Administrative Code

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Virginia Administrative Code
Title 14. Insurance
Agency 5. State Corporation Commission, Bureau of Insurance
Chapter 170. Rules Governing Minimum Standards for Medicare Supplement Policies
8/6/2020

14VAC5-170-150. Required Disclosure Provisions.

A. General rules.

1. Medicare supplement policies and certificates shall include a renewal or continuation provision. The language or specifications of such provision shall be consistent with the type of contract issued. The provision shall be appropriately captioned, shall appear on the first page of the policy, and shall include any reservation by the issuer of the right to change premiums and any automatic renewal premium increases based on the policyholder's age. Medicare supplement policies or certificates which are attained age rated shall include a clear and prominent statement, in at least 14 point type, disclosing that premiums will increase due to changes in age and the frequency under which such changes will occur.

2. 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 shall 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 shall 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. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge shall be set forth in the policy.

3. Medicare supplement policies or certificates shall not provide for the payment of benefits based on standards described as "usual and customary," "reasonable and customary" or words of similar import.

4. If a Medicare supplement policy or certificate contains any limitations with respect to preexisting conditions, such limitations shall appear as a separate paragraph of the policy and be labeled as "Preexisting Condition Limitations."

5. Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the policyholder or certificateholder shall have the right to return the policy or certificate within 30 days of its delivery and to have all premiums made for the policy refunded if, after examination of the policy or certificate, the insured person is not satisfied for any reason.

6. Issuers of accident and sickness policies or certificates which provide hospital or medical expense coverage on an expense incurred or indemnity basis to a person or persons eligible for Medicare shall 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 12 point type. Delivery of the guide shall be made whether or not such policies or certificates are advertised, solicited or issued as Medicare supplement policies or certificates as defined in this chapter. Except in the case of direct response issuers, delivery of the guide shall be made to the applicant at the time of application and acknowledgement of receipt of the guide shall be obtained by the issuer. Direct response issuers shall deliver the guide to the applicant upon request but not later than at the time the policy is delivered.

For the purposes of this section, "form" means the language, format, type size, type proportional spacing, bold character, and line spacing.

B. Notice requirements.

1. As soon as practicable, but no later than 30 days prior to the annual effective date of any Medicare benefit changes, an issuer shall notify its policyholders and certificateholders of modifications it has made to Medicare supplement insurance policies or certificates in a format acceptable to the State Corporation Commission. The notice shall:

a. 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

b. Inform each policyholder or certificateholder as to when any premium adjustment is to be made due to changes in Medicare.

2. The notice of benefit modifications and any premium adjustments shall be in outline form and in clear and simple terms so as to facilitate comprehension.

3. Such notices shall not contain or be accompanied by any solicitation.

C. Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 USC § 1395w-101).

D. Outline of coverage requirements for Medicare Supplement Policies.

1. Issuers shall provide an outline of coverage to all applicants at the time the application is presented to the prospective applicant and, except for direct response policies, shall obtain an acknowledgement of receipt of the outline from the applicant; and

2. 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 shall accompany such policy or certificate when it is delivered and contain the following statement, in no less than 12 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."

3. 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 shall be in the language and format prescribed below in no less than 12 point type. All plans shall be shown on the cover page, and the plans that are offered by the issuer shall be prominently identified. Premium information for plans that are offered shall be shown on the cover page or immediately following the cover page and shall be prominently displayed. The premium and mode shall be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant shall be illustrated.

4. The following items shall be included in the outline of coverage in the order prescribed in the following table.

Benefit Chart of Medicare Supplement Plans Sold with 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.

Plans C, F, and high deductible F are no longer available for sale to those who are newly eligible, as defined in 14VAC5-170-87, on or after January 1, 2020.

Note that the numerical figures in the following charts, including out-of-pocket limits and deductible amounts, are current as of January 1, 2018, and are subject to change.

Basic benefits:

Hospitalization – Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

Medical expenses – Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or copayments.

Blood – First three pints of blood each year.

Hospice – Part A coinsurance.

A

B

C

D

F

F*

G

K

L

M

N

Basic,
including 100% Part B coinsurance

Basic,
including 100% Part B coinsurance

Basic,
including 100% Part B coinsurance

Basic,
including 100% Part B coinsurance

Basic,
including 100% Part B coinsurance*

Basic,
including 100% Part B coinsurance

Hospitalization and preventive care paid at 100%; other basic benefits paid at 50%

Hospitalization and preventive care paid at 100%; other basic benefits paid at 75%

Basic,
including 100% Part B coinsurance

Basic,
including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER

Skilled nursing facility coinsurance

Skilled nursing facility coinsurance

Skilled nursing facility coinsurance

Skilled nursing facility coinsurance

50% skilled nursing facility coinsurance

75% skilled nursing facility coinsurance

Skilled nursing facility coinsurance

Skilled nursing facility coinsurance

Part A deductible

Part A deductible

Part A deductible

Part A deductible

Part A deductible

50% Part A deductible

75% Part A deductible

50% Part A deductible

Part A deductible

Part B deductible

Part B deductible

Part B excess (100%)

Part B excess (100%)

Foreign travel emergency

Foreign travel emergency

Foreign travel emergency

Foreign travel emergency

Foreign travel emergency

Foreign travel emergency

Out-of-pocket limit $4,940; paid at 100% after limit reached

Out-of-pocket limit $2,470; paid at 100% after limit reached

*Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.

PREMIUM INFORMATION

Boldface Type

We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this Commonwealth. [If the premium is based on attained age of the insured, include the following information:

1. When premiums will change;

2. The current premium for all ages;

3. A statement that premiums for other Medicare Supplement policies that are issue age or community rated do not increase due to changes in your age; and

4. A statement that while the cost of this policy at the covered individual's present age may be lower than the cost of a Medicare supplement policy that is based on issue age or community rated, it is important to compare the potential cost of these policies over the life of the policy.]

DISCLOSURES

Boldface Type

Use this outline to compare benefits and premiums among policies.

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

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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

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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 & 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 14VAC5-170-85.]

[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the State Corporation Commission.]

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 100% of the benefit 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 20162

$4,9602

$2,4802

1 Plans F and G also have a high deductible option that require first paying a plan deductible of $2,180 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible Plan G does not cover the Medicare Part B deductible. However, high deductible Plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible. High deductible Plan G is the same as high deductible Plan F except that where the annual out-of-pocket expenses are met with Medicare Part A expenses only, any subsequent Medicare Part B deductible expense incurred by the beneficiary after the required annual out-of-pocket expenses is met may not be paid for by the high deductible Plan G.

2 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.

3 Plan N pays 100% of the Part B coinsurance, except for a 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 $1,260

$0

$1,260 (Part A Deductible)

61st thru 90th day

All but $315 a day

$315 a day

$0

91st day and after:

While using 60 lifetime reserve days

All but $630 a day

$630 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 $157.50 a day

$0

Up to $157.50 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 A
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $147 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 $147 of Medicare-Approved Amounts*

$0

$0

$147 (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 $147 of Medicare-Approved Amounts*

$0

$0

$147 (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 $147 of Medicare-Approved Amounts*

$0

$0

$147 (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 $1,260

$1,260 (Part A Deductible)

$0

61st thru 90th day

All but $315 a day

$315 a day

$0

91st day and after:

While using 60 lifetime reserve days

All but $630 a day

$630 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 $157.50 a day

$0

Up to $157.50 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 $147 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 $147 of Medicare-Approved Amounts*

$0

$0

$147 (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 $147 of Medicare-Approved Amounts*

$0

$0

$147 (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 $147 of Medicare-Approved Amounts*

$0

$0

$147 (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 $1,260

$1,260 (Part A Deductible)

$0

61st thru 90th day

All but $315 a day

$315 a day

$0

91st day and after:

While using 60 lifetime reserve days

All but $630 a day

$630 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 $157.50 a day

Up to $157.50 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 $147 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 $147 of Medicare-Approved Amounts*

$0

$147 (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 $147 of Medicare-Approved Amounts*

$0

$147 (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

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 $147 of Medicare-Approved Amounts*

$0

$147 (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 $1,260

$1,260 (Part A Deductible)

$0

61st thru 90th day

All but $315 a day

$315 a day

$0

91st day and after:

While using 60 lifetime reserve days

All but $630 a day

$630 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 $157.50 a day

Up to $157.50 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 $147 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 $147 of Medicare-Approved Amounts*

$0

$0

$147 (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 $147 of Medicare-Approved Amounts*

$0

$0

$147 (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 $147 of Medicare-Approved Amounts*

$0

$0

$147 (Part B Deductible)

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 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 you have paid a calendar year $2,180 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2,180. 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 $2,180 DEDUCTIBLE,** PLAN PAYS

IN ADDITION TO $2,180 DEDUCTIBLE,** YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

All but $1,260

$1,260 (Part A Deductible)

$0

61st thru 90th day

All but $315 a day

$315 a day

$0

91st day and after:

While using 60 lifetime reserve days

All but $630 a day

$630 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 $157.50 a day

Up to $157.50 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 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 $147 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 you have paid a calendar year $2,180 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $2,180. 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 $2,180 DEDUCTIBLE,** PLAN PAYS

IN ADDITION TO $2,180 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 $147 of Medicare-Approved amounts*

$0

$147 (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 $147 of Medicare-Approved Amounts*

$0

$147 (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

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2,180 DEDUCTIBLE,** PLAN PAYS

IN ADDITION TO $2,180 DEDUCTIBLE,** YOU PAY

HOME HEALTH CARE
MEDICARE-APPROVED SERVICES

Medically necessary skilled care services and medical supplies

100%

$0

$0

Durable medical equipment

First $147 of Medicare-Approved Amounts*

$0

$147 (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 G OR HIGH DEDUCTIBLE PLAN G
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2,180 DEDUCTIBLE, PLAN PAYS

IN ADDITION TO $2,180 DEDUCTIBLE, YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

All but $1,288

$1,288 (Part A Deductible)

$0

61st thru 90th day

All but $322 a day

$322 a day

$0

91st day and after:

While using 60 lifetime reserve days

All but $644 a day

$644 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 $161 a day

Up to $161 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 DEDUCTIBLE PLAN G
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $166 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 $166 of Medicare-Approved Amounts*

$0

$0

$166 (Unless Part B Deductible has been met)

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 $166 of Medicare-Approved Amounts*

$0

$0

$166 (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

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 $166 of Medicare-Approved Amounts*

$0

$0

$166 (Unless Part B Deductible has been met)

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 K

*You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $4,940 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 $1,260

$630 (50% of Part A deductible)

$630 (50% of Part A deductible)♦

61st thru 90th day

All but $315 a day

$315 a day

$0

91st day and after:

While using 60 lifetime reserve days

All but $630 a day

$630 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 $157.50 a day

Up to $78.75 a day (50% of Part A coinsurance)

Up to $78.75 a day (50% of Part A coinsurance)♦

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 the 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 $147 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 $147 of Medicare-Approved Amounts****

$0

$0

$147 (Part B deductible)****♦

Preventive Benefits for Medicare covered services

Generally 80% 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 $4,940)*

BLOOD

First 3 pints

$0

50%

50%♦

Next $147 of Medicare Approved Amounts****

$0

$0

$147 (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 $4,940 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.

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 $147 of Medicare-Approved Amounts*****

$0

$0

$147 (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 $2,470 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 $1,260

$945 (75% of Part A deductible)

$315 (25% of Part A deductible)♦

61st thru 90th day

All but $315 a day

$315 a day

$0

91st day and after:

While using 60 lifetime reserve days

All but $630 a day

$630 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 $157.50a day

Up to $118.13 a day (75% of Part A coinsurance)

Up to $39.38 a day (25% of Part A coinsurance)♦

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 charge and the amount Medicare would have paid.

PLAN L
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

****Once you have been billed $147 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 $147 of Medicare-Approved Amounts****

$0

$0

$147 (Part B deductible)****♦

Preventive Benefits for Medicare covered services

Generally 80% 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 $2,470)*

BLOOD

First 3 pints

$0

75%

25%♦

Next $147 of Medicare Approved Amounts****

$0

$0

$147 (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 $2,470 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.

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 $147 of Medicare-Approved Amounts*****

$0

$0

$147 (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 $1,260

$630 (50% of Part A deductible)

$630 (50% of Part A deductible)

61st thru 90th day

All but $315 a day

$315 a day

$0

91st day and after:

While using 60 lifetime reserve days

All but $630 a day

$630 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 $157.50 a day

Up to $157.50 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 charge and the amount Medicare would have paid.

PLAN M
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $147 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 $147 of Medicare-Approved Amounts*

$0

$0

$147 (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 $147 of Medicare Approved Amounts*

$0

$0

$147 (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 $147 of Medicare-Approved Amounts*

$0

$0

$147 (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 $1,260

$1,260 (Part A deductible)

$0

61st thru 90th day

All but $315 a day

$315 a day

$0

91st day and after:

While using 60 lifetime reserve days

All but $630 a day

$630 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 $157.50 a day

Up to $157.50 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 charge and the amount Medicare would have paid.

PLAN N
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $147 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 $147 of Medicare-Approved Amounts*

$0

$0

$147 (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 visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency room 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 $147 of Medicare Approved Amounts*

$0

$0

$147 (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 $147 of Medicare-Approved Amounts*

$0

$0

$147 (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

E. Notice regarding policies or certificates that are not Medicare supplement policies.

1. Any accident and sickness insurance policy or certificate issued for delivery in this Commonwealth to persons eligible for Medicare, other than a Medicare supplement policy, a policy issued pursuant to a contract under § 1876 of the federal Social Security Act (42 USC § 1395 et seq.), a disability income policy, or other policy identified in 14VAC5-170-20 B, shall notify insureds under the policy that the policy is not a Medicare supplement policy or certificate. The notice shall either be printed or attached to the first page of the outline of coverage delivered to insureds under the policy, or if no outline of coverage is delivered, to the first page of the policy, or certificate delivered to insureds. The notice shall be in no less than 12 point type and shall contain the following language:

"THIS [POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT [POLICY OR CONTRACT]. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company."

2. Applications provided to persons eligible for Medicare for the health insurance policies or certificates described in subdivision 1 of this subsection shall disclose, using the applicable statement in Appendix C, the extent to which the policy duplicates Medicare. The disclosure statement shall be provided as a part of, or together with, the application for the policy or certificate.

F. Notice requirements for attained age rated Medicare supplement policies or certificates. Issuers of Medicare supplement policies or certificates that use attained age rating shall provide a notice to all prospective applicants at the time the application is presented, and except for direct response policies or certificates, shall obtain an acknowledgement of receipt of the notice from the applicant. The notice shall be in no less than 12 point type and shall contain the information included in Appendix D. The notice shall be provided as part of, or together with, the application for the policy or certificate.

Statutory Authority

§§ 12.1-13 and 38.2-223 of the Code of Virginia.

Historical Notes

Derived from Regulation 35, Case No. INS920112, § 16, eff. July 30, 1992; amended, Volume 12, Issue 17, eff. April 28, 1996; Volume 15, Issue 15, eff. April 26, 1999; Volume 17, Issue 24, eff. September 1, 2001; Volume 19, Issue 04, eff. October 24, 2002; Volume 21, Issue 25, eff. August 15, 2005; Errata, 22:1 VA.R. 114 September 19, 2005; amended, Virginia Register Volume 25, Issue 18, eff. May 21, 2009; Volume 34, Issue 02, eff. October 1, 2017.

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