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Floyd County Productions
Effective Date: 08-01-2017
Aetna Health Network Option
SM
- Georgia
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA HEALTH INC. AND AETNA HEALTH INSURANCE COMPANY - FULL RISK
Diagnostic X-ray for Complex
Imaging Services
20%; after deductible
40%; after deductible
EMERGENCY MEDICAL CARE
IN-NETWORK
OUT-OF-NETWORK
Urgent Care Provider
$75 copay; deductible waived
40%; after deductible
Non-Urgent Use of Urgent Care
Provider
Not Covered
Not Covered
Emergency Room
$200 copay; deductible waived
Refer to participating provider benefit.
Copay waived if admitted
Non-Emergency Care in an
Emergency Room
Not Covered
Not Covered
Emergency Use of Ambulance
$200 copay; deductible waived
Refer to participating provider benefit.
Non-Emergency Use of Ambulance
Not Covered
Not Covered
HOSPITAL CARE
IN-NETWORK
OUT-OF-NETWORK
Inpatient Coverage
20%; after deductible
40%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Inpatient Maternity Coverage
(includes delivery and postpartum
care)
$50 for Physician Maternity Services;
deductible waived; 20% for Facility
Services; after deductible
40% for Physician Maternity Services;
after deductible; 40% for Facility
Services; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Outpatient Hospital
20%; after deductible
40%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
MENTAL HEALTH SERVICES
IN-NETWORK
OUT-OF-NETWORK
Inpatient
20%; after deductible
40%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Outpatient
$50 copay; deductible waived
40%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
SUBSTANCE ABUSE
IN-NETWORK
OUT-OF-NETWORK
Inpatient Detoxification
20%; after deductible
40%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Outpatient Detoxification
$50 copay; deductible waived
40%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
Inpatient Rehabilitation
20%; after deductible
40%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Residential Treatment Facility
20%; after deductible
40%; after deductible
Outpatient Rehabilitation
$50 copay; deductible waived
40%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
OTHER SERVICES
IN-NETWORK
OUT-OF-NETWORK
Skilled Nursing Facility
20%; after deductible
40%; after deductible
Limited to 60 days; per calendar year
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Home Health Care
Covered 100%; after deductible
40%; after deductible
Limited to 60 visits; per calendar year
Limited to 3 intermittent visits per day by a participating home health care agency; 1 visit equals a period of 4 hrs or
less.
Hospice Care - Inpatient
Covered 100%; after deductible
40%; after deductible
Your cost sharing applies to all covered benefits incurred during your inpatient stay.
Hospice Care - Outpatient
Covered 100%; after deductible
40%; after deductible
Your cost sharing applies to all covered benefits incurred during your outpatient visit.
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