2019 outline of medicare supplement coverage · 2019 outline of medicare supplement coverage new...
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Form No. 0002_2_Medigap Page 1
2019 Outline of Medicare Supplement CoverageNew Hampshire
Benefit Chart of Medicare Supplement PlansSold for Effective Dates on or After June 1, 2010
This chart shows the benefits included in each of thestandard Medicare supplement plans. Every companyshall make Plan “A” available. Some plans may not beavailable in your State.
Basic Benefits:• Hospitalization – Part A Coinsurance plus coverage for 365 additional
days after Medicare benefits end.• Medical Expenses – Part B Coinsurance (generally 20% of Medicare
approved expenses) or copayments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B Coinsurance or copayments.
• Blood – First three pints of blood each year• Hospice – Part A Coinsurance
Plan A Plan B Plan C Plan D Plan FHigh
DeductiblePlan F*
Plan G Plan K Plan L Plan M Plan N
Basic,including100%Part BCoinsurance
Basic,including100%Part BCoinsurance
Basic,including100%Part BCoinsurance
Basic,including100%Part BCoinsurance
Basic,including100%Part BCoinsurance
Basic,including100%Part BCoinsurance
Basic,including100%Part BCoinsurance
Hospitalizationand preventivecare paid at100%; otherbasic benefitspaid at 50%
Hospitalizationand preventivecare paid at100%; otherbasic benefitspaid at 75%
Basic,including100% Part BCoinsurance
Basic,including100% Part BCoinsurance,except up to$20 copaymentfor office visit,and up to $50copaymentfor ER
Note: The Plans shaded in grey are currently available for sale
* Plan F also has an option called a high Deductible plan F. This high Deductible plan pays the same benefits as Plan F after one has paid a calendaryear $2,300 Deductible. Benefits for high Deductible Plan F will not begin until out-of-pocket expenses exceed $2,300. Out-of-pocket expensesfor this Deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare Deductible for Part A and Part Bbut do not include the plan’s separate foreign travel emergency deductible.
(continued next page)
Form No. 0002_2_Medigap Page 2
2019 Outline of Medicare Supplement Coverage(Page 2 of 2)
Plan A Plan B Plan C Plan D Plan FHigh
DeductiblePlan F*
Plan G Plan K Plan L Plan M Plan N
SkilledNursingFacilityCoinsurance
SkilledNursingFacilityCoinsurance
SkilledNursingFacilityCoinsurance
SkilledNursingFacilityCoinsurance
SkilledNursingFacilityCoinsurance
50% SkilledNursingFacilityCoinsurance
75% SkilledNursingFacilityCoinsurance
SkilledNursingFacilityCoinsurance
SkilledNursingFacilityCoinsurance
Part ADeductible
Part ADeductible
Part ADeductible
Part ADeductible
Part ADeductible
Part ADeductible
50% Part ADeductible
75% Part ADeductible
50% Part ADeductible
Part ADeductible
Part BDeductible
Part BDeductible
Part BExcess(100%)
Part BExcess(100%)
Part BExcess(100%)
ForeignTravelEmergency
ForeignTravelEmergency
ForeignTravelEmergency
ForeignTravelEmergency
ForeignTravelEmergency
ForeignTravelEmergency
ForeignTravelEmergency
Out-of-pocketlimit $5,560paid at 100%after limit isreached
Out-of-pocketlimit $2,780paid at 100%after limit isreached
Note: The Plans shaded in grey are currently available for sale* Plan F also has an option called a high Deductible plan F. This high Deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,300 Deductible. Benefits for high Deductible Plan F will not begin until out-of-pocket expenses exceed $2,300. Out-of-pocket expenses for this Deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare Deductible for Part A and Part B but do not include the plan’s separate foreign travel emergency deductible.
Form No. 0002_2_Medigap Page 3
Issue Age Plan A Plan F Plan G Plan M Plan N
< 65 $289.00 $433.00 $317.00 $314.00 $306.00
65 $171.00 $212.00 $145.00 $175.00 $149.00
66 $174.00 $215.00 $161.00 $177.00 $152.00
67 $178.00 $223.00 $168.00 $180.00 $156.00
68 $181.00 $226.00 $174.00 $186.00 $162.00
69 $185.00 $233.00 $181.00 $192.00 $166.00
70 $190.00 $244.00 $189.00 $198.00 $170.00
71 $198.00 $248.00 $196.00 $203.00 $177.00
72 $204.00 $254.00 $204.00 $208.00 $184.00
73 $207.00 $261.00 $212.00 $211.00 $188.00
74 $209.00 $266.00 $221.00 $217.00 $191.00
75 $214.00 $272.00 $229.00 $221.00 $196.00
76 $217.00 $277.00 $239.00 $225.00 $199.00
77 $224.00 $284.00 $248.00 $227.00 $205.00
78 $226.00 $289.00 $258.00 $232.00 $210.00
79 $231.00 $294.00 $268.00 $235.00 $212.00
80+ $289.00 $433.00 $317.00 $314.00 $306.00
Premium InformationWe, HPHC Insurance Company, Inc. can only raise your premium if we raise the premium for all Policies like yours in this State.
Form No. 0002_2_Medigap Page 4
DisclosuresUse this outline to compare benefits and premiums among
Policies.
This outline shows benefits and premiums of policies sold for
effective dates on or after June 1, 2010.
Read Your Policy Very CarefullyThis is only an outline describing your Policy’s most important
features. The Policy is your insurance contract. You must read
the Policy itself to understand all of the rights and duties of
both you and HPHC Insurance Company, Inc.
Right to Return PolicyIf you find that you are not satisfied with your Policy, you may
return it to HPHC Insurance Company, Inc.
1600 Crown Colony Drive
ATTN: Enrollment/Billing Quincy, MA 02169.
If you send the Policy back to us within 30 days after you
receive it, we will treat the Policy as if it had never been issued
and return all of your payments.
Policy ReplacementIf you are replacing another health insurance Policy, do NOT
cancel it until you have actually received your new Policy and
are sure you want to keep it.
NoticeThis Policy may not fully cover all of your medical costs. HPHC
Insurance Company, Inc. is not connected with Medicare. This
outline of coverage does not give all the details of Medicare
coverage. Contact your local Social Security Office or consult
“Medicare & You” for more details.
Complete Answers Are Very ImportantWhen you fill out the application for the new policy, be sure
to answer truthfully and completely all questions about your
medical and health history. The company may cancel your policy
and refuse to pay any claims if you leave out or falsify important
medical information. Review the application carefully before
you sign it. Be certain that all information has been properly
recorded.
Form No. 0002_2_Medigap Page 5
Plan AMedicare (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 andhave not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days of a Benefit Period All but $1,364 $0 $1,364 (Part A Deductible)
61st through 90th day of a Benefit Period All but $341 a day $341 a day $0
91st day and after of a Benefit Period- While using 60 lifetime reserve days All but $682 a day $682 a day $0
Once lifetime reserve days are used:
- Additional 365 days
- Beyond the additional 365 days
$0
$0
100% of Medicare eligible expenses
$0
$0**
All Costs
** 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.
Form No. 0002_2_Medigap Page 6
Plan A (Continued)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.
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Skilled Nursing Facility Care*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare approved facilitywithin 30 days after leaving the hospital
First 20 days of a Benefit Period All approved amounts $0 $0
21st through 100th day of a Benefit Period All but $170.50 a day $0 Up to $170.50 a day
101st day and after of a Benefit Period $0 $0 All Costs
Blood
First three pints $0 Three pints $0
Additional amounts 100% $0 $0
Hospice CareYou must meet Medicare’s requirements,including a doctor’s certification ofterminal illness
All but very limitedCopayment/Coinsurance foroutpatient drugs and inpatientrespite care
Medicare Copayment/Coinsurance
$0
Form No. 0002_2_Medigap Page 7
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Medical expenses in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medicaland surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment
First $185 of Medicare approved amounts* $0 $0 $185(Part B Deductible)
Remainder of Medicare approved amounts Generally 80% Generally 20% $0
Part B Excess Charges(Above Medicare approved amounts) $0 $0 All Costs
Blood
First three pints $0 All Costs $0
Next $185 of Medicare approved amounts* $0 $0$185(Part B Deductible)
Remainder of Medicare approved amounts 80% 20% $0
Clinical Laboratory Services – Tests forDiagnostic Services
100% $0 $0*
Plan A (Continued)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 Part B Deductiblewill have been met for the calendar year.
Form No. 0002_2_Medigap Page 8
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Home Health Care – Medicare Approved Services
Medically necessary skilled care services andmedical supplies
100% $0 $0
Durable medical equipment
- First $185 of Medicare approved amounts* $0 $0$185(Part B Deductible)
- Remainder of Medicare approved amounts 80% 20% $0
Plan A (Continued)Medicare (Parts A & B)
* Once you have been billed $185 of Medicare approved amounts for covered services (which are noted with an asterisk), your Part B Deductiblewill have been met for the calendar year.
Form No. 0002_2_Medigap Page 9
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
HOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days of a Benefit Period All but $1,364 $1,364 (Part A Deductible) $0
61st through 90th day of a Benefit Period All but $341 a day $341 a day $0
91st day and after of a Benefit Period
- 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
*** 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.
Plan FMedicare (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 havenot received skilled care in any other facility for 60 days in a row.
Form No. 0002_2_Medigap Page 10
Plan F (Continued)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.
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Skilled Nursing Facility Care*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare approved facilitywithin 30 days after leaving the hospital
First 20 days of a Benefit Period All approved amounts $0 $0
21st through 100th day of a Benefit Period All but $170.50 a day Up to $170.50 a day $0
101st day and after of a Benefit Period $0 $0 All Costs
Blood
First three pints $0 Three pints $0
Additional amounts 100% $0 $0
Hospice CareYou must meet Medicare’s requirements,including a doctor’s certification ofterminal illness
All but very limitedCopayment/Coinsurance foroutpatient drugs and inpatientrespite care
Medicare Copayment/Coinsurance
$0
Form No. 0002_2_Medigap Page 11
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Medical expenses in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medicaland surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment
First $185 of Medicare approved amounts* $0 $185(Part B Deductible)
$0
Remainder of Medicare approved amounts Generally 80% Generally 20% $0
Part B Excess Charges(Above Medicare approved amounts) $0 100% $0
Blood
First three pints $0 All Costs $0
Next $185 of Medicare approved amounts* $0$185(Part B Deductible)
$0
Remainder of Medicare approved amounts 80% 20% $0
Clinical Laboratory Services – Tests forDiagnostic Services
100% $0 $0
Plan F (Continued)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 Part B Deductiblewill have been met for the calendar year.
Form No. 0002_2_Medigap Page 12
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Home Health Care – Medicare Approved Services
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment
- First $185 of Medicare approved amounts* $0$185(Part B Deductible)
$0
- Remainder of Medicare approved amounts 80% 20% $0
Plan F (Continued)Medicare (Parts A & B)
* Once you have been billed $185 of Medicare approved amounts for covered services (which are noted with an asterisk), your Part B Deductiblewill have been met for the calendar year.
Plan F (Continued)Other Benefits – Not Covered By Medicare
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
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 $0 $250
- Remainder of charges $080% to a lifetime maximumbenefit of $50,000
20% and amounts over the$50,000 lifetime maximum
Form No. 0002_2_Medigap Page 13
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
HOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days of a Benefit Period All but $1,364 $1,364 (Part A Deductible) $0
61st through 90th day of a Benefit Period All but $341 a day $341 a day $0
91st day and after of a Benefit Period
- While using 60 lifetime reserve days All but $682 a day $682 a day $0
Once lifetime reserve days are used:
- Additional 365 days $0100% of Medicare eligibleexpenses
$0**
- Beyond the additional 365 days $0 $0 All Costs
** 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.
Plan GMedicare (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 havenot received skilled care in any other facility for 60 days in a row.
Form No. 0002_2_Medigap Page 14
Plan G (Continued)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.
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Skilled Nursing Facility Care*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare approved facilitywithin 30 days after leaving the hospital
First 20 days of a Benefit Period All approved amounts $0 $0
21st through 100th day of a Benefit Period All but $170.50 a day Up to $170.50 a day $0
101st day and after of a Benefit Period $0 $0 All Costs
Blood
First three pints $0 Three pints $0
Additional amounts 100% $0 $0
Hospice CareYou must meet Medicare’s requirements,including a doctor’s certification ofterminal illness
All but very limitedCopayment/Coinsurance foroutpatient drugs and inpatientrespite care
Medicare Copayment/Coinsurance
$0
Form No. 0002_2_Medigap Page 15
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Medical expenses in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medicaland surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment
First $185 of Medicare approved amounts* $0 $0 $185(Part B Deductible)
Remainder of Medicare approved amounts Generally 80% Generally 20% $0
Part B Excess Charges(Above Medicare approved amounts) $0 100% $0
Blood
First three pints $0 All Costs $0
Next $185 of Medicare approved amounts* $0 $0$185(Part B Deductible)
Remainder of Medicare approved amounts 80% 20% $0
Clinical Laboratory Services – Tests forDiagnostic Services
100% $0 $0*
Plan G (Continued)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 Part B Deductiblewill have been met for the calendar year.
Form No. 0002_2_Medigap Page 16
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Home Health Care – Medicare Approved Services
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment
- First $185 of Medicare approved amounts* $0 $0$185(Part B Deductible)
- Remainder of Medicare approved amounts 80% 20% $0
Plan G (Continued)Medicare (Parts A & B)
* Once you have been billed $185 of Medicare approved amounts for covered services (which are noted with an asterisk), your Part B Deductiblewill have been met for the calendar year.
Plan G (Continued)Other Benefits – Not Covered By Medicare
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
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 $0 $250
- Remainder of charges $0 80% to a lifetime maximumbenefit of $50,000
20% and amounts over the$50,000 lifetime maximum
Form No. 0002_2_Medigap Page 17
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
HOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days of a Benefit Period All but $1,364$682(50% of Part A Deductible)
$682(50% of Part A Deductible)
61st through 90th day of a Benefit Period All but $341 a day $341 a day $0
91st day and after of a Benefit Period
- While using 60 lifetime reserve days All but $682 a day $682 a day $0
Once lifetime reserve days are used:
- Additional 365 days $0100% of Medicare eligibleexpenses
$0**
- Beyond the additional 365 days $0 $0 All Costs
** 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.
Plan MMedicare (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 havenot received skilled care in any other facility for 60 days in a row.
Form No. 0002_2_Medigap Page 18
Plan M (Continued)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.
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Skilled Nursing Facility Care*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare approved facilitywithin 30 days after leaving the hospital
First 20 days of a Benefit Period All approved amounts $0 $0
21st through 100th day of a Benefit Period All but $170.50 a day Up to $170.50 a day $0
101st day and after of a Benefit Period $0 $0 All Costs
Blood
First three pints $0 Three pints $0
Additional amounts 100% $0 $0
Hospice CareYou must meet Medicare’s requirements,including a doctor’s certification ofterminal illness
All but very limitedCopayment/Coinsurance foroutpatient drugs and inpatientrespite care
Medicare Copayment/Coinsurance
$0
Form No. 0002_2_Medigap Page 19
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Medical expenses in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medicaland surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment
First $185 of Medicare approved amounts* $0 $0 $185(Part B Deductible)
Remainder of Medicare approved amounts Generally 80% Generally 20% $0
Part B Excess Charges(Above Medicare approved amounts) $0 $0 All Costs
Blood
First three pints $0 All Costs $0
Next $185 of Medicare approved amounts* $0 $0$185(Part B Deductible)
Remainder of Medicare approved amounts 80% 20% $0
Clinical Laboratory Services – Tests forDiagnostic Services
100% $0 $0*
Plan M (Continued)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 Part B Deductiblewill have been met for the calendar year.
Form No. 0002_2_Medigap Page 20
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Home Health Care – Medicare Approved Services
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment
- First $185 of Medicare approved amounts* $0 $0 $185(Part B Deductible)
- Remainder of Medicare approved amounts 80% 20% $0
Plan M (Continued)Medicare (Parts A & B)
Plan M (Continued)Other Benefits – Not Covered By Medicare
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
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 $0 $250
- Remainder of charges $0 80% to a lifetime maximumbenefit of $50,000
20% and amounts over the$50,000 lifetime maximum
Form No. 0002_2_Medigap Page 21
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
HOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days of a Benefit Period All but $1,364$1,364(Part A Deductible)
$0
61st through 90th day of a Benefit Period All but $341 a day $341 a day $0
91st day and after of a Benefit Period
- While using 60 lifetime reserve days All but $682 a day $682 a day $0
Once lifetime reserve days are used:
- Additional 365 days $0100% of Medicare eligibleexpenses
$0**
- Beyond the additional 365 days $0 $0 All Costs
** 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.
Plan NMedicare (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 havenot received skilled care in any other facility for 60 days in a row.
Form No. 0002_2_Medigap Page 22
Plan N (Continued)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.
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Skilled Nursing Facility Care*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare approved facilitywithin 30 days after leaving the hospital
First 20 days of a Benefit Period All approved amounts $0 $0
21st through 100th day of a Benefit Period All but $170.50 a day Up to $170.50 a day $0
101st day and after of a Benefit Period $0 $0 All Costs
Blood
First three pints $0 Three pints $0
Additional amounts 100% $0 $0
Hospice CareYou must meet Medicare’s requirements,including a doctor’s certification ofterminal illness
All but very limitedCopayment/Coinsurance foroutpatient drugs and inpatientrespite care
Medicare Copayment/Coinsurance
$0
Form No. 0002_2_Medigap Page 23
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Medical expenses in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medicaland surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment
First $185 of Medicare approved amounts* $0 $0 $185(Part B Deductible)
Remainder of Medicare approved amounts Generally 80% Balance, other than up to $20per office visit and up to $50per emergency room visit.The copayment of up to $50 iswaived if the insured isadmitted to any hospital andthe emergency visit is coveredas a Medicare Part A expense.
Up to $20 per office visit andup to $50 per emergency roomvisit. The copayment of up to$50 is waived if the insured isadmitted to any hospital and theemergency visit is covered as aMedicare Part A expense.
Part B Excess Charges(Above Medicare approved amounts)
$0 $0 All Costs
Plan N (Continued)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 Part B Deductiblewill have been met for the calendar year.
Form No. 0002_2_Medigap Page 24
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Blood
First three pints $0 All Costs $0
Next $185 of Medicare approved amounts* $0 $0$185(Part B Deductible)
Remainder of Medicare approved amounts 80% 20% $0
Clinical Laboratory Services – Tests forDiagnostic Services
$100 $0 $0*
Plan N (Continued)Medicare (Parts A & B)
* Once you have been billed $185 of Medicare approved amounts for covered services (which are noted with an asterisk), your Part B Deductiblewill have been met for the calendar year.
Medicare (Parts A & B)
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Home Health Care – Medicare Approved Services
Medically necessary skilled care services andmedical supplies 100% $0 $0
Durable medical equipment
- First $185 of Medicare approved amounts* $0 $0$185(Part B Deductible)
- Remainder of Medicare approved amounts 80% 20% $0
* Once you have been billed $185 of Medicare approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
Form No. 0002_2_Medigap Page 25
SERVICES MEDICARE PAYS: PLAN PAYS: YOU PAY:
Foreign Travel – Not Covered By Medicare
Medically necessary emergency care services beginningduring the first 60 days of each trip outside the USA
- First $250 each calendar year $0 $0 $250
- Remainder of charges $080% to a lifetime maximumbenefit of $50,000
20% and amounts over the$50,000 lifetime maximum
Plan N (Continued)Other Benefits – Not Covered By Medicare
Form No. 0002_2_Medigap Page 26
NOTES
Form No. 0002_2_Medigap Page 27
NOTES