Page 38 - 2021-2022 New Hire Benefits

Sudden and Unexpected Care
The same cost share applies for
both in-network and out-of- In-network member pays
network service
0% coinsurance
Ambulance
after plan deductible
Inpatient Hospital Services In-network member pays

Inpatient hospital services, 0% coinsurance
including room and board after plan deductible

Skilled nursing and
rehabilitation facilities 0% coinsurance
after plan deductible
up to 60 days per year
Outpatient Hospital Services In-network member pays
and Home Care

0% coinsurance
Hospital outpatient facilities
after plan deductible
0% coinsurance
Ambulatory surgical center
after plan deductible
Home health services 0% coinsurance
up to 100 visits per year after plan deductible
Outpatient Rehabilitative In-network member pays
Services
Rehabilitative Services
up to 20 visits per year $30 copayment/visit
includes services combined for
physical, speech, and occupational after plan deductible
therapy
Chiropractic services $45 copayment/visit
up to 10 visits per year after plan deductible
Mental Health and Substance In-network member pays
Abuse
Inpatient mental health 0% coinsurance
services after plan deductible
Inpatient alcohol and 0% coinsurance
substance abuse treatment after plan deductible
Outpatient mental health,
alcohol and substance abuse $30 copayment/visit
treatment after plan deductible
o ice visits and home services

Outpatient mental health,
alcohol and substance abuse 0% coinsurance
treatment after plan deductible
intensive outpatient treatment and
partial hospitalization

CCI/HMO OA HDHP/BS LG (01/2021) E ective Date: 7/2021
Choice_HMO-OA-129628
CT H00155571 / MA H01255572 -129628
Choice HMO-OA-CNT-HSA-3000I/6000F-30-45-05
Bene t ID: bI