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Medicare Supplemental Plan
What is Covered?
| M-1 and M-Basic Plans |
| Medicare pays: |
M-Basic pays: |
M-1 pays: |
M-Basic member pays: |
M-1 member pays: |
Part A - Inpatient Hospital Care:
All covered medical expenses from day 1-60 each benefit period*, except for the hospital deductible. |
- 0 - |
The Part A inpatient hospital deductible once during each benefit period.* |
Part A deductible. |
- 0 - |
| All covered medical expenses from day 61-90, except for the coinsurance amount per day. |
The coinsurance amount per day from day 61-90 during each benefit period. |
- 0 |
| All covered medical expenses from day 91-150, except for the coinsurance amount per day. (These 60 Lifetime Reserve Days can be used only once in a lifetime.) Medicare pays nothing for hospitalization beyond 150 continuous days. |
The coinsurance amount per day from day 91-150. All LRFA determined eligible hospital expenses for an additional 365 days (in a lifetime). Limitations apply. |
- 0 |
| Blood transfusions, except for the first 3 pints of unreplaced blood in a calendar year. |
The first three pints of unreplaced blood in a calendar year. |
- 0 - |
Skilled Nursing Facility Care:
All covered medical expenses from day 1-20 in a Medicare approved facility after a 3 day hospital stay and admitted to the facility within 30 days of discharge. From day 21-100, Medicare pays all covered medical expenses, except for the coinsurance per day.
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- 0 - |
The Skilled Nursing Facility coinsurance amount per day from day 21-100. |
The Skilled Nursing Facility coinsurance amount per day from day 21-100. |
- 0 - |
Part B - Medical Expenses:
80% of the Medicare approved physician services, diagnostic tests, and other health care services, except for the annual deductible.
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Part B coinsurance amount, generally 20% of the Medicare approved physician services, diagnostic tests, and other health care services. |
Part B deductible.
Part B coinsurance amount, generally 20% of the Medicare approved physician services, diagnostic tests, and other health care services.
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Part B deductible. |
- 0 - |
| 80% of Medicare approved blood transfusion charges, except for the first three pints of unreplaced blood in a calendar year. |
The first three pints of blood and 20% of additional approved amounts provided outside the hospital. |
- 0 - |
| * A benefit period begins on the first day you receive Medicare covered inpatient hospital care and ends when you have been out of the hospital or skilled nursing facility for 60 consecutive days. |
| M-2 Plan |
| Medicare pays: |
M-2 pays: |
M-2 member pays: |
| - 0 - |
100% of the difference between the provider charges and the amount approved by Medicare, if the provider does not accept assignment, t.i. the provider does not accept the Medicare approved amount as payment in full. The maximum benefit is $3,000 in a calendar year. |
- 0 - |
| M-3 Plan |
| Medicare pays: |
M-3 pays: |
M-3 member pays: |
| - 0 - |
50% of $8,310 out-patient prescription drug expenses up to a maximum benefit amount of $4,000 per calendar year, after the deductible is met. |
$310 deductible and remaining balance. |
| M-3D Plan |
| Medicare pays: |
M-3D pays: |
M-3D member pays: |
| Medicare prescription drug plans vary. Please refer to your plan for actual coverage details. |
Initial coverage: Covers 100% of the co-insurance amounts for Medicare approved prescription drug costs up to the Medicare Part D “coverage gap” stage, after the deductible has been
met**.
Coverage gap: Covers 50% of the out-of-pocket expenses for
Medicare approved prescription drug costs up to the
Medicare Part D “catastrophic coverage” stage.
Catastrophic coverage: Covers 100% of the co-insurance
amounts for Medicare approved prescription drug costs up to
$5,000 in total prescription drug costs in a calendar year. |
$310 deductible and remaining balance. |
| M-4 and M-4D Plans |
M-4 includes all benefits provided in M-Basic, M-1, M-2 and M-3, plus
M-4D includes all benefits provided in M-Basic, M-1, M-2 and M-3D, plus |
| Medicare pays: |
M-4 & M4D pays: |
M-4 & M4D member pays: |
| Limited Preventive Medical Services. |
Preventative Medical Care: covers up to $120 per year for preventative medical services not covered by Medicare. |
Remaining balance. |
| Limited At-Home Recovery Services. |
At-Home Recovery Services: covers up to $1,600 per year and/or $40 a day for short-term, at-home assistance recovering from an illness, injury or surgery, if already receiving Medicare covered home health care services. |
Remaining balance. |
These pages are designed to provide general descriptions of our benefit plans and further restrictions may apply or may have changed. For further information, please contact the LRFA office or refer to specific plan Regulations.
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