsurance
        up to 10 visits per year              after plan deductible               after plan deductible

        Mental Health and Substance
        Abuse                                 In-network member pays              Out-of-network member pays

        Inpatient mental health               0% coinsurance                      30% coinsurance
        services                              after plan deductible               after plan deductible

        Inpatient alcohol and                 0% coinsurance                      30% coinsurance
        substance abuse treatment             after plan deductible               after plan deductible

        Outpatient mental health,
        alcohol and substance abuse           $30 copayment/visit                 30% coinsurance
        treatment                             after plan deductible               after plan deductible
        o ice visits and home services










       CICI Flex and Combined/BS LG (01/2021) E ective Date: 7/2021
       FlexPOS-CNT-HS129631
       CT P01654141/P01654142 / MA P01754144/P01754143 -129631
       FlexPOS-CNT-HSA-2000I/4000F-30-45-08
       Bene t ID: LS/LT
   27   28   29   30   31   32   33   34   35   36   37