Page 80 - Cover Letter & Evaluation for Patricia Letizia

10/11/2018
Mental health services
Skilled Nursing Facility
Rehabilitation services
Ground ambulance
Transportation
Foot care (podiatry services)
Medical equipment/supplies
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5215&plnid=009&sgmntid=0#plan_benefits 3/6
Your Medicare Health Plan Details
Inpatient hospital - psychiatric:
In-Network: $395 per day for days 1 through 3
$0 per day for days 4 through 90
Out-of-Network: $395 per day for days 1 through 4
$0 per day for days 5 through 190
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
In-Network: $0 per day for days 1 through 20
$172 per day for days 21 through 57
$0 per day for days 58 through 100
Out-of-Network: $0 per day for days 1 through 20
$172 per day for days 21 through 57
$0 per day for days 58 through 100
Occupational therapy visit:
In-Network: $40
Out-of-Network: $50
Physical therapy and speech and language therapy visit:
In-Network: $40
Out-of-Network: $50
In-Network: $275
Out-of-Network: $275
Not covered
Foot exams and treatment:
In-Network: $50
Out-of-Network: $55
Routine foot care: Not covered
Durable medical equipment (e.g., wheelchairs, oxygen):
In-Network: 20% per item
Out-of-Network: 25% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network: 20% per item
Out-of-Network: 25% per item
Diabetes supplies:
In-Network: $0 copay
Out-of-Network: $0-10 per item