N.Y. Comp. Codes R. & Regs. tit. 11, Appendices, app 12A
APPENDIX 12A |
Required disclosure statement for policies and certificates of Medicare supplement insurance meeting the standards of sections 52.11 and 52.14 of this Title and sections 58.1 and 58.2 of this Part issued with an effective date for coverage prior to June 1, 2010. The appendix contains the items that shall be included in the disclosure statement in the order prescribed therein. |
The disclosure statement shall consist of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The disclosure statement shall be in the language and format prescribed below in no less than 12-point type. All benefit plans "A" through "L" shall be shown on the cover page, and the plan(s) that are offered by the issuer shall be prominently identified. Premium information for plans that are offered shall be shown on the cover page or immediately following the cover page and shall be prominently displayed. The premium and mode shall be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant shall be illustrated. |
PREMIUM INFORMATION (Boldface Type) |
We (insert issuer's name) can only raise your premium if we raise the premium for all policies like yours in this State. |
DISCLOSURES (Boldface Type) |
Use this outline to compare benefits and premiums among policies. |
PREMIUM INFORMATION |
(Boldface Type) |
We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this State. |
DISCLOSURES (Boldface Type) |
Use this outline to compare benefits and premiums among policies. |
READ YOUR POLICY VERY CAREFULLY (Boldface Type) |
This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. |
RIGHT TO RETURN POLICY (Boldface Type) |
If you find that you are not satisfied with your policy, you may return it to [insert issuer's address]. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments. |
POLICY REPLACEMENT (Boldface Type) |
If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. |
NOTICE (Boldface Type) |
This policy may not fully cover all of your medical costs. |
[for agents:] |
Neither [insert company's name] nor its agents are connected with Medicare. |
[for direct response:] |
[Insert company's name] is not connected with Medicare. |
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details. |
COMPLETE ANSWERS ARE VERY IMPORTANT (Boldface Type) |
Review the application carefully before you sign it. Be certain that all information has been properly recorded. (Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this regulation. An issuer may use additional benefit plan designations on these charts pursuant to section 58.2(b)(4)of this Part.) |
(Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the superintendent.) |
PLAN A
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* | |||
Semi-private room and board, general nursing and miscellaneous services and supplies | |||
First 60 days | All but $[1100] | $0 | $[1100](Part A deductible) |
61st thru 90th day | All but $[275] a day | $[275] a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $[550] day | $[550] a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days (lifetime) | $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 $[137.50] a day | $0 | Up to $[137.50] a day |
101st day and after | $0 | $0 | All costs |
BLOOD (per calendar year) | |||
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 out-patient drugs and inpatient respite care | $0 | Balance |
PLAN A
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[155] of Medicare-approved amounts for covered services (which are noted with an asterisk), your 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 $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (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 $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOME HEALTH CARE | |||
MEDICARE APPROVED SERVICES | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
PLAN B
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 $[1100] | $[1100] (Part A deductible) | $0 |
61st thru 90th day | All but $[275] a day | $[275] a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $[550] | $[550] a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days (lifetime) | $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 $[137.50] a day | $0 | Up to $[137.50] a day |
101st day and after | $0 | $0 | All costs |
BLOOD (per calendar year) | |||
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 out-patient drugs and inpatient respite care | $0 | Balance |
PLAN B
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[155] of Medicare-approved amounts for covered services (which are noted with an asterisk), your 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 $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (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 $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOME HEALTH CARE | |||
MEDICARE APPROVED SERVICES | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
PLAN C
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 $[1100] | $[1100] (Part A deductible) | $0 |
61st thru 90th day | All but $[275] a day | $[275] a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $[550] a day | $[550] a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days (lifetime) | $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 $[137.50] a day | Up to $[137.50] a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD (per calendar year) | |||
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 out-patient drugs and inpatient respite care | $0 | Balance |
PLAN C
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[155] of Medicare-approved amounts for covered services (which are noted with an asterisk), your 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 $[155] of Medicare Approved Amounts* | $0 | $[155] (Part B deductible) | $0 |
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 $[155] of Medicare Approved Amounts* | $0 | $[155] (Part B deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOME HEALTH CARE | |||
MEDICARE APPROVED SERVICES | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $[155] of Medicare Approved Amounts* | $0 | $[155] (Part B deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
| OTHER BENEFITS-NOT COVERED BY MEDICARE | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
FOREIGN TRAVEL- NOT COVERED BY MEDICARE | |||
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 benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
PLAN D
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 $[1100] | $[1100] (Part A deductible) | $0 |
61st thru 90th day | All but $[275] a day | $[275] a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $[550] a day | $[550] a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days (lifetime) | $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 $[137.50] a day | Up to $[137.50] a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD (per calendar year) | |||
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 out-patient drugs and inpatient respite care | $0 | Balance |
PLAN D
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[155] of Medicare-approved amounts for covered services (which are noted with an asterisk), your 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 $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (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 $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOME HEALTH CARE | |||
MEDICARE APPROVED SERVICES | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
AT-HOME RECOVERY SERVICES-NOT COVERED BY MEDICARE | |||
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 to $40 a visit | Balance |
-Number of visits covered (Must be received within 8 weeks of last Medicare Approved visit) | $0 | Up to the number of Medicare Approved visits, not to exceed 7 each week | |
-Calendar year maximum | $0 | $1,600 | |
OTHER BENEFITS-NOT COVERED BY MEDICARE | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
FOREIGN TRAVEL- NOT COVERED BY MEDICARE | |||
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 benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
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 $[1100] | $[1100] (Part A deductible) | $0 |
61st thru 90th day | All but $[275] a day | $[275] a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $[550] a day | $[550] a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days (lifetime) | $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 $[137.50] a day | Up to $[137.50] a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD (per calendar year) | |||
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 out-patient drugs and inpatient respite care | $0 | Balance |
PLAN E
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[155] of Medicare-approved amounts for covered services (which are noted with an asterisk), your 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 $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (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 $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOME HEALTH CARE | |||
MEDICARE APPROVED SERVICES | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
PLAN E
OTHER BENEFITS-NOT COVERED BY MEDICARE
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
FOREIGN TRAVEL-NOT COVERED BY MEDICARE | |||
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 benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
***PREVENTIVE MEDICAL CARE BENEFIT-NOT COVERED BY MEDICARE | |||
Some annual physical and preventive tests and services 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 |
***Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
PLAN F
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 $[1100] | $[1100] (Part A deductible) | $0 |
61st thru 90th day | All but $[275] a day | $[275] a day | $0 |
91st day and after: | |||
-While using 60 | |||
Lifetime reserve days | All but $[550] a day | $[550] a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days (lifetime) | $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 $[137.50] a day | Up to $[137.50] a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD (per calendar year) | |||
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 out-patient drugs and inpatient respite care | $0 | Balance |
PLAN F
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[155] of Medicare-approved amounts for covered services (which are noted with an asterisk), your 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 $[155] of Medicare Approved Amounts* | $0 | $[155] (Part B deductible) | $0 |
Remainder of Medicare Approved Amounts | Generally 80% | Generally 20% | $0 |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | 100% | $0 |
BLOOD | |||
First 3 pints | $0 | All costs | $0 |
Next $[155] of Medicare Approved amounts* | $0 | $[155] (Part B deductible) | $0 |
Remainder of Medicare- Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES | |||
-TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOME HEALTH CARE | |||
MEDICARE APPROVED SERVICES | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $[155] of Medicare Approved Amounts* | $0 | $[155] (Part B deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
OTHER BENEFITS-NOT COVERED BY MEDICARE
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
FOREIGN TRAVEL-NOT COVERED BY MEDICARE | |||
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 benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
HIGH DEDUCTIBLE PLAN F
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.
**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2000] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are [$2000]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.
SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2000] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2000] DEDUCTIBLE,** YOU PAY |
HOSPITALIZATION* | |||
Semiprivate room and board, general nursing and miscellaneous services and supplies | |||
First 60 days | All but $[1100] | $[1100] (Part A deductible) | $0 |
61st thru 90th day | All but $[275] a day | $[275] a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $[550] a day | $[550] a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days (lifetime) | $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 $[137.50] a day | Up to $[137.50] a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD (per calendar year) | |||
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 out-patient drugs and inpatient respite care | $0 | Balance |
HIGH DEDUCTIBLE PLAN F
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[155] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2000] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are [$2000]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.
SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2000]DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2000]DEDUCTIBLE,** 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 $[155] of Medicare Approved amounts* | $0 | $[155] (Part B deductible) | $0 |
Remainder of Medicare Approved Amounts | Generally 80% | Generally 20% | $0 |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | 100% | $0 |
BLOOD | |||
First 3 pints | $0 | All costs | $0 |
Next $[155] of Medicare Approved Amounts* | $0 | $[155] (Part B deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES-TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B | |||
SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2000]DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2000]DEDUCTIBLE,** YOU PAY |
HOME HEALTH CARE MEDICARE APPROVED SERVICES | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $[155] of Medicare Approved Amounts* | $0 | $[155] (Part B deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
OTHER BENEFITS-NOT COVERED BY MEDICARE
SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2000] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2000] DEDUCTIBLE,** YOU PAY |
FOREIGN TRAVEL- NOT COVERED BY MEDICARE 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 benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
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 $[1100] | $[1100] (Part A deductible) | $0 |
61st thru 90th day | All but $[275] a day | $[275] a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $[550] a day | $[550] a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days (lifetime) | $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 $[137.50] a day | Up to $[137.50] a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD (per calendar year) | |||
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 out-patient drugs and inpatient respite care | $0 | Balance |
PLAN G
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[155] of Medicare-approved amounts for covered services (which are noted with an asterisk), your 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 $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (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 $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOME HEALTH CARE | |||
MEDICARE APPROVED SERVICES | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
AT-HOME RECOVERY SERVICES-NOT COVERED BY MEDICARE | |||
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 to $40 a visit | Balance |
-Number of visits covered (Must be received within 8 weeks of last Medicare Approved visit) | $0 | Up to the number of Medicare-approved visits, not to exceed 7 each week | |
-Calendar year maximum | $0 | $1,600 | |
OTHER BENEFITS-NOT COVERED BY MEDICARE | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
FOREIGN TRAVEL- NOT COVERED BY MEDICARE | |||
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 benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
PLAN H
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 $[1100] | $[1100] (Part A deductible) | $0 |
61st thru 90th day | All but $[275] a day | $[275] a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $[550] a day | $[550] a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days (lifetime) | $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 $[137.50] a day | Up to $[137.50] a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD (per calendar year) | |||
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 out-patient drugs and inpatient respite care | $0 | Balance |
PLAN H
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[155] of Medicare-approved amounts for covered services (which are noted with an asterisk), your 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 $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (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 $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOME HEALTH CARE | |||
MEDICARE APPROVED SERVICES | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
PLAN H
OTHER BENEFITS-NOT COVERED BY MEDICARE
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
FOREIGN TRAVEL-NOT COVERED BY MEDICARE | |||
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 benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
PLAN I
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 $[1100] | $[1100] (Part A deductible) | $0 |
61st thru 90th day | All but $[275] a day | $[275] a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $[550] a day | $[550] a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days (lifetime) | $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 $[137.50] a day | Up to $[137.50] a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD (per calendar year) | |||
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 out-patient drugs and inpatient respite care | $0 | Balance |
PLAN I
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[155] of Medicare-approved amounts for covered services (which are noted with an asterisk), your 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 $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | Generally 80% | Generally 20% | $0 |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | 100% | $0 |
BLOOD | |||
First 3 pints | $0 | All costs | $0 |
Next $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOME HEALTH CARE | |||
MEDICARE APPROVED SERVICES | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $[155] of Medicare Approved Amounts* | $0 | $0 | $[155] (Part B deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
AT-HOME RECOVERY SERVICES-NOT COVERED BY MEDICARE | |||
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 to $40 a visit | Balance |
-Number of visits covered (must be received within 8 weeks of last Medicare Approved visit) | $0 | Up to the number of Medicare-approved visits, not to exceed 7 each week | |
-Calendar year maximum | $0 | $1,600 | |
OTHER BENEFITS-NOT COVERED BY MEDICARE | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
FOREIGN TRAVEL- NOT COVERED BY MEDICARE | |||
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 benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
PLAN J
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 $[1100] | $[1100] (Part A deductible) | $0 |
61st thru 90th day | All but $[275] a day | $[275] a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $[550] a day | $[550] a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days (lifetime) | $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 $[137.50] a day | Up to $[137.50] a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD (per calendar year) | |||
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 out-patient drugs and inpatient respite care | $0 | Balance |
PLAN J
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[155] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
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 out-patient drugs and inpatient respite care | $0 | Balance |
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 $[155] of Medicare Approved Amounts* | $0 | $[155] (Part B deductible) | $0 |
Remainder of Medicare Approved Amounts | Generally 80% | Generally 20% | $0 |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | 100% | $0 |
BLOOD | |||
First 3 pints | $0 | All Costs | $0 |
Next $[155] of Medicare Approved Amounts* | $0 | $[155] (Part B deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOME HEALTH CARE | |||
MEDICARE APPROVED SERVICES | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $[155] of Medicare Approved Amounts* | $0 | $[155] (Part B deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
HOME HEALTH CARE AT-HOME RECOVERY SERVICES-NOT COVERED BY MEDICARE | |||
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 to $40 a visit | Balance |
-Number of visits covered (must be received within 8 weeks of last Medicare Approved visit) | $0 | Up to the number of Medicare Approved visits, not to exceed 7 each week | |
-Calendar year maximum | $0 | $1,600 | |
PARTS A & B | |||
OTHER BENEFITS-NOT COVERED BY MEDICARE | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
FOREIGN TRAVEL- NOT COVERED BY MEDICARE | |||
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 benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
***-PREVENTIVE MEDICAL CARE BENEFIT-NOT COVERED BY MEDICARE | |||
Some annual physical and preventive tests and services 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 |
*** Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
HIGH DEDUCTIBLE PLAN J
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.
** This high deductible plan pays the same benefits as Plan J after one has paid a calendar year [$2000] deductible. Benefits from high deductible Plan J will not begin until out-of-pocket expenses are [$2000]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.
SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2000] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2000] DEDUCTIBLE,** YOU PAY |
HOSPITALIZATION* | |||
Semiprivate room and board, general nursing and miscellaneous services and supplies | |||
First 60 days | All but $[1100] | $[1100] (Part A deductible) | $0 |
61st thru 90th day | All but $[275] a day | $[275] a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $[550] a day | $[550] a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days (lifetime) | $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 $[137.50] a day | Up to $[137.50] a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD (per calendar year) | |||
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 out-patient drugs and inpatient respite care | $0 | Balance |
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[155] of Medicar-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
** This high deductible plans pays the same benefits as Plan J after one has paid a calendar year [$2000] deductible. Benefits from high deductible plan J will not begin until out-of-pocket expenses are [$2000]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.
SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2000] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2000] DEDUCTIBLE,** YOU PAY |
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 out-patient drugs and inpatient respite care | $0 | Balance |
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 $[155] of Medicare Approved Amounts* | $0 | $[155] (Part B deductible) | $0 |
Remainder of Medicare Approved Amounts | Generally 80% | Generally 20% | $0 |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | 100% | $0 |
BLOOD | |||
First 3 pints | $0 | All Costs | $0 |
Next $[155] of Medicare Approved Amounts* | $0 | $[155] (Part B deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B | |||
SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2000] DEDUCTIBLE, ** PLAN PAYS | IN ADDITION TO $[2000] DEDUCTIBLE, ** YOU PAY |
HOME HEALTH CARE | |||
MEDICARE APPROVED SERVICES | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $[155] of Medicare Approved Amounts* | $0 | $[155] (Part B deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
HOME HEALTH CARE AT-HOME RECOVERY SERVICES-NOT COVERED BY MEDICARE | |||
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 to $40 a visit | Balance |
-Number of visits covered (must be received within 8 weeks of last Medicare Approved visit) | $0 | Up to the number of Medicare Approved visits, not to exceed 7 each week | |
-Calendar year maximum | $0 | $1,600 | |
PARTS A & B | |||
OTHER BENEFITS-NOT COVERED BY MEDICARE | |||
SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2000] DEDUCTIBLE, ** PLAN PAYS | IN ADDITION TO $[2000] DEDUCTIBLE, ** YOU PAY |
FOREIGN TRAVEL- NOT COVERED BY MEDICARE | |||
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 benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
***PREVENTIVE MEDICAL CARE BENEFIT-NOT COVERED BY MEDICARE | |||
Some annual physical and preventive tests and services 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 |
*** Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
PLAN K
* You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[4620] each calendar year. The amounts that count toward your annual limit are noted with diamonds (A) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayments and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
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 $[1100] | $[550] (50% of Part A deductible) | $[550] (50% of Part A deductible)A |
61st thru 90th day | All but $[275] a day | $[275] a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $[550] a day | $[550] a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days (lifetime) | $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 $[137.50] a day | Up to $[68.75] a day | Up to $[68.75] a day A |
101st day and after | $0 | $0 | All costs |
BLOOD (per calendar year) | |||
First 3 pints | $0 | 50% | 50%A |
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 | Generally, most Medicare eligible expenses for out-patient drugs and inpatient respite care | 50% of coinsurance or copayments | 50% of coinsurance or copaymentsA |
PLAN K
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
**** Once you have been billed $[155] of Medicare-approved amounts for covered services (which are noted with an asterisk), your 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 $[155] of Medicare Approved Amounts**** | $0 | $0 | $[155] (Part B deductible)****A |
Preventive Benefits for Medicare covered services | Generally 80% or more of Medicare approved amounts | Remainder of Medicare approved amounts | All costs above Medicare approved amounts |
Remainder of Medicare Approved Amounts | Generally 80% | Generally 10% | Generally 10%A |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All cost (and they do not count toward annual out-of-pocket limit of [$4620])* |
BLOOD | |||
First 3 pints | $0 | 50% | 50%A |
Next $[155] of Medicare Approved Amounts**** | $0 | $0 | $[155] (Part B deductible)****A |
Remainder of Medicare Approved Amounts | Generally 80% | Generally 10% | Generally 10%A |
CLINICAL LABORATORY SERVICES- | |||
TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
| * This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[4620] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges" and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. | |||
| PARTS A & B | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY* |
HOME HEALTH CARE | |||
MEDICARE APPROVED SERVICES | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment First $[155] of Medicare Approved Amounts****** | |||
$0 | $0 | $[155] (Part B deductible)A | |
Remainder of Medicare Approved Amounts | 80% | 10% | 10%A |
****** Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
PLAN L
* You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[2310] each calendar year. The amounts that count toward your annual limit are noted with diamonds (A) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayments and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
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 $[1100] | $[825] (75% of Part A deductible) | $[275] (25% of Part A deductible)A |
61st thru 90th day | All but $[275] a day | $[275] a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $[550] a day | $[550] a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days (lifetime) | $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 $[137.50] a day | Up to $[103.13] a day | Up to $[34.38] a day A |
101st day and after | $0 | $0 | All costs |
BLOOD (per calendar year) | |||
First 3 pints | $0 | 75% | 25%A |
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 | Generally, most Medicare eligible expenses for out-patient drugs and inpatient respite care | 75% of coinsurance or copayments | 25% of coinsurance or copaymentsA |
PLAN L
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
****Once you have been billed $[155] of Medicare-approved amounts for covered services (which are noted with an asterisk), your 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 $[155] of Medicare Approved Amounts**** | $0 | $0 | $[155] (Part B deductible)**** A |
Preventive Benefits for Medicare covered services | Generally 80% or more of Medicare Approved amounts | Remainder of Medicare approved amounts | All costs above Medicare approved amounts |
Remainder of Medicare approved Amounts | Generally 80% | Generally 15% | Generally 5% A |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All cost (and they do not count toward annual out-of-pocket limit of [$2310])* |
BLOOD | |||
First 3 pints | $0 | 75% | 25% A |
Next $[155] of Medicare Approved Amounts**** | $0 | $0 | $[155] (Part B deductible)A |
Remainder of Medicare Approved Amounts | Generally 80% | Generally 15% | Generally 5% A |
CLINICAL LABORATORY SERVICES- TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
| * This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[2310] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. | |||
| PARTS A & B | |||
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY* |
HOME HEALTH CARE | |||
MEDICARE APPROVED SERVICES | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment First $[155] of Medicare Approved Amounts***** | |||
$0 | $0 | $[155] (Part B deductible)A | |
Remainder of Medicare Approved Amounts | 80% | 15% | 5% A |
*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
N.Y. Comp. Codes R. & Regs. tit. 11, Appendices, app 12A