of this regulation.]

of this regulation.] [Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the commissioner.] Source: Miss Code Ann §83-9-103(Rev. 2011) 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 —Beyond the additional 365 days All but $[1364] All but $[341] a day All but $[682] a day $0 $0 $0 $[ 341] a day $[682] a day 100% of Medicare eligible expenses $0 $[1364](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 $[170.50] a day $0 $0 $0 $0 $0 Up to $[170.50] a day All costs SERVICES MEDICARE PAYS PLAN PAYS YOU PAY BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited co-payment/ coinsurance for out- patient drugs and inpatient respite care Medicare co-payment/ coinsurance $0 ** 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 * Once you have been billed $[185] 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 $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $0 Generally 20% $[185] (Part B deductible) $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints Next $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $0 20% $0 $[185] (Part B deductible) $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 100% $0 80% $0 $0 20% $0 $[185] (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 —Beyond the additional 365 days All but $[1364] All but $[341] a day All but $[682] a day $0 $0 $[1364](Part A deductible) $[341] a day $[682] 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 $[170.50] a day $0 $0 $0 $0 $0 Up to $[170.50] a day All costs SERVICES MEDICARE PAYS PLAN PAYS YOU PAY BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness All but very limited co-payment/ coinsurance for out- patient drugs and inpatient respite care Medicare co- payment/ coinsurance $0 ** 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 * Once you have been billed $[185] 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 $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $0 Generally 20% $[185] (Part B deductible) $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints Next $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $0 20% $0 $[185] (Part B deductible) $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 100% $0 80% $0 $0 20% $0 $[185] (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 —Beyond the additional 365 days All but $[1364] All but $[341] a day All but $[682] a day $0 $0 $[1364](Part A deductible) $[341] a day $[682] 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 $[170.50] a day $0 $0 Up to $[170.50] a day $0 $0 $0 All costs SERVICES MEDICARE PAYS PLAN PAYS YOU PAY BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited co- payment/ coinsurance for out- patient drugs and inpatient respite Medicare co-payment/ coinsurance $0 ** 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 * Once you have been billed $[185] 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 $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $[185] (Part B deductible) Generally 20% $0 $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints Next $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $[185] (Part B deductible) 20% $0 $0 $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PLAN C 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 $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 100% $0 80% $0 $[185](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 maxi-mum 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 —Beyond the additional 365 days All but $[1364] All but $[341] a day All but $[682] a day $0 $0 $[1364] (Part A deductible) $[341] a day $[682] a day $0 100% 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 $[170.50] a day $0 $0 Up to $[170.50] a day $0 $0 $0 All costs SERVICES MEDICARE PAYS PLAN PAYS YOU PAY BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness All but very limited co- payment/ coinsurance for out- patient drugs and inpatient respite care Medicare co-payment/ coinsurance $0 ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN D MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR * Once you have been billed $[185] 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 $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $0 Generally 20% $[185] (Part B deductible) $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints Next $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $0 20% $0 $[185] (Part B deductible) $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PLAN D PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 100% $0 80% $0 $0 20% $0 $[185] (Part B deductible) $0 PLAN D 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 PLAN F or HIGH DEDUCTIBLE PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. [**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2300] deductible. Benefits from the high deductible plan F will not begin until out- of-pocket expenses are [$2300]. 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 $[2300] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2300] DEDUCTIBLE,**] YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: —While using 60 Lifetime reserve days Once lifetime reserve days are used: —Additional 365 days Beyond the additional 365 days All but $[1364] All but $[341] a day All but $[682] a day $0 $0 $[1364] (Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 $0 $0 $0 $0*** All costs PLAN F or HIGH DEDUCTIBLE PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD (cont.) SERVICES MEDICARE PAYS [AFTER YOU PAY $[2300] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2300] DEDUCTIBLE,**] YOU PAY SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days 21st thru 100th day 101st day and after All approved amounts All but $[170.50] a day $0 $0 Up to $[170.50] a day $0 $0 $0 All costs BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited co-payment/ coinsurance for out- patient drugs and inpatient respite care Medicare co- payment/co- insurance $0 *** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN F or HIGH DEDUCTIBLE PLAN F MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $[185] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. [**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2300] deductible. Benefits from the high deductible plan F will not begin until out- of-pocket expenses are [$2300]. 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 $[2300] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2300] 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 $[185] of Medicare Approved amounts* Remainder of Medicare Approved amounts $0 Generally 80% $[185] (Part B deductible) Generally 20% $0 $0 PART B EXCESS CHARGES (Above Medicare Approved Amounts) $0 100% $0 BLOOD First 3 pints Next $[185] of Medicare Approved amounts* Remainder of Medicare Approved amounts $0 $0 80% All costs $[185] (Part B deductible) 20% $0 $0 $0 CLINICAL LABORATORY SERVICES—- TESTS FOR 100% $0 $0 PLAN F or HIGH DEDUCTIBLE PLAN F PARTS A & B SERVICES MEDICARE PAYS AFTER YOU PAY $[2300] DEDUCTIBLE,** PLAN PAYS IN ADDITION TO $[2300] DEDUCTIBLE,** HOME HEALTH CARE Medicare Approved Services - Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare — Approved Amounts 100% $0 80% $0 $[185] (Part B deductible) 20% $0 $0 $0 OTHER BENEFITS - NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS AFTER YOU PAY $[2300] DEDUCTIBLE,* * PLAN PAYS IN ADDITION TO $[2300] 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 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. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used: —Additional 365 days —Beyond the additional 365 days All but $[1364] All but $[341] a day All but $[682] a day $0 $0 $[1364] (Part A deductible) $[341] a day $[682] 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 $[170.50] a day $0 $0 Up to $[170.50] a day $0 $0 $0 All costs BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness All but very limited co- payment/ coinsurance for out-patient drugs and inpatient respite care Medicare co-payment/ coinsurance $0 ** 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 * Once you have been billed $[185] 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 $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $0 Generally 20% $185 ( Unless Part B deductible has been met) $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 100% $0 BLOOD First 3 pints Next $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $0 20% $0 $185(Unless Part B Deductible has been met) $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PLAN G or HIGH DEDUCTIBLE PLAN G PARTS A & B SERVICES MEDICARE PAYS [AFTER YOU PAY $2,300 DEDUCTIBLE] PLAN PAYS [IN ADDITION TO $2,300 DEDUCTIBLE] YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 100% $0 80% $0 $0 20% $0 $185 (Unless Part B Deductible has been met) $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 PLAN K * You will pay half the cost-sharing of some covered services until you reach the annual out-of- pocket limit of $[5560] each calendar year. The amounts that count toward your annual limit are noted with diamonds (♦) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare co-payment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD ** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used: —Additional 365 days —Beyond the additional 365 days All but $[1364] All but $[341] a day All but $[682] a day $0 $0 $[682](50% of Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 $[682](50% of Part A deductible)♦ $0 $0 $0*** All costs PLAN K MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD (cont.) SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* SKILLED NURSING FACILITY CARE** You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility Within 30 days after leaving the hospital First 20 days 21st thru 100th day 101st day and after All approved amounts. All but $[170.50] a day $0 $0 Up to $[85.25] a day (50% of Part A Coinsurance) $0 $0 Up to $[85.25] a day (50% of Part A Coinsurance)♦ All costs BLOOD First 3 pints Additional amounts $0 100% 50% $0 50%♦ $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited co-payment/ coinsurance for outpatient drugs and inpatient respite care 50% of co-payment/ coinsurance 50% of Medicare co- payment/coinsurance ♦ *** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN K MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR **** Once you have been billed $[185] 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 $[185] of Medicare Approved Amounts**** Preventive Benefits for Medicare covered services Remainder of Medicare Approved Amounts $0 Generally 7580% or more of Medicare approved amounts Generally 80% $0 Remainder of Medicare approved amounts Generally 10% $[185] (Part B deductible)**** ♦ All costs above Medicare approved amounts Generally 10% ♦ Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs (and they do not count toward annual out- of-pocket limit of [$5560])* BLOOD First 3 pints Next $[185] of Medicare Approved Amounts**** Remainder of Medicare Approved Amounts $0 $0 Generally 80% 50% $0 Generally 10% 50%♦ $[185] (Part B deductible)**** ♦ Generally 10% ♦ CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 (continued) * This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[5560] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. PLAN K PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts***** Remainder of Medicare Approved Amounts 100% $0 80% $0 $0 10% $0 $[185] (Part B deductible) ♦ 10%♦ ****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. 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 $[2780] each calendar year. The amounts that count toward your annual limit are noted with diamonds (♦) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare- approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD ** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOSPITALIZATION ** Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st day thru 90th day 61st day and after: - While using 60 lifetime reserve days - Once lifetime reserve days are used - Additional 365 days - Beyond additional 365 days All but $[1364] All but $[341] a day All but $[682] a day $0 $0 $[1023] (75% of Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 $[1023] (75% of Part A deductible) ♦ $0 $0 $0*** All costs SERVICES MEDICARE PAYS PLAN PAYS YOU PAY SKILLED NURSING FACILITY CARE*** You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days 21st thru 100th day 101st day and after All approved amounts All but $[170.50] a day $0 $0 Up to $[127.88] a day (75% of Part A Coinsurance) $0 $0 Up to $[127.88] a day (75% of Part A Coinsurance) ♦ All costs BLOOD First 3 pints Additional amounts $0 100% 75% $0 25%♦ $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited co-payment/ coinsurance for outpatient drugs and inpatient respite care 75% of co- payment/ coinsurance 25% of co- payment/ coinsurance ♦ *** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid PLAN L MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR **** Once you have been billed $[185] 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 $[185] of Medicare Approved Amounts**** Preventive Benefits for Medicare covered services Remainder of Medicare Approved Amounts $0 Generally 80% or more of Medicare approved amounts Generally 80% $0 Remainder of Medicare approved amounts Generally 15% $[185] (Part B deductible)**** ♦ All costs above Medicare approved amounts Generally 5% ♦ Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs (and they do not count toward annual out- of- pocket limit of [$2780])* BLOOD First 3 pints Next $[185] of Medicare Approved Amounts**** Remainder of Medicare Approved Amounts $0 $0 Generally 80% 75% $0 Generally 15% 25%♦ $[185] (Part B deductible) ♦ Generally 5%♦ CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 * This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[2780] per year. However, this limit does NOT include charges from your provider that exceed Medicare- approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. PLAN L PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts***** Remainder of Medicare Approved Amounts 100% $0 80% $0 $0 15% $0 $[185] (Part B deductible) ♦ 5% ♦ *****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare PLAN M MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used: —Additional 365 days —Beyond the additional 365 days All but $[1364] All but $[341] a day All but $[682] a day $0 $0 $[682](50% of Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 $[682](50% of 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 $[170.50] a day $0 $0 Up to $[170.50] a day $0 $0 $0 All costs BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness All but very limited co-payment/ coinsurance for outpatient drugs and inpatient respite care Medicare co- payment/ coinsurance $0 ** 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 M MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR * Once you have been billed $[185] 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 $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $0 Generally 20% $[185] (Part B deductible) $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints Next $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $0 20% $0 $[185] (Part B deductible) $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PLAN M 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 $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 100% $0 80% $0 $0 20% $0 $[185](PartB deductible) $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 maxi-mum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum PLAN N MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used: —Additional 365 days —Beyond the additional 365 days All but $[1364] All but $[341] a day All but $[682] a day $0 $0 $[1364](Part A deductible) $[341] a day $[682] 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 $[170.50] a day $0 $0 Up to $[170.50] a day $0 $0 $0 All costs BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness All but very limited co-payment/ coinsurance for outpatient drugs and inpatient respite care Medicare co- payment/ coinsurance $0 ** 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 N MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board; general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after -While using 60 lifetime reserve days -Once lifetime reserve days are used. ---Additional 365 days ---Beyond the additional 365 days All but $[1364] All but $[341] a day All but $[682] a day $0 $0 $[1364] (Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 $0 $0 $0 $0 All costs SERVICES MEDICARE PAYS PLAN PAYS YOU PAY SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days 21st thru 100th day 101st day and after All approved amounts All but $[170.50] a day $0 $0 Up to $[170.50] a day $0 $0 $0 All costs BLOOD First 3 pints Additional Amounts $0 100% Three pints $0 $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness All but very limited co- payment coinsurance for outpatient drugs and inpatient respite care Medicare co- payment/coninsurance $0 **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 the billed charges and the amount Medicare would have paid. PLAN N MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES –IN OR OUT OF THE HOPSITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, impatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $0 Balances, other than up to [$20] per office visit and up to [$50] per emergency room visit. The co- payment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. $[185] (Part B deductible) Up to [$20] per office visit and up to [$50] per emergency room visit. The co-payment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Party A expense. Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints Next $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $0 20% $0 $[185] (Part B deductible) $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PLAN N 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 $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 100% $0 80% $0 $0 20% $0 $[185] (Part B deductible) $0 PLAN N 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 Source: Miss Code Ann §83-9-103(Rev. 2011) E. Notice Regarding Policies or Certificates Which Are Not Medicare Supplement Policies. 1. Any accident and sickness insurance policy or certificate, other than a Medicare supplement policy, a policy issued pursuant to a contract under Section 1876 of the Federal Social Security Act (42 U.S.C. § 1395 et seq.), disability income policy; or other policy identified in Rule 10.03B of this regulation, issued for delivery in this state to persons eligible for Medicare shall notify insureds under the policy that the policy is not a Medicare supplement policy or certificate. The notice shall either be printed or attached to the first page of the outline of coverage delivered to insureds under the policy, or if no outline of coverage is delivered, to the first page of the policy, or certificate delivered to insureds. The notice shall be in no less than twelve (12) point type and shall contain the following language: “THIS [POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT [POLICY OR CONTRACT]. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company.” 2. Applications provided to persons eligible for Medicare for the health insurance policies or certificates described in Subsection D(1) shall disclose, using the applicable statement in Appendix C, the extent to which the policy duplicates Medicare. The disclosure statement shall be provided as a part of, or together with, the application for the policy or certificate.