2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 45
AETNA POS PROVIDERS
MEDICAL BENEFITS
Plan Pays
Extended Care Facility/
Rehabilitation Facility
90%
Hearing Aids
100%
Maximum Benefit every 48
months
Home Health Care
Calendar Year Maximum
Benefit
Hospice Care
Hospital Expenses
(facility charges)
Inpatient
90%
10% after
Deductible
120 visits
90%
10% after
Deductible
90%
Semi-private
room rate
(private room
when Medically
Necessary)
Intensive Care Unit
Negotiated Fee
Outpatient
$0 up to
plan limit;
100%
over limit
$2,000 per ear
Room & Board Allowance
Miscellaneous Services &
Supplies
Covered Person
Pays
10% after
Deductible
10% after
Deductible
NON POS PROVIDERS
(Subject to Usual &
Customary Charges)
Plan Pays
Covered Person
Pays
90%
10% 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
70%
30% after
Deductible
120 visits
90%
70%
10% after
Deductible; subject
to POS Out-ofPocket Limits
30% after
Deductible
Semi-private
room rate
(private room
when
Medically
Necessary)
90%
10% after
Deductible
Negotiated
30% after
Deductible
10% after
Deductible
Fee 70%
30% after
Deductible
10% after
Deductible
10% after
Deductible
90%
70%
70%
30% after
Deductible
30% after
Deductible
Maternity
90%
Mental Disorders
Inpatient
90%
10% after
Deductible
70%
30% after
Deductible
Outpatient
Office Visits
100%
$20 Copay;
Deductible waived
70%
30% after
Deductible
90%
10% after
Deductible
70%
30% after
Deductible
All Other Outpatient Care
41