Sec. 3815. (1) An insurer that offers a Medicare supplement policy shall provide to the applicant at the time of application an outline of coverage in written or electronic format and, except for direct response solicitation policies, shall obtain an acknowledgment of receipt of the outline of coverage from the applicant in written or electronic format. The outline of coverage provided to applicants under this section must consist of the following 4 parts: (a) A cover page. (b) Premium information. (c) Disclosure pages. (d) Charts displaying the features of each benefit plan offered by the insurer. (2) Insurers shall comply with any notice requirements of the Medicare prescription drug, improvement, and modernization act of 2003, Public Law 108-173. (3) If an outline of coverage is provided at the time of application and the Medicare supplement policy or certificate is issued on a basis that would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany the policy or certificate when it is delivered and must contain the following statement, in not less than 12-point type, immediately above the company name: NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided on application and the coverage originally applied for has not been issued. NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided on application and the coverage originally applied for has not been issued. (4) An outline of coverage under subsection (1) must be in the language and in a written or electronic format prescribed in this section and in not less than 12-point type. The letter designation of the plan must be shown on the cover page and the plans offered by the insurer must be prominently identified. Premium information must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and method of payment mode must be stated for all plans that are offered to the applicant. All possible premiums for the applicant must be illustrated. The following items must be included in the outline of coverage in the order prescribed below and in substantially the following form, as approved by the director: BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD ON OR AFTER JUNE 1, 2010 BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD ON OR AFTER JUNE 1, 2010 This chart shows the benefits included in each of the standard Medicare supplement plans. Every company 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 must 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 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/G* Basic, Basic, Basic, Basic, Basic, Basic, including including including including including including 100% Part 100% Part 100% Part 100% Part 100% Part 100% Part B coin- B coinsur- B coinsur- B coinsur- B coinsur- B coinsur- surance ance ance ance ance ance Skilled Skilled Skilled Skilled Nursing Nursing Nursing Nursing Facility Facility Facility Facility Coinsur- Coinsur- Coinsur- Coinsur- ance ance ance ance Part A Part A Part A Part A Part A Deductible Deductible Deductible Deductible Deductible Part B Part B Deductible Deductible Part B Part B Excess Excess (100%) (100%) Foreign Foreign Foreign Foreign Travel Travel Travel Travel Emergency Emergency Emergency Emergency C** F|F* ** G/G* Basic, Basic, Basic, Basic, Basic, Basic, including including including including including including 100% Part 100% Part 100% Part 100% Part 100% Part 100% Part B coin- B coinsur- B coinsur- B coinsur- B coinsur- B coinsur- surance ance ance ance ance ance Skilled Skilled Skilled Skilled Nursing Nursing Nursing Nursing Facility Facility Facility Facility Coinsur- Coinsur- Coinsur- Coinsur- ance ance ance ance Part A Part A Part A Part A Part A Deductible Deductible Deductible Deductible Deductible Part B Part B Deductible Deductible Part B Part B Excess Excess (100%) (100%) Foreign Foreign Foreign Foreign Travel Travel Travel Travel Emergency Emergency Emergency Emergency K L M N Hospitalization Hospitalization Basic, Basic, includ- and preventive and preventive including 100% ing 100% Part B care paid at care paid at Part B coinsurance, 100%; other 100%; other coinsurance except up to basic benefits basic benefits $20 copayment paid at 50% paid at 75% for office visit, and up to $50 copay- ment for ER 50% Skilled 75% Skilled Skilled Skilled Nursing Nursing Nursing Nursing Facility Facility Facility Facility Coinsurance Coinsurance Coinsurance Coinsurance 50% Part A 75% Part A 50% Part A Part A Deductible Deductible Deductible Deductible Foreign Foreign Travel Travel Emergency Emergency Out-of-pocket Out-of-pocket limit $5,240; limit $2,620; paid at 100% paid at 100% after limit after limit reached reached Hospitalization Hospitalization Basic, Basic, includ- and preventive and preventive including 100% ing 100% Part B care paid at care paid at Part B coinsurance, 100%; other 100%; other coinsurance except up to basic benefits basic benefits $20 copayment paid at 50% paid at 75% for office visit, and up to $50 copay- ment for ER 50% Skilled 75% Skilled Skilled Skilled Nursing Nursing Nursing Nursing Facility Facility Facility Facility Coinsurance Coinsurance Coinsurance Coinsurance 50% Part A 75% Part A 50% Part A Part A Deductible Deductible Deductible Deductible Foreign Foreign Travel Travel Emergency Emergency Out-of-pocket Out-of-pocket limit $5,240; limit $2,620; paid at 100% paid at 100% after limit after limit reached reached * Plans F and G also have options called high-deductible Plan F and high-deductible Plan G. These high-deductible plans pay the same benefits as Plan F or Plan G, as applicable, after one has paid a calendar year $2,240 deductible. Benefits from high-deductible Plan F or high-deductible Plan G will not begin until out-of-pocket expenses exceed $2,240. Out-of-pocket expenses for these deductibles 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. ** Plan C, Plan F, and high-deductible Plan F are only available to individuals eligible for Medicare before January 1, 2020. PREMIUM INFORMATION PREMIUM INFORMATION We (insert insurer'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 DISCLOSURES Use this outline to compare benefits and premiums among policies, certificates, and contracts. This outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates before June 1, 2010 have different benefits and premiums. Plans E, H, I, and J are no longer available for sale. (This sentence must not appear after June 1, 2011.) READ YOUR POLICY VERY CAREFULLY READ YOUR POLICY VERY CAREFULLY 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 RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to (insert insurer'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 POLICY REPLACEMENT 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 NOTICE This policy may not fully cover all of your medical costs. [For agent issued policies] Neither (insert insurer's name) nor its agents are connected with Medicare. [For direct response issued policies] (Insert insurer'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 COMPLETE ANSWERS ARE VERY IMPORTANT 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 offered by the insurer a chart showing the services, Medicare payments, plan payments, and insured payments using the same language, in the same order, and using uniform layout and format as shown in the charts that follow. An insurer may use additional benefit plan designations on these charts under section 3809(1)(k). Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the director. The insurer issuing the policy shall change the dollar amounts each year to reflect current figures. No more than 4 plans may be shown on 1 chart.] Charts for each plan are as follows: PLAN A MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD 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 All but $0 $1,340 $1,340 (Part A Deductible) 61st thru 90th day All but $335 $0 $335 a day a day 91st day and after: —While using 60 lifetime reserve days All but $670 $0 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days $0 100% of $0** Medicare Eligible Expenses —Beyond the Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but $0 Up to $167.50 a day $167.50 a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet All but very $0 Medicare's requirements limited Medicare including a doctor's copayment/ copayment/ certification of terminal coinsurance coinsurance illness for outpatient drugs and inpatient respite care SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,340 $1,340 (Part A Deductible) 61st thru 90th day All but $335 $335 a day a day 91st day and after: —While using 60 lifetime reserve days All but $670 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days 100% of $0** Medicare Eligible Expenses —Beyond the Additional 365 days All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but Up to $167.50 a day $167.50 a day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet All but very Medicare's requirements limited Medicare including a doctor's copayment/ copayment/ certification of terminal coinsurance coinsurance illness for outpatient drugs and inpatient respite care **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 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 PLAN A MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR *Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $0 $0 $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All Costs BLOOD First 3 pints $0 All Costs $0 Next $183 of Medicare $0 $0 $183 Approved Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES— Tests for diagnostic services 100% $0 $0 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% Part B Excess Charges (Above Medicare Approved Amounts) All Costs BLOOD First 3 pints All Costs Next $183 of Medicare $183 Approved Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% CLINICAL LABORATORY SERVICES— Tests for diagnostic services 100% PARTS A & B PARTS A & B HOME HEALTH CARE Medicare Approved Services —Medically necessary skilled care services and medical supplies 100% $0 $0 —Durable medical equipment First $183 of Medicare $0 $0 $183 Approved Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 HOME HEALTH CARE Medicare Approved Services —Medically necessary skilled care services and medical supplies 100% —Durable medical equipment First $183 of Medicare $183 Approved Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% PLAN B MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD 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 All but $1,340 $0 $1,340 (Part A Deductible) 61st thru 90th day All but $335 $0 $335 a day a day 91st day and after —While using 60 lifetime reserve days All but $670 $0 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days $0 100% of $0** Medicare Eligible Expenses —Beyond the Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but $0 Up to $167.50 a day $167.50 a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE All but very limited Medicare $0 copayment/ copayment/ coinsurance coinsurance You must meet for outpatient Medicare's requirements, drugs and including a doctor's inpatient certification of respite care terminal illness SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,340 $1,340 (Part A Deductible) 61st thru 90th day All but $335 $335 a day a day 91st day and after —While using 60 lifetime reserve days All but $670 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days 100% of $0** Medicare Eligible Expenses —Beyond the Additional 365 days All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but Up to $167.50 a day $167.50 a day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE All but very limited Medicare copayment/ copayment/ coinsurance coinsurance You must meet for outpatient Medicare's requirements, drugs and including a doctor's inpatient certification of respite care terminal illness **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN B MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR PLAN B MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR *Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $0 $0 $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All Costs BLOOD First 3 pints $0 All Costs $0 Next $183 of Medicare Approved Amounts* $0 $0 $183 (Part B Remainder of Medicare Deductible) Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES— Tests for diagnostic services 100% $0 $0 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% Part B Excess Charges (Above Medicare Approved Amounts) All Costs BLOOD First 3 pints All Costs Next $183 of Medicare Approved Amounts* $183 (Part B Remainder of Medicare Deductible) Approved Amounts 80% 20% CLINICAL LABORATORY SERVICES— Tests for diagnostic services 100% PARTS A & B PARTS A & B HOME HEALTH CARE Medicare Approved Services —Medically necessary skilled care services and medical supplies 100% $0 $0 —Durable medical equipment First $183 of Medicare Approved Amounts* $0 $0 $183 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 HOME HEALTH CARE Medicare Approved Services —Medically necessary skilled care services and medical supplies 100% —Durable medical equipment First $183 of Medicare Approved Amounts* $183 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% PLAN C MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD 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 All but $1,340 $0 $1,340 (Part A Deductible) 61st thru 90th day All but $335 $0 $335 a day a day 91st day and after —While using 60 lifetime reserve days All but $670 $0 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days $0 100% of $0** Medicare Eligible Expenses —Beyond the Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but Up to $0 $167.50 a day $167.50 a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE All but very $0 limited Medicare copayment/ copayment/ coinsurance coinsurance You must meet for outpatient Medicare's requirements, drugs and including a doctor's inpatient certification of respite care terminal illness SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,340 $1,340 (Part A Deductible) 61st thru 90th day All but $335 $335 a day a day 91st day and after —While using 60 lifetime reserve days All but $670 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days 100% of $0** Medicare Eligible Expenses —Beyond the Additional 365 days All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but Up to $167.50 a day $167.50 a day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE All but very limited Medicare copayment/ copayment/ coinsurance coinsurance You must meet for outpatient Medicare's requirements, drugs and including a doctor's inpatient certification of respite care terminal illness **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN C MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR PLAN C MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR *Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $0 $183 $0 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All Costs BLOOD First 3 pints $0 All Costs $0 Next $183 of Medicare Approved Amounts* $0 $183 $0 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES— Tests for diagnostic services 100% $0 $0 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% Part B Excess Charges (Above Medicare Approved Amounts) All Costs BLOOD First 3 pints All Costs Next $183 of Medicare Approved Amounts* $183 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% CLINICAL LABORATORY SERVICES— Tests for diagnostic services 100% PARTS A & B PARTS A & B HOME HEALTH CARE Medicare Approved Services —Medically necessary skilled care services and medical supplies 100% $0 $0 —Durable medical equipment First $183 of Medicare Approved $0 $183 $0 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 HOME HEALTH CARE Medicare Approved Services —Medically necessary skilled care services and medical supplies 100% —Durable medical equipment First $183 of Medicare Approved $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% OTHER BENEFITS—NOT COVERED BY MEDICARE OTHER BENEFITS—NOT COVERED BY MEDICARE FOREIGN TRAVEL— Not covered by Medicare Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a 20% and lifetime amounts maximum over the benefit $50,000 of $50,000 lifetime maximum 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 $250 Remainder of charges 80% to a 20% and lifetime amounts maximum over the benefit $50,000 of $50,000 lifetime maximum PLAN D MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD PLAN D MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,340 $0 $1,340 (Part A Deductible) 61st thru 90th day All but $335 $0 $335 a day a day 91st day and after —While using 60 lifetime reserve days All but $670 $0 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days $0 100% of $0** Medicare Eligible Expenses —Beyond the Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but Up to $0 $167.50 a day $167.50 a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE All but very Medicare $0 limited copayment/ copayment/ coinsurance coinsurance You must meet for outpatient Medicare's requirements, drugs and including a doctor's inpatient certification of respite care terminal illness SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,340 $1,340 (Part A Deductible) 61st thru 90th day All but $335 $335 a day a day 91st day and after —While using 60 lifetime reserve days All but $670 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days 100% of $0** Medicare Eligible Expenses —Beyond the Additional 365 days All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but Up to $167.50 a day $167.50 a day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE All but very Medicare limited copayment/ copayment/ coinsurance coinsurance You must meet for outpatient Medicare's requirements, drugs and including a doctor's inpatient certification of respite care terminal illness **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 PLAN D MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR *Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $0 $0 $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All Costs BLOOD First 3 pints $0 All Costs $0 Next $183 of Medicare Approved Amounts* $0 $0 $183 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES— Tests for diagnostic services 100% $0 $0 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% Part B Excess Charges (Above Medicare Approved Amounts) All Costs BLOOD First 3 pints All Costs Next $183 of Medicare Approved Amounts* $183 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% CLINICAL LABORATORY SERVICES— Tests for diagnostic services 100% PARTS A & B PARTS A & B HOME HEALTH CARE Medicare Approved Services —Medically necessary skilled care services and medical supplies 100% $0 $0 —Durable medical equipment First $183 of Medicare Approved $0 $0 $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 HOME HEALTH CARE Medicare Approved Services —Medically necessary skilled care services and medical supplies 100% —Durable medical equipment First $183 of Medicare Approved $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% OTHER BENEFITS—NOT COVERED BY MEDICARE OTHER BENEFITS—NOT COVERED BY MEDICARE FOREIGN TRAVEL— Not covered by Medicare Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a 20% and lifetime amounts maximum over the benefit $50,000 of $50,000 lifetime maximum 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 $250 Remainder of charges 80% to a 20% and lifetime amounts maximum over the benefit $50,000 of $50,000 lifetime maximum PLAN F OR HIGH-DEDUCTIBLE PLAN F MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD 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 you have paid a calendar year $2,240 deductible. Benefits from the high-deductible plan F will not begin until out-of-pocket expenses are $2,240. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes Medicare deductibles for part A and part B, but does not include the plan's separate foreign travel emergency deductible. SERVICES MEDICARE AFTER YOU IN ADDITION PAYS PAY TO $2,240 $2,240 DEDUCTIBLE**, DEDUCTIBLE**, PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,340 $0 $1,340 (Part A Deductible) 61st thru 90th day All but $335 $0 $335 a day a day 91st day and after —While using 60 lifetime reserve days All but $670 $0 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days $0 100% of $0*** Medicare Eligible Expenses —Beyond the Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but Up to $0 $167.50 a day $167.50 a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE All but very Medicare $0 limited copayment/ copayment/ coinsurance coinsurance You must for meet Medicare's outpatient requirements, including drugs and a doctor's certification inpatient of terminal illness respite care SERVICES MEDICARE AFTER YOU IN ADDITION PAYS PAY $2,240 $2,240 DEDUCTIBLE**, DEDUCTIBLE**, PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,340 $1,340 (Part A Deductible) 61st thru 90th day All but $335 $335 a day a day 91st day and after —While using 60 lifetime reserve days All but $670 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days 100% of $0*** Medicare Eligible Expenses —Beyond the Additional 365 days All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but Up to $167.50 a day $167.50 a day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE All but very Medicare limited copayment/ copayment/ coinsurance coinsurance You must for meet Medicare's outpatient requirements, including drugs and a doctor's certification inpatient of terminal illness respite care ***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 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 MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR PLAN F MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR *Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. **This high-deductible plan pays the same benefits as plan F after you have paid a calendar year $2,240 deductible. Benefits from the high-deductible plan F will not begin until out-of-pocket expenses are $2,240. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes Medicare deductibles for part A and part B, but does not include the plan's separate foreign travel emergency deductible. SERVICES MEDICARE AFTER YOU IN ADDITION PAYS PAY TO $2,240 $2,240 DEDUCTIBLE**, DEDUCTIBLE**, PLAN PAYS YOU PAY MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $0 $183 $0 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 100% $0 BLOOD First 3 pints $0 All Costs $0 Next $183 of Medicare Approved $0 $183 $0 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES— Tests for diagnostic services 100% $0 $0 SERVICES MEDICARE AFTER YOU IN ADDITION PAYS PAY $2,240 $2,240 DEDUCTIBLE**, DEDUCTIBLE**, PLAN PAYS YOU PAY MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% Part B Excess Charges (Above Medicare Approved Amounts) 100% BLOOD First 3 pints All Costs Next $183 of Medicare Approved $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% CLINICAL LABORATORY SERVICES— Tests for diagnostic services 100% PARTS A & B PARTS A & B HOME HEALTH CARE Medicare Approved Services —Medically necessary skilled care services and medical supplies 100% $0 $0 —Durable medical equipment First $183 of Medicare Approved $0 $183 $0 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 HOME HEALTH CARE Medicare Approved Services —Medically necessary skilled care services and medical supplies 100% —Durable medical equipment First $183 of Medicare Approved $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% OTHER BENEFITS—NOT COVERED BY MEDICARE OTHER BENEFITS—NOT COVERED BY MEDICARE FOREIGN TRAVEL— Not covered by Medicare Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a 20% and lifetime amounts maximum over the benefit $50,000 of $50,000 lifetime maximum 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 $250 Remainder of charges 80% to a 20% and lifetime amounts maximum over the benefit $50,000 of $50,000 lifetime maximum PLAN G OR HIGH-DEDUCTIBLE PLAN G MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD PLAN G OR HIGH-DEDUCTIBLE PLAN G MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. ** This high-deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,240 deductible. Benefits from the high-deductible Plan G will not begin until out-of-pocket expenses are $2,240. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible. SERVICES MEDICARE PAYS AFTER YOU IN ADDITION PAY TO $2,240 $2,240 DEDUCTIBLE**, DEDUCTIBLE**, PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,340 $0 $1,340 (Part A Deductible) 61st thru 90th day All but $335 $0 $335 a day a day 91st day and after —While using 60 lifetime reserve days All but $670 $0 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days $0 100% of $0*** Medicare Eligible Expenses —Beyond the Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but Up to $0 $167.50 a day $167.50 a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE All but very $0 limited Medicare copayment/ copayment/ coinsurance coinsurance You must meet for outpatient Medicare's requirements, drugs and including a doctor's inpatient certification of respite care terminal illness SERVICES MEDICARE PAYS AFTER YOU IN ADDITION PAY $2,240 $2,240 DEDUCTIBLE**, DEDUCTIBLE**, PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,340 $1,340 (Part A Deductible) 61st thru 90th day All but $335 $335 a day a day 91st day and after —While using 60 lifetime reserve days All but $670 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days 100% of $0*** Medicare Eligible Expenses —Beyond the Additional 365 days All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but Up to $167.50 a day $167.50 a day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE All but very limited Medicare copayment/ copayment/ coinsurance coinsurance You must meet for outpatient Medicare's requirements, drugs and including a doctor's inpatient certification of respite care terminal illness ***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN G OR HIGH-DEDUCTIBLE PLAN G MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR PLAN G OR HIGH-DEDUCTIBLE PLAN G MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR *Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. ** This high-deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,240 deductible. Benefits from the high-deductible Plan G will not begin until out-of-pocket expenses are $2,240. Out-of-pocket expenses for this deductible include expenses for the Medicare part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible. SERVICES MEDICARE PAYS AFTER YOU IN ADDITION PAY TO $2,240 $2,240 DEDUCTIBLE**, DEDUCTIBLE**, PLAN PAYS YOU PAY MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $0 $0 $163 Amounts* (Unless Part B Deductible has been met) Remainder of Medicare Approved Amounts 80% 20% $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 100% 0% BLOOD First 3 pints $0 All Costs $0 Next $183 of Medicare Approved $0 $0 $183 Amounts* (Unless Part B Deductible has been met) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES— Tests for diagnostic services 100% $0 $0 SERVICES MEDICARE PAYS AFTER YOU IN ADDITION PAY $2,240 $2,240 DEDUCTIBLE**, DEDUCTIBLE**, PLAN PAYS YOU PAY MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $163 Amounts* (Unless Part B Deductible has been met) Remainder of Medicare Approved Amounts 80% 20% Part B Excess Charges (Above Medicare Approved Amounts) 100% BLOOD First 3 pints All Costs Next $183 of Medicare Approved $183 Amounts* (Unless Part B Deductible has been met) Remainder of Medicare Approved Amounts 80% 20% CLINICAL LABORATORY SERVICES— Tests for diagnostic services 100% PARTS A & B PARTS A & B HOME HEALTH CARE Medicare Approved Services —Medically necessary skilled care services and medical supplies 100% $0 $0 —Durable medical equipment First $183 of Medicare Approved $0 $0 $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 HOME HEALTH CARE Medicare Approved Services —Medically necessary skilled care services and medical supplies 100% —Durable medical equipment First $183 of Medicare Approved $183 Amounts* (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% OTHER BENEFITS—NOT COVERED BY MEDICARE OTHER BENEFITS—NOT COVERED BY MEDICARE FOREIGN TRAVEL— Not covered by Medicare Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a 20% and lifetime amounts maximum over the benefit $50,000 of $50,000 lifetime maximum 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 $250 Remainder of charges 80% to a 20% and lifetime amounts maximum over the benefit $50,000 of $50,000 lifetime maximum PLAN K PLAN K *You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $5,240 each calendar year. The amounts that count toward your annual limit are noted with diamonds 1 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. PLAN K MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD PLAN K 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 All but $670 $670 $1,340 (50% (50% of of Part A Part A Deducti- Deductible) 1 ble) 61st thru 90th day All but $335 $0 $335 a day a day 91st day and after: —While using 60 lifetime reserve days All but $670 $0 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days $0 100% of $0*** Medicare Eligible Expenses —Beyond the Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY CARE** You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but Up to Up to $167.50 a $83.75 $83.75 day a day a day 1 101st day and after $0 $0 All costs BLOOD First 3 pints $0 50% 50% 1 Additional amounts 100% $0 $0 HOSPICE CARE 50% of 50% of copayment/ Medicare coinsur- copayment/ ance coinsurance 1 You must meet Medicare's requirements, including a doctor's certification of terminal illness All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $670 $670 $1,340 (50% (50% of of Part A Part A Deducti- Deductible) 1 ble) 61st thru 90th day All but $335 $335 a day a day 91st day and after: —While using 60 lifetime reserve days All but $670 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days 100% of $0*** Medicare Eligible Expenses —Beyond the Additional 365 days All Costs SKILLED NURSING FACILITY CARE** You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but Up to Up to $167.50 a $83.75 $83.75 day a day a day 1 101st day and after All costs BLOOD First 3 pints 50% 50% 1 Additional amounts 100% HOSPICE CARE 50% of 50% of copayment/ Medicare coinsur- copayment/ ance coinsurance 1 You must meet Medicare's requirements, including a doctor's certification of terminal illness All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care ***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 PLAN K MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR ****Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $0 $0 $183 Amounts**** (Part B Deductible) **** 1 Preventive Benefits for Generally 75% Remainder All costs Medicare covered or more of of Medi- above Medi- services Medicare ap- care care proved amounts approved approved amounts amounts Remainder of Medicare Generally 80% Generally Generally Approved Amounts 10% 10% 1 Part B Excess Charges $0 $0 All costs (Above Medicare (and they do Approved Amounts) not count toward annual out- of-pocket limit of $5,240)* BLOOD First 3 pints $0 50% 50% 1 Next $183 of Medicare Approved $0 $0 $183 Amounts**** (Part B Deductible) **** 1 Remainder of Medicare Generally 80% Generally Generally Approved Amounts 10% 10% 1 CLINICAL LABORATORY SERVICES—Tests for diagnostic services 100% $0 $0 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $183 Amounts**** (Part B Deductible) **** 1 Preventive Benefits for Generally 75% Remainder All costs Medicare covered or more of of Medi- above Medi- services Medicare ap- care care proved amounts approved approved amounts amounts Remainder of Medicare Generally 80% Generally Generally Approved Amounts 10% 10% 1 Part B Excess Charges All costs (Above Medicare (and they do Approved Amounts) not count toward annual out- of-pocket limit of $5,240)* BLOOD First 3 pints 50% 50% 1 Next $183 of Medicare Approved $183 Amounts**** (Part B Deductible) **** 1 Remainder of Medicare Generally 80% Generally Generally Approved Amounts 10% 10% 1 CLINICAL LABORATORY SERVICES—Tests for diagnostic services 100% *This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $5,240 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. PARTS A & B PARTS A & B HOME HEALTH CARE Medicare Approved Services —Medically necessary skilled care services and medical supplies 100% $0 $0 —Durable medical equipment First $183 of Medicare Approved $0 $0 $183 Amounts***** (Part B Deductible)1 Remainder of Medicare Approved Amounts 80% 10% 10% 1 HOME HEALTH CARE Medicare Approved Services —Medically necessary skilled care services and medical supplies 100% —Durable medical equipment First $183 of Medicare Approved $183 Amounts***** (Part B Deductible)1 Remainder of Medicare Approved Amounts 80% 10% 10% 1 *****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. PLAN L PLAN L *You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2,620 each calendar year. The amounts that count toward your annual limit are noted with diamonds 1 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. PLAN L MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD PLAN L 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 All but $1,005 $335 $1,340 (75% of (25% of Part A Part A Deducti- Deductible) 1 ble) 61st thru 90th day All but $335 $0 $335 a day a day 91st day and after: —While using 60 lifetime reserve days All but $670 $0 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days $0 100% of $0*** Medicare Eligible Expenses —Beyond the Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY CARE** You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but Up to Up to $167.50 a $125.63 $41.88 day a day a day 1 101st day and after $0 $0 All costs BLOOD First 3 pints $0 75% 25% 1 Additional amounts 100% $0 $0 HOSPICE CARE 75% of 25% of copayment/ copayment/ coinsur- coinsurance 1 ance You must meet Medicare's requirements, including a doctor's certification of terminal All illness but very limited copay- ment/coinsur- ance for outpatient drugs and inpatient respite care SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,005 $335 $1,340 (75% of (25% of Part A Part A Deducti- Deductible) 1 ble) 61st thru 90th day All but $335 $335 a day a day 91st day and after: —While using 60 lifetime reserve days All but $670 $670 a day a day —Once lifetime reserve days are used: —Additional 365 days 100% of $0*** Medicare Eligible Expenses —Beyond the Additional 365 days All Costs SKILLED NURSING FACILITY CARE** You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but Up to Up to $167.50 a $125.63 $41.88 day a day a day 1 101st day and after All costs BLOOD First 3 pints 75% 25% 1 Additional amounts 100% HOSPICE CARE 75% of 25% of copayment/ copayment/ coinsur- coinsurance 1 ance You must meet Medicare's requirements, including a doctor's certification of terminal All illness but very limited copay- ment/coinsur- ance for outpatient drugs and inpatient respite care ***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 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 PLAN L MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR ****Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $0 $0 $183 Amounts**** (Part B Deducti- ble)**** 1 Preventive Benefits for Generally 75% Remainder All costs Medicare covered or more of of Medi- above Medi- services Medicare care care approved approved approved amounts amounts amounts Remainder of Medicare Generally Generally Generally Approved Amounts 80% 15% 5% 1 Part B Excess Charges $0 $0 All costs (Above Medicare (and they do Approved Amounts) not count toward annual out- of-pocket limit of $2,620)* BLOOD First 3 pints $0 75% 25% 1 Next $183 of Medicare Approved $0 $0 $183 Amounts**** (Part B Deductible) 1 Remainder of Medicare Generally Generally Generally Approved Amounts 80% 15% 5% 1 CLINICAL LABORATORY SERVICES—Tests for diagnostic services 100% $0 $0 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* MEDICAL EXPENSES— In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved $183 Amounts**** (Part B De
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