Rehabilitation Program) Benefit Maximum Combined • Mental Health / 20% Coinsurance after $500 Copayment per 50% Coinsurance after Substance Use Deductible admission then 40% Deductible Disorder Facility Coinsurance after Deductible • Residential 20% Coinsurance after $500 Copayment per 50% Coinsurance after Treatment Center Deductible admission then 40% Deductible Coinsurance after Deductible • Ancillary Services 20% Coinsurance after $500 Copayment per 50% Coinsurance after Deductible admission then 40% Deductible 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 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Care/Evaluation Deductible Deductible Deductible and Management (E&M) • Surgery 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Deductible Deductible Deductible • Maternity 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Deductible Deductible Deductible • Mental Health / 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Substance Use Deductible Deductible Deductible Disorder Services Maternity and Reproductive Health Services • Maternity Visits 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after (Global fee for the Deductible Deductible Deductible ObGyn’s prenatal, postnatal, and The Office Visit delivery services) Copayment will also apply to the first prenatal visit. • Inpatient Facility See “Inpatient Services” Services (Delivery) 21