Medicare Supplement Plan HDG Details
Part A |
|||
| Services | Medicare Pays | This Plan Pays | You Pay |
|---|---|---|---|
| Hospitalization | |||
| First 60 Days | All But $1676 | $1676 (Part A Deductible) | $0 |
| 61st Through 90th Day | All But $419 a Day | $419 a Day | $0 |
| 91st Day and After (60 Reserve Days) | All But $838 a Day | $838 a Day | $0 |
| After Reserve (Additional 365 Days) | $0 | 100% of Eligible Expenses | $0 |
| Beyond the Additional 365 Days | $0 | $0 | All Costs |
| Skilled Nursing Facility Care | |||
| First 20 Days | All Approved Amounts | $0 | $0 |
| 21st Through 100th Day | All But $209.50 a Day | Up to $209.50 a Day | $0 |
| 101st Day and After | $0 | $0 | All Costs |
| Blood | |||
| First Three Pints | $0 | 100% | $0 |
| Additional Amounts | 100% | $0 | $0 |
| Hospice Care | |||
| Must Meet Medicare's Requirements, including a doctor's certification of terminal illness | All but very limited coinsurance, coinsurance for outpatient drugs and inpatient respite care. | Pays Copayments and Coinsurance | $0 |
Part B |
|||
| Services | Medicare Pays | This Plan Pays | You Pay |
|---|---|---|---|
| Medical Expenses | |||
| 1st $257 of Approved Amounts | $0 | $0 | $257(Unless Part B deductible has been met) |
| Remainder of Approved Amounts | Generally 80% | Generally 20% | $0 |
| Part B Excess Charge | $0 | 100% | $0 |
| Blood | |||
| First Three Pints | $0 | All costs | $0 |
| Next $257 of Medicare Approved Amounts | $0 | $0 | $257 (Unless Part B deductible has been met) |
| Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
| Clinical Laboratory Services | |||
| Tests for Diagnostic Services | 100% | $0 | $0 |
Parts A & B |
|||
| Services | Medicare Pays | This Plan Pays | You Pay |
|---|---|---|---|
| Home Health Care | |||
| Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
| Durable Medical Equipment | |||
| 1st $257 of Medicare approved amounts | $0 | $0 | $257 (Unless Part B deductible has been met) |
| Remainder of medicare approved amounts | 80% | 20% | $0 |
Other Benefits |
|||
| Services | Medicare Pays | This Plan Pays | You Pay |
|---|---|---|---|
| Foreign Travel | |||
| 1st $250 each calendar year | $0 | $0 | $250 |
| Remainder of Charges | $0 | 80% up to a lifetime maximum benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum benefit |