20 Benefits In - Network Out - of - Network Inpatient Services Facility Room & Board Charge: • Hospital / Acute Care Facility $150 Copayment per visit then 10% Coinsurance 30% Coinsurance • Skilled Nursing Facility 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Rehabilitation 10% Coinsurance after Deductible 30% Coinsurance after Deductible Rehabilitation Services (Includes Services in an Outpatient Day Rehabilitation Program) Benefit Maximum Unlimited Skilled Nursing Facility Benefit Maximum 120 days per Benefit Period, In - and Out - of - Network combined • Mental Health / Substance Use Disorder Facility $150 Copayment per visit then 10% Coinsurance 30% Coinsurance • Residential Treatment Center $150 Copayment per visit then 10% Coinsurance 30% Coinsurance • Ancillary Services $150 Copayment per visit then 10% Coinsurance 30% Coinsurance Hospital Transfers: If you are transferred between Facilities, only one Copayment will apply. You will not have to pay separate Copayments per Facility. Hospital Readmissions: If you are readmitted to the Hospital within 72 hours of your discharge for the same medical diagnosis, you will not have to pay an additional Copayment upon readmission. Doctor Services for: • General Medical Care / Evaluation and Management (E&M) $40 Copayment per visit then 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Surgery $40 Copayment per visit then 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Maternity $40 Copayment per visit then 10% Coinsurance after Deductible 30% Coinsurance after Deductible