Alaska Admin. Code tit. 3, § 28.490 – Required disclosure provisions

(a) Medicare supplement policies and certificates must include a renewal or continuation provision. The language or specifications of the provisions must be consistent with the type of contract issued. The provisions must be appropriately captioned, must appear on the first page of the policy, and must include any reservation by the issuer of the right to change premiums and any automatic renewal premium increases based on the policyholder's age.
(b) Except for riders or endorsements by which the issuer fulfills a request made in writing by the insured, exercises a specifically reserved right under a Medicare supplement policy, or is required to reduce or eliminate benefits to avoid duplication of Medicare benefits, all riders or endorsements added to a Medicare supplement policy after the date of issue or at reinstatement or renewal that reduce or eliminate benefits or coverage in the policy must require a signed acceptance by the insured. After the date of a policy or certificate issue, a rider or an endorsement that increases benefits or coverage with a concomitant increase in premium during the policy term must be agreed to in writing and signed by the insured, unless the benefits are required by the minimum standards for Medicare supplement policies or if the increased benefits or coverage are required by law. If a separate additional premium is charged for benefits provided in connection with a rider or an endorsement, the premium charge must be set out in the policy.
(c) A Medicare supplement policy or certificate may not provide for the payment of benefits based on standards described as "usual and customary," "reasonable and customary," or words of similar import.
(d) If a Medicare supplement policy or certificate contains a limitation with respect to a preexisting condition, the limitation must appear as a separate paragraph of the policy and be labeled "preexisting condition limitation."
(e) A Medicare supplement policy or certificate must have a notice prominently printed on the first page of the policy or certificate or attached to it stating in substance that the policyholder or certificate holder shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the insured person is not satisfied for any reason.
(f) An issuer of accident and sickness policies or certificates that provide hospital or medical expense coverage on an expense incurred or indemnity basis to a person eligible for Medicare must provide to the applicant a Guide to Health Insurance for People with Medicare in the form developed jointly by the National Association of Insurance Commissioners and the Centers for Medicare and Medicaid Services and in a type size no smaller than 12-point type. Delivery of the Guide must be made regardless of whether the policies or certificates are advertised, solicited, or issued as Medicare supplement policies or certificates under 3 AAC 28.410 - 3 AAC 28.510. Except for a direct response issuer, delivery of the Guide must be made to the applicant at the time of application and acknowledgment of receipt of the Guide must be obtained by the issuer. A direct response issuer shall deliver the Guide to the applicant upon request, but not later than at the time the policy is delivered.
(g) As soon as practicable, but not later than 30 days before the annual effective date of a Medicare benefit change, an issuer shall notify its policyholders and certificate holders of modifications that the issuer has made to Medicare supplement insurance policies or certificates in a format acceptable to the director. The notice must
1. (1) include a description of revisions to the Medicare program and a description of each modification made to the coverage provided under the Medicare supplement policy or certificate; and
2. (2) inform the policyholder or certificate holder when a premium adjustment is to be made due to changes in Medicare.
(h) The notice of benefit modifications and premium adjustments must be in outline format, in clear and simple terms, to facilitate comprehension.
(i) The notice may not contain or be accompanied by any solicitation.
(j) An issuer shall provide an outline of coverage to an applicant at the time the application is presented to the prospective applicant and, except for direct response policies, shall obtain an acknowledgment of receipt of the outline from the applicant.
(k) If an outline of coverage is provided at the time of application and the Medicare supplement policy or certificate is issued on a basis that would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany the policy or certificate when it is delivered and contain the following statement, in no smaller than 12-point type, immediately above the company name: "NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued."
(l) For a Medicare supplement policy or certificate sold with an effective date of coverage before June 1, 2010, the outline of coverage provided to an applicant under this section consists of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage must be in the language and format set out in (t) of this section in no smaller than 12-point type. Plans "A" - "L" must be shown on the cover page and the plans offered by the issuer must be prominently identified. Premium information for plans that are offered must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and mode must be stated for each plan that is offered to the prospective applicant. Each possible premium for the prospective applicant must be illustrated.
(m) For a Medicare supplement policy or certificate sold with an effective date of coverage before June 1, 2010, as provided in 42 U.S.C. 1395e(b)(2), the dollar amount of the inpatient hospital deductible and all coinsurance amounts for plans "A" - "L" are determined annually by the secretary between September 1 and September 15 of the year preceding the year to which they will apply. As provided in 42 U.S.C. 1395l(b) and 1395r(a)(1), the dollar amount of the Medicare Part B deductible for plans "A" - "L" are determined annually by the secretary. Once determined, the figures are published in the Federal Register and may be obtained from the division.
(n) For a Medicare supplement policy or certificate sold with an effective date of coverage on or after June 1, 2010, the outline of coverage provided to an applicant under this section consists of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage must be in the language and format set out in (u) of this section in no smaller than 12-point type. Plans "A" - "D," plan "F," high deductible plan "F," and plans "G," "K," "L," "M," and "N" must be shown on the cover page and the plans offered by the issuer must be prominently identified. Premium information for plans that are offered must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and mode must be stated for each plan that is offered to the prospective applicant. Each possible premium for the prospective applicant must be illustrated.
(o) For a Medicare supplement policy or certificate sold with an effective date of coverage on or after June 1, 2010, as provided in 42 U.S.C. 1395e(b)(2), the dollar amount of the inpatient hospital deductible and all coinsurance amounts for plans "A" - "D," plan "F," high deductible plan "F," and plans "G," "K," "L," "M," and "N" are determined annually by the secretary between September 1 and September 15 of the year preceding the year to which they will apply. As provided in 42 U.S.C. 1395l(b) and 1395r(a)(1), the dollar amount of the Medicare Part B deductible for plans "A" - "D," plan "F," high deductible plan "F," and plans "G," "K," "L," "M," and "N" are determined annually by the secretary. Once determined, the figures are published in the Federal Register and may be obtained from the division.
(p) For a Medicare policy or certificate sold with an effective date of coverage on or after January 1, 2020, the outline of coverage provided to an applicant under this section consists of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage must be in the language and format set out in (w) of this section in no smaller than 12-point type. Plans "A" - "D," plan "F," high deductible plan "F," plan "G," high deductible plan "G," and plans "K," "L," "M," and "N" must be shown on the cover page and the plans offered by the issuer must be prominently identified. Premium information for plans that are offered must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and mode must be stated for each plan that is offered to the prospective applicant. Each possible premium for the prospective applicant must be illustrated.
(q) For a Medicare supplement policy or certificate sold with an effective date of coverage on or after January 1, 2020, as provided in 42 U.S.C. 1395e(b)(2), the dollar amount of the inpatient hospital deductible and all coinsurance amounts for plans "A" - "D," plan "F," high deductible plan "F," plan "G," high deductible plan "G," and plans "K," "L," "M," and "N" are determined annually by the secretary between September 1 and September 15 of the year preceding the year to which they will apply. As provided in 42 U.S.C. 1395l(b) and 1395r(a)(1), the dollar amount of the Medicare Part B deductible for plans "A" - "D," plan "F," high deductible plan "F," plan "G," high deductible plan "G," and plans "K," "L," "M," and "N" are determined annually by the secretary. Once determined, the figures are published in the Federal Register and may be obtained from the division.
(r) An issuer shall comply with the notice requirements of P.L. 108-173 (Medicare Prescription Drug, Improvement, and Modernization Act of 2003).
(s) For the purposes of this section, "form" means the language, format, type size, type proportional spacing, bold character, and line spacing.
(t) For a Medicare supplement policy or certificate sold with an effective date of coverage before June 1, 2010, the following items must be included in the outline of coverage in the order set out in this subsection. [COMPANY NAME] Outline of Medicare Supplement Coverage - Cover Page: 1 of 2 Benefit Plans _______________ [insert letters of plans being offered] These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make plan ''A'' available.Some plans may not be available in your state.See Outlines of Coverage for details about ALL plans.Basic Benefits for Plans A - J: Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services.Blood: First three pints of blood each year.A B C D E F F* G H I J J* Basic BenefitsBasic BenefitsBasic BenefitsBasic BenefitsBasic BenefitsBasic BenefitsBasic BenefitsBasic BenefitsBasic BenefitsBasic BenefitsSkilled Nursing Facility CoinsuranceSkilled Nursing Facility CoinsuranceSkilled Nursing Facility CoinsuranceSkilled Nursing Facility CoinsuranceSkilled Nursing Facility CoinsuranceSkilled Nursing Facility CoinsuranceSkilled Nursing Facility CoinsuranceSkilled Nursing Facility CoinsurancePart A DeductiblePart A DeductiblePart A DeductiblePart A DeductiblePart A DeductiblePart A DeductiblePart A DeductiblePart A DeductiblePart A DeductiblePart B DeductiblePart B DeductiblePart B DeductiblePart B Excess (100%)Part B Excess (80%)Part B Excess (100%)Part B Excess (100%)Foreign Travel EmergencyForeign Travel EmergencyForeign Travel EmergencyForeign Travel EmergencyForeign Travel EmergencyForeign Travel EmergencyForeign Travel EmergencyForeign Travel EmergencyAt-Home RecoveryAt-Home RecoveryAt-Home RecoveryAt-Home RecoveryPreventive Care NOT covered by MedicarePreventive Care NOT covered by Medicare *Plans F and J also have an option called a high deductible plan F and a high deductible plan J. These high deductible plans pay the same benefits as plans F and J after one has paid a calendar year [+] deductible. Benefits from high deductible plans F and J will not begin until out-of-pocket expenses exceed [+]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible. [+ The dollar amount to be inserted is determined annually, as described in (m) of this section, and may be obtained from the division.] Click to view PREMIUM INFORMATION [Boldface Type] We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this state. [If the premium is based on the increasing age of the insured, include information specifying when premiums will change.] DISCLOSURES [Boldface Type] Use this outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY [Boldface Type] This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN POLICY [Boldface Type] If you find that you are not satisfied with your policy, you may return it to [insert issuer's address] . If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments. POLICY REPLACEMENT [Boldface Type] If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. NOTICE [Boldface Type] This policy may not fully cover all of your medical costs. A. [for agents]: Neither [insert company's name] nor its agents are connected with Medicare. B. [for direct response]: [Insert company's name] is not connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details. COMPLETE ANSWERS ARE VERY IMPORTANT [Boldface Type] When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. [If the policy or certificate is guaranteed issue, this paragraph need not appear.] Review the application carefully before you sign it. Be certain that all information has been properly recorded. [Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments, and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this regulation. An issuer may use additional benefit plan designations on these charts as set out in 3 AAC 28.455(e).] [Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the director.] PLAN A MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALI- ZATION* Semiprivate room and board, general nur- sing, and miscellaneous services and supplies First 60 daysAll but $[+]$0$[+] (Part A deductible) 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime re- serve days are used: -Additional 365 days$0100% of Medicare eligi- ble expenses$0** -Beyond the addi- tional 365 days$0$0All costsSKILLED NUR- SING FACILITY CARE* You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and en- tered a Medicare- approved facility within 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a day$0Up to $[+] a day 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts100%$0$0HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to re- ceive these servicesAll but very lim- ited coinsurance for outpatient drugs and inpa- tient respite care$0Balance[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN A (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services, in- patient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medicare- approved amounts*$0$0$[+] (Part B deductible) Remainder of Medi- care-approved amountsGenerally 80%Generally 20%$0 Part B Excess Charges (Above Medicare-approved amounts)$0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medicare- approved amounts*$0$0$[+] (Part B deductible)Remainder of Medicare- approved amounts80%20%$0CLINICAL LABORA- TORY SERVICES- TESTS FOR DIAGNOS- TIC SERVICES100%$0$0 PLAN A (continued)PARTS A & B [+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE-AP- PROVED SERVICES-Medically necessary skilled care services and medical supplies100%$0$0-Durable medical equipment First $[+] of Medi- care-approved a- mounts*$0$0$[+] (Part B deductible) Remainder of Medicare-approved amounts80%20%$0[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] PLAN BMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALI- ZATION* Semiprivate room and board, general nur-sing, sing and miscellaneous services and supplies First 60 daysAll but $[+] a day$[+] (Part A deductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime re- serve days are used: -Additional 365 days$0100% of Medicare eligi ble expenses$0** -Beyond the additional 365 days$0$0All costsSKILLED NURSING FACILITY CARE* You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and enter- ed a Medicare-approv- ed facility within 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a day$0Up to $[+] a day 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts100%$0$0HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these servicesAll but very limited coinsurance for outpa- tient drugs and inpa- tient respite care$0Balance[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN B (continued)MEDICARE (PART B)-MEDICARE SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services, in- patient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medicare- approved amounts*$0$0$[+] (Part B deductible) Remainder of Medi care-approved amountsGenerally 80%Generally 20%$0 Part B Excess Charges (Above Medicare-approved amounts)$0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medicare- approved amounts*$0$0$[+] (Part B deductible)Remainder of Medicare- approved amounts80%20%$0CLINICAL LABORA- TORY SERVICES - TESTS FOR DIAGNOS- TIC SERVICES100%$0$0 PLAN B (continued)PARTS A & B [+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SER- VICES -Medically neces- sary skilled care ser- vices and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B deductible) Remainder of Medicare-approv- ed amounts80%20%$0[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] PLAN CMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZA- TION* Semiprivate room and board, gener- al nursing, and mis- cellaneous services and supplies First 60 daysAll but $[+]$[+] (Part A de- ductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0** -Beyond the ad- ditional 365 days$0$0All costsSKILLED NUR- SING FACILITY CARE* You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts100%$0$0HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these servicesAll but very lim- ited coinsurance for outpatient drugs and inpa- tient respite care$0Balance[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN C (continued)MEDICARE (PART B)-MEDICARE SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's ser- vices, inpatient and outpatient med- ical and surgical services and sup- plies, physical and speech therapy, diag- nostic tests, durable medical equipment First $[+] of Medicare- approved amounts*$0$[+] (Part B de- ductible)$0 Remainder of Medi- care-approved amountsGenerally 80%Generally 20%$0Part B Excess Charges (Above Medicare-approved amounts)$0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medi- care-approved amounts*$0$[+] (Part B de- ductible)$0Remainder of Medi- care-approved amounts80%20%$0CLINICAL LABORATORY SERVICES- TESTS FOR DIAG- NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] PLAN C (continued)PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SER- VICES -Medically neces- sary skilled care services and medi- cal supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care approved amounts*$0$[+] (Part B de- ductible)$0 Remainder of Medicare-ap- proved amounts80%20%$0 PLAN C (continued) OTHER BENEFITS-NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year$0$0$250 Remainder of charges$080% to a lifetime maximum benefit of $50,00020% and amounts over the $50,000 lifetime maximum[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] PLAN DMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous ser- vices and supplies First 60 daysAll but $[+]$[+] (Part A de- ductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve days All but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0** -Beyond the addi- tional 365 days$0$0All costsSKILLED NURSING FACILITY CARE* You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved fa- cility within 30 days after leaving the hospi- tal First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a day$0Up to $[+] a day 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts100%$0$0HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these servicesAll but very lim- ited coinsurance for outpatient drugs and inpatient respite care$0Balance[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN D (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physicians services, in- patient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medicare approved amounts*$0$0$[+] (Part B de- ductible) Remainder of Medi- care-approved amountsGenerally 80%Generally 20%$0Part B Excess Charges (Above Medicare-approved amounts)$0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medicare- approved amounts*$0$0$[+] (Part B de- ductible)Remainder of Medicare- approved amounts80%20%$0CLINICAL LABORA- TORY SERVICES - TESTS FOR DIAGNOS- TIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] PLAN D (continued)PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically necessary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care approved amounts*$0$0$[+] (Part B de- ductible) Remainder of Medi- care-approved amounts80%20%$0HOME HEALTH CARE (cont'd) AT HOME RECOVERY SERVICES - NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a home care treatment plan -Benefit for each visit$0Actual charges to $40 a visitBalance -Number of visits covered (Must be received within 8 weeks of last Medicare-approved visit)$0Up to the num- ber of Medicare- approved visits, not to exceed 7 each week -Calendar year maximum$0$1,600[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] PLAN D (continued)OTHER BENEFITS-NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically neces- sary emergency care services beginning during the first 60 days of each trip out- side the USA First $250 each calendar year $0$0$250 Remainder of charges$080% to a lifetime maximum benefit of $50,00020% and amounts over the $50,000 lifetime maximum PLAN EMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZA- TION* Semiprivate room and board, general nursing, and miscel- laneous services and supplies First 60 daysAll but $[+] $[+] (Part A de- ductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0** -Beyond the additional 365 days$0$0All costsSKILLED NURSING FACILITY CARE* You must meet Medicare's require- ments, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts100%$0$0HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these servicesAll but very lim- ted coinsurance for outpatient drugs and inpa- tient respite care$0Balance[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN E (continued) MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B deduct- ible) Remainder of Medi- care-approved amountsGenerally 80%Generally 20%$0 Part B Excess Charges (Above Medicare-approved amounts)$0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medi- care-approved amounts*$0$0$[+] (Part B deduct- ible)Remainder of Medi- care-approved amounts80%20%$0CLINICAL LABORATORY SERVICES- TESTS FOR DIAG- NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] PLAN E (continued) PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically neces-sary sary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B deduct- ible) Remainder of Medicare- approved amounts80%20%$0 PLAN E (continued) OTHER BENEFITS-NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically necessary emergency care ser- vices beginning dur- ing the first 60 days of each trip outside the USA First $250 each calendar year$0$0$250 Remainder of charges$080% to a lifetime maximum benefit of $50,00020% and amounts over the $50,000 lifetime maximum*PREVENTIVE MEDICAL CARE BENEFIT-NOT COVERED BY MEDICARE Some annual physical and preventive tests and services admin- istered or ordered by your doctor when not covered by Medi- care First $120 each calendar year$0$120$0 Additional charges$0$0All Costs[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] *Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. [Indicate Plan F or High Deductible Plan F, depending on which plan is offered: PLAN F or HIGH DEDUCTIBLE PLAN F] MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. [Language for High Deductible Plan F, if offered: **This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year $[+] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[+]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.] SERVICES MEDICARE PAYS [Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DE- DUCTIBLE, **] PLAN PAYS [Language for High Deductible Plan F, if offered: IN AD- DITION TO $[+] DE- DUCTIBLE, **] YOU PAY HOSPITALIZA- TION* Semiprivate room and board, general nursing, and miscel -laneous services and supplies First 60 daysAll but $[+]$[+] (Part A de- ductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once life- time reserve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0** -Beyond the additional 365 days$0$0All costsSKILLED NURSING FACILITY CARE* You must meet Mediare's require- ments including having been in a hospital for at least 3 days and entered a Medicare-approv- ed facility within 30 days after leaving the hospi- tal First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts100%$0$0HOSPICE CARE Available as long as your doctor cer- tifies you are term- inally ill and you elect to receive these servicesAll but very lim- ited coinsurance for outpatient drugs and inpa- tient respite care$0Balance[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] ***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. [Indicate Plan F or High Deductible Plan F, depending on which plan is offered: PLAN F or HIGH DEDUCTIBLE PLAN F (continued)] MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. [Language for High Deductible Plan F, if offered: **This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year $[+] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[+]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductible for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.] SERVICES MEDICARE PAYS [Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE, **] PLAN PAYS [Language for High Deductible Plan F, if offered: IN AD- DITION TO $[+] DEDUCTIBLE, **] YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as phys- ician's services, inpatient and out- patient medical and surgical ser- vices and supplies, physical and speech therapy, diagnos- tic tests, durable medical equipment First $[+] of Medi- care-approved amounts*$0$[+] (Part B deduct ible)$0 Remainder of Medi- care-approved amountsGenerally 80%Generally 20%$0 Part B Excess Charges (Above Medicare-approved amounts)$0100%0BLOOD First 3 pints$0All costs$0Next $[+] of Medi- care-approved amounts*$0$[+] (Part B deduct- ible)$0 Remainder of Medi- care-approved amounts80%20%$0CLINICAL LABORA- TORY SERVICES- TESTS FOR DIAG- NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] [Indicate Plan F or High Deductible Plan F, depending on which plan is offered: PLAN F or HIGH DEDUCTIBLE PLAN F (continued)] PARTS A & B SERVICESMEDICARE PAYS[Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE, **] PLAN PAYS [Language for High Deductible Plan F, if offered: IN AD- DITION TO $[+] DEDUCTIBLE, **] YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically neces- sary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medicare- approved amounts*$0$[+] (Part B de- ductible)$0 Remainder of Medicare- approved amounts80%20%$0 [Indicate Plan F or High Deductible Plan F, depending on which plan is offered: PLAN F or HIGH DEDUCTIBLE PLAN F (continued)] OTHER BENEFITS-NOT COVERED BY MEDICARE SERVICESMEDICARE PAYS[Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE, **] PLAN PAYS [Language for High Deductible Plan F, if offered: IN AD- DITION TO $[+] DEDUCT-IBLE, **] YOU PAY FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically neces- sary emergen- cy care services beginning during the first 60 days of each trip out- side the USA First $250 each calendar year$0$0$250 Remainder of charges$080% to a lifetime maximum benefit of $50,00020% and amounts over the $50,000 lifetime maximum[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] PLAN G MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZA- TION* Semiprivate room and board, general nursing, and miscel- laneous services and supplies First 60 daysAll but $[+] $[+] (Part A de- ductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime reserve days are used -Additional 365 days$0100% of Medi- care eligible expenses $0** -Beyond the additional 365 days$0$0All costsSKILLED NURSING FACILITY CARE* You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and en- tered a Medicare- approved facility within 30 days after leaving the hospital First 20 daysAll approved amounts $0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts100%$0$0HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to re- ceive these servicesAll but very limit- ed coinsurance for outpatient drugs and in- patient respite care$0Balance[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN G (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's ser- vices, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medi- care approved amounts*$0$0$[+] (Part B deduct- ible) Remainder of Medi- care-approved amountsGenerally 80%Generally 20%$0 Part B Excess Charges (Above Medicare-approved amounts)$0100%0BLOOD First 3 pints$0All costs$0Next $[+] of Medi- care-approved amounts*$0$0$[+] (Part B deduct ible)Remainder of Medi- care-approved amounts80%20%$0CLINICAL LABORA- TORY SERVICES- TESTS FOR DIAG- NOSTIC SER- VICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] PLAN G (continued)PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SER- VICES -Medically neces- sary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B deduct- ible) Remainder of Medicare-ap- proved amounts80%20%$0HOME HEALTH CARE (cont'd) AT-HOME RECOV- ERY SERVICES -NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a home care treatment plan -Benefit for each visit$0Actual charges to $40 a visitBalance -Number of visits covered (Must be received within 8 weeks of last Medicare-approved visit)$0Up to the number of Medicare-ap- proved visits, not to exceed 7 each week -Calendar year maximum$0$1,600[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] PLAN G (continued)OTHER BENEFITS-NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically necessary emergency care ser- vices beginning during the first 60 days of each trip outside the USAFirst $250 each calendar year$0$0$250Remainder of charges$080% to a lifetime maximum benefit of $50,00020% and amounts over the $50,000 lifetime maximum PLAN H MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZA- TION* Semiprivate room and board, gen- eral nursing, and miscellaneous services and supplies First 60 daysAll but $[+] a day$0$[+] (Part A deduct- ible) 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve days All but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0** -Beyond the additional 365 days$0$0All costsSKILLED NURSING FACILITY CARE* You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and en- tered a Medicare- approved facility within 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a day$0Up to $[+] a day 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts 100%$0$0HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these servicesAll but very lim- ited coinsurance for outpatient drugs and inpa- tient respite care$0Balance[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN H MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's ser- vices, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B deduct- ible) Remainder of Medi- care-approved amountsGenerally 80%Generally 20%$0 Part B Excess Charges (Above Medicare-approved amounts)$0100%0BLOOD First 3 pints$0All costs$0Next $[+] of Medi- care-approved amounts*$0$[+] (Part B deduct- ible)$0Remainder of Medi- care-approved amounts 80%20%$0CLINICAL LABORA- TORY SERVICES- TESTS FOR DIAG- NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] PLAN H (continued) PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically neces- sary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B deduct- ible) Remainder of Medicare-ap- proved amounts80%20%$0 PLAN H (continued) OTHER BENEFITS-NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year$0$0$250 Remainder of charges$080% to a lifetime maximum benefit of $50,00020% and amounts over the $50,000 lifetime maximum[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] PLAN I MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZA- TION* Semiprivate room and board, general nursing, and misc- ellaneous services and supplies First 60 daysAll but $[+] a day$0$[+] (Part A deduct- ible) 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medicare eligi- ble expenses$0** -Beyond the additional 365 days$0$0All costsSKILLED NURSING FACILITY CARE* You must meet Med- care's requirements, including having been in a hospital for at least 3 days and en- tered a Medicare- approved facility within 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a day$0Up to $[+] a day 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts100%$0$0HOSPICE CARE Available as long as your doctor cer- tifies you are termin- ally ill and you elect to receive these servicesAll but very lim- ited coinsurance for outpatient drugs and inpa- tient respite care$0Balance[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN I (continued) MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services, in- patient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B deduct- ible) Remainder of Medi- care-approved amountsGenerally 80%Generally 20%$0 Part B Excess Charges (Above Medicare-approved amounts)$0100%0BLOOD First 3 pints$0All costs$0Next $[+] of Medicare- approved amounts*$0$[+] (Part B de- ductible)$0Remainder of Medicare- approved amounts80%20%$0CLINICAL LABORA- TORY SERVICES- TESTS FOR DIAG- NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] PLAN I (continued) PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically necessary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B de- ductible) Remainder of Medi- care-approved amounts80%20%$0HOME HEALTH CARE (cont'd) AT-HOME RECOVERY SERVICES-NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a home care treatment plan -Benefit for each visit$0Actual charges to $40 a visitBalance -Number of visits covered (Must be received within 8 weeks of last Medi- care-approved visit)$0Up to the number of Medicare-ap- proved visits, not to exceed 7 each week -Calendar year maximum$0$1,600[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] PLAN I (continued) OTHER BENEFITS-NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year$0$0$250 Remainder of charges$080% to a lifetime maximum benefit of $50,00020% and amounts over the $50,000 lifetime maximum [Indicate Plan J or High Deductible Plan J, depending on which plan is offered: PLAN J OR HIGH DEDUCTIBLE PLAN J] MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. [Language for High Deductible Plan J, if offered: **This high deductible plan pays the same or offers the same benefits as Plan J after one has paid a calendar year $[+] deductible. Benefits from high deductible Plan J will not begin until out-of-pocket expenses are $[+]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.] SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 daysAll but $[+] a day$0$[+] (Part A deduct- ble) 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime re- serve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0*** -Beyond the addi- tional 365 days$0$0All costsSKILLED NURSING FACILITY CARE* You must meet Med- care's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved fa- cility within 30 days after leaving the hospi- tal First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a day$0Up to $[+] a day 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts 100%$0$0HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very lim- ited coinsurance for outpatient drugs and inpa- tient respite care $0 Balance[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] ***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. [Indicate Plan J or High Deductible Plan J, depending on which plan is offered: PLAN J OR HIGH DEDUCTIBLE PLAN J continued] MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. [Language for High Deductible Plan J, if offered: **This high deductible plan pays the same or offers the same benefits as Plan J after one has paid a calendar year $[+] deductible. Benefits from high deductible Plan J will not begin until out-of-pocket expenses are $[+]. Out-of-pocket expenses for the deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductible for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.] SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENS- ES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREAT- MENT, such as physi- cian's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, dur- able medical equipment First $[+] of Medicare- approved amounts*$0$0$[+] (Part B de- ductible) Remainder of Medi- care-approved amountsGenerally 80%Generally 20%$0 Part B Excess Charges (Above Medicare-approved amounts)$0100%0BLOOD First 3 pints$0All costs$0Next $[+] of Medicare- approved amounts*$0$[+] (Part B de- ductible)$0Remainder of Medicare- approved amounts 80%20%$0CLINICAL LABORA- TORY SERVICES- TESTS FOR DIAGNOS- TIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] [Indicate Plan J or High Deductible Plan J, depending on which plan is offered: PLAN J OR HIGH DEDUCTIBLE PLAN J continued] PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically necessary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B de- ductible) Remainder of Medicare- approved amounts80%20%$0HOME HEALTH CARE (cont'd) AT-HOME RECOV- ERY SERVICES- NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an in- jury or sickness for which Medicare approved a home care treatment plan -Benefit for each visit$0Actual charges to $40 a visitBalance -Number of visits covered (Must be received within 8 weeks of last Medicare-approved visit)$0Up to the number of Medicare-ap- proved visits, not to exceed 7 each week -Calendar year maximum$0$1,600[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] [Indicate Plan J or High Deductible Plan J, depending on which plan is offered: PLAN J OR HIGH DEDUCTIBLE PLAN J continued] OTHER BENEFITS-NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year$0$0$250 Remainder of charges$080% to a lifetime maximum benefit of $50,00020% and amounts over the $50,000 lifetime maximum***PREVENTIVE MEDICAL CARE BENEFIT-NOT COVERED BY MEDICARE Some annual physical and preventive tests and services admin- istered or ordered by your doctor when not covered by Medicare First $120 each calendar year$0$120$0 Additional charges$0$0All costs[+ The dollar amount to be inserted is determined annually, as described in (m) of this section, and may be obtained from the division.] ***Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. PLAN K *You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[+] each calendar year. The amounts that count toward your annual limit are noted with diamonds (¨) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD **A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 daysAll but $[+] a day$0$[+] (Part A de- ductible) 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0*** -Beyond the additional 365 days$0$0All costsSKILLED NURSING FACILITY CARE* You must meet Medicare's require- ments, including hav- ing been in a hospital for at least 3 days and entered a Medi- care-approved facility within 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a day$0Up to $[+] a day 101st day and after $0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts 100%$0$0HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to re- ceive these services All but very lim- ited coinsurance for outpatient drugs and inpa- tient respite care $0 Balance[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] ***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN K (continued) MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR ****Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services, in- patient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medicare- approved amounts*$0$0$[+] (Part B de- ductible) Remainder of Medi- care-approved amountsGenerally 80%Generally 20%$0 Preventive Benefits for Medicare cover- ed servicesGenerally 75% or more of Medi- care-approved amountsRemainder of Medicare-ap- proved amountsAll costs above Medicare-ap- proved amounts Remainder of Medi- care-approved amountsGenerally 80%Generally 10%Generally 10% Part B Excess Charges (Above Medicare-approved amounts)$0100%0BLOOD First 3 pints$0All costs$0Next $[+] of Medicare- approved amounts*$0$[+] (Part B de- ductible)$0Remainder of Medi- care-approved amounts80%20%$0CLINICAL LABORA- TORY SERVICES- TESTS FOR DIAG NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] *This plan limits your annual out-of-pocket payments for Medicare-approved amounts of $[+] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. PLAN K (continued) PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically necessary skilled care services and medical supplies 100%$0$0-Durable medical equipment First $[+] of Medi- care-approved amounts*****$0$0$[+] (Part B de- ductible) Remainder of Medicare-approved amounts80%10%10%[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] *****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. PLAN L *You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[+] each calendar year. The amounts that count toward your annual limit are noted with diamonds (¨) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD **A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 daysAll but $[+] a day$0$[+] (Part A deductible) 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 life- time reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime re- serve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0*** -Beyond the addi- tional 365 days$0$0All costsSKILLED NURSING FACILITY CARE* You must meet Med- care's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved fa- cility within 30 days after leaving the hospi- tal First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a day$0Up to $[+] a day 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts 100%$0$0HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these servicesAll but very limited coinsurance for outpatient drugs and inpatient respite care$0Balance[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division at the address listed in the editor's note at the end of this section.] ***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN L (continued)MEDICARE (PART B)-MEDICAL SERVICES- PER CALENDAR YEAR ****Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services, in- patient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medicare- approved amounts*$0$0$[+] (Part B deductible) Remainder of Medi- care-approved amountsGenerally 80%Generally 20%$0 Preventive Benefits for Medicare covered ser- vicesGenerally 75% or more of Medicare-approved amountsRemainder of Medi- care-approved amountsAll costs above Medi- care-approved amounts Remainder of Medi- care-approved amountsGenerally 80%Generally 10%Generally 10% Part B Excess Charges (Above Medicare-approved amounts) $0100%0BLOOD First 3 pints$0All costs$0Next $[+] of Medicare- approved amounts*$0$[+] (Part B deductible)$0Remainder of Medicare- approved amounts 80%20%$0CLINICAL LABORA- TORY SERVICES- TESTS FOR DIAGNOS- TIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] *This plan limits your annual out-of-pocket payments for Medicare-approved amounts of $[+] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. PLAN L (continued)PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES- Medically necessary skilled care services and medical supplies100%$0$0-Durable medical equipment First $[+] of Medicare- approved amounts*****$0$0$[+] (Part B deductible) Remainder of Medicare-approved amounts80%10%10%[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.] *****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
1. (u) For a Medicare supplement policy or certificate sold with an effective date of coverage on or after June 1, 2010, the following items must be included in the outline of coverage in the order set out in this subsection. The benefit chart and the "DISCLOSURES " paragraph in this subsection may not be used on or after June 1, 2011.
2. (v) For a Medicare supplement policy or certificate sold on or after June 1, 2011, the benefit chart and the "DISCLOSURES " paragraph in (u) of this section are replaced with the benefit chart and the "DISCLOSURES " paragraph in this subsection. All the rest of the items in the outline of coverage in the order set out in (u) of this section must be included.
Click to view FORM
PREMIUM INFORMATION [Boldface Type]
We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this state. [If the premium is based on the increasing age of the insured, include information specifying when premiums will change.]
DISCLOSURES [Boldface Type]
Use this outline to compare benefits and premiums among policies.
This outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates before June 1, 2010 have different benefits and premiums. Plans E, H, I, and J are no longer available for sale.
READ YOUR POLICY VERY CAREFULLY [Boldface Type]
This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.
RIGHT TO RETURN POLICY [Boldface Type]
If you find that you are not satisfied with your policy, you may return it to [insert issuer's address] . If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.
POLICY REPLACEMENT [Boldface Type]
If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
NOTICE [Boldface Type]
This policy may not fully cover all of your medical costs.
A. [for agents]:
Neither [insert company's name] nor its agents are connected with Medicare.
B. [for direct response]:
[insert company's name] is not connected with Medicare.
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT
[Boldface Type]
When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. [If the policy or certificate is guaranteed issue, this paragraph need not appear.]
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
[Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments, and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this regulation. An issuer may use additional benefit plan designations on these charts as set out in 3 AAC 28.456(f).]
[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the director.]
PLAN A MEDICARE (PART A)-HOSPITAL SERVICES-PER
BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION*
Semiprivate room and
board, general nursing,
and miscellaneous ser-
vices and supplies First 60 daysAll but $[+]$0$[+] (Part A deductible) 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 life-
time reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime re-
serve days are
used: -Additional 365
days$0100% of Medicare
eligible expenses$0** -Beyond the addi-
tional 365 days$0$0All costsSKILLED NURSING
FACILITY CARE*
You must meet Medi-
care's requirements,
including having been
in a hospital for at least
3 days and entered a
Medicare-approved fa-
cility within 30 days
after leaving the hospi-
tal First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a day$0Up to $[+] a day 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts
100%$0$0HOSPICE CARE
You must meet Medi-
care's requirements,
including a doctor's cer-
tification of terminal
illness
All but very limited
copayment/coinsurance
for outpatient drugs
and inpatient respite
care
Medicare
copayment/coinsurance$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN A (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER
CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EX-
PENSES - IN OR
OUT OF THE HOSPI-
TAL AND OUTPA-
TIENT HOSPITAL
TREATMENT, such as
physician's services, in-
patient and outpatient
medical and surgical
services and supplies,
physical and speech
therapy, diagnostic
tests, durable medical
equipmentFirst $[+] of Medicare-
approved amounts*$0$0$[+] (Part B deductible)Remainder of Medi-
care-approved
amountsGenerally 80%Generally 20%$0Part B Excess
Charges (Above
Medicare-approved
amounts)
$0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medicare-
approved amounts*$0$0$[+] (Part B deductible)Remainder of Medicare-
approved amounts80%20%$0CLINICAL LABORA-
TORY SERVICES - TESTS FOR DIAGNOS-
TIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
PLAN A (continued) PARTS A & B
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH
CARE
MEDICARE-
APPROVED SERVICES
-Medically necessary
skilled care services
and medical supplies 100%$0$0 -Durable medical
equipment First $[+] of Medicare-
approved amounts*$0$0$[+] (Part B deductible) Remainder of
Medicare-approved
amounts80%20%$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
PLAN B MEDICARE (PART A)-HOSPITAL SERVICES-PER
BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALI-
ZATION*
Semiprivate room and
board, general nursing,
and miscellaneous ser-
vices and supplies First 60 daysAll but $[+]$[+] (Part A deductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 life-
time reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime re-
serve days are used: -Additional 365
days$0100% of Medicare eligible expenses$0** - Beyond the addi-
tional 365 days$0$0All costsSKILLED NURSING
FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a day$0Up to $[+] a day 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts
100%$0$0HOSPICE CARE
You must meet Medi-
care's requirements,
including a doctor's cer-
tification of terminal illness
All but very limited
copayment/coinsurance
for outpatient drugs
and inpatient respite
care
Medicare
copayment/coinsurance
$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
PLAN B (continued)MEDICARE (PART B)-MEDICARE SERVICES-PER
CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICARE EX-
PENSES - IN OR
OUT OF THE HOSPI-
TAL AND OUTPA-
TIENT HOSPITAL
TREATMENT, such as
physician's services, in-
patient and outpatient
medical and surgical
services and supplies,
physical and speech
therapy, diagnostic
tests, durable medical
equipment First $[+] of Medicare-
approved amounts*$0$0$[+] (Part B deductible) Remainder of Medi-
care-approved
amountsGenerally 80%Generally 20%$0 Part B Excess
Charges (Above
Medicare-approved
amounts)$0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medicare-
approved amounts*$0$0$[+] (Part B deductible)Remainder of Medicare-
approved amounts
80%20%$0CLINICAL LABORA-
TORY SERVICES -
TESTS FOR DIAGNOS-
TIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
PLAN B (continued)PARTS A & B
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH
CARE
MEDICARE-
APPROVED SERVICES -Medically necessary
skilled care services
and medical supplies100%$0$0 -Durable medical
equipment First $[+] of Medi-
care-approved
amounts*$0$0$[+] (Part B deductible) Remainder of Medi-
care-approved
amounts80%20%$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
PLAN CMEDICARE (PART A)-HOSPITAL SERVICES-PER
BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION*
Semiprivate room and
board, general nursing,
and miscellaneous ser-
vices and supplies First 60 daysAll but $[+]$[+] (Part A deductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 life-
time reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime re-
serve days are used: -Additional 365
days$0100% of Medicare
eligible expenses$0 -Beyond the addi-
tional 365 days$0$0All costsSKILLED NURSING
FACILITY CARE*
You must meet Medi-
care's requirements,
including having been
in a hospital for at least
3 days and entered a
Medicare-approved fa-
cility within 30 days
after leaving the hospi-
tal First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts
100%$0$0HOSPICE CARE
You must meet Medi-
care's requirements,
including a doctor's cer-
tification of terminal
illness
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/coinsurance
$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN C (continued) MEDICARE (PART B)-MEDICAL SERVICES-PER
CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EX-
PENSES - IN OR
OUT OF THE HOSPI-
TAL AND OUTPA-
TIENT HOSPITAL
TREATMENT, such as
physician's services, in-
patient and outpatient
medical and surgical
services and supplies,
physical and speech
therapy, diagnostic
tests, durable medical
equipment First $[+] of Medicare-
approved amounts*$0$[+] (Part B deductible)$0 Remainder of Medicare-
approved amountsGenerally 80%Generally 20%$0 Part B Excess
Charges (Above
Medicare-approved
amounts)
$0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medicare-
approved amounts*$0$[+] (Part B deductible)$0Remainder of Medicare-
approved amounts
80%20%$0CLINICAL LABORA-
TORY SERVICES -
TESTS FOR DIAGNOS-
TIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
PLAN C (continued)PARTS A & B
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH
CARE
MEDICARE-
APPROVED SERVICES-Medically necessary
skilled care services
and medical supplies100%$0$0-Durable medical
equipmentFirst $[+] of Medi-
care-approved
amounts*$0$[+] (Part B deductible)$0Remainder of Medi-
care-approved
amounts80%20%$0
OTHER BENEFITS-NOT COVERED BY MEDICARE
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
FOREIGN
TRAVEL- NOT
COVERED BY
MEDICAREMedically necessary
emergency care services
beginning during the
first 60 days of each
trip outside the USAFirst $250 each
calendar year$0$0$250Remainder of
charges$080% to a lifetime
maximum benefit
of $50,00020% and amounts
over the $50,000
lifetime maximum[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
PLAN DMEDICARE (PART A)-HOSPITAL SERVICES-PER
BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION*
Semiprivate room and
board, general nursing,
and miscellaneous ser-
vices and supplies First 60 days$[+] a day$[+] (Part A deductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 life-
time reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime re-
serve days are
used: -Additional 365
days$0100% of Medicare eligible expenses$0** -Beyond the addi-
tional 365 days$0$0All costsSKILLED NURSING
FACILITY CARE*
You must meet Medi-
care's requirements,
including having been
in a hospital for at least
3 days and entered a
Medicare-approved fa-
cility within 30 days
after leaving the hospi-
tal First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after
$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts
100%$0$0HOSPICE CARE
You must meet Medi-
care's requirements,
including a doctor's cer-
tification of terminal
illness
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/coinsurance
$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN D (continued)MEDICARE (PART B)-MEDICAL SERVICES-
PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EX-
PENSES - IN OR
OUT OF THE HOSPI-
TAL AND OUTPA-
TIENT HOSPITAL
TREATMENT, such as
physicians services, in-
patient and outpatient
medical and surgical
services and supplies,
physical and speech
therapy, diagnostic
tests, durable medical
equipmentFirst $[+] of
Medicare-approved
amounts*$0$0$[+] (Part B deductible)Remainder of Medi-
care-approved
amountsGenerally 80%Generally 20%$0Part B Excess
Charges (Above
Medicare-approved
amounts)
$0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medicare-
approved amounts*$0$0$[+] (Part B deductible)Remainder of Medicare-
approved amounts
80%20%$0CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
PLAN D (continued)PARTS A & B
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH
CARE
MEDICARE-
APPROVED SERVICES -Medically necessary
skilled care services
and medical supplies100%$0$0 -Durable medical
equipment First $[+] of Medi-
care-approved
amounts*$0$0$[+] (Part B deductible) Remainder of Medi-
care-approved
amounts80%20%$0
PLAN D (continued)OTHER BENEFITS-NOT COVERED BY MEDICARE
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
FOREIGN TRAVEL-
NOT COVERED BY
MEDICARE
Medically necessary
emergency care services
beginning during the
first 60 days of each
trip outside the USAFirst $250 each
calendar year$0$0$250Remainder of
charges$080% to a lifetime
maximum benefit of
20% and amounts
over the $50,000
lifetime maximum[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
[Indicate Plan F or High Deductible Plan F, depending on which plan is offered:
PLAN F or HIGH DEDUCTIBLE PLAN F]MEDICARE (PART A)-HOSPITAL SERVICES-PER
BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
[Language for High Deductible Plan F, if offered: **This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year $[+] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[+]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.]
SERVICESMEDICARE PAYS[Language for High
Deductible Plan F, if
offered: AFTER
YOU PAY $[ + ]
DEDUCTIBLE,**]
PLAN PAYS[Language for High
Deductible Plan F, if
offered: IN ADDITION
TO $[ + ]
DEDUCTIBLE,**]
YOU PAYHOSPITALIZATION*
Semiprivate room and
board, general nursing,
and miscellaneous ser-
vices and supplies First 60 daysAll but $[+]$[+] (Part A deductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 life-
time reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime re-
serve days are used: -Additional 365
days$0100% of Medicare
eligible expenses$0*** -Beyond the addi-
tional 365 days$0$0All costsSKILLED NURSING
FACILITY CARE*
You must meet Medi-
care's requirements,
including having been
in a hospital for at least
3 days and entered a
Medicare-approved fa-
cility within 30 days
after leaving the
hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after $0$0All costsBLOOD First 3 pints $03 pints$0Additional amounts
100%$0$0HOSPICE CARE
You must meet Medi-
care's requirements,
including a doctor's cer-
tification of terminal
illness
All but very limited
copayment/coinsurance
for outpatient drugs
and inpatient respite
care
Medicare
copayment/coinsurance
$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
[Indicate Plan F or High Deductible Plan F, depending on which plan is offered:
PLAN F or HIGH DEDUCTIBLE PLAN F (continued)] MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
[Language for High Deductible Plan F, if offered: **This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year $[+] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[+]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductible for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.]
SERVICESMEDICARE PAYS[Language for High
Deductible Plan F, if
offered: AFTER
YOU PAY $[+]
DEDUCTIBLE,**]
PLAN PAYS[Language for High
Deductible Plan F, if
offered: IN ADDITION
TO $[+]
DEDUCTIBLE,**]
YOU PAYMEDICAL EX-
PENSES - IN OR
OUT OF THE HOSPI-
TAL AND OUTPA-
TIENT HOSPITAL
TREATMENT, such as
physician's services, in-
patient and outpatient
medical and surgical
services and supplies,
physical and speech
therapy, diagnostic
tests, durable medical
equipment First $[+] of Medicare-
approved amounts*$0$[+] (Part B deductible)$0 Remainder of Medicare-
approved amountsGenerally 80%Generally 20%$0 Part B Excess
Charges (Above
Medicare-approved
amounts)
$0100%$0BLOOD First 3 pints$0All costs$0Next $[+] of Medicare-
approved amounts*$0$[+] (Part B deductible)$0 Remainder of Medi-
care-approved
amounts
80%20%$0CLINICAL LABORA-
TORY SERVICES - TESTS FOR DIAGNOS-
TIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
[Indicate Plan F or High Deductible Plan F, depending on which plan is offered:
PLAN F or HIGH DEDUCTIBLE PLAN F (continued)] PARTS A & B
SERVICESMEDICARE PAYS[Language for High
Deductible Plan F, if
offered: AFTER
YOU PAY $[+]
DEDUCTIBLE,**]
PLAN PAYS[Language for High
Deductible Plan F, if
offered: IN ADDITION
TO $[ +]
DEDUCTIBLE,**]
YOU PAYHOME HEALTH
CARE
MEDICARE-
APPROVED SERVICES -Medically necessary
skilled care services
and medical supplies100%$0$0 -Durable medical
equipment First $[+] of Medi-
care-approved
amounts*$0$[+] (Part B deductible)$0 Remainder of Medi-
care-approved
amounts80%20%$0
[Indicate Plan F or High Deductible Plan F, depending on which plan is offered:
PLAN F or HIGH DEDUCTIBLE PLAN F (continued)] OTHER BENEFITS-NOT COVERED BY MEDICARE
SERVICESMEDICARE PAYS[Language for High
Deductible Plan F, if
offered: AFTER
YOU PAY $[+]
DEDUCTIBLE,**]
PLAN PAYS[Language for High
Deductible Plan F, if
offered: IN ADDITION
TO $[+]
DEDUCTIBLE,**]
YOU PAYFOREIGN
TRAVEL -NOT
COVERED BY
MEDICARE
Medically necessary
emergency care services
beginning during the
first 60 days of each
trip outside the USA First $250 each
calendar year$0$0$250 Remainder of charges$080% to a lifetime
maximum benefit of
$50,00020% and amounts over
the $50,000 lifetime
maximum[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
PLAN GMEDICARE (PART A)-HOSPITAL SERVICES-PER
BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION*
Semiprivate room and
board, general nursing,
and miscellaneous
services and supplies
First 60 daysAll but $[+]$[+] (Part A deductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 life-
time reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime re-
serve days are used: -Additional 365
days$0100% of Medicare
eligible expenses$0** -Beyond the addi-
tional 365 days
$0$0All costsSKILLED NURSING
FACILITY CARE*
You must meet Medi-
care's requirements,
including having been
in a hospital for at least
3 days and entered a
Medicare-approved
facility within 30 days
after leaving the hospital
First 20 daysAll approved amounts$0$021st - 100th dayAll but $[+] a dayUp to $[+] a day$0101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts
100%$0$0HOSPICE CARE
You must meet
Medicare's require-
ments, including a
doctor's certification
of terminal illnessAll but very limited
copayment/coinsurance
for outpatient drugs
and inpatient respite
careMedicare
copayment/coinsurance$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN G (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER
CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EX-
PENSES - IN OR
OUT OF THE HOSPI-
TAL AND OUTPA-
TIENT HOSPITAL
TREATMENT, such as
physician's services, in-
patient and outpatient
medical and surgical
services and supplies,
physical and speech
therapy, diagnostic
tests, durable medical
equipment First $[+] of Medicare-
approved amounts*$0$0$[+] (Part B deductible) Remainder of Medicare-
approved amountsGenerally 80%Generally 20%$0 Part B Excess
Charges (Above
Medicare-approved
amounts)
$0100%0%BLOOD First 3 pints$0All costs$0Next $[+] of Medicare-
approved amounts*$0$0$[+] (Part B deductible)Remainder of Medicare-
approved amounts
80%20%$0CLINICAL LABORA-
TORY SERVICES -
TESTS FOR DIAGNOS-
TIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
PLAN G (continued)PARTS A & B
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH
CARE
MEDICARE-
APPROVED SERVICES -Medically necessary
skilled care services
and medical supplies100%$0$0 -Durable medical
equipment First $[+] of Medi-
care-approved
amounts*$0$0$[+] (Part B deductible) Remainder of Medi-
care-approved
amounts80%20%$0
PLAN G (continued)OTHER BENEFITS-NOT COVERED BY MEDICARE
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
FOREIGN
TRAVEL - NOT
COVERED BY
MEDICARE
Medically necessary
emergency care services
beginning during the
first 60 days of each
trip outside the USA First $250 each
calendar year$0$0$250 Remainder of
charges$080% to a lifetime
maximum benefit of
$50,00020% and amounts
over the $50,000
lifetime maximum[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
PLAN K
*You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[+] each calendar year. The amounts that count toward your annual limit are noted with diamonds (¨) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE (PART A)-HOSPITAL SERVICES-PER
BENEFIT PERIOD
**A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY*
HOSPITALIZATION**
Semiprivate room and
board, general nursing,
and miscellaneous ser-
vices and supplies First 60 daysAll but $[+]$[+] (50% of Part A
deductible)$[+] (50% of Part A
deductible)¨ 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 life-
time reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime re-
serve days are used: -Additional 365
days$0100% of Medicare
eligible expenses$0*** -Beyond the addi-
tional 365 days
$0$0All costsSKILLED NURSING
FACILITY CARE**
You must meet Medi-
care's requirements,
including having been
in a hospital for at least
3 days and entered a
Medicare-approved
facility within 30 days
after leaving the hospi-
talFirst 20 daysAll approved amounts$0$021st - 100th dayAll but $[+] a dayUp to $[+] a dayUp to $[+] a day¨101st day and after
$0$0All costsBLOOD First 3 pints$050%50%¨Additional amounts
100%$0$0HOSPICE CARE
You must meet Medi-
care's requirements,
including a doctor's cer-
tification of terminal
illnessAll but very limited
copayment/coinsurance
for outpatient drugs
and inpatient respite
care50% of
copayment/coin-
surance50% of Medicare
copayment/coin-
surance¨[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN K (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER
CALENDAR YEAR ****Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY*
MEDICAL EX-
PENSES - IN OR
OUT OF THE HOSPI-
TAL AND OUTPA-
TIENT HOSPITAL
TREATMENT, such as
physician's services, in-
patient and outpatient
medical and surgical
services and supplies,
physical and speech
therapy, diagnostic
tests, durable medical
equipment First $[+] of Medicare-
approved amounts****$0$0$[+] (Part B deductible)****¨ Preventive Benefits for
Medicare covered
servicesGenerally 75% or more of Medicare-approved amountsRemainder of Medicare-approved amountsAll costs above Medicare-approved amounts Remainder of Medi-
care-approved
amountsGenerally 80%Generally 10%Generally 10%¨ Part B Excess
Charges (Above
Medicare-approved
amounts)
$0$0All costs (and they do not count toward annual out-of-pocket limit of $[+])*BLOOD First 3 pints$050%50%¨Next $[+] of Medicare-
approved amounts****$0$0$[+] (Part B deductible)****¨Remainder of Medicare-
approved amounts
Generally 80%Generally 10%Generally 10%¨CLINICAL LABORA-
TORY SERVICES- TESTS FOR DIAGNOS-
TIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
*This plan limits your annual out-of-pocket payments for Medicare-approved amounts of $[+] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
PLAN K (continued)PARTS A & B
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY*
HOME HEALTH
CARE
MEDICARE-
APPROVED SERVICES-Medically necessary
skilled care services
and medical supplies100%$0$0-Durable medical
equipment First $[+] of Medicare-
approved amounts*****$0$0$[+] (Part B deductible)¨ Remainder of Medicare-
approved amounts80%10%10%¨[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
PLAN L
*You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[+] each calendar year. The amounts that count toward your annual limit are noted with diamonds (¨) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE (PART A)-HOSPITAL SERVICES-PER
BENEFIT PERIOD **A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY*
HOSPITALIZATION**
Semiprivate room and
board, general nursing,
and miscellaneous
services and supplies First 60 daysAll but $[+]$[+] (75% of
Part A deduct-
ible)$[+] (25% of
Part A deduct-
ible)¨ 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60
lifetime reserve
daysAll but $[+] a day$[+] a day$0 -Once lifetime
reserve days
are used: -Additional 365
days$0100% of Medicare
eligible expenses$0*** -Beyond the
additional 365
days$0$0All costsSKILLED NURSING
FACILITY CARE**
You must meet Medi-
care's requirements,
including having been
in a hospital for at
least 3 days and
entered a Medicare-
approved facility
within 30 days after
after leaving the
hospital First 20 daysAll approved
amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a dayUp to $[+] a day¨ 101st day and after$0$0All costsBLOOD First 3 pints$075%25%¨Additional amounts
100%$0$0HOSPICE CARE
You must meet Medi-
care's requirements,
including a doctor's
certification of term-
inal illness
All but very lim-
ited copayment/
coinsurance for
outpatient drugs
and inpatient
respite care
75% of
copayment/
coinsurance
25% of
copayment/
coinsurance¨[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN L (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER
CALENDAR YEAR ****Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY*
MEDICAL EX-
PENSES - IN OR
OUT OF THE HOSPI-
TAL AND OUTPA-
TIENT HOSPITAL
TREATMENT, such as
physician's services, in-
patient and outpatient
medical and surgical
services and supplies,
physical and speech
therapy, diagnostic
tests, durable medical
equipment First $[+] of Medicare-
approved amounts****$0$0$[+] (Part B
deductible)****¨ Preventive Benefits
for Medicare cover-
ed servicesGenerally 75% or
more of Medi-
care-approved
amountsRemainder of
Medicare-ap-
proved amountsAll costs above
Medicare-ap-
proved amounts Remainder of Medi-
care-approved
amountsGenerally 80%Generally 15%Generally 5%¨ Part B Excess
Charges (Above
Medicare-approved
amounts)$00%All costs (and they
do not count toward
annual out-of-pocket
limit of $[+])*BLOOD First 3 pints$075%25%°¨Next $[+] of Medicare-
approved amounts****$0$0$[+] (Part B
deductible)****¨Remainder of Medi-
care approved amountsGenerally 80%Generally 15%Generally 5%¨CLINICAL LABORA-
TORY SERVICES- TESTS FOR DIAG-
NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
*This plan limits your annual out-of-pocket payments for Medicare-approved amounts of $[+] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
PLAN L (continued)PARTS A & B
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY*
HOME HEALTH
CARE
MEDICARE-
APPROVED
SERVICES-Medically necessary
skilled care services
and medical supplies100%$0$0-Durable medical
equipment First $[+] of Medi-
care approved
amounts*****$0$0$[+] (Part B deduct-
ible)¨ Remainder of
Medicare-approved
amounts80%15%5%¨[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
PLAN MMEDICARE (PART A)-HOSPITAL SERVICES-PER
BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION*
Semiprivate room
and board, general
nursing, and miscel-
laneous services
and supplies First 60 DaysAll but $[+]$[+] (50%
Part A de-
ductible)$[+] (50%
Part A de-
ductible) 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60
lifetime reserve
daysAll but $[+] a day$[+] a day$0 -Once lifetime
reserve days
are used: -Additional 365
days$0100% of Medi-
care eligible
expenses$0*** -Beyond the
additional 365
days$0$0All costsSKILLED NURSING
FACILITY CARE**
You must meet
Medicare's require-
ments, including
having been in a hos-
pital for at least 3 days
and entered a Medi-
care-approved fa-
cility within 30 days
after leaving the
hospital First 20 daysAll approved
amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts100%$0$0HOSPICE CARE
You must meet Medi-
care's requirements,
including a doctor's
certification of ter-
minal illness
All but very lim-
ited copayment/
coinsurance for
outpatient drugs
and inpatient respite
care
Medicare
copayment/
coinsurance
$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN M (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER
CALENDAR YEAR ****Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EX-
PENSES - IN OR
OUT OF THE HOSPI-
TAL AND OUTPA-
TIENT HOSPITAL
TREATMENT, such as
physician's services, in-
patient and outpatient
medical and surgical
services and supplies,
physical and speech
therapy, diagnostic
tests, durable medical
equipment First $[+] of Medi-
care approved
amounts****$0$0$[+] (Part B de-
ductible) Remainder of Medi-
care approved
amountsGenerally 80%Generally 20%$0 Part B Excess
Charges (Above
Medicare-approved
amounts)$0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medi-
care approved
amounts****$0$0$[+] (Part B de-
ductible) Remainder of Medi-
care approved
amounts80%20%$0CLINICAL LABORA-
TORY SERVICES-
TESTS FOR DIAG-
NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
PLAN M (continued)PARTS A & B
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH
CARE
MEDICARE-
APPROVED
SERVICES - Medically neces-
sary skilled care
services and
and medical
supplies100%$0$0 - Durable med-
ical equipment First $[+] of Medi-
care-approved
amounts$0$0$[+] (Part B deduct-
ible) Remainder of Medi-
care-approved
amounts80%20%$0FOREIGN TRAVEL - NOT COVERED BY
MEDICARE
Medically necessary
emergency care ser-
vices beginning dur-
ing the first 60 days
of each trip outside
the USA First $250 each
calendar year$0$0$250 Remainder of
charges$080% to a lifetime
maximum benefit
of $50,00020% and amounts
over the $50,000 life-
time maximum[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
PLAN NMEDICARE (PART A)-HOSPITAL SERVICES-PER
BENEFIT PERIOD **A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION**
Semiprivate room and
board, general nursing,
and miscellaneous ser-
vices and supplies First 60 DaysAll but $[+]$[+] (Part A deduct-
ible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60
lifetime reserve
daysAll but $[+] a day$[+] a day$0 -Once lifetime
reserve days
are used: -Additional
365 days$0100% of Medicare
eligible expenses$0*** -Beyond the
additional
365 days$0$0All costsSKILLED NURSING
FACILITY CARE**
You must meet Medi-
care's requirements,
including having been
in a hospital for at
least 3 days and en-
tered a Medicare-ap-
proved facility with-
in 30 days after
leaving the hospital First 20 daysAll approved
amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts100%$0$0HOSPICE CARE
You must meet
Medicare's require-
ments, including a
doctor's certification
of terminal illnessAll but very lim-
ited copayment/
coinsurance for
outpatient drugs
and inpatient
respite careMedicare
copayment/
coinsurance$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN N (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER
CALENDAR YEAR ****Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EX-
PENSES - IN OR
OUT OF THE HOSPI-
TAL AND OUTPA-
TIENT HOSPITAL
TREATMENT, such
as physician's ser-
vices, inpatient and
outpatient medical
and surgical services
and supplies, physical
and speech therapy,
diagnostic tests, dur-
able medical equip-
ment First $[+] of Medi
care-approved
amounts****$0$0$[+] (Part B deduct-
ible) Remainder of Medi-
care approved
amountsGenerally 80%Balance, other
than up to $[+]
per office visit
and up to $[+]
per emergency
room visit. The
copayment of
up to $[+] is
waived if the
insured is admitt-
ed to any hospital
and the emergen-
cy visit is covered
as a Medicare
Part A expense.Up to $[20] per
office visit and
up to $[50] per
emergency
room visit. The
copayment of up
to $[50] is waived
if the insured is
admitted to any
hospital and the
emergency visit
is covered as a
Medicare Part A
expense. Part B Excess
Charges (Above
Medicare-approved
amounts)$0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medi
care-approved
amounts****$0$0$[+] (Part B deduct-
ible)Remainder of Medi-
care-approved
amounts80%20%$0CLINICAL
LABORA-
TORY SERVICES- TESTS FOR DIAG-
NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
PLAN N (continued)PARTS A & B
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH
CARE
MEDICARE-
APPROVED
SERVICES- Medically neces-
sary skilled care
services and medical
supplies100%$0$0- Durable medical
equipment First $[+] of Medi-
care-approved
amounts$0$0$[+] (Part B deduct-
ible) Remainder of Medi-
care-approved
amounts80%20%$0FOREIGN TRAVEL -
NOT COVERED
BY MEDICARE
Medically necessary
emergency care ser-
vices beginning dur-
ing the first 60 days
of each trip outside
the USA First $250 each
calendar year$0$0$250 Remainder of
charges$080% to a life-
time maximum
benefit of
$50,00020% and amounts
over the $50,000
lifetime maximum[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
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PREMIUM INFORMATION [Boldface Type]
We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this state. [If the premium is based on the increasing age of the insured, include information specifying when premiums will change.]
DISCLOSURES [Boldface Type]
Use this outline to compare benefits and premiums among policies.
READ YOUR POLICY VERY CAREFULLY [Boldface Type]
This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.
RIGHT TO RETURN POLICY [Boldface Type]
If you find that you are not satisfied with your policy, you may return it to [insert issuer's address] . If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.
POLICY REPLACEMENT [Boldface Type]
If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
NOTICE [Boldface Type]
This policy may not fully cover all of your medical costs.
A. [for agents]:
Neither [insert company's name] nor its agents are connected with Medicare.
B. [for direct response]:
[insert company's name] is not connected with Medicare.
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT
[Boldface Type]
When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. [If the policy or certificate is guaranteed issue, this paragraph need not appear.]
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
[Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments, and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this regulation. An issuer may use additional benefit plan designations on these charts set out in 3 AAC 28.456(f).]
[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the director.]
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(w) For a Medicare supplement policy or certificate with an effective date of coverage on or after January 1, 2020, the following items must be included in the outline of coverage in the order set out in this subsection. PREMIUM INFORMATION [Boldface Type] We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this state. [If the premium is based on the increasing age of the insured, include information specifying when premiums will change.] DISCLOSURES [Boldface Type] Use this outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY [Boldface Type] This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN POLICY [Boldface Type] If you find that you are not satisfied with your policy, you may return it to [insert issuer's address] . If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments. POLICY REPLACEMENT [Boldface Type] If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. NOTICE [Boldface Type] This policy may not fully cover all of your medical costs. A. [for agents]: Neither [insert company's name] nor its agents are connected with Medicare. B. [for direct response]: [insert company's name] is not connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details. COMPLETE ANSWERS ARE VERY IMPORTANT [Boldface Type] When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. [If the policy or certificate is guaranteed issue, this paragraph need not appear.] Review the application carefully before you sign it. Be certain that all information has been properly recorded. [Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments, and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this regulation. An issuer may use additional benefit plan designations on these charts set out in 3 AAC 28.456(f).] [Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the director.] PLAN AMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days 61st - 90th dayAll but $[+]$0$[+] (Part A de- ductible) 91st day and after:All but $[+] a day$[+] a day$0 -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medi- care eligible expenses$0** -Beyond the additional 365 days$0$0All costsSKILLED NURSING FACILITY CARE* You must meet Medi- care's requirements, including having been in in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a day$0Up to $[+] a day 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts100%$0$0HOSPICE CARE You must meet Medi- care's requirements, including a doctor's certification of terminal illnessAll but very lim- ited copayment/ coinsurance for outpatient drugs and inpatient re- spite careMedicare copayment/ coinsurance$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN A (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medi- cal equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B de- ductible) Remainder of Medi- care approved amountsGenerally 80%Generally 20%$0 Part B Excess Charges (Above Medicare-approved amounts) $0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medi- care approved amounts*$0$0$[+] (Part B de- ductible)Remainder of Medi- care approved amounts 80%20%$0CLINICAL LABORATORY SERVICES - TESTS FOR DIAG- NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] PLAN A (continued)PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically necessary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B de- ductible) Remainder of Medi- care-approved amounts80%20%$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] PLAN BMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous ser- vices and supplies First 60 daysAll but $[+]$[+] (Part A de- ductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medi- care eligible expenses$0** - Beyond the additional 365 days$0$0All costsSKILLED NURSING FACILITY CARE* You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a day$0Up to $[+] a day 101st day and after$0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts100%$0$0HOSPICE CARE You must meet Medi- care's requirements, including a doctor's certification of terminal illnessAll but very lim- ited copayment/ coinsurance for outpatient drugs and inpa- tient respite careMedicare copayment/ coinsurance$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN B (continued)MEDICARE (PART B)-MEDICARE SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICARE EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services, in- patient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B de- ductible) Remainder of Medi- care-approved amountsGenerally 80%Generally 20%$0 Part B Excess Charges (Above Medicare-approved amounts) $0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medi- care-approved amounts*$0$0$[+] (Part B de- ductible)Remainder of Medi- care-approved amounts 80%20%$0CLINICAL LABORA- TORY SERVICES - TESTS FOR DIAG- NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] PLAN B (continued)PARTS A & B SERVICES MEDICARE PAYS PLAN PAYSYOU PAYHOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically necessary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B de- ductible) Remainder of Medi- care-approved amounts80%20%$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] PLAN CMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous ser- vices and supplies First 60 daysAll but $[+]$[+] (Part A de- ductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime re- serve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0** -Beyond the additional 365 days$0$0All costsSKILLED NURSING FACILITY CARE* You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and enter- ed a Medicare-approv- ed facility within 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after $0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts 100%$0$0HOSPICE CARE You must meet Medi- care's requirements, including a doctor's certification of terminal illnessAll but very lim- ited copayment/ coinsurance for outpatient drugs and inpatient respite careMedicare copayment/ coinsurance$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN C (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services, in- patient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipmentFirst $[+] of Medi- care approved amounts*$0$[+] (Part B de- ductible)$0Remainder of Medi- care-approved amounts Generally 80%Generally 20%$0Part B Excess Charges (Above Medicare-approved amounts) $0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medi- care-approved amounts*$0$[+] (Part B de- ductible)$0Remainder of Medi- care-approved amounts 80%20%$0CLINICAL LABORA- TORY SERVICES - TESTS FOR DIAG- NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] PLAN C (continued)PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically neces- sary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care approved amounts*$0$[+] (Part B de- ductible)$0 Remainder of Medi- care-approved amounts80%20%$0 OTHER BENEFITS-NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL- NOT COVERED BY MEDICAREMedically necessary emergency care ser- vices beginning during the first 60 days of each trip out- side the USAFirst $250 each calendar year$0$0$250Remainder of charges$080% to a lifetime maximum benefit of $50,00020% and amounts over the $50,000 lifetime maximum[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] PLAN DMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 daysAll but $[+]$[+] (Part A de- ductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0** -Beyond the additional 365 days $0$0All costsSKILLED NURSING FACILITY CARE* You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after $0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts 100%$0$0HOSPICE CARE You must meet Medi- care's requirements, including a doctor's certification of terminal illnessAll but very lim- ited copayment/ coinsurance for outpatient drugs and inpatient respite careMedicare copay- ment/coinsurance$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN D (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services, in- patient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medicare-approved amounts*$0$0$[+] (Part B de- ductible) Remainder of Medi- care-approved amounts Generally 80%Generally 20%$0 Part B Excess Charges (Above Medicare-approved amounts) $0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medicare- approved amounts*$0$0$[+] (Part B de- ductible)Remainder of Medicare- approved amounts 80%20%$0CLINICAL LABORATORY SERVICES- TESTS FOR DIAG- NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] PLAN D (continued)PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically necessary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B de- ductible) Remainder of Medi- care-approved amounts80%20%$0 PLAN D (continued)OTHER BENEFITS-NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care ser- vices beginning during the first 60 days of each trip outside the USA First $250 each calendar year$0$0$250 Remainder of charges$080% to a lifetime maximum benefit of $50,00020% and amounts over the $50,000 lifetime maximum[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] [Indicate Plan F or High Deductible Plan F, depending on which plan is offered: PLAN F or HIGH DEDUCTIBLE PLAN F] MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. [Language for High Deductible Plan F, if offered: **This high deductible plan pays the same or offers the same benefits as Plan F after you have paid a calendar year $[+] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[+]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.] SERVICES MEDICARE PAYS [Language for High Deductible Plan F, if offered: AFTER YOU PAY $[ # ] DEDUCTIBLE,**] PLAN PAYS [Language for High Deductible Plan F, if offered: IN ADDI- TION TO $[ # ] DEDUCTIBLE,**] YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 daysAll but $[+]$[+] (Part A de- ductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0*** -Beyond the additional 365 days $0$0All costsSKILLED NURSING FACILITY CARE* You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved fa- cility within 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after $0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts 100%$0$0HOSPICE CARE You must meet Medi- care's requirements, including a doctor's certification of terminal illnessAll but very limited copayment/coinsurance for outpatient drugs and inpatient respite careMedicare copayment/coinsurance $0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] ***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. [Indicate Plan F or High Deductible Plan F, depending on which plan is offered: PLAN F or HIGH DEDUCTIBLE PLAN F (continued)]MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. [Language for High Deductible Plan F, if offered: **This high deductible plan pays the same or offers the same benefits as Plan F after you have paid a calendar year $[+] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[+]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductible for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.] SERVICES MEDICARE PAYS [Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS [Language for High Deductible Plan F, if offered: IN ADDI- TION TO $[+] DEDUCTIBLE, **] YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services, in- patient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medi- care-approved amounts*$0$[+] (Part B de- ductible)$0 Remainder of Medi- care-approved amounts Generally 80%Generally 20%$0 Part B Excess Charges (Above Medicare-approved amounts) $0100%$0BLOOD First 3 pints$0All costs$0Next $[+] of Medi- vare-approved amounts*$0$[+] (Part B de- ductible)$0 Remainder of Medi- care-approved amounts 80%20%$0CLINICAL LABORA- TORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] [Indicate Plan F or High Deductible Plan F, depending on which plan is offered: PLAN F or HIGH DEDUCTIBLE PLAN F (continued)] PARTS A & B SERVICES MEDICARE PAYS [Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS [Language for High Deductible Plan F, if offered: IN ADDI- TION TO $[+] DEDUCTIBLE,**] YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically necessary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care-approved amounts*$0$[+] (Part B de- ductible)$0 Remainder of Medi- care-approved amounts80%20%$0 [Indicate Plan F or High Deductible Plan F, depending on which plan is offered: PLAN F or HIGH DEDUCTIBLE PLAN F (continued)] OTHER BENEFITS-NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS [Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE, **] PLAN PAYS [Language for High Deductible Plan F, if offered: IN ADDI- TION TO $[+] DEDUCTIBLE, **] YOU PAY FOREIGN TRAVEL -NOT COVERED BY MEDICAREMedically necessary emergency care ser- vices beginning dur- ing the first 60 days of each trip outside the USA First $250 each calendar year$0$0$250 Remainder of charges$080% to a lifetime maximum benefit of $50,00020% and amounts over the $50,000 lifetime maximum[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] [Indicate Plan F or High Deductible Plan F, depending on which plan is offered: PLAN G or HIGH DEDUCTIBLE PLAN G MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. [**This high deductible plan pays the same benefits as Plan G after you have paid a calendar year [+] deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are [+]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.] SERVICES MEDICARE PAYS [Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE, **] PLAN PAYS [Language for High Deductible Plan F, if offered: IN ADDI- TION TO $[+] DEDUCTIBLE, **] YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 daysAll but $[+]$[+] (Part A de- ductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0*** -Beyond the addi- tional 365 days $0$0All costsSKILLED NURSING FACILITY CARE* You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility with- in 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after $0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts 100%$0$0HOSPICE CARE You must meet Medicare's require- ments, including a doctor's certifica- tion of terminal illnessAll but very limited copayment/coinsurance for outpatient drugs and inpatient respite careMedicare copayment/coinsurance$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] ***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN G or HIGH DEDUCTIBLE PLAN G (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR *Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. [**This high deductible plan pays the same benefits as Plan G after you have paid a calendar year $[+] deductible. Benefits from the high deductible plan G will not begin until out-of-pocket expenses are $[+]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.] SERVICES MEDICARE PAYS [Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE, **] PLAN PAYS [Language for High Deductible Plan F, if offered: IN ADDI- TION TO $[+] DEDUCTIBLE, **] YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (unless Part B deductible has been met) Remainder of Medi- care-approved amountsGenerally 80%Generally 20%$0 Part B Excess Charges (Above Medicare-approved amounts)$0100%$0BLOOD First 3 pints$0All costs$0Next $[+] of Medicare- approved amounts*$0$0$[+] (Unless Part B deductible has been met) Remainder of Medi- care-approved amounts 80%20%$0CLINICAL LABORATORY SERVICES - TESTS FOR DIAG- NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] PLAN G or HIGH DEDUCTIBLE PLAN G (continued) PARTS A & B SERVICES MEDICARE PAYS [Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE, **] PLAN PAYS [Language for High Deductible Plan F, if offered: IN ADDI- TION TO $[+] DEDUCTIBLE, **] YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically necessary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Unless Part B deductible has been met) Remainder of Medi- care-approved amounts80%20%$0 PLAN G or HIGH DEDUCTIBLE PLAN G (continued) OTHER BENEFITS-NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS [Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE, **] PLAN PAYS [Language for High Deductible Plan F, if offered: IN ADDI- TION TO $[+] DEDUCTIBLE, **] YOU PAY FOREIGN TRAVEL -NOT COVERED BY MEDICAREMedically necessary emergency care ser- vices beginning during the first 60 days of each trip outside the USA First $250 each calendar year$0$0$250 Remainder of charges$080% to a lifetime maximum benefit of $50,00020% and amounts over the $50,000 lifetime maximum[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] PLAN K *You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[+] each calendar year. The amounts that count toward your annual limit are noted with diamonds (¨) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD **A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALI- ZATION* Semiprivate room and board, general nursing, and miscel- laneous services and supplies First 60 daysAll but $[+]$[+] (50% of Part A deductible)$[+] (50% of Part A deductible)¨ 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0*** -Beyond the additional 365 days $0$0All costsSKILLED NURSING FACILITY CARE** You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility with- in 30 days after leav- ing the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a dayUp to $[+] a day¨ 101st day and after $0$0All costsBLOOD First 3 pints$050%50%°¨Additional amounts 100%$0$0HOSPICE CARE You must meet Medi- care's requirements, including a doctor's certification of terminal illnessAll but very lim- ited copayment/coin- surance for outpatient drugs and inpatient respite care50% of copayment/coin- surance50% of Medicare copayment/coinsur- ance¨[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN K (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR ****Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medi- care-approved amounts****$0$0$[+] (Part B deductible)****¨ Preventive Benefits for Medicare cover- ed servicesGenerally 75% or more of Medicare- approved amountsRemainder of Medicare-ap- proved amountsAll costs above Medicare-approved amounts Remainder of Medi- care-approved amountsGenerally 80%Generally 10%Generally 10%¨ Part B Excess Charges (Above Medicare-approved amounts $0$0All costs (and they do not count toward annual out-of-pocket limit of $[+])¨ BLOOD First 3 pints$050%50%¨Next $[+] of Medicare- approved amounts****$0$0$[+] (Part B deductible)****¨Remainder of Medicare- approved amounts Generally 80%Generally 10%Generally 10%¨CLINICAL LABORA- TORY SERVICES - TESTS FOR DIAG- NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] *This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[+] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. PLAN K (continued)PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically necessary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care-approved amounts*****$0$0$[+] (Part B deductible)¨ Remainder of Medi- care-approved amounts80%10%10%¨[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] *****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. PLAN L *You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[+] each calendar year. The amounts that count toward your annual limit are noted with diamonds (¨) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service . MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD **A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZA- TION** Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 daysAll but $[+]$[+] (75% of Part A deduct- ible)$[+] (25% of Part A deduct- ible)¨ 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0*** -Beyond the additional 365 days $0$0All costsSKILLED NURSING FACILITY CARE** You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a dayUp to $[+] a day¨ 101st day and after $0$0All costsBLOOD First 3 pints$075%25%¨Additional amounts 100%$0$0HOSPICE CARE You must meet Medi- care's requirements, including a doctor's certification of termi- nal illnessAll but very lim- ited copayment/ coinsurance for outpatient drugs and inpatient respite care75% of copayment/ coinsurance25% of copayment/ coinsurance¨[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] ***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN L (continued) MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR ****Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medi- care-approved amounts****$0$0$[+] (Part B deductible)****¨ Preventive Benefits for Medicare covered servicesGenerally 75% or more of Medi- care-approved amountsRemainder of Medicare-ap- proved amountsAll costs above Medicare-ap- proved amounts Remainder of Medi- care-approved amountsGenerally 80%Generally 15%Generally 5%¨ Part B Excess Charges (Above Medicare-approved amounts)$0$0All costs (and they do not count toward annual out-of-pocket limit of $[+])*BLOOD First 3 pints$075%25%¨Next $[+] of Medicare- approved amounts****$0$0$[+] (Part B deductible)¨Remainder of Medi- care-approved amountsGenerally 80%Generally 15%Generally 5%CLINICAL LABORA- TORY SERVICES- TESTS FOR DIAG- NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] *This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[+] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. PLAN L (continued)PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically necessary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medi- care-approved amounts*****$0$0$[+] (Part B deductible)¨ Remainder of Medi- care-approved amounts80%15%5%¨[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] *****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. PLAN MMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD **A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION** Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 daysAll but $[+]$[+] (50% Part A deductible)$[+] (50% Part A deductible) 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medi- care eligible expenses$0*** -Beyond the additional 365 days $0$0All costsSKILLED NURSING FACILITY CARE** You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and en- tered a Medicare- approved facility within 30 days after leaving the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after $0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts 100%$0$0HOSPICE CARE You must meet Medi- care's requirements, including a doctor's certification of terminal illnessAll but very lim- ited copayment/ coinsurance for outpatient drugs and inpatient respite careMedicare copayment/ coinsurance$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] ***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN M (continued)MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR ****Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medi- care-approved amounts****$0$0$[+] (Part B de ductible) Remainder of Medi- care-approved amounts Generally 80%Generally 20%$0 Part B Excess Charges (Above Medicare-approved amounts) $0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medi- care-approved amounts****$0$0$[+] (Part B deductible)Remainder of Medi- care-approved amounts 80%20%$0CLINICAL LABORA- TORY SERVICES - TESTS FOR DIAG- NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] PLAN M (continued)PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically neces- sary skilled care services and medi- cal supplies 100%$0$0 -Durable medical equipment First $[+] of Medi- care-approved amounts*$0$0$[+] (Part B deductible) Remainder of Medi- care-approved amounts 80%20%$0 FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year$0$0$250 Remainder of charges$080% to a lifetime maximum benefit of $50,00020% and amounts over the $50,000 lifetime maximum [+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] PLAN NMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD **A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION** Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 daysAll but $[+]$[+] (Part A deductible)$0 61st - 90th dayAll but $[+] a day$[+] a day$0 91st day and after: -While using 60 lifetime reserve daysAll but $[+] a day$[+] a day$0 -Once lifetime reserve days are used: -Additional 365 days$0100% of Medicare eligible expenses$0*** - Beyond the additional 365 days $0$0All costsSKILLED NURSING FACILITY CARE** You must meet Medi- care's requirements, including having been in a hospital for at least 3 days and en- tered a Medicare- approved facility with- in 30 days after leav- ing the hospital First 20 daysAll approved amounts$0$0 21st - 100th dayAll but $[+] a dayUp to $[+] a day$0 101st day and after $0$0All costsBLOOD First 3 pints$03 pints$0Additional amounts 100%$0$0HOSPICE CARE You must meet Medi- care's requirements, including a doctor's certification of terminal illnessAll but very lim- ited copayment/ coinsurance for outpatient drugs and inpatient respite careMedicare copayment/ coinsurance$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN N (continued)MEDICARE (PART B)-MEDICARE SERVICES-PER CALENDAR YEAR ****Once you have been billed $[+] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICARE EX- PENSES - IN OR OUT OF THE HOSPI- TAL AND OUTPA- TIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable med- ical equipment First $[+] of Medi- care-approved amounts****$0$0$[+] (Part B de ductible) Remainder of Medi- care-approved amountsGenerally 80%Balance, other than up to $[+] per office visit and up to $[+] per emergency room visit. The copay- ment of up to $ [+] is waived if the insured is ad- mitted to any hospital and the emergency visit is covered as a Medicare Part A expense. Up to $[20] per office visit and up to $[50] per emergency room visit. The copayment of up to $ [50] is waived if the in- sured is admitted to any hospital and the emergen- cy visit is covered as a Medicare Part A expense. Part B Excess Charges (Above Medicare-approved amounts) $0$0All costsBLOOD First 3 pints$0All costs$0Next $[+] of Medi- care approved amounts****$0$0$[+] (Part B de- ductible)Remainder of Medi- care-approved amounts 80%20%$0CLINICAL LABORA- TORY SERVICES - TESTS FOR DIAG- NOSTIC SERVICES100%$0$0[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.] PLAN N (continued)PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE- APPROVED SERVICES -Medically necessary skilled care services and medical supplies100%$0$0 -Durable medical equipment First $[+] of Medicare- approved amounts$0$0$[+] (Part B deductible) Remainder of Medicare- approved amounts80%20%$0FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year$0$0$250 Remainder of charges$080% to a lifetime maximum benefit of $50,00020% and amounts over the $50,000 lifetime maximum[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

(Eff. 3/26/82, Register 81; am 8/8/90, Register 115; am 7/1/92, Register 122; am 12/4/94, Register 132; am 7/12/96, Register 139; am 4/21/99, Register 150; am 7/12/2000, Register 155; am 9/4/2005, Register 175; am 9/19/2009, Register 191; am 3/28/2019, Register 229)