Full benefits less the Part B The Part B and Nothing 23 deductible and Part B Part B deductible coinsurance coinsurance Emergency Medical Outpatient Services Full benefits less the Part B The Part B and Nothing 23 deductible and Part B Part B deductible coinsurance coinsurance Home Health Care For home health care For home health care For home health care 23 visits, full benefits visits, nothing visits, nothing** For For For 23 durable medical durable medical durable medical covered by covered by covered by equipment equipment equipment full benefits less nothing the Part B Medicare, Medicare, Medicare, the Part B (when (when deductible deductible applicable) and Part B applicable) and Part B coinsurance coinsurance Hospice Services When covered by When does not When covered by 24 Medicare full benefits for provide full benefits, the nothing Medicare, Medicare, most services difference between the amount pays and Medicare the allowed charge When not covered by When not covered by When not covered by 24 nothing full benefits nothing Medicare, Medicare, Medicare, Lab Tests, X-Rays and Other Tests Full benefits less the Part B The Part B and Nothing 24 deductible and Part B Part B deductible coinsurance coinsurance *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.) **These services are covered in full by Medicare as long as Medicare conditions are met. Mental Health Treatment for Biologically-Based Mental or Nervous Conditions***
Full benefits less the Part B deductible and Part B coinsurance The Part B deductible and Part B coinsurance Nothing 23 Emergency Medical Outpatient Services Full benefits less the Part B deductible and Part B coinsurance The Part B deductible and Part B coinsurance Nothing 23 Home Health Care For home health care visits, full benefits For home health care visits, nothing For home health care visits, nothing** 23 For durable medical equipment covered by Medicare, full benefits less the Part B deductible (when applicable) and Part B coinsurance For durable medical equipment covered by Medicare, nothing For durable medical equipment covered by Medicare, the Part B deductible (when applicable) and Part B coinsurance 23 Hospice Services When covered by Medicare, full benefits for most services When Medicare does not provide full benefits, the difference between the amount Medicare pays and the allowed charge When covered by Medicare, nothing 24 When not covered by Medicare, nothing When not covered by Medicare, full benefits When not covered by Medicare, nothing 24 Lab Tests, X-Rays and Other Tests Full benefits less the Part B deductible and Part B coinsurance The Part B deductible and Part B coinsurance Nothing 24 *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.) **These services are covered in full by Medicare as long as Medicare conditions are met. Mental Health Treatment for Biologically-Based Mental or Nervous Conditions***
ascme2-0601.docx