admissions in a admissions in a admissions in a 25 Inpatient Inpatient Inpatient general or mental general or mental general or mental Full semiprivate The Part A Nothing through hospital: hospital: hospital: benefits less the Part A for day 160 and the 365th day per deductible benefit for day 160 and Part A for day in a general deductible coinsurance period hospital; Part A for day 6190 per the and nothing for up to 120 coinsurance benefit period; 6190 per and Part A for any days per (but benefit period; coinsurance benefit period full semiprivate benefits lifetime reserve up to at least 60 days per Medicare less the Part A days; then calendar year) in a mental coinsurance Medicare for 60 lifetime days are used up, full then all charges Medicare hospital; reserve days (Benefits in a semiprivate benefits mental are limited through the 365th day per hospital to 190 days per lifetime) in a general benefit period (up to 120 days per hospital but up to at benefit period least 60 days per calendar year in a mental hospital), less any days in a hospital already covered by in that Medicare benefit (or calendar year) period and and and 26 Inpatient physician Inpatient physician Inpatient Physician covered professional other covered professional covered professional mental health provider mental health provider mental health provider services: Full benefits less services: The Part B services: Nothing for the Part B and and Part B and Medex deductible deductible Medicare Part B for as for for as coinsurance coinsurance Medicare covered services many days as are and Medex many days as are medically covered services medically for as many days as are in a general or necessary necessary in a mental nothing for medically necessary hospital; general or mental as many days as are hospital; full benefits for as many in a medically necessary days as are general and for up medically hospital in a general to 120 days per necessary benefit and for up to 120 (but up to at least 60 hospital period, days per (but days per calendar year) in a benefit period up to at least 60 days per mental when hospital calendar year) in a mental covered by Medex only; when covered by then all charges hospital Medex only *Benefits for are provided based on the You may have to pay covered services allowed charge. any amount over the (See Parts 2 and 9.) allowed charge. Mental Health Treatment for Non-Biologically-Based Mental or Nervous (continued) Conditions
Inpatient admissions in a general or mental hospital: Full semiprivate benefits less the Part A deductible for day 160 and Part A coinsurance for day 6190 per benefit period; and full semiprivate benefits less the Part A coinsurance for 60 Medicare lifetime reserve days (Benefits in a mental hospital are limited to 190 days per lifetime) Inpatient admissions in a general or mental hospital: The Part A deductible for day 160 and Part A coinsurance for day 6190 per benefit period; the Part A coinsurance for any Medicare lifetime reserve days; then Medicare days are used up, full semiprivate benefits through the 365th day per benefit period in a general hospital (up to 120 days per benefit period but up to at least 60 days per calendar year in a mental hospital), less any days in a hospital already covered by Medicare in that benefit period (or calendar year) Inpatient admissions in a general or mental hospital: Nothing through the 365th day per benefit period in a general hospital; and nothing for up to 120 days per benefit period (but up to at least 60 days per calendar year) in a mental hospital; then all charges 25 Inpatient physician and covered professional mental health provider services: Full benefits less the Part B deductible and Part B coinsurance for as many days as are medically necessary Inpatient physician and other covered professional mental health provider services: The Part B deductible and Part B coinsurance for Medicare and Medex covered services for as many days as are medically necessary in a general or mental hospital; full benefits for as many days as are medically necessary in a general hospital and for up to 120 days per benefit period (but up to at least 60 days per calendar year) in a mental hospital when covered by Medex only Inpatient Physician and covered professional mental health provider services: Nothing for Medicare and Medex covered services for as many days as are medically necessary in a general or mental hospital; nothing for as many days as are medically necessary in a general hospital and for up to 120 days per benefit period, (but up to at least 60 days per calendar year) in a mental hospital when covered by Medex only; then all charges 26 *Benefits for covered services are provided based on the allowed charge. You may have to pay any amount over the allowed charge. (See Parts 2 and 9.) Mental Health Treatment for Non-Biologically-Based Mental or Nervous Conditions (continued)
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