Orthodox Health Plans-Retiree Coverage

Orthodox Health Plans

Retiree Medical Insurance

Plan Description

Underwritten by Monumental Life Insurance Company

In New York by AUSA Life

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 PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies:
First 60 days	All but $812	$812 (Part A Deductible)	$0
61st thru 90th day	All but $203 a day	$203 a day	$0
91st day and after :
While using 60 lifetime reserve days	All but $406 a day	$406 a day	$0
Once lifetime reserve days are used:
Additional 365 days	$0	100% of Medicare Eligible Expenses	$0
Beyond the Additional 365 days	$0	$0	All costs
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 $101.50 a day	Up to $101.50 a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 pints	$0	3 pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE
Available as long as your doctor certifies you are terminally ill and you elect to receive these services.
	All but very limited coinsurance for outpatient drugs and inpatient respite care	$0	Balance

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR*

*Once you have been billed $100 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Medicare Part B Deductible will have been met for the calendar year.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
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 $100 of Medicare Approved Amounts*	$0	$100 (Part B Deductible)	$0
Remainder of Medicare Approved Amounts	Generally 80%	Generally 20%	$0
Part B Excess Charges (Above Medicare Approved Amounts)	$0	$0	All costs
BLOOD
First 3 pints	$0	All costs	$0
Next $100 of Medicare Approved Amounts*	$0	$100 (Part B Deductible)	$0
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES
Blood tests for Diagnostic Services	100%	$0	$0

MEDICARE PARTS A & B

HOME HEALTH CARE
Medicare Approved Services:
Medically necessary skilled care services and medical supplies	100%	$0	$0
Durable medical equipment:
First $100 of Medicare Approved Amounts*	$0	$100 (Part B Deductible)	$0
Remainder of Medicare Approved Amounts	80%	20%	$0

OTHER BENEFITS - NOT COVERED BY MEDICARE

FOREIGN TRAVEL Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA:
First $250 each calendar year Remainder of charges	$0 $0	$0 80% to a lifetime maximum of $50,000	$250 20% and amounts over the $50,000 lifetime maximum
PRIVATE DUTY NURSING
	$0	$25 per shift; maximum number of shifts is 30 per benefit period	Balance

Exclusions:

Benefits will not be paid for any expenses which are not determined to be Medicare-eligible expenses by the federal Medicare Program or its administrators, except as otherwise specified in the policy.

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