Basic Core Benefits - Plan H2:
The basic core benefits for Plan H2, including Medicare (PART A) - Hospital Services - Per Benefit Period , Medicare (PART B) - Medical Services - Per Calendar Year , and Part A&B , shall consist of the following:
The basic core benefits for Plan H2 shall consist of the following:
A. coverage for Part A Medicare Eligible Expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period;
B. coverage for Part A Medicare Eligible Expenses, to the extent not covered by Medicare, incurred as daily hospital charges during use of Medicare lifetime hospital inpatient reserve days;
C. upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of the Medicare Part A eligible expenses for hospitalization paid at the diagnostic related group (DRG) day outlier per diem or other appropriate standard of payment, subject to a lifetime maximum benefit of an additional 365 days;
D. coverage under Medicare Parts A and B for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulation) unless replaced in accordance with federal regulation; and
E. coverage for the coinsurance amount (or in the case of hospital outpatient department services, the copayment amount) of Medicare Eligible Expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible.
F. SOME RESTRICTIONS, LIMITATIONS AND EXCLUSIONS apply.
Additional Benefits:
The additional benefits for Plan H2 shall consist of the following:
A. Medicare Part A Deductible--Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
B. Skilled Nursing Facility Care--Coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A.
C. Medically Necessary Emergency Care in a Foreign Country--Coverage to the extent not covered by Medicare for 80% of the billed charges for Medicare-Eligible Expenses for Medically Necessary emergency hospital, physician, and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during the first 60 consecutive days of each trip outside the United States, subject to a calendar year deductible of $250, and a lifetime maximum benefit of $50,000. For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset.
The basic core benefits and additional benefits are summarized in the following table:
PLAN H2
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD *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.
**$0 Indicates your liability for covered charges. You are responsible for all other non-covered charges.
***If you do not use a Network Provider, you are responsible for all charges not paid for by Medicare. |
| SERVICE |
TYPE |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
HOSPITALIZATION*, ***
Semiprivate room and board, general nursing and miscellaneous services and supplies |
| First 60 days |
All but $1068 |
$1068 (Part A Deductible) |
$0** |
| 61st through 90th day |
All but $267 a day |
$267 a day |
$0** |
| 91st day and after: While using 60 lifetime reserve days |
All but $512 a day |
$512 a day |
$0** |
| 91st day and after: Once lifetime reserve days are used. Additional 365 lifetime days |
$0 |
100% of Medicare Eligible Expenses |
$0** |
| 91st day and after: Once lifetime reserve days are used. 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 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital |
| First 20 days |
All approved amounts |
$0 |
$0** |
| 21st through 100th day |
All but $133.50 a day |
$Up to $133.50 a day |
$0** |
| 101st day and after |
$0 |
$0 |
All costs |
| BLOOD*** |
| First 3 pints |
$0 |
3 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 services |
All but very limited coinsurance for outpatient drugs and inpatient respite care |
$0 |
Balance |
PLAN H2
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $131 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
**$0 Indicates your liability for covered charges. You are responsible for all other non-covered charges.
***If you do not use a Network Provider, you are responsible for all charges not paid for by Medicare. |
| SERVICE |
TYPE |
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 test, durable medical equipment |
| First $135 of Medicare-Approved Amounts* |
$0 |
$0 |
$135 (Part B Deductible) |
| Remainder of Medicare-Approved Amounts |
Generally 80% |
Generally 20% (or in the case of hospital outpatient department services, applicable copayments) |
$0** |
| Part B Excess Charges (Above Medicare-Approved Amounts) |
$0 |
$0 |
All costs |
| BLOOD*** |
| First 3 pints |
$0 |
All costs |
$0** |
| Next $135 of Medicare-Approved Amounts* |
$0 |
$0 |
$135 (Part B Deductible) |
| Remainder of Medicare-Approved Amounts |
80% |
20% |
$0** |
| CLINICAL LABORATORY SERVICES-BLOOD TESTS FOR DIAGNOSTIC SERVICES |
| N/A |
100% |
$0 |
$0** |
PLAN H2
PARTS A & B *Once you have been billed $131 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
**$0 Indicates your liability for covered charges. You are responsible for all other non-covered charges.
***If you do not use a Network Provider, you are responsible for all charges not paid for by Medicare. |
| SERVICE |
TYPE |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
HOME HEALTH CARE MEDICARE-APPROVED SERVICES:
Medically necessary skilled care services and medical supplies |
| N/A |
100% |
$0 |
$0** |
| DURABLE MEDICAL EQUIPMENT*** |
| First $135 of Medicare-Approved Amounts* |
$0 |
$0 |
$135 (Part B Deductible) |
| Remainder of Medicare-Approved Amounts |
80% |
20% |
$0** |
| OTHER BENEFITS - 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 benefit of $50,000 |
20% and amounts over the $50,000 lifetime maximum |
GENERAL LIMITATIONS AND EXCLUSIONS
This Health Plan does not cover any expenses of the type excluded by Medicare or not covered under the terms of this Health Plan. UTMB HP, INC. will pay full benefits under this Health Plan if you are treated by a Network Provider. If you incur Medicare Eligible Expenses for the services of a Non-network Provider, the Medicare program may provide coverage; however, no coverage will be provided under this Health Plan. Please see Provider Restrictions and Medicare Restrictions for details.
Provider Restrictions:
· The Health Plan does not restrict payment of benefits for Covered Services unless they are provided by a Non-network Provider, with certain exceptions noted below.
· Neither Part A nor Part B benefits under this Health Plan will be paid for either Hospital or Medical Services if those services are provided by a Non-network Provider.
These restrictions will not apply for Medicare Eligible Expenses if:
1. the services are for symptoms requiring Emergency Care or are immediately required for an unforeseen illness, injury, or a condition, and, it is not reasonable to obtain such services through a Network Provider; or
2. the services are not available through Network Providers.
Payment of benefits for Emergency Care or for services immediately required for an unforeseen illness or injury is conditioned on your obtaining Emergency Care or such services through Network Providers if it is reasonable to do so. You must notify UTMB HP, INC. within 48 hours or as soon as reasonably possible after you receive Emergency Care. Unless pre-approved by the Health Plan, the Health Plan does not cover follow-up or post-stabilization care provided by Non-network Providers. Services that are not available through Network Providers must be pre-authorized by the Health Plan before benefits will be paid under this Health Plan. Some Covered Services are subject to utilization management and pre-authorization. Network Providers and their locations are listed in the Provider Directory.
Medicare Restrictions:
Except as provided in the Schedule of Benefits, coverage does not include payment of benefits for any items that are not both Medicare Approved Amounts and Medicare Eligible Expenses. To the extent that Medicare copayments, deductibles, coinsurance, benefit periods, maximum benefits, or other such provisions vary from those specified in this Schedule of Benefits (such as for certain mental health services), Medicare provisions shall govern coverage under this Schedule of Benefits.