HOSPITALIZATION Semiprivate room and board, general nursing and misc. services and supplies First 60 days 61st thru 90th day 91st day and after: -- (While using 60 lifetime reserve days) - Once lifetime reserve days are used: -- Additional 365 days -- Beyond add'l 365 days |
All but $1,600 All but $400 / day All but $800 / day $0 $0 |
$0 $400 $800 100% 0% |
$1,600 $0 $0 $0 100% |
With rider you pay $0 $0 $0 $0 100% |
$1,600 $400 $800 100% 0% |
$0 $0 $0 $0 100% |
$1,600 $400 $800 100% 0% |
$0 $0 $0 $0 100% |
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 - Copay/Day 21st - 100th day- Copay/Day 101st day and after |
All approved amounts All but $200 / day $0 |
$0 $200 $0 |
$0 $0 100% |
$0 $200 $0 |
$0 $0 100% |
$0 $200 $0 |
$0 $0 100% |
|
BLOOD First 3 pints Additional amounts |
$0 100% |
100% $0 |
$0 $0 |
100% $0 |
$0 $0 |
100% $0 |
$0 $0 |
|
HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. |
All except small copayment or coinsurance. |
Remaining balance |
$0 |
Remaining balance |
$0 |
Remaining balance |
$0 |
|
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 $226 of Medicare Approved Amounts |
$0 |
$0 |
$226 |
Available rider for those born before 1955 or whose Part A date before 1-1-2020 with rider you pay $0 |
$226 |
$0 |
$0 |
$226 |
Remainder of Part B Approved claims after $226 DR Visit ER Visit |
80% 80% 80% |
20% 20% 20% |
0% 0% 0% |
20% 20% 20% |
0% 0% 0% |
20% All but $20 All but $50 |
0% $20 $50 |
|
EXCESS CHARGES |
$0 |
$0 |
100% |
Rider pays |
100% |
0% |
$0 |
100% |
BlOOD First 3 pints Next $226 of Medicare approved amounts Remainder of Medicare approved amounts |
$0 $0 80% |
100% $0 20% |
0% $226 0% |
$0 Rider pays $0 |
100% $226 20% |
0% $0 0% |
100% $0 20% |
0% $226 0% |
CLINICAL LABORATORY SERVICES Tests for Diagnostic Services |
100% |
0% |
0% |
0% |
0% |
0% |
0% |
0% |
HOME HEALTH CARE Medicare approved services Medically necessary skilled care services and medical supplies |
100% |
0% |
0% |
0% |
0% |
0% |
0% |
0% |
SERVICES | MEDICARE PAYS | ||||||
HOSPITALIZATION Semiprivate room and board, general nursing and misc. services and supplies First 60 days -Before Plan Ded./OOPM -After Plan Ded./OOPM 61st thru 90th day -Before Plan Ded./OOPM -After Plan Ded./OOPM 91st day and after, while using 60 lifetime reserve days -Before Plan Ded./OOPM -After Plan Ded./OOPM - Once reserve days are used: -Before Plan Ded./OOPM -After Plan Ded./OOPM - Additional 365 days -Before Plan Ded./OOPM -After Plan Ded./OOPM - Beyond additional 365 days -Before Plan Ded./OOPM -After Plan Ded./OOPM |
All but $1,600 All but $1,600 All but $400 / day All but $400 / day All but $800 / day All but $800 / day $0 $0 $0 $0 $0 $0 |
$0 $1,600 $0 $400 / day $0 $800 / day $0 100% $0 100% $0 $0 |
$1,600 $0 $400 / day $0 / day $800 / day $0 / day 100% $0 100% $0 100% 100% |
$800 $1,600 $400 / day $400 / day $800 / day $800 / day 100% 100% 100% 100% $0 $0 |
$800 $0 $0 $0 $0 $0 $0 $0 $0 $0 100% 100% |
$1,200 $0 $400 / day $400 / day $800 / day $800 / day 100% 100% 100% 100% $0 $0 |
$400 $0 $0 $0 $0 $0 $0 $0 $0 $0 100% 100% |
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 - Copay/Day -Before Plan Ded./OOPM -After Plan Ded./OOPM 21st - 100th day- Copay/Day -Before Plan Ded./OOPM -After Plan Ded./OOPM 101st day and after |
All approved amounts All approved amounts All but $200 / day All but $200 / day $0 |
$0 $0 $0 $200 / day $0 |
$0 $0 $200 / day $0 100% |
$0 $0 $100 / day $200 / day $0 |
$0 $0 $100 / day $0 100% |
$0 $0 $150 / day $200 / day $0 |
$0 $0 $50 / day $0 100% |
BLOOD First 3 pints -Before Plan Ded./OOPM -After Plan Ded./OOPM Additional amounts -Before Plan Ded./OOPM -After Plan Ded./OOPM |
$0 $0 100% 100% |
$0 100% $0 $0 |
100% $0 $0 $0 |
50% 100% $0 $0 |
50% $0 $0 $0 |
75% 100% $0 $0 |
25% $0 $0 $0 |
HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. -Before Plan Ded./OOPM -After Plan Ded./OOPM |
All except small copayment or coinsurance. |
$0 100% |
$0 100% |
50% 100% |
50% $0 |
75% 100% |
25% $0 |
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 $226 of Medicare Approved Amounts -Before Plan Ded./OOPM -After Plan Ded./OOPM |
$0 $0 |
$0 $0 |
$226 $226 |
$0 $0 |
$226 $226 |
$0 $0 |
$226 $226 |
Remainder of Part B Approved claims after $226 -Before Plan Ded./OOPM -After Plan Ded./OOPM |
80% 80% |
0% 20% |
20% 0% |
10% 20% |
10% 0% |
15% 20% |
5% 0% |
EXCESS CHARGES -Before Plan Ded./OOPM -After Plan Ded./OOPM |
$0 $0 |
$0 100% |
100% $0 |
$0 $0 |
100% 100% |
$0 $0 |
100% 100% |
BlOOD First 3 pints -Before Plan Ded./OOPM -After Plan Ded./OOPM Next $226 of Medicare approved amounts -Before Plan Ded./OOPM -After Plan Ded./OOPM Remainder of Medicare approved amounts -Before Plan Ded./OOPM -After Plan Ded./OOPM |
$0 $0 $0 $0 80% 80% |
$0 100% $0 $0 0% 20% |
100% $0 $226 $226 20% 0% |
50% 100% $0 $0 10% 20% |
50% $0 $226 $226 10% $0 |
75% 100% $0 $0 15% 20% |
25% $0 $226 $226 5% $0 |
CLINICAL LABORATORY SERVICES Tests for Diagnostic Services |
100% |
0% |
0% |
0% |
0% |
0% |
0% |
HOME HEALTH CARE Medicare approved services Medically necessary skilled care services and medical supplies |
100% |
0% |
0% |
0% |
0% |
0% |
0% |