Your cost* if you use a Common Medical Services You May Need Limitations & Exceptions In-Network Out-of-Network Event Provider Provider -- Coverage is limited to 60 visits per benefit period for Rehabilitation and Habilitation Habilitation services 20% Coinsurance 40% Coinsurance services combined for OT/PT and 30 visits per benefit period for Speech Therapy -- Coverage is limited to 100 visits Skilled nursing care 20% Coinsurance 40% Coinsurance per benefit period.-- Precertification required -- authorization may be required Durable medical equipment 20% Coinsurance 40% Coinsurance for benefits to be provided-- Limits may apply Hospice services 20% Coinsurance 20% Coinsurance -- Precertification may be required Excluded Eye exam Not Covered Not Covered If your needs dental or eye care Glasses Not Covered Not Covered Excluded Dental Not Covered Not Covered Excluded *HSA/HRA funds, if available, may be used to cover eligible medical expenses
Common Medical Event Services You May Need Your cost* if you use a Limitations & Exceptions In-Network Provider Out-of-Network Provider Habilitation services 20% Coinsurance 40% Coinsurance -- Coverage is limited to 60 visits per benefit period for Rehabilitation and Habilitation services combined for OT/PT and 30 visits per benefit period for Speech Therapy Skilled nursing care 20% Coinsurance 40% Coinsurance -- Coverage is limited to 100 visits per benefit period.-- Precertification required Durable medical equipment 20% Coinsurance 40% Coinsurance -- authorization may be required for benefits to be provided-- Limits may apply Hospice services 20% Coinsurance 20% Coinsurance -- Precertification may be required If your needs dental or eye care Eye exam Not Covered Not Covered Excluded Glasses Not Covered Not Covered Excluded Dental Not Covered Not Covered Excluded *HSA/HRA funds, if available, may be used to cover eligible medical expenses
Consumer%20Option%20HSA.docx