Page 55 - Cover letter and evaluation for Peter Smith
P. 55
11/27/2017 Your Medicare Health Plan Details
Doctor visits Primary: $0 copay
Specialist: $0 copay
Preventive care $0 copay
Emergency care/Urgent care Emergency: $80 per visit (always covered)
Urgent care: $10-40 per visit (always covered)
Diagnostic procedures/lab Diagnostic tests and procedures: 20%
services/imaging
Lab services: $0 or 20%
Diagnostic radiology services (e.g., MRI): $5-200
Outpatient x-rays: $5
Mental health services $0 for days 1 through 90
Outpatient group therapy visit with a psychiatrist: $30
Outpatient individual therapy visit with a psychiatrist: $40
Outpatient group therapy visit: $30
Outpatient individual therapy visit: $40
Skilled Nursing Facility $0 for days 1 through 20
$125 for days 21 through 40
$0 for days 41 through 100
Rehabilitation services Occupational therapy visit: $0 copay
Physical therapy and speech and language therapy visit: $0 copay
Ambulance $180-295
Transportation $0 copay
Foot care (podiatry services) Foot exams and treatment: $0 copay
Routine foot care: $0 copay
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen): 20% per item
Prosthetics (e.g., braces, artificial limbs): 20% per item
Diabetes supplies: $0 per item
Wellness programs (e.g., fitness, Covered
nursing hotline)
Medicare Part B drugs Chemotherapy: 20%
Other Part B drugs: 20%
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H2931&plnid=002&sgmntid=0#plan_benefits 2/5
