Page 46 - Cover Letter & Evaluation for Patricia Letizia
P. 46
10/12/2018 Your Medicare Health Plan Details
Skilled Nursing Facility
In-Network: $0 per day for days 1 through 20
$172 per day for days 21 through 100
Out-of-Network: 50% per stay
Rehabilitation services Occupational therapy visit:
In-Network: $40
Out-of-Network: 50%
Physical therapy and speech and language therapy visit:
In-Network: $40
Out-of-Network: 50%
Ground ambulance
In-Network: $265
Out-of-Network: $265
Transportation
In-Network: $0 copay
Out-of-Network: 50%
There may be limits on how much the plan will provide.
Foot care (podiatry services) Foot exams and treatment:
In-Network: $40
Out-of-Network: 50%
Routine foot care:
In-Network: $45
Out-of-Network: 50%
There may be limits on how much the plan will provide.
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen):
In-Network: 15% per item
Out-of-Network: 50% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network: 20% per item
Out-of-Network: 50% per item
Diabetes supplies:
In-Network: $0 or 10-20% per item
Out-of-Network: 50% per item
Wellness programs (e.g., fitness, Covered
nursing hotline)
Medicare Part B drugs Chemotherapy:
In-Network: 20%
Out-of-Network: 50%
Other Part B drugs:
In-Network: 20%
Out-of-Network: 50%
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Benefits Services
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5525&plnid=004&sgmntid=0#plan_benefits 3/5
