Page 115 - Cover Letter and Evaluation for John

10/9/2018
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=126&sgmntid=0#plan_benefits 2/5
Your Medicare Health Plan Details
In-Network: $225 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-Network: 40% per stay
In-Network: $40-225 per visit
Out-of-Network: 40% per visit
Primary:
In-Network: $10 per visit
Out-of-Network: 40% per visit
Specialist:
In-Network: $40 per visit
Out-of-Network: 40% per visit
In-Network: $0 copay
Out-of-Network: 0-40%
Emergency: $90 per visit (always covered)
Urgent care: $10-40 per visit (always covered)
Diagnostic tests and procedures:
In-Network: $40
Out-of-Network: 40%
Lab services:
In-Network: $40
Out-of-Network: 40%
Diagnostic radiology services (e.g., MRI):
In-Network: 20%
Out-of-Network: 40%
Outpatient x-rays:
In-Network: $40
Out-of-Network: 40%
Inpatient hospital - psychiatric:
In-Network: $1,660 per stay
Out-of-Network: 40% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network: $40
Out-of-Network: 40%
Outpatient individual therapy visit with a psychiatrist:
In-Network: $40
Out-of-Network: 40%
Outpatient group therapy visit:
In-Network: $40
Out-of-Network: 40%
Outpatient individual therapy visit:
In-Network: $40
Out-of-Network: 40%