AARP Medicare Supplement Application - Colorado Health Agents
AARP Medicare Supplement Application - Colorado Health Agents
AARP Medicare Supplement Application - Colorado Health Agents
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Outline of Coverage | United<strong>Health</strong>care Insurance Company<br />
Plan Benefit Tables: Plan L (continued)<br />
<strong>Medicare</strong> Part B: Medical Services per Calendar Year<br />
Service <strong>Medicare</strong> Pays Plan L Pays You Pay 4<br />
Medical Expenses<br />
INCLUDES TREATMENT IN<br />
OR OUT OF THE HOSPITAL,<br />
AND OUTPATIENT HOSPITAL<br />
TREATMENT, such as: physician’s<br />
services, inpatient and outpatient<br />
medical and surgical services and<br />
supplies, physical and speech<br />
therapy, diagnostic tests, durable<br />
medical equipment.<br />
Part B Excess Charges<br />
Above <strong>Medicare</strong>-approved<br />
amounts<br />
Parts A and B<br />
Preventive Benefits<br />
for <strong>Medicare</strong> Covered<br />
Services<br />
Remainder of<br />
<strong>Medicare</strong>-approved<br />
amounts<br />
Generally 75%<br />
or more of <strong>Medicare</strong>approved<br />
amounts<br />
Remainder of<br />
<strong>Medicare</strong>approved<br />
amounts<br />
First $147 of $0 $0 $147<br />
amounts 5 deduct-<br />
<strong>Medicare</strong>-approved<br />
(Part B<br />
ible) 5 <br />
All costs<br />
above<br />
<strong>Medicare</strong>approved<br />
amounts<br />
Generally 80% Generally 15% Generally<br />
5%<br />
$0 $0 All Costs<br />
(and they do<br />
not count<br />
toward<br />
annual<br />
out-of-pocket<br />
limit of<br />
$2400) 4<br />
Blood First 3 pints $0 75% 25%<br />
Next $147 of $0 $0 $147<br />
<strong>Medicare</strong>-approved<br />
(Part B<br />
amounts 5 deductible)<br />
5 <br />
Remainder of<br />
<strong>Medicare</strong>-approved<br />
Generally<br />
80%<br />
Generally<br />
15%<br />
Generally<br />
5%<br />
amounts<br />
Clinical Laboratory Services Tests for diagnostic<br />
services<br />
100% $0 $0<br />
Service <strong>Medicare</strong> Pays Plan L Pays You Pay 4<br />
Home <strong>Health</strong> Care<br />
<strong>Medicare</strong>-approved services<br />
Medically necessary<br />
skilled care services<br />
and medical supplies<br />
Notes<br />
4 This plan limits your annual out-of-pocket payments for<br />
<strong>Medicare</strong>-approved amounts to $2400 per calendar year.<br />
However, this limit does NOT include charges from your<br />
provider that exceed <strong>Medicare</strong>-approved amounts (these<br />
are called “Excess Charges”) and you will be responsible<br />
for paying this difference in the amount charged by your<br />
provider and the amount paid by <strong>Medicare</strong> for the item or<br />
service.<br />
100% $0 $0<br />
Continued on next page<br />
5 Once you have been billed $147 of <strong>Medicare</strong>-approved<br />
amounts for covered services, your Part B deductible will<br />
have been met for the calendar year.<br />
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