Common Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important Event Need In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) Home health care 15% coinsurance 40% coinsurance None 60 inpatient days / year 60 outpatient visits / year (combined with habilitation services) Rehabilitation services 15% coinsurance 40% coinsurance Includes physical therapy, occupational therapy and speech therapy. Inpatient admissions for rehabilitation services must be preauthorized. *See section Therapy: Habilitative and rehabilitative. If you need help 60 professional neurodevelopmental visits / year recovering or have (combined with outpatient rehabilitation services) other special health Habilitation services 15% coinsurance 40% coinsurance Includes physical therapy, occupational therapy and needs speech therapy. Preauthorization is required. *See section Therapy: Habilitative and rehabilitative. 150 inpatient days / year Skilled nursing care 15% coinsurance 40% coinsurance Preauthorization is required. *See section Skilled nursing facility. Durable medical 15% coinsurance 40% coinsurance None equipment Hospice services No charge 40% coinsurance Hospice care / 6 months 14 respite inpatient or outpatient days / lifetime Children's eye exam No charge, deductible does Not covered 1 routine eye exam / year not apply Limited to individuals under age 19. 1 pair of standard lenses and frames / year If your child needs Children's glasses No charge, deductible does Not covered 1 year supply of contact lenses in lieu of standard dental or eye care not apply lenses and frames Limited to individuals under age 19. Children's dental check- Not covered Not covered None up *For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc. Page 4 of 6