|
Basic Health Insurance Summary |
|
Health Benefits |
Value Plan pays: |
Enhanced Plan pays: |
|
Doctor’s Office Visits
For treatment of injury or sickness up to five visits per covered
person per calendar year, one of which may be used for wellness
care. |
$30
Per Visit |
$65
Per Visit |
|
Diagnostic Testing or X-ray
Up to three medically necessary diagnostic tests and x-rays
performed in a doctor’s office or outpatient facility. One may be
for wellness purposes. |
$30
Per Visit |
$65
Per Visit |
|
Child Wellness Visits
Benefits payable for routine well child care doctor visits at eleven
specified age intervals from birth to age five. Well child care
includes physical exams, laboratory tests, immunizations, vision
screenings and hearing screenings. |
$30
Per Visit |
$65
Per Visit |
|
Hospitalization |
|
|
|
Regular Inpatient Stay
A maximum of 100 days per confinement. |
$100
Per Day |
$300
Per Day |
|
ICU/CCU
A maximum of 30 days per confinement. |
$200
Per Day |
$600
Per Day |
|
Mental Illness
A maximum of 30 days per confinement. |
$50
Per Day |
$150
Per Day |
|
Alcohol and Substance Abuse
A maximum of 30 days per confinement. |
$50
Per Day |
$150
Per Day |
|
Convalescent Facility
Confinement must begin within three days of a hospitalization stay
of at least three days. A maximum of 60 days per confinement. |
$50
Per Day |
$150
Per Day |
|
Emergency Room
Applicable for emergency room visits when patient is not confined to
the hospital. Two visits each for injury or sickness per calendar
year. |
$100
Per Visit |
$300
Per Visit |
|
Surgery
Limited to one inpatient and one outpatient surgery per calendar
year. |
|
|
|
Inpatient
Surgery |
$500
Per Visit |
$2000
Per Visit |
|
Outpatient
Surgery |
$200
Per Visit |
$800
Per Visit |
|
Survivor Benefit
Dependent coverage continues – premium free – following an insured
employee’s death for up to 18 months. |
Included |
Included |