HB-5235, As Passed House, September 15, 2009
SUBSTITUTE FOR
HOUSE BILL NO. 5235
A bill to amend 1956 PA 218, entitled
"The insurance code of 1956,"
by amending sections 3801, 3803, 3807, 3808, 3809, 3811, 3815,
3819, 3831, and 3839 (MCL 500.3801, 500.3803, 500.3807, 500.3808,
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 sections 3803 and 3808 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.
1 (ii) For a group medicare supplement policy or certificate,
2 the proposed certificate holder.
3 (b) "Bankruptcy" means when a medicare advantage
4 organization that is not an insurer has filed, or has had filed
5 against it, a petition for declaration of bankruptcy and has
6 ceased doing business in this state.
7 (c) "Certificate" means any certificate delivered or issued
8 for delivery in this state under a group medicare supplement
9 policy.
10 (d) "Certificate form" means the form on which the
11 certificate is delivered or issued for delivery by the insurer.
12 (e) "Continuous period of creditable coverage" means the
13 period during which an individual was covered by creditable
14 coverage, if during the period of the coverage the individual had
15 no breaks in coverage greater than 63 days.
16 (f) "Creditable coverage" means coverage of an individual
17 provided under any of the following:
18 (i) A group health plan.
19 (ii) Health insurance coverage.
20 (iii) Part A or part B of medicare.
21 (iv) Medicaid other than coverage consisting solely of
22 benefits under section 1928 of medicaid, 42 USC 1396s.
23 (v) Chapter 55 of title 10 of the United States Code, 10 USC
24 1071 to 1110.
25 (vi) A medical care program of the Indian health service or
26 of a tribal organization.
27 (vii) A state health benefits risk pool.
1 (viii) A health plan offered under chapter 89 of title 5 of
2 the United States Code, 5 USC 8901 to 8914.
3 (ix) A public health plan as defined in federal regulation.
4 (x) Health care under section 5(e) of title I of the peace
5 corps act, 22 USC 2504.
6 (g) "Direct response solicitation" means solicitation in
7 which an insurer representative does not contact the applicant in
8 person and explain the coverage available, such as, but not
9 limited to, solicitation through direct mail or through
10 advertisements in periodicals and other media.
11 (h) "Employee welfare benefit plan" means a plan, fund, or
12 program of employee benefits as defined in section 3 of subtitle
13 A of title I of the employee retirement income security act of
14 1974, 29 USC 1002.
15 (i) "Insolvency" means when an insurer licensed to transact
16 the business of insurance in this state has had a final order of
17 liquidation entered against it with a finding of insolvency by a
18 court of competent jurisdiction in the insurer's state of
19 domicile.
20 (j) "Insurer" includes any entity, including a health care
21 corporation operating pursuant to the nonprofit health care
22 corporation reform act, 1980 PA 350, MCL 550.1101 to 550.1704,
23 and a health maintenance organization operating pursuant to
24 chapter 35 delivering or issuing for delivery in this state
25 medicare supplement policies.
26 (k) "Medicaid" means title XIX of the social security act,
27 42 USC 1396 to 1396v.
1 (l) "Medicare" means title XVIII of the social security act,
2 42 USC 1395 to 1395ggg 1395hhh.
3 (m) "Medicare advantage" means a plan of coverage for health
4 benefits under medicare part C as defined in section 12-2859 of
5 part C of medicare, 42 USC 1395w-28, and includes any of the
6 following:
7 (i) Coordinated care plans that provide health care services,
8 including, but not limited to, health maintenance organization
9 plans with or without a point-of-service option, plans offered by
10 provider-sponsored organizations, and preferred provider
11 organization plans.
12 (ii) Medical savings account plans coupled with a
13 contribution into a medicare advantage medical savings account.
14 (iii) Medicare advantage private fee-for-service plans.
15 (n) "Medicare supplement buyer's guide" means the document
16 entitled, "guide to health insurance for people with medicare",
17 developed by the national association of insurance commissioners
18 and the United States department of health and human services or
19 a substantially similar document as approved by the commissioner.
20 (o) "Medicare supplement policy" means an individual,
21 nongroup, or group policy or certificate that is advertised,
22 marketed, or designed primarily as a supplement to reimbursements
23 under medicare for the hospital, medical, or surgical expenses of
24 persons eligible for medicare and medicare select policies and
25 certificates under section 3817. Medicare supplement policy does
26 not include a policy, certificate, or contract of 1 or more
27 employers or labor organizations, or of the trustees of a fund
1 established by 1 or more employers or labor organizations, or
2 both, for employees or former employees, or both, or for members
3 or former members, or both, of the labor organizations. Medicare
4 supplement policy does not include medicare advantage plans
5 established under medicare part C, outpatient prescription drug
6 plans established under medicare part D, or any health care
7 prepayment plan that provides benefits pursuant to an agreement
8 under section 1833(a)(1)(A) of the social security act.
9 (p) "PACE" means a program of all-inclusive care for the
10 elderly as described in the social security act.
11 (q) "Prestandardized medicare supplement benefit plan",
12 "prestandardized benefit plan", or "prestandardized plan" means a
13 group or individual policy of medicare supplement insurance
14 issued prior to June 2, 1992.
15 (r) "1990 standardized medicare supplement benefit plan",
16 "1990 standardized benefit plan", or "1990 plan" means a group or
17 individual policy of medicare supplement insurance issued on or
18 after June 2, 1992 with an effective date for coverage prior to
19 June 1, 2010 and includes medicare supplement insurance policies
20 and certificates renewed on or after that date which are not
21 replaced by the issuer at the request of the insured.
22 (s) "2010 standardized medicare supplement benefit plan",
23 "2010 standardized benefit plan", or "2010 plan" means a group or
24 individual policy of medicare supplement insurance with an
25 effective date for coverage on or after June 1, 2010.
26 (t) (q) "Policy
form" means the form on which the policy or
27 certificate is delivered or issued for delivery by the insurer.
1 (u) (r) "Secretary"
means the secretary of the United
States
2 department of health and human services.
3 (v) (s) "Social
security act" means the social security act,
4 42 USC 301 to 1397jj.
5 Sec. 3803. (1) Except as provided in subsection subsections
6 (2) and (3), this chapter applies to a medicare supplement policy
7 delivered, issued for delivery, or renewed in this state. on
or
8 after the effective date of this chapter.
9 (2) Sections 3807, 3809, 3811, and 3819(1) do not apply 3819
10
apply to a medicare supplement policy delivered or issued before
11 the effective date of this chapter for delivery in this state on
12 or after June 2, 1992 with an effective date for coverage prior
13 to June 1, 2010.
14 (3) Sections 3807a, 3809a, 3811a, and 3819a apply to a
15 medicare supplement policy delivered or issued for delivery in
16 this state with an effective date for coverage on or after June
17 1, 2010.
18 Sec. 3807. (1) Every insurer issuing a medicare supplement
19 insurance policy in this state shall make available a medicare
20 supplement insurance policy that includes a basic core package of
21 benefits to each prospective insured. An insurer issuing a
22 medicare supplement insurance policy in this state may make
23 available to prospective insureds benefits pursuant to section
24 3809 that are in addition to, but not instead of, the basic core
25 package. The basic core package of benefits shall include all of
26 the following:
27 (a) Coverage of part A medicare eligible expenses for
1 hospitalization to the extent not covered by medicare from the
2 61st sixty-first day through the 90th ninetieth day in any
3 medicare benefit period.
4 (b) Coverage of part A medicare eligible expenses incurred
5 for hospitalization to the extent not covered by medicare for
6 each medicare lifetime inpatient reserve day used.
7 (c) Upon exhaustion of the medicare hospital inpatient
8 coverage including the lifetime reserve days, coverage of 100% of
9 the medicare part A eligible expenses for hospitalization paid at
10 the applicable prospective payment system rate or other
11 appropriate medicare standard of payment, subject to a lifetime
12 maximum benefit of an additional 365 days. The provider shall
13 accept the insurer's payment as payment in full and may not bill
14 the insured for any balance.
15 (d) Coverage under medicare parts A and B for the reasonable
16 cost of the first 3 pints of blood or equivalent quantities of
17 packed red blood cells, as defined under federal regulations
18 unless replaced in accordance with federal regulations.
19 (e) Coverage for the coinsurance amount, or the copayment
20 amount paid for hospital outpatient department services under a
21 prospective payment system, of medicare eligible expenses under
22 part B regardless of hospital confinement, subject to the
23 medicare part B deductible.
24 (2) Standards for plans K and L are as follows:
25 (a) Standardized medicare supplement benefit plan K shall
26 consist of the following:
27 (i) Coverage of 100% of the part A hospital coinsurance
1 amount for each day used from the sixty-first day through the
2 ninetieth day in any medicare benefit period.
3 (ii) Coverage of 100% of the part A hospital coinsurance
4 amount for each medicare lifetime inpatient reserve day used from
5 the ninety-first day through the one hundred fiftieth day in any
6 medicare benefit period.
7 (iii) Upon exhaustion of the medicare hospital inpatient
8 coverage, including the lifetime reserve days, coverage of 100%
9 of the medicare part A eligible expenses for hospitalization paid
10 at the applicable prospective payment system rate, or other
11 appropriate medicare standard of payment, subject to a lifetime
12 maximum benefit of an additional 365 days. The provider shall
13 accept the insurer's payment as payment in full and may not bill
14 the insured for any balance.
15 (iv) Medicare part A deductible: coverage for 50% of the
16 medicare part A inpatient hospital deductible amount per benefit
17 period until the out-of-pocket limitation is met as described in
18 subparagraph (x).
19 (v) Skilled nursing facility care: coverage for 50% of the
20 coinsurance amount for each day used from the twenty-first day
21 through the one hundredth day in a medicare benefit period for
22 posthospital skilled nursing facility care eligible under
23 medicare part A until the out-of-pocket limitation is met as
24 described in subparagraph (x).
25 (vi) Hospice care: coverage for 50% of cost sharing for all
26 part A medicare eligible expenses and respite care until the out-
27 of-pocket limitation is met as described in subparagraph (x).
1 (vii) Coverage for 50%, under medicare part A or B, of the
2 reasonable cost of the first 3 pints of blood or equivalent
3 quantities of packed red blood cells, as defined under federal
4 regulations, unless replaced in accordance with federal
5 regulations until the out-of-pocket limitation is met as
6 described in subparagraph (x).
7 (viii) Except for coverage provided in subparagraph (ix) below,
8 coverage for 50% of the cost sharing otherwise applicable under
9 medicare part B after the policyholder pays the part B deductible
10 until the out-of-pocket limitation is met as described in
11 subparagraph (x).
12 (ix) Coverage of 100% of the cost sharing for medicare part B
13 preventive services after the policyholder pays the part B
14 deductible.
15 (x) Coverage of 100% of all cost sharing under medicare
16 parts A and B for the balance of the calendar year after the
17 individual has reached the out-of-pocket limitation on annual
18 expenditures under medicare parts A and B of $4,000.00 in 2006,
19 indexed each year by the appropriate inflation adjustment
20 specified by the secretary of the United States department of
21 health and human services.
22 (b) Standardized medicare supplement benefit plan L shall
23 consist of the following:
24 (i) The benefits described in subdivision (a)(i), (ii), (iii),
25 and (ix).
26 (ii) The benefit described in subdivision (a)(iv), (v), (vi),
27 (vii), and (viii), but substituting 75% for 50%.
1 (iii) The benefit described in subdivision (a)(x), but
2 substituting $2,000.00 for $4,000.00.
3 (3) This section applies to medicare supplement policies or
4 certificates delivered or issued for delivery with an effective
5 date for coverage prior to June 1, 2010.
6 Sec. 3807a. (1) This section applies to all medicare
7 supplement policies or certificates delivered or issued for
8 delivery with an effective date for coverage on or after June 1,
9 2010. A policy or certificate shall not be advertised, solicited,
10 delivered, or issued for delivery in this state as a medicare
11 supplement policy or certificate unless it complies with these
12 benefit standards. An issuer shall not offer any 1990 plan for
13 sale on or after June 1, 2010. Benefit standards applicable to
14 medicare supplement policies and certificates issued before June
15 1, 2010 remain subject to the requirements of section 3807.
16 (2) Every insurer issuing a medicare supplement insurance
17 policy in this state shall make available a medicare supplement
18 insurance policy that includes a basic core package of benefits
19 to each prospective insured. An insurer issuing a medicare
20 supplement insurance policy in this state may make available to
21 prospective insureds benefits pursuant to section 3809a that are
22 in addition to, but not instead of, the basic core package. The
23 basic core package of benefits shall include all of the
24 following:
25 (a) Coverage of part A medicare eligible expenses for
26 hospitalization to the extent not covered by medicare from the
27 sixty-first day through the ninetieth day in any medicare benefit
1 period.
2 (b) Coverage of part A medicare eligible expenses incurred
3 for hospitalization to the extent not covered by medicare for
4 each medicare lifetime inpatient reserve day used.
5 (c) Upon exhaustion of the medicare hospital inpatient
6 coverage including the lifetime reserve days, coverage of 100% of
7 the medicare part A eligible expenses for hospitalization paid at
8 the applicable prospective payment system rate or other
9 appropriate medicare standard of payment, subject to a lifetime
10 maximum benefit of an additional 365 days. The provider shall
11 accept the insurer's payment as payment in full and may not bill
12 the insured for any balance.
13 (d) Coverage under medicare parts A and B for the reasonable
14 cost of the first 3 pints of blood or equivalent quantities of
15 packed red blood cells, as defined under federal regulations
16 unless replaced in accordance with federal regulations.
17 (e) Coverage for the coinsurance amount, or the copayment
18 amount paid for hospital outpatient department services under a
19 prospective payment system, of medicare eligible expenses under
20 part B regardless of hospital confinement, subject to the
21 medicare part B deductible.
22 (f) Coverage of cost sharing for all part A medicare
23 eligible hospice care and respite care expenses.
24 Sec. 3808. Every insurer issuing a medicare supplement
25 insurance policy in this state shall make available a medicare
26 supplement insurance policy that includes the benefits provided
27 in section 3811(5)(c) or 3811a(6)(c), whichever is applicable.
1 Sec. 3809. (1) In addition to the basic core package of
2 benefits required under section 3807, the following benefits may
3 be included in a medicare supplement insurance policy and if
4 included shall conform to section 3811(5)(b) to (j):
5 (a) Medicare part A deductible: coverage for all of the
6 medicare part A inpatient hospital deductible amount per benefit
7 period.
8 (b) Skilled nursing facility care: coverage for the actual
9 billed charges up to the coinsurance amount from the 21st day
10 through the 100th day in a medicare benefit period for
11 posthospital skilled nursing facility care eligible under
12 medicare part A.
13 (c) Medicare part B deductible: coverage for all of the
14 medicare part B deductible amount per calendar year regardless of
15 hospital confinement.
16 (d) Eighty percent of the medicare part B excess charges:
17 coverage for 80% of the difference between the actual medicare
18 part B charge as billed, not to exceed any charge limitation
19 established by medicare or state law, and the medicare-approved
20 part B charge.
21 (e) One hundred percent of the medicare part B excess
22 charges: coverage for all of the difference between the actual
23 medicare part B charge as billed, not to exceed any charge
24 limitation established by medicare or state law, and the
25 medicare-approved part B charge.
26 (f) Basic outpatient prescription drug benefit: coverage for
27 50% of outpatient prescription drug charges, after a $250.00
1 calendar year deductible, to a maximum of $1,250.00 in benefits
2 received by the insured per calendar year, to the extent not
3 covered by medicare. The outpatient prescription drug benefit may
4 be included for sale or issuance in a medicare supplement policy
5 until January 1, 2006.
6 (g) Extended outpatient prescription drug benefit: coverage
7 for 50% of outpatient prescription drug charges, after a $250.00
8 calendar year deductible, to a maximum of $3,000.00 in benefits
9 received by the insured per calendar year, to the extent not
10 covered by medicare. The outpatient prescription drug benefit may
11 be included for sale or issuance in a medicare supplement policy
12 until January 1, 2006.
13 (h) Medically necessary emergency care in a foreign country:
14 coverage to the extent not covered by medicare for 80% of the
15 billed charges for medicare-eligible expenses for medically
16 necessary emergency hospital, physician, and medical care
17 received in a foreign country, which care would have been covered
18 by medicare if provided in the United States and which care began
19 during the first 60 consecutive days of each trip outside the
20 United States, subject to a calendar year deductible of $250.00,
21 and a lifetime maximum benefit of $50,000.00. For purposes of
22 this benefit, "emergency care" means care needed immediately
23 because of an injury or an illness of sudden and unexpected
24 onset.
25 (i) Preventive medical care benefit: Coverage for the
26 following preventive health services not covered by medicare:
27 (i) An annual clinical preventive medical history and
1 physical examination that may include tests and services from
2 subparagraph (ii) and patient education to address preventive
3 health care measures.
4 (ii) Preventive screening tests or preventive services, the
5 selection and frequency of which is determined to be medically
6 appropriate by the attending physician.
7 (j) At-home recovery benefit: coverage for services to
8 provide short term, at-home assistance with activities of daily
9 living for those recovering from an illness, injury, or surgery.
10 At-home recovery services provided shall be primarily services
11 that assist in activities of daily living. The insured's
12 attending physician shall certify that the specific type and
13 frequency of at-home recovery services are necessary because of a
14 condition for which a home care plan of treatment was approved by
15 medicare. Coverage is excluded for home care visits paid for by
16 medicare or other government programs and care provided by family
17 members, unpaid volunteers, or providers who are not care
18 providers. Coverage is limited to:
19 (i) No more than the number of at-home recovery visits
20 certified as necessary by the insured's attending physician. The
21 total number of at-home recovery visits shall not exceed the
22 number of medicare approved home health care visits under a
23 medicare approved home care plan of treatment.
24 (ii) The actual charges for each visit up to a maximum
25 reimbursement of $40.00 per visit.
26 (iii) One thousand six hundred dollars per calendar year.
27 (iv) Seven visits in any 1 week.
1 (v) Care furnished on a visiting basis in the insured's
2 home.
3 (vi) Services provided by a care provider as defined in this
4 section.
5 (vii) At-home recovery visits while the insured is covered
6 under the insurance policy and not otherwise excluded.
7 (viii) At-home recovery visits received during the period the
8 insured is receiving medicare approved home care services or no
9 more than 8 weeks after the service date of the last medicare
10 approved home health care visit.
11 (k) New or innovative benefits: an insurer may, with the
12 prior approval of the commissioner, offer policies or
13 certificates with new or innovative benefits in addition to the
14 benefits provided in a policy or certificate that otherwise
15 complies with the applicable standards. The new or innovative
16 benefits may include benefits that are appropriate to medicare
17 supplement insurance, new or innovative, not otherwise available,
18 cost-effective, and offered in a manner that is consistent with
19 the goal of simplification of medicare supplement policies. After
20 December 31, 2005, the innovative benefit shall not include an
21 outpatient prescription drug benefit.
22 (2) Reimbursement for the preventive screening tests and
23 services under subsection (1)(i)(ii) shall be for the actual
24 charges up to 100% of the medicare-approved amount for each test
25 or service, as if medicare were to cover the test or service as
26 identified in the American medical association current procedural
27 terminology codes, to a maximum of $120.00 annually under this
1 benefit. This benefit shall not include payment for any procedure
2 covered by medicare.
3 (3) As used in subsection (1)(j):
4 (a) "Activities of daily living" include, but are not
5 limited to, bathing, dressing, personal hygiene, transferring,
6 eating, ambulating, assistance with drugs that are normally self-
7 administered, and changing bandages or other dressings.
8 (b) "Care provider" means a duly qualified or licensed home
9 health aide/homemaker, personal care aide, or nurse provided
10 through a licensed home health care agency or referred by a
11 licensed referral agency or licensed nurses registry.
12 (c) "Home" means any place used by the insured as a place of
13 residence, provided that it qualifies as a residence for home
14 health care services covered by medicare. A hospital or skilled
15 nursing facility shall not be considered the insured's home.
16 (d) "At-home recovery visit" means the period of a visit
17 required to provide at home recovery care, without limit on the
18 duration of the visit, except each consecutive 4 hours in a 24-
19 hour period of services provided by a care provider is 1 visit.
20 (4) This section applies to medicare supplement policies or
21 certificates delivered or issued for delivery on or after June 2,
22 1992 with an effective date for coverage prior to June 1, 2010.
23 Sec. 3809a. (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) In addition to the basic core package of benefits
1 required under section 3807a, the following benefits may be
2 included in a medicare supplement insurance policy and if
3 included shall conform to section 3811a(6)(b) to (j):
4 (a) Medicare part A deductible: coverage for 100% of the
5 medicare part A inpatient hospital deductible amount per benefit
6 period.
7 (b) Medicare part A deductible: coverage for 50% of the
8 medicare part A inpatient hospital deductible amount per benefit
9 period.
10 (c) Skilled nursing facility care: coverage for the actual
11 billed charges up to the coinsurance amount from the twenty-first
12 day through the one hundredth day in a medicare benefit period
13 for posthospital skilled nursing facility care eligible under
14 medicare part A.
15 (d) Medicare part B deductible: coverage for 100% of the
16 medicare part B deductible amount per calendar year regardless of
17 hospital confinement.
18 (e) One hundred percent of the medicare part B excess
19 charges: coverage for all of the difference between the actual
20 medicare part B charge as billed, not to exceed any charge
21 limitation established by medicare or state law, and the
22 medicare-approved part B charge.
23 (f) Medically necessary emergency care in a foreign country:
24 coverage to the extent not covered by medicare for 80% of the
25 billed charges for medicare-eligible expenses for medically
26 necessary emergency hospital, physician, and medical care
27 received in a foreign country, which care would have been covered
1 by medicare if provided in the United States and which care began
2 during the first 60 consecutive days of each trip outside the
3 United States, subject to a calendar year deductible of $250.00,
4 and a lifetime maximum benefit of $50,000.00. For purposes of
5 this benefit, "emergency care" means care needed immediately
6 because of an injury or an illness of sudden and unexpected
7 onset.
8 Sec. 3811. (1) An insurer shall make available to each
9 prospective medicare supplement policyholder and certificate
10 holder a policy form or certificate form containing only the
11 basic core benefits as provided in section 3807.
12 (2) Groups, packages, or combinations of medicare supplement
13 benefits other than those listed in this section shall not be
14 offered for sale in this state except as may be permitted in
15 section 3809(1)(k).
16 (3) Benefit plans shall contain the appropriate A through L
17 designations, shall be uniform in structure, language, and format
18 to the standard benefit plans in subsection (5), and shall
19 conform to the definitions in this chapter. Each benefit shall be
20 structured in accordance with sections 3807 and 3809 and list the
21 benefits in the order shown in subsection (5). For purposes of
22 this section, "structure, language, and format" means style,
23 arrangement, and overall content of a benefit.
24 (4) In addition to the benefit plan designations A through L
25 as provided under subsection (5), an insurer may use other
26 designations to the extent permitted by law.
27 (5) A medicare supplement insurance benefit plan shall
1 conform to 1 of the following:
2 (a) A standardized medicare supplement benefit plan A shall
3 be limited to the basic core benefits common to all benefit plans
4 as defined in section 3807.
5 (b) A standardized medicare supplement benefit plan B shall
6 include only the following: the core benefits as defined in
7 section 3807 and the medicare part A deductible as defined in
8 section 3809(1)(a).
9 (c) A standardized medicare supplement benefit plan C 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, medicare part B deductible, and medically
13 necessary emergency care in a foreign country as defined in
14 section 3809(1)(a), (b), (c), and (h).
15 (d) A standardized medicare supplement benefit plan D shall
16 include only the following: the core benefits as defined in
17 section 3807, the medicare part A deductible, skilled nursing
18 facility care, medically necessary emergency care in a foreign
19 country, and the at-home recovery benefit as defined in section
20 3809(1)(a), (b), (h), and (j).
21 (e) A standardized medicare supplement benefit plan E shall
22 include only the following: the core benefits as defined in
23 section 3807, the medicare part A deductible, skilled nursing
24 facility care, medically necessary emergency care in a foreign
25 country, and preventive medical care as defined in section
26 3809(1)(a), (b), (h), and (i).
27 (f) A standardized medicare supplement benefit plan F shall
1 include only the following: the core benefits as defined in
2 section 3807, the medicare part A deductible, skilled nursing
3 facility care, medicare part B deductible, 100% of the medicare
4 part B excess charges, and medically necessary emergency care in
5 a foreign country as defined in section 3809(1)(a), (b), (c),
6 (e), and (h). A standardized medicare supplement plan F high
7 deductible shall include only the following: 100% of covered
8 expenses following the payment of the annual high deductible plan
9 F deductible. The covered expenses include the core benefits as
10 defined in section 3807, plus the medicare part A deductible,
11 skilled nursing facility care, the medicare part B deductible,
12 100% of the medicare part B excess charges, and medically
13 necessary emergency care in a foreign country as defined in
14 section 3809(1)(a), (b), (c), (e), and (h). The annual high
15 deductible plan F deductible shall consist of out-of-pocket
16 expenses, other than premiums, for services covered by the
17 medicare supplement plan F policy, and shall be in addition to
18 any other specific benefit deductibles. The annual high
19 deductible plan F deductible is $1,790.00 for calendar year 2006,
20 and the secretary shall adjust it annually thereafter to reflect
21 the change in the consumer price index for all urban consumers
22 for the 12-month period ending with August of the preceding year,
23 rounded to the nearest multiple of $10.00.
24 (g) A standardized medicare supplement benefit plan G shall
25 include only the following: the core benefits as defined in
26 section 3807, the medicare part A deductible, skilled nursing
27 facility care, 80% of the medicare part B excess charges,
1 medically necessary emergency care in a foreign country, and the
2 at-home recovery benefit as defined in section 3809(1)(a), (b),
3 (d), (h), and (j).
4 (h) A standardized medicare supplement benefit plan H shall
5 include only the following: the core benefits as defined in
6 section 3807, the medicare part A deductible, skilled nursing
7 facility care, basic outpatient prescription drug benefit, and
8 medically necessary emergency care in a foreign country as
9 defined in section 3809(1)(a), (b), (f), and (h). The outpatient
10 drug benefit shall not be included in a medicare supplement
11 policy sold after December 31, 2005.
12 (i) A standardized medicare supplement benefit plan I shall
13 include only the following: the core benefits as defined in
14 section 3807, the medicare part A deductible, skilled nursing
15 facility care, 100% of the medicare part B excess charges, basic
16 outpatient prescription drug benefit, medically necessary
17 emergency care in a foreign country, and at-home recovery benefit
18 as defined in section 3809(1)(a), (b), (e), (f), (h), and (j).
19 The outpatient drug benefit shall not be included in a medicare
20 supplement policy sold after December 31, 2005.
21 (j) A standardized medicare supplement benefit plan J shall
22 include only the following: the core benefits as defined in
23 section 3807, the medicare part A deductible, skilled nursing
24 facility care, medicare part B deductible, 100% of the medicare
25 part B excess charges, extended outpatient prescription drug
26 benefit, medically necessary emergency care in a foreign country,
27 preventive medical care, and at-home recovery benefit as defined
1 in section 3809(1)(a), (b), (c), (e), (g), (h), (i), and (j). A
2 standardized medicare supplement benefit plan J high deductible
3 plan shall consist of only the following: 100% of covered
4 expenses following the payment of the annual high deductible plan
5 J deductible. The covered expenses include the core benefits as
6 defined in section 3807, plus the medicare part A deductible,
7 skilled nursing facility care, medicare part B deductible, 100%
8 of the medicare part B excess charges, extended outpatient
9 prescription drug benefit, medically necessary emergency care in
10 a foreign country, preventive medical care benefit and at-home
11 recovery benefit as defined in section 3809(1)(a), (b), (c), (e),
12 (g), (h), (i), and (j). The annual high deductible plan J
13 deductible shall consist of out-of-pocket expenses, other than
14 premiums, for services covered by the medicare supplement plan J
15 policy, and shall be in addition to any other specific benefit
16 deductibles. The annual deductible shall be $1,790.00 for
17 calendar year 2006, and the secretary shall adjust it annually
18 thereafter to reflect the change in the consumer price index for
19 all urban consumers for the 12-month period ending with August of
20 the preceding year, rounded to the nearest multiple of $10.00.
21 The outpatient drug benefit shall not be included in a medicare
22 supplement policy sold after December 31, 2005.
23 (k) A standardized medicare supplement benefit plan K shall
24 consist of only those benefits described in section 3807(2)(a).
25 (l) A standardized medicare supplement benefit plan L shall
26 consist of only those benefits described in section 3807(2)(b).
27 (6) This section applies to medicare supplement policies or
1 certificates delivered or issued for delivery on or after June 2,
2 1992 with an effective date for coverage prior to June 1, 2010.
3 Sec. 3811a. (1) This section applies to all medicare
4 supplement policies or certificates delivered or issued for
5 delivery with an effective date for coverage on or after June 1,
6 2010. A policy or certificate shall not be advertised, solicited,
7 delivered, or issued for delivery in this state as a medicare
8 supplement policy or certificate unless it complies with these
9 benefit standards. Benefit plan standards applicable to medicare
10 supplement policies and certificates issued before June 1, 2010
11 remain subject to the requirements of section 3811.
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 3809a(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 3809a(2)(a), (c), and
3 (f).
4 (e) A standardized medicare supplement benefit plan F shall
5 include only the following: the core benefits as defined in
6 section 3807a, 100% of the medicare part A deductible, skilled
7 nursing facility care, 100% of the medicare part B deductible,
8 100% of the medicare part B excess charges, and medically
9 necessary emergency care in a foreign country as defined in
10 section 3809a(2)(a), (c), (d), (e), and (f). A standardized
11 medicare supplement plan F high deductible shall include only the
12 following: 100% of covered expenses following the payment of the
13 annual high deductible plan F deductible. The covered expenses
14 include the core benefits as defined in section 3807a, plus 100%
15 of the medicare part A deductible, skilled nursing facility care,
16 100% of the medicare part B deductible, 100% of the medicare part
17 B excess charges, and medically necessary emergency care in a
18 foreign country as defined in section 3809a(2)(a), (c), (d), (e),
19 and (f). The annual high deductible plan F deductible shall
20 consist of out-of-pocket expenses, other than premiums, for
21 services covered by the medicare supplement plan F policy, and
22 shall be in addition to any other specific benefit deductibles.
23 The annual high deductible plan F deductible is $1,500.00 for
24 calendar year 1999, and the secretary shall adjust it annually
25 thereafter to reflect the change in the consumer price index for
26 all urban consumers for the 12-month period ending with August of
27 the preceding year, rounded to the nearest multiple of $10.00.
1 (f) A standardized medicare supplement benefit plan G shall
2 include only the following: the core benefits as defined in
3 section 3807a, 100% of the medicare part A deductible, skilled
4 nursing facility care, 100% of the medicare part B excess
5 charges, and medically necessary emergency care in a foreign
6 country as defined in section 3809a(2)(a), (c), (e), and (f).
7 (g) Standardized medicare supplement benefit plan K shall
8 consist of the following:
9 (i) Coverage of 100% of the part A hospital coinsurance
10 amount for each day used from the sixty-first day through the
11 ninetieth day in any medicare benefit period.
12 (ii) Coverage of 100% of the part A hospital coinsurance
13 amount for each medicare lifetime inpatient reserve day used from
14 the ninety-first day through the one hundred fiftieth day in any
15 medicare benefit period.
16 (iii) Upon exhaustion of the medicare hospital inpatient
17 coverage, including the lifetime reserve days, coverage of 100%
18 of the medicare part A eligible expenses for hospitalization paid
19 at 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. The provider shall
22 accept the insurer's payment as payment in full and may not bill
23 the insured for any balance.
24 (iv) Medicare part A deductible: coverage for 50% of the
25 medicare part A inpatient hospital deductible amount per benefit
26 period until the out-of-pocket limitation is met as described in
27 subparagraph (x).
1 (v) Skilled nursing facility care: coverage for 50% of the
2 coinsurance amount for each day used from the twenty-first day
3 through the one hundredth day in a medicare benefit period for
4 posthospital skilled nursing facility care eligible under
5 medicare part A until the out-of-pocket limitation is met as
6 described in subparagraph (x).
7 (vi) Hospice care: coverage for 50% of cost sharing for all
8 part A medicare eligible expenses and respite care until the out-
9 of-pocket limitation is met as described in subparagraph (x).
10 (vii) Coverage for 50%, under medicare part A or B, of the
11 reasonable cost of the first 3 pints of blood or equivalent
12 quantities of packed red blood cells, as defined under federal
13 regulations, unless replaced in accordance with federal
14 regulations until the out-of-pocket limitation is met as
15 described in subparagraph (x).
16 (viii) Except for coverage provided in subparagraph (ix) below,
17 coverage for 50% of the cost sharing otherwise applicable under
18 medicare part B after the policyholder pays the part B deductible
19 until the out-of-pocket limitation is met as described in
20 subparagraph (x).
21 (ix) Coverage of 100% of the cost sharing for medicare part B
22 preventive services after the policyholder pays the part B
23 deductible.
24 (x) Coverage of 100% of all cost sharing under medicare
25 parts A and B for the balance of the calendar year after the
26 individual has reached the out-of-pocket limitation on annual
27 expenditures under medicare parts A and B of $4,000.00 in 2006,
1 indexed each year by the appropriate inflation adjustment
2 specified by the secretary of the United States department of
3 health and human services.
4 (h) Standardized medicare supplement benefit plan L shall
5 consist of the following:
6 (i) The benefits described in subdivision (g)(i), (ii), (iii),
7 and (ix).
8 (ii) The benefits described in subdivision (g)(iv), (v), (vi),
9 (vii), and (viii), but substituting 75% for 50%.
10 (iii) The benefit described in subdivision (g)(x), but
11 substituting $2,000.00 for $4,000.00.
12 (i) A standardized medicare supplement benefit plan M shall
13 include only the following: the core benefits as defined in
14 section 3807a and 50% of the medicare part A deductible, skilled
15 nursing care, and medically necessary emergency care in a foreign
16 country as defined in section 3809a(2)(b), (c), and (f).
17 (j) A standardized medicare supplement benefit plan N shall
18 include only the following: the core benefits as defined in
19 section 3807a, 100% of the medicare part A deductible, skilled
20 nursing facility care, and medically necessary emergency care in
21 a foreign country as defined in section 3809a(2)(a), (c), and (f)
22 with copayments in the following amounts:
23 (i) The lesser of $20.00 or the medicare part B coinsurance
24 or copayment for each covered health care provider office visit,
25 including visits to medical specialists.
26 (ii) The lesser of $50.00 or the medicare part B coinsurance
27 or copayment for each covered emergency room visit. The copayment
1 shall be waived if the insured is admitted to any hospital and
2 the emergency visit is subsequently covered as a medicare part A
3 expense.
4 (k) New or innovative benefits: an insurer may, with the
5 prior approval of the commissioner, offer policies or
6 certificates with new or innovative benefits in addition to the
7 benefits provided in a policy or certificate that otherwise
8 complies with the applicable standards. The new or innovative
9 benefits may include benefits that are appropriate to medicare
10 supplement insurance, new or innovative, not otherwise available,
11 cost-effective, and offered in a manner that is consistent with
12 the goal of simplification of medicare supplement policies. The
13 innovative benefit shall not include an outpatient prescription
14 drug benefit. New or innovative benefits shall not be used to
15 change or reduce benefits, including a change of any cost-sharing
16 provision, in any standardized plan.
17 Sec. 3815. (1) An insurer that offers a medicare supplement
18 policy shall provide to the applicant at the time of application
19 an outline of coverage and, except for direct response
20 solicitation policies, shall obtain an acknowledgment of receipt
21 of the outline of coverage from the applicant. The outline of
22 coverage provided to applicants pursuant to this section shall
23 consist of the following 4 parts:
24 (a) A cover page.
25 (b) Premium information.
26 (c) Disclosure pages.
27 (d) Charts displaying the features of each benefit plan
1 offered by the insurer.
2 (2) Insurers shall comply with any notice requirements of
3 the medicare prescription drug, improvement, and modernization
4 act of 2003, Public Law 108-173.
5 (3) If an outline of coverage is provided at the time of
6 application and the medicare supplement policy or certificate is
7 issued on a basis that would require revision of the outline, a
8 substitute outline of coverage properly describing the policy or
9 certificate shall accompany the policy or certificate when it is
10 delivered and shall contain the following statement, in no less
11 than 12-point type, immediately above the company name:
12 NOTICE: Read this outline of coverage carefully.
13 It is not identical to the outline of coverage
14 provided upon application and the coverage
15 originally applied for has not been issued.
16 (4) An outline of coverage under subsection (1) shall be in
17 the language and format prescribed in this section and in not
18 less than 12-point type. The A through L letter designation of
19 the plan shall be shown on the cover page and the plans offered
20 by the insurer shall be prominently identified. Premium
21 information shall be shown on the cover page or immediately
22 following the cover page and shall be prominently displayed. The
23 premium and method of payment mode shall be stated for all plans
24 that are offered to the applicant. All possible premiums for the
25 applicant shall be illustrated. The following items shall be
26 included in the outline of coverage in the order prescribed below
1 and in substantially the following form, as approved by the
2 commissioner:
3 (Insurer Name)
4 Medicare Supplement Coverage
5 Outline of Medicare Supplement Coverage-Cover Page:
6 Benefit Plan(s)_____[insert letter(s) of plan(s) being offered]
7 Medicare supplement insurance can be sold in only 12
8 standard plans plus 2 high deductible plans. This chart shows
9 the benefits included in each plan. Every insurer shall make
10 available Plan "A". Some plans may not be available in your
11 state.
12 BASIC BENEFITS: For plans A-J.
13 Hospitalization: Part A coinsurance plus coverage for 365
14 additional days after Medicare benefits end.
15 Medical Expenses: Part B coinsurance (20% of Medicare-approved
16 expenses) or copayments for hospital outpatient services.
17 Blood: First three pints of blood each year.
18
A B C D E F|F* G H I J|J*
19 Basic Benefits x x x x x x x x x x
20 Skilled Nursing
21 Co-Insurance x x x x x x x x
22 Part A Deductible x x x x x x x x x
23 Part B Deductible x x x
24 Part B Excess x x x x
25 100% 80% 100% 100%
26 Foreign Travel
27 Emergency x x x x x x x x
1 At-Home Recovery x x x x
2
3
4
5 Preventive Care not covered by Medicare x x
6 [COMPANY NAME]
7 Outline of Medicare Supplement Coverage – Cover Page 2
8 Basic Benefits for Plans K and L include similar services as
9 plans A-J, but cost-sharing for the basic benefits is at
10 different levels.
11 K** L**
12 Basic Benefits 100% of Part A 100% of Part A
13 hospitalization hospitalization
14 coinsurance
plus coinsurance plus
15 coverage
for 365 days coverage for 365 days
16 after
Medicare after Medicare
17 benefits
end benefits end
18 50%
Hospice cost- 75% Hospice cost-
19 sharing sharing
20 50%
of Medicare- 75% of Medicare-
21 eligible eligible
22 expenses
for the expenses for the
23 first
three pints first three pints
24 of
blood of blood
25 50%
Part B 75% Part B
26 coinsurance,
except coinsurance, except
27 100%
coinsurance for 100% coinsurance for
1 Part
B preventive Part B preventive
2 services services
3 Skilled Nursing 50% skilled nursing 75% skilled nursing
4 Coinsurance facility coinsurance facility coinsurance
5 Part A Deductible 50% Part A deductible 75% Part A deductible
6 Part B Deductible
7 Part B Excess (100%)
8 Foreign Travel
9 Emergency
10 At-Home Recovery
11 Preventive Care not
12 covered by Medicare
13 $4,000
out of pocket $2,000 out of pocket
14 Annual
Limit*** Annual Limit***
15 *Plans F and J also have an option called a high deductible plan F
16 and a high deductible plan J. These high deductible plans pay the
17 same benefits as Plans F and J after one has paid a calendar year
18 ($1,790) deductible. Benefits from high deductible Plans F and J
19 will not begin until out-of-pocket expenses exceed ($1,790). Out-
20 of-pocket expenses for this deductible are expenses that would
21 ordinarily be paid by the policy. These expenses include the
22 Medicare deductibles for Part A and Part B, but do not include the
23 plan's separate foreign travel emergency deductible.
24 **Plans K and L provide for different cost-sharing for items and
25 services than Plans A-J.
26 Once you reach the annual limit, the plan pays 100% of the Medicare
1 copayments, coinsurance, and deductibles for the rest of the
2 calendar year. The out-of-pocket annual limit does NOT include
3 charges from your provider that exceed Medicare-approved amounts,
4 called "Excess Charges". You will be responsible for paying
excess
5 charges.
6 ***The out-of-pocket annual limit will increase each year for
7 inflation.
8 See Outlines of Coverage for details and exceptions.
9 BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD
10 ON OR AFTER JUNE 1, 2010
11 This chart shows the benefits included in each of the
12 standard Medicare supplement plans. Every company must make Plan
13 "A" available. Some plans may not be available in your state.
14 Plans E, H, I, and J are no longer available for sale. (This
15 sentence shall not appear after June 1, 2011.)
16 BASIC BENEFITS:
17 Hospitalization: Part A coinsurance plus coverage for 365
18 additional days after Medicare benefits end.
19 Medical Expenses: Part B coinsurance (generally 20% of
20 Medicare-approved expenses) or copayments for hospital
21 outpatient services. Plans K, L, and N require insureds
22 to pay a portion of Part B coinsurance or copayments.
23 Blood: First three pints of blood each year.
24 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
1 to $50 copay-
2 ment for ER
3 50% Skilled 75% Skilled Skilled Skilled
4 Nursing Nursing Nursing Nursing
5 Facility Facility Facility Facility
6 Coinsurance Coinsurance Coinsurance Coinsurance
7 50% Part A 75% Part A 50% Part A Part A
8 Deductible Deductible Deductible Deductible
9
10
11
12
13
14 Foreign Foreign
15 Travel Travel
16 Emergency Emergency
17 Out-of-pocket Out-of-pocket
18 limit $4,140; limit $2,070;
19 paid at 100% paid at 100%
20 after limit after limit
21 reached reached
22 * Plan F also has an option called a high-deductible Plan F.
23 This high-deductible plan pays the same benefits as Plan F after
24 one has paid a calendar year $1,860 deductible. Benefits from
25 high-deductible Plan F will not begin until out-of-pocket
26 expenses exceed $1,860. Out-of-pocket expenses for this
27 deductible are expenses that would ordinarily be paid by the
28 policy. These expenses include the Medicare deductibles for Part
29 A and Part B, but do not include the plan's separate foreign
1 travel emergency deductible.
2 PREMIUM INFORMATION
3 We (insert insurer's name) can only raise your premium if we
4 raise the premium for all policies like yours in this state. (If
5 the premium is based on the increasing age of the insured,
6 include information specifying when premiums will change).
7 DISCLOSURES
8 Use this outline to compare benefits and premiums among
9 policies, certificates, and contracts.
10 This outline shows benefits and premiums of policies sold
11 for effective dates on or after June 1, 2010. Policies sold for
12 effective dates prior to June 1, 2010 have different benefits and
13 premiums. Plans E, H, I, and J are no longer available for sale.
14 (This sentence shall not appear after June 1, 2011.)
15 READ YOUR POLICY VERY CAREFULLY
16 This is only an outline describing your policy's most
17 important features. The policy is your insurance contract. You
18 must read the policy itself to understand all of the rights and
19 duties of both you and your insurance company.
20 RIGHT TO RETURN POLICY
21 If you find that you are not satisfied with your policy, you
1 may return it to (insert insurer's address). If you send the
2 policy back to us within 30 days after you receive it, we will
3 treat the policy as if it had never been issued and return all of
4 your payments.
5 POLICY REPLACEMENT
6 If you are replacing another health insurance policy, do not
7 cancel it until you have actually received your new policy and
8 are sure you want to keep it.
9 NOTICE
10 This policy may not fully cover all of your medical costs.
11 [For agent issued policies]
12 Neither (insert insurer's name) nor its agents are connected
13 with medicare.
14 [For direct response issued policies]
15 (Insert insurer's name) is not connected with medicare.
16 This outline of coverage does not give all the details of
17 medicare coverage. Contact your local social security office or
18 consult "the medicare handbook" for more details.
19 COMPLETE ANSWERS ARE VERY IMPORTANT
20 When you fill out the application for the new policy, be
21 sure to answer truthfully and completely all questions about your
22 medical and health history. The company may cancel your policy
23 and refuse to pay any claims if you leave out or falsify
1 important medical information. [If the policy or certificate is
2 guaranteed issue, this paragraph need not appear.]
3 Review the application carefully before you sign it. Be
4 certain that all information has been properly recorded.
5 [Include for each plan offered by the insurer a chart
6 showing the services, medicare payments, plan payments, and
7 insured payments using the same language, in the same order, and
8 using uniform layout and format as shown in the charts that
9 follow. An insurer may use additional benefit plan designations
10 on these charts pursuant to section 3809(1)(k). Include an
11 explanation of any innovative benefits on the cover page and in
12 the chart, in a manner approved by the commissioner. The insurer
13 issuing the policy shall change the dollar amounts each year to
14 reflect current figures. No more than 4 plans may be shown on 1
15 chart.] Charts for each plan are as follows:
16 PLAN A
17 MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
18 *A benefit period begins on the first day you receive
19 service as an inpatient in a hospital and ends after you have
20 been out of the hospital and have not received skilled care in
21 any other facility for 60 days in a row.
22 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
23 HOSPITALIZATION*
24 Semiprivate room and
25 board, general nursing
1 and miscellaneous
2 services and supplies
3
First 60 days All but $952 $0 $952$992
4 $992 (Part A
5 Deductible)
6
61st thru 90th day All but $238 $238$248 $0
7 $248 a day a day
8 91st day and after:
9 —While using 60
10
lifetime reserve days All but $476 $476$496 $0
11 $496 a day a day
12 —Once lifetime reserve
13 days are used:
14 —Additional 365 days $0 100% of $0**
15 Medicare
16 Eligible
17 Expenses
18 —Beyond the
19 Additional 365 days $0 $0 All Costs
20 SKILLED NURSING FACILITY
21 CARE*
22 You must meet Medicare's
23 requirements, including
24 having been in a hospital
25 for at least 3 days and
26 entered a Medicare-
27 approved facility within
28 30 days after leaving the
29 hospital
30 First 20 days All approved
31 amounts $0 $0
1
21st thru 100th day All but $119 $0 Up to $119
2 $124 a day $124 a day
3 101st day and after $0 $0 All costs
4 BLOOD
5 First 3 pints $0 3 pints $0
6 Additional amounts 100% $0 $0
7 HOSPICE CARE
8 Available as long as your All
but very $0 Balance$0
9 doctor certifies you are limited
Medicare
10 terminally ill and you copayment/ copayment/
11 elect to receive these coinsurance coinsurance
12 services You must
meet for outpatient
13 Medicare's requirements, drugs and
14 including a doctor's inpatient
15 certification of terminal respite care
16 illness
17 **NOTICE: When your Medicare Part A hospital benefits are
18 exhausted, the insurer stands in the place of Medicare and will
19 pay whatever amount Medicare would have paid for up to an
20 additional 365 days as provided in the policy's "Core Benefits."
21 During this time the hospital is prohibited from billing you for
22 the balance based on any difference between its billed charges
23 and the amount Medicare would have paid.
24 PLAN A
25 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
26 *Once you have been billed $124 $131 of
Medicare-Approved
27 amounts for covered services (which are noted with an asterisk),
1 your Part B Deductible will have been met for the calendar year.
2
3 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
4 MEDICAL EXPENSES—
5 In or out of the hospital
6 and outpatient hospital
7 treatment, such as
8 Physician's services,
9 inpatient and outpatient
10 medical and surgical
11 services and supplies,
12 physical and speech
13 therapy, diagnostic
14 tests, durable medical
15 equipment,
16
First $124$131 of
17 Medicare
Approved $0 $0 $124 $131
18 Amounts* (Part B
19 Deductible)
20 Remainder of Medicare
21 Approved Amounts 80% 20% $0
22 Part B Excess Charges
23 (Above Medicare
24 Approved Amounts) $0 $0 All Costs
25 BLOOD
26 First 3 pints $0 All Costs $0
27 Next
$124$131 of
28 Medicare $0 $0 $124
$131
29 Approved Amounts* (Part B
30 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 other facility for 60 days in a row.
17 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
18 HOSPITALIZATION*
19 Semiprivate room and
20 board, general nursing
21 and miscellaneous
22 services and supplies
23 First 60 days All but $952 $952 $0
24 (Part A
25 Deductible)
26 61st thru 90th day All but $238 $238 $0
1 a day a day
2 91st day and after
3 —While using 60
4 lifetime reserve days All but $476 $476 $0
5 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 hospital
19 for at least 3 days and
20 entered a Medicare-
21 approved facility within
22 30 days after leaving the
23 hospital
24 First 20 days All approved
25 amounts $0 $0
26 21st thru 100th day All but $119 Up to $119 $0
27 a day a day
28 101st day and after $0 $0 All costs
29 BLOOD
30 First 3 pints $0 3 pints $0
31 Additional amounts 100% $0 $0
1 HOSPICE CARE
2 Available as long as your All but very $0 Balance
3 doctor certifies you are limited
4 terminally ill and you coinsurance
5 elect to receive these for outpatient
6 services drugs and
7 inpatient
8 respite care
9 PLAN H
10 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
11 *Once you have been billed $124 of Medicare-Approved amounts
12 for covered services (which are noted with an asterisk), your
13 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
26 equipment,
27 First $124 of Medicare
1 Approved Amounts* $0 $0 $124
2 (Part B
3 Deductible)
4 Remainder of Medicare
5 Approved Amounts 80% 20% $0
6 Part B Excess Charges
7 (Above Medicare
8 Approved Amounts) $0 $0 All Costs
9 BLOOD
10 First 3 pints $0 All Costs $0
11 Next $124 of Medicare
12 Approved Amounts* $0 $0 $124
13 (Part B
14 Deductible)
15 Remainder of Medicare
16 Approved Amounts 80% 20% $0
17 CLINICAL LABORATORY
18 SERVICES—
19 Tests for
20 diagnostic services 100% $0 $0
21 PARTS A & B
22 HOME HEALTH CARE
23 Medicare Approved
24 Services
25 —Medically necessary
26 skilled care services
27 and medical supplies 100% $0 $0
1 —Durable medical
2 equipment
3 First $124 of Medicare
4 Approved Amounts* $0 $0 $124
5 (Part B
6 Deductible)
7 Remainder of Medicare
8 Approved Amounts 80% 20% $0
9 OTHER BENEFITS—NOT COVERED BY MEDICARE
10 FOREIGN TRAVEL—
11 Not covered by Medicare
12 Medically necessary
13 emergency care services
14 beginning during the
15 first 60 days of each
16 trip outside the USA
17 First $250 each
18 calendar year $0 $0 $250
19 Remainder of Charges $0 80% to a 20% and
20 lifetime amounts
21 maximum over the
22 benefit $50,000
23 of $50,000 lifetime
24 maximum
25
26
27
28
1
2
3
4
5
6
7
8
9
10 PLAN I
11 MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
12 *A benefit period begins on the first day you receive
13 service as an inpatient in a hospital and ends after you have
14 been out of the hospital and have not received skilled care in
15 any other facility for 60 days in a row.
16 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
17 HOSPITALIZATION*
18 Semiprivate room and
19 board, general nursing
20 and miscellaneous
21 services and supplies
22 First 60 days All but $952 $952 $0
23 (Part A
24 Deductible)
25 61st thru 90th day All but $238 $238 $0
26 a day a day
1 91st day and after
2 —While using 60
3 lifetime reserve days All but $476 $476 $0
4 a day a day
5 —Once lifetime reserve
6 days are used:
7 —Additional 365 days $0 100% of $0
8 Medicare
9 Eligible
10 Expenses
11 —Beyond the
12 Additional 365 days $0 $0 All Costs
13 SKILLED NURSING FACILITY
14 CARE*
15 You must meet Medicare's
16 requirements, including
17 having been in a hospital
18 for at least 3 days and
19 entered a Medicare-
20 approved facility within
21 30 days after leaving the
22 hospital
23 First 20 days All approved
24 amounts $0 $0
25 21st thru 100th day All but $119 Up to $119 $0
26 a day a day
27 101st day and after $0 $0 All costs
28 BLOOD
29 First 3 pints $0 3 pints $0
30 Additional amounts 100% $0 $0
31 HOSPICE CARE
1 Available as long as your All but very $0 Balance
2 doctor certifies you are limited
3 terminally ill and you coinsurance
4 elect to receive these for outpatient
5 services drugs and
6 inpatient
7 respite care
8 PLAN I
9 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
10 *Once you have been billed $124 of Medicare-Approved amounts
11 for covered services (which are noted with an asterisk), your
12 Part B Deductible will have been met for the calendar year.
13 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
14 MEDICAL EXPENSES—
15 In or out of the hospital
16 and outpatient hospital
17 treatment, such as
18 Physician's services,
19 inpatient and outpatient
20 medical and surgical
21 services and supplies,
22 physical and speech
23 therapy, diagnostic
24 tests, durable medical
25 equipment,
26 First $124 of Medicare
27 Approved Amounts* $0 $0 $124
1 (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) $0 100% $0
8 BLOOD
9 First 3 pints $0 All Costs $0
10 Next $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 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 of Medicare
3 Approved Amounts* $0 $0 $124
4 (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
19
20
21
22
23
24
25
26
27
28
1
2
3 PLAN J OR HIGH DEDUCTIBLE PLAN J
4 MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
5 *A benefit period begins on the first day you receive
6 service as an inpatient in a hospital and ends after you have
7 been out of the hospital and have not received skilled care in
8 any other facility for 60 days in a row.
9 **This high deductible plan pays the same benefits as plan J
10 after you have paid a calendar year ($1,790) deductible. Benefits
11 from the high deductible plan J will not begin until out-of-
12 pocket expenses are $1,790. Out-of-pocket expenses for this
13 deductible are expenses that would ordinarily be paid by the
14 policy. This includes medicare deductibles for part A and part B,
15 but does not include the plan's outpatient prescription drug
16 deductible or separate foreign travel emergency deductible.
17 SERVICES MEDICARE PAYS AFTER YOU IN ADDITION
18 PAY $1,790 TO $1,790
19 DEDUCTIBLE**, DEDUCTIBLE**,
20 PLAN PAYS YOU PAY
21 HOSPITALIZATION*
22 Semiprivate room and
23 board, general nursing
24 and miscellaneous
1 services and supplies
2 First 60 days All but $952 $952 $0
3 (Part A
4 Deductible)
5 61st thru 90th day All but $238 $238 $0
6 a day a day
7 91st day and after
8 —While using 60
9 lifetime reserve days All but $476 $476 $0
10 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 Up to $119 $0
1 a day 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 ***NOTICE: When your Medicare Part A hospital benefits are
7 exhausted, the insurer stands in the place of Medicare and will
8 pay whatever amount medicare would have paid for up to an
9 additinal 365 days as provided in the policy's "core
benefits."
10 During this time the hospital is prohibited from billing you for
11 the balance based on any difference between its billed charges
12 and the amount medicare would have paid.
13 PLAN J
14 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
15 *Once you have been billed $124 of Medicare-Approved amounts
16 for covered services (which are noted with an asterisk), your
17 Part B Deductible will have been met for the calendar year.
18 **This high deductible plan pays the same benefits as plan J
19 after you have paid a calendar year ($1,790) deductible. Benefits
20 from the high deductible plan J will not begin until out-of-
21 pocket expenses are $1,790. Out-of-pocket expenses for this
22 deductible are expenses that would ordinarily be paid by the
23 policy. This includes medicare deductibles for part A and part B,
24 but does not include the plan's separate outpatient prescription
25 drug deductible or foreign travel emergency deductible.
1 SERVICES MEDICARE PAYS AFTER YOU IN ADDITION
2 PAY $1,790 TO $1,790
3 DEDUCTIBLE**, DEDUCTIBLE**,
4 PLAN PAYS YOU PAY
5 HOSPICE CARE
6 Available as long as your All but very $0 Balance
7 doctor certifies you are limited
8 terminally ill and you coinsurance
9 elect to receive these for outpatient
10 services drugs and
11 inpatient
12 respite care
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 of Medicare
26 Approved Amounts* $0 $124 $0
27 (Part B
28 Deductible)
1 Remainder of Medicare
2 Approved Amounts 80% 20% $0
3 Part B Excess Charges
4 (Above Medicare
5 Approved Amounts) $0 100% $0
6 BLOOD
7 First 3 pints $0 All Costs $0
8 Next $124 of Medicare
9 Approved Amounts* $0 $124 $0
10 (Part B
11 Deductible)
12 Remainder of Medicare
13 Approved Amounts 80% 20% $0
14 CLINICAL LABORATORY
15 SERVICES—
16 Tests for
17 diagnostic services 100% $0 $0
18 PARTS A & B
19 HOME HEALTH CARE
20 Medicare Approved
21 Services
22 —Medically necessary
23 skilled care services
24 and medical supplies 100% $0 $0
25 —Durable medical
26 equipment
27 First $124 of Medicare
28 Approved Amounts* $0 $124 $0
1 (Part B
2 Deductible)
3 Remainder of Medicare
4 Approved Amounts 80% 20% $0
5 AT-HOME RECOVERY
6 SERVICES—
7 Not covered by Medicare
8 Home care certified by
9 your doctor, for personal
10 care beginning during
11 recovery from an injury
12 or sickness for which
13 Medicare approved a
14 Home Care Treatment Plan
15 —Benefit for each visit $0 Actual
16 Charges to
17 $40 a visit Balance
18 —Number of visits
19 covered (must be
20 received within 8
21 weeks of last
22 Medicare Approved visit) $0 Up to the
23 number of
24 Medicare
25 Approved
26 visits, not
27 to exceed 7
28 each week
29 —Calendar year maximum $0 $1,600
1 OTHER BENEFITS—NOT COVERED BY MEDICARE
2 FOREIGN TRAVEL—
3 Not covered by Medicare
4 Medically necessary
5 emergency care services
6 beginning during the
7 first 60 days of each
8 trip outside the USA
9 First $250 each
10 calendar year $0 $0 $250
11 Remainder of Charges $0 80% to a 20% and
12 lifetime amounts
13 maximum over the
14 benefit $50,000
15 of $50,000 lifetime
16 maximum
17 PREVENTIVE MEDICAL CARE
18 BENEFIT-
19 Not covered by Medicare
20 Annual physical and
21 preventive tests and
22 services
23 administered
24 or ordered by your doctor
25 when not covered by
26 Medicare
27 First $120 each
28 calendar year $0 $120 $0
29 Additional charges $0 $0 All costs
1 PLAN K
2 *You will pay half the cost-sharing of some covered services
3 until you reach the annual out-of-pocket limit of $4,000$4,140
4 each calendar year. The amounts that count toward your annual
5 limit are noted with diamonds -->superscript<--1 in the chart
6 below. Once you reach the annual limit, the plan pays 100% of
7 your Medicare copayment and coinsurance for the rest of the
8 calendar year. However, this limit does NOT include charges from
9 your provider that exceed Medicare-approved amounts (these are
10 called "Excess Charges") and you will be responsible for paying
11 this difference in the amount charged by your provider and the
12 amount paid by Medicare for the item or service.
13 PLAN K
14 MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
15 **A benefit period begins on the first day you receive
16 service as an inpatient in a hospital and ends after you have
17 been out of the hospital and have not received skilled care in
18 any other facility for 60 days in a row.
19 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY*
20 HOSPITALIZATION**
21 Semiprivate room and
22 board, general nursing
23 and miscellaneous
24 services and supplies
1
First 60 days All but $952 $476$496 $476$496
2 $992 (50% (50% of
3 of Part A Part A
4 Deducti- Deductible) 1
5 ble)
6
7
61st thru 90th day All but $238 $238 $248 $0
8 $248 a day a day
9 91st day and after:
10 —While using 60
11
lifetime reserve days All but $476 $476$496
$0
12 $496 a day a day
13 —Once lifetime reserve
14 days are used:
15 —Additional 365 days $0 100% of $0***
16 Medicare
17 Eligible
18 Expenses
19 —Beyond the
20 Additional 365 days $0 $0 All Costs
21 SKILLED NURSING FACILITY
22 CARE**
23 You must meet Medicare's
24 requirements, including
25 having been in a hospital
26 for at least 3 days and
27 entered a Medicare-
28 approved facility within
29 30 days after leaving the
30 hospital
31 First 20 days All approved
1 amounts $0 $0
2 21st thru 100th day All but Up to Up to
3 $119$124 a $59.50$62 $59.50$62
4 day a day a day 1
5 101st day and after $0 $0 All costs
6 BLOOD
7 First 3 pints $0 50% 50% 1
8 Additional amounts 100% $0 $0
9 HOSPICE CARE
10 Available as long as your Generally, 50% of 50% of
11 doctor certifies you are most Medicare copayment/ Medicare
12 terminally ill and you eligible coinsur- copayment/
13 elect to receive these expenses for ance or coinsurance
14 servicesYou must meet outpatient copayments or copay-
15 Medicare's requirements, drugs
and ments
1
16 including a doctor's inpatient
17 certification of terminal respite
care
18 illness All but very
19 limited
20 copayment/
21 coinsurance for
22 outpatient
23 drugs and
24 inpatient
25 respite care
26 ***NOTICE: When your Medicare Part A hospital benefits are
27 exhausted, the insurer stands in the place of Medicare and will
28 pay whatever amount Medicare would have paid for up to an
29 additional 365 days as provided in the policy's "Core Benefits."
30 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 K
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 **** 1
26
1 Preventive Benefits for Generally 75% Remainder All costs
2 Medicare covered or more of of Medi- above Medi-
3 services Medicare ap- care care
4 proved amounts approved approved
5 amounts amounts
6 Remainder of Medicare Generally 80% Generally Generally
7 Approved Amounts 10% 10% 1
8
9 Part B Excess Charges $0 $0 All costs
10 (Above Medicare (and they do
11 Approved Amounts) not count
12 toward
13 annual out-
14 of-pocket
15 limit of
16 $4,000$4,140)*
17 BLOOD
18 First 3 pints $0 50% 50% 1
19 Next
$124$131 of
20
Medicare Approved $0 $0 $124$131
21 Amounts**** (Part B
22 Deductible)
23 **** 1
24 Remainder of Medicare Generally 80% Generally Generally
25 Approved Amounts 10% 10% 1
26 CLINICAL LABORATORY
27 SERVICES—Tests for
28 diagnostic services 100% $0 $0
29 *This plan limits your annual out-of-pocket payments for
30 Medicare-approved amounts to $4,000$4,140
per year. However, this
1 limit does NOT include charges from your provider that exceed
2 Medicare-approved amounts (these are called "Excess Charges") and
3 you will be responsible for paying this difference in the amount
4 charged by your provider and the amount paid by Medicare for the
5 item or service.
6 PARTS A & B
7 HOME HEALTH CARE
8 Medicare Approved
9 Services
10 —Medically necessary
11 skilled care services
12 and medical supplies 100% $0 $0
13 —Durable medical
14 equipment
15
First $124$131 of
16
Medicare Approved $0 $0 $124$131
17 Amounts***** (Part B
18 Deductible)1
19 Remainder of Medicare
20 Approved Amounts 80% 10% 10% 1
21 *****Medicare benefits are subject to change. Please consult
22 the latest Guide to Health Insurance for People with Medicare.
23 PLAN L
24 *You will pay one-fourth of the cost-sharing of some covered
1 services until you reach the annual out-of-pocket limit of
2 $2,000$2,070 each calendar year. The amounts that count toward
3 your annual limit are noted with diamonds -->superscript<--1 in
4 the chart below. Once you reach the annual limit, the plan pays
5 100% of your Medicare copayment and coinsurance for the rest of
6 the calendar year. However, this limit does NOT include charges
7 from your provider that exceed Medicare-approved amounts (these
8 are called "Excess Charges") and you will be responsible for
9 paying this difference in the amount charged by your provider and
10 the amount paid by Medicare for the item or service.
11 PLAN L
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 other facility for 60 days in a row.
17 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY*
18 HOSPITALIZATION**
19 Semiprivate room and
20 board, general nursing
21 and miscellaneous
22 services and supplies
23
First 60 days All but $952 $714$744 $238$248
24 $992 (75% of (25% of
25 Part A Part A
26 Deducti- Deductible) 1
1 ble)
2
61st thru 90th day All but $238 $238$248 $0
3 $248 a day a day
4 91st day and after:
5 —While using 60
6
lifetime reserve days All but $476 $476$496 $0
7 $496 a day a day
8 —Once lifetime reserve
9 days are used:
10 —Additional 365 days $0 100% of $0***
11 Medicare
12 Eligible
13 Expenses
14 —Beyond the
15 Additional 365 days $0 $0 All Costs
16 SKILLED NURSING FACILITY
17 CARE**
18 You must meet Medicare's
19 requirements, including
20 having been in a hospital
21 for at least 3 days and
22 entered a Medicare-
23 approved facility within
24 30 days after leaving the
25 hospital
26 First 20 days All approved
27 amounts $0 $0
28 21st thru 100th day All but Up to Up to
29 $119$124 a $89.25$93 $29.75$31
30 day a day a day 1
31 101st day and after $0 $0 All costs
1 BLOOD
2 First 3 pints $0 75% 25% 1
3 Additional amounts 100% $0 $0
4 HOSPICE CARE
5 Available as long as your Generally, 75% of 25% of
6 doctor certifies you are most Medicare copayment/ copayment/
7 terminally ill and you eligible coinsur- coinsurance
8 elect to receive these expenses for ance or or copay-
9 servicesYou must meet outpatient copayments ments 1
10 Medicare's requirements, drugs
and
11 including a doctor's inpatient
12 certification of terminal respite
careAll
13 illness but very
14 limited copay-
15 ment/coinsur-
16 ance for
17 outpatient
18 drugs and
19 inpatient
20 respite care
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 L
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
21 B Deducti-
22 ble)**** 1
23 Preventive Benefits for Generally 75% Remainder All costs
24 Medicare covered or more of of Medi- above Medi-
25 services Medicare care care
26 approved approved approved
27 amounts amounts amounts
28 Remainder of Medicare Generally Generally Generally
1 Approved Amounts 80% 15% 5% 1
2
3 Part B Excess Charges $0 $0 All costs
4 (Above Medicare (and they do
5 Approved Amounts) not count
6 toward
7 annual out-
8 of-pocket
9 limit of
10 $2,000$2,070)*
11 BLOOD
12 First 3 pints $0 75% 25% 1
13 Next
$124$131 of
14
Medicare Approved $0 $0 $124$131
15 Amounts**** (Part B
16 Deductible) 1
17 Remainder of Medicare Generally Generally Generally
18 Approved Amounts 80% 15% 5% 1
19 CLINICAL LABORATORY
20 SERVICES—Tests for
21 diagnostic services 100% $0 $0
22 *This plan limits your annual out-of-pocket payments for
23 Medicare-approved amounts to $2,000$2,070
per year. However, this
24 limit does NOT include charges from your provider that exceed
25 Medicare-approved amounts (these are called "Excess Charges") and
26 you will be responsible for paying this difference in the amount
27 charged by your provider and the amount paid by Medicare for the
28 item or service.
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$131 of
11
Medicare Approved $0 $0 $124$131
12 Amounts***** (Part
13 B Deducti-
14 ble) 1
15 Remainder of Medicare
16 Approved Amounts 80% 15% 5% 1
17 *****Medicare benefits are subject to change. Please consult
18 the latest Guide to Health Insurance for People with Medicare.
19 PLAN M
20 MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
21 *A benefit period begins on the first day you receive
22 service as an inpatient in a hospital and ends after you have
23 been out of the hospital and have not received skilled care in
24 any other facility for 60 days in a row.
25 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
1 HOSPITALIZATION*
2 Semiprivate room and
3 board, general nursing
4 and miscellaneous
5 services and supplies
6 First 60 days All but $992 $496 (50% $496 (50%
7 of Part A of Part A
8 Deduc- Deduc-
9 tible) tible)
10 61st thru 90th day All but $248 $248 $0
11 a day a day
12 91st day and after:
13 —While using 60
14 lifetime reserve days All but $496 $496 $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 $0 $0
4 amounts
5 21st thru 100th day All but $124 Up to $124 $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 You must meet Medicare's All but very Medicare $0
13 requirements, including limited copayment/
14 a doctor's copayment/ coinsurance
15 certification of coinsurance
16 terminal illness for outpatient
17 drugs and
18 inpatient
19 respite care
20 **NOTICE: When your Medicare Part A hospital benefits are
21 exhausted, the insurer stands in the place of Medicare and will
22 pay whatever amount Medicare would have paid for up to an
23 additional 365 days as provided in the policy's "Core Benefits".
24 During this time the hospital is prohibited from billing you for
25 the balance based on any difference between its billed charges
26 and the amount Medicare would have paid.
27 PLAN M
28 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
1 *Once you have been billed $131 of Medicare-approved amounts
2 for covered services (which are noted with an asterisk), your
3 Part B deductible will have been met for the calendar year.
4 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
5 MEDICAL EXPENSES—
6 IN OR OUT OF THE
7 HOSPITAL AND OUTPATIENT
8 HOSPITAL TREATMENT, such
9 as physician's services,
10 inpatient and outpatient
11 medical and surgical
12 services and supplies,
13 physical and speech
14 therapy, diagnostic
15 tests, durable medical
16 equipment
17 First $131 of Medicare
18 Approved Amounts* $0 $0 $131
19 (Part B
20 Deduc-
21 tible)
22 Remainder of Medicare
23 Approved Amounts Generally Generally $0
24 80% 20%
25 Part B Excess Charges
26 (Above Medicare
27 Approved Amounts) $0 $0 All costs
28 BLOOD
29 First 3 pints $0 All costs $0
1 Next $131 of Medicare
2 Approved Amounts* $0 $0 $131
3 (Part B
4 Deduc-
5 tible)
6 Remainder of Medicare
7 Approved Amounts 80% 20% $0
8 CLINICAL LABORATORY
9 SERVICES—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 $131 of
21 Medicare Approved
22 Amounts $0 $0 $131
23 (Part B
24 Deduc-
25 tible)
26 Remainder of Medicare
27 Approved Amounts 80% 20% $0
28 OTHER BENEFITS—NOT COVERED BY MEDICARE
29 FOREIGN TRAVEL—NOT
1 COVERED BY MEDICARE
2 Medically necessary
3 emergency care services
4 beginning during the
5 first 60 days of each
6 trip outside the USA
7 First $250 each
8 calendar year $0 $0 $250
9 Remainder of Charges $0 80% to a 20% and
10 lifetime amounts
11 maximum over the
12 benefit of $50,000
13 $50,000 lifetime
14 maximum
15 PLAN N
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
26 services and supplies
27 First 60 days All but $992 $992 $0
28 (Part A
1 Deduc-
2 tible)
3 61st thru 90th day All but $248 $248 $0
4 a day a day
5 91st day and after:
6 —While using 60
7 lifetime reserve days All but $496 $496 $0
8 a day a day
9 —Once lifetime reserve
10 days are used:
11 —Additional 365 days $0 100% of $0**
12 Medicare
13 Eligible
14 Expenses
15 —Beyond the
16 additional 365 days $0 $0 All costs
17 SKILLED NURSING FACILITY
18 CARE*
19 You must meet Medicare's
20 requirements, including
21 having been in a hospital
22 for at least 3 days and
23 entered a Medicare-
24 approved facility within
25 30 days after leaving the
26 hospital
27 First 20 days All approved $0 $0
28 amounts
29 21st thru 100th day All but $124 Up to $124 $0
30 a day a day
31 101st day and after $0 $0 All costs
1 BLOOD
2 First 3 pints $0 3 pints $0
3 Additional amounts 100% $0 $0
4 HOSPICE CARE
5 You must meet Medicare's All but very Medicare $0
6 requirements, including limited copayment/
7 a doctor's certification copayment/ coinsurance
8 of terminal illness coinsurance
9 for outpatient
10 drugs and
11 inpatient
12 respite care
13 **NOTICE: When your Medicare Part A hospital benefits are
14 exhausted, the insurer stands in the place of Medicare and will
15 pay whatever amount Medicare would have paid for up to an
16 additional 365 days as provided in the policy's "Core Benefits".
17 During this time the hospital is prohibited from billing you for
18 the balance based on any difference between its billed charges
19 and the amount Medicare would have paid.
20 PLAN N
21 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
22 *Once you have been billed $131 of Medicare-approved amounts
23 for covered services (which are noted with an asterisk), your
24 Part B deductible will have been met for the calendar year.
25 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
1 MEDICAL EXPENSES—
2 IN OR OUT OF THE
3 HOSPITAL AND OUTPATIENT
4 HOSPITAL TREATMENT, such
5 as physician's services,
6 inpatient and outpatient
7 medical and surgical
8 services and supplies,
9 physical and speech
10 therapy, diagnostic
11 tests, durable medical
12 equipment
13 First $131 of Medicare
14 Approved Amounts* $0 $0 $131
15 (Part B
16 Deduc-
17 tible)
18 Remainder of Medicare
19 Approved Amounts Generally Balance, Up to $20
20 80% other than per office
21 up to $20 visit and
22 per office up to $50
23 visit and per
24 up to $50 emergency
25 per room
26 emergency visit. The
27 room visit. copayment
28 The of up to
29 copayment $50 is
30 of up to waived if
31 $50 is the
1 waived if insured is
2 the insured admitted
3 is admitted to any
4 to any hospital
5 hospital and the
6 and the emergency
7 emergency visit is
8 visit is covered as
9 covered as a Medicare
10 a Medicare Part A
11 Part A expense.
12 expense.
13 Part B Excess Charges
14 (Above Medicare
15 Approved Amounts) $0 $0 All costs
16 BLOOD
17 First 3 pints $0 All costs $0
18 Next $131 of Medicare
19 Approved Amounts* $0 $0 $131
20 (Part B
21 Deduc-
22 tible)
23 Remainder of Medicare
24 Approved Amounts 80% 20% $0
25 CLINICAL LABORATORY
26 SERVICES—Tests for
27 diagnostic services 100% $0 $0
28 PARTS A & B
29 HOME HEALTH CARE
30 Medicare Approved
1 Services
2 —Medically necessary
3 skilled care services
4 and medical supplies 100% $0 $0
5 —Durable medical
6 equipment
7 First $131 of
8 Medicare Approved
9 Amounts* $0 $0 $131
10 (Part B
11 Deduc-
12 tible)
13 Remainder of Medicare
14 Approved Amounts 80% 20% $0
15 OTHER BENEFITS—NOT COVERED BY MEDICARE
16 FOREIGN TRAVEL—NOT
17 COVERED BY MEDICARE
18 Medically necessary
19 emergency care services
20 beginning during the
21 first 60 days of each
22 trip outside the USA
23 First $250 each
24 calendar year $0 $0 $250
25 Remainder of Charges $0 80% to a 20% and
26 lifetime amounts
27 maximum over the
28 benefit of $50,000
29 $50,000 lifetime
30 maximum
1 Sec. 3819. (1) An insurance policy shall not be titled,
2 advertised, solicited, or issued for delivery in this state as a
3 medicare supplement policy if the policy does not meet the
4 minimum standards prescribed in this section. These minimum
5 standards are in addition to all other requirements of this
6 chapter.
7 (2) The following standards apply to medicare supplement
8 policies:
9 (a) A medicare supplement policy shall not deny a claim for
10 losses incurred more than 6 months from the effective date of
11 coverage because it involved a preexisting condition. The policy
12 or certificate shall not define a preexisting condition more
13 restrictively than to mean a condition for which medical advice
14 was given or treatment was recommended by or received from a
15 physician within 6 months before the effective date of coverage.
16 (b) A medicare supplement policy shall not indemnify against
17 losses resulting from sickness on a different basis than losses
18 resulting from accidents.
19 (c) A medicare supplement policy shall provide that benefits
20 designed to cover cost sharing amounts under medicare will be
21 changed automatically to coincide with any changes in the
22 applicable medicare deductible,
amount and copayment percentage
23 factors copayment, or
coinsurance amounts. Premiums may be
24 modified to correspond with such changes.
25 (d) A medicare supplement policy shall be guaranteed
26 renewable. Termination shall be for nonpayment of premium or
1 material misrepresentation only.
2 (e) Termination of a medicare supplement policy shall not
3 reduce or limit the payment of benefits for any continuous loss
4 that commenced while the policy was in force, but the extension
5 of benefits beyond the period during which the policy was in
6 force may be predicated upon the continuous total disability of
7 the insured, limited to the duration of the policy benefit
8 period, if any, or payment of the maximum benefits. Receipt of
9 medicare part D benefits will not be considered in determining a
10 continuous loss.
11 (f) If a medicare supplement policy eliminates an outpatient
12 prescription drug benefit as a result of requirements imposed by
13 the medicare prescription drug, improvement, and modernization
14 act of 2003, Public Law 108-173, the modified policy shall be
15 considered to satisfy the guaranteed renewal of this subsection.
16 (g) A medicare supplement policy shall not provide for
17 termination of coverage of a spouse solely because of the
18 occurrence of an event specified for termination of coverage of
19 the insured, other than the nonpayment of premium.
20 (3) A medicare supplement policy shall provide that benefits
21 and premiums under the policy shall be suspended at the request
22 of the policyholder or certificate holder for a period not to
23 exceed 24 months in which the policyholder or certificate holder
24 has applied for and is determined to be entitled to medical
25 assistance under medicaid, but only if the policyholder or
26 certificate holder notifies the insurer of such assistance within
27 90 days after the date the individual becomes entitled to the
1 assistance. Upon receipt of timely notice, the insurer shall
2 return to the policyholder or certificate holder that portion of
3 the premium attributable to the period of medicaid eligibility,
4 subject to adjustment for paid claims. If a suspension occurs and
5 if the policyholder or certificate holder loses entitlement to
6 medical assistance under medicaid, the policy shall be
7 automatically reinstituted effective as of the date of
8 termination of the assistance if the policyholder or certificate
9 holder provides notice of loss of medicaid medical assistance
10 within 90 days after the date of the loss and pays the premium
11 attributable to the period effective as of the date of
12 termination of the assistance. Each medicare supplement policy
13 shall provide that benefits and premiums under the policy shall
14 be suspended at the request of the policyholder if the
15 policyholder is entitled to benefits under section 226(b) of
16 title II of the social security act, and is covered under a group
17 health plan as defined in section 1862(b)(1)(A)(v) of the social
18 security act. If suspension occurs and if the policyholder or
19 certificate holder loses coverage under the group health plan,
20 the policy shall be automatically reinstituted effective as of
21 the date of loss of coverage if the policyholder provides notice
22 of loss of coverage within 90 days after the date of the loss and
23 pays the premium attributable to the period, effective as of the
24 date of termination of enrollment in the group health plan. All
25 of the following apply to the reinstitution of a medicare
26 supplement policy under this subsection:
27 (a) The reinstitution shall not provide for any waiting
1 period with respect to treatment of preexisting conditions.
2 (b) Reinstituted coverage shall be substantially equivalent
3 to coverage in effect before the date of the suspension. If the
4 suspended medicare supplement policy provided coverage for
5 outpatient prescription drugs, reinstitution of the policy for
6 medicare part D enrollees shall be without coverage for
7 outpatient prescription drugs and shall otherwise provide
8 substantially equivalent coverage to the coverage in effect
9 before the date of the suspension.
10 (c) Classification of premiums for reinstituted coverage
11 shall be on terms at least as favorable to the policyholder or
12 certificate holder as the premium classification terms that would
13 have applied to the policyholder or certificate holder had the
14 coverage not been suspended.
15 (4) If an insurer makes a written offer to the medicare
16 supplement policyholders or certificate holders of 1 or more of
17 its plans, to exchange during a specified period from his or her
18 1990 standardized plan to a 2010 standardized plan, the offer and
19 subsequent exchange shall comply with the following requirements:
20 (a) An insurer need not provide justification to the
21 commissioner if the insured replaces a 1990 standardized policy
22 or certificate with an issue age rated 2010 standardized policy
23 or certificate at the insured's original issue age and duration.
24 If an insured's policy or certificate to be replaced is priced on
25 an issue age rate schedule at that time of that offer, the rate
26 charged to the insured for the new exchanged policy shall
27 recognize the policy reserve buildup, due to the prefunding
1 inherent in the use of an issue age rate basis, for the benefit
2 of the insured. The method proposed to be used by an issuer must
3 be filed with the commissioner.
4 (b) The rating class of the new policy or certificate shall
5 be the class closest to the insured's class of the replaced
6 coverage.
7 (c) An insurer may not apply new preexisting condition
8 limitations or a new incontestability period to the new policy
9 for those benefits contained in the exchanged 1990 standardized
10 policy or certificate of the insured, but may apply preexisting
11 condition limitations of no more than 6 months to any added
12 benefits contained in the new 2010 standardized policy or
13 certificate not contained in the exchanged policy.
14 (d) The new policy or certificate shall be offered to all
15 policyholders or certificate holders within a given plan, except
16 where the offer or issue would be in violation of state or
17 federal law.
18 (5) This section applies to medicare supplement policies or
19 certificates delivered or issued for delivery with an effective
20 date for coverage prior to June 1, 2010.
21 Sec. 3819a. (1) This section applies to all medicare
22 supplement policies or certificates delivered or issued for
23 delivery with an effective date for coverage on or after June 1,
24 2010.
25 (2) An insurance policy shall not be titled, advertised,
26 solicited, or issued for delivery in this state as a medicare
27 supplement policy if the policy does not meet the minimum
1 standards prescribed in this section. These minimum standards are
2 in addition to all other requirements of this chapter. An issuer
3 shall not offer any 1990 plan for sale on or after June 1, 2010.
4 Benefit standards applicable to medicare supplement policies and
5 certificates issued before June 1, 2010 remain subject to the
6 requirements of section 3819.
7 (3) The following standards apply to medicare supplement
8 policies:
9 (a) A medicare supplement policy shall not deny a claim for
10 losses incurred more than 6 months from the effective date of
11 coverage because it involved a preexisting condition. The policy
12 or certificate shall not define a preexisting condition more
13 restrictively than to mean a condition for which medical advice
14 was given or treatment was recommended by or received from a
15 physician within 6 months before the effective date of coverage.
16 (b) A medicare supplement policy shall not indemnify against
17 losses resulting from sickness on a different basis than losses
18 resulting from accidents.
19 (c) A medicare supplement policy shall provide that benefits
20 designed to cover cost-sharing amounts under medicare will be
21 changed automatically to coincide with any changes in the
22 applicable medicare deductible, copayment, or coinsurance
23 amounts. Premiums may be modified to correspond with such
24 changes.
25 (d) A medicare supplement policy shall be guaranteed
26 renewable. Termination shall be for nonpayment of premium or
27 material misrepresentation only.
1 (e) Termination of a medicare supplement policy shall not
2 reduce or limit the payment of benefits for any continuous loss
3 that commenced while the policy was in force, but the extension
4 of benefits beyond the period during which the policy was in
5 force may be predicated upon the continuous total disability of
6 the insured, limited to the duration of the policy benefit
7 period, if any, or payment of the maximum benefits. Receipt of
8 medicare part D benefits will not be considered in determining a
9 continuous loss.
10 (f) A medicare supplement policy shall not provide for
11 termination of coverage of a spouse solely because of the
12 occurrence of an event specified for termination of coverage of
13 the insured, other than the nonpayment of premium.
14 (4) A medicare supplement policy shall provide that benefits
15 and premiums under the policy shall be suspended at the request
16 of the policyholder or certificate holder for a period not to
17 exceed 24 months in which the policyholder or certificate holder
18 has applied for and is determined to be entitled to medical
19 assistance under medicaid, but only if the policyholder or
20 certificate holder notifies the insurer of such assistance within
21 90 days after the date the individual becomes entitled to the
22 assistance. Upon receipt of timely notice, the insurer shall
23 return to the policyholder or certificate holder that portion of
24 the premium attributable to the period of medicaid eligibility,
25 subject to adjustment for paid claims. If a suspension occurs and
26 if the policyholder or certificate holder loses entitlement to
27 medical assistance under medicaid, the policy shall be
1 automatically reinstituted effective as of the date of
2 termination of the assistance if the policyholder or certificate
3 holder provides notice of loss of medicaid medical assistance
4 within 90 days after the date of the loss and pays the premium
5 attributable to the period effective as of the date of
6 termination of the assistance. Each medicare supplement policy
7 shall provide that benefits and premiums under the policy shall
8 be suspended at the request of the policyholder if the
9 policyholder is entitled to benefits under section 226(b) of
10 title II of the social security act and is covered under a group
11 health plan as defined in section 1862(b)(1)(A)(v) of the social
12 security act. If suspension occurs and if the policyholder or
13 certificate holder loses coverage under the group health plan,
14 the policy shall be automatically reinstituted effective as of
15 the date of loss of coverage if the policyholder provides notice
16 of loss of coverage within 90 days after the date of the loss and
17 pays the premium attributable to the period, effective as of the
18 date of termination of enrollment in the group health plan. All
19 of the following apply to the reinstitution of a medicare
20 supplement policy under this subsection:
21 (a) The reinstitution shall not provide for any waiting
22 period with respect to treatment of preexisting conditions.
23 (b) Reinstituted coverage shall be substantially equivalent
24 to coverage in effect before the date of the suspension.
25 (c) Classification of premiums for reinstituted coverage
26 shall be on terms at least as favorable to the policyholder or
27 certificate holder as the premium classification terms that would
1 have applied to the policyholder or certificate holder had the
2 coverage not been suspended.
3 Sec. 3831. (1) Each insurer offering individual or group
4 expense incurred hospital, medical, or surgical policies or
5 certificates in this state shall provide without restriction, to
6 any person who requests coverage from an insurer and has been
7 insured with an insurer subject to this section, if the person
8 would no longer be insured because he or she has become eligible
9 for medicare or if the person loses coverage under a group policy
10 after becoming eligible for medicare, a right of continuation or
11 conversion to their choice of the basic core benefits as
12 described in section 3807 or 3807a or a type C medicare
13 supplemental package as described in section 3811(5)(c) or
14 3811a(6)(c) that is guaranteed renewable or noncancellable. A
15 person who is hospitalized or has been informed by a physician
16 that he or she will require hospitalization within 30 days after
17 the time of application shall not be entitled to coverage under
18 this subsection until the day following the date of discharge.
19 However, if the hospitalized person was insured by the insurer
20 immediately prior to becoming eligible for medicare or
21 immediately prior to losing coverage under a group policy after
22 becoming eligible for medicare, the person shall be eligible for
23 immediate coverage from the previous insurer under this
24 subsection. A person shall not be entitled to a medicare
25 supplemental policy under this subsection unless the person
26 presents satisfactory proof to the insurer that he or she was
27 insured with an insurer subject to this section. A person who
1 wishes coverage under this subsection must either request
2 coverage within 90 days before or 90 days after the month he or
3 she becomes eligible for medicare or request coverage within 180
4 days after losing coverage under a group policy. A person 60
5 years of age or older who loses coverage under a group policy is
6 entitled to coverage under a medicare supplemental policy without
7 restriction from the insurer providing the former group coverage,
8 if he or she requests coverage within 90 days before or 90 days
9 after the month he or she becomes eligible for medicare.
10 (2) Except as provided in section 3833, a person not insured
11 under an individual or group hospital, medical, or surgical
12 expense incurred policy as specified in subsection (1), after
13 applying for coverage under a medicare supplemental policy
14 required to be offered under subsection (1), shall be entitled to
15 coverage under a medicare supplemental policy that may include a
16 provision for exclusion from preexisting conditions for 6 months
17 after the inception of coverage, consistent with the provisions
18 of section 3819(2)(a) or 3819a(3)(a).
19 (3) Each insurer offering individual expense incurred
20 hospital, medical, or surgical policies in this state shall give
21 to each person who is insured with the insurer at the time he or
22 she becomes eligible for medicare, and to each applicant of the
23 insurer who is eligible for medicare, written notice of the
24 availability of coverage under this section. Each group
25 policyholder providing hospital, medical, or surgical expense
26 incurred coverage in this state shall give to each certificate
27 holder who is covered at the time he or she becomes eligible for
1 medicare, written notice of the availability of coverage under
2 this section.
3 (4) Notwithstanding the requirements of this section, an
4 insurer offering or renewing individual or group expense incurred
5 hospital, medical, or surgical policies or certificates after
6 June 27, 2005 may comply with the requirement of providing
7 medicare supplemental coverage to eligible policyholders by
8 utilizing another insurer to write this coverage provided the
9 insurer meets all of the following requirements:
10 (a) The insurer provides its policyholders the name of the
11 insurer that will provide the medicare supplemental coverage.
12 (b) The insurer gives its policyholders the telephone
13 numbers at which the medicare supplemental insurer can be
14 reached.
15 (c) The insurer remains responsible for providing medicare
16 supplemental coverage to its policyholders in the event that the
17 other insurer no longer provides coverage and another insurer is
18 not found to take its place.
19 (d) The insurer provides certification from an executive
20 officer for the specific insurer or affiliate of the insurer
21 wishing to utilize this option. This certification shall identify
22 the process provided in subdivisions (a) through (c) and shall
23 clearly state that the insurer understands that the commissioner
24 may void this arrangement if the affiliate fails to ensure that
25 eligible policyholders are immediately offered medicare
26 supplemental policies.
27 (e) The insurer certifies to the commissioner that it is in
1 the process of discontinuing in Michigan its offering of
2 individual or group expense incurred hospital, medical, or
3 surgical policies or certificates.
4 Sec. 3839. (1) Each medicare supplement policy shall include
5 a renewal or continuation provision. The provision shall be
6 appropriately captioned, shall appear on the first page of the
7 policy, and shall clearly state the term of coverage for which
8 the policy is issued and for which it may be renewed. The
9 provision shall include any reservation by the insurer of the
10 right to change premiums and any automatic renewal premium
11 increases based on the policyholder's age.
12 (2) If a medicare supplement policy is terminated by the
13 group policyholder and is not replaced as provided under
14 subsection (4), the issuer shall offer certificate holders an
15 individual medicare supplement policy that at the option of the
16 certificate holder provides for continuation of the benefits
17 contained in the group policy or provides for such benefits as
18 otherwise meet the requirements of section 3819 or 3819a.
19 (3) If an individual is a certificate holder in a group
20 medicare supplement policy and the individual terminates
21 membership in the group, the issuer shall offer the certificate
22 holder the conversion opportunity described in subsection (2) or
23 (4) or at the option of the group policyholder, offer the
24 certificate holder continuation of coverage under the group
25 policy.
26 (4) If a group medicare supplement policy is replaced by
27 another group medicare supplement policy purchased by the same
1 policyholder, the succeeding issuer shall offer coverage to all
2 persons covered under the old group policy on its date of
3 termination. Coverage under the new policy shall not result in
4 any exclusion for preexisting conditions that would have been
5 covered under the group policy being replaced.
6 (5) If a medicare supplement policy eliminates an outpatient
7 prescription drug benefit as a result of requirements imposed by
8 the medicare prescription drug, improvement, and modernization
9 act of 2003, Public Law 108-173, the modified policy shall be
10 considered to satisfy the guaranteed renewal requirements of this
11 section.