Noblesville Schools Medical Plan 17 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Same as Network Does the Annual Deductible Apply? Yes Same as Network admission if reasonably possible. The Claims Administrator may elect to transfer you to a Network Hospital as soon as it is medically appropriate to do so. If you choose to stay in the out-of-Network Hospital after the date the Claims Administrator decides a transfer is medically appropriate, Network Benefits will not be provided. Out-of-Network Benefits may be available if the continued stay is determined to be a Covered Health Care Service. If you are admitted as an inpatient to a Hospital directly from the Emergency room, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Copayment, Coinsurance and/or deductible. Allowed Amounts for Emergency Health Care Services provided by an out-of-Network provider will be determined as described below under Allowed Amounts in this Schedule of Benefits. Enteral Nutrition What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30%