Page 154 - Cover Letter and Evaluation for Gary Janke

10/8/2018
Skilled Nursing Facility
Rehabilitation services
Ground ambulance
Transportation
Foot care (podiatry services)
Medical equipment/supplies
Wellness programs (e.g., fitness,
nursing hotline)
Medicare Part B drugs
Benefits Services
Hearing exam In-Network: $10
Out-of-Network: $10
Fitting/evaluation Not covered
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H7917&plnid=032&sgmntid=0 3/6
Your Medicare Health Plan Details
In-Network: $0 per day for days 1 through 20
$172 per day for days 21 through 100
Out-of-Network: 50% per stay
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%
In-Network: $250
Out-of-Network: $250 or 20%
Not covered
Foot exams and treatment:
In-Network: $25
Out-of-Network: 50%
Routine foot care: Not covered
Durable medical equipment (e.g., wheelchairs, oxygen):
In-Network: 20% 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 copay
Out-of-Network: 20% per item
Covered
Chemotherapy:
In-Network: 20%
Out-of-Network: 50%
Other Part B drugs:
In-Network: 20%
Out-of-Network: 50%
View Less