Page 29 - Benefits-Guide-2020

MEDICAL PLANS | Summary of Benefits | Continued
Supplement-Type Standard Plan
Supplement-Type Enhanced Plan
Medicare Advantage Standard Plan
Medicare Advantage Enhanced Plan
$0 copay until 365 days, member pays 100%
of all charges beyond 365 days.
$0 copay until 365 days, member pays 100%
of all charges beyond 365 days.
$250 copay per day for days 1-5 per admission; then covered 100% by the plan.
No limit to the number of days covered by
the plan. $0 copay
for physician services received while
an inpatient during a hospital stay.
$95 copay per day for days 1-5 per admission; then covered 100% by the plan.
No limit to the number of days covered by
the plan. $0 copay
for physician services received while
an inpatient during a hospital stay.
10% coinsurance.
Member pays $0.
Surgical: $100 copay for each outpatient hospital facility or ambulatory surgical center visit
for surgery.
Non-surgical: $5 copay for a visit to a primary care physician in an outpatient hospital setting/clinic for non-surgical services.
$40 copay for a visit to a specialist in an outpatient hospital setting/clinic for non-surgical services including radiation therapy.
For both surgical
and non-surgical: $100 copay for each outpatient observation room visit.
Surgical: $100 copay for each outpatient hospital facility or ambulatory surgical center visit
for surgery.
Non-surgical: $10 copay for a visit to a primary care physician in an outpatient hospital setting/clinic for non-surgical services.
$25 copay for a visit to a specialist in an outpatient hospital setting/clinic for non-surgical services including radiation therapy.
For both surgical
and non-surgical: $100 copay for each outpatient observation room visit.
Unless otherwise noted: For the Medicare Advantage Standard Plan, members must meet their calendar-year deductible for all Part A and Part B covered services before their copayment or coinsurance will apply. For the Supplement-Type Standard Plan, members have no deductible to meet for Part A services, but for Part B services, members must meet their calendar-year deductible before their coinsurance will apply.
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OUTPATIENT HOSPITAL COVERAGE INPATIENT HOSPITAL COVERAGE