Hospital Deductible: $1,260.00 / Benefit period
Hospital Coinsurance:
- Days 0-60: $0
- Days 61-90: $315 / Day
- Days 91-150: $630/ Day
Skilled Nursing Facility Coinsurance:
- Days 1-20: $0
- Days 21-100: $157.50/ Day
Part A Premium (For voluntary enrollees only)
- With 30-39 quarters of Social Security coverage: $224.00 / Month
- With 29 or fewer quarters of Social Security coverage: $407.00 / Month
Part B
- Deductible: $147.00 / Year
- Standard Premium: $104.90 / Month*
Part B Income-Related Premium
Beneficiaries who file an individual tax return with income: | Beneficiaries who file a joint tax return with income: | Income-related monthly adjustment amount |
Total monthly premium amount |
Less than or equal to $85,000 | Less than or equal to $170,000 | $0 | $104.90 |
Greater than $85,000 and less than or equal to $107,000 | Greater than $170,000 and less than or equal to $214,000 | $42.00 | $146.90 |
Greater than $107,000 and less than or equal to $160,000 | Greater than $214,000 and less than or equal to $320,000 | $104.90 | $209.80 |
Greater than $160,000 and less than or equal to $214,000 | Greater than $320,000 and less than or equal to $428,000 | $167.80 | $272.70 |
Greater than $214 | Greater than $428,000 | $230.80 | $335.70 |
PART B PREMIUM (cont.)
In addition, the monthly Part B premium rates to be paid by beneficiaries who are married, but file a separate return from their spouse and lived with their spouse at some time during the taxable year are:
Beneficiaries who are married but file a separate tax return from their spouse: | Income-related monthly adjustment amount | Total monthly premium amount |
Less than or equal to $85,000 | $0.00 | $104.90 |
Greater than $85,000 and less than or equal to $129,000 | $167.80 | $272.70 |
Greater than $129,000 | $230.80 | $335.70 |
Standard Part D Cost-Sharing for 2015
Note: The amounts in this table do not apply to the beneficiaries who have the Part D Low Income Subsidy (“Extra Help”)
Annual Deductible Maximum: $320.00
Initial Coverage Period:
Members Pay 25% of the next… $2,640
Donut Hole Threshold Amount: $2,960
(Once the member AND the plan have spent
this amount, the member enters the Donut Hole)
Donut Hole $3,720
Catastrophic Coverage Threshold $4,700
(Begins when the member’s true out-of-pocket
costs equals this amount, including
Donut Hole discounts)
Total spending before Catastrophic Coverage $6,680
Cost Sharing During Catastrophic Coverage: $2.65 (generics)
$6.60 (brand name)
OR 5%, whichever is greater
Low-Income Subsidy Co-Payments (LIS)
1. Full Benefit Dual Eligibles Institutionalized or Receiving HCBS: $0
2. Full Benefit Dual Eligibles with incomes ≤ 100% Federal Poverty Level
- Generic/Preferred Drugs: $1.20
- Other: $3.60
- Above Catastrophic Limit: $0.00
3. Full Benefit Duals with Incomes >100% Federal Poverty Level & Other Full-Subsidy Eligible Beneficiaries
- Deductible: $0
- Generic/preferred drugs: $2.65
- Other: $6.60
- Above Catastrophic Limit: $0.00
4. Partial Subsidy Eligible Beneficiaries
- Deductible: $66.00
- Co-ins. to Initial Coverage Limit: 15%
- Generics above catastrophic limit: $2.65
- Others above catastrophic limit: $6.60