Page 36 - Demo

MEDICARE ADVANTAGE MEDICAL PLANS | Summary of Benefits | Continued
Medicare Advantage Standard Plan
Medicare Advantage Enhanced Plan
Medicare Advantage Enhanced Plus
$0 copay for days 1-20 and $50 copay per day for days 21-100 per benefit period.
No prior hospital stay required.
Your provider must obtain approval from the plan before you get skilled nursing care. This is called getting prior authorization.
$0 copay for days 1-20 and $50 copay per day for days 21-100 per benefit period.
No prior hospital stay required.
Your provider must obtain approval from the plan before you get skilled nursing care. This is called getting prior authorization.
$0 copay until 100 days, member pays 100% of all charges beyond 100 days.
No prior hospital stay required.
Your provider must obtain approval from the plan before you get skilled nursing care. This is called getting prior authorization.
$40 copay for each visit.
$30 copay for each visit.
10% coinsurance for each visit.
$0 copay.
For all preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost
to you. However, if you are treated or monitored for an existing medical condition or an additional non-preventive service, during the visit when you receive the preventive service, a copay or coinsurance may apply for that care received.
$0 copay.
For all preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost
to you. However, if you are treated or monitored for an existing medical condition or an additional non-preventive service, during the visit when you receive the preventive service, a copay or coinsurance may apply for that care received.
$0 copay.
For all preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost
to you. However, if you are treated or monitored for an existing medical condition or an additional non-preventive service, during the visit when you receive the preventive service, a copay or coinsurance may apply for that care received.
$40 copay for each x-ray visit and/or simple diagnostic test.
10% coinsurance for complex diagnostic test and/or radiology visit.
Member pays $0 for clinical lab services, blood tests, urinalysis.
10% coinsurance for each x-ray visit and/or simple diagnostic test, complex diagnostic test and/or radiology visit.
Member pays $0 for clinical lab services, blood tests, urinalysis.
10% coinsurance for each x-ray visit and/or simple diagnostic test, complex diagnostic test and/or radiology visit.
Member pays $0 for clinical lab services, blood tests, urinalysis.
If your Medical Plan has a deductible, it must be met before copayments or coinsurance will apply. See page 42 for details regarding Prescription Drug Plan deductible, copays and coinsurance.
36 | Insurance Trust For Delta Retirees | 2021 Benefits & Resources Guide
DIAGNOSTIC SERVICES/ LABS/IMAGING
PREVENTIVE CARE
URGENT SKILLED NURSING CARE FACILITY