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Facility fee (e.g.,
If you have a hospital hospital room) 20% coinsurance Not covered None
stay Physician/surgeon
fees No charge Not covered

Common Services You May What You Will Pay Limitations, Exceptions, & Other
Medical Event Need Participating Non-Participating Important
Provider (You will Provider (You will pay Information
pay the least) the most)
If you need $20 copay / office visit
mental health, Outpatient services and No charge for all Not covered
behavioral other outpatient
health, or services None
substance
abuse services Inpatient services 20% coinsurance Not covered

Cost sharing does not apply to certain
Office visits No charge Not covered preventive services. Routine pre-
natal care and first postnatal visit is
Childbirth/delivery covered at No charge. Depending on
If you are pregnant professional services No charge Not covered the type of services, additional
copayments or coinsurance may
Childbirth/delivery apply. Maternity care may include
facility services tests and services described
20% coinsurance Not covered
elsewhere in the SBC (i.e.
ultrasound).
Limited to 100 visits per year. Limit
does not apply to home health visits
If you need help Home health care $20 copay / visit Not covered for rehabilitation and habilitation
recovering or
have other purposes.
special health Rehabilitation services $20 copay / visit Not covered
needs
None
Habilitative services $20 copay / visit Not covered

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