2016 AmeriHealth Medigap Plans Information Individual health plan options for people with Medicare AM6830 (5/15) 5823(10/15)BKV1
Thank you. We appreciate your interest in AmeriHealth New Jersey. We look forward to serving you as one of the many satisfied members who ve chosen us for our stability, reliability and solid, comprehensive coverage options. This booklet provides you with information on AmeriHealth Medigap Plans, our Medicare Supplement plans, also known as Medigap. Take a few minutes to look through it and decide which plan best fits your needs and budget. Of course, you can call us with any questions about plan coverage, including monthly premiums and cost-sharing. We ve included an enrollment form for your convenience. Simply complete the form and return in the postage-paid reply envelope provided. Thanks again for requesting this information and for choosing AmeriHealth New Jersey. Questions? Call AmeriHealth New Jersey at 1-866-365-5345 (TTY/TDD:711) Seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail. Connect with us on Facebook: www.facebook.com/amerihealthmedicare Contents Introduction Benefits at a glance Ready to enroll? Outline of coverage
3 steps to finding the right Medigap plan Follow these steps to find a Medicare Supplement plan that fits your budget, needs, and lifestyle. 1 2 3 Learn about the plans we offer Compare benefits, cost-sharing, and premiums Enroll in the plan you want Let s get started
Take a look at these 2 types of plans. They cover the costs not covered by Original Medicare. Medicare Advantage Plans These plans are offered by private insurance companies that are approved by Medicare. If you join a Medicare Advantage Plan, you still have Medicare. You ll get your Medicare Part A and Medicare Part B coverage from the Medicare Advantage plan. Medicare Advantage Plans must cover all of the services that Original Medicare covers. Medicare Advantage plans are not considered Medicare Supplement plans. Medicare Supplement Plans (Medigap) With this option, you remain enrolled in Original Medicare. When you buy a Medicare Supplement plan from a private insurance company, Original Medicare will pay its share of costs for covered services, then your supplement plan will pay its share. These plans do not include prescription drug coverage. While your monthly premium may be higher than a Medicare Advantage plan, many people choose them for lower copays, deductibles and coinsurance. AmeriHealth Medicare Advantage plans are underwritten by AmeriHealth HMO, Inc. AmeriHealth Medigap Plans are offered through AmeriHealth Insurance Company of New Jersey.
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IN THIS SECTION Benefits at a glance
How to pick a plan: If you re looking for a plan with no network restrictions and no referrals AmeriHealth Medigap Plans may be the right choice for you. Choose coverage for Medicare s gaps, which may include deductibles, copayments, and coinsurance that you are left to pay under Original Medicare. AmeriHealth Medigap Plans offer a choice of four (A, C, F, and N) Medicare Supplement insurance (Medigap) plans that give you the freedom you want by allowing you to see any doctor who accepts Original Medicare. Questions? Call AmeriHealth New Jersey at 1-866-365-5345 (TTY/TDD:711) Seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail. Connect with us on Facebook: www.facebook.com/amerihealthmedicare
With AmeriHealth Medigap Plans: You re free to visit any doctor or hospital that accepts Original Medicare. There s no need to select a primary care physician. You don t need a referral to see a specialist. You re covered when you travel anywhere in the United States. You get emergency coverage outside of the United States (with plan C, F, or N). You have the option to enroll in a stand-alone Part D prescription drug plan. Our recommended Plan F pays all deductibles, all coinsurance, and the 20 percent of Part B expenses not paid by Original Medicare. With Plan N, you pay a lower monthly premium and share some of the costs with the plan like up to a $20 copayment for doctor visits. You ll also have access to our Healthy Lifestyles SM Solutions: Tobacco Cessation Program You may receive up to $150 reimbursement for completing an approved tobacco cessation program. Weight Management Program You may also receive up to $150 reimbursement for participating in an approved weight management program. Fitness Reimbursement Up to $150 reimbursement after 120 workouts in 365 days at an approved gym. Plus, you ll receive TruHearing discounts: TruHearing provides dicounted rates on hearing aids through a national provider network. AmeriHealth Medigap Plans are offered through AmeriHealth Insurance Company of New Jersey. AmeriHealth Medigap Plans plans provide hospital and medical coverage only. They do not include Medicare prescription drug benefits. TruHearing is a registered trademark of TruHearing, Inc. All other trademarks, product names, and company names are the property of their respective owners.
Terms to know: This quick list of Medicare-related terms will help you better understand the information in this Plan Information Book. Deductible: The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay. Coinsurance: An amount you may be required to pay as your share of the cost for services or prescription drugs after you pay any deductibles. Coinsurance is usually a percentage (for example, 20 percent). Copayment: An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor s visit, hospital outpatient visit, or a prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor s visit or prescription drug. Premium: The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.
Comparison of Plans Please refer to the AmeriHealth Medigap Plans Outline of Coverage for copy and rate information. Service category Medicare pays: Plan A You pay: Primary care physician visits Specialist visits Emergency room Urgent care Outpatient surgery 80% of Medicare-approved amounts after your annual Part B deductible is met Part B deductible (Plan pays 20% coinsurance) Inpatient hospital All charges except your Part A deductible and Part A coinsurance Part A deductible Part B excess charges* Nothing 100% * If the amount a doctor or other health care provider charges is higher than the Medicare-approved amount, the difference is called the excess charge.
AmeriHealth Medigap Plans Plan C You pay: Plan F You pay: Plan N You pay: $0 (Plan pays Part B deductible and 20% coinsurance) $0 (Plan pays Part B deductible and 20% coinsurance) Part B deductible; copay for doctor visits; copay for emergency room (waived if admitted) (Plan pays all other Part B coinsurance) $0 $0 $0 100% $0 100% These plans do not cover Medicare Part D prescription drug benefits, but will work with any stand-alone Medicare Part D prescription drug plan. Medicare Part D plans help cover the costs of Medicare-covered prescription drugs. You don t have to choose a prescription drug plan, but if you decide to choose a Medicare Part D prescription drug plan after your initial enrollment period or after 63 days lapse in creditable coverage, you may be subject to a Late Enrollment Penalty.
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IN THIS SECTION Ready to enroll?
Ready to sign up for one of the AmeriHealth Medigap Plans? Here are easy step-by-step instructions for filling out the enrollment form. SECTION Personal Information A Please check [ ] the box in front of the plan you want to enroll in. Then, provide the personal information requested. SECTION Medicare Insurance Information B You will need your Medicare card to complete this section. You must include your Medicare claim number on your application form. SECTION C Important Questions Please answer the questions in Part 1 and Part 2 of this section. SECTION D Important Information Please read the important information regarding eligibility. SECTION E Your Signature Please read the information provided, then sign and date your application form. You do not need to complete Section F. This section is to be completed by the certified agent. Applicants have a right to return this Policy within (30) days of delivery for refund of the full premium paid if, after examination of this Policy, the Applicant is not satisfied for any reason. This Policy may be returned to AmeriHealth Medigap Plans, 1901 Market Street, Philadelphia, Pa. 19103-1480. If the Policy is returned, it will be null and void from the beginning and no benefits will be payable under its terms. Questions? Call AmeriHealth New Jersey at 1-866-365-5345 (TTY/TDD:711) Seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail. Connect with us on Facebook: www.facebook.com/amerihealthmedicare 5823(10/15)EI
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IN THIS SECTION Outline of Coverage
This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan A available. Some plans may not be available in your state. Basic, including 100% Part B coinsurance AmeriHealth Insurance Company of New Jersey Outline of Medicare Supplement Coverage Benefit Plans Available: A, C, F and N Basic Benefits: Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end Medical expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or copayments. Blood: First three pints of blood each year Hospice: Part A coinsurance A B C D F F* G K L M N Basic, including 100% Part B coinsurance Part A Deductible Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Foreign Travel Emergency Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part B Excess (100%) Foreign Travel Emergency Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility Coinsurance 50% Part A Deductible Out-of-pocket limit $4,940; paid at 100% after limit reached Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% 75% Skilled Nursing Facility Coinsurance 75% Part A Deductible Out-of-pocket limit $2,470; paid at 100% after limit reached Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance 50% Part A Deductible Foreign Travel Emergency Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and $50 copayment for ER Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency * Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan s separate foreign travel emergency deductible. Page 1 16873 INDIVIDUAL
AmeriHealth Insurance Company of New Jersey Medicare Supplement Premium Information AmeriHealth Insurance Company of New Jersey can only raise your premium if we raise the premium for all policies like yours in this State. We will not change your premium or cancel your policy because of age or poor health. These monthly rates are subject to change with the approval of the New Jersey Department of Banking and Insurance. Attained Age Rated Age 50-64* Age 65 Age 66 Age 67 Age 68 Age 69 Age 70 Age 71 Age 72 Age 73 Age 74 Age 75-79 Age 80-84 Age 85+ Plan A NT N/A $98.89 $104.40 $108.71 $113.64 $118.25 $123.21 $128.42 $132.98 $137.05 $140.52 $150.42 $159.77 $159.77 T N/A $108.78 $114.84 $119.58 $125.00 $130.07 $135.53 $141.26 $146.28 $150.76 $154.57 $165.46 $175.74 $175.74 Plan C NT $164.65 $164.65 $170.21 $177.08 $184.89 $192.21 $200.80 $209.61 $217.31 $225.57 $232.69 $253.71 $293.13 $336.79 T $181.11 $181.11 $187.23 $194.78 $203.38 $211.44 $220.88 $230.57 $239.04 $248.13 $255.96 $279.08 $322.44 $370.47 Plan F NT N/A $156.81 $162.11 $168.64 $176.08 $183.06 $191.23 $199.63 $206.96 $214.83 $221.61 $241.63 $279.17 $320.75 T N/A $172.49 $178.32 $185.51 $193.69 $201.37 $210.36 $219.59 $227.66 $236.32 $243.77 $265.79 $307.09 $352.83 Plan N NT N/A $108.81 $115.27 $120.28 $126.05 $131.47 $137.91 $144.52 $150.31 $156.68 $162.16 $178.63 $210.44 $247.98 T N/A $119.69 $126.79 $132.31 $138.65 $144.61 $151.71 $158.97 $165.34 $172.35 $178.38 $196.49 $231.48 $272.78 *This includes people 50 and older and under 65 on Medicare due to disability. NT Non-Tobacco T Tobacco Non-Tobacco rates apply to applications submitted during the 6-month open enrollment or in a guaranteed issue situation. Applicants NOT enrolling during the 6-month open enrollment period or in a guaranteed issue situation will be evaluated for tobacco usage and charged the corresponding tobacco or non-tobacco rates. Page 2 16873 INDIVIDUAL
PREMIUM INFORMATION We, AmeriHealth Insurance Company of New Jersey, can only raise your premium if we raise the premium for all policies like yours in the State of New Jersey. Premiums for attained age plans A, C, F and N will increase beginning with the first full month that the member moved into a new age range in accordance with the premium schedule on the previous page. Disclosures Use this outline to compare benefits and premiums among policies. POLICY REPLACEMENT READ YOUR POLICY VERY CAREFULLY This is only an outline describing your policy s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN YOUR POLICY If you find that you are not satisfied with your policy, you may return it to AmeriHealth Medigap Plans, 1901 Market Street, Philadelphia, PA 19103-1480. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments. If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. NOTICE This policy may not fully cover all of your medical costs. AmeriHealth is not connected with Medicare. This Outline of Coverage does not give all of the details of Medicare coverage. Contact your local Social Security office or consult Medicare & You for more details. COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new policy, be sure to answer truthfully and complete any questions about your medical health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded. Page 3 16873 INDIVIDUAL
Plan A * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies. First 60 days All but $1,260 $0 $1,260 (Part A deductible) 61st through 90th day All but $315 a day $315 a day $0 91st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare-eligible expenses o Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st through 100th day All but $157.50 a day $0 Up to $157.50 a day 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these benefits. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/coinsurance $0** $0 **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. (continued) Page 4 16873 INDIVIDUAL
Plan A (continued) Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $147 of Medicare-approved amounts $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B excess charges (above Medicare-approved amounts) $0 $0 All costs BLOOD First three pints $0 All costs $0 Next $147 of Medicare-approved amounts $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $147 of Medicare-approved amounts $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 Deductible amounts announced annually by CMS. Page 5 16873 INDIVIDUAL
Plan C * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A deductible) $0 61st through 90th day All but $315 a day $315 a day $0 91st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare-eligible expenses o Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st through 100th day All but $157.50 a day Up to $157.50 a day $0 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these benefits. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/coinsurance $0** $0 **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. (continued) Page 6 16873 INDIVIDUAL
Plan C (continued) Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B excess charges (above Medicare-approved amounts) $0 $0 All costs BLOOD First three pints $0 All costs $0 Next $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum 20% and amounts over the of $50,000 $50,000 lifetime maximum Deductible amounts announced annually by CMS. Page 7 16873 INDIVIDUAL
Plan F *A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A deductible) $0 61st through 90th day All but $315 a day $315 a day $0 91st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare-eligible expenses o Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st through 100th day All but $157.50 a day Up to $157.50 a day $0 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these benefits. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/coinsurance $0** $0 **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. (continued) Page 8 16873 INDIVIDUAL
Plan F (continued) Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B excess charges (above Medicare-approved amounts) $0 100% $0 BLOOD First three pints $0 All costs $0 Next $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum 20% and amounts over the of $50,000 $50,000 lifetime maximum Deductible amounts announced annually by CMS. Page 9 16873 INDIVIDUAL
Plan N * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A deductible) $0 61st through 90th day All but $315 a day $315 a day $0 91st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare-eligible expenses o Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st through 100th day All but $157.50 a day Up to $157.50 a day $0 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these benefits. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/coinsurance **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. (continued) $0** $0 Page 10 16873 INDIVIDUAL
Plan N (continued) Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $147 of Medicare-approved amounts $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. Part B excess charges (above Medicare-approved amounts) $0 $0 All costs BLOOD First three pints $0 All costs $0 Next $147 of Medicare-approved amounts $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 Page 11 16873 INDIVIDUAL
Plan N (continued) Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $147 of Medicare-approved amounts $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum 20% and amounts over the of $50,000 $50,000 lifetime maximum Deductible amounts announced annually by CMS. Page 12 16873 INDIVIDUAL
Questions? Need more information? Call one of our Medicare sales representatives at 1-866-365-5345 (TTY/TDD: 711) Seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail. www.amerihealthmedicare.com AmeriHealth Insurance Company of New Jersey AM6438 (10/14) Page 13 16873 INDIVIDUAL