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.
Hospitalization: Semiprivate room and board, general nursing, and miscellaneous services and supplies
| Services | Medicare Pays | Plan F Pays | You Pay |
| First 60 Days | All but $1,184 | $1,184 (Part A Deductible) | $0 |
| 61st through 90th day | All but $296 a day | $296 a day | $0 |
| 91st day and after: While using 60 lifetime reserve days | All but $592 a day | $592 a day | $0 |
| Once lifetime reserve days are used: additional 365 days | $0 | 100% of Medicare Eligible Expenses | $0* |
| Beyond additional 365 days | $0 | $0 | All Costs |
* NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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 on any difference between its billed charges and the amount Medicare would have paid.
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.
| Services | Medicare Pays | Plan F Pays | You Pay |
| First 20 days | All approved amounts | $0 | $0 |
| 21st through 100th day | All but $148 a day | Up to $148 a day | $0 |
| 101st day and after | $0 | $0 | All Costs |
Blood
| Services | Medicare Pays | Plan F Pays | You Pay |
| 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.
| Services | Medicare Pays | Plan F Pays | You Pay |
| Hospice | All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care | Medicare copayment/coinsurance | $0 |
Medicare (Part B) – Medical Services – Per Calendar Year
*** Once you have been billed $147 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.
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 medical equipment.
| Services | Medicare Pays | Plan F Pays | You Pay |
| Part B Excess Charges (above Medicare-approved amounts) | $0 | $147 (Part B deductible) | $0 |
| Remainder of Medicare Approved Amounts | Generally 80% | Genereally 20% | $0 |
| Part B Excess Charges (above Medicare approved amounts) | $0 | 100% | $0 |
Blood
| Services | Medicare Pays | Plan F Pays | You Pay |
| First 3 pints | 100% | $0 | $0 |
| Next $147 of Medicare Approved Amounts* | $0 | $147 (Part B deductible) | $0 |
| Remainder of Medicare Approved Amounts* | 80% | 20% | $0 |
Clinical Laboratory Services: Tests for diagnostic services
| Services | Medicare Pays | Plan F Pays | You Pay |
| Lab | 100% | $0 | $0 |
Medicare (Parts A & B)
Home Health Care: Medicare Approved Services
| Services | Medicare Pays | Plan F Pays | You Pay |
| Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
| Durable Medical equipment First $147 of Medicare Approved Amounts* | $0 | $147 (Part B deductible) | $0 |
| Remainder of Charges | 80% | 20% | $0 |