SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $[1340] $[1340] (Part A $0 deductible) 61st thru 90th day All but $[335] a day $[335] a day $0 91st day and after: ---While using 60 lifetime All but $[670] a day $[670] a day $0 reserve days ---Once lifetime reserve days are used: ---Additional 365 days $0 100% of Medicare eligible $0** expenses ---Beyond the additional 365 $0 $0 All costs days SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but $[167.50] a day $0 Up to $[167.50] a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet All but very limited Medicare $0 Medicare’s requirements, including a copayment/coinsurance copayment/coinsurance doctor’s certification of terminal illness. for out-patient drugs and inpatient respite care (continued) ** 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 this time the hospital is prohibited from billing you for the balance based on any difference between its Benefits.” During billed charges and the amount Medicare would have paid. PLAN B MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR * Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: ---While using 60 lifetime reserve days ---Once lifetime reserve days are used: ---Additional 365 days ---Beyond the additional 365 days All but $[1340] All but $[335] a day All but $[670] a day $0 $0 $[1340] (Part A deductible) $[335] a day $[670] a day 100% of Medicare eligible expenses $0 $0 $0 $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 facility within 30 days after leaving the hospital First 20 days 21st thru 100th day 101st day and after All approved amounts All but $[167.50] a day $0 $0 $0 $0 $0 Up to $[167.50] a day All costs BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment/coinsurance for out-patient drugs and inpatient respite care Medicare copayment/coinsurance $0 (continued) ** 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 B MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR * Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
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