[30 Pa.B. 6886]

[Continued from previous Web Page]

PLAN C

MEDICARE (PART A) - 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 PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies       First 60 days       61st thru 90th day       91st day and after:       --While using 60 lifetime re-             serve days       --Once lifetime reserve days are             used:             --Additional 365 days             --Beyond the additional                   365 days	All but $792 All but $198 a day     All but $384 a day     $0   $0	$792 (Part A deductible) $198 a day     $384 a day     100% of Medicare eli- gible expenses $0	$0 $0     $0     $0   All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's require- ments, including having been in a hospital for at least 3 days and en- tered a Medicare-approved facility within 30 days after leaving the hos- pital       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but $99 a day $0	$0 Up to $99 a day $0	$0 $0 All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor cer- tifies you are terminally ill and you elect to receive these services	All but very limited co- insurance for out- patient drugs and inpa- tient respite care	$0	Balance

PLAN C

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

* Once you have been billed $100 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 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 $100 of Medicare             approved amounts*       Remainder of Medicare             approved amounts       Part B excess charges             (Above Medicare             approved amounts)	$0 80% (50% outpatient psychiatric services)     $0	$100 (Part B deductible) 20% (50% outpatient psychiatric services)     $0	$0 $0       All costs
BLOOD First 3 pints Next $100 of Medicare             approved amounts* Remainder of Medicare             approved amounts	$0   $0   80%	All costs   $100 (Part B deductible)   20%	$0   $0   $0
CLINICAL LABORATORY SERVICES--BLOOD TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PARTS A & B
 

HOME HEALTH CARE MEDICARE APPROVED SERVICES
--Medically necessary skilled             care services and medical             supplies       --Durable medical equipment             First $100 of Medicare                approved Amounts*             Remainder of Medicare                approved Amounts	100%     $0   80%	$0     $100 (Part B deductible)   20%	$0     $0   $0

OTHER BENEFITS - COVERED BY MEDICARE
 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
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   Remainder of charges	$0     $0	$0     80% to a lifetime maxi- mum benefit of $50,000	$250     20% and amounts over the $50,000 lifetime maximum

PLAN D

MEDICARE (PART A) - 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 PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies       First 60 days       61st thru 90th day       91st day and after:       --While using 60 lifetime             reserve days       --Once lifetime reserve days are             used:             --Additional 365 days             --Beyond the additional                   365 days	All but $792 All but $198 a day     All but $396 a day   $0   $0	$792 (Part A deductible) $198 a day     $396 a day $0   100% of Medicare eli- gible expenses $0	$0 $0     $0   $0   All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's require- ments, including having been in a hospital for at least 3 days and en- tered a Medicare-approved facility within 30 days after leaving the hos- pital       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but $99 a day $0	$0 Up to $99 a day $0	$0 $0 All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor cer- tifies you are terminally ill and you elect to receive these services	All but very limited co- insurance for out- patient drugs and inpa- tient respite care	$0	Balance

PLAN D

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

* Once you have been billed $100 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 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 $100 of Medicare             approved amounts*       Remainder of Medicare             approved amounts       Part B excess charges             (Above Medicare             approved amounts)	$0   80% (50% outpatient psychiatric services)     $0	$0   20% (50% outpatient psychiatric services)     $0	$100 (Part B deductible)   $0       All costs
BLOOD First 3 pints Next $100 of Medicare       approved amounts* Remainder of Medicare       approved amounts	$0   $0   80%	All costs   $0   20%	$0   $100 (Part B deductible)   $0
CLINICAL LABORATORY SER- VICES--BLOOD TESTS FOR DI- AGNOSTIC SERVICES	100%	$0	$0
HOMES HEALTH CARE MEDICARE APPROVED SERVICES    --Medically necessary          skilled care          services and medical          supplies    --Durable medical          equipment          First $100 of             Medicare approved             amounts*          Remainder of          Medicare approved          amounts   AT-HOME RECOVERY SERVICES- NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a home care treatment plan    --Benefit for each visit    --Number of visits       covered (must be received within       8 weeks of last Medicare ap-       proved visit)    --Calendar year          maximum	100%         $0     80%                 $0   $0       $0	$0         $0     20%                 Actual charges to $40 a visit Up to the number of Medicare approved vis- its, not to exceed 7 each week $1,600	$0         $100 (Part B deductible)     $0                 Balance

OTHER BENEFITS - NOT COVERED BY MEDICARE
 

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   Remainder of charges	$0   $0	$0   80% to a lifetime maxi- mum benefit of $50,000	$250   20% and amounts over the $50,000 lifetime maximum

PLAN E

MEDICARE (PART A) - 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 PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies    First 60 days    61st thru 90th day    91st day and after:    --While using 60 lifetime reserve       days    --Once lifetime reserve days are       used:       --Additional 365 days       --Beyond the additional 365          days	All but $792 All but $198 a day     All but $396 a day   $0   $0	$792 (Part A deductible) $198 a day     $396 a day   100% of Medicare eli- gible expenses $0	$0 $0     $0   $0   All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's require- ments, including having been in a hospital for at least 3 days and en- tered a Medicare-approved facility within 30 days after leaving the hos- pital    First 20 days    21st thru 100th day    101st day and after	All approved amounts All but $99 a day $0	$0 Up to $99 a day $0	$0 $0 All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor cer- tifies you are terminally ill and you elect to receive these services	All but very limited co- insurance for out- patient drugs and inpa- tient respite care	$0	Balance

PLAN E

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

* Once you have been billed $100 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 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 $100 of Medicare       approved amounts*    Remainder of Medicare       approved amounts    Part B excess charges       (Above Medicare       approved amounts)	$0   80% (50% outpatient psychiatric services)     $0	$0   20% (50% outpatient psychiatric services)     $0	$100 (Part B deductible)   $0       All costs
BLOOD First 3 pints Next $100 of Medicare    approved amounts* Remainder of Medicare    approved amounts	$0   $0   80%	All costs   $0   20%	$0   $100 (Part B deductible   $0
CLINICAL LABORATORY SER- VICES--BLOOD TESTS FOR DI- AGNOSTIC SERVICES	100%	$0	$0

PARTS A & B
 

HOME HEALTH CARE
MEDICARE APPROVED SERVICES    --Medically necessary skilled care          services and medical supplies    --Durable medical equipment          First $100 of Medicare             approved amounts*          Remainder of Medicare             approved amounts	100%     $0   80%	$0     $0   20%	$0     $100 (Part B deductible)   $0

OTHER BENEFITS - NOT COVERED BY MEDICARE
 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
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     Remainder of charges	$0       $0	$0       80% to a lifetime maxi- mum benefit of $50,000	$250       20% and amounts over the $50,000 life-time maximum
***PREVENTIVE MEDICAL CARE BENEFIT-NOT COVERED BY MEDICARE Some physical and preventive tests and services such as: digital rectal exam, hearing screening, dipstick urinalysis, diabe- tes screening, thyroid function test, tetanus and diphtheria booster and education, administered or ordered by your doctor when not covered by Medicare          First $120 each calendar year    Additional charges	$0 $0	$120 $0	$0 All costs

PLAN F or HIGH DEDUCTIBLE PLAN F

MEDICARE (PART A) - 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.

** This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year $1,580 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $1,580. 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 separate foreign travel emergency deductible.
 

SERVICES	MEDICARE PAYS	AFTER YOU PAY $1,580 DEDUCTIBLE,** PLAN PAYS	IN ADDITION TO $1,580 DEDUCTIBLE,** YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies       First 60 days       61st thru 90th day       91st day and after:       --While using 60 lifetime             reserve days       --Once lifetime reserve days are             used:          --Additional 365 days          --Beyond the additional 365                days	All but $792 All but $198 a day     All but $396 a day       $0   $0	$792 (Part A deductible)   $198 a day   $396 a day       100% of Medicare eli- gible expenses $0	$0 $0     $0       $0   All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's require- ments, including having been in a hospital for at least 3 days and en- tered a Medicare-approved facility within 30 days after leaving the hos- pital       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but $99 a day $0	$0 Up to $99 a day $0	$0 $0 All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor cer- tifies you are terminally ill and you elect to receive these services	All but very limited co- insurance for out- patient drugs and inpa- tient respite care	$0	Balance

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

* Once you have been billed $100 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.

** This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year $1,580 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $1,580. 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 separate foreign travel emergency deductible.
 

SERVICES	MEDICARE PAYS	AFTER YOU PAY $1,580 DEDUCTIBLE,** PLAN PAYS	IN ADDITION TO $1,580 DEDUCTIBLE,** 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 $100 of Medicare       approved amounts*    Remainder of Medicare       approved amounts    Part B excess charges       (Above Medicare       approved amounts)	$0   80% (50% outpatient psychiatric service)   $0	$100 (Part B deductible)   20% (50% outpatient psychiatric service)   100%	$0   $0   $0
BLOOD First 3 pints Next $100 of Medicare    approved amounts* Remainder of Medicare    approved amounts	$0   $0   80%	All costs   $100 (Part B deductible)   20%	$0   $0   $0
CLINICAL LABORATORY SER- VICES--BLOOD TESTS FOR DI- AGNOSTIC SERVICES	100%	$0	$0

PARTS A & B
 

HOME HEALTH CARE MEDICARE APPROVED SERVICES
--Medically necessary skilled care          services and medical supplies    --Durable medical equipment          First $100 of Medicare             approved amounts*          Remainder of Medicare             approved Amounts	100%     $0   80%	$0     $100 (Part B deductible)   20%	$0     $0   $0

OTHER BENEFITS - NOT COVERED BY MEDICARE
 

SERVICES	MEDICARE PAYS	AFTER YOU PAY $1,580 DEDUCTIBLE,** PLAN PAYS	IN ADDITION TO $1,580 DEDUCTIBLE,** YOU PAY
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 Remainder of charges	$0 $0	$0 80% to a lifetime maxi- mum benefit of $50,000	$250 20% and amounts over the $50,000 lifetime maximum

 

[Continued on next Web Page]

---

No part of the information on this site may be reproduced for profit or sold for profit.

This material has been drawn directly from the official Pennsylvania Bulletin full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.

---