| SERVICES | |||
| HOSPITALIZATION Semiprivate room and board, general nursing and misc. services and supplies First 60 days -Before Plan Deductible -After Plan Deductible 61st thru 90th day -Before Plan Deductible -After Plan Deductible 91st day and after, while using 60 lifetime reserve days -Before Plan Deductible -After Plan Deductible Once reserve days are used: Additional 365 days -Before Plan Deductible -After Plan Deductible - Beyond additional 365 days -Before Plan Deductible -After Plan Deductible |
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 $1,600 $0 $400 / day $0 $800 / day $0 100% $0 $0 |
$1,600 $0 $400 / day $0 / day $800 / day $0 / day 100% $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 Deductible -After Plan Deductible 21st - 100th day- Copay/Day -Before Plan Deductible -After Plan Deductible 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% |
| BLOOD First 3 pints -Before Plan Deductible -After Plan Deductible Additional amounts -Before Plan Deductible -After Plan Deductible |
$0 $0 100% 100% |
$0 100% $0 $0 |
100% $0 $0 $0 |
| HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. -Before Plan Deductible -After Plan Deductible |
All except small copayment or coinsurance. |
$0 100% |
$0 100% |
| 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 Deductible -After Plan Deductible |
$0 $0 |
$0 $0 |
$226 $226 |
| Remainder of Part B Approved claims after $226 -Before Plan Deductible -After Plan Deductible |
80% 80% |
0% 20% |
20% 0% |
| EXCESS CHARGES -Before Plan Deductible -After Plan Deductible |
$0 $0 |
$0 100% |
100% $0 |
| BlOOD First 3 pints -Before Plan Deductible -After Plan Deductible Next $226 of Medicare approved amounts -Before Plan Deductible -After Plan Deductible Remainder of Medicare approved amounts -Before Plan Deductible -After Plan Deductible |
$0 $0 $0 $0 80% 80% |
$0 100% $0 $226 0% 20% |
100% $0 $226 $0 20% 0% |
| CLINICAL LABORATORY SERVICES Tests for Diagnostic Services |
100% |
0% |
0% |
| HOME HEALTH CARE Medicare approved services Medically necessary skilled care services and medical supplies |
100% |
0% |
0% |