Page 71 - Evaluation for Dirk Huybrechts

9/12/2017
Ambulance
Doctor's office visits
Durable medical equipment (wheelchairs, oxygen, etc.) In-network: 20% per item
Emergency care
Home health care
Mental health care
Outpatient hospital
Renal dialysis
Inpatient hospital care
Skilled Nursing Facility (SNF)
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https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=125&sgmntid=0#plan_benefits 2/2
Your Medicare Health Plan Details
In-network: $300
Out-of-network: $300
Primary Physician
In-network: $10 per visit
Out-of-network: 40% per visit
Specialist
In-network: $40 per visit
Out-of-network: 40% per visit
Out-of-network: 40% per item
$75 per visit (always covered)
In-network: You pay nothing
Out-of-network: 40%
In-network: $1,500 per stay
Out-of-network: 40% per stay
In-network: $40-225 per visit
Out-of-network: 40% per visit
In-network: 20% per visit
Out-of-network: 20% per visit
In-network: $225 for days 1 through 6
$0 for days 7 through 90
Out-of-network: 40% per stay
In-network: $0 for days 1 through 20
$160 for days 21 through 100
Out-of-network: 40% per stay