Part 1 Schedule of Benefits Do not rely on this alone. It merely highlights some of the benefits available to a member enrolled under Hospital Insurance (Part A), Medical Insurance (Part B) and Medicare Medicare this Medex plan. Be sure to read the most current edition of your handbook, the Medicare explanations in Part 4 and the limitations and exclusions in Part 5, as well as all provisions of this Benefit Description. Note: Your or may change these benefits. If this is the case, group Blue Cross and Blue Shield the change is described in a Your can supply you with any that apply rider. plan sponsor riders to your benefits. Please keep any with this booklet for easy reference. riders Medicare Provides Provides Your Cost* Page Admissions for Inpatient Medical and Surgical Care In a general Full In a general The In a general 20 hospital: hospital: hospital: semiprivate benefits less the Part A for day Nothing through the 365th deductible Part A for day 160 and Part A day per then deductible coinsurance benefit period; 160 and Part A for day 6190 per all charges coinsurance benefit for day 6190 per the Part A benefit period; and full semiprivate for any period; coinsurance benefits less the Part A lifetime reserve Medicare for 60 days used; then after coinsurance lifetime reserve days are used up, Medicare Medicare days full semiprivate benefits through the 365th day per benefit period In a In a In a 20 skilled nursing facility skilled nursing facility skilled nursing facility that participates with that participates with that participates with Full semiprivate The Nothing for day Medicare: Medicare: Medicare: benefits for day 1-20 per Part A for day 1-100 per coinsurance benefit period; and full 21100 per and the charge over $10 per benefit period; benefit period; semiprivate benefits less the and $10 per day from day day from day 101365 per Part A 101-365 per then all Medicare benefit period benefit period; for day 21100 charges coinsurance per benefit period In a In a In a 20 skilled nursing facility skilled nursing facility skilled nursing facility that does not participate that does not participate that does not participate with Nothing with $8 per day with The charge Medicare: Medicare: Medicare: for day 1365 per over $8 per day for benefit day 1365 per period benefit period; then all charges *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.)
Part 1 Schedule of Benefits Do not rely on this alone. It merely highlights some of the benefits available to a member enrolled under Medicare Hospital Insurance (Part A), Medicare Medical Insurance (Part B) and this Medex plan. Be sure to read the most current edition of your Medicare handbook, the explanations in Part 4 and the limitations and exclusions in Part 5, as well as all provisions of this Benefit Description. Note: Your group or Blue Cross and Blue Shield may change these benefits. If this is the case, the change is described in a rider. Your plan sponsor can supply you with any riders that apply to your benefits. Please keep any riders with this booklet for easy reference. Medicare Provides Provides Your Cost* Page Admissions for Inpatient Medical and Surgical Care In a general 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 In a general 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 used; then after Medicare days are used up, full semiprivate benefits through the 365th day per benefit period In a general hospital: Nothing through the 365th day per benefit period; then all charges 20 In a skilled nursing facility that participates with Medicare: Full semiprivate benefits for day 1-20 per benefit period; and full semiprivate benefits less the Medicare Part A coinsurance for day 21100 per benefit period In a skilled nursing facility that participates with Medicare: The Part A coinsurance for day 21100 per benefit period; and $10 per day from day 101-365 per benefit period In a skilled nursing facility that participates with Medicare: Nothing for day 1-100 per benefit period; and the charge over $10 per day from day 101365 per benefit period; then all charges 20 In a skilled nursing facility that does not participate with Medicare: Nothing In a skilled nursing facility that does not participate with Medicare: $8 per day for day 1365 per benefit period In a skilled nursing facility that does not participate with Medicare: The charge over $8 per day for day 1365 per benefit period; then all charges 20 *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.)
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