19 Benefits In - Network Out - of - Network • Outpatient Hospice 0% Coinsurance after Deductible 0% Coinsurance after Deductible • Respite Care 0% Coinsurance after Deductible 0% Coinsurance after Deductible Human Organ and Tissue Transplant (Bone Marrow / Stem Cell) Services Please see the separate summary later in this section. Inpatient Services Facility Room & Board Charge: • Hospital / Acute Care Facility 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Skilled Nursing Facility 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Rehabilitation 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Rehabilitation Services (Includes Services in an Outpatient Day Rehabilitation Program) Benefit Maximum Unlimited • Skilled Nursing Facility Benefit Maximum 9 0 days per Benefit Period , In - and Out - of - Network combined • Mental Health / Substance Use Disorder Facility 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Residential Treatment Center 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Ancillary Services 20% Coinsurance after Deductible 40% Coinsurance after Deductible Doctor Services for : • General Medical Care / Evaluation and Management (E&M) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Surgery 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Maternity 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Mental Health / Substance Use Disorder Services 20% Coinsurance after Deductible 40% Coinsurance after Deductible