Hospital and Hospital-Alternative Benefits

The schedule of benefits found on this and the next page is a brief outline of the amounts the Plan will pay for Medically Necessary charges for inpatient Hospital and hospital-alternative care covered under the Plan. (For purposes of this section, hospital alternatives include birthing centers, Skilled Nursing Facilities, rehabilitation facilities, home health care and hospice care.) To fully understand the benefits provided under this Plan, and to confirm that they qualify as Covered Expenses, please refer to Section 9.

Both in- and out-of-network benefits for inpatient Hospital and hospital-alternative services are the same. However, your cost for these services depends upon whether you choose an in-or an out-of-network provider.

If you choose an in-network provider for Hospital or hospital-alternative benefits, the benefits are paid at 100% of Covered Charges, unless otherwise specified. To determine whether the Facility you have chosen to be admitted to is an in-network provider, please refer to network directories found at www.ousdhp.com

If you choose an out-of-network provider, you will be responsible for the following charges:
(1) A $500.00 per admission deductible, and
(2) Any charges that we determine to be in excess of Usual and Customary Charges.

(Note: The out-of-network deductible may be waived, after review, if the admission was the result of an Emergency as defined in this Plan, or if there is no in-network provider within a 50-mile radius of the place in which a Confinement occurs.)

Important: if you will be receiving ANY of the services described in this section, you must notify the appropriate managed benefits coordinator in advance (see Appendix A). Otherwise, you may be responsible to pay up to $500.00 of Covered Expenses, in addition to any other deductible or other payment requirements.

HOSPITAL AND HOSPITAL-ALTERNATIVE BENEFITS

Type of Service:	This Plan Pays (In-Network):
INPATIENT CARE IN A HOSPITAL Covers room and board (semi-private room) and Medically Necessary services and supplies. Call the managed benefits coordinator prior to elective Hospital admissions or, for an emergency, notify the coordinator as soon as reasonably possible or 48 hours after the emergency admission, whichever is longer.	The Covered Charges for 365 days of inpatient care per Confinement. Another 365 days becomes available after you have been out of the Facility for 90 consecutive days. Inpatient care in a Hospital for a mental or nervous condition is limited to 100 days of coverage per calendar year, unless the admission is for treatment of a “biologically based mental illness” as defined in this Plan, or the patient is a “child[ren] with serious emotional disturbances” as defined in this plan, in which case the benefit will be the same as for any Hospital admission for a medical problem. See Sec. 9 for additional details.
BIRTHING CENTER Call the managed benefits coordinator prior to admission.	The Covered Charges.
INPATIENT CARE IN A SKILLED NURSING FACILITY Covers room and board (semi-private room) and Medically Necessary services and supplies. Call the managed benefits coordinator prior to admission to a Skilled Nursing Facility.	The Covered Charges for up to 180 days of Confinement per calendar year. See Sec. 9 for additional information and limitations.
INPATIENT CARE IN A REHABILITATION FACILITY Call the managed benefits coordinator prior to admission to a rehabilitation facility.	The Covered Charges for up to 100 days of Confinement per calendar year. See Sec. 9 for additional information.
HOME HEALTH CARE Call the managed benefits coordinator prior to beginning home health care services.	The Covered Charges for up to 180 visits per calendar year. See Sec. 9 for requirements for coverage.
HOSPICE Call the managed benefits coordinator prior to beginning hospice services.	The Hospice’s Covered Charges. See Sec. 9 for additional information and requirements for coverage.

Hospital Outpatient Benefits. In addition to the benefits described in the preceding schedule, the
following Hospital outpatient services are also covered under the Plan. If services are received innetwork,
you may be responsible to pay up to a $50 per day deductible, depending on the service.
However, if these same services are provided out-of-network, your deductible will be $70 per day. The
out-patient deductible may be reduced if you are forced to utilize an out-of-network provider due to an
Emergency (as defined in this Plan), or if there is no in-network Hospital within a 50-mile radius of the
Hospital in which you are treated.

HOSPITAL OUTPATIENT BENEFITS

Type of Service:	The Plan Pays:
EMERGENCY MEDICAL TREATMENT	The Covered Charges, following a $50 in-network or $70 out-of-network deductible, per day. (Deductible may be waived if the patient is admitted directly to the Hospital.) See Sec. 9 for more information.
DIAGNOSTIC X-RAYS AND LABORATORY TESTING, INCLUDING CERVICAL CYTOLOGY SCREENING	The Covered Charges, following a $35 in-network or $70 out-of-network deductible, per day. See Sec. 9 for more information.
PRE-ADMISSION TESTING	The Covered Charges. See Sec. 9 for more information
PHYSICAL THERAPY	The Covered Charges, following a $35 in-network or $70 out-of-network deductible, per day. See Sec. 9 for more information.
HEMODIALYSIS CHEMOTHERAPY RADIATION THERAPY	The Covered Charges.
ROUTINE (SCREENING) MAMMOGRAMS	The Covered Charges.

Medical Expense Benefits

If you have a medical expense that is not covered as a Hospital or hospital-alternative benefit, it may be covered as a Medical Expense Benefit. Examples of medical expense benefits would be office visits to your Professional Provider for care and treatment. See Section 9 for a detailed description of your medical expense benefits under the Plan.

In-Network Medical Expense Benefits. Like Hospital Expense Benefits, your choice of an in- or out-ofnetwork Professional Provider determines your cost for medical services or supplies. If you choose to go to an in-network Professional Provider for primary or specialized care, your co-pay will be $15 per visit/service. To determine whether the Professional Provider you have chosen is an in-network provider, please refer to the network directories found at www.ousdhp.com.

Out-of-Network Medical Expense Benefits. If you use an out-of-network (OON) provider, rather than in-network provider, you will be responsible for the $15.00 co-pay for visits to the provider, as well as annual deductibles and co-insurance payments explained below (up to a yearly out-of-pocket maximum payment.) OON co-pays do not accumulate toward the out-of-pocket maximum.

Out-of-Network Deductibles, Co-insurance and Out-of-Pocket Maximums. If you receive care from an out-of-network provider, you are responsible for a deductible payment each calendar year before the Plan will pay any benefits at all on your behalf. The calendar year deductible is $300.00 per person if you have individual overage or $800.00 per year if you have family coverage. Any expenses incurred in the last three months of a calendar year will be carried over into the next year, and applied toward your deductible obligation for the following year. After you have satisfied the yearly deductible, you and the Plan share the cost of Covered Services, up to a specified out-of-pocket maximum. Your co-insurance obligation is payment of 20% of the first $5,000.00 of Covered Expenses (or $1,000.00 maximum) in a calendar year if you have individual coverage. If you have family coverage, you will pay 20% of the first $9,000.00 of Covered Expenses up to a maximum payment of $1,800.00 in a calendar year. Once you reach the maximum out-of-pocket payment, the Plan will pay 100% of any additional Covered Charges for that calendar year. Remember, deductibles and co-insurance obligations are in addition to the $15 co-pay per visit or service for out-of-network providers. Also, charges incurred for outpatient mental health services and treatment, deductibles & penalties resulting from failure to comply with the Managed Benefits Program requirements, as well as out-of-network co-pays are separate and not included in the co-insurance maximum. The maximum the Plan will pay for your medical expense benefits in a calendar year is $500,000.00 per person, except for mental health and/or substance abuse treatment and/or Qualified Infertility Procedures, which have separate maximum benefits (See Section 9). However, your lifetime benefits are unlimited.

In-Network Providers to whom Out-of-Network Charges Apply. A few benefits provided under this Plan do require that you pay deductibles, etc., even though the Professional Provider may actually be part of a network of providers listed in Appendix A. The table below shows those benefits that are subject to out-of-network deductibles, co-insurance and out-of-pocket maximums, even though the provider is part of a network.

In-Network Providers to Whom Out-of-Network Charges Apply.

Home Infusion or Intravenous Services Durable Medical Equipment and Supplies Non-hospital Occupational Therapy Speech Therapy All providers eligible under the Plan not specifically identified above as in-network providers of service.

You are responsible for all out-of-network deductibles, as well as coinsurance, co-pay per visit or service, and other limits, even though these providers may be innetwork.