PLAN G: MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD G *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 PLAN G PAYS YOU PAY PAYS HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,632 $1,632 $0 (Part A Deductible) 61st through 90th day All but $408 a day $408 a day $0 91st day and after: All but $816 a day $816 a day $0 (while using 60 lifetime reserve days) Once lifetime reserve days are used: $0 100% of Medicare $0*** • Additional 365 days eligible expenses • 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 $0 $0 amounts 21st through 100th day All but $204 Up to $204 $0 a day a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's All but very limited requirements, including a doctor's copayment / Medicare certification of terminal illness. coinsurance for copayment / $0 outpatient drugs coinsurance and inpatient respite care ***NOTICE: When your Medicare Part A hospital benefits are exhausted, the carrier stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the plan’s Basic Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. GOCW-G