Page 187 - Cover Letter and Evaluation for Sue Marx
P. 187
2/7/2019 Your Medicare Health Plan Details
Doctor visits Primary: $0 copay
Specialist: $35 per visit
Preventive care $0 copay
Emergency care/Urgent care Emergency: $90 per visit (always covered)
Urgent care: $50 per visit (always covered)
Diagnostic procedures/lab Diagnostic tests and procedures: $10
services/imaging
Lab services: $10
Diagnostic radiology services (e.g., MRI): $140
Outpatient x-rays: $50
Mental health services Inpatient hospital - psychiatric: $275 per stay
Outpatient group therapy visit with a psychiatrist: $35
Outpatient individual therapy visit with a psychiatrist: $35
Outpatient group therapy visit: $35
Outpatient individual therapy visit: $35
Skilled Nursing Facility $0 per day for days 1 through 20
$160 per day for days 21 through 100
Rehabilitation services Occupational therapy visit: $35
Physical therapy and speech and language therapy visit: $35
Ground ambulance $250
Transportation Not covered
Foot care (podiatry services) Foot exams and treatment: $35
Routine foot care: Not covered
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen): 20% per item
Prosthetics (e.g., braces, artificial limbs): 20% per item
Diabetes supplies: 20% per item
Wellness programs (e.g., fitness, Covered
nursing hotline)
Medicare Part B drugs Chemotherapy: 20%
Other Part B drugs: 20%
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https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H3907&plnid=046&sgmntid=0#plan_benefits 2/4
