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2/24/2017 Your Medicare Health Plan Comparison
Ambulance Ambulance

$225 In­network: $205
Out­of­network: $205

Doctor's office visits Doctor's office visits

Primary Physician Primary Physician
You pay nothing In­network: $15 per visit
Out­of­network: $45 per visit
Specialist
$45 per visit Specialist
In­network: $50 per visit
Out­of­network: $70 per visit

Durable medical equipment (wheelchairs, oxygen, etc.) Durable medical equipment (wheelchairs, oxygen, etc.)
0­20% per item In­network: 20% per item
Out­of­network: 50% per item

Emergency care Emergency care
$75 per visit (always covered) $75 per visit (always covered)

Home health care Home health care

You pay nothing In­network: You pay nothing
Out­of­network: 50%

Mental health care Mental health care

$300 for days 1 through 5 In­network: $395 for days 1 through 4
$0 for days 6 through 90 $0 for days 5 through 90
Out­of­network: 40% per stay
Outpatient hospital Outpatient hospital

$325 per visit In­network: 20% per visit
Out­of­network: 40% per visit
Renal dialysis Renal dialysis

20% per visit In­network: 20% per visit
Out­of­network: 20% per visit

Inpatient hospital care Inpatient hospital care

$225 for days 1 through 7 In­network: $395 for days 1 through 4
$0 for days 8 through 90 $0 for days 5 through 90
$0 for days 91 and beyond $0 for days 91 and beyond
Out­of­network: 40% per stay

Skilled Nursing Facility (SNF) Skilled Nursing Facility (SNF)

$0 for days 1 through 20 In­network: $0 for days 1 through 20
$164.50 for days 21 through 100 $160 for days 21 through 62
$0 for days 63 through 100
Out­of­network: $195 for days 1 through 52
$0 for days 53 through 100

https://www.medicare.gov/find­a­plan/results/planresults/plan­compare.aspx#plan_benefits 2/3