Page 79 - Cover Letter & Evaluation for Patricia Letizia
P. 79
10/11/2018 Your Medicare Health Plan Details
Inpatient hospital coverage
In-Network: $395 per day for days 1 through 4
$0 per day for days 5 through 90
Out-of-Network: $395 per day for days 1 through 5
$0 per day for days 6 and beyond
Outpatient hospital coverage
In-Network: $395 per visit
Out-of-Network: $395 per visit
Doctor visits Primary:
In-Network: $10 per visit
Out-of-Network: $20 per visit
Specialist:
In-Network: $45 per visit
Out-of-Network: $55 per visit
Preventive care
In-Network: $0 copay
Out-of-Network: $15
Emergency care/Urgent care Emergency: $90 per visit (always covered)
Urgent care: $45 per visit (always covered)
Diagnostic procedures/lab Diagnostic tests and procedures:
services/imaging In-Network: $20-40
Out-of-Network: $30-50
Lab services:
In-Network: $0-20
Out-of-Network: $30-50
Diagnostic radiology services (e.g., MRI):
In-Network: $40-125
Out-of-Network: $50-140
Outpatient x-rays:
In-Network: $35
Out-of-Network: $30-50
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5215&plnid=009&sgmntid=0#plan_benefits 2/6
