18 Benefits In-Network Out-of-Network 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 • Skilled Nursing Facility / Rehabilitation Services (Includes Services in an Outpatient Day Rehabilitation Program) Benefit Maximum Combined 100 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 Maternity and Reproductive Health Services • Maternity Visits (Global fee for the ObGyn’s prenatal, postnatal, and delivery services) 20% Coinsurance after Deductible 40% 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.