20 Benefits In - Network Out - of - Network Infertility Services See “Maternity and Reproductive Health Services.” Inpatient Services Facility Room & Board Charge: • Hospital / Acute Care Facility 10% Coinsurance after Deductible 30% Coinsurance after Deductible • 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 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Residential Treatment Center 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Ancillary Services 10% Coinsurance after Deductible 30% Coinsurance after Deductible Doctor Services for: • General Medical Care / Evaluation and Management (E&M) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Surgery 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Maternity 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Mental Health / Substance Use Disorder Services 10% Coinsurance after Deductible 30% Coinsurance after Deductible Maternity and Reproductive Health Services • Maternity Visits (Global fee for the ObGyn’s prenatal, postnatal, and delivery services) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Inpatient Facility Services (Delivery) See “Inpatient Services” Newborn / Maternity Stays: If the newborn needs services other than routine nursery care or stays in the Hospital after the mother is discharged (sent home), benefits for the newborn will be treated as a separate admission.