Plan N 2022 Coverage Details
Medicare (Part A) Hospital Services Per Benefit Period
| Services | Benefit Details | Medicare Pays | Plan Pays | You Pay |
|---|---|---|---|---|
| Hospitalization1
(Semiprivate room and board, general nursing and miscellaneous services and supplies) |
First 60 days | All but $1,556 | $1,556 (Part A Deductible) | $0 |
| Days 61-90 | All but $389 a day | $389 a day | $0 | |
| 91st day and after (while using 60 lifetime reserve days) |
All but $778 a day | $778 a day | $0 | |
| 91st day and after (once lifetime reserve days are used — additional 365 days) |
$0 | 100% of Medicare eligible expenses | $02 | |
| 91st day and after
(once lifetime reserve days are used — beyond the additional 365 days) |
$0 | $0 | All costs | |
| Skilled Nursing Facility Care1
(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 $194.50 a day | Up to $194.50 a day | $0 | |
| 101st day and after | $0 | $0 | All costs | |
| Blood | First 3 pints | $0 | 3 pints | $0 |
| Additional amounts | 100% | $0 | $0 | |
| Hospice Care | You must meet Medicare's requirements, including doctor's certification of terminal illness | All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care | Medicare copayment/coinsurance | $0 |
1A 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.
Medicare (Part B) Medical Services Per Calendar Year
| Services | Benefit Details | 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 $233 of Medicare approved amounts3 | $0 | $0 | $233 (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 member 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 member 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 3 pints | $0 | All costs | $0 |
| Next $233 of Medicare approved amounts3 | $0 | $0 | $233 (Part B deductible) | |
| Remainder of Medicare approved amounts | 80% | 20% | $0 | |
| Clinical Laboratory Services | Tests for diagnostic services | 100% | $0 | $0 |
3Once you have been billed $233 of Medicare approved amounts for covered services, your part B deductible will have been met for the calendar year.
Medicare Parts A & B
| Services | Benefit Details | Medicare Pays | Plan Pays | You Pay |
|---|---|---|---|---|
| Home Health Care Medicare approved services |
Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
| Durable medical equipment — first $233 of Medicare approved amounts3 | $0 | $0 | $233 (Part B deductible) | |
| Durable medical equipment — remainder of Medicare approved amounts | 80% | 20% | $0 |
3Once you have been billed $233 of Medicare approved amounts for covered services, your part B deductible will have been met for the calendar year.
Other Benefits Not Covered by Medicare
| Services | Benefit Details | Medicare Pays | Plan Pays | You Pay |
|---|---|---|---|---|
| Foreign Travel Not covered by Medicare |
Medically necessary skilled care services beginning during the first 60 days of each trip outside the USA — first $250 each calendar year | $0 | $0 | $250 |
| Medically necessary skilled care services beginning during the first 60 days of each trip outside the USA — remainder of charges | $0 | 80% to a lifetime maximum benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
Medicare benefits are subject to change. Please consult the latest Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare.
