Page 45 - Cover Letter & Evaluation for Patricia Letizia

10/12/2018
Inpatient hospital coverage
Outpatient hospital coverage
Doctor visits
Preventive care
Emergency care/Urgent care
Diagnostic procedures/lab
services/imaging
Mental health services
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5525&plnid=004&sgmntid=0#plan_benefits 2/5
Your Medicare Health Plan Details
In-Network: $295 per day for days 1 through 6
$0 per day for days 7 through 90
$0 per day for days 91 and beyond
Out-of-Network: 50% per stay
In-Network: $250 per visit
Out-of-Network: 50% per visit
Primary:
In-Network: $5 per visit
Out-of-Network: 50% per visit
Specialist:
In-Network: $40 per visit
Out-of-Network: 50% per visit
In-Network: $0 copay
Out-of-Network: $0 or 50%
Emergency: $90 per visit (always covered)
Urgent care: $5-40 or 50% per visit (always covered)
Diagnostic tests and procedures:
In-Network: $0-90
Out-of-Network: 50%
Lab services:
In-Network: $0-40
Out-of-Network: 50%
Diagnostic radiology services (e.g., MRI):
In-Network: $40-250
Out-of-Network: 50%
Outpatient x-rays:
In-Network: $5-90
Out-of-Network: 50%
Inpatient hospital - psychiatric:
In-Network: $265 per day for days 1 through 6
$0 per day for days 7 through 90
Out-of-Network: 50% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network: $40
Out-of-Network: 50%
Outpatient individual therapy visit with a psychiatrist:
In-Network: $40
Out-of-Network: 50%
Outpatient group therapy visit:
In-Network: $40
Out-of-Network: 50%
Outpatient individual therapy visit:
In-Network: $40
Out-of-Network: 50%