

| Admission Benefit | Low Plan | High Plan | ||
| 4 Times per Calendar Year | ||||
| Admission | $500 | $1,000 | ||
| ICU Supplemental Admission | $500 | $1,000 | ||
| ICU Supplemental Admission Benefit is paid concurrently with the Admission Benefit when a covered person is admitted to ICU | ||||
| Confinement Benefit | Low Plan | High Plan | ||
| 31-Days per Confinement | ||||
| ICU Supplemental Confinement will pay an Additional Benefit for each of those 31-Days | ||||
| Confinement | $100 | $200 | ||
| ICU Supplemental Confinement | $100 | $200 | ||
| ICU Supplement Confinement Benefit is paid concurrently with the Confinement benefit when a covered person is admitted to ICU | ||||
| Inpatient Rehabilitation Benefit | Low Plan | High Plan | ||
| 15-Days per Calendar Year | ||||
| Inpatient Rehabilitation | $100 | $200 | ||
| (For Injury or Sickness) | ||||
| Confinement Benefit | Low Plan | High Plan | ||
| for Newborn Nursery Care | ||||
| 3-Days per Confinement | ||||
| Confinement | $100 | $200 | ||
| Coverage & Rates shown are for the 2025/26 Plan Year, effective 7/1/2025 through 6/30/2026. |
| Type | Low Plan | High Plan | ||
| Employee Only | 9.91 | 19.43 | ||
| Employee & Spouse | 21.60 | 42.34 | ||
| Employee & Child(ren) | 15.27 | 29.93 | ||
| Employee, Spouse & Child(ren) | 26.96 | 52.85 |
| Eligibility: |
| For eligible active employee members only. |
| Only available if Employer group allows this coverage to be offered. |
| Opportunities: |
| OPEH&W Initial Enrollment. |
| OPEH&W Annual Open Enrollment. |
| First Offering from OPEH&W. |