Inpatient Hospital and Physician Services

MMC Benefits Handbook

What will the Plan pay if I have to go to the hospital?

The Plan pays inpatient hospital charges at:

Up to $950 copay / visit (based on provider and location) for in-network providers and up to $2,850 copay / visit (based on provider and location)for out-of-network providers per admission.

The Plan will cover the cost of a semi-private room. If you use a private room, the Plan will cover the amount up to the semi-private room rate.

You must obtain prior authorization as soon as possible but at least 14 days before you are admitted for a non-emergency hospital stay.

What approvals do I need if I am going into the hospital?

All inpatient services require Pre-Admission Notification if planned, and notification within 24 hours of admission if an emergency.

Does the Plan cover hospital visits by a physician?

While you are in the hospital, the Plan covers hospital visits by a physician at:

Up to $950 copay / visit (based on provider and location) for in-network providers and up to $2,850 copay / visit (based on provider and location) for out-of-network providers. Inpatient hospitalization/stay. Benefits include:

Physician and non-Physician services, supplies, and medications received during an inpatient stay.

Facility charges, including room and board in a semi-private room (a room with two or more beds).

Physician services for lab tests, anesthesiologists, pathologists, radiologists, and Emergency room Physicians.

Does the Plan cover ambulance charges?

The Plan covers transportation by ambulance as follows:

$125 copay / transport for in-network providers and $125 copay / transport for out-of-network providers.

Ground or air ambulance, as the Claims Administrator determines appropriate. Air ambulance is medical transport by helicopter or airplane.

Emergency ambulance services and transportation provided by a licensed ambulance service (either ground or air ambulance) to the nearest hospital that offers Emergency health services.

Ambulance service by air is covered in an emergency if ground transportation is impossible or would put your life or health in serious jeopardy. If special circumstances exist, the Claims Administrator may approve Benefits for emergency air transportation to a hospital that is not the closest facility to provide emergency health services.

Ambulance services for non-emergency: The Plan also covers transportation provided by a licensed professional ambulance (either ground or air ambulance, as Surest determines appropriate) between facilities when the transport is:

From an out-of-network hospital to an in-network hospital.

To a hospital that provides the required care that was not available at the original hospital.

To a more cost-effective acute care facility.

From an acute care facility to a sub-acute care setting.

Non-emergency ground and air ambulance services may be covered for medical, surgical, mental health, or substance abuse facilities if the transfer is medically necessary. Non-emergency ground and air ambulance services may require prior authorization and medical necessity review.

Does the Plan cover hospice care?

The Plan covers charges for hospice at:

$15 copay / visit for in-network Home Hospice Visit and $45 copay / visit for out-of-network Home Hospice Visit.

$950 copay / visit for in-network Inpatient Hospice Care and $2,850 copay / visit for out-of-network Inpatient Hospice Care.

You must obtain prior authorization before you receive hospice care.