SERVICES | PER BENEFIT PERIOD | MEDICARE PAYS | [AFTER YOU PAY A $[ ] DEDUCTIBLE] THIS POLICY PAYS | YOU PAY |
HOSPITALIZATION Semiprivate room and board, general nursing and miscellaneous hospital services and supplies. | First 60 days | All but $ [current deductible] | $0 or [V OPTIONAL PART A DEDUCTIBLE RIDER* (for non-high deductible plans)] [V PART A DEDUCTIBLE RIDER* (for high deductible plans)] V OPTIONAL MEDICARE 50% PART A DEDUCTIBLE RIDER*** |
61st to 90th days | All but $ [current amount] per day | $ [current amount] per day |
91st day and after while using 60 lifetime reserve days | All but $ [current amount] per day | $ [current amount] per day |
Once lifetime reserve days are used: Additional 365 days | $0 | 100% of Medicare eligible expenses** |
Beyond the additional 365 days | $0 | $0 |
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 |
21st through 100th day | All but $ [current amount] per day | Up to $[ ] a day |
101st day and after | $[0] | $0 |
INPATIENT PSYCHIATRIC CARE Inpatient psychiatric care in a participating psychiatric hospital | 190 days per lifetime | 175 days per lifetime |
BLOOD | First 3 pints | $0 | First 3 pints |
Additional amounts | 100% | $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 or copayment for outpatient drugs and inpatient respite care | $0 or [ ]% of coinsurance or copayments |
MEDICARE PART B BENEFITS | PER CALENDAR YEAR | MEDICARE PAYS | THIS POLICY PAYS | YOU PAY |
MEDICAL EXPENSES Eligible expense for physician’s services, in-patient and out-patient medical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment | First $[ ] of Medicare approved amounts* | $0 | $0 |
Remainder of Medicare approved amounts | Generally 80% | Generally 20% [V OPTIONAL MEDICARE PART B EXCESS CHARGES RIDER** (for non-high deductible plans)] [V MEDICARE PART B EXCESS CHARGES RIDER** (for high deductible plans)] [V OPTIONAL FOREIGN TRAVEL EMERGENCY RIDER** (non-high deductible plans)] [V FOREIGN TRAVEL EMERGENCY RIDER** (for high-deductible plans)] |
BLOOD | First 3 pints | $0 | All costs |
Next $[ ] of Medicare approved amounts* | $0 | [$] |
Remainder of Medicare approved amounts | 80% | 20% |
CLINICAL LABORATORY SERVICES Tests for diagnostic services | 100% | $0 |
HOME HEALTH CARE | 100% of charges for visits considered medically necessary by Medicare | 40 visits or V OPTIONAL ADDITIONAL HOME HEALTH CARE RIDER** |
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] | $250 | 20% and amounts over the $50,000 lifetime maximum |
Remainder of charges | 80% to a lifetime maximum benefit of $50,000 |
[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] |
[Additional charges] | [$0] | [$0] or $[dollar amount] |
SERVICES | PER BENEFIT PERIOD | MEDICARE PAYS | [AFTER YOU PAY A $[ ] DEDUCTIBLE] THIS POLICY PAYS | YOU PAY |
HOSPITALIZATION Semiprivate room and board, general nursing and miscellaneous hospital services and supplies. | First 60 days | All but $ [current deductible] | $[ ] (50% or 75% of Medicare Part A deductible.) | |
61st to 90th days | All but $ [current amount] per day | $ [current amount] per day |
91st day and after while using 60 lifetime reserve days | All but $ [current amount] per day | $ [current amount] per day |
Once lifetime reserve days are used: Additional 365 days | $0 | 100% of Medicare eligible expenses** |
Beyond the additional 365 days | $0 | $0 |
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 | |
21st through 100th day | All but $ [current amount] per day | Up to $[ ] a day |
101st day and after | $0 | $0 |
INPATIENT PSYCHIATRIC CARE Inpatient psychiatric care in a participating psychiatric hospital | 190 days per lifetime | 175 days per lifetime |
BLOOD | First 3 pints | $0 | [50% or 75%] | |
Additional amounts | 100% | $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 or copayment for outpatient drugs and inpatient respite care | [50% or 75%] of coinsurance or copayments | |
MEDICARE PART B BENEFITS | PER CALENDAR YEAR | MEDICARE PAYS | THIS POLICY PAYS | YOU PAY |
MEDICAL EXPENSES Eligible expense for physician’s services, in-patient and out-patient medical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment | First $[ ] of Medicare approved amounts* | $0 | $0 | |
Preventive Benefits for Medicare covered services | Generally 75% or more of Medicare approved amounts | Remainder of Medicare approved amounts |
Remainder of Medicare approved amounts | Generally 80% | Generally [10% or 15%] | |
BLOOD | First 3 pints | $0 | [50% or 75%] | |
Next $[ ] of Medicare approved amounts* | $0 | $0 | |
Remainder of Medicare approved amounts | Generally 80% | Generally [10% or 15%] | |
CLINICAL LABORATORY SERVICES Tests for diagnostic services | 100% | $0 |
HOME HEALTH CARE | 100% of charges for visits considered medically necessary by Medicare | 40 visits or V OPTIONAL ADDITIONAL HOME HEALTH CARE RIDER** |
[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] |
[Additional charges]** | [$0]** | [$0] or $[dollar amount]** |
SERVICES | PER BENEFIT PERIOD | MEDICARE PAYS | [AFTER YOU PAY A $[ ] DEDUCTIBLE] THIS POLICY PAYS | YOU PAY |
HOSPITALIZATION Semiprivate room and board, general nursing and miscellaneous hospital services and supplies. | First 60 days | All but $ [current deductible] | $0 or [ ]% of Medicare Part A deductible | |
61st to 90th days | All but $ [current amount] per day | $ [current amount] per day |
91st day and after while using 60 lifetime reserve days | All but $ [current amount] per day | $ [current amount] per day |
Once lifetime reserve days are used: Additional 365 days | $0 | 100% of Medicare eligible expenses** |
Beyond the additional 365 days | $0 | $0 |
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 |
21st through 100th day | All but $ [current amount] per day | Up to $[ ] a day | |
101st day and after | $0 | $0 |
INPATIENT PSYCHIATRIC CARE Inpatient psychiatric care in a participating psychiatric hospital | 190 days per lifetime | 175 days per lifetime |
BLOOD | First 3 pints | $0 | [3 pints] or [ ] % | |
Additional amounts | 100% | $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 or copayment for outpatient drugs and inpatient respite care | $0 or [ ]% of coinsurance or copayments | |
MEDICARE PART B BENEFITS | PER CALENDAR YEAR | MEDICARE PAYS | THIS POLICY PAYS | YOU PAY |
MEDICAL EXPENSES Eligible expense for physician’s services, in-patient and out-patient medical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment | First $[ ] of Medicare approved amounts | $0 | $0 | |
[Preventive Benefits for Medicare covered services**] | [Generally [ ]% or more of Medicare approved amounts**] | [Remainder of Medicare approved amounts**] |
Remainder of Medicare approved amounts | Generally 80% | Generally [10% or 15%] | |
BLOOD | First 3 pints | $0 | [ ]% | |
Next $[ ] of Medicare approved amounts* | $0 | $0 | |
Remainder of Medicare approved amounts | Generally 80% | Generally [10% or 15%] | |
CLINICAL LABORATORY SERVICES Tests for diagnostic services | 100% | $0 |
HOME HEALTH CARE | 100% of charges for visits considered medically necessary by Medicare | 365 visits for medically necessary services |
[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] |
[Additional charges]** | [$0]** | [$0] or $[dollar amount]** |
SERVICES | MEDICARE BENEFITS | YOUR [MEDICARE SUPPLEMENT OR MEDICARE REPLACEMENT COST] COVERAGE |
In 2____, Medicare Pays Per Benefit Period | Effective January 1, 2____, Medicare will Pay | In 2____, Your Coverage Pays | Effective January 1, 2____, Your Coverage will Pay Per Calendar Year |
MEDICARE PART A SERVICES AND SUPPLIES |
HOSPITALIZATION Inpatient Hospital Services, Semi-Private Room & Board, Misc. Hospital Services & Supplies, such as Drugs, X-Rays, Lab Tests & Operating Room | All but $___ for the first 60 days/benefit period All but $___ a day for 61st-90th days/benefit period All but $___ a day for 91st day and after while using 60 lifetime reserve days $0 once lifetime reserve days are used: Additional 365 days $0 beyond additional 365 days. | All but $___ for the first 60 days/benefit period All but $___ a day for 61st-90th days/benefit period All but $ [current amount] per day $0 once lifetime reserve days are used: Additional 365 days $0 beyond the additional 365 days. |
SKILLED NURSING FACILITY CARE Skilled nursing care in a facility approved by Medicare. Confinement must meet Medicare standards. You must have been in a hospital for at least 3 days and enter the facility within 30 days after discharge. | First 20 days 100% of costs All but $___ (current amount per day) for the 21st - 100th day $[0] of the 101st day and thereafter. | First 20 days 100% of costs All but $___ (current amount per day) for the 21st - 100th day $[0] of the 101st day and thereafter. |
BLOOD | Pays all costs except payment of deductible (equal to costs for first 3 pints) each calendar year. Part A blood deductible reduced to the extent paid under Part B | $0 for first 3 pints. 100% of additional amounts |
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 or copayment for outpatient drugs and inpatient respite care $0 or [ ]% of coinsurance or copayments | All but very limited coinsurance or copayment for outpatient drugs and inpatient respite care $0 or [ ]% of coinsurance or copayments | |
MEDICARE PART B SERVICES AND SUPPLIES |
MEDICAL EXPENSES Eligible expense for physician’s services, medical services in and out patient, physical and speech therapy, diagnostic tests, and durable medical equipment. | After $[ ] deductible, generally 80% of remainder of Medicare approved amounts | After $[ ] deductible, generally 80% of remainder of Medicare approved amounts |
Home Health Care | 100% of charges for visits considered medically necessary by Medicare | 40 visits |
Preventive Medical Care Benefit Some annual physical and preventive tests and services administered or ordered by your doctor when NOT covered by Medicare | $0 | $0 | $120 |
