W Outline of Medicare Supplement Coverage – Cover Page for Medicare Supplement Plans Sold on or after June 1, 2010

Section 2008.APPENDIX W   Outline of Medicare Supplement Coverage – Cover Page for Medicare Supplement Plans Sold on or after June 1, 2010 Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010 This chart shows the benefits included in each of the standard Medicare supplement plans.  Every company must make Plan "A" available.  Some plans may not be available in your state. Basic Benefits: •           Hospitalization – Part A coinsurance plus coverage for 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 K L M N Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance* Basic, including 100% Part B coinsurance Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance 50% Skilled Nursing Facility Coinsurance 75% Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible 50% Part A Deductible 75% Part A Deductible 50% Part A Deductible Part A Deductible Part B Deductible Part B Deductible Part B Excess (100%) Part B Excess (100%) Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Out-of-pocket limit $[4140]; paid at 100% after  limit reached Out-of-pocket limit $[2070]; paid at 100% after  limit reached *  Plan F also has an option called a high deductible Plan F.  This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$1860] deductible.  Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed [$1860].  Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy.  These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible. PREMIUM INFORMATION [Boldface Type] We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this State. [If the premium is based on the increasing age of the insured, include information specifying when premiums will change.] DISCLOSURES [Boldface Type] Use this outline to compare benefits and premiums among policies. This outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010.  Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums.  Plans E, H, I, and J will no longer be available for sale after May 31, 2010. 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 producers:] Neither [insert company's name] nor its agents are connected with Medicare. [for direct response:] [insert company's name] is not connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details. COMPLETE ANSWERS ARE VERY IMPORTANT [Boldface Type] When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. [If the policy or certificate is guaranteed issue, this paragraph need not appear.] Review the application carefully before you sign it. Be certain that all information has been properly recorded. [Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in Appendices AA through JJ. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this Part. An issuer may use additional benefit plan designations on these charts pursuant to Section 2008.67(e).] [Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the Director.] Benefit Chart of Medicare Supplement Plans Sold On or After January 1, 2020 This chart shows the benefits included in each of the standard Medicare supplement plans.  Some plans may not be available.  Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F. Note: A ü means 100% of the benefit is paid. Benefits Plans Available to All Applicants Medicare first eligible before 2020 only A B D G 1 K L M N C F 1 Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up) ü ü ü ü ü ü ü ü ü ü Medicare Part B coinsurance or copayment ü ü ü ü 50% 75% ü ü copays apply 3 ü ü Blood (first three pints) ü ü ü ü 50% 75% ü ü ü ü Part A hospice care coinsurance or copayment ü ü ü ü 50% 75% ü ü ü ü Skilled nursing facility coinsurance ü ü 50% 75% ü ü ü ü Medicare Part A deductible ü ü ü 50% 75% 50% ü ü ü Medicare Part B deductible ü ü Medicare Part B excess charges ü ü Foreign travel emergency (up to plan limits) ü ü ü ü ü ü Out-of-pocket limit in [2017] 2 [$5120] 2 [$2560] 2 1 Plans F and G also have a high deductible option which require first paying a plan deductible of [$2200] before the plan begins to pay.  Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year.  High deductible plan G does not cover the Medicare Part B deductible.  However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible. 2 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit. 3 Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that do not result in an inpatient admission. (Source:  Amended at 42 Ill. Reg. 21625, effective November 26, 2018