Page 22 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Covered Health The Amount You Pay The Amount You Pay What are the Limitations
Care Service Network Out-of-Network & Exceptions?
provided, Benefits will stated under each stated under Skilled Nursing
be the same as those Covered Health Care Facility/Inpatient
stated under each Service category in this Rehabilitation Services.
Covered Health Care Schedule of Benefits.
Service category in this
Schedule of Benefits.

Outpatient Network 40% Outpatient therapies:
What Is the 20% • Physical therapy.
Copayment or
Coinsurance You • Occupational
Pay? This May therapy.
Include a
Copayment, • Manipulative
Coinsurance or Treatment.
Both. • Speech therapy.

• Post-cochlear implant
aural therapy.
• Cognitive therapy.

For the above outpatient
therapies:
Limits will be the same as,
and combined with, those
stated under Rehabilitation
Services - Outpatient
Therapy and Manipulative
Treatment.
Does the Amount Network Yes
You Pay Apply to
the Out-of-Pocket Yes
Limit?

Does the Annual Network Yes
Deductible Apply?
Yes

Hearing Aids
What Is the Network 40% Limited to $1,000 every
Copayment or year.
Coinsurance You None
Pay? This May
Include a
Copayment,
Coinsurance or
Both.
Does the Amount Network Yes
You Pay Apply to
Yes

19 Schedule of Benefits Plan Set 008