|
Plan N
|
|
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
|
* A benefit period begins on the first day you receive services 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 $1,100 |
$1,100 |
$0 |
| 61st through 90th day |
All but $275 a day |
$275 a day |
$0 |
| 91st day and after: |
|
|
|
| While using 60 lifetime reserve
days |
All but $550 a day |
$550 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 $137.50 a day
|
Up to $137.50 a day
|
$0
|
| 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 inpatient 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 N
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR* |
| * Once
you have been billed $155 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 $155 of Medicare Approved
Amounts* |
$0 |
$0 |
$155 (Part B
Deductible) |
|
Remainder of Medicare Approved Amounts |
Generally 80% |
Balance, other
than up to $20 per office visit and up to $50 per emergency room visit. The
copayment of up to $50 is waived if the insured is admitted to any hospital and
the emergency visit is covered as a Medicare part A expense |
Up to $20 per office visit and up to $50 per emergency room visit. The
copayment of up to $50 is waived if the insured is admitted to any hospital and
the emergency visit is covered as a Medicare part A expense |
|
Part B Excess Charges (Above Medicare Approved Amounts) |
$0 |
$0 |
All costs |
| Service: |
BLOOD |
| First 3 pints |
$0 |
All costs |
$0 |
| Next $155 of Medicare Approved
Amounts* |
$0 |
$0 |
$155 (Part B
Deductible) |
| Remainder of Medicare Approved
Amounts |
80% |
20% |
$0 |
| Service: |
CLINICAL LABORATORY SERVICES |
|
Tests for Diagnostic Services |
100% |
$0 |
$0 |
| |
|
* This plan limits your annual out-of-pocket payments for Medicare-approve
amounts to $4620 per 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.
|
|
Plan N
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 $155 of Medicare Approved
Amounts**** |
$0 |
$0 |
$155 (Part B
Deductible) |
| Remainder of Medicare Approved
Amounts |
80% |
20% |
$0 |
|
|
OTHER BENEFITS - NOT COVERED BY MEDICARE
|
| Service: |
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 |
** Medicare Benefits are subject to change. Please consult the lastest