1. A. General Rules.

   1. (1) Medicare supplement policies and certificates shall include a renewal or continuation provision. The language or specifications of the provision shall be consistent with the type of contract issued. The provision shall be appropriately captioned and shall appear on the first page of the policy, and shall include any reservation by the issuer of the right to change premiums and any automatic renewal premium increases based on the policyholder’s age.
   2. (2) Except for riders or endorsements by which the issuer effectuates 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 date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require a signed acceptance by the insured. After the date of policy or certificate issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term shall be agreed to in writing signed by the insured, unless the benefits are required by the minimum standards for Medicare supplement policies, or if the increased benefits or coverage is required by law. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge shall be set forth in the policy.
   3. (3) Medicare supplement policies or certificates shall not provide for the payment of benefits based on standards described as “usual and customary,” “reasonable and customary” or words of similar import.
   4. (4) If a Medicare supplement policy or certificate contains any limitations with respect to preexisting conditions, such limitations shall appear as a separate paragraph of the policy and be labeled as “Preexisting Condition Limitations.”

   5. (5) Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the policyholder or certificateholder shall have the right to return the policy or certificate within thirty (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.

      1. (b) For the purposes of this rule, “form” means the language, format, type size, type proportional spacing, bold character, and line spacing.

      (6)(a) Issuers of accident and sickness policies or certificates which provide hospital or medical expense coverage on an expense incurred or indemnity basis to persons eligible for Medicare shall provide to those applicants a Guide to Health Insurance for People with Medicare in the form developed jointly by the National Association of Insurance Commissioners and CMS and in a type size no smaller than 12 point type. Delivery of the Guide shall be made whether or not the policies or certificates are advertised, solicited or issued as Medicare supplement policies or certificates as defined in this chapter. Except in the case of direct response issuers, delivery of the Guide shall be made to the applicant at the time of application and acknowledgement of receipt of the Guide shall be obtained by the issuer. Direct response issuers shall deliver the Guide to the applicant upon request but not later than at the time the policy is delivered.

2. B. Notice Requirements.

   1. (1) As soon as practicable, but no later than thirty (30) days prior to the annual effective date of any Medicare benefit changes, an issuer shall notify its policyholders and certificateholders of modifications it has made to Medicare supplement insurance policies or certificates in a format acceptable to the commissioner. The notice shall:

      1. (a) 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. (b) Inform each policyholder or certificateholder as to when any premium adjustment is to be made due to changes in Medicare.
   2. (2) The notice of benefit modifications and any premium adjustments shall be in outline form and in clear and simple terms so as to facilitate comprehension.
   3. (3) The notices shall not contain or be accompanied by any solicitation.
3. C. MMA Notice Requirements. Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement and Modernization Act of 2003.

4. D. Outline of Coverage Requirements for Medicare Supplement Policies.

   1. (1) Issuers shall provide an outline of coverage to all applicants at the time application is presented to the prospective applicant and, except for direct response policies, shall obtain an acknowledgement of receipt of the outline from the applicant; and

   2. (2) If an outline of coverage is provided at the time of application and the Medicare supplement policy or certificate is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate shall accompany the policy or certificate when it is delivered and contain the following statement, in no less than twelve (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.”

   3. (3) The outline of coverage provided to applicants pursuant to this rule 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 shall be in the language and format prescribed below in no less than twelve (12) point type. All plans shall be shown on the cover page, and the plans that are offered by the issuer shall be prominently identified. Premium information for plans that are offered shall be shown on the cover page or immediately following the cover page and shall be prominently displayed. The premium and mode shall be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant shall be illustrated.

   4. (4) The following items shall be included in the outline of coverage in the order prescribed below. Any subsequent updates to the outlines of coverage regarding cost sharing, copays or deductibles which are subject to change annually shall be published by Bulletin after the effective date of this Regulation.

      

      OUR 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.

      [for agents:]
      Neither [insert company’s name] nor its agents are connected with Medicare.

      [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 chapter. An issuer may use additional benefit plan designations on these charts pursuant to Rule 482-1-071-.09-1D of this chapter.]

      [Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the commissioner.]

      Benefit Chart of Medicare Supplement Plans Sold on or after January 1, 2020

      This chart shows the benefits included in each of the standard Medicare supplement plans. Some plans may not be available. Only applicants’ first eligible for Medicare before 2020 may purchase Plans C, F, and High Deductible F.

      Note: A ✔ means 100% of the benefit is paid.

      

      ¹ Plans F and G also have a high deductible option which require first paying a plan deductible of $[2200] before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.

      ² Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.

      ³ Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that do not result in an inpatient admission.

      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 thru 90th day
      91st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used:    —Additional 365 days    —Beyond the additional 365 days All but $[1316] All but $[329] a day All but $[658] a day $0 $0 $0 $[329] a day $[658] a day 100% of Medicare eligible expenses $0 $[1316](Part A deductible) $0 $0 $0** All costs SKILLED 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 days  21^st thru 100th day  101st day and after All approved amounts All but $[164.50] a day $0 $0 $0 $0 $0 Up to $[164.50] a day All costs BLOODFirst 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment/co-insuranc e for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance $0 ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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 paidPLAN A MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR * Once you have been billed $[183] 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 EXPENSES— 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 $[183] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts$0 Generally 80% $0 Generally 20% $[183] (Part B deductible) $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOODFirst 3 pints Next $[183] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $0 20% $0 $[183] (Part B deductible) $0 CLINICAL LABORATORYSERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PLAN A PARTS A & B  SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES —Medically necessary skilled  care services and medical  supplies —Durable medical equipment  First $[183] of Medicare  Approved Amounts* Remainder of Medicare  Approved Amounts100% $0 80% $0 $0 20% $0 $[183] (Part B deductible) $0 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 HOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies  First 60 days 61^st thru 90th day
      91^st day and after:
      —While using 60 lifetime reserve days  —Once lifetime reserve days are used:     —Additional 365 days    —Beyond the additional 365 days All but $[1316] All but $[329] a day All but $[658] a day $0 $0 $[1316](Part A deductible)
      $[329] a day $[658] a day 100% of Medicare eligible expenses $0 $0
      $0 $0 $0** All costs SKILLED 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 days  21^st thru 100^th day  101st day and after All approved amounts All but $[164.50] a day $0 $0 $0 $0 $0 Up to $[164.50] a day All costs BLOODFirst 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness All but very limited copayment/ coinsurance for out-patient drugs and inpatient respite care Medicare copayment/ coinsurance $0 ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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          MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR*                Once you have been billed $[183] 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 EXPENSES— 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 $[183] of Medicare  Approved Amounts*  Remainder of Medicare  Approved Amounts $0 Generally 80% $0 Generally 20% $[183] (Part B deductible) $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOODFirst 3 pints Next $[183] of Medicare   Approved Amounts* Remainder of Medicare   Approved Amounts $0 $0 80% All costs $0 20% $0 $[183] (Part B deductible) $0 CLINICAL LABORATORYSERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0  PLAN B PARTS A & B  SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CAREMEDICARE APPROVED SERVICES —Medically necessary skilled  care services and medical  supplies —Durable medical equipment  First $[183] of Medicare  Approved Amounts*  Remainder of Medicare  Approved Amounts  100% $0 80% $0 $0 20% $0 $[183] (Part B deductible) $0 PLAN C
      MEDICARE (PART A)—HOSPITAL SERVICE—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  61^st thru 90th day  91^st day and after:  —While using 60 lifetime reserve days  —Once lifetime reserve days are used:     —Additional 365 days     —Beyond the additional 365  days All but $[1316] All but $[329] a day  All but $[658] a day  $0 $0 $[131](Part A deductible) $[329] a day $[658] a day 100% of Medicare eligible expenses $0 $0 $0 $0 $0** All costs SKILLED 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 days  21^st thru 100th day  101st day and after All approved amounts All but $[164.50] a day $0  $0 Up to $[164.50] a day $0  $0  $0 All costs BLOODFirst 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment/co-insur ance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance $0 ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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  MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR*                Once you have been billed $[183] 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 EXPENSES—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 $[183] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $[183] (Part B deductible) Generally 20% $0 $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints Next $[183] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $[183] (Part B deductible) 20% $0 $0 $0 CLINICAL LABORATORYSERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: –First $[183] of Medicare Approved Amounts* –Remainder of Medicare Approved Amounts 100% $0 80% $0 $[183](Part deductible) 20% B $0 $0 $0  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 Remainder of Charges $0 $0 $0 80% to a lifetime maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum

      PLAN C

      PARTS A & B 

      SERVICES	MEDICARE PAYS	PLAN PAYS		YOU PAY
      HOME HEALTH CARE MEDICARE APPROVED SERVICES —Medically necessary skilled  care services and medical  supplies —Durable medical equipment First $[183] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts	100% $0 80%	$0 $[183](Part B deductible) 20%	$0 $0 $0

      OTHER BENEFITS—NOT COVERED BY MEDICARE

      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 Remainder of Charges

      $0 $0

      $0 80% to a lifetime maxi-mum benefit of $50,000

      $250 20% and amounts over the $50,000 lifetime maximum

      PLAN D  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 days  61st thru 90th day  91st day and after:  —While using 60 lifetime reserve days  —Once lifetime reserve days are used:     —Additional 365 days     —Beyond the additional 365 days All but $[1316] All but $[329] a day All but $[658] a day $0 $0 $[1316] (Part A deductible) $[329] a day $[658] a day $0 100% of Medicare eligible expenses $0 $0 $0 $0 $0** All costs SKILLED 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 days  21^st thru 100th day 101st day and after All approved amounts All but $[164.50] a day $0 $0 Up to $[164.50] a day $0 $0 $0 All costs BLOODFirst 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare copayment/coinsurance $0 ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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  MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR * Once you have been billed $[183] 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 EXPENSES— 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 $[183] of Medicare  Approved Amounts*  Remainder of Medicare  Approved Amounts $0 Generally 80% $0 Generally 20% $[183] (Part B deductible) $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOODFirst 3 pints Next $[183] of Medicare  Approved Amounts* Remainder of Medicare  Approved Amounts $0 $0 80% All costs $0 20% $0 $[183] (Part B deductible) $0 CLINICAL LABORATORYSERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PLAN D  PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CAREMEDICARE APPROVED SERVICES  —Medically necessary skilled care services and medical supplies  —Durable medical equipment  First $[183] of Medicare  Approved Amounts*  Remainder of Medicare  Approved Amounts 100% $0 80% $0 $0 20% $0 $[183] (Part B deductible) $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 USA  First $250 each calendar year  Remainder of charges $0 $0 $0 80% to a lifetime maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum

      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. [**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2200] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are [$2200]. 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 [AFTER YOU PAY $[2200] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2200] DEDUCTIBLE,**] YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies   First 60 days   61st thru 90^th day   91st day and after:   While using 60     Lifetime reserve days                     Once lifetime reserve days           are used:     Additional 365 days     Beyond the additional          365 days All but $[1316] All but $[329] a day All but $[658] a day $0 $0 $[1316] (Part A deductible) $[329] a day $[658] a day 100% of Medicare eligible expenses $0 $0 $0 $0 $0*** All costs SKILLED 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 days     21st thru 100th day     101^st day and after All approved amounts All but $[164.50] a day $0 $0 Up to $[164.50] a day $0 $0 $0 All costs BLOODFirst 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment/coinsurance for out-patient drugs and inpatient respite care Medicare copayment/coinsurance $0 *** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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 F or HIGH DEDUCTIBLE PLAN FMEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $[183] 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 F after one has paid a calendar year [$2200] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are [$2200]. 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 [AFTER YOU PAY $[2200] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2200] DEDUCTIBLE,**] YOU PAY MEDICAL EXPENSES - 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 $[183] of Medicare     Approved amounts*    Remainder of Medicare     Approved amounts $0 Generally 80% $[183] (Part B deductible) Generally 20% $0 $0 Part B excess charges (Above Medicare Approved Amounts) $0 100% $0 BLOODFirst 3 pints Next $[183] of Medicare      Approved amounts* Remainder of Medicare      Approved amounts $0 $0 80% All costs $[183] (Part B deductible) 20% $0 $0 $0 CLINICAL LABORATORY SERVICES—-TESTS  FOR DIAGNOSTIC SERVICES 100% $0 $0 PLAN F or HIGH DEDUCTIBLE PLAN FPARTS A & B    SERVICES    MEDICARE PAYS AFTER YOU PAY $[2200] DEDUCTIBLE,** PLAN PAYS IN ADDITION TO $[2200] DEDUCTIBLE,** YOU PAY HOME HEALTH CAREMEDICARE APPROVED  SERVICES    —Medically necessary skilled care services and medical  supplies    —Durable medical equipment     First $[183] of Medicare                approved amounts*     Remainder of Medicare           approved amounts 100% $0 80% $0 $[183] (Part B deductible) 20% $0 $0 $0 OTHER BENEFITS - NOT COVERED BY MEDICARE    SERVICES    MEDICARE PAYS AFTER YOU PAY $[2200] DEDUCTIBLE,** PLAN PAYS IN ADDITION TO $[2200] DEDUCTIBLE,** YOU PAY FOREIGN TRAVEL - NOT COVERED BY MEDICAREMedically necessary  emergency care services beginning during the  first 60 days of each trip outside the USA              First $250 each         calendar year       Remainder of charges $0 $0 $0 80% to a lifetime maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum

      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 $[2200] deductible. Benefits from the high deductible plan G will not begin until out-of-pocket expenses are $[2200]. 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 [AFTER YOU PAY $[2200] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2200] DEDUCTIBLE,**] YOU PAY HOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies  First 60 days  61st thru 90th day 91st day and after:  —While using 60 lifetime reserve days —Once lifetime reserve days are used:   —Additional 365 days   —Beyond the additional 365 days All but $[1316] All but $[329] a day All but $[658] a day $0 $0 $[1316] (Part A deductible) $[329] a day $[658] a day 100% of Medicare eligible expenses $0 $0 $0 $0 $0** All costs SKILLED 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 days  21^st thru 100th day  101st day and after All approved amounts All but $[164.50] a day $0 $0 Up to $[164.50] a day $0 $0 $0 All costs BLOODFirst 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness All but very limited copayment/ coinsurance for out-patient drugs and inpatient respite care Medicare copayment/coinsurance $0 ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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  MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR * Once you have been billed $[185] 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 $[2200] deductible. Benefits from the high deductible plan G will not begin until out-of-pocket expenses are $[2200]. 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.] SERVICESMEDICARE PAYS[AFTER YOU PAY $[2200] DEDUCTIBLE,**] PLAN PAYS[IN ADDITION TO $[2200] DEDUCTIBLE,**] YOU PAYMEDICAL EXPENSES—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 $[183] of Medicare  Approved Amounts*  Remainder of Medicare  Approved Amounts $0 Generally 80% $0 Generally 20% $[183] (Unless Part B deductible has been met)  $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 100% $0 BLOODFirst 3 pints Next $[183] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $0 20% $0 $[183] (Unless Part B deductible has been met)  $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PLAN G or HIGH DEDUCTIBLE PLAN G  PARTS A & B  SERVICESMEDICARE PAYS[AFTER YOU PAY $[2200] DEDUCTIBLE,**] PLAN PAYS[IN ADDITION TO $[2200] DEDUCTIBLE,**] YOU PAYHOME HEALTH CARE MEDICARE APPROVED SERVICES —Medically necessary skilled  care services and medical  supplies —Durable medical equipment  First $[183] of Medicare  Approved Amounts*  Remainder of Medicare  Approved Amounts 100% $0 80% $0 $0 20% $0 $[183] (Unless Part B deductible has been met)  $0    OTHER BENEFITS—NOT COVERED BY MEDICARE   SERVICES  MEDICARE PAYS [AFTER YOU PAY $[2200] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2200] DEDUCTIBLE,**] 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  Remainder of Charges $0 $0 $0 80% to a lifetime maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum PLAN K * You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[5120] 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 days  61^st thru 90th day  91st day and after:  —While using 60 lifetime reserve days  —Once lifetime reserve days are used: —Additional 365 days —Beyond the additional 365 days All but $[1316] All but $[329] a day All but $[658] a day $0 $0 $[658](50% of Part A deductible) $[329] a day  $[658] a day  100% of Medicare eligible expenses $0 $[658](50% of Part A deductible)♦ $0 $0 $0*** All costs SKILLED 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 days 21^st thru 100th day 101st day and after All approved amounts All but $[164.50] a day $0 $0 Up to $[82.25] a day  (50% of Part A Coinsurance) $0 $0 Up to $[82.25] a day ♦ (50% of Part A Coinsurance) All costs BLOODFirst 3 pints Additional amounts $0 100% 50% $0 50%♦ $0 HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care 50% of copayment/coinsurance  50% of Medicare copayment/coinsurance♦ *** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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  MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR **** Once you have been billed $[183] 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 EXPENSES— 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 $[183] of Medicare     Approved Amounts****             Preventive Benefits for        Medicare covered services Remainder of Medicare Approved Amounts $0 Generally 80% or more of Medicare approved amounts Generally 80% $0 Remainder of Medicare approved amounts  Generally 10%  $[183] (Part B deductible)**** ♦ All costs above Medicare approved amounts Generally 10% ♦ Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs (and they do not count toward annual out-of-pocket limit of $[5120])* BLOODFirst 3 pints Next $[183] of Medicare Approved Amounts**** Remainder of Medicare Approved Amounts $0 $0 Generally 80% 50% $0 Generally 10% 50%♦ $[183] (Part B deductible)**** ♦ Generally 10% ♦  CLINICAL LABORATORYSERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 * This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[5120] 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  PARTS A & B  SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOME HEALTH CARE MEDICARE APPROVED SERVICES —Medically necessary skilled care services and medical supplies —Durable medical equipment First $[183] of Medicare Approved Amounts*****  Remainder of Medicare Approved Amounts 100% $0 80% $0 $0 10% $0 $[183] (Part B deductible) ♦ 10%♦ *****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 $[2560] 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 days 61st thru 90th day 91st day and after:  —While using 60 lifetime reserve days  —Once lifetime reserve days are used:    —Additional 365 days    —Beyond the additional 365 days All but $[1316] All but $[329] a day All but $[658] a day $0 $0 $[987] (75% of Part A deductible) $[329] a day  $[658] a day  100% of Medicare eligible expenses $0 $[329] (25% of Part A deductible)♦ $0 $0 $0*** All costs SKILLED 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 days 21^st thru 100th day 101st day and after All approved amounts All but $[164.50] a day $0 $0 Up to $[123.38] a day  (75% of Part A Coinsurance) $0 $0 Up to $[41.13] a day  (25% of Part A Coinsurance) ♦ All costs BLOODFirst 3 pints Additional amounts $0 100% 75% $0 25%♦ $0 HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care 75% of copayment/coinsurance 25% of copayment/ coinsurance ♦ *** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR **** Once you have been billed $[183] 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 EXPENSES— 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 $[183] of Medicare Approved Amounts**** Preventive Benefits for Medicare covered services Remainder of Medicare Approved Amounts $0 Generally 80% or more of Medicare approved amounts Generally 80% $0 Remainder of Medicare approved amounts  Generally 15%  $[183] (Part B deductible)**** ♦ All costs above Medicare approved amounts  Generally 5% ♦ Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs (and they do not count toward annual out-of-pocket limit of [$2560])* BLOODFirst 3 pints Next $[183] of Medicare Approved Amounts**** Remainder of Medicare Approved Amounts $0 $0 Generally 80% 75% $0 Generally 15%  25%♦ $[183] (Part B deductible) ♦ Generally 5%♦  CLINICAL LABORATORYSERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 (continued)  * This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[2560] 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  PARTS A & B  SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOME HEALTH CARE MEDICARE APPROVED SERVICES —Medically necessary skilled care services and medical supplies —Durable medical equipment  —First $[183] of Medicare Approved Amounts***** Remainder of Medicare Approved Amounts 100% $0 80% $0 $0 15%  $0 $[183] (Part B deductible) ♦ 5% ♦ *****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. PLAN M 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 days  61^st thru 90th day 91^st day and after:  —While using 60 lifetime reserve days  —Once lifetime reserve days are used:     —Additional 365 days     —Beyond the additional 365 days All but $[1316] All but $[329] a day All but $[658] a day $0 $0 $[658](50% of Part A deductible) $[329] a day $[658] a day 100% of Medicare eligible expenses $0 $[658](50% of Part A deductible) $0 $0 $0** All costs SKILLED 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 days  21^st thru 100th day  101st day and after All approved amounts All but $[164.50] a day $0 $0 Up to $[164.50] a day $0 $0 $0 All costs BLOODFirst 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance $0 ** NOTICE:  When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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             MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR* Once you have been billed $[183] 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 EXPENSES— 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 $[183] of Medicare          Approved Amounts* Remainder of Medicare          Approved Amounts      $0 Generally 80% $0 Generally 20% $[183] (Part B deductible)  $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD-First 3 pints -Next $[183] of Medicare Approved Amounts* -Remainder of Medicare Approved Amounts $0 $0 80% All costs $0 20% $0 $[183] (Part B deductible) $0 CLINICAL LABORATORYSERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
      PLAN MPARTS A & B
      SERVICES  MEDICARE PAYS  PLAN PAYS  YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES —Medically necessary skilled care services and medical      supplies —Durable medical equipment    First $[183] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 100% $0 80% $0 $0 20% $0 $[183] (Part B deductible) $0   OTHER BENEFITS—NOT COVERED BY MEDICAREFOREIGN 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 Remainder of Charges $0 $0 $0 80% to a lifetime maxi-mum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum
      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 days  61^st thru 90th day  91^st day and after:  —While using 60 lifetime reserve days  —Once lifetime reserve days are used:   —Additional 365 days   —Beyond the additional 365 days All but $[1316] All but $[329] a day All but $[658] a day $0 $0 $[1316](Part A deductible) $[329] a day $[658] a day 100% of Medicare eligible expenses $0 $0 $0 $0 $0** All costs SKILLED 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 days 21^st thru 100th day 101st day and after All approved amounts All but $[164.50] a day $0 $0 Up to $[164.50] a day $0 $0 $0 All costs BLOODFirst 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness All but very limited copayment/coinsura nce for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance $0 ** NOTICE:  When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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

      MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

      * Once you have been billed $[135] 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 EXPENSES— 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 $[183] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts	$0 Generally 80%	$0 Balance, other than 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.	$[183] (Part B deductible) 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	$0	All costs
      BLOOD First 3 pints Next $[183] of Medicare Approved  Amounts* Remainder of Medicare Approved  Amounts	$0 $0 80%	All costs $0 20%	$0 $[183] (Part B deductible) $0
      CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

      PLAN N

      PARTS A & B

      SERVICES	MEDICARE PAYS		PLAN PAYS	YOU PAY
      HOME HEALTH CARE MEDICARE APPROVED SERVICES —Medically necessary skilled      care services and medical      supplies —Durable medical equipment First $[183] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts	100% $0 80%	$0 $0 20%		$0 $[183] (Part B deductible) $0

      OTHER BENEFITS—NOT COVERED BY MEDICARE

      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 Remainder of Charges

      $0 $0

      $0 80% to a lifetime maxi-mum benefit of $50,000

      $250 20% and amounts over the $50,000 lifetime maximum

5. E.            Notice Regarding Policies or Certificates Which Are Not Medicare Supplement Policies.

6. (1)                  Any accident and sickness insurance policy or certificate, other than a Medicare supplement policy a policy issued pursuant to a contract under Section 1876 of the Federal Social Security Act (42 U.S.C. §1395 et seq.), disability income policy; or other policy identified in Rule 482-1-071-.03B, issued for delivery in this state to persons eligible for

   Medicare shall notify insureds under the policy that the policy is not a Medicare supplement policy or certificate. The notice shall either be printed or attached to the first page of the outline of coverage delivered to insureds under the policy, or if no outline of coverage is delivered, to the first page of the policy, or certificate delivered to insureds. The notice shall be in no less than twelve (12) point type and shall contain the following language:

   “THIS [POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT

   [POLICY OR CONTRACT].  If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company.”

7. (2)                  Applications provided to persons eligible for

   Medicare for the health insurance policies or certificates described in Subsection D(1) shall disclose, using the applicable statement in Appendix C, the extent to which the policy duplicates Medicare.  The disclosure statement shall be provided as a part of, or together with, the application for the policy or certificate.

Author: Commissioner of Insurance

Statutory Authority: Code of Ala. 1975, §§27-2-17, 27-19-50 et seq.

History: New Rule: September 18, 1981; effective January 1, 1982. Revised: November 14, 1986; effective February 14, 1987. Revised: March 5, 1992; effective March 15, 1992. Revised: March 12, 1996; effective March 25, 1996. Revised: October 22, 1998; effective January 1, 1999. Revised: April 28, 1999; effective July 1, 1999. Revised: June 30, 2003; effective July 21, 2003. Filed with LRS July 11, 2003. Rule is not subject to the Alabama Administrative Procedure Act. Revised: July 14, 2005; effective August 1, 2005. Rule is not subject to the Alabama Administrative Procedure Act. Revised: June 11, 2009; effective June 30, 2009. Filed with LRS June 12, 2009. Rule is not subject to the Alabama Administrative Procedure Act. Revised: June 10, 2010; effective July 1, 2010. Filed with LRS June 11, 2010. Rule is not subject to the Alabama Administrative Procedure Act. Revised: June 14, 2017; effective January 1, 2020. Filed with LRS June 14, 2017. Rule is not subject to the Alabama Administrative Procedure Act.