20 Rehabilitation Program) Benefit Maximum Combined Mental Health / Substance Use Disorder Facility 20% Coinsurance after Deductible $500 Copayment per admission then 40% Coinsurance after Deductible 50% Coinsurance after Deductible Residential Treatment Center 20% Coinsurance after Deductible $500 Copayment per admission then 40% Coinsurance after Deductible 50% Coinsurance after Deductible Ancillary Services 20% Coinsurance after Deductible $500 Copayment per admission then 40% Coinsurance after Deductible 50% Coinsurance after Deductible 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 when billed separately from the Facility for: General Medical Care/Evaluation and Management (E&M) 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible Surgery 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible Maternity 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible Mental Health / Substance Use Disorder Services 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible Maternity and Reproductive Health Services Maternity Visits (Global fee for the ObGyns prenatal, postnatal, and delivery services) 20% Coinsurance after Deductible 40% Coinsurance after Deductible The Office Visit Copayment will also apply to the first prenatal visit. 50% Coinsurance after Deductible Inpatient Facility Services (Delivery) See Inpatient Services