100% of Part A
Hospitalization
Coinsurance plus
coverage for 365
days after Medicare
Benefits End
75% Hospice
cost-sharing
75% of
Medicare-eligible
expenses for the
first three pints of
blood
75% Part B
Coinsurance, except
100% Coinsurance for
Part B Preventive
Services
Skilled Nursing
75% Skilled Nursing
Facility Coinsurance
Part A Deductible
75% Part A
Deductible
Part B Deductible
Part B Excess (100%)
Foreign Travel
Emergency
At-Home Recovery
Preventive Care NOT
covered by Medicare
$2310 Out of Pocket
Annual Limit***
Notes
1. States may allow only
some of the ten standard
benefit plans.
2. States may approve
innovative additional
benefit plans under certain
circumstances.
3. These standard benefit
plans do not apply to
policies sold in MA, MN and
WI.
4. Availability of plans
varies from company to
company.
** Plans K and L provide for
different cost-sharing for
items and services than
Plans A-J.
Once your reach the annual
limit, the plans pays 100%
of the Medicare co-payments,
coinsurance, and deductibles
for the rest of the calendar
year. The out-of-pocket
annual limit does NOT
include charges from your
provider that exceed
Medicare-approved amounts,
called "Excess Charges". You
will be responsible for
paying excess charges.
** The out-of-pocket annual
limit will increase each
year for inflation.