Original Medicare Part A covers...(1)

Medicare-eligible Hospital Expenses for semiprivate room and board, general nursing, and miscellaneous services and supplies during each benefit period.(2)

What you pay with Medicare alone

Your out-of-pocket costs with plan:

  • A
  • F
  • G
  • N
For the first 60 days
(Part A deductible)
$ ________ $ ________ $0 $0 $0
From 61st thru 90th day $ ____a day $0 $0 $0 $0
From 91st through 150 days
(60 Lifetime Reserve Days)
$ ____a day $0 $0 $0 $0
For additional 365 days All costs $0 $0 $0 $0
Beyond additional 365 days All costs All costs All costs All costs All costs
Blood - first three pints
(not replaced)
All costs $0 $0 $0 $0
Hospice Care Copay
(for Inpatient Respite Care)
5% $0 $0 $0 $0

Skilled Nursing Care in a Medicare-certified nursing facility, when received within 30 days of a three day Medicare approved hospital stay.

What you pay with Medicare alone

Your out-of-pocket costs with plan:

  • A
  • F
  • G
  • N
For the first 20 days $0 $0 $0 $0 $0
From the 21st thru 100th day $ ____a day $ ____a day $0 $0 $0
Beyond 100 days All costs All costs All costs All costs All costs
Notes

(1) Part A benefits current as of January, 2014.

(2) “Benefit Period” means a period starting on the first day of covered hospital confinement, and ending on the 60th consecutive day you are not confined in a hospital (as defined by Medicare).

Original Medicare Part B covers...(3)

Medical Care for Medicare-approved physician services, in- and outpatient medical & surgical services and supplies, physical and speech therapy, diagnostics tests(4), and durable medical equipment.

What you pay with Medicare alone

Your out-of-pocket costs with plan:

  • A
  • F
  • G
  • N
Part B annual deductible $ ________ $ ________ $0 $ ________ $ ________
Remainder of Medicare approved charges
(Part B coinsurance)
20% $0 $0 $0 $0
Part B Office Visit copayment (5) 20% $0 $0 $0 Up to $ ____
Part B Emergency Room copayment(5) 20% $0 $0 $0 Up to $ ____
Part B excess charges All costs All costs $0 $0 All costs
Blood - first three pints
(not replaced)
All costs $0 $0 $0 $0

Foreign Travel for medically necessary emergency care that begins during the first 60 days of each trip outside the U.S. for care that would have been covered by Medicare if provided in the U.S.(6)

What you pay with Medicare alone

Your out-of-pocket costs with plan:

  • A
  • F
  • N
First $250 per year All costs All costs $250 $250 $250
Remainder of charges All costs All costs 20% 20% 20%
Notes

(3) Part B benefits current as of January 2014.

(4) Diagnostic laboratory work for Medicare-approved blood tests is paid in full by Medicare.

(5) Copayment amounts apply after the Part B Deductible has been met.

(6) The Foreign Travel benefit is subject to a Lifetime Maximum of $50,000.

Contact Us

Please fill out your information and an agent will contact you within 24 hours.
* Required Fields