Oct 15, 2008

Plan G

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*

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*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	80%	20%
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
At Home Recovery Services Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan: Benefit for each visit	$0	Actual charges up to $40 per visit	Balance
Number of visits covered	$0	Up to the number of Medicare approved visits, not to exceed 7 per week
Calendar year maximum	$0	$1,600
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

  

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