Hospital Services per Benefit Period. This plan covers Medicare Part A inpatient hospital services when you have services performed at a hospital that participates in the Plan 65 Select Hospital Network. Inpatient hospital services received from a hospital that is not a part of the Plan 65 Select Hospital Network are not covered, unless the services are required for emergency treatment or the services are not available within the Plan 65 Select Hospital Network. Except as indicated above, if you receive services at a non-participating Plan 65 Select hospital, you will be responsible to pay the applicable Medicare eligible expenses, Part A deductible and/or Part A copayment. To obtain a listing of the Plan 65 Select Hospital Network listing, please call the Medicare Concierge Team or visit our website. Contact information is in Section 9. Hospitalization/Inpatient Hospital Services at a Plan 65 Select Hospital The Medicare Part A inpatient hospital deductible for Medicare eligible expenses for your first sixty (60) days of inpatient hospitalization per benefit period is covered. This plan covers the Medicare Part A copayment for Medicare eligible expenses for the 61st through 90th day of your inpatient hospitalization. Lifetime Inpatient Reserve Days at a Plan 65 Select Hospital If you are hospitalized for more than ninety (90) days, this plan covers the Medicare Part A copayment for Medicare eligible expenses relating to the 91st to 150th day of lifetime inpatient reserve days. Lifetime inpatient hospital reserve days are limited to sixty (60) additional days of inpatient hospitalization once in your lifetime.
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 PLAN G PAYS YOU PAY PAYS HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,556 $1,556 (Part A Deductible) $0 61st through 90th day 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 Once lifetime reserve days are used: • Additional 365 days • Beyond the additional 365 days $0 $0 100% of Medicare eligible expenses $0 $0*** All costs 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 $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 a doctor's certification of terminal illness. All but very limited copayment / coinsurance for outpatient drugs and inpatient respite care Medicare copayment / coinsurance $0 ***NOTICE: When your Medicare Part A hospital benefits are exhausted, the carrier 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 plan’s Basic 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. GOCW-G PLAN G (continued): G MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR * Once you have been billed $233 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 G 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 amounts* $0 $0 $233 (Part B Deductible) Remainder of Medicare approved amounts Generally 80% Generally 20% ...
