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Providence Health Plan is a health plan with a Medicare contract. - page 7 / 32

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SUMMARY OF BENEFITS

If you have any questions about this plan’s benefits or costs, please contact Providence Health Plan.

Benefit Category INPATIENT CARE (continued) 5 - Skilled Nursing Facility In 2010 the amounts for each Original Medicare

(in a Medicare-certified skilled nursing facility)

benefit period after at least a 3-day covered hospital stay were:

Providence Medicare Extra + RX

General Authorization rules may apply.

Days 1 - 20: $0 per day Days 21 - 100: $137.50 per day

In-Network Plan covers up to 100 days each benefit period.

These amounts will change for 2011.

No prior hospital stay is required.

100 days for each benefit period.

$0 copay for SNF services.

A "benefit period" starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

$0 copay.

In-Network

$0 copay for Medicare-covered home health visits.

6 - Home Health Care

(includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc)

7

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