Outline of Coverage for Standardized
Medicare Supplement Insurance Plan G
| Part A Details | |||
|---|---|---|---|
| Services | Medicare Pays | Plan Pays | You Pay |
| Part A Deductible | $0 | $1484 | $0 |
| First 60 days | All but $1484 (Part A deductible) | $1484 (Part A deductible) | $0 |
| 61st through 90th day | All but $371 a day | $371 a day | $0 |
| 91st day and after: While using 60 lifetime reserve days | All but $742 a day | $742 a day | $0 |
| Once lifetime reserve days are used: Additional 365 days | $0 | Balance of Medicare eligible expenses. | $0 |
| Beyond the additional 365 days | $0 | $0 | All costs |
|
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. |
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| First 20 days | All approved amounts | All costs | $0 |
| 21st through 100th day | All but $185.5 a day | Coinsurance amount of Medicare eligible expenses. | $0 |
| 101st day and after | $0 | $0 | All costs |
|
BLOOD |
|||
| First 3 pints | $0 | All costs | $0 |
| Additional amounts | 100% | $0 | $0 |
|
HOSPICE CARE |
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| Details | All but very limited coinsurance for outpatient drugs and inpatient respite care | $0 | A coinsurance or copayment, up to $5 for inpatient drugs and 5% of the Medicare-approved amount for inpatient respite care. |
| Part B Details | |||
|---|---|---|---|
| Services | Medicare Pays | Plan Pays | You Pay |
| Part B Deductible | $0 | $0 | $203 (Part B deductible) |
| Remainder of Medicare approved amounts | 80% | Coinsurance amount of Medicare eligible expenses. | $0 |
| Part B excess charges (above Medicare approved amounts) | $0 | All costs | $0 |
|
BLOOD |
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| First three pints | $0 | All costs | $0 |
| Next $203 of Medicare approved amounts | $0 | $0 | $203 (Part B deductible) |
| Remainder of Medicare approved amounts | 80% | Coinsurance amount of Medicare eligible expenses. | $0 |
|
DURABLE MEDICAL EQUIPMENT |
|||
| First $203 of Medicare approved amounts | $0 | $0 | $203 (Part B deductible) |
| Remainder of Medicare approved amounts | 80% | Coinsurance amount of Medicare eligible expenses. | $0 |
|
FOREIGN TRAVEL EMERGENCY |
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| First $250 each calendar year | $0 | $0 | $250 |
| Remainder of Charges | $0 | 80% to a lifetime maximum benefit of $50,000. | 20% and amounts over the $50,000 lifetime maximum |
|
AT HOME RECOVERY |
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| At home recovery | All approved amounts | $0 | $0 |
|
PREVENTIVE CARE |
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| Details | 80% | Coinsurance amount of Medicare eligible expenses | $0 |
| Preventive Care not covered by Medicare | $0 | $0 | All costs |
|
OTHER |
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| Deductible | -------- | -------- | N/A |
| Network | -------- | -------- | No network |
| Maximum yearly copayment | -------- | -------- | N/A |
* This information is for general plan comparison only. While we strive to be accurate, we cannot guarantee the above information to be a perfect representation of benefits, nor can we guarantee the accuracy of the premium amount shown. Licensed Medicare Supplement Insurance Specialists should be consulted for a detailed description of benefits and limitations.