$50 copay/visit then 10% $50 copay/visit then 10% Copay waived if admitted or for an accidental Emergency room care coinsurance coinsurance injury. If you need immediate Emergency medical 10% coinsurance 10% coinsurance Mileage limits apply. medical attention transportation Urgent care 10% coinsurance 30% coinsurance None Facility fee (e.g., hospital 10% coinsurance 30% coinsurance Preauthorization is required. room) If you have a hospital stay Physician/surgeon fee 10% coinsurance 30% coinsurance None 30% coinsurance for Mental $20 copay/visit; deductible Your cost share may be different for services Outpatient services Health; 10% coinsurance for If you need mental health, does not apply performed in an office setting. substance abuse behavioral health, or substance use disorder 30% coinsurance for Mental services Inpatient services 10% coinsurance Health; 10% coinsurance for Preauthorization is required. substance abuse Maternity care may include services described No charge; deductible does not elsewhere in the SBC (i.e. tests) and cost share Office visits 30% coinsurance apply may apply. Cost sharing does not apply to certain maternity services considered to be preventive. If you are pregnant Childbirth/delivery 10% coinsurance 30% coinsurance None professional services Childbirth/delivery facility 10% coinsurance 30% coinsurance None services Home health care 10% coinsurance 10% coinsurance Preauthorization is required. Physical, Occupational, Speech therapy is limited Rehabilitation services 10% coinsurance 30% coinsurance to a combined maximum of 60 visits per member, per calendar year. If you need help recovering Applied behavioral analysis (ABA) treatment for or have other special health Autism – when rendered by an approved needs Habilitation services 10% coinsurance 30% coinsurance analyst - is covered through age 18, subject to preauthorization. Preauthorization is required. Limited to a maximum Skilled nursing care 10% coinsurance 10% coinsurance of 120 days per member, per calendar year.
If you need immediate medical attention Emergency room care $50 copay/visit then 10% coinsurance $50 copay/visit then 10% coinsurance Copay waived if admitted or for an accidental injury. Emergency medical transportation 10% coinsurance 10% coinsurance Mileage limits apply. Urgent care 10% coinsurance 30% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) 10% coinsurance 30% coinsurance Preauthorization is required. Physician/surgeon fee 10% coinsurance 30% coinsurance None If you need mental health, behavioral health, or substance use disorder services Outpatient services $20 copay/visit; deductible does not apply 30% coinsurance for Mental Health; 10% coinsurance for substance abuse Your cost share may be different for services performed in an office setting. Inpatient services 10% coinsurance 30% coinsurance for Mental Health; 10% coinsurance for substance abuse Preauthorization is required. If you are pregnant Office visits No charge; deductible does not apply 30% coinsurance Maternity care may include services described elsewhere in the SBC (i.e. tests) and cost share may apply. Cost sharing does not apply to certain maternity services considered to be preventive. Childbirth/delivery professional services 10% coinsurance 30% coinsurance None Childbirth/delivery facility services 10% coinsurance 30% coinsurance None If you need help recovering or have other special health needs Home health care 10% coinsurance 10% coinsurance Preauthorization is required. Rehabilitation services 10% coinsurance 30% coinsurance Physical, Occupational, Speech therapy is limited to a combined maximum of 60 visits per member, per calendar year. Habilitation services 10% coinsurance 30% coinsurance Applied behavioral analysis (ABA) treatment for Autism – when rendered by an approved analyst - is covered through age 18, subject to preauthorization. Skilled nursing care 10% coinsurance 10% coinsurance Preauthorization is required. Limited to a maximum of 120 days per member, per calendar year.
aca-summary.docx