Post on 11-Jul-2020
MediGapPlans A, C, F, G & N
TRUSTED MEDICARE. PLAN ON IT.
2019 MICHIGAN OUTLINE OF MEDICARE SUPPLEMENT COVERAGE
This
cha
rt sh
ows
the
bene
fits
incl
uded
in e
ach
of th
e st
anda
rd M
edic
are
supp
lem
ent p
lans
with
an
effe
ctiv
e da
te fo
r cov
erag
e on
or a
fter J
une
1,
2010
. Eve
ry c
ompa
ny m
ust m
ake
avai
labl
e Pl
an “A
”. So
me
plan
s m
ay n
ot b
e av
aila
ble
in y
our s
tate
.
Basi
c Be
nefit
s:
• Hos
pita
lizat
ion
– Pa
rt A
coin
sura
nce
plus
cov
erag
e fo
r 365
add
itiona
l day
s af
ter M
edic
are
bene
fits
end.
• Med
ical
Exp
ense
s –
Part
B co
insu
ranc
e (g
ener
ally
20%
of M
edic
are-
appr
oved
exp
ense
s) o
r cop
aym
ents
for h
ospi
tal o
utpa
tient
se
rvic
es. P
lan
N re
quire
insu
reds
to p
ay a
por
tion
of P
art B
coi
nsur
ance
or c
opay
men
ts.
• Blo
od –
Firs
t thr
ee p
ints
of b
lood
eac
h ye
ar.
• Hos
pice
– P
art A
coi
nsur
ance
.
BENE
FIT
CHAR
T O
F M
EDIC
ARE
SUPP
LEM
ENT
PLAN
S
SOLD
FO
R EF
FECT
IVE
DATE
S O
N O
R AF
TER
JUNE
1, 2
010
*Pla
n F
has
an o
ptio
n ca
lled
a hi
gh d
educ
tible
pla
n F.
Thi
s hi
gh d
educ
tible
pla
n pa
ys th
e sa
me
bene
fits
as p
lan
F af
ter o
ne h
as p
aid
a ca
lend
ar y
ear
$2,2
40 d
educ
tible
. Ben
efits
from
hig
h de
duct
ible
pla
n F
will
not b
egin
unt
il out
-of-p
ocke
t exp
ense
s ex
ceed
$2,
240
Out
-of-p
ocke
t exp
ense
s fo
r thi
s de
duct
ible
are
exp
ense
s th
at w
ould
ord
inar
ily b
e pa
id b
y th
e po
licy.
Thes
e ex
pens
es in
clud
e th
e M
edic
are
dedu
ctib
les
for P
art A
and
Par
t B, b
ut d
o no
t inc
lude
the
Plan
’s se
para
te fo
reig
n tra
vel e
mer
genc
y de
duct
ible
.
AB
CD
FG
KL
MN
Bas
ic, i
nclu
ding
10
0% P
art
B
coin
sura
nce
Bas
ic, i
nclu
ding
10
0% P
art
B
coin
sura
nce
Bas
ic, i
nclu
ding
10
0% P
art
B
coin
sura
nce
Bas
ic, i
nclu
ding
10
0% P
art
B
coin
sura
nce
Bas
ic, i
nclu
ding
10
0% P
art
B
coin
sura
nce
Bas
ic, i
nclu
ding
10
0% P
art
B
coin
sura
nce
Hos
pita
lizat
ion
and
prev
enti
ve
care
pai
d at
10
0%; o
ther
ba
sic
bene
fits
paid
at
50%
Hos
pita
lizat
ion
and
prev
enti
ve
care
pai
d at
10
0%; o
ther
ba
sic
bene
fits
paid
at
75%
Bas
ic, i
nclu
ding
10
0% P
art
B
coin
sura
nce
Bas
ic,
incl
udin
g 10
0%
Par
t B
co
insu
ranc
e,
exce
pt u
p to
$2
0 co
paym
ent
for
offic
e vi
sit,
an
d up
to
$50
copa
ymen
t fo
r E
R
Skill
ed N
ursi
ng
Fac
ility
C
oins
uran
ce
Skill
ed N
ursi
ng
Fac
ility
C
oins
uran
ce
Skill
ed N
ursi
ng
Fac
ility
C
oins
uran
ce
Skill
ed N
ursi
ng
Fac
ility
C
oins
uran
ce
50%
Ski
lled
Nur
sing
Fac
ility
C
oins
uran
ce
75%
Ski
lled
Nur
sing
Fac
ility
C
oins
uran
ce
Skill
ed N
ursi
ng
Fac
ility
C
oins
uran
ce
Skill
ed N
ursi
ng
Fac
ility
C
oins
uran
ce
Par
t A
D
educ
tibl
eP
art
A
Ded
ucti
ble
Par
t A
D
educ
tibl
eP
art
A
Ded
ucti
ble
Par
t A
D
educ
tibl
e50
% P
art
A
Ded
ucti
ble
75%
Par
t A
D
educ
tibl
e50
% P
art
A
Ded
ucti
ble
Par
t A
D
educ
tibl
e
Par
t B
D
educ
tibl
eP
art
B
Ded
ucti
ble
Par
t B
Exc
ess
(100
%)
Par
t B
Exc
ess
(100
%)
For
eign
Tra
vel
Em
erge
ncy
For
eign
Tra
vel
Em
erge
ncy
For
eign
Tra
vel
Em
erge
ncy
For
eign
Tra
vel
Em
erge
ncy
For
eign
Tra
vel
Em
erge
ncy
For
eign
Tra
vel
Em
erge
ncy
Out
-of-
Pock
et
Lim
it $
4,96
0;
paid
at
100%
af
ter
limit
re
ache
d
Out
-of-
Pock
et
Lim
it $
2,48
0;
paid
at
100%
af
ter
limit
re
ache
d
MEDICARE SUPPLEMENT PREMIUM INFORMATION THESE RATES ARE EFFECTIVE 01/01/2019
*Use the age 65 rate if You turned 65 this calendar year.
Paramount determines premiums for its Medicare Supplement policies based upon attained age. This means your premium will increase automatically as you get older. Your premium may also change if premiums for these policies change.
If you choose to pay directly by check, you will be billed monthly for the applicable premium listed below. If you choose to pay your premium through our automated bank deduction program, premiums will be withdrawn from your bank monthly.
To find the amount of premium you will pay, find your age as of December 31 of the previous year in the first column then choose the plan in which you are interested from one of the next five columns.
MICHIGAN 2019 MONTHLY MEDICARE SUPPLEMENT RATES
Age MediGap Plan A
without discount
MediGap Plan A
with discount
MediGapPlan C
without discount
MediGap Plan C
with discount
MediGap Plan F
without discount
MediGap Plan F
with discount
65* $104.15 $98.94 $136.04 $129.23 $142.43 $135.31 66 $108.96 $103.51 $142.31 $135.20 $149.01 $141.56 67 $113.76 $108.08 $148.59 $141.16 $155.58 $147.80 68 $119.69 $113.71 $156.34 $148.52 $163.69 $155.50 69 $125.62 $119.34 $164.08 $155.88 $171.80 $163.21 70 $131.55 $124.97 $171.82 $163.23 $179.90 $170.91 71 $137.48 $130.60 $179.57 $170.59 $188.01 $178.61 72 $143.41 $136.24 $187.31 $177.95 $196.12 $186.31 73 $149.34 $141.87 $195.06 $185.30 $204.23 $194.02 74 $155.42 $147.65 $203.01 $192.86 $212.55 $201.93 75 $161.51 $153.44 $210.96 $200.41 $220.88 $209.84 76 $167.76 $159.37 $219.12 $208.17 $229.43 $217.96 77 $174.01 $165.31 $227.29 $215.92 $237.97 $226.07 78 $180.26 $171.25 $235.45 $223.67 $246.52 $234.19 79 $186.51 $177.18 $243.61 $231.43 $255.06 $242.31 80 $192.76 $183.12 $251.77 $239.18 $263.61 $250.43 81 $199.01 $189.06 $259.93 $246.94 $272.16 $258.55 82 $205.26 $194.99 $268.10 $254.69 $280.70 $266.67 83 $211.34 $200.78 $276.05 $262.25 $289.03 $274.58 84 $217.27 $206.41 $283.79 $269.60 $297.14 $282.28 85 $223.04 $211.89 $291.33 $276.76 $305.03 $289.77 86 $228.65 $217.22 $298.65 $283.72 $312.70 $297.06 87 $233.46 $221.78 $304.93 $289.68 $319.27 $303.31 88 $238.26 $226.35 $311.21 $295.65 $325.84 $309.55 89 $243.07 $230.92 $317.49 $301.61 $332.42 $315.80
90+ $247.88 $235.48 $323.77 $307.58 $338.99 $322.04
2
MICHIGAN 2019 MONTHLY MEDICARE SUPPLEMENT RATES (Continued)
Age MediGap Plan G without
discount
MediGap Plan G with
discount
MediGapPlan N without
discount
MediGap Plan N with
discount
65* $ 128.55 $122.12 $ 113.44 $107.77 66 $ 134.48 $127.76 $ 118.68 $112.74 67 $ 140.42 $133.40 $ 123.91 $117.72 68 $ 147.73 $140.35 $ 130.37 $123.85 69 $ 155.05 $147.30 $ 136.83 $129.99 70 $ 162.37 $154.25 $ 143.29 $136.12 71 $ 169.69 $161.20 $ 149.74 $142.26 72 $ 177.00 $168.15 $ 156.20 $148.39 73 $ 184.32 $175.11 $ 162.66 $154.53 74 $ 191.84 $182.25 $ 169.29 $160.83 75 $ 199.35 $189.38 $ 175.92 $167.13 76 $ 207.07 $196.71 $ 182.73 $173.59 77 $ 214.78 $204.04 $ 189.54 $180.06 78 $ 222.49 $211.37 $ 196.34 $186.53 79 $ 230.20 $218.69 $ 203.15 $192.99 80 $ 237.92 $226.02 $ 209.96 $199.46 81 $ 245.63 $233.35 $ 216.76 $205.92 82 $ 253.34 $240.68 $ 223.57 $212.39 83 $ 260.86 $247.82 $ 230.20 $218.69 84 $ 268.18 $254.77 $ 236.66 $224.83 85 $ 275.30 $261.53 $ 242.94 $230.79 86 $ 282.22 $268.11 $ 249.05 $236.60 87 $ 288.15 $273.74 $ 254.29 $241.57 88 $ 294.08 $279.38 $ 259.52 $246.55 89 $ 300.02 $285.02 $ 264.76 $251.52
90+ $ 305.95 $290.65 $ 269.99 $256.49
MEDICARE SUPPLEMENT PREMIUM INFORMATION THESE RATES ARE EFFECTIVE 01/01/2019
*Use the age 65 rate if You turned 65 this calendar year.
3
Paramount Insurance Company 1901 Indian Wood Circle Maumee, Ohio 43537 419-887-2525 or 1-800-462-3589
PREMIUM INFORMATIONWe, Paramount Insurance Company, can only raise your premium if we raise the premium for all policies like yours in this State. Paramount determines premiums for its Medicare Supplement policies based upon attained age. This means your premium will increase automatically as you get older.
DISCLOSURESUse this outline to compare benefits and premiums among policies.
READ YOUR POLICY CAREFULLYThis is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.
RIGHT TO RETURN POLICYIf you find that you are not satisfied with your policy, you may return it to Paramount Insurance Company at our address listed above. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.
POLICY REPLACEMENTIf you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
NOTICE• This policy may not fully cover all of your medical costs.• Neither Paramount Insurance Company nor its agents are connected with Medicare.• This Outline of Coverage does not give all the details of Medicare coverage. Contact your local Social Security
office or consult Medicare & You for more details.
COMPLETE ANSWERS ARE VERY IMPORTANTWhen you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
MEDIGAP SUPPLEMENT COVERAGE BENEFIT PLANS A, C, F, G and N
MEDICARE SUPPLEMENT PREMIUM INFORMATION THESE RATES ARE EFFECTIVE 01/01/2019
4
MEDIGAP PLAN A
MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital, and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
** 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.
Services Medicare Pays Plan A Pays You PayHOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies.• First 60 days
All but $1,364
$0
$1,364 (Part A deductible)
• Days 61–90 All but $341 a day $341 a day $0• Day 91 and after:
• While using 60 lifetime reserve days All but $682 a day
$682 a day
$0
• Once lifetime reserve days are used: • Additional 365 days
$0 100% of Medicare- eligible expenses
$0**
• Beyond the additional 365 days $0 $0 All costsSKILLED NURSING FACILITY CARE*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital.• First 20 days
All approved amounts
$0
$0
• Days 21–100 All but $170.50 a day
$0 Up to $170.50 a day
• Day 101 and after $0 $0 All costsBLOOD• First three pints $0 3 pints $0• Additional amounts 100% $0 $0
HOSPICE CAREYou 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
Medicare copayment/coinsurance
$0
5
MEDIGAP PLAN A
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $185 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan A Pays You PayMEDICAL EXPENSESIn 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, and durable medical equipment.• First $183 of Medicare-approved amounts*
$0
$0
$185 (Part B deductible)
• Remainder of Medicare-approved amounts Generally 80% Generally 20% $0• Part B Excess Charges
(above Medicare-approved amounts)$0 $0 All costs
BLOOD• First three pints $0 All costs $0• Next $183 of Medicare-approved amounts* $0 $0 $185 (Part B
deductible)• Remainder of Medicare-approved amounts 80% 20% $0CLINICAL LABORATORY SERVICES• Tests for diagnostic services
100% $0 $0
PARTS A & BHOME HEALTH CARE Medicare-approved services• Medically necessary skilled care services and
medical supplies
100%
$0
$0
• Durable medical equipment: First $183 of Medicare-approved amounts*
$0 $0 $185 (Part B deductible)
• Remainder of Medicare-approved amounts 80% 20% $0
6
MEDIGAP PLAN C
MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital, and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
** 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.
Services Medicare Pays Plan C Pays You PayHOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies.• First 60 days
All but $1,364
$1,364 (Part A deductible)
$0
• Days 61–90 All but $341 a day $341 a day $0• Day 91 and after:
• While using 60 lifetime reserve days All but $682 a day
$682 a day
$0
• Once lifetime reserve days are used: • Additional 365 days
$0 100% of Medicare- eligible expenses
$0**
• Beyond the additional 365 days $0 $0 All costsSKILLED NURSING FACILITY CARE*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital.• First 20 days
All approved amounts
$0
$0
• Days 21–100 All but $170.50 a day
Up to $170.50 a day
$0
• Day 101 and after $0 $0 All costsBLOOD• First three pints $0 3 pints $0• Additional amounts 100% $0 $0HOSPICE CAREYou 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
Medicare copayment/coinsurance
$0
7
MEDIGAP PLAN C
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $185 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan C Pays You PayMEDICAL EXPENSESIn 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, and durable medical equipment.• First $183 of Medicare-approved amounts*
$0
$185 (Part B deductible)
$0
• Remainder of Medicare-approved amounts Generally 80% Generally 20% $0• Part B Excess Charges
(above Medicare-approved amounts)$0 $0 All costs
BLOOD• First three pints $0 All costs $0• Next $183 of Medicare-approved amounts* $0 $185 (Part B
deductible)$0
• Remainder of Medicare-approved amounts 80% 20% $0CLINICAL LABORATORY SERVICES• Tests for diagnostic services
100% $0 $0
PARTS A & BHOME HEALTH CARE Medicare-approved services• Medically necessary skilled care services and
medical supplies
100%
$0
$0
• Durable medical equipment: First $183 of Medicare-approved amounts*
$0 $185 (Part B deductible)
$0
• Remainder of Medicare-approved amounts 80% 20% $0OTHER BENEFITS – NOT COVERED BY MEDICARE
FOREIGN TRAVEL – Not covered by MedicareMedical emergency care services beginning during the first 60 days of each trip outside of the USA.• First $250 each calendar year
$0
$0
$250
• Remainder of charges $0 80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
8
MEDIGAP PLAN F
MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital, and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
** 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.
Services Medicare Pays Plan F Pays You PayHOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies.• First 60 days
All but $1,364
$1,364 (Part A deductible)
$0
• Days 61–90 All but $341 a day $341 a day $0• Day 91 and after:
• While using 60 lifetime reserve days All but $682 a day
$682 a day
$0
• Once lifetime reserve days are used: • Additional 365 days
$0 100% of Medicare- eligible expenses
$0**
• Beyond the additional 365 days $0 $0 All costsSKILLED NURSING FACILITY CARE*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital.• First 20 days
All approved amounts
$0
$0
• Days 21–100 All but $170.50 a day
Up to $170.50 a day
$0
• Day 101 and after $0 $0 All costsBLOOD• First three pints $0 3 pints $0• Additional amounts 100% $0 $0HOSPICE CAREYou 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
Medicare copayment/coinsurance
$0
9
MEDIGAP PLAN F
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $185 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan F Pays You PayMEDICAL EXPENSESIn 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, and durable medical equipment.• First $183 of Medicare-approved amounts*
$0
$185 (Part B deductible)
$0
• Remainder of Medicare-approved amounts Generally 80% Generally 20% $0• Part B Excess Charges
(above Medicare-approved amounts)$0 100% $0
BLOOD• First three pints $0 All costs $0• Next $183 of Medicare-approved amounts* $0 $185 (Part B
deductible)$0
• Remainder of Medicare-approved amounts 80% 20% $0CLINICAL LABORATORY SERVICES• Tests for diagnostic services
100% $0 $0
PARTS A & BHOME HEALTH CARE Medicare-approved services• Medically necessary skilled care services and
medical supplies
100%
$0
$0
• Durable medical equipment: First $183 of Medicare-approved amounts*
$0 $185 (Part B deductible)
$0
• Remainder of Medicare-approved amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICAREFOREIGN TRAVEL – Not covered by MedicareMedical emergency care services beginning during the first 60 days of each trip outside of the USA.• First $250 each calendar year
$0
$0
$250
• Remainder of charges $0 80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
10
MEDIGAP PLAN G
MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital, and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
** 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.
Services Medicare Pays Plan G Pays You PayHOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies.• First 60 days
All but $1,364
$1,364 (Part A deductible)
$0
• Days 61–90 All but $341 a day $341 a day $0• Day 91 and after:
• While using 60 lifetime reserve days All but $682 a day
$682 a day
$0
• Once lifetime reserve days are used: • Additional 365 days
$0 100% of Medicare- eligible expenses
$0**
• Beyond the additional 365 days $0 $0 All costsSKILLED NURSING FACILITY CARE*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital.• First 20 days
All approved amounts
$0
$0
• Days 21–100 All but $170.50 a day
Up to $170.50 a day
$0
• Day 101 and after $0 $0 All costsBLOOD• First three pints $0 3 pints $0• Additional amounts 100% $0 $0HOSPICE CAREYou 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
Medicare copayment/coinsurance
$0
11
MEDIGAP PLAN G
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $185 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan G Pays You PayMEDICAL EXPENSESIn 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, and durable medical equipment.• First $183 of Medicare-approved amounts*
$0
$0
$185 (Part B deductible)
• Remainder of Medicare-approved amounts Generally 80% Generally 20% $0• Part B Excess Charges
(above Medicare-approved amounts)$0 $0 All costs
BLOOD• First three pints $0 All costs $0• Next $183 of Medicare-approved amounts* $0 $0 $185 (Part B
deductible)• Remainder of Medicare-approved amounts 80% 20% $0CLINICAL LABORATORY SERVICES• Tests for diagnostic services
100% $0 $0
PARTS A & BHOME HEALTH CARE Medicare-approved services• Medically necessary skilled care services and
medical supplies
100%
$0
$0
• Durable medical equipment: First $183 of Medicare-approved amounts*
$0 $0 $185 (Part B deductible)
• Remainder of Medicare-approved amounts 80% 20% $0OTHER BENEFITS – NOT COVERED BY MEDICARE
FOREIGN TRAVEL – Not covered by MedicareMedical emergency care services beginning during the first 60 days of each trip outside of the USA.• First $250 each calendar year
$0
$0
$250
• Remainder of charges $0 80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
12
MEDIGAP PLAN N
MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital, and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
** 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.
Services Medicare Pays Plan N Pays You PayHOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies.• First 60 days
All but $1,364
$1,364 (Part A deductible)
$0
• Days 61–90 All but $341 a day $341 a day $0• Day 91 and after:
• While using 60 lifetime reserve days All but $682 a day
$682 a day
$0
• Once lifetime reserve days are used: • Additional 365 days
$0 100% of Medicare- eligible expenses
$0**
• Beyond the additional 365 days $0 $0 All costsSKILLED NURSING FACILITY CARE*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital.• First 20 days
All approved amounts
$0
$0
• Days 21–100 All but $170.50 a day
Up to $170.50 a day
$0
• Day 101 and after $0 $0 All costsBLOOD• First three pints $0 3 pints $0• Additional amounts 100% $0 $0HOSPICE CAREYou 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
Medicare copayment/coinsurance
$0
13
MEDIGAP PLAN N
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $185 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan N Pays You PayMEDICAL EXPENSESIn 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, and durable medical equipment.• First $183 of Medicare-approved amounts*
$0
$0
$185 (Part B deductible)
• Remainder of Medicare-approved amounts Generally 80% 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.
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.
• Part B Excess Charges (above Medicare-approved amounts)
$0 $0 All costs
BLOOD• First three pints $0 All costs $0• Next $183 of Medicare-approved amounts* $0 $0 $185 (Part B
deductible)• Remainder of Medicare-approved amounts 80% 20% $0CLINICAL LABORATORY SERVICES• Tests for diagnostic services
100% $0 $0
PARTS A & BHOME HEALTH CARE Medicare-approved services• Medically necessary skilled care services and
medical supplies
100%
$0
$0
• Durable medical equipment: First $183 of Medicare-approved amounts*
$0 $0 $185 (Part B deductible)
• Remainder of Medicare-approved amounts 80% 20% $0
(CONT’D ON NEXT PAGE)
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OTHER BENEFITS – NOT COVERED BY MEDICAREFOREIGN TRAVEL – Not covered by MedicareMedical emergency care services beginning during the first 60 days of each trip outside of the USA.• First $250 each calendar year
$0
$0
$250
• Remainder of charges $0 80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum