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* A benefit period begins on the first day you receive service 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.
**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.
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SERVICES
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MEDICARE PAYS
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PLAN A PAYS
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YOU PAY
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Medical Expenses-In Or Out Of 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:
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• First $155 of Medicare-Approved Amounts*
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$0
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$0
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$155 ( Part B Deductible)
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• Remainder of Medicare-Approved Amounts
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Generally 80%
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Generally 20%
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$0
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Part B Excess Charges (Above Medicare-Approved Amounts)
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$0
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$0
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All costs
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Blood
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• First 3 pints
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$0
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All costs
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$0
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• Next $155 of Medicare-Approved Amounts*
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$0
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$0
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$155 (Part B Deductible)
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• Remainder of Medicare-Approved Amounts
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80%
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20%
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$0
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Clinical Laboratory Services
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• Tests for diagnostic services
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100%
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$0
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$0
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Medicare Parts A and B
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Home Health Care Medicare-Approved Services
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• Medically necessary skilled care services and medical supplies
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100%
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$0
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$0
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• Durable medical equipment
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— First $155 of Medicare-Approved Amounts*
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$0
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$0
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$155 (Part B Deductible)
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— Remainder of Medicare-Approved Amounts
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80%
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20%
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$0
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These benefits described are issued under Policy Form Numbers: 3097, 3149, 3098, 3099 as amended CFMI HI DED PLAN F (10/04) CareFirst BlueCross BlueShield Individual Market Division 10455 Mill Run Circle, 4th floor, Owings Mills, Maryland 21117 A private not-for-profit health service plan incorporated under the laws of the State of Maryland. CareFirst BlueCross BlueShield is the business name of CareFirst of Maryland, Inc. and is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc. |
