Required disclosure provisions

1. General rules. a. Medicare supplement policies and certificates must include a renewal or continuation provision. The language or specifications of the provision must be consistent with the type of contract issued. Such provision must be appropriately captioned and must appear on the first page of the policy, and must include any reservation by the issuer of the right to change premiums and any automatic renewal premium increases based on the policyholder's age. b. Except for riders or endorsements by which the issuer effectuates a request made in writing by the insured, exercises a specifically reserved right under a Medicare supplement policy, or is required to reduce or eliminate benefits to avoid duplication of Medicare benefits, all riders or endorsements added to a Medicare supplement policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy must require a signed acceptance by the insured. After the date of policy or certificate issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term must be agreed to in writing signed by the insured, unless the benefits are required by the minimum standards for Medicare supplement policies, or if the increased benefits or coverage is required by law. When a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge must be set forth in the policy. c. Medicare supplement policies or certificates may not provide for the payment of benefits based on standards described as "usual and customary", "reasonable and customary", or words of similar import. d. If a Medicare supplement policy or certificate contains any limitations with respect to preexisting conditions, such limitations must appear as a separate paragraph of the policy and be labeled as "preexisting condition limitations". e. Medicare supplement policies and certificates must have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the policyholder or certificate holder has the right to return the policy or certificate within thirty days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the insured person is not satisfied for any reason. f. (1) Issuers of accident and sickness policies or certificates which provide hospital or medical expense coverage on an expense incurred or indemnity basis to persons eligible for Medicare must provide to those applicants a guide to health insurance for people with Medicare in the form developed jointly by the national association of insurance commissioners and the centers for Medicare and Medicaid services and in a type size no smaller than twelve-point type. Delivery of the guide must be made whether or not such policies or certificates are advertised, solicited, or issued as Medicare supplement policies or certificates as defined in this regulation. Except in the case of direct response issuers, delivery of the guide must be made to the applicant at the time of application and acknowledgment of receipt of the guide must be obtained by the insurer. Direct response issuers must deliver the guide to the applicant upon request but not later than at the time the policy is delivered. (2) For the purposes of this section, "form" means the language, format, type size, type proportional spacing, bold character, and line spacing. 2. Notice requirements. a. As soon as practicable, but no later than thirty days prior to the annual effective date of any Medicare benefit changes, an issuer must notify its policyholders and certificate holders of modifications it has made to Medicare supplement insurance policies or certificates in a format acceptable to the commissioner. The notice must: (1) Include a description of revisions to the Medicare program and a description of each modification made to the coverage provided under the Medicare supplement policy or certificate; and (2) Inform each policyholder or certificate holder as to when any premium adjustment is to be made due to changes in Medicare. b. The notice of benefit modifications and any premium adjustments must be in outline form and in clear and simple terms so as to facilitate comprehension. c. Such notices may not contain or be accompanied by any solicitation. 3. Medicare Prescription Drug Improvement and Modernization Act of 2003 notice requirements. Issuers must comply with any notice requirements of the Medicare Prescription Drug Improvement and Modernization Act of 2003. 4. Outline of coverage requirements for Medicare supplement policies. a. Issuers must provide an outline of coverage to all applicants at the time application is presented to the prospective applicant and, except for direct response policies, must obtain an acknowledgment of receipt of the outline from the applicant; and b. If an outline of coverage is provided at the time of application and the Medicare supplement policy or certificate is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany such policy or certificate when it is delivered and contain the following statement, in no less than twelve-point type, immediately above the company name: "NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued." c. The outline of coverage provided to applicants pursuant to this section consists of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage must be in the language and format prescribed below in no less than twelve-point type. All plans must be shown on the cover page, and the plans that are offered by the issuer must be prominently identified. Premium information for plans that are offered must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and mode must be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant must be illustrated. d. The following items must be included in the outline of coverage in the order prescribed below: 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 percent 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 *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 [$2,240] deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed [$2,240]. 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. Out-of-pocket limit [$5,240]; paid at 100% after limit reached Out-of-pocket limit [$2,620]; paid at 100% after limit reached 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 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 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 regulation. An issuer may use additional benefit plan designations on these charts pursuant to subsection 4 of Section 45-06-01.1-07.1.] [Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the commissioner.] 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  means one hundred percent of the benefits is paid. Benefits Plans Available to All Applicants Medicare First Eligible Before 2020 Only A B D G1 K L M N C F1 Medicare part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)           Medicare part B coinsurance or copayment     50% 75%   Copays apply3   Blood (first three pints)     50% 75%     Part A hospice care coinsurance or copayment 50% 75%     Skilled nursing facility coinsurance 50% 75%     Medicare part A deductible 50% 75% 50%    Medicare part B deductible   Medicare part B excess charges   Foreign travel emergency (up to plan limits)        Out-of-pocket limit in [2018]2 [$5,240]2 [$2,620]2 1Plans F and G also have a high deductible option which require first paying a plan deductible of [$2,240] before the plan begins to pay. Once the plan deductible is met, the plan pays one hundred percent 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. 2Plans K and L pay one hundred percent of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit. 3Plan N pays one hundred percent of the part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission. 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 All but [$1,340] $0 [$1,340] (Part A deductible) 61st thru 90th day All but [$335] a day [$335] a day $0 91st day and after: --While using 60 lifetime reserve days All but [$670] a day [$670] a day $0 --Once lifetime reserve days are used: --Additional 365 days $0 100% of Medicare-eligible expenses $0** --Beyond the additional 365 days $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 All approved amounts $0 $0 21st thru 100th day All but [$167.50] a day $0 Up to [$167.50] a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a All but very limited copayment/coinsurance for Medicare copayment/coinsurance $0 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY doctor's certification of terminal illness. outpatient drugs and inpatient respite care ** 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 [$183] 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 [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $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 100% $0 $0 --Durable medical equipment First [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $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 All but [$1,340] [$1,340] (Part A deductible) $0 61st thru 90th day All but [$335] a day [$335] a day $0 91st day and after: --While using 60 lifetime reserve days All but [$670] a day [$670] a day $0 --Once lifetime reserve days are used: --Additional 365 days $0 100% of Medicare-eligible expenses $0** --Beyond the additional 365 days $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 All approved amounts $0 $0 21st thru 100th day All but [$167.50] a day $0 Up to [$167.50] a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $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 B MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR * Once you have been billed [$183] 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 [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $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 100% $0 $0 --Durable medical equipment First [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $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 All but [$1,340] [$1,340] (Part A deductible) $0 61st thru 90th day All but [$335] a day [$335] a day $0 91st day and after: --While using 60 lifetime reserve days All but [$670] a day [$670] a day $0 --Once lifetime reserve days are used: --Additional 365 days $0 100% of Medicare-eligible expenses $0** --Beyond the additional 365 days $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 All approved amounts $0 $0 21st thru 100th day All but [$167.50] a day Up to [$167.50] a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $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 C MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR * Once you have been billed [$183] 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 [$183] of Medicare-approved amounts* $0 [$183] (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare-approved amounts* $0 [$183] (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $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 100% $0 $0 --Durable medical equipment First [$183] of Medicare-approved amounts* $0 [$183] (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $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 $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 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 All but [$1,340] [$1,340] (Part A deductible) $0 61st thru 90th day All but [$335] a day [$335] a day $0 91st day and after: --While using 60 lifetime reserve days All but [$670] a day [$670] a day $0 --Once lifetime reserve days are used: --Additional 365 days $0 100% of Medicare-eligible expenses $0** --Beyond the additional 365 days $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 All approved amounts $0 $0 21st thru 100th day All but [$167.50] a day Up to [$167.50] a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $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 [$183] 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 [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $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 100% $0 $0 --Durable medical equipment First [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $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 $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 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 [$2,240] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are [$2,240]. 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 [$2,240] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO [$2,240] DEDUCTIBLE,**] YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but [$1,340] [$1,340] (Part A deductible) $0 61st thru 90th day All but [$335] a day [$335] a day $0 91st day and after: While using 60 lifetime reserve days All but [$670] a day [$670] a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare-eligible expenses $0*** Beyond the additional 365 days $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 All approved amounts $0 $0 21st thru 100th day All but [$167.50] a day Up to [$167.50] a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $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 F or HIGH DEDUCTIBLE PLAN F MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR * Once you have been billed [$183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. [** This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year [$2,240] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are [$2,240]. 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 [$2,240] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO [$2,240] 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 [$183] of Medicare-approved amounts* $0 [$183] (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare-approved amounts* $0 [$183] (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $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 [$2,240] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO [$2,240] DEDUCTIBLE,**] YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES --Medically necessary skilled care services and medical supplies 100% $0 $0 --Durable medical equipment First [$183] of Medicare-approved amounts* $0 [$183] (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 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. [** This high deductible plan pays the same benefits as Plan G after one has paid a calendar year [$2,240] deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are [$2,240]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.] SERVICES MEDICARE PAYS [AFTER YOU PAY [$2,240] DEDUCTIBLE, **] PLAN PAYS [IN ADDITION TO [$2,240] DEDUCTIBLE, **] YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but [$1,340] [$1,340] (Part A deductible) $0 61st thru 90th day All but [$335] a day [$335] a day $0 91st day and after: --While using 60 lifetime reserve days All but [$670] a day [$670] a day $0 --Once lifetime reserve days are used: --Additional 365 days $0 100% of Medicare-eligible expenses $0*** --Beyond the additional 365 days $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 All approved amounts $0 $0 21st thru 100th day All but [$167.50] a day Up to [$167.50] a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $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 or HIGH DEDUCIBLE PLAN G MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR * Once you have been billed [$183] 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 G after one has paid a calendar year [$2,240] deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are [$2,240]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.] SERVICES MEDICARE PAYS [AFTER YOU PAY [$2,240] DEDUCTIBLE, **] PLAN PAYS [IN ADDITION TO [$2,240] 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 [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare-approved amounts* $0 $0 [$183] (unless Part B deductible has been met) Remainder of Medicare-approved amounts 80% 20% $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 [$2,240] DEDUCTIBLE, **] PLAN PAYS [IN ADDITION TO [$2,240] DEDUCTIBLE, **] YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES --Medically necessary skilled care services and medical supplies 100% $0 $0 --Durable medical equipment First [$183] of Medicare-approved amounts* $0 $0 [$183] (unless Part B deductible has been met) Remainder of Medicare-approved amounts 80% 20% $0 PLAN G or HIGH DEDUCTIBLE PLAN G OTHER BENEFITS - NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS [AFTER YOU PAY [$2,240] DEDUCTIBLE, **] PLAN PAYS [IN ADDITION TO [$2,240] 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 $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 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 [$5,240] 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 All but [$1,340] [$670] (50% of Part A deductible) [$670] (50% of Part A deductible)♦ 61st thru 90th day All but [$335] a day [$335] a day $0 91st day and after: --While using 60 lifetime reserve days All but [$670] a day --Once lifetime reserve days are used: [$670] a day $0 --Additional 365 days $0 100% of Medicare-eligible expenses $0*** --Beyond the additional 365 days $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 All approved amounts $0 $0 21st thru 100th day All but [$167.50] a day Up to [$83.75] a day Up to [$183.75] a day♦ 101st day and after $0 $0 All costs BLOOD First 3 pints $0 50% 50%♦ Additional amounts 100% $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 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 [$183] 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 [$183] of Medicare-approved amounts**** $0 $0 [$183] (Part B deductible)****♦ Preventive benefits for Medicare-covered services Generally 75% or more of Medicare-approved amounts Remainder of Medicare-approved amounts All costs above Medicare-approved amounts Remainder of Medicare-approved amounts Generally 80% Generally 10% 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 [$5,240])* BLOOD First 3 pints $0 50% 50%♦ Next [$183] of Medicare-approved amounts**** $0 $0 [$183] (Part B deductible)****♦ Remainder of Medicare-approved amounts Generally 80% Generally 10% 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 [$5,240] 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 100% $0 $0 --Durable medical equipment First [$183] of Medicare-approved amounts***** $0 $0 [$183] (Part B deductible)♦ Remainder of Medicare-approved amounts 80% 10% 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 [$2,620] 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 All but [$1,340] [$1,005] (75% of Part A deductible) [$335] (25% of Part A deductible)♦ 61st thru 90th day All but [$335] a day [$335] a day $0 91st day and after: --While using 60 lifetime reserve days All but [$670] a day [$670] a day $0 --Once lifetime reserve days are used: --Additional 365 days $0 100% of Medicare-eligible expenses $0*** --Beyond the additional 365 days $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 All approved amounts $0 $0 21st thru 100th day All but [$167.50] a day Up to [$125.63] a day Up to [$41.88] a day♦ 101st day and after $0 $0 All costs BLOOD First 3 pints $0 75% 25%♦ Additional amounts 100% $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 75% of copayment/coinsurance 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 [$183] 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 [$183] of Medicare-approved amounts**** $0 $0 [$183] (Part B deductible)****♦ Preventive benefits for Medicare-covered services Generally 75% or more of Medicare-approved amounts Remainder of Medicare-approved amounts All costs above Medicare-approved amounts Remainder of Medicare-approved amounts Generally 80% Generally 15% 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 [$2,620])* BLOOD First 3 pints $0 75% 25%♦ Next [$183] of Medicare-approved amounts**** $0 $0 [$183] (Part B deductible)♦ Remainder of Medicare-approved amounts Generally 80% Generally 15% 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 [$2,620] 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 100% $0 $0 --Durable medical equipment First [$183] of Medicare-approved amounts***** $0 $0 [$183] (Part B deductible)♦ Remainder of Medicare-approved amounts 80% 15% 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 All but [$1,340] [$670] (50% of Part A deductible) [$670] (50% of Part A deductible) 61st thru 90th day All but [$335] a day [$335] a day $0 91st day and after: --While using 60 lifetime reserve days All but [$670] a day [$670] a day $0 --Once lifetime reserve days are used: --Additional 365 days $0 100% of Medicare-eligible expenses $0** --Beyond the additional 365 days $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 All approved amounts $0 $0 21st thru 100th day All but [$167.50] a day Up to [$167.50] a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $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 M MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR * Once you have been billed [$183] 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 [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $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 100% $0 $0 First [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $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 $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 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 All but [$1,340] [$1,340] (Part A deductible) $0 61st thru 90th day All but [$335] a day [$335] a day $0 91st day and after: --While using 60 lifetime reserve days All but [$670] a day [$670] a day $0 --Once lifetime reserve days are used: --Additional 365 days $0 100% of Medicare-eligible expenses $0** --Beyond the additional 365 days $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 All approved amounts $0 $0 21st thru 100th day All but [$167.50] a day Up to [$167.50] a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $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 N MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR * Once you have been billed [$183] 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 [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts Generally 80% 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. 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 $0 All costs $0 Next [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $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 100% $0 $0 First [$183] of Medicare-approved amounts* $0 $0 [$183] (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $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 $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 5. Notice regarding policies or certificates that are not Medicare supplement policies. a. 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 Social Security Act [42 U.S.C. 1395 et seq.]; disability income policy; or other policy identified in subsection 2 of section 45-06-01.1-01, issued for delivery in this state to persons eligible for Medicare, must notify insureds under the policy that the policy is not a Medicare supplement policy or certificate. The notice must 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 must be in no less than twelve-point type and must 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." b. Applications provided to persons eligible for Medicare for the health insurance policies for certificates described in subdivision a must disclose, using the applicable statement in appendix C, the extent to which the policy duplicates Medicare. The disclosure statement must be provided as a part of, or together with, the application for the policy or certificate.