Plan D
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 $1,132 |
$1,132
(Part A Deductible) |
$0 |
| 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 |
| 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 $141.50 a day
|
Up to $141.50 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 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 D
MEDICARE
(PART B) - MEDICAL SERVICES - PER CALENDAR YEAR* |
| * Once you have been billed $162 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 $162 of
Medicare Approved Amounts* |
$0 |
$0 |
$162
(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 $162 of Medicare
Approved Amounts* |
$0 |
$0 |
$162
(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 $162 of
Medicare Approved Amounts* |
$0 |
$0 |
$162
(Part B Deductible) |
| Remainder of Medicare
Approved Amounts |
80% |
20% |
$0 |
| Service: |
AT HOME RECOVERY SERVICES - Not Covered by Medicare
Home care certified by your doctor, for personal care during recovery from an
injury or sickness for which Medicare approved a Home Care Treatment Plan:
|
| Benefit
for each visit |
$0
|
Actual
charges up to $40 per 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
|
| 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 |
