Page 15 - Empowered Learning for Dyslexic Children Benefits Guide 2022-2023

BlueChoice HMO HSA/HRA Silver 1500 ON/OFF SHOP Summary of Benefits

Services In-Network You Pay 1
DIAGNOSTIC SERVICES​
Labs 7​ ​
■ LabCorp​ Deductible, then $25 per visit​
■ Hospital​ Deductible, then $150 per visit​
X-ray 7​ ​
■ Non-Hospital/Freestanding Facility​ Deductible, then $50 per visit​
■ Hospital​ Deductible, then $200 per visit​
Imaging 7​ ​
■ Non-Hospital/Freestanding Facility​ Deductible, then $250 per visit​
■ Hospital​ Deductible, then $500 per visit​
SURGERY AND HOSPITALIZATION—(Members are responsible for both physician and facility fees)​
Outpatient Surgery (Non-Hospital)​ ​
■ Facility​ Deductible, then $300 per visit​
■ Physician​ Deductible, then $50 per visit​
Outpatient Surgery (Hospital)​ ​
■ Facility​ Deductible, then $500 per visit​
■ Physician​ Deductible, then $50 per visit​
Inpatient Surgery and Hospital Services​ ​
■ Facility​ Deductible, then $500 per admission​
■ Physician​ Deductible, then $50 per visit​
HOSPITAL ALTERNATIVES​
Home Health Care​ No charge* after deductible​
Hospice​ No charge* after deductible​
Skilled Nursing Facility​ Deductible, then $50 per admission​
(limited to 100 days/benefit period)​
MATERNITY​
Preventive Prenatal and Postnatal Office Visits​ No charge*​
Delivery and Facility Services​ Deductible, then $500 per admission​
Artificial and Intrauterine Insemination 5,8​ Deductible, then $25 per visit​
In Vitro Fertilization Procedures 5,8​ Not covered​
MENTAL HEALTH AND SUBSTANCE USE DISORDER—(Members are responsible for both physician and facility fees)​
Office Visits​ Deductible, then $25 per visit​
Outpatient Services​ ​
■ Facility​ Deductible, then $50 per visit​
■ Physician​ Deductible, then $50 per visit​
Inpatient Services​ ​
■ Facility​ Deductible, then $500 per admission​
■ Physician​ Deductible, then $50 per visit​
MEDICAL DEVICES AND SUPPLIES​
Durable Medical Equipment​ Deductible, then 25% of Allowed Benefit​
Hearing Aids​ Deductible, then 25% of Allowed Benefit​
(limited to one hearing aid per​
hearing-impaired ear every 36 months)​

SUM5569-1P (9/21) ■ MD ■ 2022 2-50 ACA Compliant (Can be sold as HDHP)​