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IAC
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191—37.17
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}
{\plain\f4\fs21\b\cf2\ulc2
(514D) Required disclosure provisions.
}
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{\plain\f4\fs21\b\cf2\ulc2
37.17(1)
}
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}
{\plain\f4\fs21\i\cf2\ulc2
General rules.
}
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}
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}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\i\cf2\ulc2
}
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}
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\tab
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Medicare supplement policies and certificates shall include a renewal or continuation provision. The language or specifications of such provisions shall be consistent with the type of contract issued. Such provision shall be appropriately captioned and shall appear on the first page of the policy, and shall include any reservation by the issuer of the right to change premiums and any automatic renewal premium increases based on the policyholder’s age.
}
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}
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}
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b.
}
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}
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}
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\tab
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Except for riders or endorsements by which the issuer effectuates a request made in writing by the insured, exercises a specifically reserved right under a Medicare supplement policy, or is required to reduce or eliminate benefits to avoid duplication of Medicare benefits, all riders or endorsements added to a Medicare supplement policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require a signed acceptance by the insured. After the date of policy or certificate issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term shall be agreed to in writing signed by the insured, unless the benefits are required by the minimum standards for Medicare supplement policies, or if the increased benefits or coverage is required by law. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, such premium charge shall be set forth in the policy.
}
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}
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}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\i\cf2\ulc2
}
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}
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\tab
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{\plain\f4\fs21\cf2\ulc2
Medicare supplement policies or certificates shall not provide for the payment of benefits based on standards described as “usual and customary,” “reasonable and customary” or words of similar import.
}
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}
{\plain\f4\fs21\i\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\i\cf2\ulc2
}
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}
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\tab
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{\plain\f4\fs21\cf2\ulc2
If a Medicare supplement policy or certificate contains any limitations with respect to preexisting conditions, such limitations shall appear as a separate paragraph of the policy and be labeled as “Preexisting Condition Limitations.”
}
\par
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}
{\plain\f4\fs21\i\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\i\cf2\ulc2
}
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}
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\tab
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{\plain\f4\fs21\cf2\ulc2
Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the policyholder or certificate holder shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the insured person is not satisfied for any reason.
}
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}
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}
{\plain\f4\fs21\i\cf2\ulc2
f.
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{\plain\f4\fs21\i\cf2\ulc2
}
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}
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\tab
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}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\~\~Issuers of accident and sickness policies, or certificates which provide hospital or medical expense coverage on an expense-incurred or indemnity basis to a person(s) eligible for Medicare shall provide to those applicants a Guide to Health Insurance for People with Medicare in the form developed jointly by the National Association of Insurance Commissioners and CMS and in a type size no smaller than 12-point type. Delivery of the Guide shall be made whether or not such policies or certificates are advertised, solicited or issued as Medicare supplement policies or certificates as defined in this chapter. Except in the case of direct response issuers, delivery of the Guide shall be made to the applicant at the time of application and acknowledgment of receipt of the Guide shall be obtained by the issuer. Direct response issuers shall deliver the Guide to the applicant upon request but not later than at the time the policy is delivered.
}
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(2)
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For the purposes of this rule, “form” means the language, format, type size, type proportional spacing, bold character and line spacing.
}
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37.17(2)
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Notice requirements.
}
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{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\i\cf2\ulc2
}
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}
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{\plain\f4\fs21\cf2\ulc2
As soon as practicable, but no later than 30 days prior to the annual effective date of any Medicare benefit changes, an issuer shall notify its policyholders and certificate holders of modifications it has made to Medicare supplement insurance policies or certificates in a format acceptable to the commissioner.
}
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{\plain\f4\fs21\cf2\ulc2
(1)
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{\plain\f4\fs21\cf2\ulc2
Include a description of revisions to the Medicare program and a description of each modification made to the coverage provided under the Medicare supplement policy or certificate, and
}
\par
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{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
(2)
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}
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{\plain\f4\fs21\cf2\ulc2
Inform each policyholder or certificate holder as to when any premium adjustment is to be made due to changes in Medicare.
}
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}
{\plain\f4\fs21\i\cf2\ulc2
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b.
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The notice of benefit modifications and any premium adjustments shall be in outline form and in clear and simple terms so as to facilitate comprehension.
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}
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Such notices shall not contain or be accompanied by any solicitation.
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37.17(3)
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MMA notice requirements.
}
{\plain\f4\fs21\cf2\ulc2
Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
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37.17(4)
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Outline of coverage requirements for Medicare supplement policies.
}
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}
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a.
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Issuers shall provide an outline of coverage to all applicants at the time application is presented to the prospective applicant and, except for direct response policies, shall obtain an acknowledgment of receipt of such outline from the applicant; and
}
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{\plain\f4\fs21\cf2\ulc2
If an outline of coverage is provided at the time of application and the Medicare supplement policy or certificate is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate shall accompany such policy or certificate when it is delivered and contain the following statement, in no less than 12-point type, immediately above the company name:
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“NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued.”
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}
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}
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c.
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}
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}
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{\plain\f4\fs21\cf2\ulc2
The outline of coverage provided to applicants pursuant to this subrule consists of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage shall be in the language and format prescribed below in no less than 12-point type. All plans shall be shown on the cover page, and the plans that are offered by the issuer shall be prominently identified. Premium information for plans that are offered shall be shown on the cover page or immediately following the cover page and shall be prominently displayed. The premium and mode shall be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant shall be illustrated.
}
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The following items shall be included in the outline of coverage in the order prescribed below.
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\par
\pard\qc\sl250
{\plain\f4\fs21\b\cf2\ulc2
Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010
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\par
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{\plain\f4\fs21\cf2\ulc2
This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan “A” available. Some plans may not be available in your state.
}
\par
\pard\qj\sl250
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Plans E, H, I, and J are no longer available for sale. [This sentence shall not appear after June 1, 2011.]
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Basic Benefits:
}
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Hospitalization
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– Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
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Medical Expenses
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– 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.
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– First three pints of blood each year.
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Hospice
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– Part A coinsurance.
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\pard\intbl\qc\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\qc\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\qc\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\qc\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\qc\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\qc\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\qc\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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\cell
\pard\intbl\qc\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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\pard\intbl\qc\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\qc\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
A
}
\cell
\pard\intbl\qc\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
B
}
\cell
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{\plain\f4\fs14\cf2\ulc2
C
}
\cell
\pard\intbl\qc\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
D
}
\cell
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{\plain\f4\fs14\cf2\ulc2
F
}
\cell
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{\plain\f4\fs14\cf2\ulc2
F*
}
\cell
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{\plain\f4\fs14\cf2\ulc2
G
}
\cell
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\cell
\pard\intbl\qc\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
K
}
\cell
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{\plain\f4\fs14\cf2\ulc2
L
}
\cell
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{\plain\f4\fs14\cf2\ulc2
M
}
\cell
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{\plain\f4\fs14\cf2\ulc2
N
}
\cell
\pard\intbl\qc\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
Basic, including 100% Part B co-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
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{\plain\f4\fs14\cf2\ulc2
Basic, including 100% Part B co-
}
\par
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{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
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{\plain\f4\fs14\cf2\ulc2
Basic, including 100% Part B co-
}
\par
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{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
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{\plain\f4\fs14\cf2\ulc2
Basic, including 100% Part B co-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
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{\plain\f4\fs14\cf2\ulc2
Basic, including 100% Part B co-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
insurance*
}
\cell
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{\plain\f4\fs14\cf2\ulc2
Basic, including 100% Part B co-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
\pard\intbl
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Hospitali-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
zation and preven-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
tive care paid at 100%; other basic benefits paid at 50%
}
\cell
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{\plain\f4\fs14\cf2\ulc2
Hospitali-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
zation and preven-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
tive care paid at 100%; other basic benefits paid at 75%
}
\cell
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{\plain\f4\fs14\cf2\ulc2
Basic, including 100% Part B co-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
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{\plain\f4\fs14\cf2\ulc2
Basic, including 100% Part B co-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
insurance, except up to $20 copay-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
ment for office visit, and up to $50 copay-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
ment for ER
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Skilled Nursing Facility Co-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Skilled Nursing Facility Co-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Skilled Nursing Facility Co-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Skilled Nursing Facility Co-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
\pard\intbl
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
50% Skilled Nursing Facility Co-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
75% Skilled Nursing Facility Co-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Skilled Nursing Facility Co-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Skilled Nursing Facility Co-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\row
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\cellx8696
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Part A Deductible
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Part A Deductible
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Part A Deductible
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Part A Deductible
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Part A Deductible
}
\cell
\pard\intbl
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
50% Part A Deduc-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
tible
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
75% Part A Deduc-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
tible
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
50% Part A Deduc-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
tible
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Part A Deduc-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
tible
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5442
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8610
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\cellx8696
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Part B Deductible
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Part B Deductible
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft0
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5341
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5442
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx7818
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\cellx8696
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Part B
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Excess (100%)
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Part B
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Excess
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
(100%)
}
\cell
\pard\intbl
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft0
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Foreign Travel Emer-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
gency
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Foreign Travel Emer-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
gency
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Foreign Travel Emergency
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Foreign Travel Emer-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
gency
}
\cell
\pard\intbl
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Foreign Travel Emer-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
gency
}
\cell
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{\plain\f4\fs14\cf2\ulc2
Foreign Travel Emer-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
gency
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft0
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Out-of-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
pocket limit $[4140]; paid at 100% after limit reached
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Out-of-
}
\par
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
pocket limit $[2070]; paid at 100% after limit reached
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadfr3\clpadr80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
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\pard\sb140\qj\sl250
{\plain\f4\fs18\cf2\ulc2
* 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 $[1860] deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $[1860]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PREMIUM INFORMATION
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
We [insert issuer’s name] can only raise your premium if we raise the premium for all policies like yours in this State. [If the premium is based on the increasing age of the insured, include information specifying when premiums will change.]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
DISCLOSURES
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
Use this outline to compare benefits and premiums among policies.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
This outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates prior to June 1, 2010, have different benefits and premiums. Plans E, H, I, and J are no longer available for sale. [The last sentence of this paragraph shall not appear after June 1, 2011.]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
READ YOUR POLICY VERY CAREFULLY
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
This 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 your insurance company.
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
RIGHT TO RETURN POLICY
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
If you find that you are not satisfied with your policy, you may return it to [insert issuer’s address]. 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.
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
POLICY REPLACEMENT
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
If 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.
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
NOTICE
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
This policy may not fully cover all of your medical costs.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
[for agents: ]
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
Neither [insert company’s name] nor its agents are connected with Medicare.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
[for direct response: ]
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
[Insert company’s name] is not connected with Medicare.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security office or consult “Medicare and You” for more details.
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
COMPLETE ANSWERS ARE VERY IMPORTANT
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
When 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. [If the policy or certificate is guaranteed issue, this paragraph need not appear.]
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
[Include for each plan prominently identified in the cover page a chart showing the services, Medicare payments, plan payments and insured payments, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this subrule. An issuer may use additional benefit plan descriptions on these charts pursuant to subrule 37.10(4).]
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the commissioner.]
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PLAN A
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
\par
\pard\plain\f0\fs16
\par
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SERVICES
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MEDICARE PAYS
}
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
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HOSPITALIZATION
}
{\plain\f4\fs16\cf2\ulc2
*
}
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{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First 60 days
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All but $[992]
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$[992] (Part A deductible)
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61st through 90th day
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{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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\clpadft3\clpadt80
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—While using 60 lifetime reserve days
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{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
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{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
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{\plain\f4\fs16\cf2\ulc2
$0
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—Once lifetime reserve days are used:
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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—Additional 365 days
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$0
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{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
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$0**
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{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
All costs
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl
\cell
\pard\intbl
\cell
\pard\intbl
\cell
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
\row
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
SERVICES
}
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\pard\intbl\qj\li80\ri90\fi130\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\fi130\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
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$0
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{\plain\f4\fs16\cf2\ulc2
All costs
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{\plain\f4\fs16\cf2\ulc2
$0
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Next $[131] of Medicare-Approved Amounts***
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$0
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$0
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$[131] (Part B deductible)
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{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
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{\plain\f4\fs16\cf2\ulc2
80%
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{\plain\f4\fs16\cf2\ulc2
20%
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
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{\plain\f4\fs16\cf2\ulc2
100%
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
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{\plain\f4\fs21\cf2\ulc2
PARTS A & B
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SERVICES
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MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
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HOME HEALTH CARE
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{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services
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{\plain\f4\fs16\cf2\ulc2
and medical supplies
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{\plain\f4\fs16\cf2\ulc2
100%
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved
}
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{\plain\f4\fs16\cf2\ulc2
Amounts***
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
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{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved
}
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{\plain\f4\fs16\cf2\ulc2
Amounts
}
\cell
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{\plain\f4\fs16\cf2\ulc2
80%
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{\plain\f4\fs16\cf2\ulc2
20%
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\cell
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
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{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
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{\plain\f4\fs21\cf2\ulc2
PLAN B
}
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{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
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HOSPITALIZATION
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{\plain\f4\fs16\cf2\ulc2
*
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{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 60 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[992] (Part A deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0**
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
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{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
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{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
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{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
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\pard\plain\f0\fs16
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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\cell
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
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\clpadfr3\clpadr80
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\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\pard\intbl\qj\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
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\pard\intbl\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
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{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
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{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts***
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\keepn\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
\par
\pard\plain\f0\fs17
\par
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
}
\par
\pard\intbl\li80\ri90\fi158\sl180
{\plain\f4\fs16\cf2\ulc2
medical supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved
}
\par
\pard\intbl\li80\ri90\fi432\sl180
{\plain\f4\fs16\cf2\ulc2
Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved
}
\par
\pard\intbl\li80\ri90\fi432\sl180
{\plain\f4\fs16\cf2\ulc2
Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PLAN C
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 60 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[992] (Part A deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0**
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadft3\clpadt80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\fi65\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\fi65\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
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{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts***
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
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{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
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\pard\plain\f0\fs17
\par
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
}
\par
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{\plain\f4\fs16\cf2\ulc2
medical supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved
}
\par
\pard\intbl\li80\ri90\fi432\sl180
{\plain\f4\fs16\cf2\ulc2
Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved
}
\par
\pard\intbl\li80\ri90\fi432\sl180
{\plain\f4\fs16\cf2\ulc2
Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\keepn\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
OTHER BENEFITS—NOT COVERED BY MEDICARE
}
\par
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\par
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
FOREIGN TRAVEL—NOT COVERED BY MEDICARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First $250 each calendar year
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$250
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{\plain\f4\fs16\cf2\ulc2
Remainder of charges
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
80% to a lifetime maximum benefit of $50,000
}
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{\plain\f4\fs16\cf2\ulc2
20% and amounts over the $50,000 lifetime maximum
}
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Medicare benefits are subject to change. Please consult the latest
}
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Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
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{\plain\f4\fs21\cf2\ulc2
PLAN D
}
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{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
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SERVICES
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MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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YOU PAY
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{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
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*
}
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{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First 60 days
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{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$[992] (Part A deductible)
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
61st through 90th day
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{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
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\cell
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{\plain\f4\fs16\cf2\ulc2
$[248] a day
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
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{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
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{\plain\f4\fs16\cf2\ulc2
$0**
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{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
All costs
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{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
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*
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{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First 20 days
}
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{\plain\f4\fs16\cf2\ulc2
All approved amounts
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
}
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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Next $[131] of Medicare-Approved Amounts***
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
$0
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$[131] (Part B deductible)
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{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
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{\plain\f4\fs16\cf2\ulc2
80%
}
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{\plain\f4\fs16\cf2\ulc2
20%
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$0
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CLINICAL LABORATORY SERVICES
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{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
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{\plain\f4\fs16\cf2\ulc2
100%
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
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{\plain\f4\fs21\cf2\ulc2
PARTS A & B
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
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{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
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{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
}
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{\plain\f4\fs16\cf2\ulc2
medical supplies
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{\plain\f4\fs16\cf2\ulc2
100%
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved
}
\par
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{\plain\f4\fs16\cf2\ulc2
Amounts***
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
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\cell
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{\plain\f4\fs16\cf2\ulc2
$0
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\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
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{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved
}
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{\plain\f4\fs16\cf2\ulc2
Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
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\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
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\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
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\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
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{\plain\f4\fs21\cf2\ulc2
OTHER BENEFITS—NOT COVERED BY MEDICARE
}
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SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
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{\plain\f4\fs16\b\cf2\ulc2
FOREIGN TRAVEL—NOT COVERED
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{\plain\f4\fs16\b\cf2\ulc2
BY MEDICARE
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{\plain\f4\fs16\cf2\ulc2
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
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\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First $250 each calendar year
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$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$250
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{\plain\f4\fs16\cf2\ulc2
Remainder of charges
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
80% to a lifetime maximum benefit of $50,000
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{\plain\f4\fs16\cf2\ulc2
20% and amounts over the $50,000 lifetime maximum
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\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
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{\plain\f4\fs21\cf2\ulc2
PLAN F or HIGH DEDUCTIBLE PLAN F
}
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{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
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{\plain\f4\fs16\cf2\ulc2
[AFTER YOU PAY $[1860] DEDUCTIBLE,**]
}
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
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{\plain\f4\fs16\cf2\ulc2
[IN ADDITION TO $[1860] DEDUCTIBLE,**] YOU PAY
}
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{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
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{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
First 60 days
}
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{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$[992] (Part A deductible)
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
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{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0***
}
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{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
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{\plain\f4\fs16\cf2\ulc2
$0
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\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
All costs
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{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
*
}
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{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First 20 days
}
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{\plain\f4\fs16\cf2\ulc2
All approved amounts
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
21st through 100th day
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{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
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\cell
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{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
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\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All costs
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
[**This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $[1860] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[1860]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.]
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
[AFTER YOU PAY $[1860] DEDUCTIBLE,**] PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
[IN ADDITION TO $[1860] DEDUCTIBLE,**] YOU PAY
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\fi101\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\fi101\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
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\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
[**This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $[1860] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[1860]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.]
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
***Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
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{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
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{\plain\f4\fs16\cf2\ulc2
[AFTER YOU PAY $[1860] DEDUCTIBLE,**] PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
[IN ADDITION TO $[1860] DEDUCTIBLE,**] YOU PAY
}
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{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
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{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services
}
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{\plain\f4\fs16\cf2\ulc2
and medical supplies
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\cell
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{\plain\f4\fs16\cf2\ulc2
100%
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved
}
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{\plain\f4\fs16\cf2\ulc2
Amounts***
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved
}
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{\plain\f4\fs16\cf2\ulc2
Amounts
}
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{\plain\f4\fs16\cf2\ulc2
80%
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\cell
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{\plain\f4\fs16\cf2\ulc2
20%
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{\plain\f4\fs16\cf2\ulc2
$0
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\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
[**This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $[1860] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[1860]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.]
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
***Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\keepn\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
OTHER BENEFITS—NOT COVERED BY MEDICARE
}
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
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{\plain\f4\fs16\cf2\ulc2
[AFTER YOU PAY $[1860] DEDUCTIBLE,**] PLAN PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
[IN ADDITION TO $[1860] DEDUCTIBLE,**] YOU PAY
}
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{\plain\f4\fs16\b\cf2\ulc2
FOREIGN TRAVEL—NOT COVERED BY MEDICARE
}
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{\plain\f4\fs16\cf2\ulc2
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First $250 each calendar year
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$250
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{\plain\f4\fs16\cf2\ulc2
Remainder of charges
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
80% to a lifetime maximum benefit of $50,000
}
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{\plain\f4\fs16\cf2\ulc2
20% and amounts over the $50,000 lifetime maximum
}
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{\plain\f4\fs21\cf2\ulc2
[**This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $[1860] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[1860]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.]
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PLAN G
}
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{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 60 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[992] (Part A deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0**
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
0%
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\keepn\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
\par
\pard\plain\f0\fs17
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
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\clpadfl3\clpadl80
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{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
}
\par
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{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
}
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{\plain\f4\fs16\cf2\ulc2
medical supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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\pard\intbl\qj\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
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{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
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{\plain\f4\fs16\cf2\ulc2
80%
}
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
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{\plain\f4\fs21\cf2\ulc2
OTHER BENEFITS—NOT COVERED BY MEDICARE
}
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
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{\plain\f4\fs16\b\cf2\ulc2
FOREIGN TRAVEL—NOT COVERED BY MEDICARE
}
\par
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{\plain\f4\fs16\cf2\ulc2
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First $250 each calendar year
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$250
}
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{\plain\f4\fs16\cf2\ulc2
Remainder of charges
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80% to a lifetime maximum benefit of $50,000
}
\cell
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{\plain\f4\fs16\cf2\ulc2
20% and amounts over the $50,000 lifetime maximum
}
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\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
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{\plain\f4\fs21\cf2\ulc2
PLAN K
}
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{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
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{\plain\f4\fs16\cf2\ulc2
YOU PAY*
}
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{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
{\plain\f4\fs16\cf2\ulc2
**
}
\par
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{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
First 60 days
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] (50% of Part A deductible)
}
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{\plain\f4\fs16\cf2\ulc2
$[496] (50% of Part A deductible)\u9830?
}
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\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0***
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
**
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[62] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[62] a day \u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
50%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
50%\u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
50% of copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
50% of Medicare copayment/
}
\par
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance\u9830?
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*You will pay half the cost sharing of some covered services until you reach the annual out-of-pocket maximum of $[4000] each calendar year. The amounts that count toward your annual limit are noted with diamonds (
}
{\plain\f4\fs16\cf2\ulc2
\u9830?
}
{\plain\f4\fs21\cf2\ulc2
) in the chart above. Once you reach the annual maximum, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
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\clpadfl3\clpadl80
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\clvertalt
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY*
}
\cell
\row
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\fi86\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts****
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)**** \u9830?
}
\cell
\row
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\fi86\sl180
{\plain\f4\fs16\cf2\ulc2
Preventive Benefits for Medicare-Covered Services
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 75% or more of Medicare-
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs above Medicare-Approved Amounts
}
\cell
\row
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\fi86\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 10%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 10% \u9830?
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs (and they do not count toward annual out-of-pocket limit of $[4140])*****
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
50%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
50%\u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts****
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)**** \u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 10%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 10% \u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*You will pay half the cost sharing of some covered services until you reach the annual out-of-pocket maximum of $[4000] each calendar year. The amounts that count toward your annual limit are noted with diamonds (
}
{\plain\f4\fs16\cf2\ulc2
\u9830?
}
{\plain\f4\fs21\cf2\ulc2
) in the chart above. Once you reach the annual maximum, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
**** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
***** This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[4140] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
}
\par
\pard\keepn\pagebb\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
\par
\pard\plain\f0\fs17
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY*
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
}
\par
\pard\intbl\li80\ri90\fi158\sl180
{\plain\f4\fs16\cf2\ulc2
medical supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\par
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved
}
\par
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Amounts****
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible) \u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
10%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
10%\u9830?
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*You will pay half the cost sharing of some covered services until you reach the annual out-of-pocket maximum of $[4000] each calendar year. The amounts that count toward your annual limit are noted with diamonds (
}
{\plain\f4\fs16\cf2\ulc2
\u9830?
}
{\plain\f4\fs21\cf2\ulc2
) in the chart above. Once you reach the annual maximum, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
**** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PLAN L
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY*
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
{\plain\f4\fs16\cf2\ulc2
**
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 60 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[744] (75% of Part A deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[248] (25% of Part A deductible)\u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0***
}
\cell
\row
\trowd\trleft5
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\clpadfl3\clpadl80
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
**
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
Up to $[93] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
Up to $[31] a day\u9830?
}
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
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\trowd\trleft5
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
75%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
25%\u9830?
}
\cell
\row
\trowd\trleft5
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\clpadfl3\clpadl80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
75% of copayment/
}
\par
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\qj\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
25% of copayment/
}
\par
\pard\intbl\qj\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance\u9830?
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* You will pay one-fourth of the cost sharing of some covered services until you reach the annual out-of-pocket limit of $[2070] each calendar year. The amounts that count toward your annual limit are noted with diamonds (\u9830?) in the chart above. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY*
}
\cell
\row
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\pard\intbl\qj\li80\ri90\fi86\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts****
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)**** \u9830?
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
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\pard\intbl\qj\li80\ri90\fi86\sl180
{\plain\f4\fs16\cf2\ulc2
Preventive Benefits for Medicare-Covered Services
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 75% or more of Medicare-
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs above Medicare-Approved Amounts
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\fi86\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 15%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 5% \u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs (and they do not count toward annual out-of-pocket limit of $[2070])*****
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
75%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
25%\u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts****
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible) \u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 15%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 5%\u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* You will pay one-fourth of the cost sharing of some covered services until you reach the annual out-of-pocket limit of $[2070] each calendar year. The amounts that count toward your annual limit are noted with diamonds (\u9830?) in the chart above. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
**** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
***** This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[2070] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
}
\par
\pard\keepn\pagebb\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
\par
\pard\plain\f0\fs17
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY*
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
}
\par
\pard\intbl\li80\ri90\fi158\sl180
{\plain\f4\fs16\cf2\ulc2
medical supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\par
\pard\intbl\qj\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts****
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible) \u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
15%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
5%\u9830?
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* You will pay one-fourth of the cost sharing of some covered services until you reach the annual out-of-pocket limit of $[2070] each calendar year. The amounts that count toward your annual limit are noted with diamonds (\u9830?) in the chart above. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
**** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
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.
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PLAN M
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MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
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SERVICES
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MEDICARE PAYS
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PLAN PAYS
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YOU PAY
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HOSPITALIZATION
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*
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Semiprivate room and board, general nursing and miscellaneous services and supplies
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\~
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\~
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\~
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First 60 days
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All but $[992]
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$[496] (50% of Part A deductible)
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$[496] (50% of Part A deductible)
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61st through 90th day
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All but $[248] a day
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$[496] a day
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$0
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91st day and after:
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\~
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\~
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\~
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—While using 60 lifetime reserve days
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All but $[496] a day
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$[496] a day
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$0
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—Once lifetime reserve days are used:
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\~
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{\plain\f4\fs16\cf2\ulc2
\~
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{\plain\f4\fs16\cf2\ulc2
\~
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—Additional 365 days
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$0
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100% of Medicare eligible expenses
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$0**
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—Beyond the additional 365 days
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$0
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$0
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All costs
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SKILLED NURSING FACILITY CARE
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*
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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.
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\~
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{\plain\f4\fs16\cf2\ulc2
\~
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{\plain\f4\fs16\cf2\ulc2
\~
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First 20 days
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All approved amounts
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$0
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$0
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21st through 100th day
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All but $[124] a day
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Up to $[124] a day
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$0
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101st day and after
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{\plain\f4\fs16\cf2\ulc2
$0
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$0
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{\plain\f4\fs16\cf2\ulc2
All costs
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{\plain\f4\fs16\b\cf2\ulc2
BLOOD
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\fi65\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\fi65\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
0%
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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CLINICAL LABORATORY SERVICES
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— TESTS FOR DIAGNOSTIC SERVICES
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{\plain\f4\fs16\cf2\ulc2
100%
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{\plain\f4\fs16\cf2\ulc2
$0
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$0
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*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
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{\plain\f4\fs21\cf2\ulc2
PARTS A & B
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SERVICES
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MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
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HOME HEALTH CARE
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{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
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{\plain\f4\fs16\cf2\ulc2
medical supplies
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{\plain\f4\fs16\cf2\ulc2
100%
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
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{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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$[131] (Part B deductible)
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{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
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{\plain\f4\fs16\cf2\ulc2
80%
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{\plain\f4\fs16\cf2\ulc2
20%
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$0
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{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
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{\plain\f4\fs21\cf2\ulc2
OTHER BENEFITS—NOT COVERED BY MEDICARE
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SERVICES
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MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
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FOREIGN TRAVEL—NOT COVERED
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{\plain\f4\fs16\b\cf2\ulc2
BY MEDICARE
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{\plain\f4\fs16\cf2\ulc2
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
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{\plain\f4\fs16\cf2\ulc2
First $250 each calendar year
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$250
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{\plain\f4\fs16\cf2\ulc2
Remainder of charges
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$0
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{\plain\f4\fs16\cf2\ulc2
80% to a lifetime maximum benefit of $50,000
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{\plain\f4\fs16\cf2\ulc2
20% and amounts over the $50,000 lifetime maximum
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Medicare benefits are subject to change. Please consult the latest
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Guide to Health Insurance for People with Medicare
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.
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{\plain\f4\fs21\cf2\ulc2
PLAN N
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{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
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SERVICES
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MEDICARE PAYS
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PLAN PAYS
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YOU PAY
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HOSPITALIZATION
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*
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{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
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{\plain\f4\fs16\cf2\ulc2
\~
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
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{\plain\f4\fs16\cf2\ulc2
First 60 days
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[992] (Part A deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0**
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0**
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
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{\plain\f4\fs16\cf2\ulc2
coinsurance
}
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\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
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\pard\plain\f0\fs16
\par
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{\plain\f4\fs16\cf2\ulc2
SERVICES
}
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
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\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5327
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6987
\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8647
\pard\intbl\li80\ri90\fi65\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Balance, other than up to $[20] per office visit and up to $[50] per emergency room visit. The copayment of up to $[50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[20] per office visit and up to $[50] per emergency room visit. The copayment of up to $[50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
}
\cell
\row
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\clpadft3\clpadt80
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{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
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{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts***
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
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\clpadfl3\clpadl80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6987
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\keepn\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
\par
\pard\plain\f0\fs17
\par
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
}
\par
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{\plain\f4\fs16\cf2\ulc2
medical supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
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\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
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\cell
\row
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
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{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
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{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
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\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
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{\plain\f4\fs21\cf2\ulc2
OTHER BENEFITS—NOT COVERED BY MEDICARE
}
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\pard\plain\f0\fs17
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
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{\plain\f4\fs16\b\cf2\ulc2
FOREIGN TRAVEL—NOT COVERED
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BY MEDICARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First $250 each calendar year
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$250
}
\cell
\row
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of charges
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
80% to a lifetime maximum benefit of $50,000
}
\cell
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{\plain\f4\fs16\cf2\ulc2
20% and amounts over the $50,000 lifetime maximum
}
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\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\keepn\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\b\cf2\ulc2
37.17(5)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Notice regarding policies or certificates which are not Medicare supplement policies.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\i\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Any accident and sickness insurance policy or certificate, other than a Medicare supplement policy
}
{\plain\f4\fs21\i\cf2\ulc2
,
}
{\plain\f4\fs21\cf2\ulc2
a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act (42 U.S.C. Section 1395 et seq.), disability income policy, or other policy identified in 191—37.2(514D) issued for delivery in this state to persons eligible for Medicare shall notify insureds under the policy that the policy is not a Medicare supplement policy or certificate. The notice shall either be printed or attached to the first page of the outline of coverage delivered to insureds under the policy, or if no outline of coverage is delivered, to the first page of the policy, or certificate delivered to insureds. The notice shall be in no less than 12-point type and shall contain the following language:
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
“THIS [POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT [POLICY OR CONTRACT]. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company.”
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\i\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Applications provided to persons eligible for Medicare for the health insurance policies or certificates described in 37.17(4)
}
{\plain\f4\fs21\i\cf2\ulc2
“a”
}
{\plain\f4\fs21\cf2\ulc2
shall disclose, using the applicable statement in Appendix C, the extent to which the policy duplicates Medicare. The disclosure statement shall be provided as a part of, or together with, the application for the policy or certificate.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\plain\f4\fs16\b\cf2
ARC 7964B
}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sect
}