Page 29 - Cover letter and evaluation for Peter Smith
P. 29
11/27/2017 Your Medicare Health Plan Details
Outpatient hospital coverage $50 per visit
Doctor visits Primary: $0 copay
Specialist: $0-35 per visit
Preventive care $0 copay
Emergency care/Urgent care Emergency: $100 per visit (always covered)
Urgent care: $20 per visit (always covered)
Diagnostic procedures/lab Diagnostic tests and procedures: $0 copay
services/imaging
Lab services: $0 copay
Diagnostic radiology services (e.g., MRI): $0-150
Outpatient x-rays: $0
Mental health services $50 for days 1 through 5
$0 for days 6 through 90
$0 for days 91 through 150
Outpatient group therapy visit with a psychiatrist: $0-35
Outpatient individual therapy visit with a psychiatrist: $0-35
Outpatient group therapy visit: $0-15
Outpatient individual therapy visit: $0-15
Skilled Nursing Facility $0 for days 1 through 20
$100 for days 21 through 100
Rehabilitation services Occupational therapy visit: $15
Physical therapy and speech and language therapy visit: $0-15
Ambulance $195
Transportation $0 copay
Foot care (podiatry services) Foot exams and treatment: $0-35
Routine foot care: $0-35
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen): 0-20% per item
Prosthetics (e.g., braces, artificial limbs): 0-20% per item
Diabetes supplies: 20% per item
Wellness programs (e.g., fitness, Covered
nursing hotline)
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H4346&plnid=001&sgmntid=0 2/5
