SCP Material ID: 2014_MedSupp_OutlineOfCoverage. Medicare Supplement Outline of Coverage

Transcription

1 Medicare Supplement Outline of Coverage

2 HOMETOWN HEALTH OFFERS PLANS A, C, F AND N Hometown Health offers the plans, shown below, shaded in gray. Benefit Chart of Medicare Supplement Plans Medicare supplement insuran can be sold in ten standard plans and one high-deductible plan. This chart shows the benefits for each plan. Every company must make available Plan A. Some plans may not be available in Nevada. Basic Benefits: Hospitalization - Part A coinsuran plus coverage for 365 additional days after Medicare benefits end. Blood - First three pints of blood each year. Medical Expenses - Part B coinsuran (generally 20 pernt of Medicare-approved expenses) or copayments for hospital outpatient servis. Plans K, Hospi - Part A coinsuran. L and N require insureds to pay a portion of Part B coinsuran or copayments. A B C D F F* G K L M N Basic, including 100% Part B coinsuran Basic, including 100% Part B coinsuran Part A Deductibl e Basic, including 100% Part B coinsuran Skilled Nursing Facility Coinsuran Part A Deductible Part B Deductible Foreign Travel Emergenc y Basic, including 100% Part B coinsuran Skilled Nursing Facility Coinsuran Part A Deductible Foreign Travel Emergenc y Basic, including 100% Part B coinsuranc e Skilled Nursing Facility Coinsuran Part A Deductible Part B Deductible Part B Exss (100%) Foreign Travel Emergenc y Basic, including 100% Part B coinsuran Skilled Nursing Facility Coinsuran Part A Deductible Part B Exss (100%) Foreign Travel Emergenc y Hospitalizati on and preventive care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility Coinsuranc e 50% Part A Deductible Out-ofpocket limit**; paid at 100% after limit reached Hospitalizati on and preventive care paid at 100%; other basic benefits paid at 75% 75% Skilled Nursing Facility Coinsuranc e 75% Part A Deductible Out-ofpocket limit**; paid at 100% after limit reached Basic, including 100% Part B coinsuran Skilled Nursing Facility Coinsuran 50% Part A Deductible Foreign Travel Emergenc y Basic, including 100% Part B coinsuranc e, expt up to *** copayment for offi visit, and up to *** copayment for ER Skilled Nursing Facility Coinsuran Part A Deductible Foreign Travel Emergenc y

3 * 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 deductible. Benefits from High Deductible Plan F will not begin until outof-pocket expenses exed the deductible. 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. ** Out-of-pocket limit will increase each year for inflation. *** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insuran for People with Medicare, which must be provided by an insurer to an applicant pursuant to NAC 687B.240.

4 Premium Rates PLAN A Area 1 - Carson City, Churchill, Douglas, Elko, Esmeralda, Eureka, Humboldt, Lander, Lincoln, Lyon, Mineral, Nye, Pershing, Storey, Washoe, White Pine, Counties Nevada Non-Tobacco Tobacco Age Band Male Female Age Band Male Female 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Area 2 - Clark County, Nevada Non-Tobacco Tobacco Age Band Male Female Age Band Male Female 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

5 Premium Rates PLAN C Area 1 - Carson City, Churchill, Douglas, Elko, Esmeralda, Eureka, Humboldt, Lander, Lincoln, Lyon, Mineral, Nye, Pershing, Storey, Washoe, White Pine, Counties Nevada Non-Tobacco Tobacco Age Band Male Female Age Band Male Female 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Area 2 - Clark County, Nevada Non-Tobacco Tobacco Age Band Male Female Age Band Male Female 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

6 Premium Rates PLAN F Area 1 - Carson City, Churchill, Douglas, Elko, Esmeralda, Eureka, Humboldt, Lander, Lincoln, Lyon, Mineral, Nye, Pershing, Storey, Washoe, White Pine, Counties Nevada Non-Tobacco Tobacco Age Band Male Female Age Band Male Female 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Area 2 - Clark County,Nevada Non-Tobacco Tobacco Age Band Male Female Age Band Male Female 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

7 Premium Rates PLAN N Area 1 - Carson City, Churchill, Douglas, Elko, Esmeralda, Eureka, Humboldt, Lander, Lincoln, Lyon, Mineral, Nye, Pershing, Storey, Washoe, White Pine, Counties Nevada Non-Tobacco Tobacco Age Band Male Female Age Band Male Female 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Area 2 - Clark County,Nevada Non-Tobacco Tobacco Age Band Male Female Age Band Male Female 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

8 PREMIUM INFORMATION We, Hometown Health, can only raise your premium if we raise the premium for all policies like yours in this State. For Attained Age policies, your premium will increase on your effective date, annually, each year as you age. If you smoke and you enroll other than during the Medicare Supplement Open Enrollment and Guaranteed Issue period, a smoker premium rate will apply. Please refer to the Guaranteed Issue Guidelines included in your enrollment materials for details on Open Enrollment and Guaranteed Issue Guidelines. Premium payments may be made on a calendar month, calendar quarter, semi-annual calendar year, or calendar year basis. For example, a monthly premium would be for the first day of a month through the last day of such month. A quarterly payment would be for any calendar quarterly period, such as January 1 through March 31. A semiannual payment would be for the period of either January 1 through June 30 or July 1 through Dember 31. An annual premium would be for January 1 through Dember 31 of the applicable year. The amount of your periodic premium payment will change as provided in the policy and from time to time based on changes in your coverage, including but not limited to, changes in benefits, payment obligations (such as deductible, coinsuran and copayments), your age, or other factors that require adjustments to the total premium. These changes may occur at times other than an annual or other policy renewal. If you elected to authorize automatic premium withdrawals from a deposit account, the automatic withdrawal will change periodically to correspond with the applicable premium. Your authorization for automatic premium withdrawals shall include authorization for automatic withdrawal of any changed amount unless you call or provide your bank with written noti not less than three (3) business days before a scheduled withdrawal to stop the payment. If you call your bank to stop payment, you may be required to provide a written request within fourteen (14) days after your call. You will be responsible for any fee assessed by your bank for stop-payment orders that you make. Hometown Health Medicare Supplement is a Medicare Supplement insuran plan. Hometown Health Medicare Supplement is not connected with or endorsed by the U.S. government or the federal Medicare program. DISCLOSURES Use this outline to compare benefits and premiums among policies. This outline shows benefits and premiums of policies sold for effective dates on or after 12/01/2014. READ YOUR POLICY VERY CAREFULLY This is only an outline describing your policy s most important features. The policy is your insuran contract. You must read the policy to understand all of the rights and duties of both you and your insuran company. RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to Hometown Health 830 Harvard Way Reno, NV If you send the policy back to us within 30 days after you reive it, we will treat the policy as if it had never been issued and return all of your payments less any claims paid.

9 POLICY REPLACEMENT If you are replacing another policy of health insuran, do NOT canl it until you have actually reived your new policy and are sure you want to keep it. POLICY LAPSE DUE TO NONPAYMENT OF PREMIUM In the event of a lapse in coverage of the policy or rtificate for nonpayment of a premium, coverage will be reinstated if: 1. Reinstatement is requested within 2 months after the date of lapse of coverage; and 2. Proof of cognitive impairment or loss of functional capacity of the insured before the lapse of coverage or the expiration of any gra period contained in the policy to supplement Medicare or the rtificate is provided to the issuer. NOTICE Noti to Buyer: This policy may not cover all of your medical costs. Neither Hometown Health nor its agents are connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local social security offi or consult Medicare & You for more details. GRIEVANCE PROCEDURES Should you ever not be fully satisfied with any aspect of the servis you reive, we want to know about it so we can correct it. If you have any dissatisfaction with your Medicare Supplement Plan, please send all written grievans within 60 days of the occurren of your dissatisfaction to: Grievan Committee-Senior Care Plus 830 Harvard Way Reno, NV or toll-free at Your grievan will be reviewed by our Grievan Committee. Upon review of your grievan, we will mail you a response within 30 days from the reipt of your written corresponden. In no case will a complete response from us take more than 60 days. COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may canl your policy and refuse to pay any claims if you leave out or falsify important medical information. (If the policy or rtificate is guaranteed issue, this paragraph need not appear.) Review the application carefully before you sign it. Be rtain that all information has been properly recorded. Your Policy is guaranteed renewable This policy is guaranteed renewable and may not be canled or non-renewed for any reason other than your failure to pay premiums or misstatements in or omissions or for a material misrepresentation. Any change in your rate will be preded by a 60-day noti.

10 PLAN A MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD Hospitalization* Semi-private room and board, general nursing and misllaneous servis and supplies. First 60 days 61 st through 90 th day 91 st day and after: While using 60 lifetime reserve days On Lifetime reserve days are used- Additional 365 days Beyond the additional 365 days Skilled Nursing Facility Care* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital: First 20 days 21 st through 100 th day 101 st day and after All But $1,216** All But $304 a Day** All But $608 a Day** All Approved Amounts All But $152 a Day** $304 a Day** $608 a Day** 100% Of Medicare Eligible Expenses $1,216 (Part A Deductible) *** All Costs Up To $152 a Day** All Costs BLOOD* First 3 pints Additional 100% 3 pints HOSPICE CARE* You must meet Medicare s All but very limited copayment/ requirements, coinsuran Medicare Copayment/ including a doctor s rtification of for outpatient drugs Coinsuran terminal illness and inpatient respite care * A benefit period begins on the first day you reive servi as an inpatient in a hospital and ends after you have been out of the hospital and have not reived skilled care in any other facility for 60 consecutive days. ** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insuran for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. *** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the pla 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 balan based on any differen between its billed charges and the amount Medicare would have paid.

11 PLAN A MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s servis, inpatient and outpatient medical and surgical servis and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved Amounts* Part B Exss Charges (Above Medicare-approved ) BLOOD First 3 pints Next portion of Medicare-approved * CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES Generally 80% Generally 20% All Costs 80% All Costs 20% 100% * On you have been billed a portion of Medicare-approved for covered servis equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. PLAN A PARTS A & B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically nessary skilled care servis and 100% medical supplies Durable Medical Equipment First portion of Medicare-approved * 80% 20% * On you have been billed a portion of Medicare-approved for covered servis equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

12 PLAN C MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD Hospitalization* Semi-private room and board, general nursing and misllaneous servis and supplies. First 60 days 61 st through 90 th day 91 st day and after: While using 60 lifetime reserve days On Lifetime reserve days are used- Additional 365 days Beyond the additional 365 days Skilled Nursing Facility Care* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital: First 20 days 21 st through 100 th day 101 st day and after All But $1,216** All But $304 a Day** All But $608 a Day** All Approved Amounts All But $152 a Day** $1,216 (Part A Deductible) $304 a Day** $608 a Day** 100% Of Medicare Eligible Expenses Up To $152 a Day** *** All Costs All Costs BLOOD* First 3 pints Additional 100% 3 pints HOSPICE CARE* You must meet Medicare s All but very limited copayment/ requirements, including a doctor s rtification of coinsuran for outpatient drugs Medicare Copayment/ Coinsuran terminal illness and inpatient respite care * A benefit period begins on the first day you reive servi as an inpatient in a hospital and ends after you have been out of the hospital and have not reived skilled care in any other facility for 60 consecutive days. ** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insuran for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. *** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the pla 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 balan based on any differen between its billed charges and the amount Medicare would have paid.

13 PLAN C MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s servis, inpatient and outpatient medical and surgical servis and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved Amounts* Part B Exss Charges (Above Medicare-approved ) BLOOD First 3 pints Next portion of Medicare-approved * CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES PARTS A & B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically nessary skilled care servis and medical supplies Durable Medical Equipment First portion of Medicare-approved * 100% 80% Generally 80% Generally 20% All Costs 80% All Costs 20% 100% * On you have been billed a portion of Medicare-approved for covered servis equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. PLAN C 20%

14 * On you have been billed a portion of Medicare-approved for covered servis equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. PLAN C OTHER BENEFITS - NOT COVERED BY MEDICARE FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically nessary emergency care servis beginning during the first 60 days of each trip outside the United States: First $250 each calendar year $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and over the $50,000 lifetime maximum

15 PLAN F MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD Hospitalization* Semi-private room and board, general nursing and misllaneous servis and supplies. First 60 days 61 st through 90 th day 91 st day and after: While using 60 lifetime reserve days On Lifetime reserve days are used- Additional 365 days Beyond the additional 365 days Skilled Nursing Facility Care* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital: First 20 days 21 st through 100 th day 101 st day and after All But $1,216** All But $304 a Day** All But $608 a Day** All Approved Amounts All But $152 a Day** $1,216 (Part A Deductible) $304 a Day** $608 a Day** 100% Of Medicare Eligible Expenses Up To $152 a Day** *** All Costs All Costs BLOOD* First 3 pints Additional 100% 3 pints HOSPICE CARE* You must meet Medicare s All but very limited copayment/ requirements, coinsuran Medicare Copayment/ including a doctor s rtification of for outpatient drugs Coinsuran terminal illness and inpatient respite care * A benefit period begins on the first day you reive servi as an inpatient in a hospital and ends after you have been out of the hospital and have not reived skilled care in any other facility for 60 consecutive days. ** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insuran for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. *** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the pla 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 balan based on any differen between its billed charges and the amount Medicare would have paid.

16 PLAN F MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s servis, inpatient and outpatient medical and surgical servis and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved Amounts* Part B Exss Charges (Above Medicare-approved ) BLOOD First 3 pints Next portion of Medicare-approved * CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES Generally 80% Generally 20% 100% All Costs 80% All Costs 20% 100% * On you have been billed a portion of Medicare-approved for covered servis equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

17 PLAN F PARTS A & B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically nessary skilled care servis and medical supplies Durable Medical Equipment First portion of Medicare-approved * 100% 80% * On you have been billed a portion of Medicare-approved for covered servis equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. PLAN F OTHER BENEFITS - NOT COVERED BY MEDICARE FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically nessary emergency care servis beginning during the first 60 days of each trip outside the United States: First $250 each calendar year $250 Remainder of charges 20% 80% to a lifetime maximum benefit of $50,000 20% and over the $50,000 lifetime maximum

18 PLAN N MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD Hospitalization* Semi-private room and board, general nursing and misllaneous servis and supplies. First 60 days 61 st through 90 th day 91 st day and after: While using 60 lifetime reserve days On Lifetime reserve days are used- Additional 365 days Beyond the additional 365 days Skilled Nursing Facility Care* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital: First 20 days 21 st through 100 th day 101 st day and after All But $1,216** All But $304 a Day** All But $608 a Day** All Approved Amounts All But $152 a Day** $1,216 (Part A Deductible) $304 a Day** $608 a Day** 100% Of Medicare Eligible Expenses Up To $152 a Day** *** All Costs All Costs BLOOD* First 3 pints Additional 100% 3 pints HOSPICE CARE* You must meet Medicare s All but very limited copayment/ requirements, coinsuran Medicare Copayment/ including a doctor s rtification of for outpatient drugs Coinsuran terminal illness and inpatient respite care * A benefit period begins on the first day you reive servi as an inpatient in a hospital and ends after you have been out of the hospital and have not reived skilled care in any other facility for 60 consecutive days. ** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insuran for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. *** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the pla 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 balan based on any differen between its billed charges and the amount Medicare would have paid.

19 PLAN N MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s servis, inpatient and outpatient medical and surgical servis and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First portion of Medicare-approved Amounts* Generally 80% Balan, other than up to $20** per offi 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 offi 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 Exss Charges (Above Medicare-approved ) All Costs BLOOD First 3 pints All Costs Next portion of Medicare-approved * 80% 20% CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC 100% SERVICES * On you have been billed a portion of Medicare-approved (equal to the Part B Deductible) for covered servis (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. ** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insuran for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

20 PLAN N PARTS A & B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically nessary skilled care servis and medical supplies Durable Medical Equipment First portion of Medicare-approved * 100% 80% 20% * On you have been billed a portion of Medicare-approved (equal to the Part B Deductible) for covered servis (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. PLAN N OTHER BENEFITS - NOT COVERED BY MEDICARE FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically nessary emergency care servis beginning during the first 60 days of each trip outside the United States: First $250 each calendar year $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and over the $50,000 lifetime maximum