Plan L


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PLAN L

Medicare (Part A) — Hospital Services — Per Benefit Period*

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY**

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

All but $1,132

$825 (75% of Part A Deductible)

$283 (25% of Part A Deductible)***

61st through 90th day

All but $283 a day

$283 a day

$0

91st day and after: While using 60 lifetime reserve days

All but $566 a day

$566 a day

$0

Once lifetime reserve days are used — Additional 365 days

$0

100% of Medicare eligible expenses

$0****

Beyond the additional 365 days

$0

$0

All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare Approved facility within 30 days after leaving the hospital

First 20 days

All approved amounts

$0

$0

21st through 100th day

All but $141.50 a day

Up to $103.13 a day

Up to $34.37 a day***

101st day and after

$0

$0

All costs

BLOOD First three pints

$0

75%

25%***

Additional amounts

100%

$0

$0

HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.

All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care

75% of copayment/ coinsurance

25% of copayment/ coinsurance3

* 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.

** You will pay one-fourth of the cost sharing of some covered services until you reach the annual out-of-pocket limit of $2,310 each 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.

*** This amount counts toward your annual out-of-pocket limit. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year.

**** 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.

Medicare (Part B) — Medical Services — Per Calendar Year

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY**

MEDICAL EXPENSES — IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT Such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $162 of Medicare Approved Amounts*****

$0

$0

$162*** (Part B Deductible) *****

Preventive Benefits for Medicare covered services

Generally 75% or more of Medicare approved amounts

Remainder of Medicare approved amounts

All costs above Medicare approved amounts

Remainder of Medicare Approved Amounts

Generally 80%

Generally 15%

Generally 5%***

PART B EXCESS CHARGES (Above Medicare Approved Amounts)

$0

$0

All costs; and they do not count toward annual out-of-pocket limit of $2,310**

BLOOD First three pints

$0

75%

25%***

Next $162 of Medicare Approved Amounts*****

$0

$0

$162 (Part B Deductible)***

Remainder of Medicare Approved Amounts

Generally 80%

Generally 15%

Generally 5%***

CLINICAL LABORATORY SERVICES Tests for Diagnostic Services

100%

$0

$0

Medicare (Part B) — Medical Services — Per Calendar Year

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY**

MEDICAL EXPENSES — IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT Such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $162 of Medicare Approved Amounts*****

$0

$0

$162*** (Part B Deductible) *****

Preventive Benefits for Medicare covered services

Generally 75% or more of Medicare approved amounts

Remainder of Medicare approved amounts

All costs above Medicare approved amounts

Remainder of Medicare Approved Amounts

Generally 80%

Generally 15%

Generally 5%***

PART B EXCESS CHARGES (Above Medicare Approved Amounts)

$0

$0

All costs; and they do not count toward annual out-of-pocket limit of $2,310**

BLOOD First three pints

$0

75%

25%***

Next $162 of Medicare Approved Amounts*****

$0

$0

$162 (Part B Deductible)***

Remainder of Medicare Approved Amounts

Generally 80%

Generally 15%

Generally 5%***

CLINICAL LABORATORY SERVICES Tests for Diagnostic Services

100%

$0

$0

Medicare Parts A and B

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies

100%

$0

$0

Durable medical equipment
First $162 of Medicare Approved Amounts******

$0

$0

$162 (Part B Deductible)***

Remainder of Medicare Approved Amounts

80%

15%

$5%***

** You will pay one-fourth of the cost sharing of some covered services until you reach the annual out-of-pocket limit of $2,310 each 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.

*** This amount counts toward your annual out-of-pocket limit. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year.

***** Once you have been billed $162 of Medicare Approved amounts for covered services your Part B Deductible will have been met for the calendar year.

******Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.