ARM 6.6.511A. SAMPLE FORMS OUTLINING COVERAGE

(1) The following amounts, as published in the Federal Register, for services furnished in the current calendar year under Medicare's hospital insurance program (Medicare Part A), must apply to the charts for Plans A, B, C, D, F, and High Deductible Plan F, G, K, L, M, and N, issued on or after June 1, 2010, in (2)(b) through (m). In each chart, the rule cited in brackets as ARM [6.6.511A(1)(a)], [6.6.511A(1)(b)], [6.6.511A(1)(c)], [6.6.511A(1)(d)], [6.6.511A(1)(e)], [6.6.511A(1)(f)], [6.6.511A(1)(g)], [6.6.511A(1)(h)], [6.6.511A(1)(i)], or [6.6.511A(1)(j)], represents the dollar amount specified in the cited rule subsection. The issuer must replace each bracket and rule cite with the correct dollar amount contained in the cited rule subsection when the issuer prints the charts: (a) inpatient hospital deductible = $1068.00; (b) daily coinsurance amount for the 61st through 90th days of hospitalization in a benefit period = $267.00; (c) daily coinsurance amount for lifetime reserve days = $534.00; (d) daily coinsurance amount for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period = $133.50; (e) 50% of inpatient hospital deductible = $534.00; (f) 75% of inpatient hospital deductible = $801.00; (g) 25% of inpatient hospital deductible = $267.00; (h) 50% of daily coinsurance amount for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period = $66.75; (i) 75% of daily coinsurance amount for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period = $100.13; and (j) 25% of daily coinsurance amount for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period = $33.38. (2) The following are sample forms of the outline of coverage for Medicare supplement policies: (a) COVER PAGE 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, are no longer available for sale. [This paragraph shall not appear after June 1, 2011.] 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] 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 the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this rule. An issuer may use additional benefit plan designations on these charts pursuant to ARM 6.6.507A(4).] [Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the commissioner.] (b) 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 $[6.6.511A(1)(a)] All but $[6.6.511A(1)(b)] a day All but $[6.6.511A(1)(c)] a day $0 $0 $0 $[6.6.511A(b)] a day $[6.6.511A(1)(c)] a day 100% of Medicare eligible expenses $0 $[6.6.511A(1)(a)] (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 $[6.6.511A(1)(d)] a day $0 $0 $0 $0 $0 Up to $[6.6.511A(1)(d)] a day 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 copayment/coinsurance for out-patient drugs and inpatient respite care $0 Balance **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 $[135] 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 $[135] of Medicare approved amounts* --Remainder of Medicare approved amounts $0 Generally 80% $0 Generally 20% $[135] (Part B deductible) $0 Part B Excess Charges (Above Medicare approved amounts) $0 $0 All costs BLOOD First 3 pints Next $[135] of Medicare ---approved amounts* Remainder of Medicare ---approved amounts $0 $0 80% All costs $0 20% $0 $[135] (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 $[135] of Medicare approved amounts* ---Remainder of Medicare approved amounts 100% $0 80% $0 $0 20% $0 $[135] (Part B deductible) $0 (c) 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. All but very limited copayment/ coinsurance for out-patient drugs and inpatient respite care Medicare copayment/ coinsurance 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 $[6.6.511A(1)(a)] All but $[6.6.511A(1)(b)] a day All but $[6.6.511A(1)(c)] a day $0 $0 $[6.6.511A(1)(a)] (Part A deductible) $[6.6.511A(1)(b)] a day $[6.6.511A(1)(c)] 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 $[6.6.511A(1)(d)] a day $0 $0 $0 $0 $0 Up to $[6.6.511A(1)(d)] a day 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 copayment/ coinsurance for out- patient drugs and inpatient respite care $0 Balance **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 $[135] 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 $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 Generally 80% $0 Generally 20% $[135] (Part B deductible) $0 Part B Excess Charges (Above Medicare approved amounts) $0 $0 All costs BLOOD First 3 pints Next $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 $0 80% All costs $0 20% $0 $[135] (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 $[135] of Medicare approved amounts* Remainder of Medicare approved amounts 100% $0 80% $0 $0 20% $0 $[135] (Part B deductible) $0 (d) 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 $[6.6.511A(1)(a)] All but $[6.6.511A(1)(b)] a day All but $[6.6.511A(1)(c)] a day $0 $0 $[6.6.511A(1)(a)] (Part A deductible) $[6.6.511A(1)(b)] a day $[6.6.511A(1)(c)] 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 $[6.6.511A(1)(d)] a day $0 $0 Up to $[6.6.511A(1)(d)] 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 coinsurance for out- patient drugs and inpatient respite care $0 Balance **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 $[135] 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 $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 Generally 80% $[135] (Part B deductible) Generally 20% $0 $0 Part B Excess Charges (Above Medicare approved amounts) $0 $0 All costs BLOOD First 3 pints Next $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 $0 80% All costs $[135] (Part B deductible) 20% $0 $0 $0 CLINICAL LABORATORY SERVICES -- 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 $[135] of Medicare approved amounts* Remainder of Medicare approved amounts 100% $0 80% $0 $[135] (Part B deductible) 20% $0 $0 $0 PLAN C 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 (e) PLAN D MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT YEAR *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 $[6.6.511A(1)(a)] All but $[6.6.511A(1)(a)] a day All but $[6.6.511A(1)(c)] a day $0 $0 $[6.6.511A(1)(a)] (Part A deductible) $[6.6.511A(1)(b)] a day $[6.6.511A(1)(c)] 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 $[6.6.511A(1)(d)] a day $0 $0 Up to $[6.6.511A(1)(d)] 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 copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ 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 $[135] 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 $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 Generally 80% $0 Generally 20% $[135] (Part B deductible) $0 Part B Excess Charges (Above Medicare approved amounts) $0 $0 All costs BLOOD First 3 pints Next $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 $0 80% All costs $0 20% $0 $[135] (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 $[135] of Medicare approved amounts* Remainder of Medicare approved amounts* 100% $0 80% $0 $0 20% $0 $[135] (Part B 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 maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum (f) 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 $[2000] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[2000]. 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 $[2000] DEDUCTIBLE, **] PLAN PAYS [IN ADDITION TO $[2000] DEDUCTIBLE, **] YOU PAY HOSPITALIZATON* 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 $[6.6.511A(1)(a)] All but [6.6.511A(1)(b)] a day All but $[6.6.511A(1)(c)] a day $0 $0 $[6.6.511A(1)(a)] (Part A deductible) $[6.6.511A(1)(b)] a day $[6.6.511A(1)(c)] a day 100% 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 $[6.6.511A(1)(d)] a day $0 $0 Up to $[6.6.511A(1)(d)] a day $0 $0 $0 All costs PLAN F or HIGH DEDUCTIBLE PLAN F MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD 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 copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare coinsurance/ 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 F or HIGH DEDUCTIBLE PLAN F MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $[135] 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 $[2000] deductible. Benefits from the high deductible Plan F will begin until out-of-pocket expenses are $[2000]. 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 $[2000] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2000] 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 $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 Generally 80% $[135] (Part B deductible) Generally 20% $0 $0 Part B excess charges (Above Medicare approved amounts) $0 100% $0 BLOOD First 3 pints Next $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 $0 80% All costs $[135] (Part B deductible) 20% $0 $0 $0 CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PLAN F or HIGH DEDUCTIBLE PLAN F PARTS A & B SERVICES MEDICARE PAYS [AFTER YOU PAY $[2000] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2000] DEDUCTIBLE,**] YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES ---Medically necessary skilled care services and medical supplies ---Durable medical equipment First $[135] of Medicare approved amounts* ---Remainder of Medicare approved amounts 100% $0 80% $0 $[135] (Part B deductible) 20% $0 $0 $0 OTHER BENEFITS - NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS [AFTER YOU PAY $[2000] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2000] 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 (g) 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 $[6.6.511A(1)(a)] All but $[6.6.511A(1)(b)] a day All but $[6.6.511A(1)(c)] a day $0 $0 $[6.6.511A(1)(a)] (Part A deductible) $[6.6.511A(1)(b)] a day $[6.6.511A(1)(c)] a day 100% 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 $[6.6.511A(1)(d)] a day $0 $0 Up to $[6.6.511A(1)(d)] 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 copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ 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 MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $[135] 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 $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 Generally 80% $0 Generally 20% $[135] (Part B deductible) $0 Part B Excess Charges (Above Medicare approved amounts) $0 100% $0 BLOOD First 3 pints Next $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 $0 80% All costs $0 20% $0 $[135] (Part B deductible) $0 CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PLAN G 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 $[135] of Medicare approved amounts* Remainder of Medicare approved amounts 100% $0 80% $0 $0 20% $0 $[135] (Part B deductible) $0 PLAN G 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 (h) PLAN K *You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[4620] 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 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 $[6.6.511A(1)(a)] All but [6.6.511A(1)(b)] a day All but $[6.6.511A(1)(c)] a day $0 $0 $[6.6.511A(1)(a)] (50% of Part A deductible) $[6.6.511A(1)(b)] a day $[6.6.511A(1)(c)] a day 100% of Medicare eligible expenses $0 $[6.6.511A(1)(e)]♦ $0 $0 $0*** All costs PLAN K MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD 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 $[6.6.511A(1)(d)] a day $0 $0 Up to $[6.6.511A(1)(h)] a day $0 $0 Up to $[6.6.511A(1)(h)]♦ 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 copayment/ coinsurance for outpatient drugs and inpatient respite care 50% of copayment/ coinsurance 50% of Medicare copayment/ 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 $[135] 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 $[135] of Medicare approved amounts* Preventive benefits for Medicare covered services Remainder of Medicare approved amounts $0 Generally 75% or more of Medicare approved amounts Generally 80% $0 Remainder of Medicare approved amounts Generally 10% $[135] (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 [$4620])* BLOOD First 3 pints Next $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 $0 Generally 80% 50% $0 Generally 10% 50%♦ $[135] (Part B deductible)****♦ Generally 10% CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 *This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[4620] 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 $[135] of Medicare approved amounts***** Remainder of Medicare approved amounts 100% $0 80% $0 $0 10% $0 $[135] (Part B deductible)♦ 10%♦ *****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare (i) 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 $[2310] each calendar year. The amounts that count toward your annual limit are noted with a diamond (♦) 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 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 $[6.6.511A(1)(a)] All but $[6.6.511A(1)(b)] a day All but $[6.6.511A(1)(c)] a day $0 $0 $[6.6.511A(1)(f)] (75% of Part A deductible) $[6.6.511A(1)(b)] a day $[6.6.511A(1)(c)] a day 100% of Medicare eligible expenses $0 $[6.6.511A(1)(g)] 25% of Part A deductible♦ $0 $0 $0*** All costs PLAN L MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD 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 $[6.6.511A(1)(d)] a day $0 $0 Up to [6.6.511A(1)(i)] a day $0 $0 Up to $[6.6.511A](1)(j)] a day♦ 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 copayment/coinsurance for outpatient drugs and inpatient respite care 75% of copayment 25% of copayment/ 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 $[135] 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 $[135] of Medicare approved amounts**** Preventive benefits for Medicare covered services Remainder of Medicare approved amounts $0 Generally 75% or more of Medicare approved amounts Generally 80% $0 Remainder of Medicare approved amounts Generally 15% $[135] (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 [$2310])* BLOOD First 3 pints Next $[135] of Medicare approved amounts**** Remainder of Medicare approved amounts $0 $0 Generally 80% 75% $0 Generally 15% 25%♦ $[135] (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 $[2310] 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 $[135] of Medicare approved amounts***** Remainder of Medicare approved amounts 100% $0 80% $0 $0 15% $0 $[135] (Part B deductible)♦ 5%♦ *****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. (j) 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 through 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 $[6.6.511A(1)(a) ] All but $[6.6.511A(1)(b)] a day All but $[6.6.511A(1)(c)] a day $0 $0 $[6.6.511A(1)(e)] (50% of Part A deductible) $[6.6.511A(1)(b)] a day $[6.6.511A(1)(c)] a day 100% of Medicare eligible expenses $0 $[6.6.511A(1)(e)] (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 through 100th day 101st day and after All approved amounts All but $[6.6.511A(1)(d)] a day $0 $0 Up to $[6.6.511A(1)(d)] 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 copayment/ coinsurance for outpatient drug and inpatient respite care Medicare copayment/ 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 $[135] 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 $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 Generally 80% $0 Generally 20% $[135] (Part B deductible) $0 Part B Excess Charges (Above Medicare approved amounts) $0 $0 All costs BLOOD First 3 pints Next $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 $0 80% All costs $0 20% $0 $[135] (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 $[135] of Medicare approved amounts* Remainder of Medicare approved amounts 100% $0 80% $0 $0 20% $0 $[135] (Part B deductible) $0 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 (k) 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 through 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 $[6.6.511A(1)(a)] All but $[6.6.511A(1)(b)] a day All but $[6.6.511A(1)(c)] a day $0 $0 $[6.6.511A(1)(a)] (Part A deductible) $[6.6.511A(1)(b)] a day $[6.6.511A(1)(c)] 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 through 100th day 101st day and after All approved amounts All but $[6.6.511A(1)(d)] a day $0 $0 Up to $[6.6.511A(1)(d)] a day $0 $0 $0 All costs MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD 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 copayment/coinsurance for outpatient drug and inpatient respite care Medicare copayment/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 B) - MEDICAL SERVICES - PER CALENDAR YEAR * Once you have been billed $[135] 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 $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 Generally 80% $0 Balance, other than up to [$20] per office visit and up to [$50] per emergency room visit. The copayment 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. $[135] (Part B deductible) Up to [$20] per office visit and up to [$50] per emergency room visit. The copayment 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. Part B Excess Charges (Above Medicare approved amounts) $0 $0 All costs BLOOD First 3 pints Next $[135] of Medicare approved amounts* Remainder of Medicare approved amounts $0 $0 80% All costs $0 20% $0 $[135] (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 $[135] of Medicare approved amounts* Remainder of Medicare approved amounts 100% $0 80% $0 $0 20% $0 $[135] (Part B deductible) $0 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