Plan C
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 $1024 |
$1024 (Part A Deductible) |
$0 |
| 61st through 90th day |
All but $256 |
$256 a day |
$0 |
| 91st day and after: |
|
|
|
| While using 60 lifetime reserve days |
All but $512 a day |
$512 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 $128.00 a day |
Up to $128.00 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
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 |
| 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 C
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR |
| Once you have been billed $135 of Medicare-Approved amounts for covered
services , 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 $135 of Medicare Approved Amounts |
$0 |
$135 (Part B Deductible) |
$0 |
| 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 cost |
$0 |
| Next $135 of Medicare Approved Amounts |
$0 |
$135 (Part B Deductible) |
$0 |
| Remainder of Medicare Approved Amounts |
80% |
20% |
$0 |
| Service: |
CLINICAL LABORATORY SERVICES |
| Blood tests for Diagnostic Services |
100% |
$0 |
$0 |
| |
|
| MEDICARE 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 $135 of Medicare Approved Amounts |
$0 |
$135
(Part B Deductible) |
$0 |
| Remainder of Medicare Approved Amounts |
80% |
20% |
$0 |
| |
|
OTHER BENEFITS - NOT COVERED BY MEDICARE |
| Service: |
FOREIGN TRAVEL
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 of $50,000 |
20% and amounts over the $50,000 lifetime maximum |