WORKSHEET FOR OTHER THAN MEDICARE SUPPLEMENT PLANS

Comprehensive Health Insurance Test for Actuarial Equivalence Other than Medicare Supplement Plans Major Medical Subparts of part 2740.9964 Benefit Basic Superimposed Comprehensive 1. Hospital room and board 2. Hospital extras 3. Surgery 4. Physician care; home, office 5. Physician care; hospital 6. Maternity 7. Diagnostic X-ray and lab 8. Drugs and medicine 9. Radioactive therapy 10. Nursing/convalescent facility 11. Home health care 12. Physical therapy 12. Oxygen 12. Prostheses 12. Durable medical equipment 12. Second opinion surgery 12. Home care nursing 12. Ambulance 13. Hospital room and board in full 14. All hospital expenses in full 15. Major medical maximums Subtotal reasonable and customary medical services 16. Deductible 16. Coinsurance Subtotal net of deductible and coinsurance 17. Adjust (Comb. medical/dental deductible) 18. COB/No-Fault 19. Limit on "out-of-pocket" expenses 20. Well baby care 21. Emergency and supplemental accident 22. Student dependents 23.-25. Superimposed major medical Grand Total Combined Basic and Superimposed XXX XXX Equivalent to Minnesota qualified plan number _____ nonqualified ______ Date _ By _