If you have a hospital stay
Facility fee (e.g.,
hospital room)
20%
coinsurance
40%
coinsurance
Not covered
Transplant services received at any
facility that is not an Institutes of
Excellence facility are not covered
Transplant services are not covered
within the Memorial Hermann ACN.
Precertification rules must be followed or
benefits are reduced by 50%, up to a
$1,000 maximum. No out-of-network
coverage.
Physician/surgeon fee
20%
coinsurance
40%
coinsurance
Not covered
Common Medical Event
Services You May
Need
Your cost if you use
a Memorial Hermann
ACN Provider
Your cost if you use an
In-Network Provider
Your cost if
you use an
Out-of-
Network
Provider
Limitations & Exceptions
If you need immediate
medical attention
Emergency room
services
20%
coinsurance
20%
coinsurance
20%
coinsurance
Non emergency use not covered.
Emergency medical
transportation
20%
coinsurance
20%
coinsurance
20%
coinsurance
Non emergency use not covered.
Urgent care
20%
coinsurance
20%
coinsurance
Not covered No out-of-network coverage.
If you have mental health,
behavioral health or
substance abuse needs
Mental/Behavioral
health outpatient
services
20%
coinsurance
40%
coinsurance
Not covered No out-of-network coverage.
Mental/Behavioral
health inpatient
services
20%
coinsurance
40%
coinsurance
Not covered No out-of-network coverage.
Substance use disorder
outpatient services
20%
coinsurance
40%
coinsurance
Not covered No out-of-network coverage.
Substance use disorder
inpatient services
20%
coinsurance
40%
coinsurance
Not covered No out-of-network coverage.
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