Page 86 - Cover Letter and Evaluation for Amy Prack
P. 86
Mental health services Inpatient hospital - psychiatric:
In-Network: $495 per day for days 1 through 3
$0 per day for days 4 through 90
Out-of-Network: $495 per day for days 1 through 3
$0 per day for days 4 through 90
Outpatient group therapy visit with a psychiatrist:
In-Network: $40
Out-of-Network: $40
Outpatient individual therapy visit with a psychiatrist:
In-Network: $40
Out-of-Network: $40
Outpatient group therapy visit:
In-Network: $40
Out-of-Network: $40
Outpatient individual therapy visit:
In-Network: $40
Out-of-Network: $40
Skilled Nursing Facility
In-Network: $0 per day for days 1 through 20
$172 per day for days 21 through 100
Out-of-Network: $0 per day for days 1 through 20
$172 per day for days 21 through 100
Rehabilitation services Occupational therapy visit:
In-Network: $40 or 20%
Out-of-Network: $40 or 20%
Physical therapy and speech and language therapy visit:
In-Network: $40 or 20%
Out-of-Network: $40 or 20%
Ground ambulance
In-Network: 20%
Out-of-Network: 20%
Transportation Not covered
Foot care (podiatry services) Foot exams and treatment:
In-Network: $50
Out-of-Network: $50
Routine foot care: Not covered
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen):
In-Network: 19% per item
Out-of-Network: 19% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network: 20% per item
Out-of-Network: 20% per item
Diabetes supplies:
In-Network: $0 or 20% per item
Out-of-Network: $0 or 20% per item
