Plan L Outline of Coverage 2011

Plan L 2011 Outline of Coverage

You will pay half of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2,320 each calendar year. The amounts that count toward your annual limit are noted with dollar signs ($ ) in the chart below. Once you reach the annual limit, the plan pays 100% of the Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

Medicare (Part A) - Hospital Services - Per Benefit Period
Services	Medicare Pays	Plan Pays	You Pay
*HOSPITALIZATION-** Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but $1,132	$849 (75% of Part A deductible	$283 (25% of Part A Deductible)
61st through 90th day	All but $283 a day	$283 a day	$0
91st day and after:
-While using 60 lifetime reserve days	All but $566 a day	$566 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 $141.50 a day	Up to $96 per day	$32 a day
101st day and after	$0	$0	All cost
Blood - First 3 Pints	$0	75%	25%
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.	75% of coinsurance or copayments	25% of coinsurance or copayments

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 $162 of Medicare-approved amounts***	$0	$0	$162 (Part B Deductible) ***
Preventive benefits for Medicare Covered Services	Generally 75% or more of Medicare -approved amounts	Remainder of Medicare-approved amounts	All cost above Medicare-approved amounts
Remainder of Medicare-approved amounts	Generally 80%	Generally 10%	Generally 10%
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All cost (and they do not count toward annual out - of pocket limit of ($2,310)
Blood - First 3 pints	$0	75%	25%
Next $162 of Medicare-approved amounts***	$0	$0	$162 (Part B Deductible)***
Remainder of Medicare-approved amounts	Generally 80%	Generally 15%	Generally 15%
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 $162 of Medicare-approved amounts***	$0	$0	$162 (Part B deductible)***
>Remainder of Medicare-approved amounts	80%	15%	15%