1. (1) General Rules.

   1. (a) 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. (b) 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 the 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 STANDARDS 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. (c) 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. (d) 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. (e) 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 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.

   6. (f) 1. 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 twelve (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.

      1. 2. For the purposes of this Rule, “form” means the language, format, type size, type proportional spacing, bold character, and line spacing.

2. (2) Notice Requirements.

   1. (a) 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 certificate holders of modifications it has made to Medicare supplement insurance policies or certificates in a format acceptable to the commissioner. The notice shall:

      1. 1. Include a description of revisions to the Medicare program and a description of each modification made to the coverage provided under the Medicare supplement policy or certificate, and
      2. 2. Inform each policyholder or certificate holder as to when any premium adjustment is to be made due to changes in Medicare.
   2. (b) 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. STANDARDS
   3. (c) The notices shall not contain or be accompanied by any solicitation.
3. (3) MMA Notice Requirements. Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement and Modernization Act of 2003.

4. (4) Outline of Coverage Requirements for Medicare Supplement Policies.

   1. (a) 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. (b) 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. (c) The outline of coverage provided to applicants pursuant to this Paragraph consists of four (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 twelve

5. (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.

   1. (d) The following items shall be included in the outline of coverage in the order prescribed below: Benefit Chart of Medicare Supplement Plans Sold with an effective date of coverage on or After June 1, 2010 This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan A available. Some plans may not be available in your state. Basic Benefits: Hospitalization – Part A coinsurance plus coverage for three hundred sixty- five (365) additional days after Medicare benefits end. Medical Expenses – Part B coinsurance (generally twenty percent (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. Blood – First three (3) pints of blood each year. Hospice – Part A coinsurance STANDARDS A B C D F/F* G K L M N Basic including Basic, Basic, Basic, Basic, Basic, Basic, Hospitalization Hospitalization Basic, 100% Part B Including including including including including including and preventive and preventive including coinsurance 100% Part B 100% Part B 100% Part B 100% Part B 100% Part B 100% Part B care paid at care paid at 100% Part B except up to coinsurance coinsurance coinsurance coinsurance coinsurance coinsurance* 100%; other 100%; other coinsurance $20 basic benefits basic benefits copayment paid at 50% paid at 75% for office visit and up to $50 copayment for ER Skilled Skilled Skilled Skilled 50% Skilled 75% Skilled Skilled Skilled Nursing Nursing Nursing Nursing Nursing Nursing Facility Nursing Nursing Facility Facility Facility Facility Facility Coinsurance Facility Facility Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Part A Part A Part A Part A Part A 50% Part A 75% Part A 50% Part A Part A Deductible Deductible Deductible Deductible Deductible Deductible Deductible Deductible Deductible Part B Part B Deductible Deductible Part B Part B Excess Excess (100%) (100%) Foreign Foreign Foreign Foreign Foreign Travel Foreign Travel Travel Travel Travel Emergency Travel Emergency Emergency Emergency Emergency Emergency Out-of-pocket Out-of-pocket limit [$5,120]; limit [$2,560]; paid at 100% paid at 100% after limit after limit reached 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 [$2,200] deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed [$2,200]. 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. STANDARDS PREMIUM INFORMATION [Boldface Type] We [insert issuer’s name] can only raise your premium if we raise the premium for all policies like yours in this State. [If the premium is based on the increasing age of the insured, include information specifying when premiums will change.] DISCLOSURES [Boldface Type] Use this outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY [Boldface Type] This is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN POLICY [Boldface Type] If you find that you are not satisfied with your policy, you may return it to [insert issuer’s address]. If you send the policy back to us within thirty (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 (4) 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 0780-0 1-58-.11(4) of this Chapter.] STANDARDS [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 (1st) eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F. Note: A ✔means 100% of the benefit is paid. Medicare Plans Available to All Applicants first Benefits eligible 1 D G before A B K L M N 2020 only 1 Medicare Part A C F coinsurance and hospital coverage (up to an ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ additional 365 days after Medicare benefits are used ✔ ✔ up) ✔ Medicare Part B ✔ ✔ ✔ ✔ ✔ ✔ 50% 75% ✔ Coinsurance or copays Copayment apply 3 ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Blood (first three pints) 50% 75% Part A hospice care ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ coinsurance or copayment 50% 75% Skilled nursing facility ✔ ✔ ✔ ✔ ✔ ✔ coinsurance 50% 75% ✔ ✔ ✔ ✔ ✔ ✔ Medicare Part A deductible 50% 75% 50 % Medicare Part B deductible ✔ ✔ Medicare Part B excess ✔ ✔ charges Foreign travel emergency ✔ ✔ ✔ ✔ ✔ ✔ (up to plan limits) Out-of-pocket limit in 2 2 2 [$5,120] [$2,560] [2017] 1 Plans F and G also have a high deductible option which require first paying a plan deductible of [$2,200] before the plan begins to pay. Once the plan deductible is met, the plan pays one hundred percent (100%) of covered services for the rest of the calendar year. High deductible plan G does STANDARDS 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 one hundred percent (100%) of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit. 3 Plan N pays one hundred percent (100%) of the Part B coinsurance, except for a co-payment of up to twenty dollars ($20) for some office visits and up to a fifty dollar ($50) co-payment for emergency room visits that do not result in an inpatient admission. STANDARDS PLAN A MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the first (1st) 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 sixty
6. (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 All but [$1,316] $0 [$1,316](Part A deductible) 61st thru 90th day All but [$329] a day [$329] a day $0 91st day and after: —While using 60 lifetime reserve days All but [$658] a day [$658] a day $0 —Once lifetime reserve days are used: $0 100% of Medicare $0** —Additional 365 days eligible expenses —Beyond the additional 365 $0 $0 All costs Days 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 All approved amounts $0 $0 21st thru 100th day All but [$164.50] a $0 Up to [$164.50] a day Day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 STANDARDS SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPICE CARE You must meet Medicare's All but very limited Medicare $0 requirements, including a co-payment/ co-payment/ doctor's certification of coinsurance for out- coinsurance terminal illness. patient drugs and inpatient respite care ** 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 three hundred sixty-five (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. STANDARDS 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* $0 $0 [$183] (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare Approved $0 $0 All costs Amounts) BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare $0 $0 [$183] (Part B Approved Amounts* deductible) Remainder of Medicare 80% 20% $0 Approved Amounts STANDARDS SERVICES MEDICARE PAYS PLAN PAYS YOU PAY CLINICAL LABORATORY SERVICES—TESTS FOR 100% $0 $0 DIAGNOSTIC SERVICES PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled 100% $0 $0 care services and medical supplies —Durable medical equipment First [$183] of Medicare $0 $0 [$183] (Part B Approved Amounts* deductible) Remainder of Medicare Approved Amounts 80% 20% $0 STANDARDS PLAN B MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the first (1st) 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 sixty
7. (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 All but [$1,316] [$1,316](Part A $0 deductible) 61st thru 90th day All but [$329] a day [$329] a day $0 91st day and after: —While using 60 lifetime reserve days All but [$658] a day [$658] a day $0 —Once lifetime reserve days are used: $0 100% of Medicare $0** —Additional 365 days eligible expenses —Beyond the additional 365 $0 $0 All costs days 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 All approved amounts $0 $0 21st thru 100th day All but [$164.50] a $0 Up to [$164.50] a day day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 STANDARDS SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPICE CARE All but very limited Medicare co-payment/ $0 You must meet Medicare's co-payment/ coinsurance requirements, including a coinsurance for out- doctor's certification of terminal patient drugs and illness inpatient respite care ** 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 three hundred sixty-five (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. STANDARDS 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, F First [$183] of Medicare Approved Amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare Approved $0 $0 All costs Amounts) BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare Approved Amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES—TESTS FOR 100% $0 $0 DIAGNOSTIC SERVICES STANDARDS PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled 100% $0 $0 care services and medical supplies —Durable medical equipment First [$183] of Medicare $0 $0 [$183] (Part B Approved Amounts* deductible) Remainder of Medicare Approved Amounts 80% 20% $0 PLAN C MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the first (1st) 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 sixty
8. (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 All but [$1,316] [$1,316](Part A $0 deductible) 61st thru 90th day All but [$329] a day [$329] a day $0 91st day and after: —While using 60 lifetime reserve days All but [$658] a day [$658] a day $0 —Once lifetime reserve days are used: $0 100% of Medicare $0** Additional 365 days eligible expenses —Beyond the additional 365 days $0 $0 All costs STANDARDS 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 All approved amounts $0 $0 21st thru 100th day All but [$164.50] a Up to [$164.50] a day $0 day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's All but very limited Medicare co- $0 requirements, including a co-payment/ payment/coinsurance doctor's certification of terminal coinsurance for out- illness. patient drugs and inpatient respite care ** 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 three hundred sixty-five (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. STANDARDS 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* $0 [$183] (Part B $0 deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare Approved $0 $0 All costs Amounts) BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare Approved Amounts* $0 [$183] (Part B $0 deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES—TESTS FOR 100% $0 $0 DIAGNOSTIC SERVICES STANDARDS PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES 100% $0 $0 Medically necessary skilled care services and medical supplies —Durable medical equipment First [$183] of Medicare Approved Amounts* $0 [$183](Part B $0 deductible) Remainder of Medicare Approved Amounts 80% 20% $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 $0 $0 $250 80% to a lifetime 20% and amounts over Remainder of Charges $0 maximum benefit of the $50,000 lifetime $50,000 maximum STANDARDS PLAN D MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the first (1st) 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 sixty
9. (60) days in a row. STANDARDS SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but [$1,316] [$1,316] (Part A $0 deductible) 61st thru 90th day All but [$329] a day [$329] a day $0 91st day and after: —While using 60 lifetime reserve days All but [$658] a day [$658] a day $0 $0 —Once lifetime reserve days are used: $0 100% of Medicare $0** Additional 365 days eligible expenses —Beyond the additional 365 days $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 All approved amounts $0 $0 21st thru 100th day All but [$164.50] a Up to [$164.50] a day $0 day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE All but very limited co- Medicare co-payment/ $0 You must meet Medicare's payment/ coinsurance requirements, including a coinsurance for out- doctor's certification of terminal patient drugs and illness inpatient respite care STANDARDS ** 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 three hundred sixty-five (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* $0 $0 [$183] (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare Approved $0 $0 All costs Amounts) BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare $0 $0 [$183] (Part B Approved Amounts* deductible) Remainder of Medicare 80% 20% $0 Approved Amounts CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 STANDARDS PLAN D PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled 100% $0 $0 care services and medical supplies —Durable medical equipment First [$183] of Medicare $0 $0 [$183] (Part B Approved Amounts* deductible) Remainder of Medicare 80% 20% $0 Approved Amounts OTHER BENEFITS—NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL—NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime 20% and amounts maximum benefit of over the $50,000 $50,000 lifetime maximum STANDARDS PLAN F or HIGH DEDUCTIBLE PLAN F MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD • A benefit period begins on the first (1st) 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 sixty (60) days in a row. [**This high deductible plan pays the same benefits as Plan F after you have paid a calendar year [$2,200] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are [$2,200]. 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.] [AFTER YOU PAY [IN ADDITION TO [$2,200] [$2,200] DEDUCTIBLE,**] DEDUCTIBLE,**] SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but [$1,316] [$1,316](Part A $0 deductible) 61st thru 90th day All but [$329] a day [$329] a day $0 91st day and after: —While using 60 Lifetime reserve days All but [$658] a day [$658] a day $0 —Once lifetime reserve days are used: —Additional 365 days $0 100% of Medicare $0** Eligible expenses —Beyond the additional 365 days $0 $0 All costs STANDARDS 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 All approved amounts $0 $0 21st thru 100th day All but [$164.50] a Up to [$164.50] a day $0 day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE All but very limited co- Medicare co-payment/ $0 You must meet Medicare's payment/ coinsurance requirements, including a coinsurance for out- doctor's certification of terminal patient drugs and illness inpatient respite care *** 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 three hundred sixty-five (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 [$1,835] 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 [$2,200] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are [$2,200]. 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.] STANDARDS [AFTER YOU PAY [IN ADDITION TO [$2,200] [$2,200] SERVICES MEDICARE PAYS DEDUCTIBLE,**] DEDUCTIBLE,**] 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* $0 [$183] (Part B $0 deductible) Remainder of Medicare Approved amounts Generally 80% Generally 20% $0 Part B excess charges $0 100% $0 (Above Medicare Approved Amounts) BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare Approved amounts* $0 [$183] (Part B $0 deductible) Remainder of Medicare Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC 100% $0 $0 SERVICES STANDARDS PLAN F or HIGH DEDUCTIBLE PLAN F PARTS A & B [AFTER YOU PAY [IN ADDITION TO [$2,200] [$2,200] DEDUCTIBLE,**] DEDUCTIBLE,**] SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care 100% $0 $0 services and medical supplies —Durable medical equipment First [$183] of Medicare Approved Amounts* $0 [$183] (Part B $0 deductible) Remainder of Medicare — Approved Amounts 80% 20% $0 OTHER BENEFITS—NOT COVERED BY MEDICARE [AFTER YOU PAY [IN ADDITION TO [$2,200] [$2,200] DEDUCTIBLE,**] DEDUCTIBLE,**] SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL— NOT COVERED BY MEDICARE Medically necessary Emergency care services Beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime 20% and amounts maximum benefit over the $50,000 of $50,000 lifetime maximum STANDARDS PLAN G or HIGH DEDUCTIBLE PLAN G MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the first (1st) 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 sixty (60) days in a row. [**This high deductible plan pays the same benefits as Plan G after you have paid a calendar year [$2,200] deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are [$2,200]. 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.] STANDARDS [AFTER YOU PAY [IN ADDITION TO [$2,200] [$2,200] DEDUCTIBLE,**] DEDUCTIBLE,**] SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but [$1,316] [$1,316] (Part A $0 deductible) 61st thru 90th day All but [$329] a day [$329] a day $0 91st day and after: —While using 60 lifetime reserve days All but [$658] a day [$658] a day $0 —Once lifetime reserve days are used: $0 100% of Medicare $0** —Additional 365 days eligible expenses —Beyond the additional 365 $0 $0 All costs days 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 All approved amounts $0 $0 21st thru 100th day All but [$164.50] a Up to [$164.50] a day $0 day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's All but very limited Medicare co-payment/ $0 requirements, including a co-payment/ coinsurance STANDARDS doctor's certification of terminal coinsurance for out- illness patient drugs and inpatient respite care *** 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 three hundred sixty-five (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 [$2,200] deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are [$2,200]. 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.] STANDARDS [AFTER YOU PAY [IN ADDITION TO [$2,200] [$2,200] DEDUCTIBLE,**] DEDUCTIBLE,**] 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 $0 $0 [$183] (Unless Part B deductible has been met) Approved Amounts* Remainder of Medicare Generally 80% Generally 20% $0 Approved Amounts Part B Excess Charges (Above Medicare Approved $0 100% All costs Amounts) BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare [$183] (Unless Part B deductible has Approved Amounts* $0 $0 been met) Remainder of Medicare 80% 20% $0 Approved Amounts CLINICAL LABORATORY SERVICES—TESTS FOR 100% $0 $0 DIAGNOSTIC SERVICES STANDARDS PLAN G or HIGH DEDUCTIBLE PLAN G PARTS A & B [AFTER YOU PAY [IN ADDITION TO [$2,200] [$2,200] DEDUCTIBLE,**] DEDUCTIBLE,**] SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled 100% $0 $0 care services and medical supplies —Durable medical equipment First [$183] of Medicare $0 $0 [$183] (Unless Part Approved Amounts* B deductible has been met) Remainder of Medicare 80% 20% $0 Approved Amounts OTHER BENEFITS—NOT COVERED BY MEDICARE [AFTER YOU PAY [IN ADDITION TO [$2,200] [$2,200] DEDUCTIBLE,**] DEDUCTIBLE,**] 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 $0 $0 $250 year Remainder of Charges $0 80% to a lifetime maxi- 20% and amounts mum benefit of over the $50,000 $50,000 lifetime maximum STANDARDS PLAN K * You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of [$5,120] 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 one hundred percent (100%) of your Medicare co-payment 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 (1st) 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 sixty
10. (60) days in a row. STANDARDS SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but [$1,316] [$658](50% of Part A [$658](50% of Part A deductible) deductible)♦ 61st thru 90th day All but [$329] a day [$329] a day $0 91st day and after: —While using 60 lifetime reserve days All but [$658] a day [$658] a day $0 —Once lifetime reserve days are used: —Additional 365 days $0 100% of Medicare $0** eligible expenses —Beyond the additional 365 $0 $0 All costs days 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 All approved amounts $0 $0 Up to [$82.25] 21st thru 100th day All but [$164.50] a day Up to [$82.25] a day a day ♦ 101st day and after $0 $0 All costs BLOOD First 3 pints $0 50% 50%♦ Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's All but very limited 50% of Co-payment/ 50% of Medicare Co- requirements, including a co-payment/ coinsurance payment/coinsurance♦ doctor's certification of terminal coinsurance for out- illness patient drugs and inpatient respite care STANDARDS *** 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 three hundred sixty-five (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**** $0 $0 [$183] (Part B deductible)**** ♦ Preventive Benefits for Medicare covered services Generally 75% or Remainder of All costs above more of Medicare Medicare approved Medicare approved approved amounts amounts amounts Remainder of Medicare Approved Amounts Generally 80% Generally 10% Generally 10% ♦ Part B Excess Charges (Above Medicare $0 $0 All costs (and they do Approved Amounts) not count toward annual out-of-pocket limit of [$5,120])* BLOOD First 3 pints $0 50% 50%♦ Next [$183] of Medicare $0 $0 [$183] (Part B Approved Amounts**** deductible)**** ♦ Remainder of Medicare Generally 80% Generally 10% Generally 10% ♦ Approved Amounts CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 (continued) STANDARDS * This plan limits your annual out-of-pocket payments for Medicare-approved amounts to [$5,120] 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 100% $0 $0 care services and medical supplies —Durable medical equipment First [$183] of Medicare $0 $0 [$183] (Part B Approved Amounts***** deductible) ♦ Remainder of Medicare Approved Amounts 80% 10% 10%♦ *****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. STANDARDS 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 [$2,560] 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 one hundred percent (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. STANDARDS MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD ** A benefit period begins on the first (1st) 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 sixty (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 All but [$1,316] [$987] (75% of Part [$329] (25% of Part A A deductible) deductible)♦ 61st thru 90th day All but [$329] a day [$329] a day $0 91st day and after: —While using 60 lifetime reserve days All but [$658] a day [$658] a day $0 —Once lifetime reserve days are used: —Additional 365 days $0 100% of Medicare $0*** eligible expenses —Beyond the additional 365 days $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 All approved amounts $0 $0 Up to [$123.38] a day Up to [$41.13] a day (75% of Part A (25% of Part A 21st thru 100th day All but [$164.50] a day Coinsurance) Coninsurance)♦ 101st day and after $0 $0 All costs STANDARDS SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* BLOOD First 3 pints $0 75% 25%♦ Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's All but very limited co- 75% of co-payment/ 25% of co-payment/ requirements, including a payment/ coinsurance coinsurance ♦ doctor's certification of terminal coinsurance for illness. outpatient drugs and inpatient respite care *** 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 three hundred sixty-five (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 Physi- cian’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First [$183] of Medicare $0 $0 [$183] (Part B Approved Amounts**** deductible)**** ♦ Preventive Benefits for Generally 80% or Remainder of All costs above Medicare covered services more of Medicare Medicare approved Medicare approved approved amounts amounts amounts Remainder of Medicare Generally 80% Generally 15% Generally 5% ♦ Approved Amounts Part B Excess Charges (Above Medicare Approved $0 $0 All costs (and they STANDARDS Amounts) do not count toward annual out-of-pocket limit of [$2,560])* SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* BLOOD First 3 pints $0 75% 25%♦ Next [$183] of Medicare $0 $0 [$183] (Part B Approved Amounts**** deductible) ♦ Remainder of Medicare Generally 80% Generally 15% Generally 5%♦ Approved Amounts CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 * This plan limits your annual out-of-pocket payments for Medicare-approved amounts to [$2,560] 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 100% $0 $0 care services and medical supplies —Durable medical equipment First [$183] of Medicare $0 $0 [$183] (Part B Approved Amounts***** deductible) ♦ Remainder of Medicare Approved Amounts 80% 15% 5% ♦ *****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. STANDARDS PLAN M MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the first (1st) 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 sixty
11. (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 All but [$1,316] [$658](50% of Part A [$658](50% of Part deductible) A deductible) 61st thru 90th day All but [$329] a day [$329] a day $0 91st day and after: —While using 60 lifetime reserve days All but [$658] a day [$658] a day $0 —Once lifetime reserve days are used: —Additional 365 days $0 100% of Medicare $0** eligible expenses —Beyond the additional 365 days $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 All approved amounts $0 $0 21st thru 100th day All but [$164.50] a Up to [$164.50] a day $0 day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 STANDARDS SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPICE CARE All but very limited Medicare co-payment/ $0 You must meet Medicare’s co-payment/ coinsurance requirements, including a coinsurance for doctor’s certification of terminal outpatient drugs and illness inpatient respite care ** 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 three hundred sixty-five (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 $0 $0 [$183] (Part B Medicare Approved deductible) Amounts* Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare $0 $0 All costs Approved Amounts) STANDARDS BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare Approved Amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 —Durable medical equipment First [$183] of Medicare $0 $0 [$183](Part B Approved Amounts* deductible) Remainder of Medicare 80% 20% $0 Approved Amounts STANDARDS OTHER BENEFITS—NOT COVERED BY MEDICARE MEDICARE SERVICES 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 $0 $0 $250 First $250 each calendar year $0 80% to a lifetime maxi- 20% and amounts over Remainder of Charges mum benefit of the $50,000 lifetime $50,000 maximum PLAN N MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the (1st) 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 sixty
12. (60) days in a row. STANDARDS SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but [$1,316] [$1,316](Part A $0 deductible) 61st thru 90th day All but [$329] a day [$329] a day $0 91st day and after: —While using 60 lifetime reserve days All but [$658] a day [$658] a day $0 —Once lifetime reserve days are used: 100% of Medicare —Additional 365 days $0 eligible expenses $0** —Beyond the additional 365 $0 $0 All costs days 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 All approved amounts $0 $0 21st thru 100th day All but [$164.50] a Up to [$164.50] a day $0 day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 STANDARDS SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPICE CARE All but very limited Medicare co-payment/ $0 You must meet Medicare’s co-payment/ coinsurance requirements, including a coinsurance for doctor’s certification of terminal outpatient drugs and illness inpatient respite care ** 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 three hundred sixty-five (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. STANDARDS 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* $0 $0 [$183] (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Balance, other than Up to [$20] per office visit up to [$20] per office and up to [$50] per visit and up to [$50] emergency room visit. per emergency room The co-payment of up to visit. The co- [$50] is waived if the payment of up to insured is admitted to any [$50] is waived if the hospital and the insured is admitted to emergency visit is any hospital and the covered as a Medicare emergency visit is Part A expense. covered as a Medicare Part A expense. Part B Excess Charges (Above Medicare Approved $0 $0 All costs Amounts) STANDARDS BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare Approved Amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 —Durable medical equipment First [$183] of Medicare Approved Amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare 80% 20% $0 Approved Amounts OTHER BENEFITS—NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL— NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of Charges $0 80% to a lifetime 20% and amounts over maximum benefit of the $50,000 lifetime STANDARDS

13. (5) Notice Regarding Policies or Certificates Which Are Not Medicare Supplement Policies.

    1. (a) 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 0780-01-58-.03(2), 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.”
    2. (b) Applications provided to persons eligible for Medicare for the health insurance policies or certificates described in subparagraph (4)(a) 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.

Authority: T.C.A. §§ 56-1-701; 56-2-301; 56-6-112; 56-6-124(a); 56-7-1401, et seq.; 56-7-1453; 56-7- 1454; 56-7-1455; 56-7-1457; 56-7-1501, et seq.; 56-7-1503; 56-7-1504; 56-7-1505; 56-7-1507; and 56- 32-118(a); Omnibus Budget Reconciliation Act of 1990, Pub. L. No. 101-508, (1990); Genetic Information Non Discrimination Act, Pub. L. No. 110-233 (2008); Medicare Improvements for Patients and Providers Act, Pub. L. No. 110-275 (2008); and Medicare Access and CHIP Reauthorization Act, Pub. L. No. 114- 10 (2015). Administrative History: Original rule filed August 14, 1989; effective September 28, 1989. New rule filed November 26, 1990; effective January 10, 1991. Repealed and new rule filed September 16, 1992; effective November 1, 1992. (Formerly 0780-01-58-.18) Amendment filed October 25, 1999; effective January 3, 2000. Public necessity rule filed September 1, 2005; effective through February 13, 2006. Public necessity rule filed September 1, 2005; expired on February 13, 2006. On February 14, 2006, reverted to rule in effect on August 31, 2005. Repeal and new rule filed October 13, 2006; effective December 27, 2006. Public necessity rule filed June 30, 2009; effective through December 12, 2009. Emergency rule filed December 9, 2009; effective through June 7, 2010. Amendment filed December 3, 2009; effective March 3, 2010. Administrative changes made to the authority of this chapter due to revisions in the 2016 Tennessee Code Annotated. Rule was previously numbered 0780-01-58-.19 but was renumbered 0780-01-58-.20 with the addition of a new rule 0780-01-58-.12 filed November 20, 2018; effective February 18, 2019. Amendments filed November 20, 2018; effective February 18, 2019.