Page 167 - Cover Letter and Evaluation for Gary Janke

10/8/2018
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=H7917&plnid=013&sgmntid=0#plan_benefits 2/6
Your Medicare Health Plan Details
In-Network: $260 per day for days 1 through 4
$0 per day for days 5 through 90
Out-of-Network: 50% per stay
In-Network: $260 per visit
Out-of-Network: 50% per visit
Primary:
In-Network: $15 per visit
Out-of-Network: 50% per visit
Specialist:
In-Network: $35 per visit
Out-of-Network: 50% per visit
In-Network: $0 copay
Out-of-Network: 50%
Emergency: $85 per visit (always covered)
Urgent care: $55 per visit (always covered)
Diagnostic tests and procedures:
In-Network: $10-100
Out-of-Network: 50%
Lab services:
In-Network: $0-40 or 20%
Out-of-Network: 50%
Diagnostic radiology services (e.g., MRI):
In-Network: $200
Out-of-Network: 50%
Outpatient x-rays:
In-Network: $15-50
Out-of-Network: 50%
Inpatient hospital - psychiatric:
In-Network: $260 per day for days 1 through 4
$0 per day for days 5 through 90
Out-of-Network: 50% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network: $20
Out-of-Network: 50%
Outpatient individual therapy visit with a psychiatrist:
In-Network: $30
Out-of-Network: 50%
Outpatient group therapy visit:
In-Network: $20
Out-of-Network: 50%
Outpatient individual therapy visit:
In-Network: $30
Out-of-Network: 50%