Breakdown of Your Costs by Medicare Plan Design

2023 Plan Year For Retirees with Medicare

The table below lists cost information for services covered under each Medicare plan design option.

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	Health Plan Medicare & IYC Medicare Advantage	Medicare Plus²
Annual Medical Deductible¹	Medicare pays: Allowable services after Part A ($1,600) and Part B ($226) deductibles Plan pays: Part A inpatient hospital deductible of $1,600 and Part B deductible of $226 You pay: $0	Medicare pays: Allowable services after Part A ($1,600) and Part B ($226) deductibles Plan pays: Plan pays: Part A inpatient hospital deductible of $1,600 and Part B deductible of $226 You pay: $0
Annual Medical Coinsurance¹	Medicare pays: For Part A, varying coinsurance as listed below for hospital inpatient and skilled nursing facility care. After Part B deductible, 80% Plan pays: Part B deductible and 20% coinsurance You pay: $0	Medicare pays: For Part A, varying coinsurance as listed below for hospital inpatient and skilled nursing facility care. After Part B deductible, 80% Plan pays: Part B deductible and 20% coinsurance You pay: $0
Annual Medical Out-of-Pocket Limit (OOPL)	You pay: $0 Except for up to $500 per individual for durable medical equipment as listed below	You pay: $0
Outpatient illness/injury related services	Medicare pays: After Part B deductible, 80% Plan pays: Part B deductible and 20% coinsurance You pay: $0	Medicare pays: After Part B deductible, 80% Plan pays: Part B deductible and 20% coinsurance You pay: $0
Emergency Room Copay	Medicare pays: After Part B deductible, 80% Plan pays: Part B deductible and 20% coinsurance You pay: $60 copayment (waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer)	Medicare pays: After Part B deductible, 80% Plan pays: Part B deductible and 20% coinsurance You pay: $0
Hospital Semiprivate room and board, and miscellaneous hospital services and supplies such as drugs, X-rays, lab tests and operating room. “Lifetime reserve” days are a one-time additional 60 days of hospital coverage paid by Medicare.	Medicare pays: After Part A deductible; full cost for the first 60 days 61st to 90th day, all but $400 per day 91st to 150th day, all but $800 per day (if using “lifetime reserve”), if “lifetime reserve” days are exhausted, $0 Plan pays: 100% as medically necessary. No day limit Health Plan Medicare will pay plan providers only Medicare Advantage will pay any provider will accepts Medicare and is willing to treat you and bill UnitedHealthcare You pay: $0	Medicare pays: After Part A deductible; full cost for the first 60 days 61st to 90th day, all but $400 per day 91st to 150th day, all but $800 per day (if using “lifetime reserve), if “lifetime reserve” days are exhausted, $0 Plan pays: Initial Part A deductible of $1,364 for the first 60 days 61st to 90th day, $400 per day 91st to 150th day, $800 per day if under “lifetime reserve” period You pay: $0 for first 90 days of confinement, and up to 150 under “lifetime reserve.” Once “lifetime reserve” is exhausted, you pay the full cost after 90 days
Licensed Skilled Nursing Facility Medicare covered services in a Medicare approved facility	Health Plan Medicare requires a 3-day hospital stay Medicare Advantage has no 3-day requirement Medicare pays: 100% for the first 20 days 21st to 100th days, all but $200 per day Beyond 100 days, $0 Plan pays: 100% as medically necessary, for the first 120 days per benefit period; plan providers only Beyond 120 days, $0 You pay: $0 for the first 120 days, full cost after 120 days	Requires a 3-day period of hospital stay Medicare pays: 100% for the first 20 days 21st to 100th days, all but $200 per day Beyond 100 days, $0 Plan pays: 21st to 100th days, $200 per day 101st to 120th days, all covered services up to a maximum of 120 days per benefit period Beyond 120 days, $0 You pay: $0 for the first 120 days, full cost after 120 days
Licensed Skilled Nursing Facility (Non-Medicare approved facility) If admitted within 24 hours following a hospital stay	Medicare pays: $0 Plan pays: 120 days per benefit period for skilled care in a facility licensed in a state You pay: Full cost after 120 days	Medicare pays: $0 Plan pays: Maximum daily rate for up to 30 days per confinement; covers only the same type of expenses normally covered by Medicare in a Medicare-approved facility You pay: $0 for eligible expenses for the first 30 days, full cost after 30 days
Medicare Approved: Medical Supplies, Durable Medical Equipment and Durable Diabetic Equipment and Related Supplies	Medicare Pays: After Part B deductible, 80% Plan pays: If you have not met the Part B deductible, 80% If you have met the Part B deductible, but you have not met the $500 OOPL per participant, 0% If you have met the Part B deductible, and also the $500 OOPL per participant, 20% You pay: 20% up to $500 OOPL per participant, after OOPL, $0	Medicare Pays: After Part B deductible, 80% Plan pays: Part B deductible and 20% coinsurance You pay: $0
Not covered by Medicare: Medical Supplies, Durable Medical Equipment and Durable Diabetic Equipment and Related Supplies	Medicare pays: None Plan pays: If you have not met the $500 OOPL per participant, 80% If you have met the $500 OOPL per participant, 100% You pay: 20% up to $500 OOPL per participant, after OOPL, $0	Medicare pays: None Plan pays: None You pay: Full cost of supplies
Home Health Care You’re under the care of a doctor and the doctor certifies you need part-time skilled nursing care, part-time home health aide care, physical therapy, occupational therapy, speech-language pathology services, or medical social services	Medicare pays: 100% of charges for visits considered medically necessary by Medicare, generally fewer than 7 days a week, less than 8 hours a day and 28 or fewer hours per week for up to 21 days Health Plan Medicare pays: 100% for 50 visits per year, plan may approve an additional 50 visits Medicare Advantage pays: 100% for up to 365 visits per year You pay, under Health Plan Medicare: Full cost of visits not covered by Medicare and the plan beyond the 50 (or if approved, 100) visits per year You pay, under Medicare Advantage: Full cost of visits beyond 365 per year	Medicare pays: 100% of charges for visits considered medically necessary by Medicare, generally fewer than 7 days a week, less than 8 hours a day and 28 or fewer hours per week for up to 21 days Plan pays: 100% for up to 365 visits per year You pay: Full cost of visits beyond 365 per year
Routine Hearing Exam	Medicare Pays: None Plan pays: 100% You pay: $0	Medicare pays: None Plan pays: None You pay: Full cost of hearing exam
Hearing Exam for Illness or Disease	Medicare pays: After Part B deductible, 80% Plan pays: Deductible and 20% coinsurance You pay: $0	Medicare pays: After Part B deductible, 80% Plan pays: Deductible and 20% coinsurance You pay: $0
Hearing Aid (per ear)	Medicare pays: No coverage for adults Plan pays: 80% for adults up to plan paid $1,000 every three years (does not count toward OOPL) You pay: 20% coinsurance and 100% of costs exceeding plan payment of $1,000	Medicare pays: No coverage for adults Plan pays: None You pay: Full cost of hearing aid

¹Medicare deductible and coinsurance amounts listed are from 2023. Medicare deductible amounts are listed only to describe how your benefits work under the available plan designs. Your out-of-pocket costs are indicated in the "You pay" line.

²Medicare Plus pays only for services that Medicare covers. You pay the full cost of any non-covered services.