|
Modernized Plan K
2019
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. |
Service: |
HOSPITALIZATION*
Semiprivate room and
board, general nursing
and miscellaneous
services and supplies: |
|
MEDICARE PAYS |
PLAN PAYS |
YOU PAY**▲ |
First 60 days |
All but $1,364 |
$682 (Part A
Deductible) |
$658**▲ |
61st through 90th day |
All but $341 a day |
$341 a day |
$0 |
91st day and after: |
|
|
|
While using 60 lifetime
reserve days |
All but $682 a day |
$682 a day |
$0 |
Once lifetime reserve
days are used: |
|
|
|
Additional 365 days |
$0 |
100% of Medicare
Eligible Expenses |
$0** |
Beyond the Additional
365 days |
$0 |
$0 |
All costs |
Service: |
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 through 100th day |
All
but $170.50 a day |
Up to
$85.25 a day |
$85.25
per day**▲ |
101st day and after |
$0 |
$0 |
All costs |
Service: |
BLOOD
|
First 3 pints |
$0 |
50% |
50%**▲ |
Additional amounts |
100% |
$0 |
$0 |
Service: |
HOSPICE CARE
Available as long as you
meet Medicare's
requirements,
your doctor certifies
you are terminally ill
and you elect to receive
these services. |
Outpatient Prescription
Drugs |
All but $5 |
50% co-payment /
co-insurance |
50% Medicare
co-payment/coinsurance**▲ |
Inpatient Respite Care |
All but 5% |
50% of Medicare's
approved amount |
50% of Medicare's
approved amount**▲ |
**NOTICE: When your
Medicare Part A hospital
benefits are exhausted,
the insurer stands in
the place of Medicare
and will pay whatever
amount Medicare would
have paid for up to an
additional 365 days as
provided in the policy's
"Core Benefits." During
this time the hospital
is prohibited from
billing you for the
balance based on any
difference between its
billed charges and the
amount Medicare would
have paid. |
|
Modernized Plan K
2019
MEDICARE (PART B)
- MEDICAL SERVICES - PER
CALENDAR YEAR* |
* Once you have been
billed $185 of
Medicare-Approved
amounts for covered
services (which are
noted with an asterisk),
your Medicare Part B
Deductible will have
been met for the
calendar year.
|
Service: |
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: |
|
MEDICARE PAYS |
PLAN PAYS |
YOU PAY**▲ |
First $185 of Medicare
Approved Amounts* |
$0 |
$0 |
$185 |
Preventive Benefits for
Medicare Covered
Services |
Generally 75% or more of
Medicare approved
amounts |
Remainder of Medicare
approved amounts. |
All cost above Medicare
approved amounts |
Remainder of Medicare
Approved Amounts |
Generally 80% |
Generally 10% |
Generally 10%**▲ |
Part B Excess Charges
(Above Medicare Approved
Amounts) |
$0 |
$0 |
All cost (and they don't
count toward annual out
of pocket limit of $5560 |
Service: |
BLOOD |
First 3 pints |
$0 |
50% |
50%**▲ |
Next $185 of Medicare
Approved Amounts* |
$0 |
$0 |
$185 (Part B Deductible)**▲ |
Remainder of Medicare
Approved Amounts |
80% |
10% |
Generally 10%**▲ |
Service: |
CLINICAL LABORATORY
SERVICES |
Tests for Diagnostic
Services |
100% |
$0 |
$0 |
|
PARTS A & B* |
Service: |
HOME HEALTH CARE
Medicare Approved
Services: |
|
MEDICARE PAYS |
PLAN PAYS |
YOU PAY* |
Medically necessary
skilled care services
and medical supplies |
100% |
$0 |
$0 |
Durable medical
equipment:
Medicare-approved
services |
$0 |
$0 |
$185.00**▲ |
Remainder of Medicare
Approved Amounts |
80% |
10% |
10%**▲ |
|
Annual out-of-pocket
limit |
|
|
$5560**▲ |
* This plan limits your
annual out-of-pocket
payments for
Medicare-approved
amounts to $5560 per
calendar year. However,
this limit does NOT
include charges from a
provider that exceed
Medicare-approved
amounts (these amounts
are called " Excess
Charges") and you will
be responsible for
paying the difference in
the amount charged by
your provider and the
amount paid by Medicare
for the item of service. |
|
|
**▲ You will pay half
the coat-sharing until
you meet the annual
out-of-pocket limit of
$5560 each calendar
year. The amounts that
count toward your annual
limit are noted with the
(**▲)symbol's in the
chart above. Once you
meet the annual limit,
the plan pays 100% of
the co-payment and
co-insurance for the
rest of the calendar
year. However, this
limit does NOT include
charges from your
provider that exceed
Medicare-approved
amounts (these amounts
are called " Excess
Charges") and you will
be responsible for
paying the difference in
the amount charged by
your provider and the
amount paid by Medicare
for the item of service. |