Basic Benefits (Included in All Plans)


•Hospitalization Coinsurance for days 61-90 is ($322 per day) and days 91 and after while using lifetime reserve days is ($644 per day)
• Payment in full for 365 additional hospital days
• 20% coinsurance for physician and other Medicare Part B services

Medicare Part A Hospital Deductible
• The 2016 deductible is $1288

Skilled Nursing Facility (SNF) Coinsurance
• $161 a day for days 21-100 in a Skilled Nursing Facility in 2016

Medicare Part B Yearly Deductible
• The 2016 deductible is $166

Medicare Part B Excess Charges
• Difference between doctor's charge and Medicare's approved amount
• Up to 15% above the Medicare approved charge which is the doctor’s maximum charge

Foreign Travel Emergency
• Pays 80% of the cost of emergency care during the first two months of each trip after you pay a $250 deductible
• Lifetime maximum of $50,000
Plan A

Coverage with your:
Medicare Part A- Hospital Services
*Per Benefit Period

Service: HOSPITALIZATION
Semiprivate room and board, general nursing and miscellaneous services and supplies
  MEDICARE PAYS PLAN PAYS YOU PAY
First 60 days All but $1288 $0 $1288 (Per Benefit Period)
61st through 90th day All but $315 $315 a day $0
91st day and after:
(Using 60 lifetime reserve days) 		All but $630 a day $630 a day $0
Once lifetime reserve days are used,
365 Additional Days: 		$0 100% of Medicare Eligible Expenses $0**
Beyond the Additional 365 days $0 $0 All costs
Service: SKILLED NURSING FACILITY CARE
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:
First 20 days All approved amounts $0 $0
21st through 100th day All but $157.50 a day $0 Up to $157.50 a day
101st day and after $0 $0 All costs
Service: BLOOD
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Service: HOSPICE CARE
Available as long as you meet Medicare's requirements, your doctor certifies you are terminally ill and you elect to receive these services.
Outpatient Prescription Drugs All but $5 $5 $0
Inpatient Respite Care All but 5% 5% of Medicare's approved amount $0
* 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.
 
Plan A
Coverage with your:
Medicare Part B- Medical Services
*Per Calendar Year
Service: 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:
  MEDICARE PAYS PLAN PAYS YOU PAY
First $166 of Medicare Approved Amounts* $0 $0 $166 (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
Service: BLOOD
First 3 pints $0 All cost $0
Next $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved Amounts 80% 20% $0
Service: CLINICAL LABORATORY SERVICES
Blood tests for Diagnostic Services 100% $0 $0
 
MEDICARE  PARTS  A & B
Service: HOME HEALTH CARE
Medicare Approved Services:
  MEDICARE PAYS PLAN PAYS YOU PAY
Medically necessary skilled care services and medical supplies 100% $0 $0
Durable medical equipment:         
First $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved Amounts 80% 20% $0
* Once You have filled $166 of Medicare-Approved amounts for covered services(which are noted with an asterisk),Your Medicare Part B Deductible will have
met for the calendar year.
Plan B

Coverage with your:
Medicare Part A- Hospital Services
*Per Benefit Period
Service: HOSPITALIZATION
Semiprivate room and board, general nursing and miscellaneous services and supplies:
  MEDICARE PAYS PLAN PAYS YOU PAY
First 60 days All but $1288 $1288 (Part A Deductible) $0
61st through 90th day All but $315 a day $315 a day $0
91st day and after:
(Using 60 lifetime reserve days)		 All but $630 a day $630 a day $0
Once lifetime reserve days are used,
365 Additional Days: 		$0 100% of Medicare Eligible Expenses $0**
Beyond the Additional 365 days $0 $0 All costs
Service: SKILLED NURSING FACILITY CARE
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:
First 20 days All approved amounts $0 $0
21st through 100th day All but $157.50 a day $0 Up to $157.50 a day
101st day and after $0 $0 All costs
Service: BLOOD
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Service: HOSPICE CARE
Available as long as you meet Medicare's requirements, your doctor certifies you are terminally ill and you elect to receive these services.
Outpatient Prescription Drugs All but $5 $5 $0
Inpatient Respite Care All but 5% 5% of Medicare's approved amount $0
* 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.
 
Plan B
Coverage with your:
Medicare Part B- Medical Services
*Per Calendar Year
Service: 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:
  MEDICARE PAYS PLAN PAYS YOU PAY
First $166 of Medicare Approved Amounts* $0 $0 $166 (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
Service: BLOOD
First 3 pints $0 All cost $0
Next $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved Amounts 80% 20% $0
Service: CLINICAL LABORATORY SERVICES
Blood tests for Diagnostic Services 100% $0 $0
 
MEDICARE  PARTS  A & B
Service: HOME HEALTH CARE
Medicare Approved Services:
  MEDICARE PAYS PLAN PAYS YOU PAY
Medically necessary skilled care services and medical supplies 100% $0 $0
Durable medical equipment:        
First $140 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved Amounts 80% 20% $0
* Once You have filled $166 of Medicare-Approved amounts for covered services(which are noted with an asterisk),Your Medicare Part B Deductible will have
met for the calendar year.
Plan C

Coverage with your:
Medicare Part A- Hospital Services
*Per Benefit Period
Service: HOSPITALIZATION
Semiprivate room and board, general nursing and miscellaneous services and supplies:
  MEDICARE PAYS PLAN PAYS YOU PAY
First 60 days All but $1288 $1288 (Part A Deductible) $0
61st through 90th day All but $315 $315 a day $0
91st day and after:
(Using 60 lifetime reserve days)		 All but $630 a day $630 a day $0
Once lifetime reserve days are used,
365 Additional Days: 		$0 100% of Medicare Eligible Expenses $0**
Beyond the Additional 365 days $0 $0 All costs
Service: SKILLED NURSING FACILITY CARE
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:
First 20 days All approved amounts $0 $0
21st through 100th day All but $157.50 a day Up to $157.50 a day $0
101st day and after $0 $0 All costs
Service: BLOOD
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Service: HOSPICE CARE
Available as long as you meet Medicare's requirements, your doctor certifies you are terminally ill and you elect to receive these services
Outpatient Prescription Drugs All but $5 $5 $0
Inpatient Respite Care All but 5% 5% of Medicare's approved amount $0
* 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.
 
Plan C
Coverage with your:
Medicare Part B- Medical Services
*Per Calendar Year
Service: 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:
  MEDICARE PAYS PLAN PAYS YOU PAY
First $166 of Medicare Approved Amounts* $0 $166 (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
Service: BLOOD
First 3 pints $0 All cost $0
Next $166 of Medicare Approved Amounts* $0 $166 (Part B Deductible) $0
Remainder of Medicare Approved Amounts 80% 20% $0
Service: CLINICAL LABORATORY SERVICES
Blood tests for Diagnostic Services 100% $0 $0
 
MEDICARE  PARTS  A & B
Service: HOME HEALTH CARE
Medicare Approved Services:
  MEDICARE PAYS PLAN PAYS YOU PAY
Medically necessary skilled care services and medical supplies 100% $0 $0
Durable medical equipment:        
First $166 of Medicare Approved Amounts* $0 $166
(Part B Deductible)		 $0
Remainder of Medicare Approved Amounts 80% 20% $0
 
OTHER BENEFITS - NOT COVERED BY MEDICARE
Service:
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 $0 $0 $250
Remainder of charges $0 80% to a lifetime maximum of $50,000 20% and amounts over the $50,000 lifetime maximum
* Once You have filled $166 of Medicare-Approved amounts for covered services(which are noted with an asterisk),Your Medicare Part B Deductible will have
met for the calendar year.
Plan D

Coverage with your:
Medicare Part A- Hospital Services
*Per Benefit Period
Service: HOSPITALIZATION
Semiprivate room and board, general nursing and miscellaneous services and supplies:
  MEDICARE PAYS PLAN PAYS YOU PAY
First 60 days All but $1288 $1288 (Part A Deductible) $0
61st through 90th day All but $315 a day $315 a day $0
91st day and after:
(Using 60 lifetime reserve days)		 All but $630 a day $630 a day $0
Once lifetime reserve days are used,
365 Additional Days: 		$0 100% of Medicare Eligible Expenses $0**
Beyond the Additional 365 days $0 $0 All costs
Service: SKILLED NURSING FACILITY CARE
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:
First 20 days All approved amounts $0 $0
21st through 100th day All but $157.50 a day Up to $157.50 a day $0
101st day and after $0 $0 All costs
Service: BLOOD
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Service: HOSPICE CARE
Available as long as you meet Medicare's requirements, your doctor certifies you are terminally ill and you elect to receive these services.
Outpatient Prescription Drugs All but $5 $5 $0
Inpatient Respite Care All but 5% 5% of Medicare's approved amount $0
* 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.
 
Plan D
Coverage with your:
Medicare Part B- Medical Services
*Per Calendar Year
Service: 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:
  MEDICARE PAYS PLAN PAYS YOU PAY
First $166 of Medicare Approved Amounts* $0 $0 $166 (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
Service: BLOOD
First 3 pints $0 All cost $0
Next $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved Amounts 80% 20% $0
Service: CLINICAL LABORATORY SERVICES
Blood tests for Diagnostic Services 100% $0 $0
 
MEDICARE  PARTS  A & B
Service: HOME HEALTH CARE
Medicare Approved Services:
  MEDICARE PAYS PLAN PAYS YOU PAY
Medically necessary skilled care services and medical supplies 100% $0 $0
Durable medical equipment:  
First $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved Amounts 80% 20% $0
OTHER BENEFITS - NOT COVERED BY MEDICARE
Service:
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 $0 $0 $250
Remainder of charges $0 80% to a lifetime maximum of $50,000 20% and amounts over the $50,000 lifetime maximum
* Once You have filled $166 of Medicare-Approved amounts for covered services(which are noted with an asterisk),Your Medicare Part B Deductible will have
met for the calendar year.
Plan F

Coverage with your:
Medicare Part A- Hospital Services
*Per Benefit Period

Service: HOSPITALIZATION
Semiprivate room and board, general nursing and miscellaneous services and supplies:
  MEDICARE PAYS PLAN PAYS YOU PAY
First 60 days All but $1288 $1288 (Part A Deductible) $0
61st through 90th day All but $315 a day $315 a day $0
91st day and after:
(Using 60 lifetime reserve days) 		All but $630 a day $630 a day $0
Once lifetime reserve days are used,
365 Additional Days: 		$0 100% of Medicare Eligible Expenses $0**
Beyond the Additional 365 days $0 $0 All costs
Service: SKILLED NURSING FACILITY CARE
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:
First 20 days All approved amounts $0 $0
21st through 100th day All but $157.50 a day Up to $157.50 a day $0
101st day and after $0 $0 All costs
Service: BLOOD
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Service: HOSPICE CARE
Available as long as you meet Medicare's requirements, your doctor certifies you are terminally ill and you elect to receive these services.
Outpatient Prescription Drugs All but $5 $5 $0
Inpatient Respite Care All but 5% 5% of Medicare's approved amount $0
* 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.
 
Plan F
Coverage with your:
Medicare Part B- Medical Services
*Per Calendar Year
Service: 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:
  MEDICARE PAYS PLAN PAYS YOU PAY
First $166 of Medicare Approved Amounts* $0 $166 (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
Service: BLOOD
First 3 pints $0 All costs $0
Next $166 of Medicare Approved Amounts* $0 $166 (Part B Deductible) $0
Remainder of Medicare Approved Amounts 80% 20% $0
Service: CLINICAL LABORATORY SERVICES
Tests for Diagnostic Services 100% $0 $0
 
PARTS  A & B
Service: HOME HEALTH CARE
Medicare Approved Services:
  MEDICARE PAYS PLAN PAYS YOU PAY
Medically necessary skilled care services and medical supplies 100% $0 $0
Durable medical equipment:        
First $166 of Medicare Approved Amounts* $0 $166 (Part B Deductible) $0
Remainder of Medicare Approved Amounts 80% 20% $0
 
OTHER BENEFITS - NOT COVERED BY MEDICARE
Service:
FOREIGN TRAVEL NOT COVERED BY MEDICARE
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA:
  MEDICARE PAYS PLAN PAYS YOU PAY
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
* Once You have filled $166 of Medicare-Approved amounts for covered services(which are noted with an asterisk),Your Medicare Part B Deductible will have
met for the calendar year.
Plan G

Coverage with your:
Medicare Part A- Hospital Services
*Per Benefit Period
Service: HOSPITALIZATION
Semiprivate room and board, general nursing and miscellaneous services and supplies:
  MEDICARE PAYS PLAN PAYS YOU PAY
First 60 days All but $1288 $1288 (Part A Deductible) $0
61st through 90th day All but $315 a day $315 a day $0
91st day and after:
(Using 60 lifetime reserve days)		 All but $630 a day $630 a day $0
Once lifetime reserve days are used,
365 Additional Days: 		$0 100% of Medicare Eligible Expenses $0**
Beyond the Additional 365 days $0 $0 All costs
Service: SKILLED NURSING FACILITY CARE
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:
First 20 days All approved amounts $0 $0
21st through 100th day All but $157.50 a day Up to $157.50 a day $0
101st day and after $0 $0 All costs
Service: BLOOD
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Service: HOSPICE CARE
Available as long as you meet Medicare's requirements, your doctor certifies you are terminally ill and you elect to receive these services
Outpatient Prescription Drugs All but $5 $5 $0
Inpatient Respite Care All but 5% 5% of Medicare's approved amount $0
* 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.
 
Plan G
Coverage with your:
Medicare Part B- Medical Services
*Per Calendar Year
Service: 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:
  MEDICARE PAYS PLAN PAYS YOU PAY
First $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0
Part B Excess Charges (Above Medicare Approved Amounts) $0 100% 0%
Service: BLOOD
First 3 pints $0 All costs $0
Next $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved Amounts 80% 20% $0
Service: CLINICAL LABORATORY SERVICES
Tests for Diagnostic Services 100% $0 $0
 
PARTS  A & B
Service: HOME HEALTH CARE
Medicare Approved Services:
  MEDICARE PAYS PLAN PAYS YOU PAY
Medically necessary skilled care services and medical supplies 100% $0 $0
Durable medical equipment:        
First $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved Amounts 80% 20% $0
 
OTHER BENEFITS - NOT COVERED BY MEDICARE
Service:
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 $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
* Once You have filled $166 of Medicare-Approved amounts for covered services(which are noted with an asterisk),Your Medicare Part B Deductible will have
met for the calendar year.
Plan K

Coverage with your:
Medicare Part A- Hospital Services
*Per Benefit Period
Service: HOSPITALIZATION
Semiprivate room and board, general nursing and miscellaneous services and supplies:
  MEDICARE PAYS PLAN PAYS YOU PAY**▲
First 60 days All but $1288 $630 (Part A Deductible) $630**▲
61st through 90th day All but $315 a day $315 a day $0
91st day and after:
(Using 60 lifetime reserve days)		 All but $630 a day $630 a day $0
Once lifetime reserve days are used,
365 Additional Days: 		$0 100% of Medicare Eligible Expenses $0**
Beyond the Additional 365 days $0 $0 All costs
Service: SKILLED NURSING FACILITY CARE
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:
First 20 days All approved amounts $0 $0
21st through 100th day All but $157.50 a day

Up to $78.75 a day

 $78.75 per day**▲
101st day and after $0 $0 All costs
Service: BLOOD
First 3 pints $0 50% 50%**▲
Additional amounts 100% $0 $0
Service: HOSPICE CARE
Available as long as you meet Medicare's requirements, your doctor certifies you are terminally ill and you elect to receive these services.
Outpatient Prescription Drugs All but $5 50% co-payment / co-insurance 50% Medicare co-payment/coinsurance**▲
Inpatient Respite Care All but 5% 50% of Medicare's approved amount 50% of Medicare's approved amount**▲
* 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.
 
Plan K
Coverage with your:
Medicare Part B- Medical Services
*Per Calendar Year
Service: 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:
  MEDICARE PAYS PLAN PAYS YOU PAY**▲
First $166 of Medicare Approved Amounts* $0 $0 $166
Preventive Benefits for Medicare Covered Services Generally 75% or more of Medicare approved amounts Remainder of Medicare approved amounts. All cost above Medicare approved amounts
Remainder of Medicare Approved Amounts Generally 80% Generally 10% Generally 10%**▲
Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All cost (and they don't count toward annual out of pocket limit of $4940
Service: BLOOD
First 3 pints $0 50% 50%**▲
Next $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)**▲
Remainder of Medicare Approved Amounts 80% 10% Generally 10%**▲
Service: CLINICAL LABORATORY SERVICES
Tests for Diagnostic Services 100% $0 $0
 
PARTS  A & B*
Service: HOME HEALTH CARE
Medicare Approved Services:
  MEDICARE PAYS PLAN PAYS YOU PAY*
Medically necessary skilled care services and medical supplies 100% $0 $0
Durable medical equipment: Medicare-approved services  $0 $0 $166.00**▲
Remainder of Medicare Approved Amounts 80% 10% 10%**▲
 
Annual out-of-pocket limit     $4940**▲
* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $4940 per calendar year. However, this limit does NOT include charges from a provider that exceed Medicare-approved amounts (these amounts are called " Excess Charges") and you will be responsible for paying the difference in the amount charged by your provider and the amount paid by Medicare for the item of service.     **▲ You will pay half the coat-sharing until you meet the annual out-of-pocket limit of $4940 each calendar year. The amounts that count toward your annual limit are noted with the (**▲)symbol's in the chart above. Once you meet the annual limit, the plan pays 100% of the co-payment and co-insurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these amounts are called " Excess Charges") and you will be responsible for paying the difference in the amount charged by your provider and the amount paid by Medicare for the item of service.
* Once You have filled $166 of Medicare-Approved amounts for covered services(which are noted with an asterisk),Your Medicare Part B Deductible will have
met for the calendar year.
Plan L

Coverage with your:
Medicare Part A- Hospital Services
*Per Benefit Period
Service: HOSPITALIZATION
Semiprivate room and board, general nursing and miscellaneous services and supplies:
  MEDICARE PAYS PLAN PAYS YOU PAY**▲
First 60 days All but $1,216 $945 (Part A Deductible) $315**▲
61st through 90th day All but $315 a day $315 a day $0
91st day and after:
(Using 60 lifetime reserve days)		 All but $630 a day $630 a day $0
Once lifetime reserve days are used,
365 Additional Days: 		$0 100% of Medicare Eligible Expenses $0**
Beyond the Additional 365 days $0 $0 All costs
Service: SKILLED NURSING FACILITY CARE
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:
First 20 days All approved amounts $0 $0
21st through 100th day All but $157.50 a day

Up to $118.13 a day

 $39.38 per day**▲
101st day and after $0 $0 All costs
Service: BLOOD
First 3 pints $0 75% 25%**▲
Additional amounts 100% $0 $0
Service: HOSPICE CARE
Available as long as you meet Medicare's requirements, your doctor certifies you are terminally ill and you elect to receive these services.
Outpatient Prescription Drugs All but $5 75% co-payment / co-insurance 25% Medicare co-payment/coinsurance**▲
Inpatient Respite Care All but 5% 75% of Medicare's approved amount 25% of Medicare's approved amount**▲
* 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.
 
Plan L
Coverage with your:
Medicare Part B- Medical Services
*Per Calendar Year
Service: 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:
  MEDICARE PAYS PLAN PAYS YOU PAY**▲
First $166 of Medicare Approved Amounts* $0 $0 $166
Preventive Benefits for Medicare Covered Services Generally 75% or more of Medicare approved amounts Remainder of Medicare approved amounts. All cost above Medicare approved amounts
Remainder of Medicare Approved Amounts Generally 80% Generally 15% Generally 5%**▲
Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All cost (and they don't count toward annual out of pocket limit of $2470
Service: BLOOD
First 3 pints $0 50% 50%**▲
Next $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)**▲
Remainder of Medicare Approved Amounts 80% 10% Generally 10%**▲
Service: CLINICAL LABORATORY SERVICES
Tests for Diagnostic Services 100% $0 $0
 
PARTS  A & B*
Service: HOME HEALTH CARE
Medicare Approved Services:
  MEDICARE PAYS PLAN PAYS YOU PAY*
Medically necessary skilled care services and medical supplies 100% $0 $0
Durable medical equipment: Medicare-approved services  $0 $0 $166.00**▲
Remainder of Medicare Approved Amounts 80% 15% 5%**▲
 
Annual out-of-pocket limit     $2470**▲
* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2470 per calendar year. However, this limit does NOT include charges from a provider that exceed Medicare-approved amounts (these amounts are called " Excess Charges") and you will be responsible for paying the difference in the amount charged by your provider and the amount paid by Medicare for the item of service.     **▲ You will pay half the coat-sharing until you meet the annual out-of-pocket limit of $2470 each calendar year. The amounts that count toward your annual limit are noted with the (**▲)symbol's in the chart above. Once you meet the annual limit, the plan pays 100% of the co-payment and co-insurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these amounts are called " Excess Charges") and you will be responsible for paying the difference in the amount charged by your provider and the amount paid by Medicare for the item of service.
* Once You have filled $166 of Medicare-Approved amounts for covered services(which are noted with an asterisk),Your Medicare Part B Deductible will have
met for the calendar year.
Plan M

Coverage with your:
Medicare Part A- Hospital Services
*Per Benefit Period
Service: HOSPITALIZATION
Semiprivate room and board, general nursing and miscellaneous services and supplies:
  MEDICARE PAYS PLAN PAYS YOU PAY
First 60 days All but $1288 $630.00 (50% of the Part A Deductible) $630.00
61st through 90th day All but $315 a day $315 a day $0
91st day and after:
(Using 60 lifetime reserve days)		 All but $630 a day $630 a day $0
Once lifetime reserve days are used,
365 Additional Days: 		$0 100% of Medicare Eligible Expenses $0**
Beyond the Additional 365 days $0 $0 All costs
Service: SKILLED NURSING FACILITY CARE
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:
First 20 days All approved amounts $0 $0
21st through 100th day All but $157.50 a day Up to $157.50 a day $0
101st day and after $0 $0 All costs
Service: BLOOD
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Service: HOSPICE CARE
Available as long as you meet Medicare's requirements, your doctor certifies you are terminally ill and you elect to receive these services
Outpatient Prescription Drugs All but $5 $5 $0
Inpatient Respite Care All but 5% 5% of Medicare's approved amount $0
* 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.
 
Plan M
Coverage with your:
Medicare Part B- Medical Services
*Per Calendar Year
Service: 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:
  MEDICARE PAYS PLAN PAYS YOU PAY
First $166 of Medicare Approved Amounts* $0 $0 $166 (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
Service: BLOOD
First 3 pints $0 All costs $0
Next $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved Amounts 80% 20% $0
Service: CLINICAL LABORATORY SERVICES
Tests for Diagnostic Services 100% $0 $0
 
PARTS  A & B
Service: HOME HEALTH CARE
Medicare Approved Services:
  MEDICARE PAYS PLAN PAYS YOU PAY
Medically necessary skilled care services and medical supplies 100% $0 $0
Durable medical equipment:        
First $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved Amounts 80% 20% $0
 
OTHER BENEFITS - NOT COVERED BY MEDICARE
Service:
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 $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
* Once You have filled $166 of Medicare-Approved amounts for covered services(which are noted with an asterisk),Your Medicare Part B Deductible will have
met for the calendar year.
Plan N

Coverage with your:
Medicare Part A- Hospital Services
*Per Benefit Period
Service: HOSPITALIZATION
Semiprivate room and board, general nursing and miscellaneous services and supplies:
  MEDICARE PAYS PLAN PAYS YOU PAY
First 60 days All but $1288 $1288 (Part A Deductible) $0
61st through 90th day All but $315 a day $315 a day $0
91st day and after:
(Using 60 lifetime reserve days)		 All but $630 a day $630 a day $0
Once lifetime reserve days are used,
365 Additional Days: 		$0 100% of Medicare Eligible Expenses $0**
Beyond the Additional 365 days $0 $0 All costs
Service: SKILLED NURSING FACILITY CARE
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:
First 20 days All approved amounts $0 $0
21st through 100th day All but $157.50 a day Up to $157.50 a day $0
101st day and after $0 $0 All costs
Service: BLOOD
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Service: HOSPICE CARE
Available as long as you meet Medicare's requirements, your doctor certifies you are terminally ill and you elect to receive these services
Outpatient Prescription Drugs All but $5 $5 $0
Inpatient Respite Care All but 5% 5% of Medicare's approved amount $0
* 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.
 
Plan N
Coverage with your:
Medicare Part B- Medical Services
*Per Calendar Year
Service: 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:
  MEDICARE PAYS PLAN PAYS YOU PAY
First $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved Amounts Generally 80% Generally 20% except for copay A maximum $20 copay for a doctor's office visit but may be less and a $50 copay for a emergency room visit if not admitted.
Part B Excess Charges (Above Medicare Approved Amounts) $0 0% All costs
Service: BLOOD
First 3 pints $0 All costs $0
Next $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved Amounts 80% 20% $0
Service: CLINICAL LABORATORY SERVICES
Tests for Diagnostic Services 100% $0 $0
 
PARTS  A & B
Service: HOME HEALTH CARE
Medicare Approved Services:
  MEDICARE PAYS PLAN PAYS YOU PAY
Medically necessary skilled care services and medical supplies 100% $0 $0
Durable medical equipment:        
First $166 of Medicare Approved Amounts* $0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved Amounts 80% 20% $0
 
OTHER BENEFITS - NOT COVERED BY MEDICARE
Service:
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 $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
* Once You have filled $166 of Medicare-Approved amounts for covered services(which are noted with an asterisk),Your Medicare Part B Deductible will have
met for the calendar year.