[30 Pa.B. 6886]

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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.
 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies       First 60 days       61st thru 90th day       91st day and after:       --While using 60 lifetime             reserve days       --Once lifetime reserve days are             used:             --Additional 365 days             --Beyond the additional 365             days	All but $792 All but $198 a day     All but $396 a day   $0 $0	$792 (Part A deductible)   $198 a day     $396 a day 100% of Medicare eli- gible expenses $0	$0 $0     $0 $0   All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's require- ments, including having been in a hospital for at least 3 days and en- tered a Medicare-approved facility within 30 days after leaving the hos- pital       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but $99 a day $0	$0 Up to $99 a day $0	$0 $0 All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor cer- tifies you are terminally ill and you elect to receive these services	All but very limited co- insurance for out- patient drugs and inpa- tient respite care	$0	Balance

PLAN G

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

* Once you have been billed $100 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 PAYS	YOU PAY
MEDICAL EXPENSES-- IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpa- tient and outpatient medical and surgical services and supplies, physi- cal and speech therapy, diagnostic tests, durable medical equipment,    First $100 of Medicare       approved amounts*    Remainder of Medicare       approved amounts    Part B excess charges       (Above Medicare       approved amounts)	$0   80% (50% outpatient psychiatric services)   $0	$0   20% (50% outpatient psychiatric services)   80%	$100 (Part B deductible)   $0     20%
BLOOD First 3 pints Next $100 of Medicare       approved amounts* Remainder of Medicare       approved amounts	$0   $0   80%	All costs   $0   20%	$0   $100 (Part B deductible)   $0
CLINICAL LABORATORY SER- VICES--BLOOD TESTS FOR DI- AGNOSTIC SERVICES	100%	$0	$0

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE APPROVED SERVICES       --Medically necessary skilled             care services and medical             supplies       --Durable medical equipment             First $100 of Medicare                approved amounts*             Remainder of Medicare                approved amounts   AT-HOME RECOVERY SERVICES-NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a home care treatment plan       --Benefit for each visit       --Number of visits covered          (must be received within 8          weeks of last Medicare ap-          proved visit)        --Calendar year          maximum	100%     $0   80%                   $0     $0     $0	$0     $0   20%                 Actual charges to $40 a visit   Up to the number of Medicare approved vis- its, not to exceed 7 each week $1,600	$0     $100 (Part B deductible)   $0                   Balance

OTHER BENEFITS - NOT COVERED BY MEDICARE
 

FOREIGN TRAVEL-- NOT COVERED BY MEDICARE
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA    First $250 each calendar year    Remainder of charges	$0 $0	$0 80% to a lifetime maxi- mum benefit of $50,000	$250 20% and amounts over the $50,000 life- time maximum

PLAN H

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.
 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies       First 60 days       61st thru 90th day       91st day and after:       --While using 60 lifetime             reserve days       --Once lifetime reserve days are             used:          --Additional 365 days          --Beyond the additional 365                days	All but $792 All but $198 a day   All but $396 a day     $0   $0	$792 (Part A deductible)   $198 a day   $396 a day     100% of Medicare eli- gible expenses $0	$0 $0   $0     $0   All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's require- ments, including having been in a hospital for at least 3 days and en- tered a Medicare-approved facility within 30 days after leaving the hos- pital       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but $99 a day $0	$0 Up to $99 a day $0	$0 $0 All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor cer- tifies you are terminally ill and you elect to receive these services	All but very limited co- insurance for out- patient drugs and inpa- tient respite care	$0	Balance

PLAN H

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

* Once you have been billed $100 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 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 $100 of Medicare          approved amounts*       Remainder of Medicare          approved amounts       Part B excess charges          (Above Medicare          approved amounts)	$0 80% (50% outpatient psychiatric services)     $0	$0 20% (50% outpatient psychiatric services)     $0	$100 (Part B deductible) $0       All costs
BLOOD First 3 pints Next $100 of Medicare       approved amounts* Remainder of Medicare       approved amounts	$0 $0   80%	All costs $0   20%	$0 $100 (Part B deductible)   $0
CLINICAL LABORATORY SER- VICES--BLOOD TESTS FOR DI- AGNOSTIC SERVICES	100%	$0	$0

PARTS A & B
 

HOME HEALTH CARE MEDICARE APPROVED SERVICES
--Medically necessary skilled             care services and medical             supplies       --Durable medical equipment          First $100 of Medicare             approved amounts*          Remainder of Medicare             approved amounts	100%     $0   80%	$0     $0   20%	$0     $100 (Part B deductible   $0

OTHER BENEFITS - NOT COVERED BY MEDICARE
 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
FOREIGN TRAVEL-- NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA       First $250 each          calendar year         Remainder of charges	$0   $0	$0   80% to a lifetime maxi- mum benefit of $50,000	$250   20% and amounts over the $50,000 lifetime maximum
BASIC OUTPATIENT PRESCRIP- TION DRUGS--NOT COVERED BY MEDICARE First $250 each calendar year   Next $2,500 each calendar year   Over $2,500 each calendar year	$0   $0   $0	$0   50%--$1,250 calendar year maximum benefit $0	$250   50%   All costs

PLAN I

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.
 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies       First 60 days       61st thru 90th day       91st day and after:       --While using 60 lifetime             reserve days       --Once lifetime reserve days are             used:             --Additional 365 days             --Beyond the additional 365                   days	All but $792 All but $198 a day     All but $396 a day   $0   $0	$792 (Part A deductible)   $198 a day     $396 a day   100% of Medicare eli- gible expenses $0	$0 $0     $0   $0   All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's require- ments, including having been in a hospital for at least 3 days and en- tered a Medicare-approved facility within 30 days after leaving the hos- pital       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but $99 a day $0	$0 Up to $99 a day $0	$0 $0 All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor cer- tifies you are terminally ill and you elect to receive these services	All but very limited co- insurance for out- patient drugs and inpa- tient respite care	$0	Balance

PLAN I

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

* Once you have been billed $100 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 PAYS	YOU PAY
MEDICAL EXPENSES-- IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpa- tient and outpatient medical and surgical services and supplies, physi- cal and speech therapy, diagnostic tests, durable medical equipment,       First $100 of Medicare             approved amounts*       Remainder of Medicare             approved amounts       Part B excess charges             (Above Medicare             approved amounts)	$0 80% (50% outpatient psychiatric services)     $0	$0 20% (50% outpatient psychiatric services)     100%	$100 (Part B deductible) $0       $0
BLOOD First 3 pints Next $100 of Medicare       approved amounts* Remainder of Medicare       approved amounts	$0   $0   80%	All costs   $0   20%	$0   $100 (Part B deductible)   $0
CLINICAL LABORATORY SER- VICES--BLOOD TESTS FOR DI- AGNOSTIC SERVICES	100%	$0	$0

PARTS A & B
 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE APPROVED SERVICES       --Medically necessary             skilled care services and             medical supplies       --Durable medical equipment             First $100 of Medicare                approved amounts*             Remainder of Medicare                approved amounts   AT-HOME RECOVERY SERVICES- NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan       --Benefit for each visit       --Number of visits covered             (must be received within             8 weeks of last Medicare             approved visit)       --Calendar year maximum	100%     $0   80%                 $0     $0   $0	$0     $0   20%               Actual charges to $40 a visit Up to the number of Medicare approved vis- its, not to exceed 7 each week $1,600	$0     $100 (Part B deductible)   $0                 Balance

OTHER BENEFITS - NOT COVERED BY MEDICARE

FOREIGN TRAVEL - NOT COVERED BY MEDICARE
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA       First $250 each calendar year       Remainder of charges	$0 $0	$0 80% to a lifetime maxi- mum benefit of $50,000	$250 20% and amounts over the $50,000 lifetime maximum

PLAN I

OTHER BENEFITS - NOT COVERED BY MEDICARE
 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
BASIC OUTPATIENT PRE- SCRIPTION DRUGS - NOT COV- ERED BY MEDICARE First $250 each calendar year   Next $2,500 each calendar year   Over $2,500 each calendar year	$0   $0   $0	$0   50%--$1,250 calendar year maximum benefit $0	$250   50%   All costs

 

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