Summary of Benefits Clause Samples

Summary of Benefits. Medicare Part A helps pay for health care in hospitals, skilled nursing facilities, hospice care, and some home health care services. The table below shows how much Medicare, this plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan Select G. 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 Days 61 thru 90 All but $389 per day $389 per day $0 Days 91 and after while using 60 lifetime reserve days All but $778 per day $778 per day $0 Once lifetime reserve days are used, an additional 365 days $0 100% of Medicare eligible expenses (**) $0(**) Beyond the additional 365 days $0 $0 100% Skilled Nursing Facility (SNF) 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 Days 21 thru 100 All but $194.50 per day Up to $194.50 per day $0 Days 101 and after $0 $0 100% Blood (inpatient) First 3 pints $0 100% $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 or coinsurance for outpatient drugs and inpatient respite care Medicare copayment or coinsurance for outpatient drugs and inpatient respite care $0 (*) A benefit period begins on the first day you receive services 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. (**) When your Medicare Part A hospital benefits are exhausted, BCBSRI stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days. 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. Medicare Part B helps pay for doctors’ services, outpatient hospital care, certain medically necessary home health care services and other medical services that Part A does not cover, such as physical and speech therapy. The table below shows how much Medicare, your plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Suppleme...