{ "plan_name": { "A": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$0", "$1676 (Part A Deductible)" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Additional Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "$0", "Up to $209.50 a Day" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "You must meet Medicare's requirements, including a doctor's certification of terminal illness", "All but very limited copayment / coinsurance for outpatient drugs and inpatient respite care", "Medicare copayment / coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ], [ "Part B Excess Charge", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ] }, "Parts A & B": { "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "1st $257 of Medicare approved amounts", "$0", "$0", "$257 (Part B deductible)" ], [ "Remainder of medicare approved amounts", "80%", "20%", "$0" ] ] } }, "B": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$1676 (Part A Deductible)", "$0" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Additional Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "Up to $209.50 a Day" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "Must Meet Medicare's Requirements", "All but very limited coinsurance, coinsurance for outpatient drugs and inpatient respite care.", "Pays Copayments and Coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ], [ "Part B Excess Charge", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ] }, "Parts A & B": { "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "1st $257 of Medicare approved amounts", "$0", "$0", "$257 (Part B deductible)" ], [ "Remainder of medicare approved amounts", "80%", "20%", "$0" ] ] } }, "C": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$1676 (Part A Deductible)", "$0" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Additional Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "Must Meet Medicare's Requirements", "All but very limited coinsurance, coinsurance for outpatient drugs and inpatient respite care.", "Pays Copayments and Coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0", "$257 (Part B Deductible)", "$0" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ], [ "Part B Excess Charge", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$257 (Part B Deductible)", "$0" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ] }, "Parts A & B": { "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "1st $257 of Medicare approved amounts", "$0", "$257 (Part B deductible)", "$0" ], [ "Remainder of medicare approved amounts", "80%", "20%", "$0" ] ] }, "Other Benefits": { "Foreign Travel": [ [ "First $250 each calendar year", "$0", "$0", "$250" ], [ "Remainder of Charges", "$0", "80% to a lifetime maximum of $50,000", "20% until the lifetime maximum, then all costs." ] ] } }, "D": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$1676 (Part A Deductible)", "$0" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "You must meet Medicare's requirements, including a doctor's certification of terminal illness", "All but very limited copayment / coinsurance for outpatient drugs and inpatient respite care", "Medicare copayment / coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ], [ "Part B Excess Charge", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ] }, "Parts A & B": { "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "1st $257 of Medicare approved amounts", "$0", "$0", "$257 (Part B deductible)" ], [ "Remainder of medicare approved amounts", "80%", "20%", "$0" ] ] }, "Other Benefits": { "Foreign Travel": [ [ "First $250 each calendar year", "$0", "$0", "$250" ], [ "Remainder of Charges", "$0", "80% to a lifetime maximum of $50,000", "20% until the lifetime maximum, then all costs." ] ] } }, "F": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$1676 (Part A Deductible)", "$0" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "You must meet Medicare's requirements, including a doctor's certification of terminal illness", "All but very limited copayment / coinsurance for outpatient drugs and inpatient respite care", "Medicare copayment / coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0", "$257 (Part B Deductible)", "$0" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ], [ "Part B Excess Charge", "$0", "100%", "$0" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$257 (Part B Deductible)", "$0" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ] }, "Parts A & B": { "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "1st $257 of Medicare approved amounts", "$0", "$257 (Part B deductible)", "$0" ], [ "Remainder of medicare approved amounts", "80%", "20%", "$0" ] ] }, "Other Benefits": { "Foreign Travel": [ [ "First $250 each calendar year", "$0", "$0", "$250" ], [ "Remainder of Charges", "$0", "80% to a lifetime maximum of $50,000", "20% until the lifetime maximum, then all costs." ] ] } }, "HDF": { "deductible": "2870", "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$1676 (Part A Deductible)", "$0" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "Must Meet Medicare's Requirements", "All but very limited coinsurance, coinsurance for outpatient drugs and inpatient respite care.", "Pays Copayments and Coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0", "$257 (Part B Deductible)", "$0" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ], [ "Part B Excess Charge", "$0", "100%", "$0" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$257 (Part B Deductible)", "$0" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ] }, "Parts A & B": { "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "1st $257 of Medicare approved amounts", "$0", "$257 (Part B deductible)", "$0" ], [ "Remainder of medicare approved amounts", "80%", "20%", "$0" ] ] }, "Other Benefits": { "Foreign Travel": [ [ "First $250 each calendar year", "$0", "$0", "$250" ], [ "Remainder of Charges", "$0", "80% to a lifetime maximum of $50,000", "20% until the lifetime maximum, then all costs." ] ] } }, "G": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$1676 (Part A Deductible)", "$0" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "You must meet Medicare's requirements, including a doctor's certification of terminal illness", "All but very limited copayment / coinsurance for outpatient drugs and inpatient respite care", "Medicare copayment / coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ], [ "Part B Excess Charge", "$0", "100%", "$0" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ] }, "Parts A & B": { "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "1st $257 of Medicare approved amounts", "$0", "$0", "$257 (Part B deductible)" ], [ "Remainder of medicare approved amounts", "80%", "20%", "$0" ] ] }, "Other Benefits": { "Foreign Travel": [ [ "First $250 each calendar year", "$0", "$0", "$250" ], [ "Remainder of Charges", "$0", "80% to a lifetime maximum of $50,000", "20% until the lifetime maximum, then all costs." ] ] } }, "HDG": { "deductible": "2870", "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$1676 (Part A Deductible)", "$0" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "Must Meet Medicare's Requirements, including a doctor's certification of terminal illness", "All but very limited coinsurance, coinsurance for outpatient drugs and inpatient respite care.", "Pays Copayments and Coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0", "$0", "$257(Unless Part B deductible has been met)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ], [ "Part B Excess Charge", "$0", "100%", "$0" ] ], "Blood": [ [ "First Three Pints", "$0", "All costs", "$0" ], [ "Next $257 of Medicare Approved Amounts", "$0", "$0", "$257 (Unless Part B deductible has been met)" ], [ "Remainder of Medicare Approved Amounts", "80%", "20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ] }, "Parts A & B": { "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "1st $257 of Medicare approved amounts", "$0", "$0", "$257 (Unless Part B deductible has been met)" ], [ "Remainder of medicare approved amounts", "80%", "20%", "$0" ] ] }, "Other Benefits": { "Foreign Travel": [ [ "1st $250 each calendar year", "$0", "$0", "$250" ], [ "Remainder of Charges", "$0", "80% up to a lifetime maximum benefit of $50,000", "20% and amounts over the $50,000 lifetime maximum benefit" ] ] } }, "K": { "Part A": { "-Plan Notes-": [ [ "Annual out-of-pocket limit", "$0", "$0", "Up to $7220" ] ], "Hospitalization": [ [ "First 60 Days", "All But $1676", "$838 (50% of Deductible)", "$838 (50% of Deductible)" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $100 a Day (50%)", "Up to $100 a Day (50%)" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "50%", "50%" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "Must Meet Medicare's Requirements", "All but very limited coinsurance, coinsurance for outpatient drugs and inpatient respite care.", "50% of Copayments and Coinsurance", "50% of Copayments and Coinsurance" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Preventative Benefits", "Generally 75%", "Remainder of Approved Costs", "All Costs Above Approved Costs" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 10%", "Generally 10%" ], [ "Part B Excess Charge", "$0", "$0", "All Costs (NA to Max Out of Pocket" ] ], "Blood": [ [ "First Three Pints", "$0", "50%", "50%" ], [ "Next $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 10%", "Generally 10%" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ] }, "Parts A & B": { "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "1st $257 of Medicare approved amounts", "$0", "$0", "$257 (Part B deductible)" ], [ "Remainder of medicare approved amounts", "80%", "10%", "10%" ] ] } }, "L": { "Part A": { "-Plan Notes-": [ [ "Annual out-of-pocket limit", "$0", "$0", "Up to $3610" ] ], "Hospitalization": [ [ "First 60 Days", "All But $1676", "$1224 (75% of Deductible)", "$419 (25% of Deductible)" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $153 a Day (75%)", "Up to $51 a Day (25%)" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "75%", "25%" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "Must Meet Medicare's Requirements", "All but very limited coinsurance, coinsurance for outpatient drugs and inpatient respite care.", "75% of Copayments and Coinsurance", "25% of Copayments and Coinsurance" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Preventative Benefits", "Generally 75%", "Remainder of Approved Costs", "All Costs Above Approved Costs" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 15%", "Generally 5%" ], [ "Part B Excess Charge", "$0", "$0", "All Costs (NA to Max Out of Pocket" ] ], "Blood": [ [ "First Three Pints", "$0", "75%", "25%" ], [ "Next $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 15%", "Generally 5%" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ] }, "Parts A & B": { "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "1st $257 of Medicare approved amounts", "$0", "$0", "$257 (Part B deductible)" ], [ "Remainder of medicare approved amounts", "80%", "15%", "5%" ] ] } }, "M": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$838 (50% of Deductible)", "$838 (50% of Deductible)" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "10%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "Must Meet Medicare's Requirements", "All but very limited coinsurance, coinsurance for outpatient drugs and inpatient respite care.", "Pays Copayments and Coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ], [ "Part B Excess Charge", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ] }, "Parts A & B": { "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "1st $257 of Medicare approved amounts", "$0", "$0", "$257 (Part B deductible)" ], [ "Remainder of medicare approved amounts", "80%", "20%", "0%" ] ] }, "Other Benefits": { "Foreign Travel": [ [ "First $250 each calendar year", "$0", "$0", "$250" ], [ "Remainder of Charges", "$0", "80% to a lifetime maximum of $50,000", "20% until the lifetime maximum, then all costs." ] ] } }, "N": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$1676 (Part A Deductible)", "$0" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "You must meet Medicare's requirements, including a doctor's certification of terminal illness", "All but very limited copayment / coinsurance for outpatient drugs and inpatient respite care", "Medicare copayment / coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Balance, Other than Copays", "Up to $20/$50 Copays, Emergency visit copay waived if admitted" ], [ "Part B Excess Charge", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ] }, "Parts A & B": { "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "1st $257 of Medicare approved amounts", "$0", "$0", "$257 (Part B deductible)" ], [ "Remainder of medicare approved amounts", "80%", "20%", "0%" ] ] }, "Other Benefits": { "Foreign Travel": [ [ "First $250 each calendar year", "$0", "$0", "$250" ], [ "Remainder of Charges", "$0", "80% to a lifetime maximum of $50,000", "20% until the lifetime maximum, then all costs." ] ] } }, "WI_BASE": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$0 or Optional Part A Deductible Rider", "$1676 or $0 (Optional Rider)" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Inpatient Psychiatric Care": [ [ "Inpatient psychiatric care in participating psychiatric hospital", "190 days per lifetime", "175 additional days per lifetime", "Beyond 365 Days" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "You must meet Medicare's requirements, including a doctor's certification of terminal illness", "\tAll but very limited $0 or 100% of copayment/ $0 copayment/coinsurance for outpatient drugs and inpatient respite care", "$0 or 100% of copayment/coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0", "$0 or Optional Part B Deductible Rider", "$257 (Part B Deductible) or $0" ], [ "Remainder of Approved Amounts", "Generally 80%", "(1) Generally 20%, (2) or Optional Part B Excess Charges Rider, (3) or Optional Part B Copayment or Coinsurance Rider", "(1) Charges in excess of Medicare-approved charges. (2) Charges not paid by Medicare or the policy. (3) Up to $20 per office visit and up to $50 per emergency room visit." ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$257 (Part B Deductible)", "$0" ], [ "Remainder of Approved Amounts", "80%", "(1) 20%, (2) or Optional Part B Excess Charges Rider, (3) or Optional Part B Copayment or Coinsurance Rider", "(1) Charges in excess of Medicare-approved charges. (2) Charges not paid by Medicare or the policy. (3) Up to $20 per office visit and up to $50 per emergency room visit." ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ], "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100% of charges for visits considered medically necessary by Medicare", "40 visits in addition to those paid by Medicare or Optional Additional Home Health Rider", "Beyond 40 visits per calendar year or Beyond 365 visits" ] ], "Preventative Medical Care Benefit": [ [ "PREVENTATIVE MEDICAL CARE BENEFIT - NOT COVERED BY MEDICARE", "", "", "" ], [ "Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare.", "", "", "" ], [ "First $120 each calendar year", "$0", "$120", "$0" ], [ "Additional Charges", "$0", "(1) $0, (2) or Optional Part B Excess Charges Rider, (3) or Optional Part B Copayment or Coinsurance Rider", "(1) Charges in excess of Medicare-approved charges. (2) Charges not paid by Medicare or the policy. (3) Up to $20 per office visit and up to $50 per emergency room visit." ] ], "Foreign Travel": [ [ "FOREIGN TRAVEL - NOT COVERED BY MEDICARE", "", "", "" ], [ "Medically necessary emergency care services beginning during the first 60 days of each trip outside of the USA.", "", "", "" ], [ "First $250 each calendar year", "$0", "$0", "$250" ], [ "Remainder of charges", "$0", "(1) $0 or, (2) Optional Foreign Travel Emergency Rider** (80% to a lifetime maximum benefit of $50,000)", "(1) All costs or, (2) 20% and amounts over the $50,000 lifetime maximum" ] ] }, "Additional": { "Diabetic Equipment & Supplies": [ [ "Self-education programs and infusion pump (provided you use it for 30 days before buying it)", "Medicare generally does not cover diabetic supplies", "The full usual, customary and reasonable charge, less what Medicare paid", "Charges in excess of the full usual, customary and reasonable charge" ] ], "Licensed Skilled Nursing Facility Care": [ [ "The facility does not have to be certified by Medicare, no prior hospitalization is required and the stay does not have to meet Medicare's definition", "$0 for services beyond those covered under Part A", "Up to 30 days per admission for medically necessary care", "Charges for care beyond 30 days per admission of skilled care." ] ], "Chiropractic Services": [ [ "", "80% for manual manipulations of the spine to correct a subluxation that can be demonstrated by X-ray", "The full usual, customary and reasonable charge, less what Medicare pays for Medicare- eligible expenses", "Charges in excess of the full, usual, customary and reasonable charge" ] ], "Kidney Disease Care": [ [ "Inpatient and outpatient expenses for dialysis, transplantation or donor-related services", "80%", "Up to $30,000 per year", "Charges in excess of $30,000" ] ] }, "Riders": { "Optional Riders": [ [ "Part A Deductible", "$0", "100% of Part A Deductible", "$0" ], [ "365 Home Health Care Visits", "100% of charges for visits considered medically necessary by Medicare", "An aggregate of 365 visits per year including those covered by Medicare", "Charges for visits beyond 365 per year" ], [ "Part B Deductible", "$0", "100% of Part B Deductible", "$0" ], [ "Part B Copayment/Coinsurance", "Generally 80%, after that Part B Deductible has been met.", "Coverage of the Medicare Part B medical coinsurance, subject to a copayment or coinsurance of no more than $20 per office visit and no more than $50 per emergency room visit. If admitted, the $50 is waived and the emergency visit is covered as a Medicare Part A expense.", "$257 (Part B Deductible) and no more than $20 per office visit and no more than $50 per emergency room visit. If admitted, the $50 is waved and the emergency visit is covered as a Medicare Part A expense." ], [ "Part B Excess Charges", "$0", "Difference between what Medicare pays and the amount charged by the provider, up to the limiting charge allowed by Medicare.", "$0" ], [ "Foreign Travel Emergency Rider", "$0", "After a separate Foreign Travel Emergency Rider deductible of $250, covers 80% of expenses associated with emergency medical care received outside the U.S.A. during the first 60 days of a trip with a lifetime maximum of $50,000 in covered expenses", "$250, Then 20% of charges for the first 60 Days up to the $50,000 Lifetime maximum; 100% beyond 60 Days or over $50,000 maximum" ] ] } }, "WI_HDED": { "deductible": "2870", "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$0 or Optional Part A Deductible Rider", "$1676 or $0 (Optional Rider)" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Inpatient Psychiatric Care": [ [ "Inpatient psychiatric care in participating psychiatric hospital", "190 days per lifetime", "175 additional days per lifetime", "Beyond 365 Days" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "You must meet Medicare's requirements, including a doctor's certification of terminal illness", "\tAll but very limited $0 or 100% of copayment/ $0 copayment/coinsurance for outpatient drugs and inpatient respite care", "$0 or 100% of copayment/coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0 or Optional Part B Deductible Rider or Optional Part B Copayment or Coinsurance Rider", "257 (Part B deductible) or $0 or $257 (Part B Deductible) and no more than $20 per office visit and no more than $50 per emergency room visit", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20% or Optional Part B Excess Charges Rider", "Charges in excess of Medicare approved charges or charges not paid by Medicare or $0" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0 or Optional Part B Deductible Rider or Optional Part B Copayment or Coinsurance Rider", "$257 (Part B deductible) or $0" ], [ "Remainder of Approved Amounts", "Generally 80%", "20% or Optional Part B Excess Charges Rider", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ], "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100% of charges for visits considered medically necessary by Medicare", "40 visits in addition to those paid by Medicare or Optional Additional Home Health Rider", "Beyond 40 visits per calendar year or Beyond 365 visits" ] ], "Preventative Medical Care Benefit": [ [ "Coverage for preventive health $0 care services not covered by Medicare and as determined to be medically appropriate by an attending physician", "$0", "80%", "20%" ] ] }, "Additional": { "Diabetic Equipment & Supplies": [ [ "Self-education programs and infusion pump (provided you use it for 30 days before buying it)", "Medicare generally does not cover diabetic supplies", "The full usual, customary and reasonable charge, less what Medicare paid", "Charges in excess of the full usual, customary and reasonable charge" ] ], "Licensed Skilled Nursing Facility Care": [ [ "The facility does not have to be certified by Medicare, no prior hospitalization is required and the stay does not have to meet Medicare's definition", "$0 for services beyond those covered under Part A", "Up to 30 days per admission for medically necessary care", "Charges for care beyond 30 days per admission of skilled care." ] ], "Chiropractic Services": [ [ "", "80% for manual manipulations of the spine to correct a subluxation that can be demonstrated by X-ray", "The full usual, customary and reasonable charge, less what Medicare pays for Medicare- eligible expenses", "Charges in excess of the full, usual, customary and reasonable charge" ] ], "Kidney Disease Care": [ [ "Inpatient and outpatient expenses for dialysis, transplantation or donor-related services", "80%", "Up to $30,000 per year", "Charges in excess of $30,000" ] ] }, "Riders": { "Optional Riders": [ [ "Part A Deductible", "$0", "100% of Part A Deductible", "$0" ], [ "365 Home Health Care Visits", "100% of charges for visits considered medically necessary by Medicare", "An aggregate of 365 visits per year including those covered by Medicare", "Charges for visits beyond 365 per year" ], [ "Part B Deductible", "$0", "100% of Part B Deductible", "$0" ], [ "Part B Copayment/Coinsurance", "Generally 80%, after that Part B Deductible has been met.", "Coverage of the Medicare Part B medical coinsurance, subject to a copayment or coinsurance of no more than $20 per office visit and no more than $50 per emergency room visit. If admitted, the $50 is waived and the emergency visit is covered as a Medicare Part A expense.", "$257 (Part B Deductible) and no more than $20 per office visit and no more than $50 per emergency room visit. If admitted, the $50 is waved and the emergency visit is covered as a Medicare Part A expense." ], [ "Part B Excess Charges", "$0", "Difference between what Medicare pays and the amount charged by the provider, up to the limiting charge allowed by Medicare.", "$0" ], [ "Foreign Travel Emergency Rider", "$0", "After a separate Foreign Travel Emergency Rider deductible of $250, covers 80% of expenses associated with emergency medical care received outside the U.S.A. during the first 60 days of a trip with a lifetime maximum of $50,000 in covered expenses", "$250, Then 20% of charges for the first 60 Days up to the $50,000 Lifetime maximum; 100% beyond 60 Days or over $50,000 maximum" ] ] } }, "WI_50": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$0 or Optional Part A Deductible Rider", "$1676 or $0 (Optional Rider)" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Inpatient Psychiatric Care": [ [ "Inpatient psychiatric care in participating psychiatric hospital", "190 days per lifetime", "175 additional days per lifetime", "Beyond 365 Days" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "You must meet Medicare's requirements, including a doctor's certification of terminal illness", "\tAll but very limited $0 or 100% of copayment/ $0 copayment/coinsurance for outpatient drugs and inpatient respite care", "$0 or 100% of copayment/coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0 or Optional Part B Deductible Rider or Optional Part B Copayment or Coinsurance Rider", "$257 (Part B deductible) or $0 or $257 (Part B Deductible) and no more than $20 per office visit and no more than $50 per emergency room visit", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20% or Optional Part B Excess Charges Rider", "Charges in excess of Medicare approved charges or charges not paid by Medicare or $0" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0 or Optional Part B Deductible Rider or Optional Part B Copayment or Coinsurance Rider", "$257 (Part B deductible) or $0" ], [ "Remainder of Approved Amounts", "Generally 80%", "20% or Optional Part B Excess Charges Rider", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ], "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100% of charges for visits considered medically necessary by Medicare", "40 visits in addition to those paid by Medicare or Optional Additional Home Health Rider", "Beyond 40 visits per calendar year or Beyond 365 visits" ] ], "Preventative Medical Care Benefit": [ [ "Coverage for preventive health $0 care services not covered by Medicare and as determined to be medically appropriate by an attending physician", "$0", "80%", "20%" ] ] }, "Additional": { "Diabetic Equipment & Supplies": [ [ "Self-education programs and infusion pump (provided you use it for 30 days before buying it)", "Medicare generally does not cover diabetic supplies", "The full usual, customary and reasonable charge, less what Medicare paid", "Charges in excess of the full usual, customary and reasonable charge" ] ], "Licensed Skilled Nursing Facility Care": [ [ "The facility does not have to be certified by Medicare, no prior hospitalization is required and the stay does not have to meet Medicare's definition", "$0 for services beyond those covered under Part A", "Up to 30 days per admission for medically necessary care", "Charges for care beyond 30 days per admission of skilled care." ] ], "Chiropractic Services": [ [ "", "80% for manual manipulations of the spine to correct a subluxation that can be demonstrated by X-ray", "The full usual, customary and reasonable charge, less what Medicare pays for Medicare- eligible expenses", "Charges in excess of the full, usual, customary and reasonable charge" ] ], "Kidney Disease Care": [ [ "Inpatient and outpatient expenses for dialysis, transplantation or donor-related services", "80%", "Up to $30,000 per year", "Charges in excess of $30,000" ] ] }, "Riders": { "Optional Riders": [ [ "Part A Deductible", "$0", "100% of Part A Deductible", "$0" ], [ "365 Home Health Care Visits", "100% of charges for visits considered medically necessary by Medicare", "An aggregate of 365 visits per year including those covered by Medicare", "Charges for visits beyond 365 per year" ], [ "Part B Deductible", "$0", "100% of Part B Deductible", "$0" ], [ "Part B Copayment/Coinsurance", "Generally 80%, after that Part B Deductible has been met.", "Coverage of the Medicare Part B medical coinsurance, subject to a copayment or coinsurance of no more than $20 per office visit and no more than $50 per emergency room visit. If admitted, the $50 is waived and the emergency visit is covered as a Medicare Part A expense.", "$257 (Part B Deductible) and no more than $20 per office visit and no more than $50 per emergency room visit. If admitted, the $50 is waved and the emergency visit is covered as a Medicare Part A expense." ], [ "Part B Excess Charges", "$0", "Difference between what Medicare pays and the amount charged by the provider, up to the limiting charge allowed by Medicare.", "$0" ], [ "Foreign Travel Emergency Rider", "$0", "After a separate Foreign Travel Emergency Rider deductible of $250, covers 80% of expenses associated with emergency medical care received outside the U.S.A. during the first 60 days of a trip with a lifetime maximum of $50,000 in covered expenses", "$250, Then 20% of charges for the first 60 Days up to the $50,000 Lifetime maximum; 100% beyond 60 Days or over $50,000 maximum" ] ] } }, "WI_75": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$0 or Optional Part A Deductible Rider", "$1676 or $0 (Optional Rider)" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Inpatient Psychiatric Care": [ [ "Inpatient psychiatric care in participating psychiatric hospital", "190 days per lifetime", "175 additional days per lifetime", "Beyond 365 Days" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "You must meet Medicare's requirements, including a doctor's certification of terminal illness", "\tAll but very limited $0 or 100% of copayment/ $0 copayment/coinsurance for outpatient drugs and inpatient respite care", "$0 or 100% of copayment/coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0 or Optional Part B Deductible Rider or Optional Part B Copayment or Coinsurance Rider", "$257 (Part B deductible) or $0 or $257 (Part B Deductible) and no more than $20 per office visit and no more than $50 per emergency room visit", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20% or Optional Part B Excess Charges Rider", "Charges in excess of Medicare approved charges or charges not paid by Medicare or $0" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0 or Optional Part B Deductible Rider or Optional Part B Copayment or Coinsurance Rider", "$257 (Part B deductible) or $0" ], [ "Remainder of Approved Amounts", "Generally 80%", "20% or Optional Part B Excess Charges Rider", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ], "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100% of charges for visits considered medically necessary by Medicare", "40 visits in addition to those paid by Medicare or Optional Additional Home Health Rider", "Beyond 40 visits per calendar year or Beyond 365 visits" ] ], "Preventative Medical Care Benefit": [ [ "Coverage for preventive health $0 care services not covered by Medicare and as determined to be medically appropriate by an attending physician", "$0", "80%", "20%" ] ] }, "Additional": { "Diabetic Equipment & Supplies": [ [ "Self-education programs and infusion pump (provided you use it for 30 days before buying it)", "Medicare generally does not cover diabetic supplies", "The full usual, customary and reasonable charge, less what Medicare paid", "Charges in excess of the full usual, customary and reasonable charge" ] ], "Licensed Skilled Nursing Facility Care": [ [ "The facility does not have to be certified by Medicare, no prior hospitalization is required and the stay does not have to meet Medicare's definition", "$0 for services beyond those covered under Part A", "Up to 30 days per admission for medically necessary care", "Charges for care beyond 30 days per admission of skilled care." ] ], "Chiropractic Services": [ [ "", "80% for manual manipulations of the spine to correct a subluxation that can be demonstrated by X-ray", "The full usual, customary and reasonable charge, less what Medicare pays for Medicare- eligible expenses", "Charges in excess of the full, usual, customary and reasonable charge" ] ], "Kidney Disease Care": [ [ "Inpatient and outpatient expenses for dialysis, transplantation or donor-related services", "80%", "Up to $30,000 per year", "Charges in excess of $30,000" ] ] }, "Riders": { "Optional Riders": [ [ "Part A Deductible", "$0", "100% of Part A Deductible", "$0" ], [ "365 Home Health Care Visits", "100% of charges for visits considered medically necessary by Medicare", "An aggregate of 365 visits per year including those covered by Medicare", "Charges for visits beyond 365 per year" ], [ "Part B Deductible", "$0", "100% of Part B Deductible", "$0" ], [ "Part B Copayment/Coinsurance", "Generally 80%, after that Part B Deductible has been met.", "Coverage of the Medicare Part B medical coinsurance, subject to a copayment or coinsurance of no more than $20 per office visit and no more than $50 per emergency room visit. If admitted, the $50 is waived and the emergency visit is covered as a Medicare Part A expense.", "$257 (Part B Deductible) and no more than $20 per office visit and no more than $50 per emergency room visit. If admitted, the $50 is waved and the emergency visit is covered as a Medicare Part A expense." ], [ "Part B Excess Charges", "$0", "Difference between what Medicare pays and the amount charged by the provider, up to the limiting charge allowed by Medicare.", "$0" ], [ "Foreign Travel Emergency Rider", "$0", "After a separate Foreign Travel Emergency Rider deductible of $250, covers 80% of expenses associated with emergency medical care received outside the U.S.A. during the first 60 days of a trip with a lifetime maximum of $50,000 in covered expenses", "$250, Then 20% of charges for the first 60 Days up to the $50,000 Lifetime maximum; 100% beyond 60 Days or over $50,000 maximum" ] ] } }, "MN_BASIC": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All but $1676 Deductible", "$0 or $1676 (Optional Part A Deductible Rider)", "$1676 or $0 (Optional Rider)" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "Beyond the Additional 150 Days", "$0", "100% of Medicare Eligible Expenses", "$0" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "$209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "3 Pints", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "", "All but very limited coinsurance for inpatient respite care.", "Remaining costs", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Medicare Approved Amounts", "$0", "$0 or $257 (Optional Part B Deductible Rider)", "$257 or $0 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ], [ "Part B Excess Charge (above Medicare Approved Amounts)", "$0", "$0 or 100% (Optional Part B Excess Rider)", "All Costs or $0 (Part B Excess Rider)" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0 or $257 (Optional Part B Rider)", "$257 or $0 (Optional Part B Rider)" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "100% of any remaining Medicare eligible expenses", "$0" ] ] }, "Parts A & B": { "Home Health Care & Medicare Approved Services": [ [ "Medically Necessary Skilled Care Services and Medical Supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "First $257 of Medicare Approved Amounts", "$257", "$0 or $257 (Optional Part B Rider)", "$257 or $0 (Part B Rider)" ], [ "Remainder of Medicare Approved Amounts", "80%", "20%", "$0" ] ], "Emergency Foreign Travel Care": [ [ "Only the services listed above while traveling outside of the United States", "$0", "80% of covered expenses", "Remaining Costs" ] ], "Preventative Medical Care Benefit": [ [ "First $120 each calendar year", "$0", "$0 or $120 (Preventative Care Rider)", "All Costs or $0 (Preventative Care Rider)" ], [ "Additional Charges", "$0", "$0", "All Costs" ] ] } }, "MN_EXTB": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All but $1676 Deductible", "$1676 (Part A Deductible)", "$0" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "Beyond the Additional 150 Days", "$0", "100% of Medicare Eligible Expenses", "$0" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "$209.50 a Day", "$0" ], [ "101st Day and After", "$0", "80% of covered expenses up to 120 days per calendar year", "Remaining Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "3 Pints", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "", "All but very limited coinsurance for inpatient respite care.", "Medicare copayment/coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Medicare Approved Amounts", "$0", "$257 (Part B Deductible)", "$0" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ], [ "Part B Excess Charge (above Medicare Approved Amounts)", "$0", "100%", "$0" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$257", "$0" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ] }, "Parts A & B": { "Home Health Care & Medicare Approved Services": [ [ "Medically Necessary Skilled Care Services and Medical Supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "First $257 of Medicare Approved Amounts", "$0", "$257 (Part B Deductible)", "$0" ], [ "Remainder of Medicare Approved Amounts", "80%", "20%", "$0" ] ], "Emergency Foreign Travel Care": [ [ "Only the services listed above while traveling outside of the United States", "$0", "80% of covered expenses", "Remaining Costs" ] ], "Preventative Medical Care Benefit": [ [ "First $120 each calendar year", "$0", "$120", "$0" ], [ "Additional Charges", "$0", "$0", "All Costs" ] ] } }, "MN_HDED": { "deductible": "2870", "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$1676 (Part A Deductible) ", "$0" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "$0" ], [ "101st Day and After", "$0", "80%", "20%" ], [ "121st Day and After", "$0", "$0", "All Costs" ] ], "Inpatient Psychiatric Care": [ [ "Inpatient psychiatric care in participating psychiatric hospital", "190 days per lifetime", "175 additional days per lifetime", "Beyond 365 Days" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "You must meet Medicare's requirements, including a doctor's certification of terminal illness", "\tAll but very limited copayment/coinsurance for outpatient drugs and inpatient respite care", "Medicare copayment/coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0", "$257 (Part B deductible)" ], [ "Remainder of Approved Amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ], "Home Health Care": [ [ "Medically necessary skilled care services and medical supplies", "100%", "$0", "$0" ], [ "Durable medical equipment First $257 of Medicare-approved amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ " Remainder of medicare approved amounts", "80%", "20%", "$0" ] ] }, "Additional": { "Preventative Medical Care Benefit": [ [ "Up to $120 each calendar year for routine annual medical exam, including diagnostic X-rays and laboratory services", "$0", "$120", "Balance" ], [ "Immunizations not otherwise covered under Part D and routine screenings for cancer", "$0", "100%", "$0" ] ], "Foreign Travel": [ [ "Medically necessary emergency care services beginning during travel outside the USA", "$0", "100% of covered services", "Expenses not paid by Medicare or the policy" ] ] } }, "MN_HDED2": { "deductible": "2870", "Part A": { "Hospitalization": [ [ "First 60 Days", "All But $1676", "$1676 (Part A Deductible) ", "$0" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Eligible Expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "Up to $209.50 a Day", "$0" ], [ "101st Day and After", "$0", "80%", "20%" ], [ "121st Day and After", "$0", "$0", "All Costs" ] ], "Inpatient Psychiatric Care": [ [ "Inpatient psychiatric care in participating psychiatric hospital", "190 days per lifetime", "175 additional days per lifetime", "Beyond 365 Days" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "You must meet Medicare's requirements, including a doctor's certification of terminal illness", "\tAll but very limited copayment/coinsurance for outpatient drugs and inpatient respite care", "Medicare copayment/coinsurance", "$0" ] ] }, "Additional": { "Preventative Medical Care Benefit": [ [ "Up to $120 each calendar year for routine annual medical exam, including diagnostic X-rays and laboratory services", "$0", "$120", "Balance" ], [ "Immunizations not otherwise covered under Part D and routine screenings for cancer", "$0", "100%", "$0" ] ], "Foreign Travel": [ [ "Medically necessary emergency care services beginning during travel outside the USA", "$0", "100% of covered services", "Expenses not paid by Medicare or the policy" ] ] } }, "MN_PBCO": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All but $1676 Deductible", "$1676", "$0" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "Beyond the Additional 150 Days", "$0", "100% of Medicare Eligible Expenses", "$0" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "$209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "3 Pints", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "", "All but very limited coinsurance for inpatient respite care.", "Remaining costs", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Medicare Approved Amounts", "$0", "$0", "$257" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ], [ "Part B Excess Charge (above Medicare Approved Amounts)", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0", "$257" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "100% of any remaining Medicare eligible expenses", "$0" ] ] }, "Parts A & B": { "Home Health Care & Medicare Approved Services": [ [ "Medically Necessary Skilled Care Services and Medical Supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "First $257 of Medicare Approved Amounts", "$257", "$0", "$257" ], [ "Remainder of Medicare Approved Amounts", "80%", "20%", "$0" ] ], "Emergency Foreign Travel Care": [ [ "Only the services listed above while traveling outside of the United States", "$0", "80% of covered expenses", "Remaining Costs" ] ], "Preventative Medical Care Benefit": [ [ "First $120 each calendar year", "$0", "$0", "All Costs" ], [ "Additional Charges", "$0", "$0", "All Costs" ] ] } }, "MN_XBAS": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All but $1676 Deductible", "$0 or $1676 (Optional Part A Deductible Rider)", "$1676 or $0 (Optional Rider)" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "Beyond the Additional 150 Days", "$0", "100% of Medicare Eligible Expenses", "$0" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "$209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "3 Pints", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "", "All but very limited coinsurance for inpatient respite care.", "Remaining costs", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Medicare Approved Amounts", "$0", "$0 or $257 (Optional Part B Deductible Rider)", "$257 or $0 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ], [ "Part B Excess Charge (above Medicare Approved Amounts)", "$0", "$0 or 100% (Optional Part B Excess Rider)", "All Costs or $0 (Part B Excess Rider)" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0 or $257 (Optional Part B Rider)", "$257 or $0 (Optional Part B Rider)" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "100% of any remaining Medicare eligible expenses", "$0" ] ] }, "Parts A & B": { "Home Health Care & Medicare Approved Services": [ [ "Medically Necessary Skilled Care Services and Medical Supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "First $257 of Medicare Approved Amounts", "$257", "$0 or $257 (Optional Part B Rider)", "$257 or $0 (Part B Rider)" ], [ "Remainder of Medicare Approved Amounts", "80%", "20%", "$0" ] ], "Emergency Foreign Travel Care": [ [ "Only the services listed above while traveling outside of the United States", "$0", "80% of covered expenses", "Remaining Costs" ] ], "Preventative Medical Care Benefit": [ [ "First $120 each calendar year", "$0", "$0 or $120 (Preventative Care Rider)", "All Costs or $0 (Preventative Care Rider)" ], [ "Additional Charges", "$0", "$0", "All Costs" ] ] } }, "MN_XBAS2": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All but $1676 Deductible", "$1676 (Part A Deductible)", "$0" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "Beyond the Additional 150 Days", "$0", "100% of Medicare Eligible Expenses", "$0" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "$209.50 a Day", "$0" ], [ "101st Day and After", "$0", "80% of covered expenses up to 120 days per calendar year", "Remaining Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "3 Pints", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "", "All but very limited coinsurance for inpatient respite care.", "Medicare copayment/coinsurance", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Medicare Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ], [ "Part B Excess Charge (above Medicare Approved Amounts)", "$0", "100%", "$0" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "$0", "$0" ] ] }, "Parts A & B": { "Home Health Care & Medicare Approved Services": [ [ "Medically Necessary Skilled Care Services and Medical Supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "First $257 of Medicare Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Medicare Approved Amounts", "80%", "20%", "$0" ] ], "Emergency Foreign Travel Care": [ [ "Only the services listed above while traveling outside of the United States", "$0", "80% of covered expenses", "Remaining Costs" ] ], "Preventative Medical Care Benefit": [ [ "First $120 each calendar year", "$0", "$120", "$0" ], [ "Additional Charges", "$0", "$0", "All Costs" ] ] } }, "MN_50": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All but $1676 Deductible", "$0 or $1676 (Optional Part A Deductible Rider)", "$1676 or $0 (Optional Rider)" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "Beyond the Additional 150 Days", "$0", "100% of Medicare Eligible Expenses", "$0" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "$209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "3 Pints", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "", "All but very limited coinsurance for inpatient respite care.", "Remaining costs", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Medicare Approved Amounts", "$0", "$0 or $257 (Optional Part B Deductible Rider)", "$257 or $0 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ], [ "Part B Excess Charge (above Medicare Approved Amounts)", "$0", "$0 or 100% (Optional Part B Excess Rider)", "All Costs or $0 (Part B Excess Rider)" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0 or $257 (Optional Part B Rider)", "$257 or $0 (Optional Part B Rider)" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "100% of any remaining Medicare eligible expenses", "$0" ] ] }, "Parts A & B": { "Home Health Care & Medicare Approved Services": [ [ "Medically Necessary Skilled Care Services and Medical Supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "First $257 of Medicare Approved Amounts", "$257", "$0 or $257 (Optional Part B Rider)", "$257 or $0 (Part B Rider)" ], [ "Remainder of Medicare Approved Amounts", "80%", "20%", "$0" ] ], "Emergency Foreign Travel Care": [ [ "Only the services listed above while traveling outside of the United States", "$0", "80% of covered expenses", "Remaining Costs" ] ], "Preventative Medical Care Benefit": [ [ "First $120 each calendar year", "$0", "$0 or $120 (Preventative Care Rider)", "All Costs or $0 (Preventative Care Rider)" ], [ "Additional Charges", "$0", "$0", "All Costs" ] ] } }, "MN_A50": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All but $1676 Deductible", "$0 or $1676 (Optional Part A Deductible Rider)", "$1676 or $0 (Optional Rider)" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "Beyond the Additional 150 Days", "$0", "100% of Medicare Eligible Expenses", "$0" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "$209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "3 Pints", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "", "All but very limited coinsurance for inpatient respite care.", "Remaining costs", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Medicare Approved Amounts", "$0", "$0 or $257 (Optional Part B Deductible Rider)", "$257 or $0 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ], [ "Part B Excess Charge (above Medicare Approved Amounts)", "$0", "$0 or 100% (Optional Part B Excess Rider)", "All Costs or $0 (Part B Excess Rider)" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0 or $257 (Optional Part B Rider)", "$257 or $0 (Optional Part B Rider)" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "100% of any remaining Medicare eligible expenses", "$0" ] ] }, "Parts A & B": { "Home Health Care & Medicare Approved Services": [ [ "Medically Necessary Skilled Care Services and Medical Supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "First $257 of Medicare Approved Amounts", "$257", "$0 or $257 (Optional Part B Rider)", "$257 or $0 (Part B Rider)" ], [ "Remainder of Medicare Approved Amounts", "80%", "20%", "$0" ] ], "Emergency Foreign Travel Care": [ [ "Only the services listed above while traveling outside of the United States", "$0", "80% of covered expenses", "Remaining Costs" ] ], "Preventative Medical Care Benefit": [ [ "First $120 each calendar year", "$0", "$0 or $120 (Preventative Care Rider)", "All Costs or $0 (Preventative Care Rider)" ], [ "Additional Charges", "$0", "$0", "All Costs" ] ] } }, "MN_75": { "Part A": { "Hospitalization": [ [ "First 60 Days", "All but $1676 Deductible", "$0 or $1676 (Optional Part A Deductible Rider)", "$1676 or $0 (Optional Rider)" ], [ "61st Through 90th Day", "All But $419 a Day", "$419 a Day", "$0" ], [ "91st Day and After (60 Reserve Days)", "All But $838 a Day", "$838 a Day", "$0" ], [ "Beyond the Additional 150 Days", "$0", "100% of Medicare Eligible Expenses", "$0" ] ], "Skilled Nursing Facility Care": [ [ "First 20 Days", "All Approved Amounts", "$0", "$0" ], [ "21st Through 100th Day", "All But $209.50 a Day", "$209.50 a Day", "$0" ], [ "101st Day and After", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First Three Pints", "$0", "3 Pints", "$0" ], [ "Additional Amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "", "All but very limited coinsurance for inpatient respite care.", "Remaining costs", "$0" ] ] }, "Part B": { "Medical Expenses": [ [ "1st $257 of Medicare Approved Amounts", "$0", "$0 or $257 (Optional Part B Deductible Rider)", "$257 or $0 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ], [ "Part B Excess Charge (above Medicare Approved Amounts)", "$0", "$0 or 100% (Optional Part B Excess Rider)", "All Costs or $0 (Part B Excess Rider)" ] ], "Blood": [ [ "First Three Pints", "$0", "100%", "$0" ], [ "Next $257 of Approved Amounts", "$0", "$0 or $257 (Optional Part B Rider)", "$257 or $0 (Optional Part B Rider)" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Tests for Diagnostic Services", "100%", "100% of any remaining Medicare eligible expenses", "$0" ] ] }, "Parts A & B": { "Home Health Care & Medicare Approved Services": [ [ "Medically Necessary Skilled Care Services and Medical Supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "First $257 of Medicare Approved Amounts", "$257", "$0 or $257 (Optional Part B Rider)", "$257 or $0 (Part B Rider)" ], [ "Remainder of Medicare Approved Amounts", "80%", "20%", "$0" ] ], "Emergency Foreign Travel Care": [ [ "Only the services listed above while traveling outside of the United States", "$0", "80% of covered expenses", "Remaining Costs" ] ], "Preventative Medical Care Benefit": [ [ "First $120 each calendar year", "$0", "$0 or $120 (Preventative Care Rider)", "All Costs or $0 (Preventative Care Rider)" ], [ "Additional Charges", "$0", "$0", "All Costs" ] ] } }, "MA_CORE": { "Part A": { "Hospitalization": [ [ "First 60 days of a Benefit Period", "All but $1676", "$0", "$1676 (Part A Deductible)" ], [ "61st through 90th day of a Benefit Period", "All but $419 a day", "$419 a day", "$0" ], [ "91st day and after a Benefit Period (60 Reserve Days)", "All but $838 a day", "$838 a day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100%", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Licensed Mental Hospital": [ [ "First 60 days of a Benefit Period", "All but $1676", "$0", "$1676 (Part A Deductible)" ], [ "61st through 90th day of a Benefit Period", "$0", "100% of Medicare eligible expenses", "$0" ], [ "91st day and after of a Benefit Period (60 Reserve Days)", "$0", "100% of Medicare eligible expenses", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Medicare eligible expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Licensed Mental Hospital Stays": [ [ "First 60 days per calendar year unless days covered by Medicare or already covered by the Plan in that calendar year for other mental disorders", "$0", "All but $1676", "$1676 (Part A Deductible)" ], [ "61st through 120th day of a Benefit Period", "$0", "100% of Medicare eligible expenses", "$0" ], [ "Days after 60 days per calendar year less days covered by Medicare or plan in that calendar year", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 days", "All Approved Amounts", "$0", "$0" ], [ "21st through 100th day", "All but $209.50 a day", "$0", "$209.50" ], [ "101st day and after", "$0", "$0", "All Costs" ] ], "Hospice Care": [ [ "Hospice Care available as long as your doctor certifies you are terminally ill and you elect to receive these services", "All but very limited coinsurance for outpatient drugs and inpatient respite care", "Coinsurance", "$0" ] ] }, "Part B": { "Medical expenses in or out of the Hospital and outpatient Hospital treatment": [ [ "First $257 of Medicare Approved amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Medicare Approved amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Outpatient treatment for biologically-based mental disorders": [ [ "First $257 of Medicare Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "50%", "50%", "$0" ] ], "Outpatient treatment for other mental health disorders": [ [ "First 24 visits per calendar year", "$0", "100%", "$0" ], [ "Visits 25 and after", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First three pints", "$0", "100%", "$0" ], [ "Next $257 of Medicare Approved amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Medicare Approved amounts", "80%", "20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Blood Tests for diagnostic services", "100%", "$0", "$0" ] ], "Special Medical Formulas Mandated by Law (Covered by Medicare)": [ [ "First $257 of Medicare Approved amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Medicare Approved amounts", "80%", "20%", "$0" ] ], "Special Medical Formulas Mandated by Law (Not covered by Medicare)": [ [ "", "$0", "All allowed charges", "Remaining costs" ] ] }, "Parts A & B": { "Home Health Care & Medicare Approved Services": [ [ "Medically Necessary skilled care services and medical supplies", "100%", "$0", "$209.50" ] ], "Durable Medical Equipment": [ [ "First $257 of Medicare Approved amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Medicare Approved amounts", "80%", "20%", "$0" ] ] }, "Other": { "Plan Details": [ [ "Outpatient Prescription Drugs Not Covered by Medicare", "$0", "$0", "All Costs" ], [ "Fitness Program Not Covered by Medicare", "$0", "$150", "All charges after $150" ] ] } }, "MA_SUPP1": { "Part A": { "Hospitalization": [ [ "First 60 days of a Benefit Period", "All but $1676", "$1676 (Part A Deductible)", "$0" ], [ "61st through 90th day of a Benefit Period", "All but $419 a day", "$419 a day", "$0" ], [ "91st day and after a Benefit Period (60 Reserve Days)", "All but $838 a day", "$838 a day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100%", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Licensed Mental Hospital": [ [ "First 60 days of a Benefit Period", "All but $1676", "100% of Medicare eligible expenses", "$0" ], [ "61st through 90th day of a Benefit Period", "$0", "100% of Medicare eligible expenses", "$0" ], [ "91st day and after of a Benefit Period (60 Reserve Days)", "$0", "100% of Medicare eligible expenses", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Medicare eligible expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Licensed Mental Hospital Stays": [ [ "First 60 days per calendar year unless days covered by Medicare or already covered by the Plan in that calendar year for other mental disorders", "$0", "100% of Medicare eligible expenses", "$0" ], [ "61st through 120th day of a Benefit Period", "$0", "100% of Medicare eligible expenses", "$0" ], [ "Days after 60 days per calendar year less days covered by Medicare or plan in that calendar year", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 days", "All Approved Amounts", "$0", "$0" ], [ "21st through 100th day", "All but $209.50 a day", "$209.50 a day", "$0" ], [ "101st day through 365th day of a Benefit Period", "$0", "$10", "Balance" ], [ "Beyond the 365th day of a Benefit Period", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First three pints", "$0", "Three pints", "$0" ], [ "Additional amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "Hospice Care available as long as your doctor certifies you are terminally ill and you elect to receive these services", "All but very limited coinsurance for outpatient drugs and inpatient respite care", "Coinsurance", "$0" ] ] }, "Part B": { "Medical expenses in or out of the Hospital and outpatient Hospital treatment": [ [ "First $257 of Medicare Approved amounts", "$0", "$257 (Part B Deductible)", "$0" ], [ "Remainder of Medicare Approved amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Outpatient treatment for biologically-based mental disorders": [ [ "First $257 of Medicare Approved Amounts", "$0", "$257 (Part B Deductible)", "$0" ], [ "Remainder of Approved Amounts", "50%", "50%", "$0" ] ], "Outpatient treatment for other mental health disorders": [ [ "First 24 visits per calendar year", "$0", "100%", "$0" ], [ "Visits 25 and after", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First three pints", "$0", "100%", "$0" ], [ "Next $257 of Medicare Approved amounts", "$0", "$257 (Part B Deductible)", "$0" ], [ "Remainder of Medicare Approved amounts", "80%", "20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Blood Tests for diagnostic services", "100%", "$0", "$0" ] ], "Special Medical Formulas Mandated by Law (Covered by Medicare)": [ [ "First $257 of Medicare Approved amounts", "$0", "$257 (Part B Deductible)", "$0" ], [ "Remainder of Medicare Approved amounts", "80%", "20%", "$0" ] ], "Special Medical Formulas Mandated by Law (Not covered by Medicare)": [ [ "", "$0", "All allowed charges", "Remaining costs" ] ] }, "Parts A & B": { "Home Health Care & Medicare Approved Services": [ [ "Medically Necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "First $257 of Medicare Approved amounts", "$0", "$257 (Part B Deductible)", "$0" ], [ "Remainder of Medicare Approved amounts", "80%", "20%", "$0" ] ] }, "Other": { "Plan Details": [ [ "Only the services listed in this plan while traveling outside the United States", "$0", "Remainder of charges (including portion normally paid by Medicare)", "$0" ], [ "Outpatient Prescription Drugs Not Covered by Medicare", "$0", "$0", "All Costs" ], [ "Fitness Program Not Covered by Medicare", "$0", "$150", "All charges after $150" ] ] } }, "MA_SUPP1A": { "Part A": { "Hospitalization": [ [ "First 60 days of a Benefit Period", "All but $1676", "$1676 (Part A Deductible)", "$0" ], [ "61st through 90th day of a Benefit Period", "All but $419 a day", "$419 a day", "$0" ], [ "91st day and after a Benefit Period (60 Reserve Days)", "All but $838 a day", "$838 a day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100%", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Licensed Mental Hospital": [ [ "First 60 days of a Benefit Period", "$0", "100% of Medicare eligible expenses", "$0" ], [ "61st through 90th day of a Benefit Period", "$0", "100% of Medicare eligible expenses", "$0" ], [ "91st day and after of a Benefit Period (60 Reserve Days)", "$0", "100% of Medicare eligible expenses", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Medicare eligible expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Licensed Mental Hospital Stays": [ [ "First 60 days per calendar year unless days covered by Medicare or already covered by the Plan in that calendar year for other mental disorders", "$0", "100% of Medicare eligible expenses", "$0" ], [ "61st through 120th day of a Benefit Period", "$0", "100% of Medicare eligible expenses", "$0" ], [ "Days after 60 days per calendar year less days covered by Medicare or plan in that calendar year", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 days", "All Approved Amounts", "$0", "$0" ], [ "21st through 100th day", "All but $209.50 a day", "$209.50 a day", "$0" ], [ "101st day through 365th day of a Benefit Period", "$0", "$10 a day", "Balance" ], [ "Beyond the 365th day of a Benefit Period", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First three pints", "$0", "Three pints", "$0" ], [ "Additional amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "Hospice Care available as long as your doctor certifies you are terminally ill and you elect to receive these services", "All but very limited coinsurance for outpatient drugs and inpatient respite care", "Coinsurance", "$0" ] ] }, "Part B": { "Medical expenses in or out of the Hospital and outpatient Hospital treatment": [ [ "First $257 of Medicare Approved amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Medicare Approved amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Outpatient treatment for biologically-based mental disorders": [ [ "First $257 of Medicare Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ] ], "Outpatient treatment for other mental health disorders": [ [ "First 24 visits per calendar year", "$0", "100%", "$0" ], [ "Visits 25 and after", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First three pints", "$0", "All Costs", "$0" ], [ "Next $257 of Medicare Approved amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Medicare Approved amounts", "80%", "20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Blood Tests for diagnostic services", "100%", "$0", "$0" ] ], "Special Medical Formulas Mandated by Law (Covered by Medicare)": [ [ "First $257 of Medicare Approved amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Medicare Approved amounts", "80%", "20%", "$0" ] ], "Special Medical Formulas Mandated by Law (Not covered by Medicare)": [ [ "", "$0", "All allowed charges", "Remaining costs" ] ] }, "Parts A & B": { "Home Health Care & Medicare Approved Services": [ [ "Medically Necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "First $257 of Medicare Approved amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Medicare Approved amounts", "80%", "20%", "$0" ] ] }, "Other": { "Plan Details": [ [ "Only the services listed in this plan while traveling outside the United States", "$0", "Remainder of charges (including portion normally paid by Medicare)", "$0" ], [ "Outpatient Prescription Drugs Not Covered by Medicare", "$0", "$0", "All Costs" ], [ "Fitness Program Not Covered by Medicare", "$0", "$150", "All charges after $150" ] ] } }, "MA_SUPP2": { "Part A": { "Hospitalization": [ [ "First 60 days of a Benefit Period", "All but $1676", "$1676 (Part A Deductible)", "$0" ], [ "61st through 90th day of a Benefit Period", "All but $419 a day", "$419 a day", "$0" ], [ "91st day and after a Benefit Period (60 Reserve Days)", "All but $838 a day", "$838 a day", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100%", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Licensed Mental Hospital": [ [ "First 60 days of a Benefit Period", "$0", "100% of Medicare eligible expenses", "$0" ], [ "61st through 90th day of a Benefit Period", "$0", "100% of Medicare eligible expenses", "$0" ], [ "91st day and after of a Benefit Period (60 Reserve Days)", "$0", "100% of Medicare eligible expenses", "$0" ], [ "After Reserve (Additional 365 Days)", "$0", "100% of Medicare eligible expenses", "$0" ], [ "Beyond the Additional 365 Days", "$0", "$0", "All Costs" ] ], "Licensed Mental Hospital Stays": [ [ "First 60 days per calendar year unless days covered by Medicare or already covered by the Plan in that calendar year for other mental disorders", "$0", "100% of Medicare eligible expenses", "$0" ], [ "61st through 120th day of a Benefit Period", "$0", "100% of Medicare eligible expenses", "$0" ], [ "Days after 60 days per calendar year less days covered by Medicare or plan in that calendar year", "$0", "$0", "All Costs" ] ], "Skilled Nursing Facility Care": [ [ "First 20 days", "All Approved Amounts", "$0", "$0" ], [ "21st through 100th day", "All but $209.50 a day", "$209.50 a day", "$0" ], [ "101st day through 365th day of a Benefit Period", "$0", "$10 a day", "Balance" ], [ "Beyond the 365th day of a Benefit Period", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First three pints", "$0", "Three pints", "$0" ], [ "Additional amounts", "100%", "$0", "$0" ] ], "Hospice Care": [ [ "Hospice Care available as long as your doctor certifies you are terminally ill and you elect to receive these services", "All but very limited coinsurance for outpatient drugs and inpatient respite care", "Coinsurance", "$0" ] ] }, "Part B": { "Medical expenses in or out of the Hospital and outpatient Hospital treatment": [ [ "First $257 of Medicare Approved amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Medicare Approved amounts", "Generally 80%", "Generally 20%", "$0" ] ], "Outpatient treatment for biologically-based mental disorders": [ [ "First $257 of Medicare Approved Amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Approved Amounts", "80%", "20%", "$0" ] ], "Outpatient treatment for other mental health disorders": [ [ "First 24 visits per calendar year", "$0", "100%", "$0" ], [ "Visits 25 and after", "$0", "$0", "All Costs" ] ], "Blood": [ [ "First three pints", "$0", "All Costs", "$0" ], [ "Next $257 of Medicare Approved amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Medicare Approved amounts", "80%", "20%", "$0" ] ], "Clinical Laboratory Services": [ [ "Blood Tests for diagnostic services", "100%", "$0", "$0" ] ], "Special Medical Formulas Mandated by Law (Covered by Medicare)": [ [ "First $257 of Medicare Approved amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Medicare Approved amounts", "80%", "20%", "$0" ] ], "Special Medical Formulas Mandated by Law (Not covered by Medicare)": [ [ "", "$0", "All allowed charges", "Remaining costs" ] ] }, "Parts A & B": { "Home Health Care & Medicare Approved Services": [ [ "Medically Necessary skilled care services and medical supplies", "100%", "$0", "$0" ] ], "Durable Medical Equipment": [ [ "First $257 of Medicare Approved amounts", "$0", "$0", "$257 (Part B Deductible)" ], [ "Remainder of Medicare Approved amounts", "80%", "20%", "$0" ] ] }, "Other": { "Plan Details": [ [ "Only the services listed in this plan while traveling outside the United States", "$0", "Remainder of charges (including portion normally paid by Medicare)", "$0" ], [ "Outpatient Prescription Drugs Not Covered by Medicare", "$0", "$0", "All Costs" ], [ "Fitness Program Not Covered by Medicare", "$0", "$150", "All charges after $150" ] ] } } } }