Page 65 - Cover Letter & Evaluation for Patricia Letizia

10/11/2018
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=H5521&plnid=150&sgmntid=0#plan_benefits 2/6
Your Medicare Health Plan Details
In-Network: $280 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-Network: $420 per day for days 1 through 7
$0 per day for days 8 through 90
In-Network: $30-250 per visit
Out-of-Network: 50% per visit
Primary:
In-Network: $0 copay
Out-of-Network: $20 per visit
Specialist:
In-Network: $30 per visit
Out-of-Network: $50 per visit
In-Network: $0 copay
Out-of-Network: 0-50%
Emergency: $90 per visit (always covered)
Urgent care: $0-30 per visit (always covered)
Diagnostic tests and procedures:
In-Network: $75
Out-of-Network: 50%
Lab services:
In-Network: $5
Out-of-Network: $20
Diagnostic radiology services (e.g., MRI):
In-Network: $0-200
Out-of-Network: 50%
Outpatient x-rays:
In-Network: $20
Out-of-Network: 50%
Inpatient hospital - psychiatric:
In-Network: $315 per day for days 1 through 5
$0 per day for days 6 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%