Page 35 - 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
10% coinsurance.
Member pays $0.
$40 copay for each:
• professional or group therapy visit.
• professional partial hospitalization visit.
$0 copay for each:
• outpatient hospital facility individual or group therapy visit.
• partial hospitalization facility visit.
Your provider must obtain prior plan approval for intensive outpatient mental health services or partial hospitalization for mental health.
$25 copay for each:
• professional or group therapy visit.
• professional partial hospitalization visit.
$0 copay for each:
• outpatient hospital facility individual or group therapy visit.
• partial hospitalization facility visit.
Your provider must obtain prior plan approval for intensive outpatient mental health services or partial hospitalization for mental health.
$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 by the plan 100%.
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 by the plan 100%.
No limit to the number of days covered by
the plan.
$0 copay for physician services received while an inpatient during
a hospital stay.
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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MENTAL HEALTH: INPATIENT MENTAL HEALTH: OUTPATIENT