IMPORTANT INFORMATION

Original Medicare

2012
Senior Preferred Value

Premium and Other Important Information

You pay the Medicare Part B premium of $115.40 each month. (This is the 2011 premium and it may change 1/1/2012.)

Most people will pay the standard monthly Part B premium. However, starting January 1, 2007, some people are required to pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information on Part B premiums based on income, call Social Security at (800) 772-1213. TTY users should call (800) 325-0778.

You pay $0 each month for Senior Preferred Value benefits.

You pay the Medicare Part B premium of  $115.40 each month. (This is the 2011 premium and it may change 1/1/2012). 

There is a $3,400.00 maximum out-of-pocket limit every year for Medicare covered services when received in-network only.

Doctor and Hospital Choice

(For more information, see Emergency and Urgently Needed Care

You may go to any doctor, specialist or hospital that accepts Medicare.

You must go to network doctors, specialists, and hospitals. You do NOT need a referral to go to network doctors, specialists, and hospitals.

A separate doctor office visit copayment may apply for certain services.

INPATIENT CARE

Inpatient Hospital Care

You pay for each benefit period (3):

• Days 1–60: an initial deductible of $1,132.

• Days 61–90: $283 each day.

• Days 91–150: $566 each lifetime reserve day

(These are the 2011 amounts and they may change 1/1/2012.)

Please call 1-800-MEDICARE
(1-800-633-4227) for information about lifetime reserve days (4).

If you receive inpatient care at a non-plan hospital and choose not to return to the network after your emergency condition is stabilized, you may be responsible for payment.

There is a copay of $200 per day for days 1-17 for inpatient hospital services received at a network hospital.

You are covered for unlimited days each benefit period based on medical necessity.

Inpatient Mental Health Care

You pay the same deductible and copayments as inpatient hospital care (above) except Medicare beneficiaries may only receive 190 days in a Psychiatric Hospital in a lifetime.

There is a $500.00 copayment for services received at a network hospital.

There is no copayment for additional days received at a network hospital based on medical necessity.

Skilled Nursing Facility

Covered services include, but are not limited to, the following:

• Semiprivate room (or a private room if medically necessary).

• Meals, including special diets.

• Regular nursing services.

• Physical therapy, occupational therapy, and speech therapy.

• Drugs (This includes substances that are naturally present in the body, such as blood clotting factors).

• Blood - including storage and administration.

• Medical and surgical supplies.

• Laboratory tests.

• X-rays and other radiology services.

• Use of appliances such as wheelchairs.

• Physician services.

You pay for each benefit period (3), following at least a 3-day covered hospital stay:

• Days 1–20: $0 for each day.

• Days 21–100: $141.50 for each day.

(This is the 2011 amount and it may change 1/1/2012).

There is a combined limit (Skilled Nursing Facility and Swing Bed) of 100 days for each benefit period. (3)

You pay:

• 10% of the cost each day for days 1–20.

• 0% of the cost each day for days 21–100.

No prior hospital stay is required.

There is a combined limit (Skilled Nursing Facility and Swing Bed) of 100 days for each benefit period based on medical necessity and skilled nursing needs.

Prior Authorization is required.

Swing Bed

Facility charges and costs associated with an approved swing bed stay when meeting the following criteria:

• Your physician must certify your stay as medically necessary and daily skilled needs are identified;

• You must be confined and receive treatment for which you were hospitalized;

• Intensity and frequency of services requires 24-hour nursing intervention;

• Frequent or daily physician monitoring is needed;

• Services will likely be for a short term period and may not exceed seven days; and

• There is likely no further need for skilled nursing services post discharge.

You pay for each benefit period (3), following at least a 3-day covered hospital stay:

• Days 1–20: $0 for each day.

• Days 21–100: $141.50 for each day.

(This is the 2011 amount and it may change 1/1/2012).

There is a combined limit (Skilled Nursing Facility and Swing Bed) of 100 days for each benefit period. (3)

You pay:

• 10% of the cost each day for days 1–20.

• 0% of the cost each day for days 21–100.

No prior hospital stay is required.

There is a combined limit (Skilled Nursing Facility and Swing Bed) of 100 days for each benefit period based on medical necessity and skilled nursing needs.

Prior Authorization is required.

Home Health Care

(Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.)

There is no copayment for all covered home health visits.

There is no copayment for covered home health visits.

Hospice Care

You pay part of the cost for outpatient drugs and inpatient respite care.

You must receive care from a Medicare-certified hospice.

When you enroll in a Medicare certified Hospice program, your hospice services are paid for by Medicare, not our Plan.

You pay $35 for the consultation service.

DOCTOR SERVICES/ OUTPATIENT CARE

Doctor Office Visits

You pay 20% of Medicare-approved amounts. (1)(2)

You pay $35 for each primary care physician office visit for covered services.

You pay $35 for each specialist visit for covered services.

Chiropractic Services

You pay 20% of Medicare-approved amounts. (1)(2)

You are covered for manual manipulation of the spine to correct subluxation, provided by chiropractors or other qualified providers.

You pay 100% for routine care.

You pay $15 for each covered visit.

You pay 10% of the cost for each lab and x-ray.

Coverage does not include maintenance therapy.

Podiatry Services

You pay 20% of Medicare-approved amounts. (1)(2)

You are covered for medically necessary foot care, including care for medical conditions affecting the lower limbs.

You pay 100% for routine care.

You pay $35 for each covered visit (medically necessary foot care).

Outpatient Mental Health Care

(Including partial hospitalization services).

You pay 45% of Medicare-approved amounts with the exception of certain situations and services for which you pay 20% of approved charges. (1)(2)

(This is the 2011 coinsurance and it may change 1/1/2012.)

For covered Mental Health services, you pay $35 for each individual/group therapy visit.

There is no copayment for covered partial hospitalization services.

Coverage does not include maintenance or activity therapy.

Outpatient Substance Abuse Services

You pay 45% of Medicare-approved amounts with the exception of certain situations and services for which you pay 20% of approved charges. (1)(2)

(This is the 2011 coinsurance and it may change 1/1/2012.)

For covered services you pay $35 for each individual/group visit.

Outpatient Services/ Surgery

You pay 20% of Medicare-approved amounts for the doctor. (1)(2)

You pay 20% of outpatient facility charges. (1)(2)

There is a $75 copayment for each covered visit to an ambulatory surgical center.

There is a $75 copayment for each covered visit to an outpatient hospital facility.

Prior authorization may be required.

Ambulance Services

(Medically necessary ambulance services)

You pay 20% of Medicare-approved amounts or applicable fee schedule charge. (1)(2)

There is no copayment for covered ambulance services.

Emergency Care

(You may go to any emergency room if you reasonably believe you need emergency care.)

You pay 20% of the facility charge or applicable Copayment for each emergency room visit; you do NOT pay this amount if you are admitted to the hospital for the same condition within 3 days of the emergency room visit. (1)(2)

You pay 20% of doctor charges.
(1)(2)

NOT covered outside the U.S. except under limited circumstances.

You pay $50 for each covered emergency room visit; You do not pay this amount if you are admitted to the hospital within the next three days for the same condition.

* Worldwide Coverage

Urgently Needed Care

(This is NOT emergency care, and in most cases, is out of the service area.)

You pay 20% of Medicare-approved amounts or applicable Copayment. (1)(2)

NOT covered outside the U.S. except under limited circumstances.

You pay $35 for each covered urgently needed care visit.

* Worldwide Coverage

Outpatient Rehabilitation Services

(Occupational Therapy, Physical Therapy, Speech and Language Therapy, Cardiac or Pulmonary Rehabilitation Therapy)

You pay 20% of Medicare-approved amounts. (1)(2)

You pay $35 daily for each covered Occupational, Physical and/or Speech/Language Therapy visit.

You pay $15 for each covered Cardiac or Pulmonary Rehabilitation Therapy visit.

Durable Medical Equipment

(Includes Wheelchairs, oxygen, etc.)

You pay 20% of Medicare-approved amounts (1)(2)

You pay 20% of the cost for each covered item.

Prior Authorization is required for purchases and repairs over $1,000, and all rentals.

Prosthetic Devices

(Include braces, artificial limbs and eyes, etc.)

You pay 20% of Medicare-approved amounts. (1)(2)

You pay 20% of the cost for each covered item.

Prior Authorization is required for purchases and repairs over $1,000, and all rentals.

Diabetes Self-Monitoring, Training and Supplies

(Includes coverage for glucose monitors, test strips, lancets, screening tests and self-management training.)

You pay 20% of Medicare-approved amounts. (1)(2)

There is no copay for covered Diabetes self-monitoring training.

You pay 15% of the cost for each covered Diabetic testing supply item. Non-preferred blood glucose monitors and blood glucose test strips require a Prior Authorization. If approved, you will pay 35% of the cost for each covered Diabetes supply item.

There is no copayment for covered diabetic screening tests.

Medical Nutrition Therapy

There is no copay for each covered Medical Nutrition Therapy visit.

There is no copay for each covered Medical Nutrition Therapy visit.

Diagnostic Tests, X-Rays and Lab Services

You pay 20% of Medicare-approved amounts, except for approved lab services. (1)(2)

There is no copayment for Medicare-approved lab services.

You pay:

• 10% of the cost for each covered clinical/diagnostic lab service.
• 10% of the cost for each covered radiation therapy service.
• 10% of the cost for each covered x-ray visit.

PREVENTIVE CARE AND SCREENING TESTS

Abdominal Aorta Ultrasound Screening

There is no copayment for one screening Abdominal Aorta Ultrasound per lifetime.

There is no copayment for 1 screening Abdominal Aorta Ultrasound per lifetime.

Bone-Mass Measurements

(For People with Medicare who are at risk.)

There is no copayment for each covered Bone Mass Measurement.

There is no copayment for each covered Bone Mass Measurement.

You pay nothing for the test, but you generally have to pay the doctor 20% of the Medicare-approved amount for the doctor's visit. (1)(2)

You pay nothing for this one-time screening EKG if ordered by your doctor as part of your "Welcome to Medicare" physical exam. You pay 20% of the Medicare-approved amount for the doctor visit. (1)(2)

Colorectal Screening

You pay nothing for the test, however you generally have to pay 20% of the Medicare-approved amount for the doctor visit. (1)(2)

There is no copayment for covered colorectal screening exams.

Immunizations

(Flu Vaccine, Hepatitis B Vaccine – for people with Medicare who are at risk, Pneumonia Vaccine).

There is no copayment for the Pneumonia and Flu vaccines.

You pay 20% of Medicare-approved amounts for the Hepatitis B vaccine. (1)(2)

You may only need the Pneumonia vaccine once in your lifetime.

Please contact your doctor for further details.

There is no copayment for the Pneumonia and Flu vaccines.

Flu and Pneumonia vaccines by any qualified practitioner are covered.

There is no copayment for the Hepatitis B vaccine.

Mammography Screening

(Annual Screening)

There is no copayment for 1 screening mammogram every calendar year.

No referral necessary for Medicare covered screenings.

There is no copayment for 1 screening mammogram every calendar year.

Pap Smears, Pelvic Exams and Clinical Breast Exams

(For women with Medicare)

There is no copayment for a pap smear, pelvic exam and clinical breast exam once every 2 years or annually for beneficiaries at high risk.

There is no copayment for 1 screening pap smear, pelvic exam and clinical breast exam every calendar year.

Prostate Cancer Screening Exams

(For men with Medicare age 50 and older).

There is no copayment for approved lab services and a copayment of 20% of Medicare-approved amounts for other related services. (1)(2)

There is no copayment for 1 screening Prostate Cancer exam every calendar year.

Cardiovascular Screening

Blood Tests for the early detection of cardiovascular disease (or abnormalities associated with an elevated risk of cardiovascular disease).

There is no copayment for the test once every 5 years. You pay 20% of the Medicare-approved amount for the doctor's visit. (1)(2)

There is no copayment for covered tests.

Physical Exams

There is no copayment for a one time "Welcome to Medicare" exam within the first 12 months of having Part B.

There is no copayment for a yearly "Wellness" exam.

This will not include lab tests.

There is no copayment for routine physical exams. If the exam is for the treatment of a suspected or existing condition, $35 office copay may apply.

Tobacco/ Smoking Cessation

You pay 20% of Medicare-approved amounts. (1)(2)

If you haven't been diagnosed with an illness caused or complicated by tobacco use, you pay nothing for the counseling sessions.

You pay a $35 copayment for each tobacco counseling session.

Reimbursement of approved smoking cessation program upon receipt of your program completion certificate and proof of payment.

Dental Services

In general, you pay 100% for preventive dental services.

In general, you pay 100% for preventive dental services.

You pay $35 for each covered dental exam.

Hearing Services

(You pay 100% for Hearing Aids).

You pay 100% for routine hearing exams and hearing aids.

You pay 20% of Medicare-approved amounts for diagnostic hearing exams. (1)(2)

There is no copayment for the following services:

• Covered hearing tests (diagnostic hearing tests).

• Routine hearing tests up to 1 test every calendar year.

Vision Care

You are covered for one pair of eye glasses or contact lenses after each cataract surgery. (1)(2)

For people with Medicare who are at risk, you are covered for annual glaucoma screenings. (1)(2)

You pay 20% of Medicare approved amounts for diagnosis and treatment of diseases and conditions of the eye. (1)(2)

You pay 100% for routine eye exams and glasses.

There is no copayment for the following items:

Covered eyewear include:

• One pair of eyeglasses or contact lenses after each cataract surgery
• $100.00 limit for routine eyewear every year (for frames, lenses, and eyewear upgrades at participating network providers).
• First Routine Eye Exam each calendar year.

You pay:

• Any amount over the allowable amount for frames.

• $35 for each covered eye exam (diagnosis and treatment for diseases and conditions of the eye).

• There is no co-pay for each annual glaucoma exam.

Health and Wellness Education

The following is available to you at no cost:

• Health Education Classes

• Newsletter

• Nurse Advisor Line

• Disease Management

• Case Management

You pay 100%.

There is no copayment for these services.

PART D DRUG BENEFIT

Prescription Drugs

You pay 100% for most prescription drugs, unless you enroll in the Medicare Part D Prescription Drug program.

Most people will pay the standard monthly Part D premium.

However, starting January 1, 2011, some people are required to pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information on Part B premiums based on income, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

You pay 100% for most prescription drugs. This Plan does not cover Medicare Part D prescription drugs or vaccines.

There is no benefit limit on drugs covered under Original Medicare. Some quantity limits may apply.