| Services |
Medicare Pays |
Plan Pays |
You Pay |
|
HOSPITALIZATION*- Semiprivate room and board,
general nursing and miscellaneous services and supplies |
| First 60 days |
All but $1,068 |
$1,068 (Part A Deductible) |
$0 |
| 61st through 90th day |
All but $267 a day |
$267 a day |
$0 |
| 91st day and after: |
|
|
|
| -While using 60 lifetime reserve days |
All but $534 a day |
$534 a day |
$0 |
| -Once lifetime reserve days are used: |
|
|
|
| >Additional 365 days |
$0 |
100% of Medicare eligible expenses |
$0** |
| >Beyond the additional 365 days |
$0 |
$0 |
all costs |
|
SKILLED NURSING FACILITY CARE*- You must meet
Medicare’s requirements, including having been in a hospital for at
least 3 days and entered a Medicare-approved facility within 30 days
after leaving the hospital |
| First 20 days |
All approved amounts |
$0 |
$0 |
| 21st through 100th day |
All but $133.50 a day |
up to
$133.50 a day |
$0 |
| 101st day and after |
$0 |
$0 |
All cost |
| Blood - First 3 Pints |
$0 |
3 pints |
$0 |
| Additional amounts |
100% |
$0 |
$0 |
| Hospice Care - Available as long as
your doctor certifies you are terminally ill and you elect to receive
these services. |
All but very limited coinsurance for
outpatient drugs and inpatient respite care. |
$0 |
Balance |
|
*A benefit period
begins on the first day you receive service as an inpatient in a hospital and
ends after you have been out of the hospital and have not received skilled care
in any other facility for 60 days in a row.
** NOTICE: When your Medicare Part A hospital benefits are
exhausted, the insurer stands in the place of Medicare and will pay whatever
amount Medicare would have paid for up to an additional 365 days as provided in
the policy’s "Core Benefits." During this time the hospital is prohibited from
billing you for the balance based on any difference between its billed charges
and the amount Medicare would have paid.
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR
YEAR
|
| Services |
Medicare Pays |
Plan Pays |
You Pay |
|
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND
OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient
and outpatient medical and surgical services and supplies, physical and
speech therapy, diagnostic tests, durable med medical equipment |
| First $135 of Medicare-approved amounts*** |
$0 |
$0 |
$135
(Part B Deductible) |
| Remainder of Medicare-approved amounts |
Generally 80% |
Generally 20% |
$0 |
| Part B Excess Charges (Above
Medicare-approved amounts) |
$0 |
80% |
20% |
| Blood - First 3 pints |
$0 |
All cost |
$0 |
| Next $135 of Medicare-approved amounts*** |
$0 |
$0 |
$135
(Part B Deductible) |
| Remainder of Medicare-approved amounts |
80% |
20% |
$0 |
| Clinical Laboratory Services - |
|
|
|
| Test for Diagnostic Services |
100% |
$0 |
$0 |
|
Parts A&B |
|
HOME HEALTH CARE – MEDICARE-APPROVED SERVICES |
| - Medically necessary skilled care
services and medical supplies |
100% |
$0 |
$0 |
| -
Durable medical equipment: |
|
|
|
| >First $135 of Medicare-approved
amounts*** |
$0 |
$0 |
$135
(Part B Deductible) |
| >Remainder of Medicare-approved amounts |
80% |
20% |
$0 |
|
At-Home Recovery Services -
NOT COVERED BY MEDICARE Home care certified by your doctor, for
personal care during recovery from any injury or sickness for which
Medicare approved a Home Care Treatment plan. |
| Benefit for each visit |
$0 |
Actual charges up to $40 a visit |
Balance |
| Number of visits covered (must be received
within 8 weeks of last Medicare-approved visit |
$0 |
Up to the number of Medicare-approved
visits, not to exceed 7 each week |
Balance |
| Calendar year maximum |
$0 |
$1,600 |
Balance |
|
Other Benefits Not Covered by
Medicare |
|
FOREIGN TRAVEL – NOT COVERED BY MEDICARE – Medically
necessary emergency care services beginning during the first 60 days of
each trip outside the USA |
| First $250 each calendar year |
$0 |
$0 |
$250 |
| Remainder of Charges |
$0 |
80% to a lifetime maximum benefit of
$50,000 |
$20% and amounts over the $50,000 lifetime
maximum |
***Once you have been billed $135 of Medicare-approved amounts
for covered services (which are noted with an asterisk), your Part B Deductible
will have been met for the calendar year.