Gold Classic Standard - 40572FL0200053 Health Insurance Plan

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

Exclusions: Maternity services rendered to a covered person who is acting as a gestational surrogate are excluded.

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings

Limit: 20.0 Days per Benefit Period

Exclusions: Part-time- Services limited to less than 8 hours a day, less than 40 hours a week. Intermittent- Services limited to each visit up to but not exceeding 2 hours a day. Excluded: Services rendered by an employee/operator of an adult congregate living facility, adult foster home, adult day care center, or a nursing facility.

Exclusions: Exclusion of "inpatient (overnight) mental health services received in a residential treatment facility."

Exclusions: Excludes services for psychological testing associated with the evaluation and diagnosis of learning disabilities or for mental retardation.

The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

Diabetes coverage includes "nutrition counseling"; home health services include "nutritional guidance"

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

Cost share applies to both in-person and telemedicine services.

Only for Breast reconstruction following a Mastectomy.

Limit: 35.0 Visit(s) per Benefit Period

Exclusions: If provided in an Inpatient setting, member must be able to actively participate in 2 rehabilitative therapies and be able to tolerate at least 3 hours per day of skilled Rehab services for at least 5 days a week. Member's condition must be likely to significantly improve. Inpatient rehab limit is 21 days.

Combined limit for all outpatient therapy plus chiropractic.

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

Limit: 60.0 Days per Benefit Period

Cost share applies to both in-person and telemedicine services.

Exclusions: Exclusion of "expenses for prolonged care and treatment of Substance Dependency in a specialized inpatient or residential treatment facility"

The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

Exclusions: Services involving bones or joints of the jaw (e.g., Services to treat temporomandibular joint [TMJ] dysfunction) or facial region if, under accepted medical standards, such diagnostic Services are necessary to treat Conditions caused by congenital or developmental deformity, disease, or injury. Payment for splints for the treatment of temporomandibular joint ("TMJ") dysfunction is limited to one splint in a six-month period unless a more frequent replacement is determined by us to be Medically Necessary

Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full.