GHI Direct Pay HMO - Plan Details

Inpatient Hospital Services*	In Network	Out of Network
Hospital Coverage	Covered in full.after $500 copay per admission	Not Covered
Skilled Nursing	Covered in full	Not Covered
Hospice Care	Covered in full.after $500 copay (210 days)	Not Covered
Outpatient Hospital Services*	In Network	Out of Network
Ambulatory Surgery	Covered in full after $75 copoay	Not Covered
Home Health Care	Copayment (200 visit limit)	Not Covered
Medical Services	In Network	Out of Network
Home and Office Visits	Copayment	Not Covered
Chiropractic Care	Not Covered	Not Covered
Physical Therapy, Osteopathic Manipulation, Occupational Therapy	OP subject to copayment	Not Covered
Speech Therapy	Not Covered	Not Covered
Well-baby and Well-child Care up to Age 19	Covered in full	Not Covered
Lab and Radiology Services	In Network	Out of Network
Diagnostic Lab Tests and Radiology Procedures	Copayment	Not Covered
Emergency Services	In Network	Out of Network
Emergency Facility Charge (Waived if Admitted)	$50 copay, waived if admitted	$50 copay, waived if admitted
Mental Health and Chemical Dependency Services*	In Network	Out of Network
Inpatient Mental Health	30 days combined with inpatient detox. Covered in full after $500 copayment	Not covered
Outpatient Mental Health	30 visits for regular treatment and 3 visits for crisis intervention. 10 % coinsurance	Not Covered
Pharmacy	In Network	Out of Network
Pharmacy	This plan includes in -network Pharmacy Benefits	Not Covered

*Services may be subject to Precertification or Pre-authorization.

The benefits described here are only brief highlights of the coverage available. Some benefits may have calendar year limits and/or maximums. The terms, limitations, conditions, and exclusions of the insurance contract and certificate will govern.