Page 39 - Demo

MEDICARE ADVANTAGE MEDICAL PLANS | Summary of Benefits | Continued
Medicare Advantage Standard Plan
Medicare Advantage Enhanced Plan
Medicare Advantage Enhanced Plus
$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.
10% coinsurance.
Your provider must obtain prior plan approval for intensive outpatient mental health services or partial hospitalization for mental health.
$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.
$0 copay per admission
No limit to the number of days covered by the plan.
$0 copay for physician services received while an inpatient during a hospital stay.
$5 copay per visit to a Primary Care Physician (PCP) or retail health clinic.
$40 copay per visit to a specialist.
$10 copay per visit to a Primary Care Physician (PCP) or retail health clinic.
$25 copay per visit to a specialist.
10% coinsurance per visit to a Primary Care Physician (PCP) or retail health clinic.
10% coinsurance per visit to a specialist.
*Hearing services refer to Medicare-covered basic diagnostic hearing and balance exams; to determine if you need medical treatment, and these services are furnished by a physician, audiologist, or other qualified provider.
If your Medical Plan has a deductible, it must be met before copayments or coinsurance will apply. See page 42 for details regarding Prescription Drug Plan deductible, copays and coinsurance.
Insurance Trust For Delta Retirees | 2021 Benefits & Resources Guide | 39
HEARING MENTAL HEALTH: MENTAL HEALTH: SERVICES* INPATIENT OUTPATIENT