| Benefits |
Current PPO |
Current Mental Health Benefits |
Holman Federal Parity Compliant Plan |
Mental Health Substance Abuse |
| In-Network |
Out-of-Network |
|
In- Network |
Out-of- Network |
|
| In-Network |
Out-of-Network |
|
| Outpatient |
| $15/visit, no deductible |
20% co-insurance after deductible |
|
$20 visit |
30% of UCR, $75 UCR/visit, 30 visits/year |
|
| $15/visit, no deductible |
20% co-insurance after deductible |
|
| Subacute-100 days/calendar year |
| 10% co-insurance after deductible |
30% co-insurance after deductible |
|
|
| 10% co-insurance after deductible |
30% co-insurance after deductible |
|
| Inpatient |
| 10% co-insurance after deductible |
30% co-insurance after deductible |
|
20% copay
|
30% of UCR, $250 deductible per admission |
|
| 10% co-insurance after deductible |
30% co-insurance after deductible |
|
| Emergency Room |
| $100/visit, no deductible, waived if admitted or for observation stay |
|
$100 copay/day, waived if admitted
|
|
| $100/visit, no deductible, waived if admitted or for observation stay |
|
| Deductible |
| $250/person, $500/family for in-network and out-of-network combined |
|
|
| $250/person, $500/family for in-network and out-of-network combined |
|
| Annual Maximum |
Subacute 100 days per year
|
|
50 outpatient visits/year, 45 subacute and inpatient days/year combined mental health, in and out of network |
|
Subacute 100 days per year combined (in and out of network) |
|
| Lifetime Maximum |
|
| N/A |
2 courses substance abuse treatment per lifetime |
|
|
| Out-of-Pocket Maximum |
| $5,000/person, $10,000/family for in-network and out-of-network services combined |
|
|
| $5,000/person, $10,000/family for in-network and out-of-network services combined |
|
| Ambulance |
| Covered by medical |
Covered by medical |
|
|
| Covered by medical |
Covered by medical |
|