NEW YORK STATE
INSURANCE DEPARTMENT

TWENTY-FOURTH AMENDMENT TO REGULATION 62
(11 NYCRR 52)

MINIMUM STANDARDS FOR THE FORM, CONTENT AND SALE OF HEALTH
INSURANCE, INCLUDING STANDARDS OF FULL AND FAIR DISCLOSURE

        I, NEIL D. LEVIN, Superintendent of Insurance of the State of New York, pursuant to the authority granted by the federal Social Security Act (42 U.S.C. section 1395ss) and by Sections 201, 301, 3201, 3216, 3217, 3218, 3221, 3231, 3232, 4235, 4237 and Article 43 of the Insurance Law, do hereby promulgate the following Twenty-fourth amendment to Part 52 of Title 11 of the Official Compilation of Codes, Rules and Regulations of the State of New York (Regulation No. 62), to take effect upon publication in the State Register.

(NEW MATTER UNDERLINED; DELETED MATTER IN BRACKETS)

        Section 52.2 is hereby amended by adding a new subdivision (q) and renumbering existing subdivisions (q) through (w) as (r) through (x) to read as follows:

        (q) Medicare+Choice plan means a plan of coverage for health benefits under Part C of Title XVIII of the Social Security Act as added by the Balanced Budget Act of 1997 (Public Law 105-33) as then constituted or later amended (42 U.S.C. section 1395w-21 et seq.).

        Section 52.11(b) is hereby amended to read as follows:

        (b) Medicare supplement insurance shall not include:

            (1) a policy or certificate which provides continued coverage for persons beyond age 65;
            (2) a policy or certificate issued pursuant to a contract under section 1876 of the Federal Social Security Act (42 U.S.C. section 1395 et seq.);
            (3) a policy or certificate issued under a demonstration project specified in 42 U.S.C. section 1395ss(g)(1); [or]
            (4) a policy or contract offered through one or more employers or labor organizations, or through the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations[.]; or
            (5) a Medicare+Choice plan under Part C of Medicare (42 U.S.C. section 1395w-21 et seq.).

        Section 52.17(a) is hereby amended by adding a new paragraph (34) to read as follows:

        (34) At the time of an event described in 42 U.S.C. section 1395ss(s)(3)(B) because of which an individual loses coverage or benefits due to the termination of the policy or the individual ceases enrollment under the policy, the insurer of the policy from which termination or disenrollment  occurs shall provide the individual with written notification of his or her rights and of the obligations of issuers of Medicare supplement insurance policies under sections 52.22(b)(3) and (k) of this Part. If an individual loses coverage or benefits due to termination of the policy, such notification must be provided contemporaneously with the notification of termination. If an individual ceases enrollment under the policy, such notification must be provided within ten working days of the insurer receiving notification of disenrollment.

        Section 52.18(a) is hereby amended by adding a new paragraph (9) to read as follows:

        (9) At the time of an event described in 42 U.S.C. section 1395ss(s)(3)(B) because of which an individual loses coverage or benefits due to the termination of the policy or the individual ceases enrollment under the policy, the insurer of the policy from which termination or disenrollment occurs shall provide the individual with written notification of his or her rights and of the obligations of issuers of Medicare supplement insurance policies under sections 52.22(b)(3) and (k) of this Part. If an individual loses coverage or benefits due to termination of the policy, such notification must be provided contemporaneously with the notification of termination. If an individual ceases enrollment under the policy, such notification must be provided within ten working days of the insurer receiving notification of disenrollment.

        Section 52.22(a) is hereby amended by adding a new paragraph (5) and renumbering existing paragraphs (5) through (11) as (6) through (12) to read as follows:

        (5)(i) The term creditable coverage means, with respect to an individual, coverage of the individual provided under any of the following:

            (a) A group health plan;
            (b) Health insurance coverage;
            (c) Part A or Part B of Title XVIII of the Social Security Act (Medicare);
            (d)Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928;
            (e) Chapter 55 of Title 10, United States Code (CHAMPUS and TRICARE health care programs for the uniformed military services);
            (f) A medical care program of the Indian Health Service or of a tribal organization;
            (g) A State health benefits risk pool;
            (h) A health plan offered under chapter 89 of Title 5, United States Code (Federal Employees Health Benefits Program);
            (i) A public health plan;
            (j) A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. section 2504(e)); and
            (k) Medicare supplement insurance, Medicare select coverage or Medicare+Choice plan.

            (ii) Except as specified in subparagraph (i) of this paragraph, creditable coverage shall not include any coverage in relation to its provision of "excepted benefits" as defined in section 2791(c) of the Federal Public Health Service Act (42 U.S.C. section 300gg-91(c)) and meeting the requirements for exception as set forth in section 2721(c) or (d) of the Federal Public Health Service Act (42 U.S.C. section 300gg-21(c) and (d) or section 2763(a) or (b) of the Federal Public Health Service Act (42 U.S.C. section 300gg-63(a) and (b)). However, this exemption shall not be applicable to any coverage providing hospital or surgical indemnity benefits with specific dollar amounts that exceed the amounts required to meet the definitions of basic hospital and basic medical insurance in sections 52.5 and 52.6 of this Part.

            (iii) For purposes of section 52.22(b)(3)(ii) of this Part, credit for the time that a person was previously covered under Part A or Part B of Title XVIII of the Social Security Act (Medicare) shall be required only if the applicant submits an application for Medicare supplement insurance prior to or during the six month period beginning with the first day of the first month in which an individual is both 65 years of age or older and is enrolled for benefits under Medicare Part B.

        Section 52.22(b)(3) is hereby amended to read as follows:

        (i) Notwithstanding section 52.16(c) of this Part, the only permissible preexisting condition limitations applicable to Medicare supplement insurance are ones which exclude coverage, for no more than six months after the effective date of coverage under the policy or certificate, for a condition for which medical advice was given or treatment was recommended by or received from a physician, within six months before the effective date of coverage.
        (ii) In applying a preexisting condition limitation to a covered person, an issuer shall credit the time the person was previously covered under [previous health insurance plans or policies (including Medicare supplement and Medicare select), health maintenance organization contracts, or employer-provided health benefit arrangements, whether insured or self-insured,] creditable coverage, including Medicare supplement insurance, Medicare select coverage and Medicare+Choice plans, if the previous creditable coverage was continuous to a date not more than [60] 63 days prior to the [effective] enrollment date of the new coverage. For purposes of this paragraph, "enrollment date" means the first day of coverage of the individual under the policy or certificate or, if earlier, the first day of the waiting period that must pass with respect to an individual before such individual is eligible to be covered for benefits. Any period after the date the individual files a substantially complete application for coverage and before the first day of coverage is a waiting period.
        (iii) For purposes of applying the credit of creditable coverage, an issuer shall reduce the period of any preexisting condition limitation by the aggregate of the period of creditable coverage without regard to the specific benefits covered during the period.
        [(iii)] (iv) If a Medicare supplement insurance policy or certificate contains any limitations with respect to preexisting conditions, such limitations shall appear as a separate paragraph of the policy or certificate and be labeled as "Pre-existing Condition Limitations."

        Section 52.22(e) is hereby amended by adding new paragraphs (7) and (12) and renumbering existing paragraphs (7) through (10) as (8) through (11) to read as follows:

        (7) Standardized Medicare supplement benefit high deductible plan "F" shall include only the following: 100 percent of covered expenses following the payment of the annual high deductible plan "F" deductible. The covered expenses include the core benefit as defined in paragraph (d)(5) of this section, plus the Medicare Part A deductible, skilled nursing facility care, the Medicare Part B deductible, 100 percent of the Medicare Part B excess charges and medically necessary emergency care in a foreign country as defined in subparagraphs (d)(6)(i), (ii), (iii), (v) and (viii) of this section. The annual high deductible plan "F" deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan "F" policy, and shall be in addition to any other specific benefit deductibles. The annual high deductible plan "F" deductible shall be $1,500 for 1998 and 1999, and shall be based on the calendar year. Such deductible shall be adjusted annually thereafter by the Secretary of the United States Department of Health and Human Services to reflect the change in the Consumer Price Index for all urban consumers for the twelve month period ending with August of the preceding year, and rounded to the nearest multiple of $10.

        (12) Standardized Medicare supplement benefit high deductible plan "J" shall consist of only the following: 100 percent of covered expenses following the payment of the annual high deductible plan "J" deductible. The covered expenses include the core benefit as defined in paragraph (d)(5) of this section, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, 100 percent of the Medicare Part B excess charges, extended prescription drug benefit, medically necessary emergency care in a foreign country, preventive medical care and at-home recovery benefit as defined in subparagraphs (d)(6)(i), (ii), (iii), (v), (vii), (viii), (ix) and (x) of this section. The annual high deductible plan "J" deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan "J" policy, and shall be in addition to any other specific benefit deductibles. The annual high deductible plan "J" deductible shall be $1,500 for 1998 and 1999, and shall be based on a calendar year. Such deductible shall be adjusted annually thereafter by the Secretary of the United States Department of Health and Human Services to reflect the change in the Consumer Price Index for all urban consumers for the twelve month period ending with August of the preceding year, and rounded to the nearest multiple of $10.

        Section 52.22(f) is hereby amended by amending existing paragraphs (2), (5) and (6) to read as follows:

        (2) Applications for Medicare supplement insurance shall include a conspicuous bold face notice advising the applicant that the sale of a Medicare supplement policy [to an individual who has such a policy in force is prohibited except where the individual desires to replace an existing Medicare supplement policy] is prohibited where an individual has a Medicare supplement policy in force and does not desire to replace the existing policy or where the Medicare supplement policy would duplicate benefits to which the individual is entitled under a Medicare+Choice plan.
        (5) Any sale of Medicare supplement insurance coverage that will provide an individual with more than one Medicare supplement policy or certificate or duplicate benefits to which an individual is entitled under a Medicare+Choice plan is prohibited.
        (6) Application forms shall include the following questions and statements designed to elicit information as to whether, as of the date of the application, the applicant for a policy or certificate has another Medicare supplement or other accident and health insurance policy or certificate in force [or] and whether [a] the Medicare supplement policy or certificate being applied for is intended to replace [any other accident and health policy or certificate presently in force] such existing coverage. A supplementary application or other form to be signed by the applicant containing such questions and statements may be used. Where the application is taken by an agent, such application or supplementary application form shall also be signed by the agent.

        (i) Statements.
            (a) You do not need more than one Medicare supplement policy or certificate.
            (b) If you purchase this policy (certificate), you may want to evaluate your existing health coverage and decide if you need multiple coverages.
            (c) You may be eligible for benefits under Medicaid and may not need a Medicare supplement policy (certificate).
            (d) The benefits and premiums under your Medicare supplement policy (certificate) may be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your policy (certificate) will be reinstituted if requested within 90 days of losing Medicaid eligibility.
            (e) Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement insurance and concerning medical assistance through the State Medicaid Program, including benefits as a qualified Medicare beneficiary (QMB) and a specified low-income Medicare beneficiary (SLMB).

        (ii) Questions. To the best of your knowledge and belief:
            (a) Do you have another Medicare supplement insurance policy or certificate in force?
                (1) If so, with which company?
            (b) Do you have any other accident and health insurance policies or certificates (including a health maintenance organization contract) that provide benefits similar to this Medicare supplement policy (certificate)?
                (1) If so, with which company?
                (2) What kind of policy?
            (c) Are you enrolled in a Medicare+Choice plan that provides benefits which duplicate those provided by this Medicare supplement policy (certificate)?
                (1) If so, with which company?
                (2) What type of plan?
            [(c)] (d) If the answer to question (a), [or] (b) or (c) is yes, do you intend to replace any of these policies or certificates with this policy (certificate)?
                (1) If so, identify the policies (certificates) to be replaced.
            [(d)] (e) Are you covered for medical assistance through the State Medicaid program:
                (1) As a specified low-income Medicare beneficiary (SLMB)?
                (2) As a qualified Medicare beneficiary (QMB)?
                (3) For other Medicaid medical benefits?
            [(e)] (f) If the answer to question [(d)] (e) (1), (2) or (3) is yes, will the State Medicaid program pay the premiums for the policy (certificate) being applied for?

        Section 52.22(g) is hereby amended to read as follows:

        (g) Rules relating to the replacement of health coverage with Medicare supplement insurance coverage. (1) Upon determining that a sale of a Medicare supplement insurance or Medicare select policy or certificate will involve replacement of accident and health insurance (including Medicare supplement insurance, [and] Medicare select or Medicare+Choice coverage), health maintenance organization coverage or any employer-provided health benefit arrangement, an issuer, other than a direct response issuer, or its agent, shall furnish the applicant, prior to issuance or delivery of the Medicare supplement or Medicare select policy or certificate, a notice regarding replacement of coverage. One copy of such notice signed by the applicant and the agent, except where the coverage is sold without an agent, shall be provided to the applicant and an additional signed copy shall be retained by the issuer. A direct response issuer shall deliver to the applicant at the time of the issuance of the policy the notice regarding replacement of coverage.
            (2) The notice required by paragraph (1) of this subdivision for an issuer shall be provided in substantially the following form in no less than 12 point type:

NOTICE TO APPLICANT REGARDING REPLACEMENT
OF ACCIDENT AND HEALTH INSURANCE, HMO COVERAGE OR
EMPLOYER-PROVIDED HEALTH BENEFIT ARRANGEMENT
(Insurance Company’s Name and Address)

SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.

According to (your application) (information you have furnished), you intend to terminate existing accident and health insurance, health maintenance organization coverage or employer-provided health benefit coverage and replace it with a policy (certificate) to be issued by (Company Name) Insurance Company. Your new policy (certificate) will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy (certificate).

You should review this new coverage carefully. Compare it with all health coverage you now have and evaluate the need for existing coverage that may duplicate this policy (certificate). Terminate you present coverage only if, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision.

STATEMENT TO APPLICANT BY ISSUER, AGENT (BROKER OR OTHER REPRESENTATIVE):

I have reviewed your current medical or health insurance coverage. The replacement of insurance involved in this transaction (does) (does not) duplicate coverage, to the best of my knowledge. The replacement policy is being purchased for the following reason(s) checked below:

___Additional [Benefits] benefits.
___No change in benefits, but lower premiums.
___Fewer benefits and lower premiums.
___Other. (please specify)___________________________________

________________________________________________________

________________________________________________________

        1. Health conditions which you may presently have may be considered preexisting conditions and may not be immediately or fully covered under the new policy (certificate). This could result in denial or delay of a claim for benefits under the new policy (certificate), whereas a similar claim might have been payable under your present coverage. (This paragraph may be deleted if the replacement does not involve application of a new preexisting condition limitation.)

        2. [State law provides that if a Medicare supplement insurance policy or certificate replaces a previous health insurance plan or policy (including Medicare supplement and Medicare select), health maintenance organization (HMO) contract or employer-provided health benefit arrangement, the replacing issuer shall waive any time periods applicable to preexisting conditions in the new policy or certificate to the extent such time period has expired under the original policy or certificate.] State regulation provides that in applying a preexisting condition limitation, a Medicare supplement issuer must credit the time the applicant was previously covered under creditable coverage (including Medicare supplement insurance, Medicare select coverage and Medicare+Choice plans) if the previous creditable coverage was continuous to a date not more than 63 days prior to the enrollment date of the new policy or certificate. (This paragraph may be deleted if the replacement does not involve application of a new preexisting condition limitation.)

        3. If you still wish to terminate your present policy or certificate and replace it with new coverage, review the application carefully before you sign it to be certain that all information has been properly recorded.

Do not cancel your present coverage until you have received your new policy (certificate) and are sure that you want to keep it.

__________________________________________________
Signature of Agent, Broker or other Representative
(Signature not required for direct response sales.)

[_________________________________________________]
(Insert typed name and address of issuer, agent or broker)

___________________________________
(Applicant’s signature)

___________________________________
(Date)

            (3) If a Medicare supplement or Medicare select policy or certificate replaces another Medicare supplement policy or certificate, a Medicare select policy or certificate, a Medicare+Choice plan or a policy or certificate issued pursuant to a contract under section 1876 of the Federal Social Security Act, then the replacing issuer must provide the policyholder or certificateholder with the following written notice:

"Your application for the Medicare supplement insurance policy (certificate) issued by this company indicates that you intended to terminate existing Medicare supplement insurance coverage, Medicare select coverage, Medicare+Choice plan or health maintenance organization (HMO) issued Medicare [risk or] cost contract and replace it with the coverage applied for with this company. Duplicate [Medicare supplement insurance] coverage is unnecessary and you should terminate one of your [Medicare supplement insurance, Medicare select or HMO contracts] existing coverages if more than one such [contract] plan is still in force."

At the option of the issuer, such notice shall either be included with the first premium due notice mailed to the policyholder or certificateholder after the replacement coverage is issued, or sent separately within 30 days of the date of the first premium due notice, but in no event shall such notice be provided later than six months after issuance of the replacement policy or certificate.

        Section 52.22(h)(3) is hereby amended to read as follows:

        (3) No issuer shall provide compensation to its agents or other producers and no agent or producer shall receive compensation greater than the renewal compensation payable by the replacing issuer on renewal policies or certificates if an existing Medicare supplement insurance policy or certificate, Medicare select policy or certificate, Medicare+Choice plan or a policy or certificate issued pursuant to a contract under section 1876 [or section 1833] of the Federal Social Security Act is replaced by a Medicare supplement insurance or Medicare select policy or certificate.

        Section 52.22(k) is hereby amended by amending existing paragraph (3) and adding a new paragraph (4) to read as follows:

        (3) Paragraph (1) of this subdivision shall not be construed as preventing an issuer from applying a preexisting condition limitation in accordance with the requirements of [subdivision (b)(3)(i), (ii) and (iii)] paragraph (b)(3) of this section except as provided in paragraph (4) of this subdivision.

        (4) The issuer of a Medicare supplement insurance policy or certificate may not impose an exclusion of benefits based upon a preexisting condition under such policy or certificate in the case of an individual described in 42 U.S.C. section 1395ss(s)(3)(B) who seeks to enroll under the Medicare supplement insurance policy or certificate not later than 63 days after the date of the termination of enrollment described in 42 U.S.C. section 1395ss(s)(3)(B) and who submits evidence of the date of termination or disenrollment along with the application for such Medicare supplement insurance policy or certificate.

        Section 52.63(a) is hereby repealed and a new subdivision (a) is added to read as follows:

        (a) The following items shall be included in the disclosure statement in the order prescribed below.


(COMPANY NAME)
Outline of Medicare Supplement Coverage - Cover Page:
Benefit Plan(s) ________(insert letter(s) of plan(s) being offered)

Medicare supplement insurance can be sold in only ten standard plans plus two high deductible plans. This chart shows the benefits included in each plan.
Every company must make available Plans "A" and "B". Some plans may not be available in your state.

Basic Benefits: Included in All Plans.
Hospitalization: Part A coinsurance plus coverage for 365 additional days in your lifetime after Medicare benefits end.
Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses).
Blood: First three pints of blood each year.

A

B

C

D

E

F

F*

G

H

I

J

J*

Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits
Skilled Nursing

Co-Insurance

Skilled Nursing

Co-Insurance

Skilled Nursing

Co-Insurance

Skilled Nursing

Co-Insurance

Skilled Nursing

Co-Insurance

Skilled Nursing

Co-Insurance

Skilled Nursing

Co-Insurance

Skilled Nursing

Co-Insurance

Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible
Part B Deductible Part B Deductible Part B Deductible
  Part B Excess (100%) Part B Excess (80%) Part B Excess (100%) Part B Excess (100%)
Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency
At-Home Recovery At-Home Recovery At-Home Recovery At-Home Recovery
Basic Drugs ($1,250 Limit) Basic Drugs ($1,250 Limit) Extended Drugs ($3,000 Limit)
Preventive Care Preventive Care

*Plans "F" and "J" also have an option called a high deductible Plan "F" and a high deductible Plan "J". These high deductible plans pay the same or offer the same benefits as Plans "F" and "J" after one has paid a calendar year $ deductible. Benefits from high deductible Plans "F" and "J" will not begin until out-of-pocket expenses are $ . Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include, in Plan "J", the plan’s separate prescription drug deductible or, in Plans "F" and "J", the plan’s separate foreign travel emergency deductible. (The calendar year high deductible for high deductible Plans "F" and "J" shall be $1,500 for 1998 and 1999. Such deductible shall be adjusted annually thereafter by the Secretary of the United States Department of Health and Human Services. The cover page must specify the applicable deductible amount.)


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.

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)

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. The dollar amounts of such payments must be updated by the issuer to specify the amounts then currently applicable under Medicare and the Medicare supplement insurance policy. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this regulation. An issuer may use additional benefit plan designations on these charts pursuant to Section 52.22(d)(4) of this Part.)

(Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the superintendent.)


PLAN A

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

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

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION*
Semiprivate room and board,
general nursing and
miscellaneous services and
supplies
    First 60 days
    61st thru 90th day
    91st day and after:
      -While using 60 lifetime
       reserve days
      -Once lifetime reserve days
       are used:
          -Additional 365 days
           (lifetime)
          -Beyond the Additional
           365 days
 
 
 
 
 
All but $
All but $ a day
 
All but $ a day
 
 
 
$0
 
$0
 
 
 
 
 
$0
$ a day
 
$ a day
 
 
 
100% of Medicare
Eligible Expenses
$0
 
 
 
 
 
$ (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 $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
$0
$0
 
 
 
 
 
 
 
 
 
$0
 
Up to $ a day
All Costs
BLOOD (per calendar year)
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

(PLAN A - continued)

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
    Part B Excess Charges
        (Above Medicare-
        Approved Amounts)
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 80%
 
 
$0
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 20%
 
 
$0
 
 
 
 
 
 
 
 
 
 
$100 (Part B Deductible)
$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—
BLOOD 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 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
         (lifetime)
         -Beyond the Additional
         365 days
 
 
 
 
 
All but $
All but $ a day
 
All but $ a day
 
 
 
$0
 
$0
 
 
 
 
 
$ (Part A Deductible)
$ a day
 
$ 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 $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
$0
$0
 
 
 
 
 
 
 
 
 
$0
 
Up to $ a day
All Costs
BLOOD (per calendar year)
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

(PLAN B - continued)

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
    Part B Excess Charges
        (Above Medicare-
        Approved Amounts)
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 80%
 
$0
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 20%
 
$0
 
 
 
 
 
 
 
 
 
 
$100 (Part B Deductible)
$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—
BLOOD 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 Amount
 
 
 
100%
 
 
 
$0
 
 
80%
 
 
 
$0
 
 
 
$0
 
 
20%
 
 
 
$0
 
 
 
$100 (Part B Deductible)
 
$0

PLAN C

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

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

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION*
Semiprivate room and board,
general nursing and
miscellaneous services and
supplies
    First 60 days
    61st thru 90th day
    91st day and after:
        -While using 60
         lifetime reserve days
        -Once lifetime reserve
          days are used:
            -Additional 365
           days (lifetime)
            -Beyond the
           Additional 365 days
 
 
 
 
 
All but $
All but $ a day
 
All but $ a day
 
 
 
$0
 
$0
 
 
 
 
 
$ (Part A Deductible)
$ a day
 
$ 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 $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
Up to $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
$0
All Costs
BLOOD (per calendar year)
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

(PLAN C - continued)

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
    Part B Excess Charges
        (Above Medicare-
        Approved Amounts)
 
 
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 80%
 
 
$0
 
 
 
 
 
 
 
 
 
 
 
 
$100 (Part B
Deductible)
Generally 20%
 
 
$0
 
 
 
 
 
 
 
 
 
 
 
 
$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—
BLOOD 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
 
 
$100 (Part B
Deductible)
 
20%
 
 
 
 
 
$0
 
 
$0
 
 
$0

(PLAN C – continued)

OTHER BENEFITS—NOT COVERED BY MEDICARE

FOREIGN TRAVEL—NOT
COVERED BY MEDICARE

Medically necessary
emergency care services
beginning during the first
60 days of each trip
outside the USA
    First $250 each calendar
       year
    Remainder of charges
 
 
 
 
 
 
 
$0
 
$0
 
 
 
 
 
 
 
$0
 
80% to a lifetime maximum benefit of $50,000
 
 
 
 
 
 
 
$250
 
20% and amounts over the $50,000 lifetime maximum

PLAN D

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

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

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION*
Semiprivate room and board,
general nursing and
miscellaneous services and
supplies
    First 60 days
    61st thru 90th day
    91st day and after:
        -While using 60 lifetime
         reserve days
        -Once lifetime reserve
         days are used:
            -Additional 365 days
            (lifetime)
            -Beyond the Additional
            365 days
 
 
 
 
 
All but $
All but $ a day
 
All but $ a day
 
 
 
$0
 
$0
 
 
 
 
 
$ (Part A Deductible)
$ a day
 
$ 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 $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
Up to $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
$0
All Costs
BLOOD (per calendar year)
    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

(PLAN D - continued)

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
    Part B Excess Charges
        (Above Medicare-
        Approved Amounts)
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 80%
 
$0
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 20%
 
$0
 
 
 
 
 
 
 
 
 
 
$100 (Part B
Deductible)
$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—
BLOOD TESTS FOR DIAGNOSTIC SERVICES
 
 
100%
 
 
$0
 
 
$0

(PLAN D - continued)

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

FOREIGN TRAVEL—NOT
COVERED BY MEDICARE

Medically necessary emergency
care services beginning during
the first 60 days of each trip
outside the USA
    First $250 each calendar year
 
    Remainder of charges
 
 
 
 
 
 
$0
 
$0
 
 
 
 
 
 
$0
 
80% to a lifetime maximum benefit of $50,000
 
 
 
 
 
 
$250
 
20% and amounts over the $50,000 lifetime maximum

PLAN E

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
            (lifetime)
            -Beyond the Additional
            365 days
 
 
 
 
 
All but $
All but $ a day
 
All but $ a day
 
 
 
$0
 
$0
 
 
 
 
 
$ (Part A Deductible)
$ a day
 
$ 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 $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
Up to $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
$0
All Costs
BLOOD (per calendar year)
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

(PLAN E - continued)

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
    Part B Excess Charges
        (Above Medicare-
        Approved Amounts)
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 80%
 
$0
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 20%
 
$0
 
 
 
 
 
 
 
 
 
 
$100 (Part B Deductible)
$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—
BLOOD 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 - continued)

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 MEDICAL CARE BENEFIT—NOT COVERED BY MEDICARE**
Some annual physical and
preventive tests and services
such as: digital rectal exam,
hearing screening, dipstick
urinalysis, diabetes screening,
thyroid function test, tetanus
and diphtheria booster and education, 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 and the latest Medicare handbook.


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.

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
             (lifetime)
           -Beyond the Additional
            365 days
 
 
 
 
 
All but $
 
All but $ a day
 
 
All but $ a day
 
 
 
$0
 
$0
 
 
 
 
 
$(Part A
Deductible)
$ a day
 
 
$ 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 $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
Up to $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
$0
All Costs
BLOOD (per calendar year)
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

(PLAN F – continued)

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
    Part B excess charges
        (Above Medicare-
        Approved Amounts)
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 80%
 
$0
 
 
 
 
 
 
 
 
 
 
$100 (Part B Deductible)
Generally 20%
 
100%
 
 
 
 
 
 
 
 
 
 
$0
 
$0
 
$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—
BLOOD TESTS
FOR DIAGNOSTIC SERVICES
 
 
100%
 
 
$0
 
 
$0

(PLAN F - continued)

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

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

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 or offers the same benefits as Plan F after one has paid a calendar year $______ deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $______. 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
$_____
DEDUCTIBLE,**
PLAN PAYS

IN ADDITION TO $_____
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
            (lifetime)
           -Beyond the Additional
            365 days
 
 
 
 
 
All but $
 
All but $ a day
 
All but $ a day
 
 
 
$0
 
$0
 
 
 
 
 
$ (Part A
Deductible)
$ a day
 
$ 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 $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
Up to $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
$0
All Costs
BLOOD (per calendar year)
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

(HIGH DEDUCTIBLE PLAN F - continued)

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 or offers the same benefits as Plan F after one has paid a calendar year $_____ deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $_____. 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
$_____
DEDUCTIBLE,**
PLAN PAYS

IN ADDITION TO
$____
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
Part B excess charges
        (Above Medicare-
        Approved Amounts)
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 80%
 
$0
 
 
 
 
 
 
 
 
 
 
$100 (Part B Deductible)
Generally 20%
 
100%
 
 
 
 
 
 
 
 
 
 
$0
 
$0
 
$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—
BLOOD TESTS
FOR DIAGNOSTIC SERVICES
 
 
100%
 
 
$0
 
 
$0

(HIGH DEDUCTIBLE PLAN F - continued)

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

OTHER BENEFITS—NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

AFTER YOU PAY
$_____
DEDUCTIBLE,**
PLAN PAYS

IN ADDITION TO
$_____
DEDUCTIBLE,**
YOU PAY

FOREIGN TRAVEL—NOT COVERED BY MEDICARE
Medically necessary emergency care services beginning during
the first 60 days of each trip
outside the USA
First $250 each calendar year
Remainder of charges
 
 
 
 
 
 
$0
$0
 
 
 
 
 
 
$0
80% to a lifetime maximum benefit of $50,000
 
 
 
 
 
 
$250
20% and amounts over the $50,000 lifetime maximum

PLAN 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
            (lifetime)
           -Beyond the Additional
            365 days
 
 
 
 
 
All but $
All but $ a day
 
All but $ a day
 
 
 
$0
 
$0
 
 
 
 
 
$ (Part A Deductible)
$ a day
 
$ 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 $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
Up to $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
$0
All Costs
BLOOD (per calendar year)
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

(PLAN G - continued)

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
    Part B Excess Charges
        (Above Medicare-
        Approved Amounts)
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 80%
 
$0
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 20%
 
80%
 
 
 
 
 
 
 
 
 
 
$100 (Part B Deductible)
$0
 
20%
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—
BLOOD TESTS
FOR DIAGNOSTIC SERVICES
 
 
100%
 
 
$0
 
 
$0

(PLAN G - continued)

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
 
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

FOREIGN TRAVEL—NOT
COVERED BY MEDICARE
Medically necessary
emergency care services
beginning during the first
60 days of each trip outside
the USA
    First $250 each calendar
      year
    Remainder of charges
 
 
 
 
 
 
 
$0
 
$0
 
 
 
 
 
 
 
$0
 
80% to a lifetime maximum benefit of $50,000
 
 
 
 
 
 
 
$250
 
20% and amounts over the $50,000 lifetime maximum

PLAN 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 (lifetime)
            -Beyond the Additional
             365 days
 
 
 
 
 
All but $
 
All but $ a day
 
All but $ a day
 
 
 
$0
 
$0
 
 
 
 
 
$  (Part A
Deductible)
$ a day
 
$ 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 $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
Up to $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
$0
All Costs
BLOOD (per calendar year)
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

(PLAN H - continued)

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
    Part B Excess Charges
        (Above Medicare-
        Approved Amounts)
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 80%
 
$0
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 20%
 
$0
 
 
 
 
 
 
 
 
 
 
$100 (Part B Deductible)
$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—
BLOOD 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 H - continued)

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
BASIC OUTPATIENT
PRE-SCRIPTION DRUGS—NOT
COVERED BY MEDICARE

First $250 each calendar year
 
Next $2,500 each calendar year
 
 
Over $2,500 each calendar year
 
 
 
$0
 
$0
 
 
$0
 
 
 
$0
 
50% ($1,250)
calendar year
maximum benefit
$0
 
 
 
$250
 
50%
 
 
All Costs

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
             (lifetime)
            -Beyond the Additional
             365 days
 
 
 
 
All but $
 
All but $ a day
 
All but $ a day
 
 
 
$0
 
$0
 
 
 
 
$ (Part A
Deductible)
$ a day
 
$ 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 $ a day
$0
 
 
 
 
 
 
 
 
$0
 
Up to $ a day
$0
 
 
 
 
 
 
 
 
$0
 
$0
All Costs
BLOOD (per calendar year)
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

(PLAN I - continued)

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
    Part B Excess Charges
        (Above Medicare-
        Approved Amounts)
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 80%
 
$0
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 20%
 
100%
 
 
 
 
 
 
 
 
 
 
$100 (Part B Deductible)
$0
 
$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—
BLOOD TESTS
FOR DIAGNOSTIC SERVICES
 
 
100%
 
 
$0
 
 
$0

(PLAN I - continued)

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
 
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

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
BASIC OUTPATIENT
PRESCRIPTION DRUGS
—NOT COVERED BY
MEDICARE

First $250 each calendar
   year
Next $2,500 each calendar
   year
 
Over $2,500 each calendar
    year
 
 
 
 
$0
 
$0
 
 
$0
 
 
 
 
$0
 
50% ($1,250)
calendar year
maximum benefit
$0
 
 
 
 
$250
 
50%
 
 
All Costs

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.

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
            (lifetime)
           -Beyond the Additional
            365 days
 
 
 
 
 
All but $
All but $ a day
 
All but $ a day
 
 
 
$0
 
$0
 
 
 
 
 
$(Part A Deductible)
$ a day
 
$ 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 $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
Up to $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
$0
All Costs
BLOOD (per calendar year)
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

(PLAN J - continued)

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
    Part B Excess Charges
        (Above Medicare-
        Approved Amounts)
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 80%
 
$0
 
 
 
 
 
 
 
 
 
 
$100 (Part B
Deductible)
Generally 20%
 
100%
 
 
 
 
 
 
 
 
 
 
$0
 
$0
 
$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—
BLOOD TESTS
FOR DIAGNOSTIC SERVICES
 
 
100%
 
 
$0
 
 
$0

(PLAN J - continued)

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
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 - continued)

OTHER BENEFITS—NOT COVERED BY MEDICARE

FOREIGN TRAVEL—NOT
COVERED BY MEDICARE
Medically necessary
emergency care services
beginning during the first 60
days of each trip outside the
USA
    First $250 each calendar
      year
    Remainder of charges
 
 
 
 
 
 
 
$0
 
$0
 
 
 
 
 
 
 
$0
 
80% to a lifetime maximum benefit of $50,000
 
 
 
 
 
 
 
$250
 
20% and amounts over the $50,000 lifetime maximum
EXTENDED OUTPATIENT PRESCRIPTION DRUGS—
NOT COVERED BY
MEDICARE

    First $250 each calendar
      year
    Next $6,000 each calendar
      year
 
    Over $6,000 each calendar
      year
 
 
 
 
$0
 
$0
 
 
$0
 
 
 
 
$0
 
50% ($3,000)
calendar year
maximum benefit
$0
 
 
 
 
$250
 
50%
 
 
All Costs
PREVENTIVE MEDICAL
CARE BENEFIT—NOT
COVERED BY MEDICARE**

Some annual physical and
preventive tests and services
such as: digital rectal exam,
hearing screening, dipstick
urinalysis, diabetes screening,
thyroid function test, tetanus
and diphtheria booster and
education, 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 and the latest Medicare handbook.


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 or offers the same benefits as Plan J after one has paid a calendar year $______ deductible. Benefits from high deductible Plan J will not begin until out-of-pocket expenses are $______. 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 prescription drug deductible or the plan’s separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

AFTER YOU PAY
$______
DEDUCTIBLE,**
PLAN PAYS

IN ADDITION TO
$____
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
             (lifetime)
            -Beyond the Additional
             365 days
 
 
 
 
 
All but $
 
All but $ a day
 
All but $ a day
 
 
 
$0
 
$0
 
 
 
 
 
$ (Part A
Deductible)
$ a day
 
$ 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 $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
Up to $ a day
$0
 
 
 
 
 
 
 
 
 
$0
 
$0
All Costs
BLOOD (per calendar year)
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

(HIGH DEDUCTIBLE PLAN J - continued)

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 or offers the same benefits as Plan J after one has paid a calendar year $______ deductible. Benefits from high deductible Plan J will not begin until out-of-pocket expenses are $______. 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 prescription drug deductible or the plan’s separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

AFTER YOU PAY
$_____
DEDUCTIBLE,**
PLAN PAYS

IN ADDITION TO
$_____
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
    Part B Excess Charges
        (Above Medicare-
         Approved Amounts)
 
 
 
 
 
 
 
 
 
 
$0
 
Generally 80%
 
$0
 
 
 
 
 
 
 
 
 
 
$100 (Part B
Deductible)
Generally 20%
 
100%
 
 
 
 
 
 
 
 
 
 
$0
 
$0
 
$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—
BLOOD TESTS FOR DIAGNOSTIC SERVICES
 
 
100%
 
 
$0
 
 
$0

(HIGH DEDUCTIBLE PLAN J - continued)

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
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

(HIGH DEDUCTIBLE PLAN J - continued)

OTHER BENEFITS—NOT COVERED BY MEDICARE

FOREIGN TRAVEL—NOT
COVERED BY MEDICARE
Medically necessary
emergency care services
beginning during the first 60
days of each trip outside
the USA
    First $250 each calendar
     year
    Remainder of charges
 
 
 
 
 
 
 
$0
 
$0
 
 
 
 
 
 
 
$0
 
80% to a lifetime
maximum benefit
of $50,000
 
 
 
 
 
 
 
$250
 
20% and amounts
over the $50,000
lifetime maximum
EXTENDED OUTPATIENT PRESCRIPTION DRUGS—NOT
COVERED BY MEDICARE

    First $250 each calendar
     year
    Next $6,000 each calendar
     year
 
    Over $6,000 each calendar
     year
 
 
 
$0
 
$0
 
 
$0
 
 
 
$0
 
50% ($3,000)
calendar year
maximum benefit
$0
 
 
 
$250
 
50%
 
 
All Costs
PREVENTIVE MEDICAL
CARE BENEFIT—NOT
COVERED BY MEDICARE**

Some annual physical and
preventive tests and services
such as: digital rectal exam,
hearing screening, dipstick
urinalysis, diabetes screening,
thyroid function test, tetanus
and diphtheria booster and
education, 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 and the latest Medicare handbook.


Section 52.90(a) is hereby amended by adding a new paragraph (17) to read as follows:

(17) On April 22, 1999 with respect to amendments to Sections 52.2, 52.11, 52.17, 52.18, 52.22 and 52.63 of this Part, except that for insurers currently in the Medicare supplement insurance market, compliance with the amendments required by sections 52.22(f)(2), 52.22(f)(6)(ii)(c), 52.22(g) and 52.63 shall be no later than June 30, 1999.


        I, NEIL D. LEVIN, Superintendent of Insurance of the State of New York, do hereby certify that the foregoing Twenty-Fourth Amendment to 11 NYCRR Part 52 (Regulation 62) was duly adopted by me on this day pursuant to the authority granted by the federal Social Security Act (42 U.S.C. Section 1395ss) and by Sections 201, 301, 3201, 3216, 3217, 3218, 3221, 3231, 3232, 4235, 4237 and Article 43 of the Insurance Law, to take effect upon publication in the State Register.

        Pursuant to the provisions of Section 202(6) of the State Administrative Procedure Act, this Twenty-Fourth Amendment to Regulation No. 62 was previously adopted as an emergency measure on April 22, 1999 and readopted as an emergency measure on July 20, 1999 and September 15, 1999. This regulation amendment supercedes the emergency measure without substantive change. A prior notice of this regulation amendment was published in the State Register on August 4, 1999 as a Notice of Emergency Adoption and Proposed Rulemaking. No other publication or prior notice is required by statute.

__________________________
Neil D. Levin
Superintendent of Insurance
 
Dated: October 18, 1999