Covered Benefits: Inpatient Services


	Plan's Coinsurance Percentage for In-Network Care	Plan's Coinsurance Percentage for Out-of-Network Care*
Inpatient Services (precertification recommended, please see "Prior Authorization")
Acute Hospital Care (based on hospital's standard rate for semi-private or common rooms, except for isolation of communicable diseases)	80% coverage after deductible	50% coverage after deductible
Hospice Care	80% coverage after deductible	50% coverage after deductible
Mental Health Care	80% coverage after deductible	50% coverage after deductible
Skilled Nursing Facility (includes charges for services and supplies provided while patient is under continuous care and requires 24-hour skilled nursing care and room and board; limited to combined in-network and out-of-network maximum of 365 days/lifetime for each covered individual**)	80% coverage after deductible	50% coverage after deductible
Substance Use Disorder Services	80% coverage after deductible	50% coverage after deductible

* Covered out-of-network expenses are subject to reasonable and customary (R&C) charges. You are responsible for paying any charges above the R&C amount.

** Combined in-network and out-of-network. All out-of-network expenses are subject to reasonable and customary (R&C) charges. You are responsible for paying any charges above the R&C amount. Since in-network charges for covered services have been negotiated with the providers, those charges would always be within the R&C limits.