Page 34 - Touching All the Bases- Power point 2023 Umpires_Neat

What You Will Pay
Common Medical Services You May Need Limitations, Exceptions, & Other
Event Network Provider (You Out-of-Network Provider Important Information
will pay the least) (You will pay the most)
If you need help Home health care No charge 30% coinsurance Precertification may be required.
recovering or have Rehabilitation services $30 copay/visit 30% coinsurance Combined network and out-of-
other special network: 30 physical medicine visits,
health needs 20 speech therapy visits, and 20
occupational therapy visits per benefit
period. Limit does not apply to
Therapy Services prescribed for the
treatment of Mental Health or
Substance Abuse.
Precertification may be required.
Habilitation services Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
Skilled nursing care No charge 30% coinsurance Combined network and out-of-
network: 100 days per benefit period.
Precertification may be required.
Out-of-network: Failure to precertify
will result in benefits payable being
reduced by $1,000.
Durable medical equipment No charge 30% coinsurance Precertification may be required.
Hospice services No charge 30% coinsurance Precertification may be required.
If your child needs Children’s eye exam Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
dental or eye care Children’s glasses Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
Children’s dental check-up Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−

5 of 10