CONTENT: Outpatient and Inpatient Services
Services | In-Network Costs | Out-of-Network Costs | Notes |
|---|---|---|---|
Outpatient Surgery | |||
Facility fee (e.g., ambulatory surgery center) | 20% coinsurance | 40% coinsurance | |
Provider/surgeon fees | 20% coinsurance | 40% coinsurance | |
Immediate Medical Attention | |||
Emergency room care | $50 copay/1st visit; $200 copay/each additional visit plus 20% coinsurance | $50 copay/1st visit; $200 copay/each additional visit plus 20% coinsurance | Copayment waived if admitted. |
Emergency medical transportation | 20% coinsurance | 40% coinsurance | |
Urgent care | 20% coinsurance | 40% coinsurance | |
Hospital Stay | |||
Facility fee (e.g., hospital room) | 20% coinsurance | 40% coinsurance | Prior approval required to avoid penalty. |
Provider/surgeon fees | 20% coinsurance | 40% coinsurance | |
Mental Health, Behavioral Health, or Substance Abuse Services | |||
Outpatient services | 20% coinsurance | 40% coinsurance | Prior approval required to avoid penalty. |
Inpatient services | 20% coinsurance | 40% coinsurance |