High Deductible Plan G 2024 Coverage Details
Medicare (Part A) Hospital Services Per Benefit Period
| Services | Benefit Details | Medicare Pays | Plan Pays After You Pay $2,800 Deductible1 | You Pay |
|---|---|---|---|---|
| Hospitalization2
(Semiprivate room and board, general nursing and miscellaneous services and supplies) |
First 60 days | All but $1,632 | $1,632 (Part A Deductible) | $0 |
| Days 61-90 | All but $408 a day | $408 a day | $0 | |
| 91st day and after (while using 60 lifetime reserve days) |
All but $816 a day | $816 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 costs3 | |
| Skilled Nursing Facility Care2
(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 $204 a day | Up to $204 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 |
1This high-deductible plan pays the same benefits as Plan G after you have paid a calendar year $2,800 deductible. Benefits from the High Deductible Plan G will not begin until out-of-pocket expenses are $2,800. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the plan's foreign travel emergency deductible.
2A 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 After You Pay $2,800 Deductible1 | 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 $240 of Medicare approved amounts2 | $0 | $0 | $240 (Part B deductible) |
| Remainder of Medicare approved amounts | Generally 80% | Generally 20% | $0 | |
| Part B Excess Charges | Above Medicare approved amounts | $0 | 100% | $0 |
| Blood | First 3 pints | $0 | All costs | $0 |
| Next $240 of Medicare approved amounts2 | $0 | $0 | $240 (Part B deductible) | |
| Remainder of Medicare approved amounts | 80% | 20% | $0 | |
| Clinical Laboratory Services | Tests for diagnostic services | 100% | $0 | $0 |
1This high-deductible plan pays the same benefits as Plan G after you have paid a calendar year $2,800 deductible. Benefits from the High Deductible Plan G will not begin until out-of-pocket expenses are $2,800. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the plan's foreign travel emergency deductible.
2Once you have been billed $240 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 After You Pay $2,800 Deductible1 | You Pay |
|---|---|---|---|---|
| Home Health Care Medicare approved services |
Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
| Durable medical equipment — first $240 of Medicare approved amounts2 | $0 | $0 | $240 (Part B deductible) | |
| Durable medical equipment — remainder of Medicare approved amounts | 80% | 20% | $0 |
1This high-deductible plan pays the same benefits as Plan G after you have paid a calendar year $2,800 deductible. Benefits from the High Deductible Plan G will not begin until out-of-pocket expenses are $2,800. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the plan's foreign travel emergency deductible.
2Once you have been billed $240 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 After You Pay $2,800 Deductible1 | 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 |
1This high-deductible plan pays the same benefits as Plan G after you have paid a calendar year $2,800 deductible. Benefits from the High Deductible Plan G will not begin until out-of-pocket expenses are $2,800. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the plan's foreign travel emergency deductible.
Note: Members enrolled in High Deductible Plan G for 12 consecutive months will be allowed to move to Plan G during the Annual Enrollment Period (AEP) from Oct. 15-Dec. 7 for coverage to be effective Jan. 1. members who move from High Deductible Plan G to Plan G will keep their same rating structure. So if a member has the preferred rating in High Deductible Plan G, then they will get the preferred rating when they move to Plan G. Members moving from High Deductible Plan G to Plan G outside the AEP will be required to answer health questions on the application.
Medicare benefits are subject to changes. Please visit Medicare.gov and consult the latest Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare.
