Skip to main content

Coverage and benefits

XXX XXXXXXX XXXXXXXXXX XXXXXXXX

XXXXXXXX XXXXXXXX XXXXXXX XXXXXX

Monthly Premium      

Member name:
Member ID:
Coverage:
8/11/2022-8/11/2022

Part A hospital services

Part A inpatient hospital deductible

The amount required to be paid when you are admitted to a Hospital for the first time in each Benefit Period.

$X,XXX

Hospitalization & skilled nursing facility care

Inpatient hospital care

Care received as an inpatient in a hospital that is a approved for payment by Medicare. You would be responsible to pay any balance after Medicare and your plan pays for days 1-60. For days 61-90, the plan pays for Part A daily co-insurance.

For days 91 and later, this plan will pay your daily co-insurance while you are using your 60 Lifetime Reserve Days. Once Lifetime Reserve Days are used up you have no out of pocket costs for an additional 365 days. Beyond the additional 365 days, you pay all costs.

You pay$0$X,XXXafter you meet your deductible except as noted
Skilled nursing facility care

Care received during a skilled nursing facility stay, that follows a hospital stay. The facility must provide skilled nursing care and be approved for payment by Medicare.

You pay all costs for days 101 and later

You pay$0$X,XXXper day for days 1-100