2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 41
AETNA POS PROVIDERS
MEDICAL BENEFITS
Plan Pays
Extended Care
Facility/ Rehabilitation
Facility
80%
Hearing Aids
100%
Maximum Benefit every
48 months
80%
Calendar Year
Maximum Benefit
Hospice Care
120 visits
80%
Room & Board Allowance
Intensive Care Unit
Miscellaneous Services
& Supplies
$0 up to
plan limit;
100% over
limit
$2,000 per ear
Home Health Care
Hospital Expenses
(facility
charges)
Inpatient
Covered Person
Pays
20% after
Deductible
20% after
Deductible
20% after
Deductible
20% after
Deductible
80%
Semi-private
room rate
(private room
when
Medically
Necessary)
Negotiated
Fee
60%
20% after
Deductible; subject
to POS Out-ofPocket Limits
40% after
Deductible
20% after
Deductible
Negotiated
40% after
Deductible
20% after
Deductible
Fee 60%
40% after
Deductible
20% after
Deductible
60%
40% after
Deductible
80%
Maternity
80%
80%
Mental Disorders
Inpatient
20% after
Deductible
60%
40% after
Deductible
80%
20% after
Deductible
60%
40% after
Deductible
100%
$25 Copay;
Deductible waived
20% after
Deductible
60%
40% after
Deductible
40% after
Deductible
80%
All Other Outpatient Care
120 visits
80%
Semi-private
room rate
(private room
when
Medically
Necessary)
Outpatient
Outpatient
Office
Visits
NON POS PROVIDERS
(Subject to Usual &
Customary Charges)
Plan Pays
Covered Person
Pays
80%
20% after
Deductible; subject
to POS Out-ofPocket Limits
100%
$0 up to
plan limit;
$2,000 per ear
100% over
limit; not
subject to
usual &
customary
charges
60%
40% after
Deductible
37
60%