Page 55 - Evaluation for 2018
P. 55
1/3/2018 Your Medicare Health Plan Details
Outpatient hospital coverage $10 or 20% per visit
Doctor visits Primary: $10 per visit
Specialist: $50 per visit
Preventive care $0 copay
Emergency care/Urgent care Emergency: $80 per visit (always covered)
Urgent care: $10-50 per visit (always covered)
Diagnostic procedures/lab Diagnostic tests and procedures: $0-50 or 20%
services/imaging
Lab services: $0-40
Diagnostic radiology services (e.g., MRI): $45-400 or 20%
Outpatient x-rays: $10-15
Mental health services $305 for days 1 through 5
$0 for days 6 through 90
Outpatient group therapy visit with a psychiatrist: $40
Outpatient individual therapy visit with a psychiatrist: $40
Outpatient group therapy visit: $40
Outpatient individual therapy visit: $40
Skilled Nursing Facility $0 for days 1 through 20
$167.50 for days 21 through 100
Rehabilitation services Occupational therapy visit: $40 or 20%
Physical therapy and speech and language therapy visit: $40 or 20%
Ambulance $265 or 20%
Transportation Not covered
Foot care (podiatry services) Foot exams and treatment: $50
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: $0 or 10-20% 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=H5619&plnid=060&sgmntid=0#plan_benefits 2/4
