1. (a) General rules shall be as follows:

   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 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; and

   6. (6) 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:

      1. a. 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 rule. 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; and
      2. b. For the purposes of this section, "form" means the language, format, type size, type proportional spacing, bold character, and line spacing.
2. (b) Notice Requirements shall be as follows:
3. (l) As soon as practicable, but no later than 30 days prior to the annual effective date of any Medicare benefit changes, an issuer shall notify its policyholders and certificate holders of modifications it has made to Medicare supplement insurance policies or certificates in a format acceptable to the commissioner. The notice shall:
4. 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
5. b. Inform each policyholder or certificate holder as to when any premium adjustment is to be made due to changes in Medicare;
6. (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; and
7. (3) The notices shall not contain or be accompanied by any solicitation.
8. (c) MMA Notice Requirements. Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement and Modernization Act of 2003.
9. (d) Outline of Coverage Requirements for Medicare Supplement Policies.
10. (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 acknowledgment of receipt of the outline from the applicant;

11. (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 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."

12. (3) The outline of coverage provided to applicants pursuant to this section shall consist of 4 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 12 point type. All plans A-L 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; and

13. (4) The following items shall be included in the outline of coverage in the order prescribed below:

    Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010

    This chart shows the benefits included in each of the standard Medicare supplement plans. Every company shall make Plan “A” available. Some plans may not be available in your state.

    Basic Benefits:

    if !supportLists?· endif?Hospitalization - Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

    if !supportLists?· endif?Medical Expenses - Part B coinsurance (generally 20% of Medicare-approved expenses) or co-payments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or co-payments.

    if !supportLists?· endif?Blood - First three pints of blood each year.

    if !supportLists?· endif?Hospice - Part A coinsurance

    A

    B

    C

    D

    F

    F*

    G

    K

    L

    M

    N

    Basic, incl.

    100%

    Part B co-

    insurance

    Basic, incl.

    100%

    Part B co-insurance

    Basic, incl. 100%

    Part B co-

    insurance

    Basic, incl.

    100%

    Part B co-insurance

    Basic, incl.

    100%

    Part B co-insurance

    Basic, incl.

    100%

    Part B co-insurance

    Basic, incl.

    100%

    Part B co-insurance

    Hospitalization and preventive care paid at 100%; other basic benefits paid at 50%

    Hospitalization and preventive care paid at 100%; other basic benefits paid at 75%

    Basic, incl. 100% Part B co-insurance

    Basic, incl. 100% Part B co-insurance, except up to $20 copayment for office visit, and up to $50 copayment for ER

    Skilled Nursing Facility Co-insurance

    Skilled Nursing Facility Co-insurance

    Skilled Nursing Facility Co-insurance

    Skilled Nursing Facility Co-insurance

    Skilled Nursing Facility Co-insurance

    50% Skilled Nursing Facility Co-insurance

    75% Skilled Nursing Facility Co-insurance

    Skilled Nursing Facility Co-insurance

    Skilled Nursing Facility Co-insurance

    Part A

    Deductible

    Part A

    Deductible

    Part A

    Deductible

    Part A

    Deductible

    Part A

    Deductible

    Part A

    Deductible

    50% Part A

    Deductible

    75% Part A

    Deductible

    50%

    Part A

    Deductible

    Part A

    Deductible

    Part B

    Deductible

    Part B

    Deductible

    Part B

    Excess

    (100%)

    Part B

    Excess

    (100%)

    Part B

    Excess

    (100%)

    Foreign

    Travel

    Emergency

    Foreign

    Travel Emergency

    Foreign

    Travel Emergency

    Foreign Travel Emergency

    Foreign Travel

    Emergency

    Foreign Travel

    Emergency

    Foreign Travel Emergency

    Out-of-Pocket limit $[5120] paid at 100% after limit reached

    Out-of-Pocket limit $[2560] paid at 100% after limit reached

    *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2200] deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed [$2200]. 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.

    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 prior to June 1, 2010 have different benefits and premiums. Plans E, H, I, and J are no longer available for sale. [This paragraph shall not appear after June 1, 2011.]

    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.

    [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 rule. An issuer may use additional benefit plan designations on these charts pursuant to Ins 1905.10(d) of this rule.]

    [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 ü means 100% of the benefit is paid.

    Benefits

    Plans Available to All Applicants

    Medicare

    first

    eligible

    before

    A

    B

    C

    G¹

    K

    L

    M

    N

    C

    F¹

    Medicare Part A coinsurance and hospital coverage (up to an addition 365 days after

    Medicare benefits are used

    up)

    ü

    ü

    ü

    ü

    ü

    ü

    ü

    ü

    ü

    ü

    Medicare Part B

    coinsurance or Copayment

    ü

    ü

    ü

    ü

    50%

    75%

    ü

    ü

    copays

    apply³

    ü

    ü

    Blood (first three pints)

    ü

    ü

    ü

    ü

    50%

    75%

    ü

    ü

    ü

    ü

    Part A hospice care

    coinsurance or copayment

    ü

    ü

    ü

    ü

    50%

    75%

    ü

    ü

    ü

    ü

    Skilled nursing facility

    coinsurance

    ü

    ü

    50%

    75%

    ü

    ü

    ü

    ü

    Medicare Part A deductible

    ü

    ü

    ü

    50%

    75%

    50%

    ü

    ü

    ü

    Medicare Part B deductible

    ü

    ü

    Medicare Part B excess

    Charges

    ü

    ü

    Foreign travel emergency

    (up to plan limits)

    ü

    ü

    ü

    ü

    ü

    ü

    Out-of-pocket limit in

    [2017]²

    [$5120]²

    [$2560]²

    ¹Plans 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.

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

    ³Plan 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 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

    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
    
    if !supportLineBreakNewLine?
    endif?

    All but $[658] a day
    if !supportLineBreakNewLine?
    endif?

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    $0

    
    
    $0

    
    $[329] a day
    if !supportLineBreakNewLine?
    endif?

    
    
    $[658] a day
    if !supportLineBreakNewLine?
    endif?

    100% of Medicare eligible expenses

    $0

    
    
    $[1316] (Part A deductible)

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    $0
    
    if !supportLineBreakNewLine?
    endif?

    $0**
    if !supportLineBreakNewLine?
    endif?

    
    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

    SERVICES

    MEDICARE PAYS

    PLAN PAYS

    YOU PAY

    BLOOD
    First 3 pints

    
    Additional amounts

    
    $0

    
    100%

    
    3 pints

    
    $0

    
    $0

    
    $0

    HOSPICE CARE
    You must meet Medicare's requirements, including a doctor's certification of terminal illness.

    
    All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

    
    Medicare co-payment/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 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
    if !supportLineBreakNewLine?
    endif?

    
    Generally 80%
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    Generally 20%
    
    if !supportLineBreakNewLine?
    endif?

    
    $[183] (Part B deductible)
    
    $0
    
    if !supportLineBreakNewLine?
    endif?

    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 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 Amounts

    
    
    
    
    100%
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    80%

    
    
    
    
    $0
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    20%

    
    
    
    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    $[183] (Part B deductible)
    if !supportLineBreakNewLine?
    endif?

    $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
    if !supportLineBreakNewLine?
    endif?

    
    All but $[658] a day
    
    if !supportLineBreakNewLine?
    endif?

    $0

    $0

    
    $[1316] (Part A deductible)

    $[329] a day
    if !supportLineBreakNewLine?
    endif?

    
    $[658] a day
    
    if !supportLineBreakNewLine?
    endif?

    
    100% of Medicare eligible expenses

    
    $0

    
    $0

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    $0
    
    if !supportLineBreakNewLine?
    endif?

    
    $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

    SERVICES

    MEDICARE PAYS

    PLAN PAYS

    YOU PAY

    BLOOD
    First 3 pints

    
    Additional amounts

    
    $0

    
    100%

    
    3 pints

    
    $0

    
    $0

    
    $0

    HOSPICE CARE
    You must meet Medicare's requirements, including a doctor's certification of terminal illness

    
    All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

    
    Medicare co-payment/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
    if !supportLineBreakNewLine?
    endif?

    
    Generally 80%

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    Generally 20%
    if !supportLineBreakNewLine?
    endif?

    
    $[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
    if !supportLineBreakNewLine?
    endif?

    
    80%

    
    All costs
    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    20%

    
    $0
    
    $[183] (Part B deductible)
    if !supportLineBreakNewLine?
    endif?

    
    $0

    CLINICAL LABORATORY
    SERVICES—TESTS FOR DIAGNOSTIC SERVICES

    
    
    100%

    
    
    $0

    
    
    $0

    PLAN B

    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%
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    80%

    
    
    
    
    $0
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    20%

    
    
    
    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    
    $[183] (Part B deductible)
    if !supportLineBreakNewLine?
    endif?

    
    $0

    PLAN C

    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
    if !supportLineBreakNewLine?
    endif?

    
    All but $[658] a day
    if !supportLineBreakNewLine?
    endif?

    
    $0

    $0

    
    $[1316] (Part A deductible)
    if !supportLineBreakNewLine?
    endif?

    $[329] a day
    if !supportLineBreakNewLine?
    endif?

    
    $[658] a day
    if !supportLineBreakNewLine?
    endif?

    
    100% of Medicare eligible expenses

    
    $0

    
    $0

    
    $0
    if !supportLineBreakNewLine?
    endif?

    $0
    if !supportLineBreakNewLine?
    endif?

    
    
    $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

    SERVICES

    MEDICARE PAYS

    PLAN PAYS

    YOU PAY

    BLOOD

    
    First 3 pints

    
    Additional amounts

    
    $0

    
    100%

    
    3 pints

    
    $0

    
    $0

    
    $0

    HOSPICE CARE
    You must meet Medicare's requirements, including a doctor's certification of terminal illness.

    
    All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

    
    Medicare co-payment/coinsurance
    
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    
    
    if !supportLineBreakNewLine?
    endif?

    ** 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
    if !supportLineBreakNewLine?
    endif?

    
    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    Generally 80%
    if !supportLineBreakNewLine?
    endif?

    
    $[183] (Part B deductible)
    if !supportLineBreakNewLine?
    endif?

    Generally 20%
    if !supportLineBreakNewLine?
    endif?

    
    $0
    if !supportLineBreakNewLine?
    endif?

    $0
    if !supportLineBreakNewLine?
    endif?

    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
    if !supportLineBreakNewLine?
    endif?

    
    80%

    
    All costs
    
    $[183] (Part B deductible)
    
    20%

    
    $0
    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    $0

    CLINICAL LABORATORY
    SERVICES—TESTS FOR DIAGNOSTIC SERVICES

    
    100%

    
    $0

    
    $0

    PLAN C

    PARTS A & B

    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%
    
    if !supportLineBreakNewLine?
    endif?

    $0
    if !supportLineBreakNewLine?
    endif?

    
    80%

    
    $0
    
    if !supportLineBreakNewLine?
    endif?

    
    $[183] (Part B deductible)
    
    20%

    $0
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    $0

    PLAN C

    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 maximum 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
    if !supportLineBreakNewLine?
    endif?

    
    All but $[658] a day
    if !supportLineBreakNewLine?
    endif?

    
    $0

    
    $0

    
    
    $[1316] (Part A deductible)
    if !supportLineBreakNewLine?
    endif?

    $[329] a day
    if !supportLineBreakNewLine?
    endif?

    
    $[658] a day $0
    
    if !supportLineBreakNewLine?
    endif?

    
    100% of Medicare eligible expenses

    
    $0

    
    
    $0

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    $0
    
    if !supportLineBreakNewLine?
    endif?

    
    
    $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
    if !supportLineBreakNewLine?
    endif?

    $0

    
    
    $0

    
    Up to $[164.50] a day

    
    $0

    
    
    $0

    
    $0

    
    All costs

    SERVICES

    MEDICARE PAYS

    PLAN PAYS

    YOU PAY

    BLOOD

    
    First 3 pints

    
    Additional amounts

    
    $0

    
    100%

    
    3 pints

    
    $0

    
    $0

    
    $0

    HOSPICE CARE
    You must meet Medicare's requirements, including a doctor's certification of terminal illness

    
    All but very limited

    co-payment/

    coinsurance for out-patient drugs and inpatient respite care

    
    Medicare co-payments/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
    if !supportLineBreakNewLine?
    endif?

    
    Generally 80%
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    Generally 20%
    
    if !supportLineBreakNewLine?
    endif?

    
    $[183] (Part B deductible)
    if !supportLineBreakNewLine?
    endif?

    $0
    
    if !supportLineBreakNewLine?
    endif?

    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
    if !supportLineBreakNewLine?
    endif?

    
    80%

    All costs
    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    20%

    $0
    
    $[183] (Part B deductible)
    if !supportLineBreakNewLine?
    endif?

    $0

    CLINICAL LABORATORY
    SERVICES—TESTS FOR DIAGNOSTIC SERVICES

    
    
    100%

    
    
    $0

    
    
    $0

    PLAN D

    PARTS A & B

    SERVICES

    MEDICARE PAYS

    PLAN PAYS

    YOU PAY

    HOME HEALTH CARE
    MEDICARE APPROVED
    SERVICES

    
    Medically necessary skilled
    care services and medical
    supplies
    if !supportLineBreakNewLine?
    endif?

    Durable medical equipment

    
    - First $[183] of Medicare
    Approved Amounts*
    if !supportLineBreakNewLine?
    endif?

    - Remainder of Medicare
    Approved Amounts
    if !supportLineBreakNewLine?
    endif?

    
    
    
    
    100%
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    80%
    if !supportLineBreakNewLine?
    endif?

    
    
    
    
    $0
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    20%
    if !supportLineBreakNewLine?
    endif?

    
    
    
    
    $0
    
    if !supportLineBreakNewLine?
    endif?

    
    $[183] (Part B deductible)
    if !supportLineBreakNewLine?
    endif?

    $0
    if !supportLineBreakNewLine?
    endif?

    PLAN D

    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 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
    if !supportLineBreakNewLine?
    endif?

    
    
    All but $[658] a day
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    $0

    
    $[1316] (Part A deductible)
    if !supportLineBreakNewLine?
    endif?

    $[329] a day
    if !supportLineBreakNewLine?
    endif?

    
    
    $[658] a day
    
    if !supportLineBreakNewLine?
    endif?

    
    100% of Medicare
    eligible expenses

    
    $0

    
    
    $0

    
    $0
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    
    if !supportLineBreakNewLine?
    endif?

    
    $0***
    if !supportLineBreakNewLine?
    endif?

    
    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

    BLOOD
    First 3 pints

    Additional amounts

    $0

    100%

    
    3 pints

    
    $0

    
    $0

    
    $0

    HOSPICE CARE
    You must meet Medicare's requirements, including a doctor's certification of terminal illness

    
    All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

    
    Medicare co-payment/coinsurance
    
    if !supportLineBreakNewLine?
    endif?

    $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 F

    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.

    [**This high deductible plan pays the same benefits as Plan F after you have 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
    if !supportLineBreakNewLine?
    endif?

    
    Generally 80%
    if !supportLineBreakNewLine?
    endif?

    
    $[183] (Part B
    deductible)

    
    Generally 20%
    if !supportLineBreakNewLine?
    endif?

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    $0
    
    if !supportLineBreakNewLine?
    endif?

    Part B Excess Charges

    (Above Medicare Approved Amounts)

    $0

    100%

    $0

    
    
    SERVICES

    
    
    MEDICARE PAYS

    [AFTER YOU PAY
    $[2200] DEDUCTIBLE,**]
    PLAN PAYS

    [IN ADDITION TO $[2200] DEDUCTIBLE,**]
    YOU PAY

    BLOOD

    
    First 3 pints

    
    Next $[183] of Medicare
    Approved amounts*

    
    Remainder of Medicare
    Approved amounts

    
    $0
    if !supportLineBreakNewLine?
    endif?

    $0
    if !supportLineBreakNewLine?
    endif?

    
    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 F

    PARTS A & B

    
    
    SERVICES

    
    
    MEDICARE PAYS

    AFTER YOU PAY
    $[2200] DEDUCTIBLE,**
    PLAN PAYS

    IN ADDITION TO $[2200] DEDUCTIBLE,**
    YOU PAY

    HOME HEALTH CARE
    MEDICARE APPROVED
    SERVICE

    
    Medically necessary skilled
    care services and medical
    supplies
    if !supportLineBreakNewLine?
    endif?

    Durable medical equipment
    

    - First $[183] of Medicare Approved Amounts*

    
    - Remainder of Medicare Approved Amounts

    
    
    
    
    100%
    
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    
    
    80%

    
    
    
    
    $0
    
    
    if !supportLineBreakNewLine?
    endif?

    
    $[183] (Part B
    deductible)
    
    20%

    
    
    
    
    $0
    
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    
    
    $0

    PLAN F or HIGH DEDUCTIBLE PLAN F

    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
    if !supportLineBreakNewLine?
    endif?

    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 life-time 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
    
    if !supportLineBreakNewLine?
    endif?

    All but $[658] a day
    
    
    
    if !supportLineBreakNewLine?
    endif?

    $0

    
    $0

    $[1316] (Part A deductible)

    $[329] a day
    
    if !supportLineBreakNewLine?
    endif?

    $[658] a day
    
    
    
    if !supportLineBreakNewLine?
    endif?

    100% of Medicare eligible expenses

    
    $0

    
    $0

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    $0
    
    
    if !supportLineBreakNewLine?
    endif?

    
    $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

    BLOOD

    
    First 3 pints

    
    Additional amounts

    
    $0

    
    100%

    
    3 pints

    
    $0

    
    $0

    
    $0

    HOSPICE CARE
    You must meet Medicare's requirements, including a doctor's certification of terminal illness

    
    All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

    
    Medicare co-payment/coinsurance
    
    
    if !supportLineBreakNewLine?
    endif?

    
    $0
    
    
    if !supportLineBreakNewLine?
    endif?

    ***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 $[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 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

    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
    if !supportLineBreakNewLine?
    endif?

    
    Generally 80%
    if !supportLineBreakNewLine?
    endif?

    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    Generally 20%

    
    $[183] (Unless Part B deductible has been met)
    if !supportLineBreakNewLine?
    endif?

    $0
    if !supportLineBreakNewLine?
    endif?

    Part B Excess Charges

    (Above Medicare Approved Amounts)

    $0

    100%

    $0

    BLOOD

    
    First 3 pints

    
    Next $[183] of Medicare Approved Amounts*

    
    Remainder of Medicare Approved Amounts

    
    $0
    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    80%

    
    All costs
    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    20%

    
    $0
    
    $[183] (Unless Part B deductible has been met)
    if !supportLineBreakNewLine?
    endif?

    $0

    SERVICES

    MEDICARE PAYS

    [AFTER YOU PAY
    $[2200] DEDUCTIBLE,**]
    PLAN PAYS

    [IN ADDITION TO $[2200] DEDUCTIBLE,**]
    YOU PAY

    CLINICAL LABORATORY
    SERVICES—TESTS FOR DIAGNOSTIC SERVICES

    
    
    100%

    
    
    $0

    
    
    $0

    PLAN G or HIGH DEDUCTIBLE PLAN G

    PARTS A & B

    SERVICES

    MEDICARE PAYS

    [AFTER YOU PAY
    $[2200] DEDUCTIBLE,**]
    PLAN PAYS

    [IN ADDITION TO $[2200] DEDUCTIBLE,**]
    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
    if !supportLineBreakNewLine?
    endif?

    80%
    if !supportLineBreakNewLine?
    endif?

    
    
    $0
    
    $0
    if !supportLineBreakNewLine?
    endif?

    
    20%
    
    if !supportLineBreakNewLine?
    endif?

    
    
    $0
    
    $[183] (Unless Part B deductible has been met)

    
    $0
    if !supportLineBreakNewLine?
    endif?

    PLAN G or HIGH DEDUCTIBLE PLAN G

    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

    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

    $[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

    SERVICES

    MEDICARE PAYS

    PLAN PAYS

    YOU PAY*

    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

    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

    BLOOD

    First 3 pints

    Additional amounts

    $0

    100%

    50%

    $0

    50% ♦

    $0

    HOSPICE CARE

    You must meet Medicare's requirements, including a doctor's certification of terminal illness

    All but very limited co-payment/coinsurance for outpatient drugs and inpatient respite care

    50% of co-payment/coinsurance

    50% of Medicare co-payment/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])*

    BLOOD

    First 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 LABORATORY SERVICES – 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 notice 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 payment 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

    SERVICES

    MEDICARE PAYS

    PLAN PAYS

    YOU PAY*

    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

    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

    BLOOD

    First 3 pints

    Additional amounts

    $0

    100%

    75%

    $0

    25% ♦

    $0

    HOSPICE CARE

    You must meet Medicare's requirements, including a doctor's certification of terminal illness

    All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

    75% of co-payment/coinsurance

    25% of co-payment/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])*

    BLOOD

    First 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 LABORATORY SERVICES – TEST FOR DIAGNOSTIC SERVICES

    100%

    $0

    $0

    *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 Approval 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

    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

    $[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

    21st thru 100th day

    101st day and after

    All approved amount

    All but $[164.50] a day

    $0

    $0

    Up to $[164.50] a day

    $0

    $0

    $0

    All costs

    SERVICES

    MEDICARE PAYS

    PLAN PAYS

    YOU PAY*

    BLOOD

    First 3 pints

    Additional amounts

    $0

    100%

    3 Pints

    $0

    $0

    $0

    HOSPICE CARE

    You must meet Medicare's requirements, including a doctor's certification of terminal illness

    All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

    Medicare co-payment/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 LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES

    100%

    $0

    $0

    PLAN M

    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 Approval 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 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 N

    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

    91day 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

    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

    SERVICES

    MEDICARE PAYS

    PLAN PAYS

    YOU PAY*

    BLOOD

    First 3 pints

    Additional amounts

    $0

    100%

    3 Pints

    $0

    $0

    $0

    HOSPICE CARE

    You must meet Medicare's requirements, including a doctor's certification of terminal illness

    All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care

    Medicare co-payment/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 $[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

    Balance, other than up to [$20] per office visit and up to [$50] per emergency room visit. The co-payment 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 co-payment 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.

    SERVICES

    MEDICARE PAYS

    PLAN PAYS

    YOU PAY*

    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 Approval Amounts*

    - Remainder of Medicare Approved Amounts

    100%

    $0

    80%

    $0

    $0

    20%

    $0

    $[183] (Part B deductible)

    $0

    PLAN N

    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

14. (e) Notice Regarding Policies or Certificates Which Are Not Medicare Supplement Policies.

    1. (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 Ins 1905.02(b) 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 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."

    2. (2) Applications provided to persons eligible for Medicare for the health insurance policies or certificates described in Ins 1905.19(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.

Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99 New. #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.16); ss by #12370, eff 10-13-17 (from Ins 1905.18)