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2016AmeriHealth Medigap Plans Information
Individual health plan options for people with Medicare
5823(10/15)BKV1AM6830 (5/15)
Questions? Call AmeriHealth New Jersey at
Seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.
Connect with us on Facebook: www.facebook.com/amerihealthmedicare
1-866-365-5345 (TTY/TDD: 711)
Contents
Introduction
Benefits at a glance
Ready to enroll?
Outline of coverage
We look forward to serving you as one of the many satisfied members who’ve chosen us
for our stability, reliability and solid, comprehensive coverage options.
This booklet provides you with information on AmeriHealth Medigap Plans, our Medicare
Supplement plans, also known as Medigap. Take a few minutes to look through it and
decide which plan best fits your needs and budget. Of course, you can call us with any
questions about plan coverage, including monthly premiums and cost-sharing.
We’ve included an enrollment form for your convenience. Simply complete the form and
return in the postage-paid reply envelope provided.
Thanks again for requesting this information and for choosing AmeriHealth New Jersey.
Facebook “f ” Logo CMYK / .eps Facebook “f ” Logo CMYK / .eps
Thank you.We appreciate your interest in AmeriHealth New Jersey.
3 steps to finding the right Medigap planFollow these steps to find a Medicare Supplement plan that fits your budget, needs, and lifestyle.
Learn about the plans we offer
1
Compare benefits, cost-sharing, and premiums
2
Enroll in the plan you want
Let’s get started
3
Medicare Advantage PlansThese plans are offered by private
insurance companies that are
approved by Medicare. If you join
a Medicare Advantage Plan, you
still have Medicare. You’ll get your
Medicare Part A and Medicare
Part B coverage from the Medicare
Advantage plan. Medicare
Advantage Plans must cover all of
the services that Original Medicare
covers. Medicare Advantage plans
are not considered Medicare
Supplement plans.
Medicare Supplement Plans (Medigap)With this option, you remain
enrolled in Original Medicare.
When you buy a Medicare
Supplement plan from a private
insurance company, Original
Medicare will pay its share of
costs for covered services, then
your supplement plan will pay its
share. These plans do not include
prescription drug coverage. While
your monthly premium may be
higher than a Medicare Advantage
plan, many people choose them
for lower copays, deductibles
and coinsurance.
Take a look at these 2 types of plans.They cover the costs not covered by Original Medicare.
AmeriHealth Medicare Advantage plans are underwritten by AmeriHealth HMO, Inc. AmeriHealth Medigap Plans are offered through AmeriHealth Insurance Company of New Jersey.
22
THIS PAGE INTENTIONALLY LEFT BLANK.
IN THIS SECTION Benefits at a glance
If you’re looking for a plan with no network restrictions and no referrals … AmeriHealth Medigap Plans may be the right choice for you.
How to pick a plan:
Choose coverage for Medicare’s “gaps,” which may include deductibles, copayments, and coinsurance that you are left to pay under Original Medicare. AmeriHealth Medigap Plans offer a choice of four (A, C, F, and N) Medicare Supplement insurance (Medigap) plans that give you the freedom you want by allowing you to see any doctor who accepts Original Medicare.
Questions? Call AmeriHealth New Jersey at
Seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.
Connect with us on Facebook: www.facebook.com/amerihealthmedicare
1-866-365-5345 (TTY/TDD: 711)Facebook “f ” Logo CMYK / .eps Facebook “f ” Logo CMYK / .eps
• You’re free to visit any doctor or hospital that accepts Original Medicare.
• There’s no need to select a primary care physician.
• You don’t need a referral to see a specialist.
• You’re covered when you travel anywhere in the United States.
• You get emergency coverage outside of the United States (with plan C, F, or N).
• You have the option to enroll in a stand-alone Part D prescription drug plan.
• Our recommended Plan F pays all deductibles, all coinsurance, and the 20 percent of Part B expenses not paid by Original Medicare.
• With Plan N, you pay a lower monthly premium and share some of the costs with the plan — like up to a $20 copayment for doctor visits.
With AmeriHealth Medigap Plans:
AmeriHealth Medigap Plans are offered through AmeriHealth Insurance Company of New Jersey. AmeriHealth Medigap Plans plans provide hospital and medical coverage only. They do not include Medicare prescription drug benefits.TruHearing® is a registered trademark of TruHearing, Inc. All other trademarks, product names, and company names are the property of their respective owners.
You’ll also have access to our Healthy LifestylesSM Solutions:
• Tobacco Cessation Program — You may receive up to $150 reimbursement for completing an approved tobacco cessation program.
• Weight Management Program — You may also receive up to $150 reimbursement for participating in an approved weight management program.
• Fitness Reimbursement — Up to $150 reimbursement after 120 workouts in 365 days at an approved gym.
Plus, you’ll receive TruHearing® discounts:
• TruHearing provides dicounted rates on hearing aids through a national provider network.
This quick list of Medicare-related terms will help you better understand the information in this Plan Information Book.
Terms to know:
Deductible:The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.
Coinsurance: An amount you may be required to pay as your share of the cost for services or prescription drugs after you pay any deductibles. Coinsurance is usually a percentage (for example, 20 percent).
Copayment: An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription drug.
Premium: The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.
Comparison of PlansPlease refer to the AmeriHealth Medigap Plans Outline of Coverage for copy and rate information.
Plan AYou pay:
Part B deductible
(Plan pays 20% coinsurance)
Part A deductible
100%
Medicare pays:
80% of Medicare-approved
amounts after your annual Part B deductible is met
All charges except your Part A deductible and Part A coinsurance
Nothing
Service category
Primary care physician visits
Specialist visits
Emergency room
Urgent care
Outpatient surgery
Inpatient hospital
Part B excess charges*
* If the amount a doctor or other health care provider charges is higher than the Medicare-approved amount, the difference is called the excess charge.
Plan NYou pay:
Part B deductible; copay for doctor visits; copay for emergency
room (waived if admitted)
(Plan pays all other Part B coinsurance)
$0
100%
Plan FYou pay:
$0
(Plan pays Part B deductible and 20%
coinsurance)
$0
$0
Plan CYou pay:
$0
(Plan pays Part B deductible and 20%
coinsurance)
$0
100%
AmeriHealth Medigap Plans
These plans do not cover Medicare Part D prescription drug benefits, but will work with any stand-alone Medicare Part D prescription drug plan. Medicare Part D plans help cover the costs of Medicare-covered prescription drugs. You don’t have to choose a prescription drug plan, but if you decide to choose a Medicare Part D prescription drug plan after your initial enrollment period or after 63 days lapse in creditable coverage, you may be subject to a Late Enrollment Penalty.
22
THIS PAGE INTENTIONALLY LEFT BLANK.
IN THIS SECTION Ready to enroll?
5823(10/15)EI
Applicants have a right to return this Policy within (30) days of delivery for refund of the full premium paid if, after examination of this Policy, the Applicant is not satisfied for any reason. This Policy may be returned to AmeriHealth Medigap Plans, 1901 Market Street, Philadelphia, Pa. 19103-1480. If the Policy is returned, it will be null and void from the beginning and no benefits will be payable under its terms.
Ready to sign up for one of the AmeriHealth Medigap Plans?Here are easy step-by-step instructions for filling out the enrollment form.
SECTION
APersonal InformationPlease check [✔] the box in front of the plan you want to enroll in. Then, provide the personal information requested.
SECTION
BMedicare Insurance InformationYou will need your Medicare card to complete this section. You must include your Medicare claim number on your application form.
SECTION
CImportant QuestionsPlease answer the questions in Part 1 and Part 2 of this section.
SECTION
DImportant InformationPlease read the important information regarding eligibility.
SECTION
EYour Signature Please read the information provided, then sign and date your application form. You do not need to complete Section F. This section is to be completed by the certified agent.
Questions? Call AmeriHealth New Jersey at
Seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.
Connect with us on Facebook: www.facebook.com/amerihealthmedicare
1-866-365-5345 (TTY/TDD: 711)Facebook “f ” Logo CMYK / .eps Facebook “f ” Logo CMYK / .eps
22
THIS PAGE INTENTIONALLY LEFT BLANK.
IN THIS SECTION Outline of Coverage
Amer
iHea
lth In
sura
nce
Com
pany
of N
ew Je
rsey
O
utlin
e of
Med
icar
e Su
pple
men
t Cov
erag
e Be
nefit
Pla
ns A
vaila
ble:
A, C
, F a
nd N
Ba
sic
Bene
fits:
Ho
spita
lizat
ion:
Par
t A c
oins
uran
ce p
lus c
over
age
for 3
65 a
dditi
onal
day
s aft
er M
edic
are
bene
fits e
nd
Med
ical
exp
ense
s: P
art B
coi
nsur
ance
(gen
eral
ly 2
0% o
f Med
icar
e-ap
prov
ed e
xpen
ses)
or c
opay
men
ts fo
r ho
spita
l out
patie
nt se
rvic
es. P
lans
K, L
, and
N re
quire
insu
reds
to p
ay a
por
tion
of P
art B
coi
nsur
ance
or
copa
ymen
ts.
Bloo
d: F
irst t
hree
pin
ts o
f blo
od e
ach
year
Ho
spic
e: P
art A
coi
nsur
ance
A
B C
D
F|F*
G
K
L M
N
Ba
sic,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basic
, in
clud
ing
100%
Par
t B
coin
sura
nce
Basic
, in
clud
ing
100%
Par
t B
coin
sura
nce
Basic
, in
clud
ing
100%
Par
t B
coin
sura
nce
Basic
, in
clud
ing
100%
Par
t B
coin
sura
nce
Basic
, in
clud
ing
100%
Par
t B
coin
sura
nce
Hosp
italiz
atio
n an
d pr
even
tive
care
pai
d at
100
%; o
ther
bas
ic
bene
fits p
aid
at 5
0%
Hosp
italiz
atio
n an
d pr
even
tive
care
pai
d at
100
%; o
ther
bas
ic
bene
fits p
aid
at 7
5%
Basic
, in
clud
ing
100%
Par
t B
coin
sura
nce
Basic
, inc
ludi
ng 1
00%
Pa
rt B
coi
nsur
ance
, ex
cept
up
to $
20
copa
ymen
t for
offi
ce
visit
, and
$50
co
paym
ent f
or E
R
Sk
illed
Nur
sing
Faci
lity
Coin
sura
nce
Skill
ed N
ursin
g Fa
cilit
y Co
insu
ranc
e
Skill
ed N
ursin
g Fa
cilit
y Co
insu
ranc
e
Skill
ed N
ursin
g Fa
cilit
y Co
insu
ranc
e
50%
Ski
lled
Nur
sing
Faci
lity
Coin
sura
nce
75%
Ski
lled
Nur
sing
Faci
lity
Coin
sura
nce
Skill
ed N
ursin
g Fa
cilit
y Co
insu
ranc
e
Skill
ed N
ursin
g Fa
cilit
y Co
insu
ranc
e
Pa
rt A
De
duct
ible
Pa
rt A
De
duct
ible
Pa
rt A
De
duct
ible
Pa
rt A
De
duct
ible
Pa
rt A
De
duct
ible
50
% P
art A
De
duct
ible
75
% P
art A
De
duct
ible
50
% P
art A
De
duct
ible
Pa
rt A
Ded
uctib
le
Part
B
Dedu
ctib
le
Pa
rt B
De
duct
ible
Part
B E
xces
s (1
00%
) Pa
rt B
Exc
ess
(100
%)
Fore
ign
Trav
el
Emer
genc
y Fo
reig
n Tr
avel
Em
erge
ncy
Fore
ign
Trav
el
Emer
genc
y Fo
reig
n Tr
avel
Em
erge
ncy
Fore
ign
Trav
el
Emer
genc
y Fo
reig
n Tr
avel
Em
erge
ncy
Out
-of-p
ocke
t lim
it $4
,940
; pai
d at
100
%
afte
r lim
it re
ache
d
Out
-of-p
ocke
t lim
it $2
,470
; pai
d at
100
%
afte
r lim
it re
ache
d
* Pl
an F
also
has
an
optio
n ca
lled
a hi
gh d
educ
tible
Pla
n F.
Thi
s hig
h de
duct
ible
pla
n pa
ys th
e sa
me
bene
fits a
s Pla
n F
afte
r one
has
pai
d a
cale
ndar
ye
ar $
2,18
0 de
duct
ible
. Ben
efits
from
hig
h de
duct
ible
Pla
n F
will
not
beg
in u
ntil
out-
of-p
ocke
t exp
ense
s exc
eed
$2,1
80. O
ut-o
f-poc
ket e
xpen
ses f
or
this
dedu
ctib
le a
re e
xpen
ses t
hat w
ould
ord
inar
ily b
e pa
id b
y th
e po
licy.
The
se e
xpen
ses i
nclu
de th
e M
edic
are
dedu
ctib
les f
or P
art A
and
Par
t B,
but d
o no
t inc
lude
the
plan
’s se
para
te fo
reig
n tr
avel
em
erge
ncy
dedu
ctib
le.
This
cha
rt sh
ows t
he b
enef
its
incl
uded
in e
ach
of th
e st
anda
rd
Med
icar
e su
pple
men
t pla
ns. E
very
co
mpa
ny m
ust m
ake
Plan
A
avai
labl
e. S
ome
plan
s may
not
be
avai
labl
e in
you
r sta
te.
Page
1
1687
3
IN
DIVI
DUAL
Amer
iHea
lth In
sura
nce
Com
pany
of N
ew Je
rsey
M
edic
are
Supp
lem
ent P
rem
ium
Info
rmat
ion
Amer
iHea
lth In
sura
nce
Com
pany
of N
ew Je
rsey
can
onl
y ra
ise y
our p
rem
ium
if w
e ra
ise th
e pr
emiu
m fo
r all
polic
ies l
ike
your
s in
this
Stat
e. W
e w
ill
not c
hang
e yo
ur p
rem
ium
or c
ance
l you
r pol
icy
beca
use
of a
ge o
r poo
r hea
lth. T
hese
mon
thly
rate
s are
subj
ect t
o ch
ange
with
the
appr
oval
of t
he
New
Jers
ey D
epar
tmen
t of B
anki
ng a
nd In
sura
nce.
*Thi
s inc
lude
s peo
ple
50 a
nd o
lder
and
und
er 6
5 on
Med
icar
e du
e to
disa
bilit
y.N
T –
Non
-Tob
acco
T
– To
bacc
o
N
on-T
obac
co ra
tes a
pply
to a
pplic
atio
ns su
bmitt
ed d
urin
g th
e 6-
mon
th o
pen
enro
llmen
t or i
n a
gu
aran
teed
issu
e sit
uatio
n. A
pplic
ants
NO
T en
rolli
ng d
urin
g th
e 6-
mon
th o
pen
enro
llmen
t per
iod
or in
a
guar
ante
ed is
sue
situa
tion
will
be
eval
uate
d fo
r tob
acco
usa
ge a
nd c
harg
ed th
e co
rres
pond
ing
toba
cco
or n
on-t
obac
co ra
tes.
Atta
ined
Ag
e Ra
ted
Age
50-6
4*
Age
65
Age
66
Age
67
Age
68
Age
69
Age
70
Age
71
Age
72
Age
73
Age
74
Age
75-7
9 Ag
e 80
-84
Age
85+
Plan
A
NT
N/A
$9
8.89
$1
04.4
0 $1
08.7
1 $1
13.6
4 $1
18.2
5 $1
23.2
1 $1
28.4
2 $1
32.9
8 $1
37.0
5 $1
40.5
2 $1
50.4
2 $1
59.7
7 $1
59.7
7
T N
/A
$108
.78
$114
.84
$119
.58
$125
.00
$130
.07
$135
.53
$141
.26
$146
.28
$150
.76
$154
.57
$165
.46
$175
.74
$175
.74
Plan
C
NT
$164
.65
$164
.65
$170
.21
$177
.08
$184
.89
$192
.21
$200
.80
$209
.61
$217
.31
$225
.57
$232
.69
$253
.71
$293
.13
$336
.79
T $1
81.1
1 $1
81.1
1 $1
87.2
3 $1
94.7
8 $2
03.3
8 $2
11.4
4 $2
20.8
8 $2
30.5
7 $2
39.0
4 $2
48.1
3 $2
55.9
6 $2
79.0
8 $3
22.4
4 $3
70.4
7
Plan
F
NT
N/A
$1
56.8
1 $1
62.1
1 $1
68.6
4 $1
76.0
8 $1
83.0
6 $1
91.2
3 $1
99.6
3 $2
06.9
6 $2
14.8
3 $2
21.6
1 $2
41.6
3 $2
79.1
7 $3
20.7
5
T N
/A
$172
.49
$178
.32
$185
.51
$193
.69
$201
.37
$210
.36
$219
.59
$227
.66
$236
.32
$243
.77
$265
.79
$307
.09
$352
.83
Plan
N
NT
N/A
$1
08.8
1 $1
15.2
7 $1
20.2
8 $1
26.0
5 $1
31.4
7 $1
37.9
1 $1
44.5
2 $1
50.3
1 $1
56.6
8 $1
62.1
6 $1
78.6
3 $2
10.4
4 $2
47.9
8
T N
/A
$119
.69
$126
.79
$132
.31
$138
.65
$144
.61
$151
.71
$158
.97
$165
.34
$172
.35
$178
.38
$196
.49
$231
.48
$272
.78
Page
2
1687
3 IN
DIVI
DUAL
PREM
IUM
INFO
RMAT
ION
W
e, A
mer
iHea
lth In
sura
nce
Com
pany
of N
ew Je
rsey
, can
onl
y ra
ise y
our p
rem
ium
if w
e ra
ise th
e pr
emiu
m fo
r all
polic
ies l
ike
your
s in
the
Stat
e of
N
ew Je
rsey
. Pre
miu
ms f
or a
ttai
ned
age
plan
s A, C
, F a
nd N
will
incr
ease
beg
inni
ng w
ith th
e fir
st fu
ll m
onth
that
the
mem
ber m
oved
into
a n
ew a
ge
rang
e in
acc
orda
nce
with
the
prem
ium
sche
dule
on
the
prev
ious
pag
e.
Disc
losu
res
Use
this
outli
ne to
com
pare
ben
efits
and
pre
miu
ms a
mon
g po
licie
s.
READ
YO
UR
POLI
CY V
ERY
CARE
FULL
Y
This
is on
ly a
n ou
tline
des
crib
ing
your
pol
icy’
s mos
t im
port
ant
feat
ures
. The
pol
icy
is yo
ur in
sura
nce
cont
ract
. You
mus
t rea
d th
e po
licy
itsel
f to
unde
rsta
nd a
ll of
the
right
s and
dut
ies o
f bot
h yo
u an
d yo
ur in
sura
nce
com
pany
.
RIG
HT T
O R
ETU
RN Y
OU
R PO
LICY
If yo
u fin
d th
at y
ou a
re n
ot sa
tisfie
d w
ith y
our p
olic
y, y
ou m
ay re
turn
it
to A
mer
iHea
lth M
edig
ap P
lans
, 190
1 M
arke
t Str
eet,
Phila
delp
hia,
PA
191
03-1
480.
If y
ou se
nd th
e po
licy
back
to u
s with
in 3
0 da
ys a
fter
yo
u re
ceiv
e it,
we
will
trea
t the
pol
icy
as if
it h
ad n
ever
bee
n iss
ued
and
retu
rn a
ll of
you
r pay
men
ts.
POLI
CY R
EPLA
CEM
ENT
If yo
u ar
e re
plac
ing
anot
her h
ealth
insu
ranc
e po
licy,
do
NO
T ca
ncel
it
until
you
hav
e ac
tual
ly re
ceiv
ed y
our n
ew p
olic
y an
d ar
e su
re y
ou
wan
t to
keep
it.
NO
TICE
This
polic
y m
ay n
ot fu
lly c
over
all
of y
our m
edic
al c
osts
. Am
eriH
ealth
is
not c
onne
cted
with
Med
icar
e. T
his O
utlin
e of
Cov
erag
e do
es n
ot
give
all
of th
e de
tails
of M
edic
are
cove
rage
. Con
tact
you
r loc
al S
ocia
l Se
curit
y of
fice
or c
onsu
lt “M
edic
are
& Y
ou”
for m
ore
deta
ils.
COM
PLET
E AN
SWER
S AR
E VE
RY IM
PORT
ANT
Whe
n yo
u fil
l out
the
appl
icat
ion
for t
he n
ew p
olic
y, b
e su
re to
an
swer
trut
hful
ly a
nd c
ompl
ete
any
ques
tions
abo
ut y
our m
edic
al
heal
th h
isto
ry. T
he c
ompa
ny m
ay c
ance
l you
r pol
icy
and
refu
se to
pa
y an
y cl
aim
s if y
ou le
ave
out o
r fal
sify
impo
rtan
t med
ical
in
form
atio
n. R
evie
w th
e ap
plic
atio
n ca
refu
lly b
efor
e yo
u sig
n it.
Be
cert
ain
that
all
info
rmat
ion
has b
een
prop
erly
reco
rded
.
Page
3
1687
3 IN
DIVI
DUAL
Plan
A
*A
bene
fit p
erio
d be
gins
on
the
first
day
you
rece
ive
serv
ices
as a
n in
patie
nt in
a h
ospi
tal a
nd e
nds a
fter
you
hav
e be
en o
ut o
f the
hos
pita
l and
hav
e no
tre
ceiv
ed sk
illed
car
e in
any
oth
er fa
cilit
y fo
r 60
days
in a
row
. M
EDIC
ARE
(PAR
T A)
— H
OSP
ITAL
SER
VICE
S —
PER
BEN
EFIT
PER
IOD
SERV
ICES
M
EDIC
ARE
PAYS
PL
AN P
AYS
YOU
PAY
HO
SPIT
ALIZ
ATIO
N*
Sem
ipriv
ate
room
and
boa
rd, g
ener
al n
ursin
g, a
nd m
iscel
lane
ous
serv
ices
and
supp
lies.
Firs
t 60
days
Al
l but
$1,
260
$0
$1,2
60 (P
art A
ded
uctib
le)
61st
thro
ugh
90th
day
Al
l but
$31
5 a
day
$315
a d
ay
$0
91st
day
and
aft
er:
•W
hile
usin
g 60
life
time
rese
rve
days
All b
ut $
630
a da
y $6
30 a
day
$0
•
Onc
e lif
etim
e re
serv
e da
ys a
re u
sed:
oAd
ditio
nal 3
65 d
ays
$0
100%
of M
edic
are-
elig
ible
ex
pens
es
$0**
oBe
yond
the
addi
tiona
l 365
day
s$0
$0
Al
l cos
ts
SKIL
LED
NU
RSIN
G F
ACIL
ITY
CARE
* Yo
u m
ust m
eet M
edic
are’
s req
uire
men
ts, i
nclu
ding
hav
ing
been
in
a h
ospi
tal f
or a
t lea
st th
ree
days
and
ent
ered
a M
edic
are-
appr
oved
faci
lity
with
in 3
0 da
ys a
fter l
eavi
ng th
e ho
spita
l. Fi
rst 2
0 da
ys
All a
ppro
ved
amou
nts
$0
$0
21st
thro
ugh
100t
h da
y Al
l but
$15
7.50
a d
ay
$0
Up
to $
157.
50 a
day
10
1st d
ay a
nd a
fter
$0
$0
All c
osts
BL
OO
D Fi
rst t
hree
pin
ts
$0
Thre
e pi
nts
$0
Addi
tiona
l am
ount
s 10
0%
$0
$0
HOSP
ICE
CARE
Av
aila
ble
as lo
ng a
s you
r doc
tor c
ertif
ies y
ou a
re te
rmin
ally
ill a
nd
you
elec
t to
rece
ive
thes
e be
nefit
s.
All b
ut v
ery
limite
d co
paym
ent/
coin
sura
nce
for
outp
atie
nt d
rugs
and
in
patie
nt re
spite
car
e
Med
icar
e co
paym
ent/
coin
sura
nce
$0
**N
OTI
CE: W
hen
your
Med
icar
e Pa
rt A
hos
pita
l ben
efits
are
exh
aust
ed, t
he in
sure
r sta
nds i
n th
e pl
ace
of M
edic
are
and
will
pay
wha
teve
r am
ount
Med
icar
e w
ould
hav
e pa
id fo
r up
to a
n ad
ditio
nal 3
65 d
ays a
s pro
vide
d in
the
polic
y’s “
Core
Ben
efits
.” D
urin
g th
is tim
e, th
e ho
spita
l is p
rohi
bite
d fr
om b
illin
g yo
u fo
r the
ba
lanc
e ba
sed
on a
ny d
iffer
ence
bet
wee
n its
bill
ed c
harg
es a
nd th
e am
ount
Med
icar
e w
ould
hav
e pa
id.
(c
ontin
ued)
Page
4
1687
3 IN
DIVI
DUAL
Plan
A (c
ontin
ued)
†
Onc
e yo
u ha
ve b
een
bille
d $1
47 o
f Med
icar
e-ap
prov
ed a
mou
nts f
or c
over
ed se
rvic
es (w
hich
are
not
ed w
ith a
dag
ger)
, you
r Par
t B d
educ
tible
will
hav
e be
en
met
for t
he c
alen
dar y
ear.
MED
ICAR
E (P
ART
B) —
MED
ICAL
SER
VICE
S —
PER
CAL
ENDA
R YE
AR
SERV
ICES
M
EDIC
ARE
PAYS
PL
AN P
AYS
YOU
PAY
M
EDIC
AL E
XPEN
SES
— IN
OR
OU
T O
F TH
E HO
SPIT
AL A
ND
OU
TPAT
IEN
T HO
SPIT
AL T
REAT
MEN
T, su
ch a
s phy
sicia
n’s s
ervi
ces,
inpa
tient
and
out
patie
nt m
edic
al a
nd su
rgic
al se
rvic
es a
nd
supp
lies,
phy
sical
and
spee
ch th
erap
y, d
iagn
ostic
test
s, du
rabl
e m
edic
al e
quip
men
t.
Firs
t $14
7 of
Med
icar
e-ap
prov
ed a
mou
nts†
$0
$0
$1
47 (P
art B
ded
uctib
le)
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
Gene
rally
80%
Ge
nera
lly 2
0%
$0
Part
B e
xces
s cha
rges
(abo
ve M
edic
are-
appr
oved
am
ount
s)
$0
$0
All c
osts
BL
OO
D
Firs
t thr
ee p
ints
$0
Al
l cos
ts
$0
Nex
t $14
7 of
Med
icar
e-ap
prov
ed a
mou
nts†
$0
$0
$1
47 (P
art B
ded
uctib
le)
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
80%
20
%
$0
CLIN
ICAL
LAB
ORA
TORY
SER
VICE
S —
TES
TS F
OR
DIAG
NO
STIC
SE
RVIC
ES
100%
$0
$0
MED
ICAR
E (P
ARTS
A &
B)
SERV
ICES
M
EDIC
ARE
PAYS
PL
AN P
AYS
YOU
PAY
HO
ME
HEAL
TH C
ARE
— M
EDIC
ARE-
APPR
OVE
D SE
RVIC
ES
M
edic
ally
nec
essa
ry sk
illed
car
e se
rvic
es a
nd m
edic
al su
pplie
s 10
0%
$0
$0
Dura
ble
med
ical
equ
ipm
ent
•
Firs
t $14
7 of
Med
icar
e-ap
prov
ed a
mou
nts†
$0
$0
$1
47 (P
art B
ded
uctib
le)
•Re
mai
nder
of M
edic
are-
appr
oved
am
ount
s 80
%
20%
$0
De
duct
ible
am
ount
s ann
ounc
ed a
nnua
lly b
y CM
S.
Page
5
1687
3
IN
DIVI
DUAL
Plan
C
*A
bene
fit p
erio
d be
gins
on
the
first
day
you
rece
ive
serv
ices
as a
n in
patie
nt in
a h
ospi
tal a
nd e
nds a
fter
you
hav
e be
en o
ut o
f the
hos
pita
l and
hav
e no
tre
ceiv
ed sk
illed
car
e in
any
oth
er fa
cilit
y fo
r 60
days
in a
row
. M
EDIC
ARE
(PAR
T A)
— H
OSP
ITAL
SER
VICE
S —
PER
BEN
EFIT
PER
IOD
SERV
ICES
M
EDIC
ARE
PAYS
PL
AN P
AYS
YOU
PAY
HO
SPIT
ALIZ
ATIO
N*
Sem
ipriv
ate
room
and
boa
rd, g
ener
al n
ursin
g, a
nd m
iscel
lane
ous
serv
ices
and
supp
lies.
Firs
t 60
days
Al
l but
$1,
260
$1,2
60 (P
art A
ded
uctib
le)
$0
61st
thro
ugh
90th
day
Al
l but
$31
5 a
day
$315
a d
ay
$0
91st
day
and
aft
er:
•W
hile
usin
g 60
life
time
rese
rve
days
All b
ut $
630
a da
y $6
30 a
day
$0
•
Onc
e lif
etim
e re
serv
e da
ys a
re u
sed:
oAd
ditio
nal 3
65 d
ays
$0
100%
of M
edic
are-
elig
ible
ex
pens
es
$0**
oBe
yond
the
addi
tiona
l 365
day
s$0
$0
Al
l cos
ts
SKIL
LED
NU
RSIN
G F
ACIL
ITY
CARE
* Yo
u m
ust m
eet M
edic
are’
s req
uire
men
ts, i
nclu
ding
hav
ing
been
in
a h
ospi
tal f
or a
t lea
st th
ree
days
and
ent
ered
a M
edic
are-
appr
oved
faci
lity
with
in 3
0 da
ys a
fter l
eavi
ng th
e ho
spita
l. Fi
rst 2
0 da
ys
All a
ppro
ved
amou
nts
$0
$0
21st
thro
ugh
100t
h da
y Al
l but
$15
7.50
a d
ay
Up
to $
157.
50 a
day
$0
10
1st d
ay a
nd a
fter
$0
$0
All c
osts
BL
OO
D Fi
rst t
hree
pin
ts
$0
Thre
e pi
nts
$0
Addi
tiona
l am
ount
s 10
0%
$0
$0
HOSP
ICE
CARE
Av
aila
ble
as lo
ng a
s you
r doc
tor c
ertif
ies y
ou a
re te
rmin
ally
ill a
nd
you
elec
t to
rece
ive
thes
e be
nefit
s.
All b
ut v
ery
limite
d co
paym
ent/
coin
sura
nce
for
outp
atie
nt d
rugs
and
in
patie
nt re
spite
car
e
Med
icar
e co
paym
ent/
coin
sura
nce
$0
**N
OTI
CE: W
hen
your
Med
icar
e Pa
rt A
hos
pita
l ben
efits
are
exh
aust
ed, t
he in
sure
r sta
nds i
n th
e pl
ace
of M
edic
are
and
will
pay
wha
teve
r am
ount
Med
icar
e w
ould
hav
e pa
id fo
r up
to a
n ad
ditio
nal 3
65 d
ays a
s pro
vide
d in
the
polic
y’s “
Core
Ben
efits
.” D
urin
g th
is tim
e, th
e ho
spita
l is p
rohi
bite
d fr
om b
illin
g yo
u fo
r the
ba
lanc
e ba
sed
on a
ny d
iffer
ence
bet
wee
n its
bill
ed c
harg
es a
nd th
e am
ount
Med
icar
e w
ould
hav
e pa
id.
(c
ontin
ued)
Page
6
1687
3 IN
DIVI
DUAL
Plan
C (c
ontin
ued)
†
Onc
e yo
u ha
ve b
een
bille
d $1
47 o
f Med
icar
e-ap
prov
ed a
mou
nts f
or c
over
ed se
rvic
es (w
hich
are
not
ed w
ith a
dag
ger)
, you
r Par
t B d
educ
tible
will
hav
e be
en
met
for t
he c
alen
dar y
ear.
MED
ICAR
E (P
ART
B) —
MED
ICAL
SER
VICE
S —
PER
CAL
ENDA
R YE
AR
SERV
ICES
M
EDIC
ARE
PAYS
PL
AN P
AYS
YOU
PAY
M
EDIC
AL E
XPEN
SES
— IN
OR
OU
T O
F TH
E HO
SPIT
AL A
ND
OU
TPAT
IEN
T HO
SPIT
AL T
REAT
MEN
T, su
ch a
s phy
sicia
n’s s
ervi
ces,
inpa
tient
and
out
patie
nt m
edic
al a
nd su
rgic
al se
rvic
es a
nd
supp
lies,
phy
sical
and
spee
ch th
erap
y, d
iagn
ostic
test
s, du
rabl
e m
edic
al e
quip
men
t. Fi
rst $
147
of M
edic
are-
appr
oved
am
ount
s†
$0
$147
(Par
t B d
educ
tible
) $0
Re
mai
nder
of M
edic
are-
appr
oved
am
ount
s Ge
nera
lly 8
0%
Gene
rally
20%
$0
Pa
rt B
exc
ess c
harg
es (a
bove
Med
icar
e-ap
prov
ed a
mou
nts)
$0
$0
Al
l cos
ts
BLO
OD
Firs
t thr
ee p
ints
$0
Al
l cos
ts
$0
Nex
t $14
7 of
Med
icar
e-ap
prov
ed a
mou
nts†
$0
$1
47 (P
art B
ded
uctib
le)
$0
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
80%
20
%
$0
CLIN
ICAL
LAB
ORA
TORY
SER
VICE
S —
TES
TS F
OR
DIAG
NO
STIC
SE
RVIC
ES
100%
$0
$0
MED
ICAR
E (P
ARTS
A &
B)
SERV
ICES
M
EDIC
ARE
PAYS
PL
AN P
AYS
YOU
PAY
HO
ME
HEAL
TH C
ARE
— M
EDIC
ARE-
APPR
OVE
D SE
RVIC
ES
Med
ical
ly n
eces
sary
skill
ed c
are
serv
ices
and
med
ical
supp
lies
100%
$0
$0
Du
rabl
e m
edic
al e
quip
men
t •
Firs
t $14
7 of
Med
icar
e-ap
prov
ed a
mou
nts†
$0
$147
(Par
t B d
educ
tible
) $0
•
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
80%
20
%
$0
OTH
ER B
ENEF
ITS
— N
OT
COVE
RED
BY M
EDIC
ARE
SERV
ICES
M
EDIC
ARE
PAYS
PL
AN P
AYS
YOU
PAY
FO
REIG
N T
RAVE
L —
NO
T CO
VERE
D BY
MED
ICAR
E M
edic
ally
nec
essa
ry e
mer
genc
y ca
re se
rvic
es b
egin
ning
dur
ing
the
first
60
days
of e
ach
trip
out
side
the
USA
Fi
rst $
250
each
cal
enda
r yea
r $0
$0
$2
50
Rem
aind
er o
f cha
rges
$0
80
% to
a li
fetim
e m
axim
um
of $
50,0
00
20%
and
am
ount
s ove
r the
$5
0,00
0 lif
etim
e m
axim
um
Dedu
ctib
le a
mou
nts a
nnou
nced
ann
ually
by
CMS.
Pa
ge 7
16
873
INDI
VIDU
AL
Plan
F
*A
bene
fit p
erio
d be
gins
on
the
first
day
you
rece
ive
serv
ices
as a
n in
patie
nt in
a h
ospi
tal a
nd e
nds a
fter
you
hav
e be
en o
ut o
f the
hos
pita
l and
hav
e no
tre
ceiv
ed sk
illed
car
e in
any
oth
er fa
cilit
y fo
r 60
days
in a
row
. M
EDIC
ARE
(PAR
T A)
— H
OSP
ITAL
SER
VICE
S —
PER
BEN
EFIT
PER
IOD
SERV
ICES
M
EDIC
ARE
PAYS
PL
AN P
AYS
YOU
PAY
HO
SPIT
ALIZ
ATIO
N*
Sem
ipriv
ate
room
and
boa
rd, g
ener
al n
ursin
g, a
nd m
iscel
lane
ous
serv
ices
and
supp
lies.
Firs
t 60
days
Al
l but
$1,
260
$1,2
60 (P
art A
ded
uctib
le)
$0
61st
thro
ugh
90th
day
Al
l but
$31
5 a
day
$315
a d
ay
$0
91st
day
and
aft
er:
•W
hile
usin
g 60
life
time
rese
rve
days
All b
ut $
630
a da
y $6
30 a
day
$0
•
Onc
e lif
etim
e re
serv
e da
ys a
re u
sed:
oAd
ditio
nal 3
65 d
ays
$0
100%
of M
edic
are-
elig
ible
ex
pens
es
$0**
oBe
yond
the
addi
tiona
l 365
day
s$0
$0
Al
l cos
ts
SKIL
LED
NU
RSIN
G F
ACIL
ITY
CARE
* Yo
u m
ust m
eet M
edic
are’
s req
uire
men
ts, i
nclu
ding
hav
ing
been
in
a h
ospi
tal f
or a
t lea
st th
ree
days
and
ent
ered
a M
edic
are-
appr
oved
faci
lity
with
in 3
0 da
ys a
fter l
eavi
ng th
e ho
spita
l. Fi
rst 2
0 da
ys
All a
ppro
ved
amou
nts
$0
$0
21st
thro
ugh
100t
h da
y Al
l but
$15
7.50
a d
ay
Up
to $
157.
50 a
day
$0
10
1st d
ay a
nd a
fter
$0
$0
All c
osts
BL
OO
D Fi
rst t
hree
pin
ts
$0
Thre
e pi
nts
$0
Addi
tiona
l am
ount
s 10
0%
$0
$0
HOSP
ICE
CARE
Av
aila
ble
as lo
ng a
s you
r doc
tor c
ertif
ies y
ou a
re te
rmin
ally
ill a
nd
you
elec
t to
rece
ive
thes
e be
nefit
s.
All b
ut v
ery
limite
d co
paym
ent/
coin
sura
nce
for
outp
atie
nt d
rugs
and
in
patie
nt re
spite
car
e
Med
icar
e co
paym
ent/
coin
sura
nce
$0
**N
OTI
CE: W
hen
your
Med
icar
e Pa
rt A
hos
pita
l ben
efits
are
exh
aust
ed, t
he in
sure
r sta
nds i
n th
e pl
ace
of M
edic
are
and
will
pay
wha
teve
r am
ount
Med
icar
e w
ould
hav
e pa
id fo
r up
to a
n ad
ditio
nal 3
65 d
ays a
s pro
vide
d in
the
polic
y’s “
Core
Ben
efits
.” D
urin
g th
is tim
e, th
e ho
spita
l is p
rohi
bite
d fr
om b
illin
g yo
u fo
r the
ba
lanc
e ba
sed
on a
ny d
iffer
ence
bet
wee
n its
bill
ed c
harg
es a
nd th
e am
ount
Med
icar
e w
ould
hav
e pa
id.
(c
ontin
ued)
Page
8
1687
3 IN
DIVI
DUAL
Plan
F (c
ontin
ued)
†
Onc
e yo
u ha
ve b
een
bille
d $1
47 o
f Med
icar
e-ap
prov
ed a
mou
nts f
or c
over
ed se
rvic
es (w
hich
are
not
ed w
ith a
dag
ger)
, you
r Par
t B d
educ
tible
will
hav
e be
en
met
for t
he c
alen
dar y
ear.
MED
ICAR
E (P
ART
B) —
MED
ICAL
SER
VICE
S —
PER
CAL
ENDA
R YE
AR
SERV
ICES
M
EDIC
ARE
PAYS
PL
AN P
AYS
YOU
PAY
M
EDIC
AL E
XPEN
SES
— IN
OR
OU
T O
F TH
E HO
SPIT
AL A
ND
OU
TPAT
IEN
T HO
SPIT
AL T
REAT
MEN
T, su
ch a
s phy
sicia
n’s s
ervi
ces,
inpa
tient
and
out
patie
nt m
edic
al a
nd su
rgic
al se
rvic
es a
nd
supp
lies,
phy
sical
and
spee
ch th
erap
y, d
iagn
ostic
test
s, du
rabl
e m
edic
al e
quip
men
t. Fi
rst $
147
of M
edic
are-
appr
oved
am
ount
s†
$0
$147
(Par
t B d
educ
tible
) $0
Re
mai
nder
of M
edic
are-
appr
oved
am
ount
s Ge
nera
lly 8
0%
Gene
rally
20%
$0
Pa
rt B
exc
ess c
harg
es (a
bove
Med
icar
e-ap
prov
ed a
mou
nts)
$0
10
0%
$0
BLO
OD
Firs
t thr
ee p
ints
$0
Al
l cos
ts
$0
Nex
t $14
7 of
Med
icar
e-ap
prov
ed a
mou
nts†
$0
$1
47 (P
art B
ded
uctib
le)
$0
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
80%
20
%
$0
CLIN
ICAL
LAB
ORA
TORY
SER
VICE
S —
TES
TS F
OR
DIAG
NO
STIC
SE
RVIC
ES
100%
$0
$0
MED
ICAR
E (P
ARTS
A &
B)
SERV
ICES
M
EDIC
ARE
PAYS
PL
AN P
AYS
YOU
PAY
HO
ME
HEAL
TH C
ARE
— M
EDIC
ARE-
APPR
OVE
D SE
RVIC
ES
Med
ical
ly n
eces
sary
skill
ed c
are
serv
ices
and
med
ical
supp
lies
100%
$0
$0
Du
rabl
e m
edic
al e
quip
men
t •
Firs
t $14
7 of
Med
icar
e-ap
prov
ed a
mou
nts†
$0
$147
(Par
t B d
educ
tible
) $0
•
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
80%
20
%
$0
OTH
ER B
ENEF
ITS
— N
OT
COVE
RED
BY M
EDIC
ARE
SERV
ICES
M
EDIC
ARE
PAYS
PL
AN P
AYS
YOU
PAY
FO
REIG
N T
RAVE
L —
NO
T CO
VERE
D BY
MED
ICAR
E M
edic
ally
nec
essa
ry e
mer
genc
y ca
re se
rvic
es b
egin
ning
dur
ing
the
first
60
days
of e
ach
trip
out
side
the
USA
Fi
rst $
250
each
cal
enda
r yea
r $0
$0
$2
50
Rem
aind
er o
f cha
rges
$0
80
% to
a li
fetim
e m
axim
um
of $
50,0
00
20%
and
am
ount
s ove
r the
$5
0,00
0 lif
etim
e m
axim
um
Dedu
ctib
le a
mou
nts a
nnou
nced
ann
ually
by
CMS.
Page
9
1687
3 IN
DIVI
DUAL
Plan
N
*A
bene
fit p
erio
d be
gins
on
the
first
day
you
rece
ive
serv
ices
as a
n in
patie
nt in
a h
ospi
tal a
nd e
nds a
fter
you
hav
e be
en o
ut o
f the
hos
pita
l and
hav
e no
tre
ceiv
ed sk
illed
car
e in
any
oth
er fa
cilit
y fo
r 60
days
in a
row
. M
EDIC
ARE
(PAR
T A)
— H
OSP
ITAL
SER
VICE
S —
PER
BEN
EFIT
PER
IOD
SERV
ICES
M
EDIC
ARE
PAYS
PL
AN P
AYS
YOU
PAY
HO
SPIT
ALIZ
ATIO
N*
Sem
ipriv
ate
room
and
boa
rd, g
ener
al n
ursin
g, a
nd m
iscel
lane
ous
serv
ices
and
supp
lies.
Firs
t 60
days
Al
l but
$1,
260
$1,2
60 (P
art A
ded
uctib
le)
$0
61st
thro
ugh
90th
day
Al
l but
$31
5 a
day
$315
a d
ay
$0
91st
day
and
aft
er:
•W
hile
usin
g 60
life
time
rese
rve
days
All b
ut $
630
a da
y $6
30 a
day
$0
•
Onc
e lif
etim
e re
serv
e da
ys a
re u
sed:
oAd
ditio
nal 3
65 d
ays
$0
100%
of M
edic
are-
elig
ible
ex
pens
es
$0**
oBe
yond
the
addi
tiona
l 365
day
s$0
$0
Al
l cos
ts
SKIL
LED
NU
RSIN
G F
ACIL
ITY
CARE
* Yo
u m
ust m
eet M
edic
are’
s req
uire
men
ts, i
nclu
ding
hav
ing
been
in
a h
ospi
tal f
or a
t lea
st th
ree
days
and
ent
ered
a M
edic
are-
appr
oved
faci
lity
with
in 3
0 da
ys a
fter l
eavi
ng th
e ho
spita
l. Fi
rst 2
0 da
ys
All a
ppro
ved
amou
nts
$0
$0
21st
thro
ugh
100t
h da
y Al
l but
$15
7.50
a d
ay
Up
to $
157.
50 a
day
$0
10
1st d
ay a
nd a
fter
$0
$0
All c
osts
BL
OO
D Fi
rst t
hree
pin
ts
$0
Thre
e pi
nts
$0
Addi
tiona
l am
ount
s 10
0%
$0
$0
HOSP
ICE
CARE
Av
aila
ble
as lo
ng a
s you
r doc
tor c
ertif
ies y
ou a
re te
rmin
ally
ill a
nd
you
elec
t to
rece
ive
thes
e be
nefit
s.
All b
ut v
ery
limite
d co
paym
ent/
coin
sura
nce
for
outp
atie
nt d
rugs
and
in
patie
nt re
spite
car
e
Med
icar
e co
paym
ent/
coin
sura
nce
$0
**N
OTI
CE: W
hen
your
Med
icar
e Pa
rt A
hos
pita
l ben
efits
are
exh
aust
ed, t
he in
sure
r sta
nds i
n th
e pl
ace
of M
edic
are
and
will
pay
wha
teve
r am
ount
Med
icar
e w
ould
hav
e pa
id fo
r up
to a
n ad
ditio
nal 3
65 d
ays a
s pro
vide
d in
the
polic
y’s “
Core
Ben
efits
.” D
urin
g th
is tim
e, th
e ho
spita
l is p
rohi
bite
d fr
om b
illin
g yo
u fo
r the
ba
lanc
e ba
sed
on a
ny d
iffer
ence
bet
wee
n its
bill
ed c
harg
es a
nd th
e am
ount
Med
icar
e w
ould
hav
e pa
id.
(c
ontin
ued)
Page
10
1687
3 IN
DIVI
DUAL
Plan
N (c
ontin
ued)
†
Onc
e yo
u ha
ve b
een
bille
d $1
47 o
f Med
icar
e-ap
prov
ed a
mou
nts f
or c
over
ed se
rvic
es (w
hich
are
not
ed w
ith a
dag
ger)
, you
r Par
t B d
educ
tible
will
hav
e be
en
met
for t
he c
alen
dar y
ear.
MED
ICAR
E (P
ART
B) —
MED
ICAL
SER
VICE
S —
PER
CAL
ENDA
R YE
AR
SERV
ICES
M
EDIC
ARE
PAYS
PL
AN P
AYS
YOU
PAY
M
EDIC
AL E
XPEN
SES
— IN
OR
OU
T O
F TH
E HO
SPIT
AL A
ND
OU
TPAT
IEN
T HO
SPIT
AL T
REAT
MEN
T, su
ch a
s phy
sicia
n’s s
ervi
ces,
inpa
tient
and
out
patie
nt m
edic
al a
nd su
rgic
al se
rvic
es a
nd
supp
lies,
phy
sical
and
spee
ch th
erap
y, d
iagn
ostic
test
s, du
rabl
e m
edic
al e
quip
men
t. Fi
rst $
147
of M
edic
are-
appr
oved
am
ount
s†
$0
$0
$147
(Par
t B d
educ
tible
) Re
mai
nder
of M
edic
are-
appr
oved
am
ount
s Ge
nera
lly 8
0%
Bala
nce,
oth
er th
an u
p to
$2
0 pe
r offi
ce v
isit a
nd u
p to
$5
0 pe
r em
erge
ncy
room
vi
sit. T
he c
opay
men
t of u
p to
$50
is w
aive
d if
the
insu
red
is ad
mitt
ed to
any
ho
spita
l and
the
emer
genc
y vi
sit is
cov
ered
as a
M
edic
are
Part
A e
xpen
se.
Up
to $
20 p
er o
ffice
visi
t and
up
to $
50 p
er e
mer
genc
y ro
om v
isit.
The
copa
ymen
t of
up
to $
50 is
wai
ved
if th
e in
sure
d is
adm
itted
to a
ny
hosp
ital a
nd th
e em
erge
ncy
visit
is c
over
ed a
s a
Med
icar
e Pa
rt A
exp
ense
.
Part
B e
xces
s cha
rges
(abo
ve M
edic
are-
appr
oved
am
ount
s)
$0
$0
All c
osts
BL
OO
D Fi
rst t
hree
pin
ts
$0
All c
osts
$0
N
ext $
147
of M
edic
are-
appr
oved
am
ount
s†
$0
$0
$147
(Par
t B d
educ
tible
) Re
mai
nder
of M
edic
are-
appr
oved
am
ount
s 80
%
20%
$0
CL
INIC
AL L
ABO
RATO
RY S
ERVI
CES
—TE
STS
FOR
DIAG
NO
STIC
SE
RVIC
ES
100%
$0
$0
Page
11
1687
3 IN
DIVI
DUAL
Plan
N (c
ontin
ued)
† O
nce
you
have
bee
n bi
lled
$147
of M
edic
are-
appr
oved
am
ount
s for
cov
ered
serv
ices
(whi
ch a
re n
oted
with
a d
agge
r), y
our P
art B
ded
uctib
le w
ill h
ave
been
m
et fo
r the
cal
enda
r yea
r. M
EDIC
ARE
(PAR
TS A
& B
) SE
RVIC
ES
MED
ICAR
E PA
YS
PLAN
PAY
S YO
U P
AY
HOM
E HE
ALTH
CAR
E —
MED
ICAR
E-AP
PRO
VED
SERV
ICES
M
edic
ally
nec
essa
ry sk
illed
car
e se
rvic
es a
nd m
edic
al su
pplie
s 10
0%
$0
$0
Dura
ble
med
ical
equ
ipm
ent
•Fi
rst $
147
of M
edic
are-
appr
oved
am
ount
s†$0
$0
$1
47 (P
art B
ded
uctib
le)
•Re
mai
nder
of M
edic
are-
appr
oved
am
ount
s80
%
20%
$0
O
THER
BEN
EFIT
S —
NO
T CO
VERE
D BY
MED
ICAR
E SE
RVIC
ES
MED
ICAR
E PA
YS
PLAN
PAY
S YO
U P
AY
FORE
IGN
TRA
VEL
— N
OT
COVE
RED
BY M
EDIC
ARE
Med
ical
ly n
eces
sary
em
erge
ncy
care
serv
ices
beg
inni
ng d
urin
g th
e fir
st 6
0 da
ys o
f eac
h tr
ip o
utsid
e th
e U
SA
Firs
t $25
0 ea
ch c
alen
dar y
ear
$0
$0
$250
Re
mai
nder
of c
harg
es
$0
80%
to a
life
time
max
imum
of
$50
,000
20
% a
nd a
mou
nts o
ver t
he
$50,
000
lifet
ime
max
imum
Dedu
ctib
le a
mou
nts a
nnou
nced
ann
ually
by
CMS.
Page
12
1687
3 IN
DIVI
DUAL
Amer
iHea
lth In
sura
nce
Com
pany
of N
ew Je
rsey
AM64
38 (1
0/14
)
Que
stio
ns?
Nee
d m
ore
info
rmat
ion?
Call
one
of o
ur M
edic
are
sale
s rep
rese
ntat
ives
at
1-86
6-36
5-53
45
(TTY
/TDD
: 711
)
Seve
n da
ys a
wee
k , 8
a.m
. to 8
p.m
. Pl
ease
not
e th
at o
n w
eeke
nds a
nd h
olid
ays f
rom
Feb
ruar
y 15
thro
ugh
Sept
embe
r 30,
you
r cal
l may
be
sent
to v
oice
mai
l. w
ww
.am
erih
ealth
med
icar
e.co
m
Page
13
1687
3 IN
DIVI
DUAL
