Page 9 - Touching All the Bases- Power point 2023 Umpires_Neat

Medical Plan Benefits Summary

In-Network Out-of-Network

Calendar Year Deductible $0 / $0 $500 / $1,000
(Individual/Family)

Coinsurance 100% 70%
Out-of-Pocket Maximum $2,000 / $4,000 $2,000 / $4,000
(Includes Deductible)
Primary Care Provider Office Visit $30 copay 70% (after deductible)

Specialist Office Visit $30 copay 70% (after deductible)
Preventive Care Covered in Full 70% (after deductible)
Adult
Routine Physical Exams 100% 70% after deductible

Routine Gynecological Exams 100% 70% after deductible

Mammograms, as required 100% 70% after deductible
Pediatric
Routine Physical Exams 100% 70% after deductible

Pediatric Immunizations 100% 70% after deductible
Emergency Room 100% after $100 Copay(waived if admitted)

Ambulance 100% (no deductible)
Inpatient Hospital Stay 100% 70% after deductible
Outpatient Hospital Services 100% 70% after deductible
Maternity 100% 70% after deductible

Infertility Counseling, Testing, 100% 70% after deductible
Treatment
Assisted Fertilization Procedures 100% 70% after deductible

Medical/Surgical Expenses 100% 70% after deductible
Spinal Manipulations $15 copay 70% after deductible
Diagnostic Services (lab/x-ray/other 100% 70% after deductible
tests)
Hearing Services 100% 70% after deductible
Physical Medicine $30 copay 70% after deductible

Combined Limit: 30 visits per calendar year
Speech Therapy $30 copay 70% after deductible
Combined Limit: 20 visits per calendar year
Occupational Therapy $30 copay 70% after deductible

Combined Limit: 20 visits per calendar year
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