Hospital Services (Medicare Part A)
| Benefit: | Medicare Pays | The Plan Pays | You Pay | ||||||
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Hospitalization |
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Skilled Nursing Facility Care |
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| Hospice Care | All but a very limited copayment or coinsurance for outpatient drugs and inpatient respite care |
Medicare co-payment or co-insurance |
$0 |
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Home Health Care |
100% Medicare allowance |
$0 |
$0 |
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Blood (Part A and Part B) |
All costs except non - replacement fees (blood deductible) for first 3 pints each calendar year |
First 3 pints of blood or blood derivatives, unless replaced or paid for under part B benefit |
Up to 100% of the Part B deductible |
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Medical Services (Medicare Part B)
*See any doctor or specialist that accepts Medicare
| Benefit: | Medicare Pays | The Plan Pays | You Pay |
|---|---|---|---|
|
Physician Services |
80% Medicare allowance |
20% of Medicare allowance after meeting the Part B deductible |
100% of the Part B deductible |
|
Part B Excess Charges |
$0 |
For non-assigned claims, 100% of difference between actual billed charge and Medicare''s eligible expense |
$0 |
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Durable Medical Equipment (DME) |
80% of Medicare allowance after Part B deductible has been met |
20% of Medicare allowance after meeting the Part B deductible |
100% of the Part B deductible |
|
Foreign Travel (Not covered by Medicare) |
$0 |
80% to lifetime maximum benefit of $50,000 after initial $250 |
Initial $250 then 20% up to the $50,000 lifetime Maximum and any amount over that Maximum |
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