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Montana Administrative Register Notice 6-203 No. 14   07/25/2013    
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BEFORE THE COMMISSIONER OF SECURITIES AND INSURANCE

MONTANA STATE AUDITOR

 

In the matter of the amendment of ARM 6.6.507B, 6.6.507C, 6.6.507D, 6.6.507E, 6.6.509, 6.6.511, and 6.6.511A pertaining to Medicare Supplements

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT

 

 

TO: All Concerned Persons

 

1. On August 19, 2013, at 10:30 a.m., the Commissioner of Securities and Insurance, Montana State Auditor, will hold a public hearing in the 2nd floor conference room, at the Office of the Commissioner of Securities and Insurance, Montana State Auditor (CSI), 840 Helena Ave., Helena, Montana, to consider the proposed amendment of the above-stated rules.

 

2. The CSI will make reasonable accommodations for persons with disabilities who wish to participate in this public hearing, or need an alternative accessible format of this notice. If you require an accommodation, contact the CSI no later than 5:00 p.m., August 12, 2013, to advise us of the nature of the accommodation that you need. Please contact Darla Sautter, CSI, 840 Helena Avenue, Helena, Montana, 59601; telephone (406) 444-2726; TDD (406) 444-3246; fax (406) 444-3499; or e-mail dsautter@mt.gov.

 

3. The rules as proposed to be amended provide as follows, stricken matter interlined, new matter underlined:

 

            6.6.507B OPEN ENROLLMENT (1) No issuer shall deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this state, nor discriminate in the pricing of such a policy or certificate because of the health status, claims experience, receipt of health care, or medical condition of an applicant where an application for a policy or certificate is submitted:

            (a) prior to or during the six month period beginning with the first day of the first month in which an individual is both 65 years of age or older and is enrolled for benefits under Medicare Part B; or

            (b) during the 63-day period following termination of coverage under a group or individual health insurance policy or certificate for a person enrolled, or eligible for enrollment in Medicare Part B, and who resides in this state, upon the request of the individual.

            (2) Each Medicare supplement policy or certificate currently available from an issuer must be made available to all applicants who qualify under this rule without regard to age:

            (2)(a) If an applicant qualifies under ARM 6.6.507B(1)(a) or (b), and submits an application during the either time period referenced in (1) and, as of the date of application, has had a continuous period of creditable coverage of at least six months, the issuer shall not exclude benefits based on a preexisting condition.; and

            (3)(b) If the applicant qualifies under ARM 6.6.507B(1)(a) or (b), and submits an application during the either time period referenced in (1) and, as of the date of application, has had a continuous period of creditable coverage that is less than six months, the issuer shall reduce the period of any preexisting condition exclusion by the aggregate of the period of creditable coverage applicable to the applicant as of the enrollment date. The secretary shall specify the manner of the reduction under this rule.

            (4)(3) This rule must not be construed as preventing the exclusion of benefits under a policy, except as provided in (2)(a) and (3)(2)(b), ARM 6.6.507C, and 6.6.522 during the first six months, based on a preexisting condition for which the policyholder or certificateholder received treatment or was otherwise diagnosed during the six months before it became effective.

 

            AUTH: 33-1-313, 33-22-904, 33-22-905, MCA

            IMP: 33-22-902, 33-22-904, MCA

 

            6.6.507C GUARANTEED ISSUE FOR ELIGIBLE PERSONS (1) through (2)(f) remain the same.

            (g) the individual enrolls in a Medicare Part D plan during the initial enrollment period and, at the time of enrollment in Part D, was enrolled under a Medicare supplement policy that covers outpatient prescription drugs and the individual terminates enrollment in the Medicare supplement policy and submits evidence of enrollment in Medicare Part D along with the application for a policy described in (5)(e).;

            (h) the individual, upon first becoming eligible for benefits under Medicare Part A and B enrolls in the Qualified Medicare Beneficiary Program as defined in section 6408(d)(2) of the Federal Omnibus Budget Reconciliation Act of 1989, Public Law 101-239, or full Medicaid (ARM 37.83.802), and no longer qualifies due to income or eligibility changes;

            (i) the individual, upon first becoming eligible for benefits under Medicare Part A and B enrolls in the  Montana Comprehensive Health Association and coverage under the Montana Comprehensive Health Association terminates; or

            (j) the individual becomes eligible for benefits under Medicare Part A and B by reason of disability.

            (3) through (3)(a)(iii) remain the same.

            (b) an individual described in (2)(b), (c), (e), or (f), (h), or (i) whose enrollment is terminated involuntarily, the guaranteed issue period begins on the date that the individual receives a notice of termination and ends 63 days after the date the applicable coverage is terminated;

            (c) through (6)(b) remain the same.

 

            AUTH: 33-1-313, 33-22-904, 33-2-905 33-22-905, MCA

            IMP: 33-22-902, 33-22-904, 33-22-905, MCA

 

            6.6.507D BENEFIT STANDARDS FOR 2010 STANDARDIZED MEDICARE SUPPLEMENT BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED FOR DELIVERY WITH AN EFFECTIVE DATE FOR COVERAGE ON OR AFTER JUNE 1, 2010 (1) through (4)(b)(iii) remain the same.

            (iv) coverage for all of the Medicare Part B deductible amount per calendar year regardless of hospital confinement, less any applicable copayments for advanced imaging services and power-operated vehicles or scooters, as described in (7)(c) and (7)(e) for new Plan C and F policies, or certificates with an effective date on or after January 1, 2015;

            (v) and (vi) remain the same.

 

            AUTH: 33-1-313, 33-22-904, 33-22-905, MCA

            IMP: 33-15-303, 33-22-901, 33-22-902, 33-22-903, 33-22-904, 33-22-905, 33-22-909, 33-22-910, 33-22-911, 33-22-921, 33-22-922, 33-22-923, 33-22-924, MCA

 

            6.6.507E STANDARD MEDICARE SUPPLEMENT BENEFIT PLANS FOR 2010 STANDARDIZED MEDICARE SUPPLEMENT BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED WITH AN EFFECTIVE DATE FOR COVERAGE ON OR AFTER JUNE 1, 2010 (1) through (7)(c)(i) remain the same.

            (ii) 100% of the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, and medically necessary emergency care in a foreign country as established in ARM 6.6.507D(4)(b)., with copayments in the following amounts for new policies and certificates with effective dates on or after January 1, 2015:

            (A) the lesser of $25 or the Medicare Part B coinsurance or copayment for each primary covered advanced imaging service; and

            (B) the lesser of $50 or the Medicare Part B coinsurance or copayment for the purchase of each covered power operated vehicle or scooter.

            (iii) for purposes of this subsection:

            (A) "advanced imaging service" means those Medicare Part B services, such as magnetic resonance imaging scans (MRIs), computerized tomography scans (CAT or CT scans) and positron emission tomography scans (PET scans), defined in separate guidance by the NAIC, in consultation with CMS, for purposes of establishing which covered services are subject to cost sharing. This definition may be updated periodically as needed; and

            (B) "power operated vehicle" or "scooter" means certain durable medical equipment defined in separate guidance by the NAIC, in consultation with CMS, for purposes of establishing which covered services are subject to cost sharing. This definition may be updated periodically as needed.

            (7)(d) through (7)(e)(i) remain the same.

            (ii) 100% of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign county, established in ARM 6.6.507D(4)(b)., with copayments in the following amounts for the new policies and certificates with effective dates on or after January 1, 2015:

            (A) the lesser of $25 or the Medicare Part B coinsurance or copayment for each primary covered advanced imaging service; and

            (B) the lesser of $50 or the Medicare Part B coinsurance or copayment for the purchase of each covered power-operated vehicle or scooter where the supplier accepts Medicare assignment for the claim.

            (iii) for purposes of this subsection:

            (A) "advanced imaging service" means those Medicare Part B services, such as magnetic resonance imaging scans (MRIs), computerized tomography scans (CAT or CT scans) and positron emission tomography scans (PET scans), defined in separate guidance by the NAIC, in consultation with CMS, for purposes of establishing which covered services are subject to cost-sharing. The definition may be updated periodically as needed; and

            (B) "power-operated vehicle" or "scooter" means certain durable medical equipment defined in separate guidance by the NAIC, in consultation with CMS, for purposes of establishing which covered services are subject to cost-sharing. This definition may be updated periodically as needed.

            (7)(f) through (7)(f)(i)(B) remain the same.

            (ii) The annual high deductible Plan F deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement regular Plan F policy, and shall be in addition to any other specific benefit deductibles. The basis for the deductible shall be $1500 and shall be adjusted annually from 1999 by the Secretary to reflect the change in the consumer price index for all urban consumers for the 12-month period ending with August of the preceding year, and rounded to the nearest multiple of $10. Copays for advanced imaging services and power-operated vehicles applied under regular Plan F for new policies issued on or after January 1, 2015, are not applicable under Plan F With High Deductible.

(7)(g) through (11) remain the same.

 

            AUTH: 33-1-313, 33-22-904, 33-22-905, MCA

            IMP: 33-15-303, 33-22-901, 33-22-902, 33-22-903, 33-22-904, 33-22-905, 33-22-909, 33-22-910, 33-22-911, 33-22-921, 33-22-922, 33-22-923, 33-22-924, MCA

 

            6.6.509 REQUIRED DISCLOSURE PROVISIONS (1) through (9)(b) remain the same.

            (c) The following items must be included in the outline of coverage in the order prescribed below:

 

[COMPANY NAME]

Outline of Medicare Supplement Coverage-Cover Page: 1 of 2

Benefit Plan(s)____[insert letter(s) of plan(s) being offered]

 

These charts show the benefits included in each of the 1990 standardized Medicare supplement plans. Every company must make available Plan A. Some plans may not be available in your state. New 1990 standardized benefit plans may not be issued on or after June 1, 2010.

 

See Outline of Coverage sections for details about ALL plans

 

Basic Benefits for Plans A-J:

Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses), copayments for hospital outpatient services.

Blood: First three pints of blood each year.

 

A

B

C

D

E

Basic Benefits

Basic Benefits

Basic Benefits

Basic Benefits

Basic Benefits

 

 

Skilled Nursing Facility

Coinsurance

Skilled Nursing Facility

Coinsurance

Skilled Nursing Facility

Coinsurance

 

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

 

 

Part B Deductible

 

 

 

 

Foreign Travel Emergency

Foreign Travel Emergency

Foreign Travel Emergency

 

 

 

At-Home Recovery

 

 

 

 

 

Preventive Care NOT covered by Medicare

 


F

F*

G

H

I

J

J*

Basic Benefits

Basic Benefits

Basic Benefits

Basic Benefits

Basic Benefits

Skilled Nursing Facility

Coinsurance

Skilled Nursing Facility

Coinsurance

Skilled Nursing Facility

Coinsurance

Skilled Nursing Facility

Coinsurance

Skilled Nursing Facility

Coinsurance

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part B Deductible

 

 

 

Part B Deductible

Part B Excess (100%)

Part B Excess (80%)

 

Part B Excess (100%)

Part B Excess (100%)

Foreign Travel Emergency

Foreign Travel Emergency

Foreign Travel Emergency

Foreign Travel Emergency

Foreign Travel Emergency

 

At-Home Recovery

 

At-Home Recovery

At-Home Recovery

 

 

 

 

Preventive Care NOT covered by Medicare

 

* Plans F and J also have an option called a high deductible Plan F and a high deductible Plan J. These high deductible plans pay the same benefits as Plans F and J after one has paid a calendar year $2000 deductible. Benefits from high deductible Plans F and J will not begin until out-of-pocket expenses exceed $2000. 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.

 

                                                          [COMPANY NAME]

 

                       Outline of Medicare Supplement Coverage - Cover Page 2

 

Basic Benefits for Plans K and L: include similar services as Plans A-J, but cost-sharing for the basic benefits is at different levels.

 

J

K**

L**

Basic Benefits

100% of Part A

hospitalization coinsurance plus coverage for 365 days after Medicare benefits end

50%   hospice cost-sharing

50%   of Medicare-eligible expenses for the first three pints of blood

50%   Part B coinsurance, except 100% coinsurance for Part B preventive services

100% of Part A

hospitalization coinsurance plus coverage for 365 days after Medicare benefits end

75%   hospice cost-sharing

75%   of Medicare-eligible expenses for the first three pints of blood

75%   Part B coinsurance, except 100% coinsurance for Part B preventive services

Skilled Nursing Coinsurance

50%   Skilled Nursing Facility Coinsurance

75%   Skilled Nursing Facility Coinsurance

Part A Deductible

50%   Part A Deductible

75%   Part A Deductible

Part B Deductible

 

 

Part B Excess (100%)

 

 

Foreign Travel Emergency

 

 

At-Home Recovery

 

 

Preventive Care NOT covered by Medicare

 

 

 

$[4620] Out of Pocket Annual Limit***

$[2310] Out of Pocket Annual Limit***

 

**Plans K and L provide for different cost-sharing for items and services than Plan

A - J. Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance, and deductibles for the rest of the calendar year.  The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called "Excess Charges." You will be responsible for paying excess charges.

 

***The out-of-pocket annual limit will increase each year for inflation.

 

See Outlines of Coverage for details and exceptions.

 

Benefit Chart of Medicare Supplement Plans Sold with an effective date for 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.

 

Plans E, H, I, and J are no longer available for sale. [This sentence shall not appear after June 1, 2011.]

 

Basic Benefits:

            Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses), or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or copayments.

Blood: First three pints of blood each year.

Hospice: Part A coinsurance.

 

A

B

C

D


F

F*

G

Basic,

including 100% Part B coinsurance

Basic,

including 100% Part B coinsurance

Basic,

including

100% Part B coinsurance

Basic,

including 100% Part B coinsurance

Basic,

including 100% Part B coinsurance

Basic,

including 100% Part B coinsurance

 

 

Skilled Nursing Facility Coinsurance

Skilled Nursing Facility Coinsurance

Skilled Nursing Facility

Coinsurance

Skilled Nursing Facility

Coinsurance

 

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

 

 

Part B Deductible

 

Part B Deductible

 

 

 

 

 

Part B Excess

(100%)

Part B Excess

(100%)

 

 

Foreign Travel Emergency

Foreign Travel Emergency

Foreign Travel Emergency

Foreign Travel Emergency

 

 

K

L

M

N

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, including 100% Part B coinsurance

Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER

 

50% Skilled

Nursing Facility Coinsurance

 

75% Skilled

Nursing Facility Coinsurance

 

Skilled

Nursing Facility Coinsurance

 

Skilled

Nursing Facility Coinsurance

 

50% Part A Deductible

 

50% Part A Deductible

 

50% Part A Deductible

 

50% Part A Deductible

 

 

Foreign Travel Emergency

Foreign Travel Emergency

Out-of-pocket limit $[4620]; paid at 100% after limit reached

Out-of-pocket limit $[2310]; 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 [$2000] deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses exceed [$2000]. 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.

            (10) The CSI adopts and incorporates by reference the National Association of Insurance Commissioners (NAIC) Model Regulation to Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act, page 651-56 through page 651-106, which sets forth the Medicare payment tables for insurers, and specifically in this rule are the Outlines of Medicare Supplement Coverage-Cover Page: 1 of 2: Benefit Plan(s) A, B, C, D, E, F, G, H, I, J, and High Deductible Plans F & J; Outline of Medicare Supplement Coverage - Cover Page 2: Benefit Plan(s) K, L, M & N, which include similar services as Plans A-J, but cost-sharing for the basic benefits is at different levels, adopted 7/17/09. Copies of the NAIC Model rule containing Plans A - N are available for public inspection at the Office of the Commissioner of Securities and Insurance, Montana State Auditor, Legal Department, 840 Helena Avenue, Helena, Montana 59601, or on the department's web site. Persons obtaining a copy of these forms must pay the cost of providing such copies.

            (10) and (11) remain the same, but are renumbered (11) and (12).

 

            AUTH: 33-1-313, 33-22-904, 33-22-907, MCA

            IMP: 33-15-303, 33-22-902, 33-22-904, 33-22-907, MCA

                                    

            6.6.511 SAMPLE FORMS OUTLINING COVERAGE (1) through (2) remain the same.

 

            (a)                                             COVER PAGE

                                      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 with an effective dates prior to June January 1, 20102015Policies sold for with an effective dates prior to January 1, 2015, have different benefits and premiums.

 

                       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 "The Medicare Handbook" 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 ARM 6.6.507A(4).]

 

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

 

            (b)                                                   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 $[6.6.511(1)(a)]

 

All but $[6.6.511(1)(b)]

a day

 

 

All but $[6.6.511(1)(c)]

a day

 

 

 

$0

 

$0

 

 

 

 

 

 

$0

 

$[6.6.511(b)]

a day

 

 

$[6.6.511(1)(c)] a day

 

 

100% of Medicare eligible expenses

 

$0

 

 

 

 

$[6.6.511(1)(a)] (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 amounts

 

 

All but $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

$0

 

 

 

$0

 

$0

 

 

 

 

 

 

 

 

$0

 

Up to

$[6.6.511(1)(d)] a day

 

All costs

BLOOD

First 3 pints

Additional amounts

 

$0

100%

 

3 pints

$0

 

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

 

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

 

 

 

 

$0

 

 

 

 

Balance

 

**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 $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

 

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES -

IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT,

such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

--First $[135] of Medicare

 approved amounts*

 

--Remainder of Medicare

 approved amounts

 

 

 

 

 

 

 

 

 

 

$0

 

 

Generally 80%

 

 

 

 

 

 

 

 

 

 

$0

 

 

Generally 20%

 

 

 

 

 

 

 

 

 

$[135] (Part B deductible)

 

 

$0

Part B Excess Charges

(Above Medicare approved amounts)

 

$0

 

$0

 

All costs

BLOOD

First 3 pints

 

Next $[135] of Medicare

 ---approved amounts*

 

Remainder of Medicare

---approved amounts

 

$0

 

 

$0

 

 

80%

 

All costs

 

 

$0

 

 

20%

 

$0

 

$[135] (Part B deductible)

 

 

$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

 

--Durable medical equipment

 

---First $[135] of Medicare      approved amounts*

 

---Remainder of Medicare

     approved amounts

 

 

 

100%

 

 

 

 

$0

 

 

80%

 

 

 

$0

 

 

 

 

$0

 

 

20%

 

 

 

$0

 

 

 

$[135] (Part B deductible)

 

 

$0

 

 

            (c)                                                   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

 

 

 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 $[6.6.511(1)(a)]

 

All but $[6.6.511(1)(b)] a day

 

 

All but $[6.6.511(1)(c)] a day

 

 

 

$0

 

$0

 

 

 

$[6.6.511(1)(a)]

(Part A deductible)

 

$[6.6.511(1)(b)]

a day

 

 

$[6.6.511(1)(c)]

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 $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

$0

 

 

 

$0

 

$0

 

 

 

 

 

 

 

 

$0

 

Up to

$[6.6.511(1)(d)]

a day

 

All costs

BLOOD

First 3 pints

Additional amounts

 

$0

100%

 

3 pints

$0

 

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these

All but very limited copayment/

coinsurance for out-patient drugs and inpatient respite care

 

 

 

 

$0

 

 

 

 

Balance

 

**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 $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

 

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES -

IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT,

such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

 First $[135] of Medicare

    approved amounts*

 Remainder of Medicare

    approved amounts

 

 

 

 

 

 

 

 

 

 

$0

 

Generally 80%

 

 

 

 

 

 

 

 

 

 

$0

 

Generally 20%

 

 

 

 

 

 

 

 

 

$[135] (Part B deductible)

 

$0

Part B Excess Charges

(Above Medicare approved amounts)

 

$0

 

$0

 

All costs

BLOOD

First 3 pints

Next $[135] of Medicare

 approved amounts*

 

Remainder of Medicare

 approved amounts

 

$0

 

$0

 

 

80%

 

All costs

 

$0

 

 

20%

 

$0

$[135] (Part B deductible)

 

 

$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

---Durable medical equipment

   First $[135] of Medicare

    approved amounts*

   Remainder of Medicare

    approved amounts

 

 

 

 

100%

 

 

$0

 

80%

 

 

 

 

$0

 

 

$0

 

20%

 

 

 

 

$0

 

$[135] (Part B deductible)

 

$0

 

            (d)                                                   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

 

 

 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 $[6.6.511(1)(a)]

 

 

All but $[6.6.511(1)(b)]

a day

 

 

All but $[6.6.511(1)(c)]

a day

 

 

 

$0

 

$0

 

 

 

 

 

$[6.6.511(1)(a)]

(Part A deductible)

 

$[6.6.511(1)(b)]

a day

 

 

$[6.6.511(1)(c)] 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 $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

$0

 

Up to $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

$0

 

 

$0

 

All costs

BLOOD

First 3 pints

Additional amounts

 

$0

100%

 

3 pints

$0

 

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

 

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

 

 

 

 

$0

 

 

 

 

Balance

 

**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 $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

 

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES -

IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT,

such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

 First $[135] of Medicare

   approved amounts*

 

 Remainder of Medicare

   approved amounts

 

 

 

 

 

 

 

 

 

 

$0

 

 

Generally 80%

 

 

 

 

 

 

 

 

 

$[135] (Part B deductible)

 

 

Generally 20%

 

 

 

 

 

 

 

 

 

 

$0

 

 

$0

Part B Excess Charges

(Above Medicare approved amounts)

 

$0

 

$0

 

All costs

BLOOD

First 3 pints

 

Next $[135] of Medicare

 approved amounts*

 

Remainder of Medicare

 approved amounts

 

$0

 

 

$0

 

 

80%

 

All costs

 

$[135] (Part B deductible)

 

 

20%

 

$0

 

 

$0

 

 

$0

CLINICAL LABORATORY

SERVICES -- TESTS

FOR DIAGNOSTIC SERVICES

 

 

100%

 

 

$0

 

 

$0

 

PARTS A & B

 

HOME HEALTH CARE

MEDICARE APPROVED SERVICES

---Medically necessary skilled care services and medical supplies

---Durable medical equipment

 

   First $[135] of Medicare

    approved amounts*

 

   Remainder of Medicare

    approved amounts

 

 

 

100%

 

 

 

$0

 

 

80%

 

 

 

$0

 

 

$[135] (Part B deductible)

 

 

20%

 

 

 

$0

 

 

 

$0

 

 

$0

 

PLAN C

 

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

 

            (e)                                                   PLAN D

 

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT YEAR

 

*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 $[6.6.511(1)(a)]

 

 

All but $[6.6.511(1)(a)] a day

 

 

All but $[6.6.511(1)(c)] a day

 

 

$0

 

$0

 

 

 

 

$[6.6.511(1)(a)]

(Part A deductible)

 

$[6.6.511(1)(b)]

a day

 

 

$[6.6.511(1)(c)]

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 $[6.6.511(1)(d)] a day

 

$0

 

 

 

 

 

 

 

 

$0

 

Up to $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

$0

 

 

$0

 

All costs

BLOOD

First 3 pints

Additional amounts

 

$0

100%

 

3 pints

$0

 

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsurance for outpatient drugs and inpatient respite care

 

 

 

$0

 

 

 

Balance

 

**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 $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

 

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES -

IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT,

such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

 

 First $[135] of Medicare

    approved amounts*

 

Remainder of Medicare

    approved amounts

 

 

 

 

 

 

 

 

 

 

 

$0

 

 

Generally 80%

 

 

 

 

 

 

 

 

 

 

 

$0

 

 

Generally 20%

 

 

 

 

 

 

 

 

 

 

$[135] (Part B deductible)

 

 

$0

Part B Excess Charges

(Above Medicare approved amounts)

 

$0

 

$0

 

All costs

BLOOD

First 3 pints

 

Next $[135] of Medicare

 approved amounts*

 

Remainder of Medicare

 approved amounts

 

$0

 

 

$0

 

 

80%

 

All costs

 

 

$0

 

 

20%

 

$0

 

$[135] (Part B deductible)

 

 

$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

Durable medical equipment

First $[135] of Medicare approved amounts*

 

Remainder of Medicare approved amounts*

 

AT-HOME RECOVERY SERVICES-NOT COVERED BY MEDICARE

Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan

 

---Benefit for each visit

 

 

---Number of visits covered (must be received within 8 weeks of last Medicare approved visit)

 

---Calendar year maximum

 

 

 

100%

 

 

$0

 

 

80%

 

 

 

 

 

 

 

 

 

$0

 

 

 

 

$0

 

$0

 

 

 

$0

 

 

$0

 

 

20%

 

 

 

 

 

 

 

 

Actual charges to $40 a visit

 

Up to the number of Medicare approved visits, not to exceed 7 each week

 

$1,600

 

 

 

$0

 

$[135] (Part B deductible)

 

 

$0

 

 

 

 

 

 

 

 

 

Balance

 

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

 

          (f)                                                      PLAN E

 

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

 

*A benefit period begins on the first day you receive services 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 $[6.6.511(1)(a)]

 

All but $[6.6.511(1)(b)] a day

 

 

All but $[6.6.511(1)(c)] a day

 

 

 

$0

 

$0

 

 

 

$[6.6.511(1)(a)]

(Part A deductible)

 

$[6.6.511(1)(b)]

a day

 

 

$[6.6.511(1)(c)]

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 $[6.6.511(1)(d)] a day

 

 

$0

 

 

 

 

 

 

 

 

$0

Up to $[6.6.511(1)(d)]

a day

 

 

$0

 

 

 

 

 

 

 

 

$0

 

$0

 

 

All costs

BLOOD

First 3 pints

Additional amounts

 

$0

100%

 

3 pints

$0

 

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

 

All but very limited coinsurance for outpatient drugs and inpatient respite care

 

 

 

 

$0

 

 

 

 

Balance

 

**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 E

MEDICARE (PART B) - MEDICAL SERVICES - PER BENEFIT PERIOD

 

*Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

 

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES -

IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT,

such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

 First $[135] of Medicare

    approved amounts*

 

 Remainder of Medicare

    approved amounts

 

 

 

 

 

 

 

 

 

 

$0

 

 

Generally 80%

 

 

 

 

 

 

 

 

 

 

$0

 

 

Generally 20%

 

 

 

 

 

 

 

 

 

$[135] (Part B deductible)

 

 

$0

Part B Excess Charges

(Above Medicare approved amounts)

 

$0

 

$0

 

All costs

BLOOD

First 3 pints

 

Next $[135] of Medicare

 approved amounts*

 

Remainder of Medicare

 approved amounts

 

$0

 

 

$0

 

 

80%

 

All costs

 

 

$0

 

 

20%

 

$0

 

$[135] (Part B deductible)

 

 

$0

CLINICAL LABORATORY

SERVICES -- TESTS

FOR DIAGNOSTIC SERVICES

 

 

100%

 

 

$0

 

 

$0

 

PARTS A & B

 

HOME HEALTH CARE

MEDICARE APPROVED SERVICES

 

---Medically necessary skilled care services and medical supplies

 

---Durable medical equipment

 First $[135] of Medicare

    approved amounts*

 

Remainder of Medicare

    approved amounts

 

 

 

 

100%

 

 

 

$0

 

 

80%

 

 

 

 

$0

 

 

 

$0

 

 

20%

 

 

 

 

$0

 

 

$[135] (Part B deductible)

 

 

$0

 

PLAN E

 

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

***PREVENTIVE MEDICARE CARE BENEFIT-NOT COVERED BY MEDICARE

Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare

 

 First $120 each

    calendar year

 

Additional charges

 

 

 

 

 

 

 

 

$0

 

 

$0

 

 

 

 

 

 

 

 

$120

 

 

$0

 

 

 

 

 

 

 

 

$0

 

 

All costs

 

***Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

 

            (g)                       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 $[2000] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[2000]. 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

$[2000]

DEDUCTIBLE, **] PLAN PAYS

[IN ADDITION TO $[2000] DEDUCTIBLE, **] YOU PAY

HOSPITALIZATON*

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 $[6.6.511(1)(a)]

 

All but

[6.6.511(1)(b)]

 a day

 

 

 

All but

$[6.6.511(1)(c)]

 a day

 

 

 

$0

 

$0

 

 

 

 

 

$[6.6.511(1)(a)]

(Part A deductible)

 

 

$[6.6.511(1)(b)]

a day

 

 

 

 

$[6.6.511(1)(c)]

a day

 

 

100% 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 $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

 

$0

 

 

Up to $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

 

$0

 

 

 

$0

 

All costs

 

                                       PLAN F or HIGH DEDUCTIBLE PLAN F

 

          MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

 

BLOOD

First 3 pints

Additional amounts

 

$0

100%

 

3 pints

$0

 

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited

coinsurance for outpatient drugs and inpatient respite care

 

 

 

 

 

$0

 

 

 

 

 

Balance

 

***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 $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. [**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $[2000] deductible. Benefits from the high deductible Plan F will begin until out-of-pocket expenses are $[2000]. 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 $[2000] DEDUCTIBLE,**] PLAN PAYS

[IN ADDITION TO $[2000] 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 $[135] of

 Medicare approved

 amounts*

 

Remainder of

 Medicare approved

 Amounts

 

 

 

 

 

 

 

 

 

 

 

 

 

$0

 

 

 

Generally 80%

 

 

 

 

 

 

 

 

 

 

 

 

$[135] (Part B deductible)

 

 

 

Generally 20%

 

 

 

 

 

 

 

 

 

 

 

 

 

$0

 

 

 

$0

Part B excess charges

(Above Medicare approved amounts)

 

 

$0

 

 

100%

 

 

$0

BLOOD

First 3 pints

 

Next $[135] of Medicare

 approved amounts*

Remainder of Medicare

 approved amounts

 

$0

 

 

$0

 

80%

 

All costs

 

$[135] (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 $[2000] DEDUCTIBLE,**] PLAN PAYS

[IN ADDITION TO $[2000] DEDUCTIBLE,**] YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES

---Medically necessary

   skilled care services

   and medical supplies

 

---Durable medical

   equipment

   First $[135] of

   Medicare approved amounts*

 

 ---Remainder of Medicare

     approved amounts

 

 

 

 

 

100%

 

 

 

 

$0

 

 

80%

 

 

 

 

 

$0

 

 

 

$[135] (Part B deductible)

 

 

20%

 

 

 

 

 

$0

 

 

 

 

$0

 

 

$0

 

OTHER BENEFITS - NOT COVERED BY MEDICARE

 

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2000] DEDUCTIBLE,**] PLAN PAYS

[IN ADDITION TO $[2000] 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

 

            (h)                                                   PLAN G

 

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

 

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

 

SERVICES

MEDICARE PAYS

PLAN PAYS

**YOU PAY

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 $[6.6.511(1)(a)]

 

All but $[6.6.511(1)(b)] a day

 

All but

$[6.6.511(1)(c)] a day

 

 

 

$0

 

$0

 

 

 

 

 

$[6.6.511(1)(a)]

(Part A deductible)

 

 

$[6.6.511(1)(b)]

a day

 

 

$[6.6.511(1)(c)]

a day

 

 

100% 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 $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

$0

 

 

Up to $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

$0

 

 

 

$0

 

All costs

BLOOD

First 3 pints

Additional amounts

 

$0

100%

 

3 pints

$0

 

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsurance for outpatient drugs and inpatient respite care

 

 

 

$0

 

 

 

Balance

 

**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

 

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

 

*Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

 

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES-

IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT,

such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

 First $[135] of

 Medicare approved

 amounts*

 

Remainder of

 Medicare approved

 Amounts

 

 

 

 

 

 

 

 

 

 

 

 

 

$0

 

 

 

Generally 80%

 

 

 

 

 

 

 

 

 

 

 

 

 

$0

 

 

 

Generally 20%

 

 

 

 

 

 

 

 

 

 

 

 

$[135] (Part B deductible)

 

 

 

$0

Part B Excess Charges

(Above Medicare approved amounts)

 

 

$0

 

 

100%

 

 

$0

BLOOD

First 3 pints

 

Next $[135] of Medicare

 approved amounts*

 

Remainder of Medicare

 approved amounts

 

$0

 

 

$0

 

 

80%

 

All costs

 

 

$0

 

 

20%

 

$0

 

$[135] (Part B deductible)

 

 

$0

CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES

 

 

100%

 

 

$0

 

 

$0

 

PLAN G

 

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 $[135] of Medicare

    approved amounts*

 

Remainder of Medicare

    approved amounts

 

AT-HOME RECOVERY SERVICES-NOT COVERED BY MEDICARE

Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a home care treatment plan

 ---Benefit for each visit

 

 ---Number of visits covered

    (Must be received within

    8 weeks of last Medicare

    approved visit)

 

 ---Calendar year maximum

 

 

 

 

100%

 

 

 

$0

 

 

80%

 

 

 

 

 

 

 

$0

 

 

 

 

$0

 

$0

 

 

 

 

$0

 

 

 

$0

 

 

20%

 

 

 

 

 

 

Actual charges to $40 a visit

 

Up to the number of Medicare-approved visits, not to exceed 7 each week

 

$1,600

 

 

 

 

$0

 

 

$[135] (Part B deductible)

 

 

$0

 

 

 

 

 

 

 

Balance

 

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

 

            (i)                                                      PLAN H

 

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

 

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

 

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

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

$[6.6.511(1)(a)]

 

All but $[6.6.511(1)(b)] a day

 

All but $[6.6.511(1)(c)] a day

 

 

 

$0

 

$0

 

 

 

 

$[6.6.511(1)(a)]

(Part A deductible)

 

 

$[6.6.511(1)(b)]

a day

 

 

$[6.6.511(1)(c)]

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 $[6.6.511(1)(d)]a day

 

$0

 

 

 

 

 

 

 

 

$0

 

 

Up to $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

$0

 

 

 

$0

 

All costs

BLOOD

First 3 pints

Additional amounts

 

$0

100%

 

3 pints

$0

 

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsurance for outpatient drugs and inpatient respite care

 

 

 

 

$0

 

 

 

 

Balance

**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 H

 

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

 

*Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

 

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES-

IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT,

such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

 First $[135] of

 Medicare approved

 amounts*

 

 Remainder of

 Medicare approved

 Amounts

 

 

 

 

 

 

 

 

 

 

 

 

 

$0

 

 

 

Generally 80%

 

 

 

 

 

 

 

 

 

 

 

 

 

$0

 

 

 

Generally 20%

 

 

 

 

 

 

 

 

 

 

 

 

$[135] (Part B deductible)

 

 

 

$0

Part B Excess Charges

(Above Medicare approved amounts)

 

 

$0

 

 

0%

 

 

All costs

BLOOD

First 3 pints

 

Next $[135] of Medicare

 approved amounts*

 

Remainder of Medicare

 Approved amounts

 

$0

 

 

$0

 

 

80%

 

All costs

 

 

$0

 

 

20%

 

$0

 

$[135] (Part B deductible)

 

 

$0

CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES

 

 

100%

 

 

$0

 

 

$0

 

PLAN H

 

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 $[135] of Medicare approved amounts*

 

Remainder of Medicare approved amounts

 

 

 

100%

 

 

 

$0

 

 

80%

 

 

 

$0

 

 

 

$0

 

 

20%

 

 

 

$0

 

 

$[135] (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

 

            (j)                                                      PLAN I

 

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

 

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

 

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

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

$[6.6.511(1)(a)]

 

All but $[6.6.511(1)(b)] a day

 

All but $[6.6.511(1)(c)] a day

 

 

 

 

$0

 

$0

 

 

 

 

 

$[6.6.511(1)(a)]

(Part A deductible)

 

 

$[6.6.511(1)(b)]

a day

 

 

$[6.6.511(1)(c)]

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 $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

 

$0

 

 

Up to $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

 

$0

 

 

 

$0

 

All costs

 

                                                                     PLAN I

 

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

 

BLOOD

First 3 pints

Additional amounts

 

$0

100%

 

3 pints

$0

 

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsurance for outpatient drugs and inpatient respite care

 

 

 

 

$0

 

 

 

 

Balance

 

**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 I

 

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

 

*Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

 

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES-

IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT,

such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

 First $[135] of

 Medicare approved

 amounts*

 

 Remainder of

 Medicare approved

 amounts

 

 

 

 

 

 

 

 

 

 

 

 

 

$0

 

 

 

Generally 80%

 

 

 

 

 

 

 

 

 

 

 

 

 

$0

 

 

 

Generally 20%

 

 

 

 

 

 

 

 

 

 

 

 

$[135] (Part B deductible)

 

 

 

$0

Part B Excess Charges

(Above Medicare approved amounts)

 

 

$0

 

 

100%

 

 

$0

BLOOD

First 3 pints

 

Next $[135] of Medicare

 approved amounts*

 

Remainder of Medicare

 approved amounts

 

$0

 

 

$0

 

 

80%

 

All costs

 

 

$0

 

 

20%

 

$0

 

$[135] (Part B deductible)

 

 

$0

CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES

 

 

100%

 

 

$0

 

 

$0

 

PLAN I

 

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 $[135] of Medicare

 approved amounts*

 

 Remainder of Medicare

 approved amounts

 

AT-HOME RECOVERY SERVICES--NOT COVERED BY MEDICARE

Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan

---Benefit for each visit

 

 

---Number of visits covered (must be received within 8 weeks of last Medicare approved visit)

 

---Calendar year maximum

 

 

 

 

100%

 

 

 

$0

 

 

80%

 

 

 

 

 

 

 

 

 

$0

 

 

 

 

$0

 

$0

 

 

 

 

$0

 

 

 

$0

 

 

20%

 

 

 

 

 

 

 

 

Actual charges to $40 a visit

 

Up to the number of Medicare-approved visits, not to exceed 7 each week

 

$1,600

 

 

 

 

$0

 

 

$[135] (Part B deductible)

 

 

$0

 

 

 

 

 

 

 

 

 

Balance

 

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

 

            (k)                       PLAN J or HIGH DEDUCTIBLE PLAN J

 

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

 

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

[**This high deductible plan pays the same benefits as plan J after one has paid a calendar year $[2000] deductible. Benefits from the high deductible plan J will not begin until out-of-pocket expenses are $[2000]. 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 $[2000] DEDUCTIBLE,**] PLAN PAYS

[IN ADDITION TO [$2000] 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

$[6.6.511(1)(a)]

 

All but $[6.6.511(1)(b)] a day

 

All but $[6.6.511(1)(c)] a day

 

 

 

$0

 

$0

 

 

 

 

 

$[6.6.511(1)(a)]

(Part A deductible)

 

 

$[6.6.511(1)(b)]

a day

 

 

$[6.6.511(1)(c)]

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 $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

 

$0

 

 

Up to $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

 

$0

 

 

 

$0

 

All costs

 

                                        PLAN J or HIGH DEDUCTIBLE PLAN J

 

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

 

 

BLOOD

First 3 pints

Additional amounts

 

$0

100%

 

3 pints

$0

 

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsurance for outpatient drugs and inpatient respite care

 

 

 

 

$0

 

 

 

 

Balance

 

***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 J or HIGH DEDUCTIBLE PLAN J

 

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

 

*Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

[**This high deductible plan pays the same as plan J after one has paid a calendar year $[2000] deductible. Benefits from the high deductible plan J will not begin until out-of-pocket expenses are $[2000]. 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 $[2000] DEDUCTIBLE,**] PLAN PAYS

[IN ADDITION TO $[2000] 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 $[135] of

 Medicare approved

 amounts*

 

Remainder of

 Medicare approved

 Amounts

 

 

 

 

 

 

 

 

 

 

 

 

 

$0

 

 

 

Generally 80%

 

 

 

 

 

 

 

 

 

 

 

 

$[135] (Part B deductible)

 

 

 

Generally 20%

 

 

 

 

 

 

 

 

 

 

 

 

 

$0

 

 

 

$0

Part B Excess Charges (above Medicare approved amounts)

 

$0

 

100%

 

$0

BLOOD

First 3 pints

 

Next $[135] of Medicare

 approved amounts*

Remainder of Medicare

 approved amounts

 

$0

 

 

$0

 

$0

 

 

 

All costs $[135] (Part B deductible)

 

20%

 

$0

 

 

$0

 

$0

CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES

 

 

100%

 

 

$0

 

 

$0

 

                                        PLAN J or HIGH DEDUCTIBLE PLAN J

 

PARTS A & B

 

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2000] DEDUCTIBLE,**] PLAN PAYS

[IN ADDITION TO $[2000] DEDUCTIBLE,**] YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES

Medically necessary skilled care services and medical supplies

 

Durable medical equipment

 First $[135] of Medicare

 approved amounts*

 

 Remainder of Medicare

 approved amounts

 

 

 

 

100%

 

 

 

$0

 

 

80%

 

 

 

 

$0

 

 

$[135] (Part B deductible)

 

 

20%

 

 

 

 

$0

 

 

 

$0

 

 

$0

HOME HEALTH CARE

AT-HOME RECOVERY SERVICES-NOT COVERED BY MEDICARE

Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan

 

 Benefit for each visit

 

 

Number of visits covered (Must        be received within 8 weeks of last Medicare approved visit)

 

Calendar year maximum

 

 

 

 

 

 

 

 

 

 

 

$0

 

 

 

 

$0

 

$0

 

 

 

 

 

 

 

 

 

 

Actual charges to $40 a visit

 

Up to the number of Medicare approved visits, not to exceed 7 each week

 

$1,600

 

 

 

 

 

 

 

 

 

 

 

Balance

 

 

 

 

 

 

 

 

PLAN J or HIGH DEDUCTIBLE PLAN J

 

OTHER BENEFITS - NOT COVERED BY MEDICARE

 

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2000] DEDUCTIBLE,**] PLAN PAYS

[IN ADDITION TO $[2000] 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

***PREVENTIVE MEDICAL CARE BENEFIT-NOT COVERED BY MEDICARE

Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare

 First $120 each

    calendar year

 Additional charges

 

 

 

 

 

 

 

 

 

$0

$0

 

 

 

 

 

 

 

 

 

$120

$0

 

 

 

 

 

 

 

 

 

$0

All costs

 

***Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

 

            (l)                                                    PLAN K

 

*You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[4620] 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

$[6.6.511(1)(a)]

 

 

All but [6.6.511(1)(b)]

a day

 

 

All but $[6.6.511(1)(c)] a day

 

 

 

$0

 

 

$0

 

 

 

 

$[6.6.511(1)(a)]

(50% of Part A deductible)

 

 

$[6.6.511(1)(b)]

a day

 

 

 

$[6.6.511(1)(c)] a day

 

 

100% of Medicare eligible expenses

 

 

$0

 

 

 

 

 

 

$[6.6.511(1)(e)]

 

 

 

$0

 

 

 

$0

 

 

 

$0***

 

 

All costs

 

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

 

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 $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

 

 

$0

 

 

Up to $[6.6.511(1)(h)] a day

 

$0

 

 

 

 

 

 

 

 

 

 

$0

 

 

Up to $[6.6.511(1)(h)]

 

All costs

BLOOD

First 3 pints

Additional amounts

 

$0

100%

 

50%

$0

 

50%

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

Generally, most Medicare eligible expenses for out-patient drugs and inpatient respite care

 

 

 

50% of coinsurance or copayments

 

 

50% of coinsurance or copayments

 

***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 $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

 

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES-

IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT

such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

 

First $[135] of Medicare approved amounts*

 

 

Preventive benefits for Medicare covered services

 

Remainder of Medicare   approved amounts

 

 

 

 

 

 

 

 

 

 

 

 

 

$0

 

Generally 75% or more of Medicare approved amounts

 

 

Generally 80%

 

 

 

 

 

 

 

 

 

 

 

 

 

$0

 

 

Remainder of Medicare approved amounts

 

 

Generally 10%

 

 

 

 

 

 

 

 

 

 

 

 

$[135] (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 [$4620])*

BLOOD

First 3 pints

 

Next $[135] of Medicare

 approved amounts*

 

Remainder of Medicare

 Approved amounts

 

$0

 

 

$0

 

 

Generally 80%

 

50%

 

 

$0

 

 

Generally 10%

 

50%♦

 

$[135] (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 $[4620] 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 $[135] of Medicare approved amounts*****

 

Remainder of Medicare approved amounts

 

 

 

 

100%

 

 

 

$0

 

 

80%

 

 

 

 

$0

 

 

 

$0

 

 

10%

 

 

 

 

$0

 

 

$[135] (Part B deductible)

 

 

10%

 

*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare

 

            (m)                                                  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 $[2310] each calendar year. The amounts that count toward your annual limit are noted with a diamond (♦) 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

$[6.6.511(1)(a)]

 

All but $[6.6.511(1)(b)]

a day

 

All but $[6.6.511(1)(c)]

a day

 

 

 

$0

 

 

$0

 

 

 

 

 

$[6.6.511(1)(f)]

(75% of Part A deductible)

 

 

$[6.6.511(1)(b)]

a day

 

 

$[6.6.511(1)(c)]

a day

 

 

100% of Medicare eligible expenses

 

 

$0

 

 

 

 

 

$[6.6.511(1)(g)] 25% of Part A deductible

 

 

 

$0

 

 

 

$0

 

 

 

$0***

 

 

All costs

 

PLAN L

 

          MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

 

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 $[6.6.511(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

 

$0

 

 

Up to $[6.6.511(1)(i)]

a day

 

$0

 

 

 

 

 

 

 

 

 

$0

 

Up to $[6.6.511](1)(j)]

a day

 

All costs

BLOOD

First 3 pints

Additional amounts

 

$0

100%

 

75%

$0

 

25%

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

Generally, most Medicare eligible expenses for outpatient drugs and inpatient respite care

 

 

 

75% of

coinsurance or copayments

 

 

 

 

25% of coinsurance or copayments

 

***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 $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

 

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES-

IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT

such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

 First $[135] of

 Medicare approved

 amounts****

 

 

Preventive benefits for Medicare covered services

 

Remainder of Medicare approved   amounts

 

 

 

 

 

 

 

 

 

 

 

 

 

$0

 

Generally 75% or more of Medicare approved amounts

 

 

Generally 80%

 

 

 

 

 

 

 

 

 

 

 

 

 

$0

 

Remainder of Medicare approved amounts

 

 

Generally 15%

 

 

 

 

 

 

 

 

 

 

 

 

$[135] (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 [$2310])*

BLOOD

First 3 pints

Next $[135] of Medicare

 approved amounts****

Remainder of Medicare

 Approved amounts

 

$0

 

$0

 

Generally 80%

 

75%

 

$0

 

Generally 15%

 

25%♦

$[135] (Part B deductible)

 

Generally 5%♦

CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES

 

 

100%

 

 

$0

 

 

$0

 

*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[2310] 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 $[135] of Medicare approved amounts*****

 

Remainder of Medicare approved amounts

 

 

 

 

100%

 

 

 

$0

 

 

80%

 

 

 

 

$0

 

 

 

$0

 

 

15%

 

 

 

 

$0

 

 

$[135] (Part B deductible)

 

 

5%

 

*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. 

 

            (3)  The CSI adopts and incorporates by reference the National Association of Insurance Commissioners (NAIC) Model Regulation to Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act, page 651-56 through page 651-106, which sets forth the Medicare payment tables for insurers, and specifically in this rule are Plans A, B, C, D, E, F or High Deductible F, G, H, I, J or High Deductible J, K, L, Medicare Part A - Hospital Services - Per Benefit Period; Plans A, B, C, D, E, F or High Deductible F, G, H, I, J or High Deductible J, K, L, Medicare Part B - Medical Services - Per Calendar Year; Plans A, B, C, D, E, F or High Deductible F, G, H, I, J or High Deductible J, K, L, Medicare Parts A & B; Plans C, D, E, F or High Deductible F, G, H, I, J or High Deductible J, Other Benefits - Not Covered by Medicare; adopted 7/17/09. Copies of the NAIC Model rule containing Plans A - L are available for public inspection at the Office of the Commissioner of Securities and Insurance, Montana State Auditor, Legal Department, 840 Helena Avenue, Helena, Montana 59601, or on the department's web site. Persons obtaining a copy of these forms must pay the cost of providing such copies.

 

            AUTH: 33-1-313, 33-22-904, MCA

            IMP: 33-15-303, 33-22-901, 33-22-902, 33-22-903, 33-22-904, 33-22-905, 33-22-906, 33-22-907, 33-22-908, 33-22-909, 33-22-910, 33-22-911, 33-22-921, 33-22-922, 33-22-923, 33-22-924, MCA

 

6.6.511A SAMPLE FORMS OUTLINING COVERAGE (1) through (2) remain the same.

 

            (a)                                             COVER PAGE

                                      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 "The Medicare Handbook" 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 ARM 6.6.507A(4).]

 

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

 

            (b)                                                     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 $[6.6.511A(1)(a)]

 

All but $[6.6.511A(1)(b)]

a day

 

 

All but $[6.6.511A(1)(c)]

a day

 

 

 

$0

 

 

$0

 

 

 

 

 

 

 

$0

 

$[6.6.511A(b)]

a day

 

 

$[6.6.511A(1)(c)] a day

 

100% of Medicare eligible expenses

 

 

$0

 

 

 

 

 

$[6.6.511A(1)(a)]

(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 amounts

 

 

All but $[6.6.511A(1)(d)]

a day

 

$0

 

 

 

 

 

 

 

 

$0

 

 

 

$0

 

$0