Plan A
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD |
| * 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. |
| Service: |
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and
supplies |
| |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
| First 60 days |
All but $1,184 |
$0 |
$1,184 (Part A
Deductible) |
| 61st through 90th day |
All but $296 a day |
$296 a day |
$0 |
| 91st day and after: |
|
|
|
| While using 60 lifetime reserve
days |
All but $592 a day |
$592 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 |
| Service: |
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 $148 a day
|
$0
|
Up to $148 a day
|
| 101st day and after |
$0 |
$0 |
All costs |
| Service: |
BLOOD
|
| First 3 pints |
$0 |
3 pints |
$0 |
| Additional amounts |
100% |
$0 |
$0 |
| Service: |
HOSPICE CARE
You must meet Medicare’s requirements, including a doctor’s certification of
terminal illness. |
| |
All but very limited copayment/coinsurance for outpatient drugs and impatient
respite care
|
Medicare
copayment/coinsurance |
$0 |
| **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.
|
|
Plan A MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR* |
| * Once you have been billed $147 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Medicare Part B Deductible will have been met for the calendar year. |
| Service: |
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
medical equipment: |
| |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
| First $147 of Medicare Approved
Amounts* |
$0 |
$0 |
$147 (Part B
Deductible) |
| Remainder of Medicare Approved
Amounts |
Generally 80% |
Generally 20% |
$0 |
| Part B Excess Charges (Above
Medicare Approved Amounts) |
$0 |
$0 |
All costs |
| Service: |
BLOOD |
| First 3 pints |
$0 |
All costs |
$0 |
| Next $147 of Medicare Approved
Amounts* |
$0 |
$0 |
$147 (Part B
Deductible) |
| Remainder of Medicare Approved
Amounts |
80% |
20% |
$0 |
| Service: |
CLINICAL LABORATORY SERVICES |
|
Tests for Diagnostic Services |
100% |
$0 |
$0 |
| |
| PARTS
A & B |
| Service: |
HOME HEALTH CARE
Medicare Approved Services: |
| |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
| Medically necessary skilled care
services and medical supplies |
100% |
$0 |
$0 |
| Durable medical equipment:
|
|
|
|
| First $147 of Medicare Approved
Amounts* |
$0 |
$0 |
$147 (Part B
Deductible) |
| Remainder of Medicare Approved
Amounts |
80% |
20% |
$0 |