Md. Code Regs. 31.10.06.30

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.10.06.30 - Outlines of Coverage for Standardized Medicare Supplement Benefit Plans

A. Forms.

(1) The issuer shall include in the outline of coverage for:

(a) Policies or certificates sold with an effective date for coverage on or after June 1, 2010 and before January 1, 2020, the forms that appear in §§B(1), C-G, H(1), and I-L of this regulation, in the order that the forms appear in this regulation; and

(b) Policies and certificates with an effective date for coverage on or after January 1, 2020, the forms that appear in §§B(2), C-G, H(2), and I-L of this regulation, in the order that the forms appear in this regulation.

(2) The term "certificate" shall be substituted for the word "policy" throughout the outline of coverage, where appropriate.

B. Cover Page.

(1) Benefit Chart of Medicare Supplement Plans Sold With an Effective Date for Coverage on or After June 1, 2010 and Before January 1, 2020.

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% 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	FF*	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% PartB 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
		PartB Deductible		PartB Deductible
				PartB Excess (100%)	PartB Excess (100%)
		Foreign Travel Emergency	Foreign Travel Emergency	Foreign Travel Emergency	Foreign Travel Emergency			Foreign Travel Emergency	Foreign Travel Emergency
						Out-of-pocket limit $ {Insert Plan K out-of-pocket limit}; paid at 100% after limit reached	Out-of-pocket limit $ {Insert Plan L out-of-pocket limit}; 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 ${insert amount of Plan F high deductible} deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed ${insert amount of Plan F high deductible}. 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 {BoldfaceType}

We {insert insurer'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.}

READ YOUR POLICY VERY CAREFULLY {BoldfaceType}

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 {BoldfaceType}

If you find that you are not satisfied with your policy, you may return it to {insert insurer'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 {BoldfaceType}

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 {BoldfaceType}

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 Regulation .28G of this chapter.}

{Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the Commissioner.}

(2) 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 [TICK] 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
	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)	[TICK]	[TICK]	[TICK]	[TICK]	[TICK]	[TICK]	[TICK]	[TICK]	[TICK]	[TICK]
Medicare Part B coinsurance or Copayment	[TICK]	[TICK]	[TICK]	[TICK]	50%	75%	[TICK]	copays apply³	[TICK]	[TICK]
Blood (first three pints)	[TICK]	[TICK]	[TICK]	[TICK]	50%	75%	[TICK]	[TICK]	[TICK]	[TICK]
Part A hospice care coinsurance or copayment	[TICK]	[TICK]	[TICK]	[TICK]	50%	75%	[TICK]	[TICK]	[TICK]	[TICK]
Skilled nursing facility coinsurance			[TICK]	[TICK]	50%	75%	[TICK]	[TICK]	[TICK]	[TICK]
Medicare Part A deductible		[TICK]	[TICK]	[TICK]	50%	75%	50%	[TICK]	[TICK]	[TICK]
Medicare Part B deductible									[TICK]	[TICK]
Medicare Part B excess charges				[TICK]						[TICK]
Foreign travel emergency (up to plan limits)			[TICK]	[TICK]			[TICK]	[TICK]	[TICK]	[TICK]
Out-of-pocket limit					{Insert PlanK out-of-pocket limit}²	{Insert PlanL out-of-pocket limit}²

¹ Plans F and G also have a high deductible option which require first paying a plan deductible of {Insert amount of Plans F and G high deductible} 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.

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 co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that do not result in an inpatient admission.

PREMIUM INFORMATION {BoldfaceType}

READ YOUR POLICY VERY CAREFULLY {BoldfaceType}

RIGHT TO RETURN POLICY {BoldfaceType}

POLICY REPLACEMENT {BoldfaceType}

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 {BoldfaceType}

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 {BoldfaceType}

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

{Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the Commissioner.}

C. Plan A.

PLANA

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 $ {Insert amount of Medicare Part A deductible}	$0	$ {Insert amount of Medicare Part A Deductible}
61st thru 90th day	All but $ {Insert amount equal to 25% of Medicare Part A deductible} a day	$ {Insert amount equal to 25% of Medicare Part A deductible} a day	$0
91st day and after:
- While using 60 lifetime reserve days	All but $ {Insert amount equal to 50% of Medicare Part A deductible} a day	$ {Insert amount equal to 50% of Medicare Part A deductible} 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 $ {Insert amount equal to 12.5% of Medicare Part A deductible} a day	$0	Up to $ {Insert amount equal to 12.5% of Medicare Part A deductible} 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 ${Insert amount of Medicare Part B deductible} 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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Part B Deductible} (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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Part B deductible} (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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Part B deductible} (Part B Deductible)
Remainder of Medicare-approved amounts	80%	20%	$0

D. Plan B.

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 $ {Insert amount of Medicare Part A deductible}	$ {Insert amount of Medicare Part A deductible} (Part A Deductible)	$0
61st thru 90th day	All but $ {Insert amount equal to 25% of Medicare Part A deductible} a day	$ {Insert amount equal to 25% of Medicare Part A deductible} a day	$0
91st day and after:
- While using 60 lifetime reserve days	All but $ {Insert amount equal to 50% of Medicare Part A deductible} a day	$ {Insert amount equal to 50% of Medicare Part A deductible} 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 $ {Insert amount equal to 12.5% of Medicare Part A deductible} a day	$0	Up to $ {Insert amount equal to 12.5% of Medicare Part A deductible} 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

PLAN B

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

*Once you have been billed $ {Insert amount of Medicare Part B deductible} 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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount equal of Medicare Part B deductible} (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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Part B deductible} (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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Part B deductible} (Part B Deductible)
Remainder of Medicare-approved amounts	80%	20%	$0

E. Plan C.

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 $ {Insert amount of Medicare Part A deductible}	$ {Insert amount of Medicare Part A} (Part A Deductible)	$0
61st thru 90th day	All but $ {Insert amount equal to 25% of Medicare Part A deductible} a day	{Insert amount equal to 25% of Medicare Part A deductible} a day	$0
91st day and after:
- While using 60 lifetime reserve days	All but $ {Insert amount equal to 50% of Medicare Part A deductible} a day	$ {Insert amount equal to 50% of Medicare Part A deductible} 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 $ {Insert amount equal to 12.5% of Medicare Part A deductible} a day	Up to $ {Insert amount equal to 12.5% of Medicare Part A deductible} 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

PLAN C

MEDICARE (PART B)-MEDICAL SERVICES-PER 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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$ {Insert amount of Medicare Part B deductible} (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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$ {Insert amount of Medicare Part B deductible} (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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$ {Insert amount of Medicare Part B deductible} (Part B Deductible)	$0
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

F. Plan D.

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 ${Insert amount of Medicare Part A deductible}	$ {Insert amount of Medicare Part A deductible} (Part A Deductible)	$0
61st thru 90th day	All but $ {Insert amount equal to 25% of Medicare Part A deductible} a day	$ {Insert amount equal to 25% of Medicare Part A deductible} a day	$0
91st day and after:
- While using 60 lifetime reserve days	All but $ {Insert amount equal to 50% of Medicare Part A deductible} a day	$ {Insert amount equal to 50% of Medicare Part A deductible} 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 $ {Insert amount equal to 12.5% of Medicare Part A deductible} a day	Up to $ {Insert amount equal to 12.5% of Medicare Part A deductible} 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

PLAN D

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

*Once you have been billed ${Insert amount of Medicare Plan B deductible} 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 {Insert amount of Medicare Plan B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Plan B deductible} (PartB 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 $ {Insert amount of Medicare Plan B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Plan B deductible} (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 $ {Insert amount of Medicare Plan B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Plan B deductible} (PartB 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

G. Plan F or High Deductible Plan F.

PLAN F or HIGH DEDUCTIBLE PLAN F

MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD

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

{**This high deductible plan pays the same benefits as plan F after you have paid a calendar year ${Insert amount of Plan F high deductible} deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $ {Insert amount of Plan F high deductible}. 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 $ {Insert amount of Plan F high deductible} DEDUCTIBLE,**} PLAN PAYS	{IN ADDITION TO $ {Insert amount of Plan F high deductible} DEDUCTIBLE,**} YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but ${Insert amount of Medicare Part A deductible}	$ {Insert amount of Medicare Part A deductible} (Part A Deductible)	$0
61st thru 90th day	All but $ {Insert amount equal to 25% of Medicare Part A deductible} a day	$ {Insert amount equal to 25% of Medicare Part A deductible} a day	$0
91st day and after:
- While using 60 lifetime reserve days	All but $ {Insert amount equal to 50% of Medicare Part A deductible} a day	$ {Insert amount equal to 50% of Medicare Part A deductible} 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 $ {Insert amount equal to 12.5% of Medicare Part A deductible} a day	Up to $ {Insert amount equal to 12.5% of Medicare Part A deductible} 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 ${Insert amount of Medicare Part B deductible} of Medicare-approved amounts for the covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES	MEDICARE PAYS	{AFTER YOU PAY $ {Insert amount of Plan F high deductible} DEDUCTIBLE,**} PLAN PAYS	{IN ADDITION TO $ {Insert amount of Plan F high deductible} 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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$ {Insert amount of Medicare Part B deductible} (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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$ {Insert amount of Medicare Part B deductible} (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 $ {Insert amount of Plan F high deductible} DEDUCTIBLE,**} PLAN PAYS	{IN ADDITION TO $ {Insert amount of Plan F high deductible} DEDUCTIBLE,**} YOU PAY
HOME HEALTH CARE MEDICARE APPROVED SERVICES
- Medically necessary skilled care services and medical supplies	100%	$0	$0
- Durable medical equipment
First $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$ {Insert amount of Medicare Part B deductible} (PartB Deductible)	$0
Remainder of Medicare-approved amounts	80%	20%	$0

OTHER BENEFITS-NOT COVERED BY MEDICARE

SERVICES	MEDICARE PAYS	{AFTER YOU PAY $ {Insert amount of Plan F high deductible} DEDUCTIBLE,**} PLAN PAYS	{IN ADDITION TO $ {Insert amount of Plan F high deductible} 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

H. Plan G and Plan G or High Deductible Plan G.

(1) PLAN G

PLAN G

MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but $ {Insert amount of Medicare plan A deductible}	$ {Insert amount of Medicare plan A deductible} (Part A Deductible)	$0
61st thru 90th day	All but $ {Insert amount equal to 25% of Medicare plan A deductible} a day	$ {Insert amount equal to 25% of Medicare plan A deductible} a day	$0
91st day and after:
- While using 60 lifetime reserve days	All but $ {Insert amount equal to 50% of Medicare plan A deductible} a day	$ {Insert amount equal to 50% of Medicare plan A deductible} 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 $ {Insert amount equal to 12.5% of Medicare plan A deductible} a day	Up to $ {Insert amount equal to 12.5% of Medicare plan A deductible} a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 pints Additional amounts	$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.

PLANG

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

*Once you have been billed $ {Insert amount of Medicare Part B deductible} 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 EXPENSESIN 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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Part B deductible} (PartB 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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Part B deductible} (PartB Deductible)
Remainder of Medicare-approved amounts	80%	20%	$0
CLINICAL LABORATORY SERVICESTESTS 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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Part B deductible} (PartB Deductible)
Remainder of Medicare-approved amounts	80%	20%	$0

OTHER BENEFITS-NOT COVERED BY MEDICARE

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
FOREIGN TRAVELNOT 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

(2) Plan G or High Deductible Plan G.

PLAN G or HIGH DEDUCTIBLE PLAN G

MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD

{**This high deductible plan pays the same benefits as Plan G after you have paid a calendar year $ {Insert amount of Plan G high deductible} deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are ${Insert amount of Plan G high deductible}. 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 $ {Insert amount of Plan G high deductible} DEDUCTIBLE,**} PLAN PAYS	{IN ADDITION TO $ {Insert amount of Plan G high deductible} DEDUCTIBLE,**} YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but $ {Insert amount of Medicare plan A deductible}	$ {Insert amount of Medicare plan A deductible} (Part A Deductible)	$0
61st thru 90th day	All but $ {Insert amount equal to 25% of Medicare plan A deductible} a day	$ {Insert amount equal to 25% of Medicare plan A deductible} a day	$0
91st day and after:
- While using 60 lifetime reserve days	All but $ {Insert amount equal to 50% of Medicare plan A deductible} a day	$ {Insert amount equal to 50% of Medicare plan A deductible} 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 $ {Insert amount equal to 12.5% of Medicare plan A deductible} a day	Up to $ {Insert amount equal to 12.5% of Medicare plan A deductible} 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

PLAN G or HIGH DEDUCTIBLE PLAN G

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

{**This high deductible plan pays the same benefits as Plan G after you have paid a calendar year ${Insert amount of Plan G high deductible} deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are ${Insert amount of Plan G high deductible}. 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 $ {Insert amount of Plan G high deductible} DEDUCTIBLE,**} PLAN PAYS	{IN ADDITION TO $ {Insert amount of Plan G high deductible} 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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Part B deductible} (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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Part B deductible} (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

OTHER BENEFITS-NOT COVERED BY MEDICARE

SERVICES	MEDICARE PAYS	{AFTER YOU PAY $ {Insert amount of Plan G high deductible} DEDUCTIBLE,**} PLAN PAYS	{IN ADDITION TO $ {Insert amount of Plan G high deductible} DEDUCTIBLE,**} YOU PAY
HOME HEALTH CARE MEDICARE APPROVED SERVICES
- Medically necessary skilled care services and medical supplies	100%	$0	$0
- Durable medical equipment
First $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Part B deductible} (Unless Part B deductible has been met)
Remainder of Medicare-approved amounts	80%	20%	$0

OTHER BENEFITS-NOT COVERED BY MEDICARE

SERVICES	MEDICARE PAYS	{AFTER YOU PAY $ {Insert amount of Plan G high deductible} DEDUCTIBLE,**} PLAN PAYS	{IN ADDITION TO $ {Insert amount of Plan G high deductible} 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

I. Plan K.

PLAN K

* You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $ {Insert Plan K out-of-pocket limit} each calendar year. The amounts that count toward your annual limit are noted with diamonds (amp;diams;) 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 $ {Insert amount of Medicare Part A deductible}	$ {Insert amount equal to 50% of Medicare Part A deductible} (50% of Part A deductible)	$ {Insert amount equal to 50% of Medicare Part A deductible} (50% of Part A deductible) [DIAMOND]
61st thru 90th day	All but $ {Insert amount equal to 25% of the Medicare Part A deductible} a day	$ {Insert amount equal to 25% of the Medicare Part A deductible} a day	$0
91st day and after:
- While using 60 lifetime reserve days	All but $ {Insert amount equal to 50% of Medicare Part A deductible} a day	$ {Insert amount equal to 50% of Medicare Part A deductible} 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 $ {Insert amount equal to 12.5% of Medicare Part A deductible} a day	Up to $ {Insert amount equal to 6.25% of Medicare Part A deductible} a day (50% of Part A Coinsurance)	Up to $ {Insert amount equal to 6.25% of Medicare Part A deductible} a day (50% of Part A Coinsurance) [DIAMOND]
101st day and after	$0	$0	All costs
BLOOD
First 3 pints	$0	50%	50%4
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 [DIAMOND]

*** 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.

PLANK

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

**** Once you have been billed $ {Insert amount of Medicare Part B deductible} 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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts****	$0	$0	$ {Insert amount of Medicare Part B deductible)**** [DIAMOND]
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% [DIAMOND]
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs (and they do not count toward annual out-of-pocket limit of $ {Insert Plan K out-of-pocket limit})*
BLOOD
First 3 pints	$0	50%	50% [DIAMOND]
Next $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts****	$0	$0	$ {Insert amount of Medicare Part B deductible} (PartB deductible)**** [DIAMOND]
Remainder of Medicare-approved amounts	Generally 80%	Generally 10%	Generally 10% [DIAMOND]
CLINICAL LABORATORY SERVICES-TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $ {Insert Plan K out-of-pocket limit} 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 $ {Insert amount of Medicare PartB deductible} of Medicare-approved amounts*****	$0	$0	$ {Insert amount of Medicare Part B deductible} (PartB deductible) [DIAMOND]
Remainder of Medicare-approved amounts	80%	10%	10% [DIAMOND]

*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

J. Plan L.

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 $ {Insert Plan L out-of-pocket limit} each calendar year. The amounts that count toward your annual limit are noted with diamonds ([DIAMOND]) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOSPITALIZATION* *
Semiprivate room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but ${Insert amount of Medicare Part A deductible}	$ {Insert amount equal to 75% of Medicare Part A deductible} (75% of Part A deductible)	$ {Insert amount equal to 25% of Medicare Part A deductible} (25% of Part A deductible) [DIAMOND]
61st thru 90th day	All but $ {Insert amount equal to 25% of Medicare Part A deductible} a day	$ {Insert amount equal to 25% of Medicare Part A deductible} a day	$0
91st day and after:
- While using 60 lifetime reserve days	All but $ {Insert amount equal to 50% of Medicare Part A deductible} a day	$ {Insert amount equal to 50% of Medicare Part A deductible} 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 $ {Insert amount equal to 12.5% of Medicare Part A deductible} a day	Up to $ {Insert amount equal to 75% of the amount remaining after the Medicare payment} a day (75% of Part A Coinsurance) amp;diams;	Up to $ {Insert amount equal to 25% of the amount remaining after the Medicare payment} a day (25% of Part A Coinsurance) [DIAMOND]
101st day and after	$0	$0	All costs
BLOOD
First 3 pints	$0	75%	25% [DIAMOND]
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 amp;diams;

*** 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 ${Insert amount of Medicare Part B deductible} 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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts****	$0	$0	$ {Insert amount of Medicare Part B deductible} (PartB deductible)**** [DIAMOND]
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% [DIAMOND]
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs (and they do not count toward annual out-of-pocket limit of {Insert Plan L annual out-of-pocket limit}*
BLOOD
First 3 pints	$0	$75%	25% [DIAMOND]
Next $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts****	$0	$0	$ {Insert amount of Medicare Part B deductible} (PartB deductible) [DIAMOND]
Remainder of Medicare-approved amounts	Generally 80%	Generally 15%	Generally 5% [DIAMOND]
CLINICAL LABORATORY SERVICES-TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to ${Insert Plan L out-of-pocket limit} 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 $ {Insert amount of Medicare Part B deductible} of Medicare-approved amounts*****	$0	$0	{Insert amount of Medicare Part B deductible} (PartB deductible) [DIAMOND]
Remainder of Medicare-approved amounts	80%	15%	5% [DIAMOND]

*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

K. Plan M.

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 $ {Insert amount of Medicare Part A deductible}	$ {Insert amount equal to 50% of Medicare Part A deductible} (50% of Part A Deductible)	$ {Insert amount equal to 50% of Medicare Part A deductible} (50% of Part A Deductible)
61st thru 90th day	All but $ {Insert amount equal to 25% of Medicare Part A deductible} a day	$ {Insert amount equal to 25% of Medicare Part A deductible} a day	$0
91st day and after:
- While using 60 lifetime reserve days	All but $ {Insert amount equal to 50% of Medicare Part A deductible} a day	$ {Insert amount equal to 50% of Medicare Part A deductible} 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 $ {Insert amount equal to 12.5% of Medicare Part A deductible} a day	Up to $ {Insert amount equal to 12.5% of Medicare Part A deductible} 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

PLAN M

MEDICARE (PART B)-MEDICAL SERVICES-PER 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 {Insert amount of Medicare Plan B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Plan B deductible} (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 $ {Insert amount of Medicare Plan B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Plan B deductible} (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 $ {Insert amount of Medicare Plan B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Plan B deductible} (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

L. Plan N

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 ${Insert amount of Medicare Part A deductible}	$ {Insert amount of Medicare Part A deductible} (Part A Deductible)	$0
61st thru 90th day	All but $ {Insert amount equal to 25% of Medicare Part A deductible} a day	$ {Insert amount equal to 25% of Medicare Part A deductible} a day	$0
91st day and after:
- While using 60 lifetime reserve days	All but $ {Insert amount equal to 50% of Medicare Part A deductible} a day	$ {Insert amount equal to 50% of Medicare Part A deductible} 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 $ {Insert amount equal to 12.5% of Medicare Part A deductible} a day	Up to $ {Insert amount equal to 12.5% of Medicare Part A deductible} 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

PLAN N

MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR

*Once you have been billed $ {Insert amount of Medicare Plan B deductible} 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 {Insert amount of Medicare Plan B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Plan B deductible} (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 $ {Insert amount of Medicare Plan B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Plan B deductible} (PartB 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 $ {Insert amount of Medicare Plan B deductible} of Medicare-approved amounts*	$0	$0	$ {Insert amount of Medicare Plan B deductible} (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

Md. Code Regs. 31.10.06.30

Regulations .30 adopted effective September 21, 2009 (36:19 Md. R. 1439)
Regulation .30I, J amended effective November 29, 2010 (37:24 Md. R. 1660); amended effective 46:1 Md. R. 13, eff. 1/14/2019