Retiree Benefits
Benefit Summary
Hartford Plans I & II
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD*
* A
benefit period begins on the first day you receive service as an inpatient in
a hospital and ends after you have been out of the hospital and have not received
skilled care in any other facility for 60 days in a row.
| SERVICES |
MEDICARE PAYS
|
PLAN I PAYS
|
PLAN II PAYS
|
|
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services
and supplies:
|
|
First 60 days
|
All but $992
|
$0
|
$992 (Part A Deductible)
|
|
61st thru 90th day
|
All but $248 a day
|
$248 a day
|
$248 a day
|
|
91st day and after:
|
|
|
|
|
While using 60 lifetime reserve days
|
All but $496 a day
|
$496 a day
|
$496 a day
|
|
Once lifetime reserve days are used:
|
|
|
|
|
Additional 365 days
|
$0
|
100% of Medicare Eligible Expenses
|
100% of Medicare Eligible Expenses
|
|
Beyond the Additional 365 days
|
$0
|
$0
|
$0
|
|
SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital
for at least 3 days and entered a Medicare-approved facility within 30
days after leaving the hospital:
|
|
First 20 days
|
All approved amounts
|
$0
|
$0
|
|
21st thru 100th day
|
All but $124 a day
|
$0
|
Up to $124 a day
|
|
101st day thru 365th day
|
$0
|
$0
|
$0
|
|
366th day and after
|
$0
|
$0
|
$0
|
|
BLOOD
|
|
First 3 pints
|
$0
|
3 pints
|
3 pints
|
|
Additional amounts
|
100%
|
$0
|
$0
|
MEDICARE
(PART B) - MEDICAL SERVICES - PER CALENDAR YEAR*
| SERVICES |
MEDICARE PAYS
|
PLAN I PAYS
|
PLAN II PAYS
|
|
MEDICAL EXPENSES
- In or Out of the Hospital and Outpatient Hospital Treatment,
such as Physician's services, inpatient and outpatient medical and surgical
services and supplies, physical and speech therapy, diagnostic tests,
durable medical equipment:
|
|
First $131 of Medicare Approved Amounts**
|
$0
|
$0
|
$0
|
|
Remainder of Medicare Approved Amounts
|
80%
|
20%
|
20%
|
|
Part B Excess Charges (Above Medicare Approved Amounts)
|
$0
|
$0
|
$0
|
|
BLOOD
|
|
First 3 pints
|
$0
|
All costs
|
All costs
|
|
Next $131 of Medicare Approved Amounts**
|
$0
|
$0
|
$0
|
|
Remainder of Medicare Approved Amounts
|
80%
|
20%
|
20%
|
|
CLINICAL LABORATORY SERVICES
|
|
Blood tests for Diagnostic Services
|
100%
|
$0
|
$0
|
MEDICARE
PARTS A & B
| SERVICES |
MEDICARE PAYS
|
PLAN I PAYS
|
PLAN II PAYS
|
|
HOME HEALTH CARE
|
|
Medicare Approved Services:
|
|
|
|
|
Medically necessary skilled care services and medical
supplies
|
100%
|
$0
|
$0
|
|
Durable medical equipment:
|
|
|
|
|
First $131 of Medicare Approved Amounts**
|
$0
|
$0
|
$0
|
|
Remainder of Medicare Approved Amounts
|
80%
|
20%
|
20%
|
OTHER BENEFITS - NOT COVERED BY MEDICARE
| SERVICES |
MEDICARE PAYS
|
PLAN I PAYS
|
PLAN II PAYS
|
|
FOREIGN TRAVEL
Medically necessary emergency care services beginning during the first
60 days of each trip outside the USA:
|
| First $250 each
calendar year |
$0
|
$0
|
$0
|
| Remainder of charges |
$0
|
80% to a lifetime maximum of $50,000
|
80% to a lifetime maximum of $50,000
|
OUTPATIENT PRESCRIPTION DRUGS ***
|
COST OF PRESCRIPTIONS |
PLAN PAYS |
YOU PAY |
Medicare Part D with Supplement |
| First $265 |
$0 |
$265 |
| $266 to $14,605 |
75% |
25% |
| $14,605 and up |
95% |
5% |
* A benefit period begins
on the first day you receive service as an inpatient in a hospital and ends
after you have been out of the hospital and have not received skilled care
in any other facility for 60 days in a row.
** Once you have been billed
$131 of Medicare approved amounts for covered services, your Medicare Part
B Deductible will have been met for the calendar year.
*** Prescription drugs are a stand-alone benefit issued through Sterling Retiree Rx/IdealScripts. Benefits are paid only when using one of the approximately 42,000 Sterling Retiree Rx/IdealScripts Participating Pharmacies.
The summary of program
benefits described herein is for illustrative purposes only. In case of differences
or errors, the Group Policy governs.
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