August 11, 2009, Introduced by Rep. Byrum and referred to the Committee on Insurance.
A bill to amend 1956 PA 218, entitled
"The insurance code of 1956,"
by amending sections 3801, 3803, 3807, 3809, 3811, 3815, 3819,
3831, and 3839 (MCL 500.3801, 500.3803, 500.3807, 500.3809,
500.3811, 500.3815, 500.3819, 500.3831, and 500.3839), sections
3801, 3807, 3809, 3811, 3815, 3819, 3831, and 3839 as amended by
2006 PA 462 and section 3803 as added by 1992 PA 84, and by
adding sections 3807a, 3809a, 3811a, and 3819a.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
1 Sec. 3801. As used in this chapter:
2 (a) "Applicant" means:
3 (i) For an individual medicare supplement policy, the person
4 who seeks to contract for benefits.
5 (ii) For a group medicare supplement policy or certificate,
1 the proposed certificate holder.
2 (b) "Bankruptcy" means when a medicare advantage
3 organization that is not an insurer has filed, or has had filed
4 against it, a petition for declaration of bankruptcy and has
5 ceased doing business in this state.
6 (c) "Certificate" means any certificate delivered or issued
7 for delivery in this state under a group medicare supplement
8 policy.
9 (d) "Certificate form" means the form on which the
10 certificate is delivered or issued for delivery by the insurer.
11 (e) "Continuous period of creditable coverage" means the
12 period during which an individual was covered by creditable
13 coverage, if during the period of the coverage the individual had
14 no breaks in coverage greater than 63 days.
15 (f) "Creditable coverage" means coverage of an individual
16 provided under any of the following:
17 (i) A group health plan.
18 (ii) Health insurance coverage.
19 (iii) Part A or part B of medicare.
20 (iv) Medicaid other than coverage consisting solely of
21 benefits under section 1928 of medicaid, 42 USC 1396s.
22 (v) Chapter 55 of title 10 of the United States Code, 10 USC
23 1071 to 1110.
24 (vi) A medical care program of the Indian health service or
25 of a tribal organization.
26 (vii) A state health benefits risk pool.
27 (viii) A health plan offered under chapter 89 of title 5 of
1 the United States Code, 5 USC 8901 to 8914.
2 (ix) A public health plan as defined in federal regulation.
3 (x) Health care under section 5(e) of title I of the peace
4 corps act, 22 USC 2504.
5 (g) "Direct response solicitation" means solicitation in
6 which an insurer representative does not contact the applicant in
7 person and explain the coverage available, such as, but not
8 limited to, solicitation through direct mail or through
9 advertisements in periodicals and other media.
10 (h) "Employee welfare benefit plan" means a plan, fund, or
11 program of employee benefits as defined in section 3 of subtitle
12 A of title I of the employee retirement income security act of
13 1974, 29 USC 1002.
14 (i) "Insolvency" means when an insurer licensed to transact
15 the business of insurance in this state has had a final order of
16 liquidation entered against it with a finding of insolvency by a
17 court of competent jurisdiction in the insurer's state of
18 domicile.
19 (j) "Insurer" includes any entity, including a health care
20 corporation operating pursuant to the nonprofit health care
21 corporation reform act, 1980 PA 350, MCL 550.1101 to 550.1704,
22 delivering or issuing for delivery in this state medicare
23 supplement policies.
24 (k) "Medicaid" means title XIX of the social security act,
25 42 USC 1396 to 1396v.
26 (l) "Medicare" means title XVIII of the social security act,
27 42 USC 1395 to 1395ggg.
1 (m) "Medicare advantage" means a plan of coverage for health
2 benefits under medicare part C as defined in section 12-2859 of
3 part C of medicare, 42 USC 1395w-28, and includes any of the
4 following:
5 (i) Coordinated care plans that provide health care services,
6 including, but not limited to, health maintenance organization
7 plans with or without a point-of-service option, plans offered by
8 provider-sponsored organizations, and preferred provider
9 organization plans.
10 (ii) Medical savings account plans coupled with a
11 contribution into a medicare advantage medical savings account.
12 (iii) Medicare advantage private fee-for-service plans.
13 (n) "Medicare supplement buyer's guide" means the document
14 entitled, "guide to health insurance for people with medicare",
15 developed by the national association of insurance commissioners
16 and the United States department of health and human services or
17 a substantially similar document as approved by the commissioner.
18 (o) "Medicare supplement policy" means an individual,
19 nongroup, or group policy or certificate that is advertised,
20 marketed, or designed primarily as a supplement to reimbursements
21 under medicare for the hospital, medical, or surgical expenses of
22 persons eligible for medicare and medicare select policies and
23 certificates under section 3817. Medicare supplement policy does
24 not include a policy, certificate, or contract of 1 or more
25 employers or labor organizations, or of the trustees of a fund
26 established by 1 or more employers or labor organizations, or
27 both, for employees or former employees, or both, or for members
1 or former members, or both, of the labor organizations. Medicare
2 supplement policy does not include medicare advantage plans
3 established under medicare part C, outpatient prescription drug
4 plans established under medicare part D, or any health care
5 prepayment plan that provides benefits pursuant to an agreement
6 under section 1833(a)(1)(A) of the social security act.
7 (p) "PACE" means a program of all-inclusive care for the
8 elderly as described in the social security act.
9 (q) "Prestandardized medicare supplement benefit plan",
10 "prestandardized benefit plan", or "prestandardized plan" means a
11 group or individual policy of medicare supplement insurance
12 issued prior to June 2, 1992.
13 (r) "1990 standardized medicare supplement benefit plan",
14 "1990 standardized benefit plan", or "1990 plan" means a group or
15 individual policy of medicare supplement insurance issued on or
16 after June 2, 1992 with an effective date for coverage prior to
17 June 1, 2010 and includes medicare supplement insurance policies
18 and certificates renewed on or after that date which are not
19 replaced by the issuer at the request of the insured.
20 (s) "2010 standardized medicare supplement benefit plan",
21 "2010 standardized benefit plan", or "2010 plan" means a group or
22 individual policy of medicare supplement insurance with an
23 effective date for coverage on or after June 1, 2010.
24 (t) (q) "Policy
form" means the form on which the policy or
25 certificate is delivered or issued for delivery by the insurer.
26 (u) (r) "Secretary"
means the secretary of the United
States
27 department of health and human services.
1 (v) (s) "Social
security act" means the social security act,
2 42 USC 301 to 1397jj.
3 Sec. 3803. (1) Except as provided in subsection (2), this
4 chapter applies to a medicare supplement policy delivered, issued
5 for delivery, or renewed in this state with an effective date on
6 or after the effective date of this chapter June 2, 1992.
7 (2) Sections Except
for sections 3807a, 3809, 3811, and
8 3819(1) do not apply 3819(1)
and (4), and 3819a, this chapter
9
applies to a medicare supplement policy
issued before the
10 effective date of this chapter June 2, 1992.
11 Sec. 3807. (1) Every insurer issuing a medicare supplement
12 insurance policy in this state shall make available a medicare
13 supplement insurance policy that includes a basic core package of
14 benefits to each prospective insured. An insurer issuing a
15 medicare supplement insurance policy in this state may make
16 available to prospective insureds benefits pursuant to section
17 3809 that are in addition to, but not instead of, the basic core
18 package. The basic core package of benefits shall include all of
19 the following:
20 (a) Coverage of part A medicare eligible expenses for
21 hospitalization to the extent not covered by medicare from the
22 61st day through the 90th day in any medicare benefit period.
23 (b) Coverage of part A medicare eligible expenses incurred
24 for hospitalization to the extent not covered by medicare for
25 each medicare lifetime inpatient reserve day used.
26 (c) Upon exhaustion of the medicare hospital inpatient
27 coverage including the lifetime reserve days, coverage of 100% of
1 the medicare part A eligible expenses for hospitalization paid at
2 the applicable prospective payment system rate or other
3 appropriate medicare standard of payment, subject to a lifetime
4 maximum benefit of an additional 365 days.
5 (d) Coverage under medicare parts A and B for the reasonable
6 cost of the first 3 pints of blood or equivalent quantities of
7 packed red blood cells, as defined under federal regulations
8 unless replaced in accordance with federal regulations.
9 (e) Coverage for the coinsurance amount, or the copayment
10 amount paid for hospital outpatient department services under a
11 prospective payment system, of medicare eligible expenses under
12 part B regardless of hospital confinement, subject to the
13 medicare part B deductible.
14 (2) Standards for plans K and L are as follows:
15 (a) Standardized medicare supplement benefit plan K shall
16 consist of the following:
17 (i) Coverage of 100% of the part A hospital coinsurance
18 amount for each day used from the sixty-first day through the
19 ninetieth day in any medicare benefit period.
20 (ii) Coverage of 100% of the part A hospital coinsurance
21 amount for each medicare lifetime inpatient reserve day used from
22 the ninety-first day through the one hundred fiftieth day in any
23 medicare benefit period.
24 (iii) Upon exhaustion of the medicare hospital inpatient
25 coverage, including the lifetime reserve days, coverage of 100%
26 of the medicare part A eligible expenses for hospitalization paid
27 at the applicable prospective payment system rate, or other
1 appropriate medicare standard of payment, subject to a lifetime
2 maximum benefit of an additional 365 days. The provider shall
3 accept the insurer's payment as payment in full and may not bill
4 the insured for any balance.
5 (iv) Medicare part A deductible: coverage for 50% of the
6 medicare part A inpatient hospital deductible amount per benefit
7 period until the out-of-pocket limitation is met as described in
8 subparagraph (x).
9 (v) Skilled nursing facility care: coverage for 50% of the
10 coinsurance amount for each day used from the twenty-first day
11 through the one hundredth day in a medicare benefit period for
12 posthospital skilled nursing facility care eligible under
13 medicare part A until the out-of-pocket limitation is met as
14 described in subparagraph (x).
15 (vi) Hospice care: coverage for 50% of cost sharing for all
16 part A medicare eligible expenses and respite care until the out-
17 of-pocket limitation is met as described in subparagraph (x).
18 (vii) Coverage for 50%, under medicare part A or B, of the
19 reasonable cost of the first 3 pints of blood or equivalent
20 quantities of packed red blood cells, as defined under federal
21 regulations, unless replaced in accordance with federal
22 regulations until the out-of-pocket limitation is met as
23 described in subparagraph (x).
24 (viii) Except for coverage provided in subparagraph (ix) below,
25 coverage for 50% of the cost sharing otherwise applicable under
26 medicare part B after the policyholder pays the part B deductible
27 until the out-of-pocket limitation is met as described in
1 subparagraph (x).
2 (ix) Coverage of 100% of the cost sharing for medicare part B
3 preventive services after the policyholder pays the part B
4 deductible.
5 (x) Coverage of 100% of all cost sharing under medicare
6 parts A and B for the balance of the calendar year after the
7 individual has reached the out-of-pocket limitation on annual
8 expenditures under medicare parts A and B of $4,000.00 in 2006,
9 indexed each year by the appropriate inflation adjustment
10 specified by the secretary of the United States department of
11 health and human services.
12 (b) Standardized medicare supplement benefit plan L shall
13 consist of the following:
14 (i) The benefits described in subdivision (a)(i), (ii), (iii),
15 and (ix).
16 (ii) The benefit described in subdivision (a)(iv), (v), (vi),
17 (vii), and (viii), but substituting 75% for 50%.
18 (iii) The benefit described in subdivision (a)(x), but
19 substituting $2,000.00 for $4,000.00.
20 (3) This section applies to medicare supplement policies or
21 certificates delivered or issued for delivery with an effective
22 date for coverage prior to June 1, 2010.
23 Sec. 3807a. (1) This section applies to all medicare
24 supplement policies or certificates delivered or issued for
25 delivery with an effective date for coverage on or after June 1,
26 2010.
27 (2) Every insurer issuing a medicare supplement insurance
1 policy in this state shall make available a medicare supplement
2 insurance policy that includes a basic core package of benefits
3 to each prospective insured. An insurer issuing a medicare
4 supplement insurance policy in this state may make available to
5 prospective insureds benefits pursuant to section 3809a that are
6 in addition to, but not instead of, the basic core package. The
7 basic core package of benefits shall include all of the
8 following:
9 (a) Coverage of part A medicare eligible expenses for
10 hospitalization to the extent not covered by medicare from the
11 sixty-first day through the ninetieth day in any medicare benefit
12 period.
13 (b) Coverage of part A medicare eligible expenses incurred
14 for hospitalization to the extent not covered by medicare for
15 each medicare lifetime inpatient reserve day used.
16 (c) Upon exhaustion of the medicare hospital inpatient
17 coverage including the lifetime reserve days, coverage of 100% of
18 the medicare part A eligible expenses for hospitalization paid at
19 the applicable prospective payment system rate or other
20 appropriate medicare standard of payment, subject to a lifetime
21 maximum benefit of an additional 365 days.
22 (d) Coverage under medicare parts A and B for the reasonable
23 cost of the first 3 pints of blood or equivalent quantities of
24 packed red blood cells, as defined under federal regulations
25 unless replaced in accordance with federal regulations.
26 (e) Coverage for the coinsurance amount, or the copayment
27 amount paid for hospital outpatient department services under a
1 prospective payment system, of medicare eligible expenses under
2 part B regardless of hospital confinement, subject to the
3 medicare part B deductible.
4 (f) Coverage of cost sharing for all part A medicare
5 eligible hospice care and respite care expenses.
6 Sec. 3809. (1) In addition to the basic core package of
7 benefits required under section 3807, the following benefits may
8 be included in a medicare supplement insurance policy and if
9 included shall conform to section 3811(5)(b) to (j):
10 (a) Medicare part A deductible: coverage for all of the
11 medicare part A inpatient hospital deductible amount per benefit
12 period.
13 (b) Skilled nursing facility care: coverage for the actual
14 billed charges up to the coinsurance amount from the 21st day
15 through the 100th day in a medicare benefit period for
16 posthospital skilled nursing facility care eligible under
17 medicare part A.
18 (c) Medicare part B deductible: coverage for all of the
19 medicare part B deductible amount per calendar year regardless of
20 hospital confinement.
21 (d) Eighty percent of the medicare part B excess charges:
22 coverage for 80% of the difference between the actual medicare
23 part B charge as billed, not to exceed any charge limitation
24 established by medicare or state law, and the medicare-approved
25 part B charge.
26 (e) One hundred percent of the medicare part B excess
27 charges: coverage for all of the difference between the actual
1 medicare part B charge as billed, not to exceed any charge
2 limitation established by medicare or state law, and the
3 medicare-approved part B charge.
4 (f) Basic outpatient prescription drug benefit: coverage for
5 50% of outpatient prescription drug charges, after a $250.00
6 calendar year deductible, to a maximum of $1,250.00 in benefits
7 received by the insured per calendar year, to the extent not
8 covered by medicare. The outpatient prescription drug benefit may
9 be included for sale or issuance in a medicare supplement policy
10 until January 1, 2006.
11 (g) Extended outpatient prescription drug benefit: coverage
12 for 50% of outpatient prescription drug charges, after a $250.00
13 calendar year deductible, to a maximum of $3,000.00 in benefits
14 received by the insured per calendar year, to the extent not
15 covered by medicare. The outpatient prescription drug benefit may
16 be included for sale or issuance in a medicare supplement policy
17 until January 1, 2006.
18 (h) Medically necessary emergency care in a foreign country:
19 coverage to the extent not covered by medicare for 80% of the
20 billed charges for medicare-eligible expenses for medically
21 necessary emergency hospital, physician, and medical care
22 received in a foreign country, which care would have been covered
23 by medicare if provided in the United States and which care began
24 during the first 60 consecutive days of each trip outside the
25 United States, subject to a calendar year deductible of $250.00,
26 and a lifetime maximum benefit of $50,000.00. For purposes of
27 this benefit, "emergency care" means care needed immediately
1 because of an injury or an illness of sudden and unexpected
2 onset.
3 (i) Preventive medical care benefit: Coverage for the
4 following preventive health services not covered by medicare:
5 (i) An annual clinical preventive medical history and
6 physical examination that may include tests and services from
7 subparagraph (ii) and patient education to address preventive
8 health care measures.
9 (ii) Preventive screening tests or preventive services, the
10 selection and frequency of which is determined to be medically
11 appropriate by the attending physician.
12 (j) At-home recovery benefit: coverage for services to
13 provide short term, at-home assistance with activities of daily
14 living for those recovering from an illness, injury, or surgery.
15 At-home recovery services provided shall be primarily services
16 that assist in activities of daily living. The insured's
17 attending physician shall certify that the specific type and
18 frequency of at-home recovery services are necessary because of a
19 condition for which a home care plan of treatment was approved by
20 medicare. Coverage is excluded for home care visits paid for by
21 medicare or other government programs and care provided by family
22 members, unpaid volunteers, or providers who are not care
23 providers. Coverage is limited to:
24 (i) No more than the number of at-home recovery visits
25 certified as necessary by the insured's attending physician. The
26 total number of at-home recovery visits shall not exceed the
27 number of medicare approved home health care visits under a
1 medicare approved home care plan of treatment.
2 (ii) The actual charges for each visit up to a maximum
3 reimbursement of $40.00 per visit.
4 (iii) One thousand six hundred dollars per calendar year.
5 (iv) Seven visits in any 1 week.
6 (v) Care furnished on a visiting basis in the insured's
7 home.
8 (vi) Services provided by a care provider as defined in this
9 section.
10 (vii) At-home recovery visits while the insured is covered
11 under the insurance policy and not otherwise excluded.
12 (viii) At-home recovery visits received during the period the
13 insured is receiving medicare approved home care services or no
14 more than 8 weeks after the service date of the last medicare
15 approved home health care visit.
16 (k) New or innovative benefits: an insurer may, with the
17 prior approval of the commissioner, offer policies or
18 certificates with new or innovative benefits in addition to the
19 benefits provided in a policy or certificate that otherwise
20 complies with the applicable standards. The new or innovative
21 benefits may include benefits that are appropriate to medicare
22 supplement insurance, new or innovative, not otherwise available,
23 cost-effective, and offered in a manner that is consistent with
24 the goal of simplification of medicare supplement policies. After
25 December 31, 2005, the innovative benefit shall not include an
26 outpatient prescription drug benefit.
27 (2) Reimbursement for the preventive screening tests and
1 services under subsection (1)(i)(ii) shall be for the actual
2 charges up to 100% of the medicare-approved amount for each test
3 or service, as if medicare were to cover the test or service as
4 identified in the American medical association current procedural
5 terminology codes, to a maximum of $120.00 annually under this
6 benefit. This benefit shall not include payment for any procedure
7 covered by medicare.
8 (3) As used in subsection (1)(j):
9 (a) "Activities of daily living" include, but are not
10 limited to, bathing, dressing, personal hygiene, transferring,
11 eating, ambulating, assistance with drugs that are normally self-
12 administered, and changing bandages or other dressings.
13 (b) "Care provider" means a duly qualified or licensed home
14 health aide/homemaker, personal care aide, or nurse provided
15 through a licensed home health care agency or referred by a
16 licensed referral agency or licensed nurses registry.
17 (c) "Home" means any place used by the insured as a place of
18 residence, provided that it qualifies as a residence for home
19 health care services covered by medicare. A hospital or skilled
20 nursing facility shall not be considered the insured's home.
21 (d) "At-home recovery visit" means the period of a visit
22 required to provide at home recovery care, without limit on the
23 duration of the visit, except each consecutive 4 hours in a 24-
24 hour period of services provided by a care provider is 1 visit.
25 (4) This section applies to medicare supplement policies or
26 certificates delivered or issued for delivery on or after June 2,
27 1992 with an effective date for coverage prior to June 1, 2010.
1 Sec. 3809a. (1) This section applies to all medicare
2 supplement policies or certificates delivered or issued for
3 delivery with an effective date for coverage on or after June 1,
4 2010.
5 (2) In addition to the basic core package of benefits
6 required under section 3807a, the following benefits may be
7 included in a medicare supplement insurance policy and if
8 included shall conform to section 3811a(6)(b) to (j):
9 (a) Medicare part A deductible: coverage for 100% of the
10 medicare part A inpatient hospital deductible amount per benefit
11 period.
12 (b) Medicare part A deductible: coverage for 50% of the
13 medicare part A inpatient hospital deductible amount per benefit
14 period.
15 (c) Skilled nursing facility care: coverage for the actual
16 billed charges up to the coinsurance amount from the twenty-first
17 day through the one hundredth day in a medicare benefit period
18 for posthospital skilled nursing facility care eligible under
19 medicare part A.
20 (d) Medicare part B deductible: coverage for 100% of the
21 medicare part B deductible amount per calendar year regardless of
22 hospital confinement.
23 (e) One hundred percent of the medicare part B excess
24 charges: coverage for all of the difference between the actual
25 medicare part B charge as billed, not to exceed any charge
26 limitation established by medicare or state law, and the
27 medicare-approved part B charge.
1 (f) Medically necessary emergency care in a foreign country:
2 coverage to the extent not covered by medicare for 80% of the
3 billed charges for medicare-eligible expenses for medically
4 necessary emergency hospital, physician, and medical care
5 received in a foreign country, which care would have been covered
6 by medicare if provided in the United States and which care began
7 during the first 60 consecutive days of each trip outside the
8 United States, subject to a calendar year deductible of $250.00,
9 and a lifetime maximum benefit of $50,000.00. For purposes of
10 this benefit, "emergency care" means care needed immediately
11 because of an injury or an illness of sudden and unexpected
12 onset.
13 Sec. 3811. (1) An insurer shall make available to each
14 prospective medicare supplement policyholder and certificate
15 holder a policy form or certificate form containing only the
16 basic core benefits as provided in section 3807.
17 (2) Groups, packages, or combinations of medicare supplement
18 benefits other than those listed in this section shall not be
19 offered for sale in this state except as may be permitted in
20 section 3809(1)(k).
21 (3) Benefit plans shall contain the appropriate A through L
22 designations, shall be uniform in structure, language, and format
23 to the standard benefit plans in subsection (5), and shall
24 conform to the definitions in this chapter. Each benefit shall be
25 structured in accordance with sections 3807 and 3809 and list the
26 benefits in the order shown in subsection (5). For purposes of
27 this section, "structure, language, and format" means style,
1 arrangement, and overall content of a benefit.
2 (4) In addition to the benefit plan designations A through L
3 as provided under subsection (5), an insurer may use other
4 designations to the extent permitted by law.
5 (5) A medicare supplement insurance benefit plan shall
6 conform to 1 of the following:
7 (a) A standardized medicare supplement benefit plan A shall
8 be limited to the basic core benefits common to all benefit plans
9 as defined in section 3807.
10 (b) A standardized medicare supplement benefit plan B shall
11 include only the following: the core benefits as defined in
12 section 3807 and the medicare part A deductible as defined in
13 section 3809(1)(a).
14 (c) A standardized medicare supplement benefit plan C shall
15 include only the following: the core benefits as defined in
16 section 3807, the medicare part A deductible, skilled nursing
17 facility care, medicare part B deductible, and medically
18 necessary emergency care in a foreign country as defined in
19 section 3809(1)(a), (b), (c), and (h).
20 (d) A standardized medicare supplement benefit plan D shall
21 include only the following: the core benefits as defined in
22 section 3807, the medicare part A deductible, skilled nursing
23 facility care, medically necessary emergency care in a foreign
24 country, and the at-home recovery benefit as defined in section
25 3809(1)(a), (b), (h), and (j).
26 (e) A standardized medicare supplement benefit plan E shall
27 include only the following: the core benefits as defined in
1 section 3807, the medicare part A deductible, skilled nursing
2 facility care, medically necessary emergency care in a foreign
3 country, and preventive medical care as defined in section
4 3809(1)(a), (b), (h), and (i).
5 (f) A standardized medicare supplement benefit plan F shall
6 include only the following: the core benefits as defined in
7 section 3807, the medicare part A deductible, skilled nursing
8 facility care, medicare part B deductible, 100% of the medicare
9 part B excess charges, and medically necessary emergency care in
10 a foreign country as defined in section 3809(1)(a), (b), (c),
11 (e), and (h). A standardized medicare supplement plan F high
12 deductible shall include only the following: 100% of covered
13 expenses following the payment of the annual high deductible plan
14 F deductible. The covered expenses include the core benefits as
15 defined in section 3807, plus the medicare part A deductible,
16 skilled nursing facility care, the medicare part B deductible,
17 100% of the medicare part B excess charges, and medically
18 necessary emergency care in a foreign country as defined in
19 section 3809(1)(a), (b), (c), (e), and (h). The annual high
20 deductible plan F deductible shall consist of out-of-pocket
21 expenses, other than premiums, for services covered by the
22 medicare supplement plan F policy, and shall be in addition to
23 any other specific benefit deductibles. The annual high
24 deductible plan F deductible is $1,790.00 for calendar year 2006,
25 and the secretary shall adjust it annually thereafter to reflect
26 the change in the consumer price index for all urban consumers
27 for the 12-month period ending with August of the preceding year,
1 rounded to the nearest multiple of $10.00.
2 (g) A standardized medicare supplement benefit plan G shall
3 include only the following: the core benefits as defined in
4 section 3807, the medicare part A deductible, skilled nursing
5 facility care, 80% of the medicare part B excess charges,
6 medically necessary emergency care in a foreign country, and the
7 at-home recovery benefit as defined in section 3809(1)(a), (b),
8 (d), (h), and (j).
9 (h) A standardized medicare supplement benefit plan H shall
10 include only the following: the core benefits as defined in
11 section 3807, the medicare part A deductible, skilled nursing
12 facility care, basic outpatient prescription drug benefit, and
13 medically necessary emergency care in a foreign country as
14 defined in section 3809(1)(a), (b), (f), and (h). The outpatient
15 drug benefit shall not be included in a medicare supplement
16 policy sold after December 31, 2005.
17 (i) A standardized medicare supplement benefit plan I shall
18 include only the following: the core benefits as defined in
19 section 3807, the medicare part A deductible, skilled nursing
20 facility care, 100% of the medicare part B excess charges, basic
21 outpatient prescription drug benefit, medically necessary
22 emergency care in a foreign country, and at-home recovery benefit
23 as defined in section 3809(1)(a), (b), (e), (f), (h), and (j).
24 The outpatient drug benefit shall not be included in a medicare
25 supplement policy sold after December 31, 2005.
26 (j) A standardized medicare supplement benefit plan J shall
27 include only the following: the core benefits as defined in
1 section 3807, the medicare part A deductible, skilled nursing
2 facility care, medicare part B deductible, 100% of the medicare
3 part B excess charges, extended outpatient prescription drug
4 benefit, medically necessary emergency care in a foreign country,
5 preventive medical care, and at-home recovery benefit as defined
6 in section 3809(1)(a), (b), (c), (e), (g), (h), (i), and (j). A
7 standardized medicare supplement benefit plan J high deductible
8 plan shall consist of only the following: 100% of covered
9 expenses following the payment of the annual high deductible plan
10 J deductible. The covered expenses include the core benefits as
11 defined in section 3807, plus the medicare part A deductible,
12 skilled nursing facility care, medicare part B deductible, 100%
13 of the medicare part B excess charges, extended outpatient
14 prescription drug benefit, medically necessary emergency care in
15 a foreign country, preventive medical care benefit and at-home
16 recovery benefit as defined in section 3809(1)(a), (b), (c), (e),
17 (g), (h), (i), and (j). The annual high deductible plan J
18 deductible shall consist of out-of-pocket expenses, other than
19 premiums, for services covered by the medicare supplement plan J
20 policy, and shall be in addition to any other specific benefit
21 deductibles. The annual deductible shall be $1,790.00 for
22 calendar year 2006, and the secretary shall adjust it annually
23 thereafter to reflect the change in the consumer price index for
24 all urban consumers for the 12-month period ending with August of
25 the preceding year, rounded to the nearest multiple of $10.00.
26 The outpatient drug benefit shall not be included in a medicare
27 supplement policy sold after December 31, 2005.
1 (k) A standardized medicare supplement benefit plan K shall
2 consist of only those benefits described in section 3807(2)(a).
3 (l) A standardized medicare supplement benefit plan L shall
4 consist of only those benefits described in section 3807(2)(b).
5 (6) This section applies to medicare supplement policies or
6 certificates delivered or issued for delivery on or after June 2,
7 1992 with an effective date for coverage prior to June 1, 2010.
8 Sec. 3811a. (1) This section applies to all medicare
9 supplement policies or certificates delivered or issued for
10 delivery with an effective date for coverage on or after June 1,
11 2010.
12 (2) An insurer shall make available to each prospective
13 medicare supplement policyholder and certificate holder a policy
14 form or certificate form containing only the basic core benefits
15 as provided in section 3807a. If an insurer makes available any
16 of the additional benefits described in section 3809a or offers
17 standardized benefit plans K or L, the insurer shall make
18 available to each prospective medicare supplement policyholder
19 and certificate holder a policy form or certificate form
20 containing either standardized benefit plan C or standardized
21 benefit plan F.
22 (3) Groups, packages, or combinations of medicare supplement
23 benefits other than those listed in this section shall not be
24 offered for sale in this state except as may be permitted in
25 subsection (6)(k).
26 (4) Benefit plans shall be uniform in structure, language,
27 designation, and format to the standard benefit plans in
1 subsection (6) and shall conform to the definitions in this
2 chapter. Each benefit shall be structured in accordance with
3 sections 3807a and 3809a and list the benefits in the order shown
4 in subsection (6). For purposes of this section, "structure,
5 language, and format" means style, arrangement, and overall
6 content of a benefit.
7 (5) In addition to the benefit plan designations as provided
8 under subsection (6), an insurer may use other designations to
9 the extent permitted by law.
10 (6) A medicare supplement insurance benefit plan shall
11 conform to 1 of the following:
12 (a) A standardized medicare supplement benefit plan A shall
13 be limited to the basic core benefits common to all benefit plans
14 as defined in section 3807a.
15 (b) A standardized medicare supplement benefit plan B shall
16 include only the following: the core benefits as defined in
17 section 3807a and 100% of the medicare part A deductible as
18 defined in section 3809a(2)(a).
19 (c) A standardized medicare supplement benefit plan C shall
20 include only the following: the core benefits as defined in
21 section 3807a, 100% of the medicare part A deductible, skilled
22 nursing facility care, 100% of the medicare part B deductible,
23 and medically necessary emergency care in a foreign country as
24 defined in section 3809(2)(a), (c), (d), and (f).
25 (d) A standardized medicare supplement benefit plan D shall
26 include only the following: the core benefits as defined in
27 section 3807a, 100% of the medicare part A deductible, skilled
1 nursing facility care, and medically necessary emergency care in
2 a foreign country as defined in section 3809(2)(a), (c), and (f).
3 (e) A standardized medicare supplement benefit plan F shall
4 include only the following: the core benefits as defined in
5 section 3807a, 100% of the medicare part A deductible, skilled
6 nursing facility care, 100% of the medicare part B deductible,
7 100% of the medicare part B excess charges, and medically
8 necessary emergency care in a foreign country as defined in
9 section 3809(2)(a), (c), (e), and (f). A standardized medicare
10 supplement plan F high deductible shall include only the
11 following: 100% of covered expenses following the payment of the
12 annual high deductible plan F deductible. The covered expenses
13 include the core benefits as defined in section 3807a, plus 100%
14 of the medicare part A deductible, skilled nursing facility care,
15 100% of the medicare part B deductible, 100% of the medicare part
16 B excess charges, and medically necessary emergency care in a
17 foreign country as defined in section 3809(2)(a), (c), (d), (e),
18 and (f). The annual high deductible plan F deductible shall
19 consist of out-of-pocket expenses, other than premiums, for
20 services covered by the medicare supplement plan F policy, and
21 shall be in addition to any other specific benefit deductibles.
22 The annual high deductible plan F deductible is $1,500.00 for
23 calendar year 1999, and the secretary shall adjust it annually
24 thereafter to reflect the change in the consumer price index for
25 all urban consumers for the 12-month period ending with August of
26 the preceding year, rounded to the nearest multiple of $10.00.
27 (f) A standardized medicare supplement benefit plan G shall
1 include only the following: the core benefits as defined in
2 section 3807a, 100% of the medicare part A deductible, skilled
3 nursing facility care, 100% of the medicare part B excess
4 charges, and medically necessary emergency care in a foreign
5 country as defined in section 3809(2)(a), (c), (e), and (f).
6 (g) Standardized medicare supplement benefit plan K shall
7 consist of the following:
8 (i) Coverage of 100% of the part A hospital coinsurance
9 amount for each day used from the sixty-first day through the
10 ninetieth day in any medicare benefit period.
11 (ii) Coverage of 100% of the part A hospital coinsurance
12 amount for each medicare lifetime inpatient reserve day used from
13 the ninety-first day through the one hundred fiftieth day in any
14 medicare benefit period.
15 (iii) Upon exhaustion of the medicare hospital inpatient
16 coverage, including the lifetime reserve days, coverage of 100%
17 of the medicare part A eligible expenses for hospitalization paid
18 at the applicable prospective payment system rate, or other
19 appropriate medicare standard of payment, subject to a lifetime
20 maximum benefit of an additional 365 days. The provider shall
21 accept the insurer's payment as payment in full and may not bill
22 the insured for any balance.
23 (iv) Medicare part A deductible: coverage for 50% of the
24 medicare part A inpatient hospital deductible amount per benefit
25 period until the out-of-pocket limitation is met as described in
26 subparagraph (x).
27 (v) Skilled nursing facility care: coverage for 50% of the
1 coinsurance amount for each day used from the twenty-first day
2 through the one hundredth day in a medicare benefit period for
3 posthospital skilled nursing facility care eligible under
4 medicare part A until the out-of-pocket limitation is met as
5 described in subparagraph (x).
6 (vi) Hospice care: coverage for 50% of cost sharing for all
7 part A medicare eligible expenses and respite care until the out-
8 of-pocket limitation is met as described in subparagraph (x).
9 (vii) Coverage for 50%, under medicare part A or B, of the
10 reasonable cost of the first 3 pints of blood or equivalent
11 quantities of packed red blood cells, as defined under federal
12 regulations, unless replaced in accordance with federal
13 regulations until the out-of-pocket limitation is met as
14 described in subparagraph (x).
15 (viii) Except for coverage provided in subparagraph (ix) below,
16 coverage for 50% of the cost sharing otherwise applicable under
17 medicare part B after the policyholder pays the part B deductible
18 until the out-of-pocket limitation is met as described in
19 subparagraph (x).
20 (ix) Coverage of 100% of the cost sharing for medicare part B
21 preventive services after the policyholder pays the part B
22 deductible.
23 (x) Coverage of 100% of all cost sharing under medicare
24 parts A and B for the balance of the calendar year after the
25 individual has reached the out-of-pocket limitation on annual
26 expenditures under medicare parts A and B of $4,000.00 in 2006,
27 indexed each year by the appropriate inflation adjustment
1 specified by the secretary of the United States department of
2 health and human services.
3 (h) Standardized medicare supplement benefit plan L shall
4 consist of the following:
5 (i) The benefits described in subdivision (g)(i), (ii), (iii),
6 and (ix).
7 (ii) The benefits described in subdivision (g)(iv), (v), (vi),
8 (vii), and (viii), but substituting 75% for 50%.
9 (iii) The benefit described in subdivision (g)(x), but
10 substituting $2,000.00 for $4,000.00.
11 (i) A standardized medicare supplement benefit plan M shall
12 include only the following: the core benefits as defined in
13 section 3807a and 50% of the medicare part A deductible, skilled
14 nursing care, and medically necessary emergency care in a foreign
15 country as defined in section 3809a(2)(b), (c), (d), and (f).
16 (j) A standardized medicare supplement benefit plan N shall
17 include only the following: the core benefits as defined in
18 section 3807a, 100% of the medicare part A deductible, skilled
19 nursing facility care, and medically necessary emergency care in
20 a foreign country as defined in section 3809(2)(a), (c), and (f)
21 with copayments in the following amounts:
22 (i) The lesser of $20.00 of the medicare part B coinsurance
23 or copayment for each covered health care provider office visit,
24 including visits to medical specialists.
25 (ii) The lesser of $50.00 or the medicare part B coinsurance
26 or copayment for each covered emergency room visit. The copayment
27 shall be waived if the insured is admitted to any hospital and
1 the emergency visit is subsequently covered as a medicare part A
2 expense.
3 (k) New or innovative benefits: an insurer may, with the
4 prior approval of the commissioner, offer policies or
5 certificates with new or innovative benefits in addition to the
6 benefits provided in a policy or certificate that otherwise
7 complies with the applicable standards. The new or innovative
8 benefits may include benefits that are appropriate to medicare
9 supplement insurance, new or innovative, not otherwise available,
10 cost-effective, and offered in a manner that is consistent with
11 the goal of simplification of medicare supplement policies. The
12 innovative benefit shall not include an outpatient prescription
13 drug benefit. New or innovative benefits shall not be used to
14 change or reduce benefits, including a change of any cost-sharing
15 provision, in any standardized plan.
16 Sec. 3815. (1) An insurer that offers a medicare supplement
17 policy shall provide to the applicant at the time of application
18 an outline of coverage and, except for direct response
19 solicitation policies, shall obtain an acknowledgment of receipt
20 of the outline of coverage from the applicant. The outline of
21 coverage provided to applicants pursuant to this section shall
22 consist of the following 4 parts:
23 (a) A cover page.
24 (b) Premium information.
25 (c) Disclosure pages.
26 (d) Charts displaying the features of each benefit plan
27 offered by the insurer.
1 (2) Insurers shall comply with any notice requirements of
2 the medicare prescription drug, improvement, and modernization
3 act of 2003, Public Law 108-173.
4 (3) If an outline of coverage is provided at the time of
5 application and the medicare supplement policy or certificate is
6 issued on a basis that would require revision of the outline, a
7 substitute outline of coverage properly describing the policy or
8 certificate shall accompany the policy or certificate when it is
9 delivered and shall contain the following statement, in no less
10 than 12-point type, immediately above the company name:
11 NOTICE: Read this outline of coverage carefully.
12 It is not identical to the outline of coverage
13 provided upon application and the coverage
14 originally applied for has not been issued.
15 (4) An outline of coverage under subsection (1) shall be in
16 the language and format prescribed in this section and in not
17 less than 12-point type. The A through L letter designation of
18 the plan shall be shown on the cover page and the plans offered
19 by the insurer shall be prominently identified. Premium
20 information shall be shown on the cover page or immediately
21 following the cover page and shall be prominently displayed. The
22 premium and method of payment mode shall be stated for all plans
23 that are offered to the applicant. All possible premiums for the
24 applicant shall be illustrated. The following items shall be
25 included in the outline of coverage in the order prescribed below
26 and in substantially the following form, as approved by the
1 commissioner:
2 (Insurer Name)
3 Medicare Supplement Coverage
4 Outline of Medicare Supplement Coverage-Cover Page:
5 Benefit Plan(s)_____[insert letter(s) of plan(s) being offered]
6 Medicare supplement insurance can be sold in only 12
7 standard plans plus 2 high deductible plans. This chart shows
8 the benefits included in each plan. Every insurer shall make
9 available Plan "A". Some plans may not be available in your
10 state.
11 BASIC BENEFITS: For plans A-J.
12 Hospitalization: Part A coinsurance plus coverage for 365
13 additional days after Medicare benefits end.
14 Medical Expenses: Part B coinsurance (20% of Medicare-approved
15 expenses) or copayments for hospital outpatient services.
16 Blood: First three pints of blood each year.
17
A B C D E F|F* G H I J|J*
18 Basic Benefits x x x x x x x x x x
19 Skilled Nursing
20 Co-Insurance x x x x x x x x
21 Part A Deductible x x x x x x x x x
22 Part B Deductible x x x
23 Part B Excess x x x x
24 100% 80% 100% 100%
25 Foreign Travel
26 Emergency x x x x x x x x
27 At-Home Recovery x x x x
1
2
3
4 Preventive Care not covered by Medicare x x
5 [COMPANY NAME]
6 Outline of Medicare Supplement Coverage – Cover Page 2
7 Basic Benefits for Plans K and L include similar services as
8 plans A-J, but cost-sharing for the basic benefits is at
9 different levels.
10 K** L**
11 Basic Benefits 100% of Part A 100% of Part A
12 hospitalization hospitalization
13 coinsurance
plus coinsurance plus
14 coverage
for 365 days coverage for 365 days
15 after
Medicare after Medicare
16 benefits
end benefits end
17 50%
Hospice cost- 75% Hospice cost-
18 sharing sharing
19 50%
of Medicare- 75% of Medicare-
20 eligible eligible
21 expenses
for the expenses for the
22 first
three pints first three pints
23 of
blood of blood
24 50%
Part B 75% Part B
25 coinsurance,
except coinsurance, except
26 100%
coinsurance for 100% coinsurance for
27 Part
B preventive Part B preventive
1 services services
2 Skilled Nursing 50% skilled nursing 75% skilled nursing
3 Coinsurance facility coinsurance facility coinsurance
4 Part A Deductible 50% Part A deductible 75% Part A deductible
5 Part B Deductible
6 Part B Excess (100%)
7 Foreign Travel
8 Emergency
9 At-Home Recovery
10 Preventive Care not
11 covered by Medicare
12 $4,000
out of pocket $2,000 out of pocket
13 Annual
Limit*** Annual Limit***
14 *Plans F and J also have an option called a high deductible plan F
15 and a high deductible plan J. These high deductible plans pay the
16 same benefits as Plans F and J after one has paid a calendar year
17 ($1,790) deductible. Benefits from high deductible Plans F and J
18 will not begin until out-of-pocket expenses exceed ($1,790). Out-
19 of-pocket expenses for this deductible are expenses that would
20 ordinarily be paid by the policy. These expenses include the
21 Medicare deductibles for Part A and Part B, but do not include the
22 plan's separate foreign travel emergency deductible.
23 **Plans K and L provide for different cost-sharing for items and
24 services than Plans A-J.
25 Once you reach the annual limit, the plan pays 100% of the Medicare
26 copayments, coinsurance, and deductibles for the rest of the
1 calendar year. The out-of-pocket annual limit does NOT include
2 charges from your provider that exceed Medicare-approved amounts,
3 called "Excess Charges". You will be responsible for paying
excess
4 charges.
5 ***The out-of-pocket annual limit will increase each year for
6 inflation.
7 See Outlines of Coverage for details and exceptions.
8 BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD
9 ON OR AFTER JUNE 1, 2010
10 This chart shows the benefits included in each of the
11 standard Medicare supplement plans. Every company must make Plan
12 "A" available. Some plans may not be available in your state.
13 Plans E, H, I, and J are no longer available for sale. (This
14 sentence shall not appear after June 1, 2011.)
15 BASIC BENEFITS:
16 Hospitalization: Part A coinsurance plus coverage for 365
17 additional days after Medicare benefits end.
18 Medical Expenses: Part B coinsurance (generally 20% of
19 Medicare-approved expenses) or copayments for hospital
20 outpatient services. Plans K, L, and N require insureds
21 to pay a portion of Part B coinsurance or copayments.
22 Blood: First three pints of blood each year.
23 Hospice: Part A coinsurance
1 A B C D F|F* G
2 Basic, Basic, Basic, Basic, Basic, Basic,
3 including including including including including including
4 100% Part 100% Part 100% Part 100% Part 100% Part 100% Part
5 B coin- B coinsur- B coinsur- B coinsur- B coinsur- B coinsur-
6 surance ance ance ance ance ance
7 Skilled Skilled Skilled Skilled
8 Nursing Nursing Nursing Nursing
9 Facility Facility Facility Facility
10 Coinsur- Coinsur- Coinsur- Coinsur-
11 ance ance ance ance
12 Part A Part A Part A Part A Part A
13 Deductible Deductible Deductible Deductible Deductible
14 Part B Part B
15 Deductible Deductible
16 Part B Part B
17 Excess Excess
18 (100%) (100%)
19 Foreign Foreign Foreign Foreign
20 Travel Travel Travel Travel
21 Emergency Emergency Emergency Emergency
22 K L M N
23 Hospitalization Hospitalization Basic, Basic, includ-
24 and preventive and preventive including 100% ing 100% Part B
25 care paid at care paid at Part B coinsurance,
26 100%; other 100%; other coinsurance except up to
27 basic benefits basic benefits $20 copayment
28 paid at 50% paid at 75% for office
29 visit, and up
30 to $50 copay-
1 ment for ER
2 50% Skilled 75% Skilled Skilled Skilled
3 Nursing Nursing Nursing Nursing
4 Facility Facility Facility Facility
5 Coinsurance Coinsurance Coinsurance Coinsurance
6 50% Part A 75% Part A 50% Part A Part A
7 Deductible Deductible Deductible Deductible
8
9
10
11
12
13 Foreign Foreign
14 Travel Travel
15 Emergency Emergency
16 Out-of-pocket Out-of-pocket
17 limit $4,140; limit $2,070;
18 paid at 100% paid at 100%
19 after limit after limit
20 reached reached
21 * Plan F also has an option called a high-deductible Plan F.
22 This high-deductible plan pays the same benefits as Plan F after
23 one has paid a calendar year $1,860 deductible. Benefits from
24 high-deductible Plan F will not begin until out-of-pocket
25 expenses exceed $1,860. Out-of-pocket expenses for this
26 deductible are expenses that would ordinarily be paid by the
27 policy. These expenses include the Medicare deductibles for Part
28 A and Part B, but do not include the plan's separate foreign
29 travel emergency deductible.
1 PREMIUM INFORMATION
2 We (insert insurer's name) can only raise your premium if we
3 raise the premium for all policies like yours in this state. (If
4 the premium is based on the increasing age of the insured,
5 include information specifying when premiums will change).
6 DISCLOSURES
7 Use this outline to compare benefits and premiums among
8 policies, certificates, and contracts.
9 This outline shows benefits and premiums of policies sold
10 for effective dates on or after June 1, 2010. Policies sold for
11 effective dates prior to June 1, 2010 have different benefits and
12 premiums. Plans E, H, I, and J are no longer available for sale.
13 (This sentence shall not appear after June 1, 2011.)
14 READ YOUR POLICY VERY CAREFULLY
15 This is only an outline describing your policy's most
16 important features. The policy is your insurance contract. You
17 must read the policy itself to understand all of the rights and
18 duties of both you and your insurance company.
19 RIGHT TO RETURN POLICY
20 If you find that you are not satisfied with your policy, you
21 may return it to (insert insurer's address). If you send the
1 policy back to us within 30 days after you receive it, we will
2 treat the policy as if it had never been issued and return all of
3 your payments.
4 POLICY REPLACEMENT
5 If you are replacing another health insurance policy, do not
6 cancel it until you have actually received your new policy and
7 are sure you want to keep it.
8 NOTICE
9 This policy may not fully cover all of your medical costs.
10 [For agent issued policies]
11 Neither (insert insurer's name) nor its agents are connected
12 with medicare.
13 [For direct response issued policies]
14 (Insert insurer's name) is not connected with medicare.
15 This outline of coverage does not give all the details of
16 medicare coverage. Contact your local social security office or
17 consult "the medicare handbook" for more details.
18 COMPLETE ANSWERS ARE VERY IMPORTANT
19 When you fill out the application for the new policy, be
20 sure to answer truthfully and completely all questions about your
21 medical and health history. The company may cancel your policy
22 and refuse to pay any claims if you leave out or falsify
23 important medical information. [If the policy or certificate is
1 guaranteed issue, this paragraph need not appear.]
2 Review the application carefully before you sign it. Be
3 certain that all information has been properly recorded.
4 [Include for each plan offered by the insurer a chart
5 showing the services, medicare payments, plan payments, and
6 insured payments using the same language, in the same order, and
7 using uniform layout and format as shown in the charts that
8 follow. An insurer may use additional benefit plan designations
9 on these charts pursuant to section 3809(1)(k). Include an
10 explanation of any innovative benefits on the cover page and in
11 the chart, in a manner approved by the commissioner. The insurer
12 issuing the policy shall change the dollar amounts each year to
13 reflect current figures. No more than 4 plans may be shown on 1
14 chart.] Charts for each plan are as follows:
15 PLAN A
16 MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
17 *A benefit period begins on the first day you receive
18 service as an inpatient in a hospital and ends after you have
19 been out of the hospital and have not received skilled care in
20 any other facility for 60 days in a row.
21 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
22 HOSPITALIZATION*
23 Semiprivate room and
24 board, general nursing
25 and miscellaneous
1 services and supplies
2
First 60 days All but $952 $0 $952$992
3 $992 (Part A
4 Deductible)
5
61st thru 90th day All but $238 $238$248 $0
6 $248 a day a day
7 91st day and after:
8 —While using 60
9
lifetime reserve days All but $476 $476$496 $0
10 $496 a day a day
11 —Once lifetime reserve
12 days are used:
13 —Additional 365 days $0 100% of $0**
14 Medicare
15 Eligible
16 Expenses
17 —Beyond the
18 Additional 365 days $0 $0 All Costs
19 SKILLED NURSING FACILITY
20 CARE*
21 You must meet Medicare's
22 requirements, including
23 having been in a hospital
24 for at least 3 days and
25 entered a Medicare-
26 approved facility within
27 30 days after leaving the
28 hospital
29 First 20 days All approved
30 amounts $0 $0
31
21st thru 100th day All but $119 $0 Up to $119
1 $124 a day $124 a day
2 101st day and after $0 $0 All costs
3 BLOOD
4 First 3 pints $0 3 pints $0
5 Additional amounts 100% $0 $0
6 HOSPICE CARE
7 Available as long as your All
but very $0 Balance$0
8 doctor certifies you are limited
Medicare
9 terminally ill and you copayment/ copayment/
10 elect to receive these coinsurance coinsurance
11 services You must
meet for outpatient
12 Medicare's requirements, drugs and
13 including a doctor's inpatient
14 certification of terminal respite care
15 illness
16 **NOTICE: When your Medicare Part A hospital benefits are
17 exhausted, the insurer stands in the place of Medicare and will
18 pay whatever amount Medicare would have paid for up to an
19 additional 365 days as provided in the policy's "Core Benefits."
20 During this time the hospital is prohibited from billing you for
21 the balance based on any difference between its billed charges
22 and the amount Medicare would have paid.
23 PLAN A
24 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
25 *Once you have been billed $124 $131 of
Medicare-Approved
26 amounts for covered services (which are noted with an asterisk),
27 your Part B Deductible will have been met for the calendar year.
1
2 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
3 MEDICAL EXPENSES—
4 In or out of the hospital
5 and outpatient hospital
6 treatment, such as
7 Physician's services,
8 inpatient and outpatient
9 medical and surgical
10 services and supplies,
11 physical and speech
12 therapy, diagnostic
13 tests, durable medical
14 equipment,
15
First $124$131 of
16 Medicare
Approved $0 $0 $124 $131
17 Amounts* (Part B
18 Deductible)
19 Remainder of Medicare
20 Approved Amounts 80% 20% $0
21 Part B Excess Charges
22 (Above Medicare
23 Approved Amounts) $0 $0 All Costs
24 BLOOD
25 First 3 pints $0 All Costs $0
26 Next
$124$131 of
27 Medicare $0 $0 $124
$131
28 Approved Amounts* (Part B
29 Deductible)
1 Remainder of Medicare
2 Approved Amounts 80% 20% $0
3 CLINICAL LABORATORY
4 SERVICES—
5 Tests for
6 diagnostic services 100% $0 $0
7 PARTS A & B
8 HOME HEALTH CARE
9 Medicare Approved
10 Services
11 —Medically necessary
12 skilled care services
13 and medical supplies 100% $0 $0
14 —Durable medical
15 equipment
16
First $124$131 of
17
Medicare $0 $0 $124 $131
18 Approved Amounts* (Part B
19 Deductible)
20 Remainder of Medicare
21 Approved Amounts 80% 20% $0
22 PLAN B
23 MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
24 *A benefit period begins on the first day you receive
25 service as an inpatient in a hospital and ends after you have
1 been out of the hospital and have not received skilled care in
2 any other facility for 60 days in a row.
3 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
4 HOSPITALIZATION*
5 Semiprivate room and
6 board, general nursing
7 and miscellaneous
8 services and supplies
9
First 60 days All but $952 $952$992 $0
10 $992 (Part A
11 Deductible)
12
61st thru 90th day All but $238 $238$248 $0
13 $248 a day a day
14 91st day and after
15 —While using 60
16
lifetime reserve days All but $476 $476$496 $0
17 $496 a day a day
18 —Once lifetime reserve
19 days are used:
20 —Additional 365 days $0 100% of $0**
21 Medicare
22 Eligible
23 Expenses
24 —Beyond the
25 Additional 365 days $0 $0 All Costs
26 SKILLED NURSING FACILITY
27 CARE*
28 You must meet Medicare's
29 requirements, including
1 having been in a hospital
2 for at least 3 days and
3 entered a Medicare-
4 approved facility within
5 30 days after leaving the
6 hospital
7 First 20 days All approved
8 amounts $0 $0
9
21st thru 100th day All but $119 $0 Up to $119
10 $124 a day $124 a day
11 101st day and after $0 $0 All costs
12 BLOOD
13 First 3 pints $0 3 pints $0
14 Additional amounts 100% $0 $0
15 HOSPICE CARE
16 Available as long as your All
but very $0 Balance
17 doctor certifies you are limited
Medicare $0
18 terminally ill and you copayment/
copayment/
19 elect to receive these coinsurance coinsurance
20 servicesYou must meet for outpatient
21 Medicare's requirements, drugs and
22 including a doctor's inpatient
23 certification of respite care
24 terminal illness
25 **NOTICE: When your Medicare Part A hospital benefits are
26 exhausted, the insurer stands in the place of Medicare and will
27 pay whatever amount Medicare would have paid for up to an
28 additional 365 days as provided in the policy's "Core Benefits."
29 During this time the hospital is prohibited from billing you for
1 the balance based on any difference between its billed charges
2 and the amount Medicare would have paid.
3 PLAN B
4 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
5 *Once you have been billed $124 $131 of
Medicare-Approved
6 amounts for covered services (which are noted with an asterisk),
7 your Part B Deductible will have been met for the calendar year.
8 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
9 MEDICAL EXPENSES—
10 In or out of the hospital
11 and outpatient hospital
12 treatment, such as
13 Physician's services,
14 inpatient and outpatient
15 medical and surgical
16 services and supplies,
17 physical and speech
18 therapy, diagnostic
19 tests, durable medical
20 equipment,
21
First $124$131 of
22
Medicare Approved $0 $0 $124$131
23 Amounts* (Part B
24 Deductible)
25 Remainder of Medicare
26 Approved Amounts 80% 20% $0
27 Part B Excess Charges
1 (Above Medicare
2 Approved Amounts) $0 $0 All Costs
3 BLOOD
4 First 3 pints $0 All Costs $0
5 Next
$124$131 of Medicare
6
Approved Amounts* $0 $0 $124$131
7 (Part B
8 Remainder of Medicare Deductible)
9 Approved Amounts 80% 20% $0
10 CLINICAL LABORATORY
11 SERVICES—
12 Tests for
13 diagnostic services 100% $0 $0
14 PARTS A & B
15 HOME HEALTH CARE
16 Medicare Approved
17 Services
18 —Medically necessary
19 skilled care services
20 and medical supplies 100% $0 $0
21 —Durable medical
22 equipment
23
First $124$131 of
24 Medicare
25
Approved Amounts* $0 $0 $124$131
26 (Part B
27 Deductible)
28 Remainder of Medicare
1 Approved Amounts 80% 20% $0
2 PLAN C
3 MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
4 *A benefit period begins on the first day you receive
5 service as an inpatient in a hospital and ends after you have
6 been out of the hospital and have not received skilled care in
7 any other facility for 60 days in a row.
8 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
9 HOSPITALIZATION*
10 Semiprivate room and
11 board, general nursing
12 and miscellaneous
13 services and supplies
14
First 60 days All but $952 $952$992 $0
15 $992 (Part A
16 Deductible)
17
61st thru 90th day All but $238 $238$248 $0
18 $248 a day a day
19 91st day and after
20 —While using 60
21
lifetime reserve days All but $476 $476$496 $0
22 $496 a day a day
23 —Once lifetime reserve
24 days are used:
25 —Additional 365 days $0 100% of $0**
26 Medicare
1 Eligible
2 Expenses
3 —Beyond the
4 Additional 365 days $0 $0 All Costs
5 SKILLED NURSING FACILITY
6 CARE*
7 You must meet Medicare's
8 requirements, including
9 having been in a hospital
10 for at least 3 days and
11 entered a Medicare-
12 approved facility within
13 30 days after leaving the
14 hospital
15 First 20 days All approved
16 amounts $0 $0
17
21st thru 100th day All but $119 Up to $119 $0
18 $124 a day $124 a day
19 101st day and after $0 $0 All costs
20 BLOOD
21 First 3 pints $0 3 pints $0
22 Additional amounts 100% $0 $0
23 HOSPICE CARE
24 Available as long as your All
but very $0 Balance$0
25 doctor certifies you are limited
Medicare
26 terminally ill and you copayment/
copayment/
27 elect to receive these coinsurance coinsurance
28 servicesYou must meet for outpatient
29 Medicare's requirements, drugs and
30 including a doctor's inpatient
31 certification of respite care
1 terminal illness
2 **NOTICE: When your Medicare Part A hospital benefits are
3 exhausted, the insurer stands in the place of Medicare and will
4 pay whatever amount Medicare would have paid for up to an
5 additional 365 days as provided in the policy's "Core Benefits."
6 During this time the hospital is prohibited from billing you for
7 the balance based on any difference between its billed charges
8 and the amount Medicare would have paid.
9 PLAN C
10 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
11 *Once you have been billed $124 $131 of
Medicare-Approved
12 amounts for covered services (which are noted with an asterisk),
13 your Part B Deductible will have been met for the calendar year.
14 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
15 MEDICAL EXPENSES—
16 In or out of the hospital
17 and outpatient hospital
18 treatment, such as
19 Physician's services,
20 inpatient and outpatient
21 medical and surgical
22 services and supplies,
23 physical and speech
24 therapy, diagnostic
25 tests, durable medical
1 equipment,
2
First $124$131 of
3
Medicare Approved $0 $124$131 $0
4 Amounts* (Part B
5 Deductible)
6 Remainder of Medicare
7 Approved Amounts 80% 20% $0
8 Part B Excess Charges
9 (Above Medicare
10 Approved Amounts) $0 $0 All Costs
11 BLOOD
12 First 3 pints $0 All Costs $0
13 Next
$124$131 of Medicare
14
Approved Amounts* $0 $124$131 $0
15 (Part B
16 Deductible)
17 Remainder of Medicare
18 Approved Amounts 80% 20% $0
19 CLINICAL LABORATORY
20 SERVICES—
21 Tests for
22 diagnostic services 100% $0 $0
23 PARTS A & B
24 HOME HEALTH CARE
25 Medicare Approved
26 Services
27 —Medically necessary
1 skilled care services
2 and medical supplies 100% $0 $0
3 —Durable medical
4 equipment
5
First $124$131 of
6
Medicare Approved $0 $124$131 $0
7 Amounts* (Part B
8 Deductible)
9 Remainder of Medicare
10 Approved Amounts 80% 20% $0
11 OTHER BENEFITS—NOT COVERED BY MEDICARE
12 FOREIGN TRAVEL—
13 Not covered by Medicare
14 Medically necessary
15 emergency care services
16 beginning during the
17 first 60 days of each
18 trip outside the USA
19 First $250 each
20 calendar year $0 $0 $250
21 Remainder of charges $0 80% to a 20% and
22 lifetime amounts
23 maximum over the
24 benefit $50,000
25 of $50,000 lifetime
26 maximum
1 PLAN D
2 MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
3 *A benefit period begins on the first day you receive
4 service as an inpatient in a hospital and ends after you have
5 been out of the hospital and have not received skilled care in
6 any other facility for 60 days in a row.
7 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
8 HOSPITALIZATION*
9 Semiprivate room and
10 board, general nursing
11 and miscellaneous
12 services and supplies
13
First 60 days All but $952 $952$992 $0
14 $992 (Part A
15 Deductible)
16
61st thru 90th day All but $238 $238$248 $0
17 $248 a day a day
18 91st day and after
19 —While using 60
20
lifetime reserve days All but $476 $476$496 $0
21 $496 a day a day
22 —Once lifetime reserve
23 days are used:
24 —Additional 365 days $0 100% of $0**
25 Medicare
26 Eligible
27 Expenses
28 —Beyond the
1 Additional 365 days $0 $0 All Costs
2 SKILLED NURSING FACILITY
3 CARE*
4 You must meet Medicare's
5 requirements, including
6 having been in a hospital
7 for at least 3 days and
8 entered a Medicare-
9 approved facility within
10 30 days after leaving the
11 hospital
12 First 20 days All approved
13 amounts $0 $0
14
21st thru 100th day All but $119 Up to $119 $0
15 $124 a day $124 a day
16 101st day and after $0 $0 All costs
17 BLOOD
18 First 3 pints $0 3 pints $0
19 Additional amounts 100% $0 $0
20 HOSPICE CARE
21 Available as long as your All
but very $0Medicare Balance$0
22 doctor certifies you are limited
copayment/
23 terminally ill and you copayment/
coinsurance
24 elect to receive these coinsurance
25 servicesYou must meet for outpatient
26 Medicare's requirements, drugs and
27 including a doctor's inpatient
28 certification of respite care
29 terminal illness
30 **NOTICE: When your Medicare Part A hospital benefits are
1 exhausted, the insurer stands in the place of Medicare and will
2 pay whatever amount Medicare would have paid for up to an
3 additional 365 days as provided in the policy's "Core Benefits."
4 During this time the hospital is prohibited from billing you for
5 the balance based on any difference between its billed charges
6 and the amount Medicare would have paid.
7 PLAN D
8 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
9 *Once you have been billed $124$131
of Medicare-Approved
10 amounts for covered services (which are noted with an asterisk),
11 your Part B Deductible will have been met for the calendar year.
12 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
13 MEDICAL EXPENSES—
14 In or out of the hospital
15 and outpatient hospital
16 treatment, such as
17 Physician's services,
18 inpatient and outpatient
19 medical and surgical
20 services and supplies,
21 physical and speech
22 therapy, diagnostic
23 tests, durable medical
24 equipment,
25
First $124$131 of
26
Medicare Approved $0 $0 $124$131
1 Amounts* (Part B
2 Deductible)
3 Remainder of Medicare
4 Approved Amounts 80% 20% $0
5 Part B Excess Charges
6 (Above Medicare
7 Approved Amounts) $0 $0 All Costs
8 BLOOD
9 First 3 pints $0 All Costs $0
10 Next
$124$131 of Medicare
11
Approved Amounts* $0 $0 $124$131
12 (Part B
13 Deductible)
14 Remainder of Medicare
15 Approved Amounts 80% 20% $0
16 CLINICAL LABORATORY
17 SERVICES—
18 Tests for
19 diagnostic services 100% $0 $0
20 PARTS A & B
21 HOME HEALTH CARE
22 Medicare Approved
23 Services
24 —Medically necessary
25 skilled care services
26 and medical supplies 100% $0 $0
27 —Durable medical
1 equipment
2
First $124$131 of
3
Medicare Approved $0 $0 $124$131
4 Amounts* (Part B
5 Deductible)
6 Remainder of Medicare
7 Approved Amounts 80% 20% $0
8 AT-HOME RECOVERY
9 SERVICES—
10 Not covered by Medicare
11 Home care certified by
12 your doctor, for personal
13 care during recovery from
14 an injury or sickness for
15 which Medicare approved a
16 Home Care Treatment Plan
17 —Benefit for each visit $0 Actual
18 Charges to
19 $40 a visit Balance
20 —Number of visits
21 covered (must be
22 received within 8
23 weeks of last
24 Medicare Approved
25 visit) $0 Up to the
26 number of
27 Medicare
28 Approved
29 visits, not
30 to exceed 7
31 each week
1 —Calendar year maximum $0 $1,600
2 OTHER BENEFITS—NOT COVERED BY MEDICARE
3 FOREIGN TRAVEL—
4 Not covered by Medicare
5 Medically necessary
6 emergency care services
7 beginning during the
8 first 60 days of each
9 trip outside the USA
10 First $250 each
11 calendar year $0 $0 $250
12 Remainder of charges $0 80% to a 20% and
13 lifetime amounts
14 maximum over the
15 benefit $50,000
16 of $50,000 lifetime
17 maximum
18 PLAN E
19 MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
20 *A benefit period begins on the first day you receive
21 service as an inpatient in a hospital and ends after you have
22 been out of the hospital and have not received skilled care in
23 any other facility for 60 days in a row.
1 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
2 HOSPITALIZATION*
3 Semiprivate room and
4 board, general nursing
5 and miscellaneous
6 services and supplies
7 First 60 days All but $952 $952 $0
8 (Part A
9 Deductible)
10 61st thru 90th day All but $238 $238 $0
11 a day a day
12 91st day and after
13 —While using 60
14 lifetime reserve days All but $476 $476 $0
15 a day a day
16 —Once lifetime reserve
17 days are used:
18 —Additional 365 days $0 100% of $0
19 Medicare
20 Eligible
21 Expenses
22 —Beyond the
23 Additional 365 days $0 $0 All Costs
24 SKILLED NURSING FACILITY
25 CARE*
26 You must meet Medicare's
27 requirements, including
28 having been in a hospital
29 for at least 3 days and
30 entered a Medicare-
31 approved facility within
1 30 days after leaving the
2 hospital
3 First 20 days All approved
4 amounts $0 $0
5 21st thru 100th day All but $119 Up to $119 $0
6 a day a day
7 101st day and after $0 $0 All costs
8 BLOOD
9 First 3 pints $0 3 pints $0
10 Additional amounts 100% $0 $0
11 HOSPICE CARE
12 Available as long as your All but very $0 Balance
13 doctor certifies you are limited
14 terminally ill and you coinsurance
15 elect to receive these for outpatient
16 services drugs and
17 inpatient
18 respite care
19 PLAN E
20 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
21 *Once you have been billed $124 of Medicare-Approved amounts
22 for covered services (which are noted with an asterisk), your
23 Part B Deductible will have been met for the calendar year.
24 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
25 MEDICAL EXPENSES—
26 In or out of the hospital
27 and outpatient hospital
1 treatment, such as
2 Physician's services,
3 inpatient and outpatient
4 medical and surgical
5 services and supplies,
6 physical and speech
7 therapy, diagnostic
8 tests, durable medical
9 equipment,
10 First $124 of Medicare
11 Approved Amounts* $0 $0 $124
12 (Part B
13 Deductible)
14 Remainder of Medicare
15 Approved Amounts 80% 20% $0
16 Part B Excess Charges
17 (Above Medicare
18 Approved Amounts) $0 $0 All Costs
19 BLOOD
20 First 3 pints $0 All Costs $0
21 Next $124 of Medicare
22 Approved Amounts* $0 $0 $124
23 (Part B
24 Deductible)
25 Remainder of Medicare
26 Approved Amounts 80% 20% $0
27 CLINICAL LABORATORY
28 SERVICES—
29 Tests for
30 diagnostic services 100% $0 $0
1 PARTS A & B
2 HOME HEALTH CARE
3 Medicare Approved
4 Services
5 —Medically necessary
6 skilled care services
7 and medical supplies 100% $0 $0
8 —Durable medical
9 equipment
10 First $124 of Medicare
11 Approved Amounts* $0 $0 $124
12 (Part B
13 Deductible)
14 Remainder of Medicare
15 Approved Amounts 80% 20% $0
16 OTHER BENEFITS—NOT COVERED BY MEDICARE
17 FOREIGN TRAVEL—
18 Not covered by Medicare
19 Medically necessary
20 emergency care services
21 beginning during the
22 first 60 days of each
23 trip outside the USA
24 First $250 each
25 calendar year $0 $0 $250
1 Remainder of Charges $0 80% to a 20% and
2 lifetime amounts
3 maximum over the
4 benefit $50,000
5 of $50,000 lifetime
6 maximum
7 PREVENTIVE MEDICAL CARE
8 BENEFIT—
9 Not covered by Medicare
10 Annual physical and
11 preventive tests and
12 services
13
14
15
16
17
18
19
20
21
22 administered
23 or ordered by your
24 doctor when not covered
25 by Medicare
26 First $120 each
27 calendar year $0 $120 $0
28 Additional charges $0 $0 All Costs
29 PLAN F OR HIGH DEDUCTIBLE PLAN F
1 MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
2 *A benefit period begins on the first day you receive
3 service as an inpatient in a hospital and ends after you have
4 been out of the hospital and have not received skilled care in
5 any other facility for 60 days in a row.
6 **This high deductible plan pays the same benefits as plan F
7 after you have paid a calendar year ($1,790)($1,860)
deductible.
8 Benefits from the high deductible plan F will not begin until
9 out-of-pocket expenses are $1,790$1,860. Out-of-pocket
expenses
10 for this deductible are expenses that would ordinarily be paid by
11 the policy. This includes medicare deductibles for part A and
12 part B, but does not include the plan's separate foreign travel
13 emergency deductible.
14 SERVICES MEDICARE AFTER YOU IN ADDITION
15 PAYS PAY $1,790 TO $1,790
16 $1,860 $1,860
17 DEDUCTIBLE**, DEDUCTIBLE**,
18 PLAN PAYS YOU PAY
19 HOSPITALIZATION*
20 Semiprivate room and
21 board, general nursing
22 and miscellaneous
23 services and supplies
24
First 60 days All but $952 $952$992 $0
25 $992 (Part A
26 Deductible)
27
61st thru 90th day All but $238 $238$248 $0
1 $248 a day a day
2 91st day and after
3 —While using 60
4
lifetime reserve days All but $476 $476$496 $0
5 $496 a day a day
6 —Once lifetime reserve
7 days are used:
8 —Additional 365 days $0 100% of $0***
9 Medicare
10 Eligible
11 Expenses
12 —Beyond the
13 Additional 365 days $0 $0 All Costs
14 SKILLED NURSING FACILITY
15 CARE*
16 You must meet Medicare's
17 requirements, including
18 having been in a
19 hospital for at least
20 3 days and entered a
21 Medicare-approved
22 facility within 30 days
23 after leaving the
24 hospital
25 First 20 days All approved
26 amounts $0 $0
27
21st thru 100th day All but $119 Up to $119 $0
28 $124 a day $124 a day
29 101st day and after $0 $0 All costs
30 BLOOD
31 First 3 pints $0 3 pints $0
1 Additional amounts 100% $0 $0
2 HOSPICE CARE
3 Available as long as All
but very $0Medicare Balance$0
4 your doctor certifies limited copayment/
5 you are terminally ill copayment/ coinsurance
6 and you elect to receive coinsurance
7 these servicesYou
must for
8 meet Medicare's outpatient
9 requirements, including drugs and
10 a doctor's certification inpatient
11 of terminal illness respite care
12 ***NOTICE: When your Medicare Part A hospital benefits are
13 exhausted, the insurer stands in the place of Medicare and will
14 pay whatever amount Medicare would have paid for up to an
15 additional 365 days as provided in the policy's "Core Benefits."
16 During this time the hospital is prohibited from billing you for
17 the balance based on any difference between its billed charges
18 and the amount Medicare would have paid.
19 PLAN F
20 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
21 *Once you have been billed $124$131
of Medicare-Approved
22 amounts for covered services (which are noted with an asterisk),
23 your Part B Deductible will have been met for the calendar year.
24 **This high deductible plan pays the same benefits as plan F
25 after you have paid a calendar year ($1,790)($1,860)
deductible.
26 Benefits from the high deductible plan F will not begin until
1 out-of-pocket expenses are $1,790$1,860. Out-of-pocket
expenses
2 for this deductible are expenses that would ordinarily be paid by
3 the policy. This includes medicare deductibles for part A and
4 part B, but does not include the plan's separate foreign travel
5 emergency deductible.
6 SERVICES MEDICARE AFTER YOU IN ADDITION
7 PAYS PAY $1,790 TO $1,790
8 $1,860 $1,860
9 DEDUCTIBLE**, DEDUCTIBLE**,
10 PLAN PAYS YOU PAY
11 MEDICAL EXPENSES—
12 In or out of the hospital
13 and outpatient hospital
14 treatment, such as
15 Physician's services,
16 inpatient and outpatient
17 medical and surgical
18 services and supplies,
19 physical and speech
20 therapy, diagnostic
21 tests, durable medical
22 equipment,
23
First $124$131 of
24
Medicare Approved $0 $124$131 $0
25 Amounts* (Part B
26 Deductible)
27 Remainder of Medicare
28 Approved Amounts 80% 20% $0
29 Part B Excess Charges
30 (Above Medicare
1 Approved Amounts) $0 100% $0
2 BLOOD
3 First 3 pints $0 All Costs $0
4 Next
$124$131 of
5
Medicare Approved $0 $124$131 $0
6 Amounts* (Part B
7 Deductible)
8 Remainder of Medicare
9 Approved Amounts 80% 20% $0
10 CLINICAL LABORATORY
11 SERVICES—
12 Tests for
13 diagnostic services 100% $0 $0
14 PARTS A & B
15 HOME HEALTH CARE
16 Medicare Approved
17 Services
18 —Medically necessary
19 skilled care services
20 and medical supplies 100% $0 $0
21 —Durable medical
22 equipment
23
First $124$131 of
24
Medicare Approved $0 $124$131 $0
25 Amounts* (Part B
26 Deductible)
27 Remainder of Medicare
1 Approved Amounts 80% 20% $0
2 OTHER BENEFITS—NOT COVERED BY MEDICARE
3 FOREIGN TRAVEL—
4 Not covered by Medicare
5 Medically necessary
6 emergency care services
7 beginning during the
8 first 60 days of each
9 trip outside the USA
10 First $250 each
11 calendar year $0 $0 $250
12 Remainder of charges $0 80% to a 20% and
13 lifetime amounts
14 maximum over the
15 benefit $50,000
16 of $50,000 lifetime
17 maximum
18 PLAN G
19 MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
20 *A benefit period begins on the first day you receive
21 service as an inpatient in a hospital and ends after you have
22 been out of the hospital and have not received skilled care in
23 any other facility for 60 days in a row.
1 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
2 HOSPITALIZATION*
3 Semiprivate room and
4 board, general nursing
5 and miscellaneous
6 services and supplies
7
First 60 days All but $952 $952$992 $0
8 $992 (Part A
9 Deductible)
10
61st thru 90th day All but $238 $238$248 $0
11 $248 a day a day
12 91st day and after
13 —While using 60
14
lifetime reserve days All but $476 $476$496 $0
15 $496 a day a day
16 —Once lifetime reserve
17 days are used:
18 —Additional 365 days $0 100% of $0**
19 Medicare
20 Eligible
21 Expenses
22 —Beyond the
23 Additional 365 days $0 $0 All Costs
24 SKILLED NURSING FACILITY
25 CARE*
26 You must meet Medicare's
27 requirements, including
28 having been in a hospital
29 for at least 3 days and
30 entered a Medicare-
31 approved facility within
1 30 days after leaving the
2 hospital
3 First 20 days All approved
4 amounts $0 $0
5
21st thru 100th day All but $119 Up to $119 $0
6 $124 a day $124 a day
7 101st day and after $0 $0 All costs
8 BLOOD
9 First 3 pints $0 3 pints $0
10 Additional amounts 100% $0 $0
11 HOSPICE CARE
12 Available as long as your All
but very $0 Balance$0
13 doctor certifies you are limited
Medicare
14 terminally ill and you copayment/ copayment/
15 elect to receive these coinsurance coinsurance
16 servicesYou must meet for outpatient
17 Medicare's requirements, drugs and
18 including a doctor's inpatient
19 certification of respite care
20 terminal illness
21 **NOTICE: When your Medicare Part A hospital benefits are
22 exhausted, the insurer stands in the place of Medicare and will
23 pay whatever amount Medicare would have paid for up to an
24 additional 365 days as provided in the policy's "Core Benefits."
25 During this time the hospital is prohibited from billing you for
26 the balance based on any difference between its billed charges
27 and the amount Medicare would have paid.
28 PLAN G
1 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
2 *Once you have been billed $124$131
of Medicare-Approved
3 amounts for covered services (which are noted with an asterisk),
4 your Part B Deductible will have been met for the calendar year.
5 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
6 MEDICAL EXPENSES—
7 In or out of the hospital
8 and outpatient hospital
9 treatment, such as
10 Physician's services,
11 inpatient and outpatient
12 medical and surgical
13 services and supplies,
14 physical and speech
15 therapy, diagnostic
16 tests, durable medical
17 equipment,
18
First $124$131 of
19
Medicare Approved $0 $0 $124$131
20 Amounts* (Part B
21 Deductible)
22 Remainder of Medicare
23 Approved Amounts 80% 20% $0
24 Part B Excess Charges
25 (Above Medicare
26
Approved Amounts) $0 80%100% 20%0%
27 BLOOD
28 First 3 pints $0 All Costs $0
1 Next
$124$131 of
2
Medicare Approved $0 $0 $124$131
3 Amounts* (Part B
4 Deductible)
5 Remainder of Medicare
6 Approved Amounts 80% 20% $0
7 CLINICAL LABORATORY
8 SERVICES—
9 Tests for
10 diagnostic services 100% $0 $0
11 PARTS A & B
12 HOME HEALTH CARE
13 Medicare Approved
14 Services
15 —Medically necessary
16 skilled care services
17 and medical supplies 100% $0 $0
18 —Durable medical
19 equipment
20
First $124$131 of
21
Medicare Approved $0 $0 $124$131
22 Amounts* (Part B
23 Deductible)
24 Remainder of Medicare
25 Approved Amounts 80% 20% $0
26 AT-HOME RECOVERY
27 SERVICES—
28 Not covered by Medicare
1 Home care certified by
2 your doctor, for personal
3 care during recovery from
4 an injury or sickness for
5 which Medicare approved a
6 Home Care Treatment Plan
7 —Benefit for each visit $0 Actual
8 Charges to
9 $40 a visit Balance
10 —Number of visits
11 covered (must be
12 received within 8
13 weeks of last
14 Medicare Approved
15 visit) $0 Up to the
16 number of
17 Medicare
18 Approved
19 visits, not
20 to exceed 7
21 each week
22 —Calendar year maximum $0 $1,600
23 OTHER BENEFITS—NOT COVERED BY MEDICARE
24 FOREIGN TRAVEL—
25 Not covered by Medicare
26 Medically necessary
27 emergency care services
28 beginning during the
1 first 60 days of each
2 trip outside the USA
3 First $250 each
4 calendar year $0 $0 $250
5 Remainder of charges $0 80% to a 20% and
6 lifetime amounts
7 maximum over the
8 benefit $50,000
9 of $50,000 lifetime
10 maximum
11 PLAN H
12 MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
13 *A benefit period begins on the first day you receive
14 service as an inpatient in a hospital and ends after you have
15 been out of the hospital and have not received skilled care in
16 any othe