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Plan E 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.
| Services |
Medicare Pays |
Plan Pays |
You Pay |
Hospitalization*
Semiprivate room and board, general nursing
and miscellaneous services and supplies:
First 60 days |
All but $912 |
$912(Part A Deductable) |
$0 |
61st thru 90th day
|
All but $228/day |
$228/day |
$0 |
91st day and after:
While using 60 lifetime reserve days |
All but $456/day |
$456/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 |
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 thru 100th day |
All but $114/day |
Up to $114/day |
$0 |
| 101st day and after |
$0 |
$0 |
All costs |
Blood
First 3 pints
|
$0 |
3 pints |
$0 |
| Additional amounts |
100% |
$0 |
$0 |
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 |
Medicare (Part B) - Medical Services - per calendar year*
*Once you have been billed $110 of Medicare–approved amounts for covered services (which are noted with an asterisk), your Medicare Part B Deductible will have been met for the calendar year.
| Services |
Medicare Pays |
Plan Pays |
You Pay |
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:
First $110 of Medicare Approved Amounts*
|
$0 |
$0 |
$110
(Part B Deductible) |
| Remainder of Medicare Approved Amounts |
generally 80% |
generally 20% |
$0 |
Part B Excess Charges
(Above Medicare Approved Amounts) |
$0 |
$0 |
All costs |
Blood
First 3 pints |
$0 |
All Costs |
$0 |
| Next $110 of Medicare Approved Amounts* |
$0 |
$0 |
$110
(Part B Deductible) |
| Remainder of Medicare Approved Amounts |
80% |
20% |
$0 |
Clinical Laboratory Services
Blood tests for Diagnostic Services |
100% |
$0 |
$0 |
| Medicare Parts A & B |
Home Health Care
Medicare Approved Services:
Medically necessary skilled care services and
medical supplies |
100% |
$0 |
$0 |
Durable medical equipment:
First $110 of Medicare Approved Arnounts* |
$0 |
$0 |
$110
(Part B Deductible) |
| Remainder of Medicare Approved Amounts |
80% |
20% |
$0 |
| Other Benefits-Not Covered by Medicare |
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 |
Preventive Medical Care
Some annual physical and preventative tests and
services such as: digital rectal exam, hearing
screening, dipstick urinalysis, diabetes screening,
thyroid function test, tetanus and diphtheria booster
and education, administered or ordered by your
doctor when not covered by Medicare
First $120 each calendar year |
$0 |
$120 |
$0 |
| Additional Charges |
$0 |
$0 |
All costs |
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