CHCGA - Coventry Health Care of Georgia

HEALTH PLANS COMPARISONSUMMARY HMO PLAN PATIENT DRIVEN HEALTH PLANGHS ASO Network You Pay Coventry In Network You Pay Coventry Out of Network You Pay*In Network You PayMental Health &Chemical DependencySpecialist physician office $40 per visit $60 per visit 10% after HRA dollars and 40% after HRA dollarsvisit (outpatient) limited to 30 deductible met and deductible metvisits/plan yearInpatient care (up to 30 $300 per admission $600 per admission 10% after HRA dollars and 40% after HRA dollarsdays/plan year) deductible met and deductible metInpatient residential $300 per admission $600 per admission 10% after HRA dollars and 40% after HRA dollarstreatment (up to 90 deductible met and deductible metdays/plan year)Outpatient facility care $40 per visit $60 per visit 10% after HRA dollars and 40% after HRA dollarsspecialist (up to 30 deductible met and deductible metvisits/plan year). Outpatientevening program and partialhospital program (up to 90days/plan year).Alcoholism and chemical dependency treatment is limited to $25,000 lifetime maximum.Home Health CareHome health care services $30 per visit $50 per visit 10% after HRA dollars 40% after HRA dollarsincluding home visits by a and deductible met and deductible metnurse; physical, respiratory,or occupational therapist; orhospice care in the home byhome health care providers(combined maximum of 100visits/plan year).• Hospice outpatient $30 per visit $50 per visit 10% after HRA dollars 40% after HRA dollarsoffice visit and deductible met and deductible met• Home visits by plan $30 per visit $50 per visit 10% after HRA dollars 40% after HRA dollarsphysician and deductible met and deductible met• Home IV therapy (after No charge No charge 10% after HRA dollars 40% after HRA dollarsinitial setup) and deductible met and deductible metShort-termRehabilitationTherapy (Outpatient)Rehab therapy by a $25 per visit $40 per visit 10% after HRA dollars 40% after HRA dollarsphysical, occupational, and deductible met and deductible metrespiratory, or speechtherapist for asingle illness or injury(limited to 20 medicallynecessary office visitsper condition per plan year)Reconstructive SurgeryInpatient or outpatient Inpatient: Inpatient: 10% after HRA dollars 40% after HRA dollarssurgery to repair or alleviate $300 per admission $600 per admission and deductible met and deductible metbodily damage caused byillness or injury that occurred Outpatient: Outpatient:to a member while covered $200 per surgery $400 per surgeryby this plan, within 12months of the illness orinjury and reconstructivesurgery incidental to amastectomy.Emergency ServicesEmergency room services $150 per visit $150 per visit 10% after HRA dollars 40% after HRA dollarswhen medically necessary and deductible met and deductible met(waived if admitted within24 hours)Urgent care facilities $50 per visit $50 per visit 10% after HRA dollars 40% after HRA dollarswhen medically necessary and deductible met and deductible metAmbulance for emergency No charge No charge 10% after HRA dollars 40% after HRA dollarsservices and deductible met and deductible met* Patient Driven Health Plan out-of-network benefits pay at 60% of the out-of-network rate after the deductible has been met.Your provider may charge you more than the out-of network rate. You will be responsible for any charges over the out-ofnetworkrate and these charges will not apply to your deductible, coinsurance maximum or maximum out-of-pocket.9