Benefit Plans A, C, G and N

(1)

Pa g e 1 A dministr ativ e O ffic e - P .O . B

ox 27248 Salt Lake Cit

y, U tah 84127-0248 - P hone: 1-844-442-3847 C LM ED -O O C-K Y R ev 0 70 11 9

Ke

nt

uc

ky

E

ff

ec

ti

ve

0 1/

01 /2

02

0 This char

t sho

w

s the benefits included in each of the standar

d M

edicar

e Supplemen

t plans

. E

ver

y C

ompan

y must make P

lan

“A

” and either P

lan C or F

av

ailable f

or those elig

ible f

or M

edicar

e pr

ior t

o Januar

y 1, 2020 and either P

lan D or G a

vailable f

or those elig

ible f

or M

edicar

e on or af

ter Januar

y 1 2020.

Only applican

ts first elig

ible f

or M

edicar

e bef

or

e 2020 ma

y pur

chase P

lans C, F

, and H

igh D

educ

tible F

.

B

asic

B

ene

fi

ts

H

o

sp

it

al

iz

at

ion

: P

ar

t A c

o‑insur

anc

e plus c

ov

er

age f

or 365 additional da

ys af

ter M

edicar

e benefits end

.

M

ed

ic

al

E

xp

en

se

s:

P

ar

t B c

o‑insur

anc

e (gener

ally 20% of M

edicar

e‑

appr

ov

ed expenses), or c

o‑

pa

ymen

t f

or hospital outpa

tien

t ser

vic

es

.

Plans K

, L and N r

equir

e insur

ed t

o pa

y a por

tion of P

ar

t B c

o‑insur

anc

e or c

o‑

pa

ymen

ts

.

Bl

oo

d

: F

irst thr

ee pin

ts of blood each y

ear

.

H

os

p

ice

: P

ar

t A c

o‑insur

anc

e.

B

enefit Pla

ns A, C, G a

nd N

Outline of M

edicar

e Supplemen

t C

ov

er

age – C

ov

er P

age

Plans A

vailable t

o A

ll A

pplic

an

ts

Medic

ar

e first eligible

bef

or

e 2020 only

A

B

D

G

1

K

L

M

N

C

F

1

FHD

1

Basic, including 100% Part B co‑insurance

Basic, including 100% Part B co‑insurance; o

th

er

ba

sic be

ne

fit

s pa

id

at

50 %

Basic, including 100% Part B co‑insurance; o

th

er

ba

sic be

ne

fit

s pa

id

at

75 %

Basic, including 100% Part B co‑insurance

Basic, including 100% Part

B co‑insurance, e

xc

ep

t

up t

o $

20 c

o‑

pa

ym

en

t f

or

offi

ce v

isi

ts, a

nd u

p t

o $

50 co

‑p

ay

me

nt

for

ER

Basic, including 100% Part B co‑insurance

Skilled Nursing

Facility

co‑insurance

Skilled Nursing

Facility

co‑insurance

50 % Skilled

Nursing Facility co‑insurance

75 % Skilled

Nursing Facility co‑insurance

Skilled Nursing

Facility

co‑insurance

Skilled Nursing

Facility

co‑insurance

Skilled Nursing

Facility

co‑insurance

Skilled Nursing

Facility

co‑insurance

Part A

Deductible

Part A

Deductible

Part A

Deductible

50 % Part A

Deductible

75 % Part A

Deductible

50 % Part A

Deductible

Part A

Deductible

Part A

Deductible

Part A

Deductible

Part B

Deductible

Par

t B

Deduc

tible

Par

t B Ex

cess

(100%)

Par

t B Ex

cess

(100%)

For

eign T

ra

vel

Emer

genc

y

For

eign T

ra

vel

Emer

genc

y

For

eign T

ra

vel

Emer

genc

y

For

eign T

ra

vel

Emer

genc

y

For

eign T

ra

vel

Emer

genc

y

For

eign T

ra

vel

Emer

genc

y

Out

‑of

‑P

ock

et

Limit $5,880 ; paid

at 100% af

ter limit

reached

Out

‑of

‑P

ock

et

Limit $2,940 ; paid

at 100% af

ter limit

reached

Plans F and G also ha

ve a high deduc

tible option which r

equir

e first pa

ying a plan deduc

tible of $2,340 bef

or

e the plan beg

ins t

o pa

y. Onc

e the plan deduc

tible is

met, the plan pa

ys 100% of c

ov

er

ed ser

vic

es f

or the r

est of the calendar y

ear

. H

igh deduc

tible plan G does not c

ov

er the M

edicar

e P

ar

t B deduc

tible

. Ho

w

ev

er

, high

deduc

tible plans F and G c

oun

t y

our pa

ymen

t of the M

edicar

e P

ar

t B deduc

tible t

ow

ar

d meeting the plan deduc

tible

(2)

Pa g e 2 A dministr ativ e O ffic e - P .O . B

ox 27248 Salt Lake Cit

y, U tah 84127-0248 - P hone: 1-844-442-3847 A C LM ED -O O C-K Y R ev 0 70 11 9

PR

EM

IU

M

INF

OR

M

A

TI

ON

W

e, A

tlan

tic C

oast Lif

e I

nsur

anc

e C

ompan

y, can only r

aise y

our

pr

emium if (a) w

e change the pr

emium r

at

es which apply t

o all

policies of this f

or

m issued b

y us and inf

or

ce in y

our sta

te; (b)

co

ver

age under M

edicar

e changes; or (c) y

ou mo

ve t

o a diff

er

en

t

Zip C

ode

. W

e will send y

ou the adv

anc

e wr

itt

en notic

e r

equir

ed b

y

your sta

te when w

e change the pr

emium r

at

es f

or all policies of

this f

or

m issued b

y us and inf

or

ce in y

our sta

te

.

Ther

e will be a one

‑time enr

ollmen

t f

ee of $25.00 added t

o the

first pr

emium.

HOUSEHOLD DISC

OUNT

If y

ou ar

e applying f

or an A

tlan

tic C

oast Lif

e I

nsur

anc

e C

ompan

y

Standar

d P

lan, y

ou ma

y be elig

ible f

or a Household P

remium

Disc

oun

t.

The disc

oun

t is a

vailable if y

ou cur

ren

tly ha

ve a

household r

esiden

t (a

t least one

, no mor

e than thr

ee):

‑ with whom y

ou ha

ve c

on

tinuously r

esided f

or the past 12

mon

ths or t

o whom y

ou ar

e either mar

ried or with whom y

ou ar

e

in a civil union par

tnership; or

‑ who has an existing M

edicar

e Supplemen

t polic

y, or is applying

for a polic

y, with A

tlan

tic C

oast Lif

e I

nsur

anc

e C

ompan

y.

The r

emo

val of the disc

oun

t will incr

ease y

our pr

emium.

D

IS

C

LO

SU

R

ES

U

se this Outline of C

ov

er

age t

o c

ompar

e benefits and pr

emiums

among policies

.

R

EA

D Y

O

UR P

O

LIC

Y

V

ER

Y

C

A

R

EF

U

LL

Y

This is only an Outline of C

ov

er

age

, descr

ibing y

our polic

y’

s most

impor

tan

t f

ea

tur

es

. T

he polic

y is y

our insur

anc

e c

on

tr

ac

t.

You

must r

ead the polic

y itself t

o understand all of the r

igh

ts and

duties of both y

ou and y

our insur

anc

e c

ompan

y.

30 -D

A

Y R

IG

H

T T

O R

ET

UR

N P

O

LIC

Y

If y

ou ar

e not sa

tisfied with y

our polic

y, y

ou ma

y r

etur

n it t

o A

tlan

tic

C

oast Lif

e I

nsur

anc

e C

ompan

y, A

dministr

ativ

e O

ffic

e, P

.O

. B

ox 27248,

Salt Lake Cit

y, UT 84127

‑0248. I

f y

ou send the polic

y back t

o us

within 30 da

ys af

ter y

ou r

ec

eiv

e it, w

e will tr

ea

t the polic

y as if it had

nev

er been issued and r

etur

n all of y

our pr

emiums

.

P

O

LIC

Y R

EP

LA

C

EM

EN

T

If y

ou ar

e r

eplacing another health insur

anc

e polic

y, do NO

T canc

el

it un

til y

ou ha

ve ac

tually r

ec

eiv

ed y

our new polic

y and ar

e sur

e y

ou

w

an

t t

o keep it.

N

O

TI

C

E

Th

is p

ol

ic

y m

ay n

ot f

ul

ly c

ov

er a

ll o

f y

ou

r m

ed

ic

al c

os

ts

. N

ei

th

er

A

tla

nt

ic C

oa

st L

ife I

ns

ur

an

ce C

om

p

an

y n

or i

ts a

ge

nt

s a

re c

on

ne

ct

ed

w

ith M

ed

ic

ar

e. T

hi

s Ou

tli

ne o

f C

ov

er

ag

e d

oe

s n

ot g

iv

e a

ll t

he d

et

ai

ls

of M

ed

ic

ar

e c

ov

er

ag

e. C

on

ta

ct y

ou

r l

oc

al S

oc

ia

l S

ec

ur

it

y O

ffi

ce o

r

co

ns

ul

t t

he M

ed

ic

ar

e B

uy

ers G

ui

de f

or m

or

e d

et

ai

ls

.

CO

M

PL

ET

E A

N

SW

ER

S A

R

E V

ER

Y I

M

P

O

R

TA

N

T

W

hen y

ou fill out the applica

tion f

or the new polic

y, be sur

e t

o

answ

er truthfully and c

omplet

ely all questions about y

our medical

and health hist

or

y. A

tlan

tic C

oast Lif

e I

nsur

anc

e C

ompan

y ma

y

canc

el y

our polic

y and r

efuse t

o pa

y an

y claims if y

ou lea

ve out or

falsify impor

tan

t medical inf

or

ma

tion.

Review the applica

tion car

efully bef

or

e y

ou sig

n it. B

e c

er

tain tha

t all

inf

or

ma

tion has been pr

oper

ly r

ec

or

ded

.

R

EN

EWA

B

IL

IT

Y

Th

is

p

ol

ic

y i

s g

ua

ra

nt

ee

d

re

ne

wa

b

le

for

li

fe

, a

s long

a

s p

re

m

iu

m

s

ar

e p

ai

d o

n t

im

e a

nd t

he i

nf

or

m

at

io

n o

n y

ou

r a

p

lic

at

io

n i

s c

or

re

ct

.

(3)

Pa g e 3

HOU

SEHOLD DIS

COUNT M

ONTHL

Y R

ATES*

(R

ef

er t

o page 2 of this Outline of C

ov

er

age f

or Household Disc

oun

t rules)

C LM ED -O O C-K Y R ev 0 70 11 9

S

tan

dard

*T

o

ob

ta

in

a

n

u

al

, se

mia

n

u

al

, or

qu

ar

te

rly

p

re

mi

u

ms

, m

u

lt

ip

ly

t

he

M

on

thly

P

re

mi

u

ms

A

m

o

u

n

t b

y 1

2,

6 , or

3 , re

sp

ec

ti

ve

ly

.

NON-TOB

A

CC

O

ZIP C

ODES:

400-401,403-409,

411-415,419-428

Female M ale St d. P lan A St d. P lan C St d. P lan G St d. P lan N A ttained Ag e St d. P lan A St d. P lan C St d. P lan G St d. P lan N A CLA10ST ‑K Y A CL C10ST ‑KY A CL G10ST ‑KY A CLN10ST ‑KY A CLA10ST ‑KY A CL C10ST ‑KY A CL G10ST ‑KY A CLN10ST ‑KY $394.30 $521.91 $361.88 $284.57 <65 $453.22 $599.90 $415.96 $327.09 $98.58 $130.48 $90.47 $71.14 6 5 $113.31 $149.97 $103.99 $81.77 $98.58 $130.48 $90.47 $71.14 6 6 $113.31 $149.97 $103.99 $81.77 $98.58 $130.48 $90.47 $71.14 6 7 $113.31 $149.97 $103.99 $81.77 $98.58 $130.48 $90.47 $71.14 6 8 $113.31 $149.97 $103.99 $81.77 $98.58 $130.48 $90.47 $71.14 6 9 $113.31 $149.97 $103.99 $81.77 $100.72 $132.99 $92.58 $72.39 7 0 $115.77 $152.87 $106.41 $83.21 $103.73 $137.26 $95.88 $75.48 7 1 $119.23 $157.77 $110.21 $86.76 $107.06 $141.96 $99.48 $78.80 7 2 $123.06 $163.17 $114.35 $90.58 $110.97 $147.42 $103.62 $82.55 7 3 $127.55 $169.44 $119.10 $94.89 $115.49 $153.71 $108.35 $86.79 7 4 $132.75 $176.68 $124.54 $99.76 $120.35 $160.46 $113.41 $91.30 7 5 $138.34 $184.43 $130.36 $104.94 $124.01 $166.34 $117.79 $95.30 7 6 $142.54 $191.19 $135.39 $109.54 $127.89 $172.55 $122.39 $99.50 7 7 $147.00 $198.34 $140.68 $114.37 $131.98 $179.11 $127.25 $103.93 7 8 $151.70 $205.87 $146.27 $119.46 $136.32 $186.03 $132.38 $108.60 7 9 $156.70 $213.83 $152.16 $124.83 $141.21 $193.73 $138.07 $113.75 8 0 $162.31 $222.68 $158.70 $130.75 $146.12 $202.21 $144.32 $119.38 8 1 $167.95 $232.43 $165.88 $137.22 $151.63 $211.63 $151.24 $125.59 8 2 $174.29 $243.25 $173.84 $144.35 $156.58 $220.34 $157.67 $131.42 8 3 $179.98 $253.27 $181.23 $151.05 $161.98 $229.77 $164.63 $137.70 8 4 $186.18 $264.11 $189.23 $158.28 $167.86 $239.99 $172.15 $144.50 8 5 $192.94 $275.85 $197.88 $166.09 $173.10 $249.32 $178.99 $150.67 8 6 $198.96 $286.57 $205.74 $173.18 $178.34 $258.71 $185.89 $156.90 8 7 $204.99 $297.37 $213.67 $180.34 $183.55 $268.17 $192.84 $163.20 8 8 $210.98 $308.24 $221.66 $187.59 $187.99 $276.58 $199.05 $168.89 8 9 $216.08 $317.91 $228.79 $194.13 $192.34 $284.94 $205.22 $174.56 9 0 $221.08 $327.52 $235.89 $200.65 $196.00 $292.57 $210.84 $179.70 9 1 $225.29 $336.29 $242.34 $206.55 $199.52 $300.09 $216.37 $184.78 9 2 $229.34 $344.93 $248.71 $212.39 $202.91 $307.47 $221.82 $189.79 9 3 $233.23 $353.42 $254.97 $218.15 $206.16 $314.71 $227.16 $194.73 9 4 $236.96 $361.74 $261.11 $223.82 $209.24 $321.78 $232.39 $199.57 9 5 $240.51 $369.86 $267.11 $229.39 $211.96 $325.96 $235.40 $202.16 9 6 $243.64 $374.67 $270.58 $232.37 $214.51 $329.87 $238.23 $204.58 9 7 $246.56 $379.16 $273.82 $235.15 $216.87 $333.50 $240.85 $206.84 9 8 $249.27 $383.34 $276.84 $237.74 $219.03 $336.83 $243.26 $208.91 9 9 $251.76 $387.16 $279.60 $240.12

(4)

Pa g e 4

HOU

SEHOLD DIS

COUNT M

ONTHL

Y R

ATES*

(R

ef

er t

o page 2 of this Outline of C

ov

er

age f

or Household Disc

oun

t rules)

A C LM ED -O O C-K Y R ev 0 70 11 9

S

tan

dard

*T

o

ob

ta

in

a

n

u

al

, se

mia

n

u

al

, or

qu

ar

te

rly

p

re

mi

u

ms

, m

u

lt

ip

ly

t

he

M

on

thly

P

re

mi

u

ms

A

m

o

u

n

t b

y 1

2,

6 , or

3 , re

sp

ec

ti

ve

ly

.

TO

B

A

CCO

ZIP C

ODES:

400-401,403-409,

411-415,419-428

(5)

Pa g e 5

M

ONTHL

Y R

ATES*

C LM ED -O O C-K Y R ev 0 70 11 9

St

an

d

ard

*T

o

ob

ta

in

a

n

u

al

, se

mia

n

u

al

, or

qu

ar

te

rly

p

re

mi

u

ms

, m

u

lt

ip

ly

t

he

M

on

thly

P

re

mi

u

ms

A

m

o

u

n

t b

y 1

2,

6 , or

3 , re

sp

ec

ti

ve

ly

.

NON-TOB

A

CC

O

ZIP C

ODES:

400-401,403-409,

411-415,419-428

(6)

Pa g e 6

M

ONTHL

Y R

ATES*

St

an

d

ard

*T

o

ob

ta

in

a

n

u

al

, se

mia

n

u

al

, or

qu

ar

te

rly

p

re

mi

u

ms

, m

u

lt

ip

ly

t

he

M

on

thly

P

re

mi

u

ms

A

m

o

u

n

t b

y 1

2,

6 , or

3 , re

sp

ec

ti

ve

ly

.

TO

B

A

CCO

ZIP C

ODES:

400-401,403-409,

411-415,419-428

(7)

Pa g e 7

HOU

SEHOLD DIS

COUNT M

ONTHL

Y R

ATES*

(R

ef

er t

o page 2 of this Outline of C

ov

er

age f

or Household Disc

oun

t rules)

C LM ED -O O C-K Y R ev 0 70 11 9

S

tan

dard

*T

o

ob

ta

in

a

n

u

al

, se

mia

n

u

al

, or

qu

ar

te

rly

p

re

mi

u

ms

, m

u

lt

ip

ly

t

he

M

on

thly

P

re

mi

u

ms

A

m

o

u

n

t b

y 1

2,

6 , or

3 , re

sp

ec

ti

ve

ly

.

NON-TOB

A

CC

O

ZIP C

ODES:

402,410,416-418

(8)

Pa g e 8

HOU

SEHOLD DIS

COUNT M

ONTHL

Y R

ATES*

(R

ef

er t

o page 2 of this Outline of C

ov

er

age f

or Household Disc

oun

t rules)

S

tan

dard

*T

o

ob

ta

in

a

n

u

al

, se

mia

n

u

al

, or

qu

ar

te

rly

p

re

mi

u

ms

, m

u

lt

ip

ly

t

he

M

on

thly

P

re

mi

u

ms

A

m

o

u

n

t b

y 1

2,

6 , or

3 , re

sp

ec

ti

ve

ly

.

TO

B

A

CCO

ZIP C

ODES:

402,410,416-418

(9)

Pa g e 9

M

ONTHL

Y R

ATES*

C LM ED -O O C-K Y R ev 0 70 11 9

St

an

d

ard

*T

o

ob

ta

in

a

n

u

al

, se

mia

n

u

al

, or

qu

ar

te

rly

p

re

mi

u

ms

, m

u

lt

ip

ly

t

he

M

on

thly

P

re

mi

u

ms

A

m

o

u

n

t b

y 1

2,

6 , or

3 , re

sp

ec

ti

ve

ly

.

NON-TOB

A

CC

O

ZIP C

ODES:

402,410,416-418

(10)

Pa g e 10

M

ONTHL

Y R

ATES*

St

an

d

ard

*T

o

ob

ta

in

a

n

u

al

, se

mia

n

u

al

, or

qu

ar

te

rly

p

re

mi

u

ms

, m

u

lt

ip

ly

t

he

M

on

thly

P

re

mi

u

ms

A

m

o

u

n

t b

y 1

2,

6 , or

3 , re

sp

ec

ti

ve

ly

.

TO

B

A

CCO

ZIP C

ODES:

402,410,416-418

(11)

Pa g e 11 C LM ED -O O C-K Y R ev 0 70 11 9

*

A benefit per

iod beg

ins on the first da

y y

ou r

ec

eiv

e ser

vic

e as an inpa

tien

t in a hospital and ends af

ter y

ou ha

ve been out of the

hospital and ha

ve not r

ec

eiv

ed sk

illed car

e in an

y other facilit

y f

or 60 da

ys in a r

ow

.

**NO

TI

C

E:

W

he

n y

ou

r M

ed

ic

ar

e P

ar

t A h

os

p

it

al b

en

efi

ts a

re e

xh

au

st

ed

, t

he i

ns

ur

er s

ta

nd

s i

n p

la

ce o

f M

ed

ic

ar

e a

nd w

ill p

ay w

ha

te

ve

r

am

ou

nt M

ed

ic

ar

e w

ou

ld h

av

e p

ai

d f

or u

p t

o a

n a

d

di

ti

on

al 3

65 d

ay

s a

s p

ro

vi

d

ed i

n t

he p

ol

ic

y’

s “

C

or

e B

en

efi

ts

.” D

ur

in

g t

hi

s t

im

e t

he

ho

sp

it

al i

s p

ro

hi

b

ite

d f

ro

m b

ill

in

g y

ou f

or t

he b

al

an

ce b

as

ed o

n a

ny d

iff

er

en

ce b

et

w

ee

n i

ts b

ill

ed c

ha

rg

es a

nd t

he a

m

ou

nt M

ed

ic

ar

e

w

oul

d

ha

ve

p

ai

d

.

SER

VICES

MEDIC

ARE P

AY

S

PL

AN P

AY

S

YOU P

AY

HO

SP

ITAL

IZA

TIO

N*

Se

m

i‑p

riv

at

e r

oo

m a

nd b

oa

rd

, g

en

era

l

nu

rsi

ng a

nd m

isc

ell

an

eo

us s

er

vic

es a

nd

su

pp

lie

s

Fir

st 6

0 d

ays

61 st t

hr

u 9

0t

h d

ay

91 st d

ay a

nd a

fte

r:

• W

hil

e u

sin

g 6

0 l

ifet

im

e r

es

erv

e d

ays

• On

ce

life

tim

e r

ese

rve

da

ys

ar

e u

sed

:

‑ A

dd

iti

on

al 3

65 d

ays

‑ B

ey

on

d t

he a

dd

iti

on

al 3

65 d

ays

Al

l b

ut $

1,4

08 Al

l b

ut $

35 2 a d

ay

Al

l b

ut $

70 4 a d

ay

$0

$3

52 a d

ay

$7

04 a d

ay

10 0%

of

Me

dic

are

El

igib

le E

xp

en

se

s

$0

$1

,408 (

Pa

rt A D

ed

uc

tib

le)

$0

**

Al

l Co

sts

SK

ILLE

D N

UR

SIN

G F

ACI

LIT

Y C

AR

E*

Yo

u m

us

t m

eet M

ed

ica

re

’s r

eq

uir

em

en

ts,

inc

lud

ing

ha

ving

be

en

in

a ho

sp

ita

l fo

r

at l

ea

st 3 d

ays a

nd e

nt

er

ed a M

ed

ica

re

‑

ap

pr

ov

ed f

aci

lit

y w

ith

in 3

0 d

ays a

fte

r

lea

vin

g t

he

ho

sp

ital

.

Fir

st 2

0 d

ays

21 st t

hr

u 1

00 th d

ay

10 1s

t d

ay a

nd a

fte

r

Al

l ap

pr

ov

ed

am

ou

nt

s

Al

l b

ut $

17 6 a d

ay

$0

Up t

o $

17 6 a d

ay

Al

l Co

sts

BLO

OD

Fir

st 3

pin

ts

Ad

dit

ion

al am

ou

nt

s

$0

10 0%

3 p

int

s

$0

HOS

PICE

CA

RE

Yo

u m

us

t m

eet M

ed

ica

re

’s r

eq

uir

em

en

ts,

incl

ud

ing a d

oc

to

r’s c

er

tifi

ca

tio

n o

f

te

rm

ina

l illn

es

s.

Al

l b

ut v

er

y l

im

ite

d c

o‑i

ns

ura

nc

e f

or

ou

tp

at

ien

t d

ru

gs

an

d in

pa

tien

t r

es

pit

e c

ar

e

M

ed

icar

e c

o‑

pa

ym

en

t/c

o‑

insu

ran

ce

$0

PL

AN A MEDIC

ARE (P

AR

T A) – HOSP

IT

AL SER

VICES – P

ER BENEFIT P

ERIOD

(12)

Pa g e 12 A C LM ED -O O C-K Y R ev 0 70 11 9

*

O

nc

e y

ou h

av

e b

ee

n b

ill

ed $

19 8 o

f M

ed

ic

ar

e‑

ap

p

ro

ve

d a

m

ou

nt

s f

or c

ov

er

ed s

er

vi

ce

s (

w

hi

ch a

re n

ot

ed w

ith a

n a

st

er

is

k)

, y

ou

r P

ar

t B

D

ed

uc

tib

le

w

ill

h

av

e b

ee

n m

et

for

the

c

ale

nd

ar

y

ea

r.

SER

VICES

MEDIC

ARE P

AY

S

PL

AN P

AY

S

YOU P

AY

ME

DI

CA

L E

XP

EN

SE

S – I

N O

R O

UT O

F T

HE H

OS

PIT

AL A

ND O

UT

PA

TIE

NT

HO

SP

ITA

L T

RE

AT

ME

NT

, s

uch a

s p

hys

ici

an

’s s

er

vic

es

, in

pa

tie

nt a

nd

ou

tp

at

ien

t m

ed

ical

an

d su

rg

ical

se

rv

ice

s an

d su

pp

lie

s, p

hy

sic

al an

d

spe

ech t

he

ra

py

, d

iag

no

sti

c t

es

ts, d

ura

ble m

ed

ica

l e

qu

ipm

en

t.

Fir

st $

19 8 of

Me

dic

ar

e‑

ap

pr

ov

ed

amo

un

ts*

(th

e P

ar

t B D

ed

uc

tib

le)

Re

ma

ind

er

of

M

ed

icar

e‑

ap

pr

ov

ed

am

ou

nt

s

$0

Gen

er

ally

80 %

$0

Gen

er

ally

20 %

$1

98 (

Pa

rt B D

ed

uc

tib

le)

$0

Par

t B

Ex

ce

ss C

har

ge

s

(A

bo

ve

M

ed

icar

e‑

ap

pr

ov

ed

am

ou

nt

s)

$0

Al

l co

sts

BLO

OD

Fir

st 3

pin

ts

Ne

xt

$1

98 of

Me

dic

ar

e‑

ap

pr

ov

ed

amo

un

ts*

Re

ma

ind

er

of

M

ed

icar

e‑

ap

pr

ov

ed

am

ou

nt

s

$0

80 %

Al

l co

sts

$0

20 %

$0

$1

98 (

Pa

rt B D

ed

uc

tib

le)

$0

CL

IN

ICA

L L

AB

OR

AT

OR

Y S

ER

VI

CE

S – T

ES

TS F

OR D

IA

GN

OS

TIC S

ER

VI

CE

S

10 0%

$0

HO

ME

HE

AL

THC

ARE

M

ED

ICA

RE

‑A

PP

RO

VE

D S

ER

VIC

ES

• M

ed

ical

ly n

ec

es

sar

y s

kil

led

car

e s

er

vic

es

an

d m

ed

ical

su

pp

lie

s

• D

ur

ab

le m

edi

ca

l e

quip

m

en

t

‑

F

irs

t $

19 8 of

Me

dic

ar

e‑

ap

pr

ov

ed

amo

un

ts*

‑

R

ema

ind

er

of

M

ed

icar

e‑

ap

pr

ov

ed

am

ou

nt

s

10 0%

$0

80 %

$0

20 %

$0

$1

98 (

Pa

rt B D

ed

uc

tib

le)

$0

PA

R

TS A & B

PL

AN A MEDIC

ARE (P

AR

T B) – MEDIC

AL SER

VICES – P

ER C

ALEND

AR Y

EAR