(1) The following amounts, as published in the Federal Register, for services furnished in the current calendar year under medicare's hospital insurance program (medicare part A) , must apply to the charts for plans A through L in (2) (b) through (m) . In each chart, the rule cited in brackets as ARM [ 6.6.511 (1) (a) ], [ 6.6.511 (1) (b) ], [ 6.6.511 (1) (c) ], [ 6.6.511 (1) (d) ], [ 6.6.511 (1) (e) ], [ 6.6.511 (1) (f) ], [ 6.6.511 (1) (g) ], [ 6.6.511 (1) (h) ], [ 6.6.511 (1) (i) ], or [ 6.6.511 (1) (j) ], represents the dollar amount specified in the cited rule subsection. The issuer must replace each bracket and rule cite with the correct dollar amount contained in the cited rule subsection when the issuer prints the charts:
(a) inpatient hospital deductible = $912.00;
(b) daily coinsurance amount for the 61st through 90th days of hospitalization in a benefit period = $228.00;
(c) daily coinsurance amount for lifetime reserve days = $456.00;
(d) daily coinsurance amount for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period = $114.00;
(e) 50% of inpatient hospital deductible = $456.00;
(f) 75% of inpatient hospital deductible = $684.00;
(g) 25% of inpatient hospital deductible = $228.00;
(h) 50% of daily coinsurance amount for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period = $57.00;
(i) 75% of daily coinsurance amount for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period = $85.50;
(j) 25% of daily coinsurance amount for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period = $28.50.
(2) The following are sample forms of the outline of coverage for medicare supplement policies:
(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.
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 day
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
|
|
Continued on next page
|
| 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.
*Once you have been billed $[100] 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.
MEDICARE (PART B) - MEDICAL SERVICES - PER 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 $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
Generally 80%
|
$0
Generally 20%
|
$[100] (Part B deductible)
$0
|
|
Part B Excess Charges
(Above Medicare approved amounts)
|
$0
|
$0
|
All costs
|
|
BLOOD
First 3 pints
Next $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
$0
80%
|
All costs
$0
20%
|
$0
$[100] (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 $[100] of Medicare approved amounts*
Remainder of Medicare
approved amounts
|
100%
$0
80%
|
$0
$0
20%
|
$0
$[100] (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 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 B
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
*Once you have been billed $[100] 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 $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
Generally 80%
|
$0
Generally 20%
|
$[100] (Part B deductible)
$0
|
|
Part B Excess Charges
(Above Medicare approved amounts)
|
$0
|
$0
|
All costs
|
|
BLOOD
First 3 pints
Next $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
$0
80%
|
All costs
$0
20%
|
$0
$[100] (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 $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
100%
$0
80%
|
$0
$0
20%
|
$0
$[100] (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
|
|
Continued on next page
|
**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 $[100] 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 $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
Generally 80%
|
$[100] (Part B deductible)
Generally 20%
|
$0
$0
|
|
Part B Excess Charges
(Above Medicare approved amounts)
|
$0
|
$0
|
All costs
|
|
BLOOD
First 3 pints
Next $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
$0
80%
|
All costs
$[100] (Part B deductible)
20%
|
$0
$0
$0
|
|
CLINICAL LABORATORY
SERVICES -- TESTS
FOR DIAGNOSTIC SERVICES
|
100%
|
$0
|
$0
|
|
Continued on next page
|
PARTS A & B
|
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
---Medically necessary skilled care services and medical supplies
---Durable medical equipment
First $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
100%
$0
80%
|
$0
$[100] (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 $[100] 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 $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
Generally 80%
|
$0
Generally 20%
|
$[100] (Part B deductible)
$0
|
|
Part B Excess Charges
(Above Medicare approved amounts)
|
$0
|
$0
|
All costs
|
|
BLOOD
First 3 pints
Next $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
$0
80%
|
All costs
$0
20%
|
$0
$[100] (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 $[100] 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
$[100] (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 miscel-lanous 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 $[100] 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 $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
Generally 80%
|
$0
Generally 20%
|
$[100] (Part B deductible)
$0
|
|
Part B Excess Charges
(Above Medicare approved amounts)
|
$0
|
$0
|
All costs
|
|
BLOOD
First 3 pints
Next $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
$0
80%
|
All costs
$0
20%
|
$0
$[100] (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 $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
100%
$0
80%
|
$0
$0
20%
|
$0
$[100] (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 $[1730] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $[1730]. 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
$[1730] DEDUCTIBLE, **] PLAN PAYS
|
[IN ADDITION TO $[1730] 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 (a) (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
|
|
Continued on next page
|
|
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 $[100] 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 $[1730] deductible. Benefits from the high deductible plan F will begin until out-of-pocket expenses are $[1730]. 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 $[1730] DEDUCTIBLE,**] PLAN PAYS
|
[IN ADDITION TO $[1730] 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 $[100] of
Medicare approved
amounts*
Remainder of
Medicare approved
amounts
|
$0
Generally 80%
|
$[100] (Part B deductible)
Generally 20%
|
$0
$0
|
|
Part B excess charges
(Above Medicare approved amounts)
|
$0
|
100%
|
$0
|
|
BLOOD
First 3 pints
Next $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
$0
80%
|
All costs
$[100] (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 $[1730] DEDUCTIBLE,**] PLAN PAYS
|
[IN ADDITION TO $[1730] DEDUCTIBLE,**] YOU PAY
|
|
HOME HEALTH CARE MEDICARE APPROVED SERVICES
---Medically necessary
skilled care services
and medical supplies
---Durable medical
equipment
First $[100] of
Medicare approved
amounts*
Remainder of Medicare approved amounts
|
100%
$0
80%
|
$0
$[100] (Part B deductible)
20%
|
$0
$0
$0
|
OTHER BENEFITS - NOT COVERED BY MEDICARE
|
SERVICES
|
MEDICARE PAYS
|
[AFTER YOU PAY $[1730] DEDUCTIBLE,**] PLAN PAYS
|
[IN ADDITION TO $[1730] 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 (a) (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 $[100] 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 $[100] of
Medicare approved
amounts*
Remainder of
Medicare approved
amounts
|
$0
Generally 80%
|
$0
Generally 20%
|
$[100] (Part B deductible)
$0
|
|
Part B Excess Charges
(Above Medicare approved amounts)
|
$0
|
100%
|
$0
|
|
BLOOD
First 3 pints
Next $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
$0
80%
|
All costs
$0
20%
|
$0
$[100] (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 $[100] 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
$[100] (Part B deductible)
$0
Balance
|
OTHER BENEFITS - NOT COVERED BY MEDICARE
| SERVICES
|
MEDICARE PAYS
|
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
|
|
Continued on next page
|
|
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 $[100] 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 $[100] of
Medicare approved
amounts*
Remainder of
Medicare approved
amounts
|
$0
Generally 80%
|
$0
Generally 20%
|
$[100] (Part B deductible)
$0
|
|
Part B Excess Charges
(Above Medicare approved amounts)
|
$0
|
0%
|
All costs
|
|
BLOOD
First 3 pints
Next $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
$0
80%
|
All costs
$0
20%
|
$0
$[100] (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 $[100] of Medicare approved amounts*
Remainder of Medicare approved amounts
|
100%
$0
80%
|
$0
$0
20%
|
$0
$[100] (Part B deductible)
$0
|
OTHER BENEFITS - NOT COVERED BY MEDICARE
|
SERVICES
|
MEDICARE PAYS
|
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
|
| BLOOD
First 3 pints
Additional amounts
|
$0
100%
|
3 pints
$0
|
$0
$0
|
|
Continued on next page
|
|
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 $[100] 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 $[100] of
Medicare approved
amounts*
Remainder of
Medicare approved
amounts
|
$0
Generally 80%
|
$0
Generally 20%
|
$[100] (Part B deductible)
$0
|
|
Part B Excess Charges
(Above Medicare approved amounts)
|
$0
|
100%
|
$0
|
|
BLOOD
First 3 pints
Next $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
$0
80%
|
All costs
$0
20%
|
$0
$[100] (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 $[100] 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
$[100] (Part B deductible)
$0
Balance
|
OTHER BENEFITS - NOT COVERED BY MEDICARE
|
SERVICES
|
MEDICARE PAYS
|
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 $[1730] deductible. Benefits from the high deductible plan J will not begin until out-of-pocket expenses are $[1730]. 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 $[1730] DEDUCTIBLE,**] PLAN PAYS |
[IN ADDITION TO [$1730] 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
|
|
Continued on next page
|
|
SERVICES
|
MEDICARE PAYS
|
[AFTER YOU PAY $[1730] DEDUCTIBLE,**] PLAN PAYS
|
[IN ADDITION TO $[1730] DEDUCTIBLE,**] YOU PAY
|
|
SKILLED NURSING
FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days
21st thru 100th day
101st day and after
|
All approved amounts
All but $[ 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 J or HIGH DEDUCTIBLE PLAN J
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
*Once you have been billed $[100] 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 $[1730] deductible. Benefits from the high deductible plan J will not begin until out-of-pocket expenses are $[1730]. 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 $[1730] DEDUCTIBLE,**] PLAN PAYS
|
[IN ADDITION TO $[1730] 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 $[100] of
Medicare approved
amounts*
Remainder of
Medicare approved
amounts
|
$0
Generally 80%
|
$[100] (Part B deductible)
Generally 20%
|
$0
$0
|
|
Part B Excess Charges (above Medicare approved amounts)
|
$0
|
100%
|
$0
|
|
BLOOD
First 3 pints
Next $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
$0
$0
|
All costs $[100] (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 $[1730] DEDUCTIBLE,**] PLAN PAYS
|
[IN ADDITION TO $[1730] DEDUCTIBLE,**] YOU PAY
|
|
HOME HEALTH CARE MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies
Durable medical equipment
First $[100] of Medicare approved amounts*
Remainder of Medicare
approved amounts
|
100%
$0
80%
|
$0
$[100] (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 $[1730] DEDUCTIBLE,**] PLAN PAYS
|
[IN ADDITION TO $[1730] 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 $[4000] 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
|
|
Continued on next page
|
|
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
|
All but very limited coinsurance for outpatient 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 $[100] 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 $[100] 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%
|
$[100] (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 [$4000]) *
|
|
BLOOD
First 3 pints
Next $[100] of Medicare
approved amounts*
Remainder of Medicare
approved amounts
|
$0
$0
Generally 80%
|
50%
$0
Generally 10%
|
50%
$[100] (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 $[4000] 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 $[100] of Medicare approved amounts*****
Remainder of Medicare approved amounts
|
100%
$0
80%
|
$0
$0
10%
|
$0
$[100] (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 $[2000] 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
|
|
Continued on next page
|
|
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) ]
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 $[100] 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 $[100] 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%
|
$[100] (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 [$2000]) *
|
|
BLOOD
First 3 pints
Next $[100] of Medicare
approved amounts****
Remainder of Medicare
approved amounts
|
$0
$0
Generally 80%
|
75%
$0
Generally 15%
|
25%
$[100] (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 $[2000] 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 $[100] of Medicare approved amounts*****
Remainder of Medicare approved amounts
|
100%
$0
80%
|
$0
$0
15%
|
$0
$[100] (Part B deductible)
5%
|
*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
