Hospital, Mental Health, and Pregnancy Services
Common Medical Event | Services You May Need | In-Network Provider (You pay less) | Out-of-Network Provider (You pay more) | Limitations and Important Information |
|---|---|---|---|---|
Hospital Stay | Facility fee | 20% coinsurance | 40% coinsurance | Prior approval needed to avoid penalty. $500 penalty for no approval. $250 penalty if approved late. |
Provider/surgeon fees | 20% coinsurance | 40% coinsurance | ||
Mental Health | Outpatient services | 20% coinsurance | 40% coinsurance | Prior approval needed to avoid penalty. $500 penalty for no approval. $250 penalty if approved late. |
Inpatient services | 20% coinsurance | 40% coinsurance | Preventive services exempt from cost sharing. Limitations on frequency. Prenatal/postnatal not covered for dependents. | |
Pregnancy | Office visits | 20% coinsurance | 40% coinsurance | |
Childbirth/delivery professional services | 20% coinsurance | 40% coinsurance | Delivery expenses not covered for dependent children. No charge for employees and spouses completing the Maternity Management Program. | |
Childbirth/delivery facility services | 20% coinsurance | 40% coinsurance |