Mich. Comp. Laws § 500.3815
NOTICE: Read this outline of coverage carefully. |
It is not identical to the outline of coverage |
provided on application and the coverage |
originally applied for has not been issued. |
BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD |
ON OR AFTER JUNE 1, 2010 |
This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan "A" available. Some plans may not be available in your state.
Plans E, H, I, and J are no longer available for sale. (This sentence must not appear after June 1, 2011.)
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/G* |
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 |
Skilled Nursing Facility Coinsurance | 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 | |
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 |
K | L | M | N |
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, includ ing 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER |
50% Skilled Nursing Facility Coinsurance | 75% Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance |
50% Part A Deductible | 75% Part A Deductible | 50% Part A Deductible | Part A Deductible |
Foreign Travel Emergency | Foreign Travel Emergency | ||
Out-of-pocket limit $5,240; paid at 100% after limit reached | Out-of-pocket limit $2,620; paid at 100% after limit reached |
* Plans F and G also have options called high-deductible Plan F and high-deductible Plan G. These high-deductible plans pay the same benefits as Plan F or Plan G, as applicable, after one has paid a calendar year $2,240 deductible. Benefits from high-deductible Plan F or high-deductible Plan G will not begin until out-of-pocket expenses exceed $2,240. Out-of-pocket expenses for these deductibles 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.
** Plan C, Plan F, and high-deductible Plan F are only available to individuals eligible for Medicare before January 1, 2020.
PREMIUM INFORMATION |
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).
DISCLOSURES |
Use this outline to compare benefits and premiums among policies, certificates, and contracts.
This outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates before June 1, 2010 have different benefits and premiums. Plans E, H, I, and J are no longer available for sale. (This sentence must not appear after June 1, 2011.)
READ YOUR POLICY VERY CAREFULLY |
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 |
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 |
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 |
This policy may not fully cover all of your medical costs.
[For agent issued policies]
Neither (insert insurer's name) nor its agents are connected with Medicare.
[For direct response issued policies]
(Insert insurer's name) is not connected with Medicare.
This outline of coverage does not give all the details of Medicare coverage. Contact your local social security office or consult "The Medicare Handbook" for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT |
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 offered by the insurer a chart showing the services, Medicare payments, plan payments, and insured payments using the same language, in the same order, and using uniform layout and format as shown in the charts that follow. An insurer may use additional benefit plan designations on these charts under section 3809(1)(k). Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the director. The insurer issuing the policy shall change the dollar amounts each year to reflect current figures. No more than 4 plans may be shown on 1 chart.] Charts for each plan are as follows:
PLAN A |
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD |
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOSPITALIZATION* | |||
Semiprivate room and board, general nursing and miscellaneous services and supplies | |||
First 60 days | All but $1,340 | $0 | $1,340 (Part A Deductible) |
61st thru 90th day | All but $335 a day | $335 a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $670 a day | $670 a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days | $0 | 100% of Medicare Eligible Expenses | $0** |
-Beyond the Additional 365 days | $0 | $0 | All Costs |
SKILLED NURSING FACILITY CARE* | |||
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within30 days after leaving the hospital | |||
First 20 days | All approved amounts | $0 | $0 |
21st thru 100th day | All but $167.50 a day | $0 | Up to $167.50 a day |
101st day and after | $0 | $0 | All costs |
BLOOD | |||
First 3 pints | $0 | 3 pints | $0 |
Additional amounts | 100% | $0 | $0 |
HOSPICE CARE | |||
You must meet Medicare's requirements including a doctor's certification of terminal illness drugs and inpatient respite care | All but very limited copayment/coinsurance for outpatient | 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 $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
MEDICAL EXPENSES- | |||
In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved Amounts* | $0 | $0 | $183 (Part B Deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All Costs |
BLOOD | |||
First 3 pints | $0 | All Costs | $0 |
Next $183 of Medicare Approved Amounts* | $0 | $0 | $183 (Part B Deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
Tests for diagnostic services | 100% | $0 | $0 |
PARTS A & B |
HOME HEALTH CARE | |||
Medicare Approved Services | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment First $183 of Medicare Approved Amounts* | $0 | $0 | $183 (Part B Deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
PLAN B |
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD |
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOSPITALIZATION* | |||
Semiprivate room and board, general nursing and miscellaneous services and supplies | |||
First 60 days | All but $1,340 | $1,340 (Part A Deductible) | $0 |
61st thru 90th day | All but $335 a day | $335 a day | $0 |
91st day and after - While using 60 lifetime reserve days | All but $670 a day | $670 a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days | $0 | 100% of Medicare Eligible Expenses | $0** |
-Beyond the Additional 365 days | $0 | $0 | All Costs |
SKILLED NURSING FACILITY CARE* | |||
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital | |||
First 20 days | All approved amounts | $0 | $0 |
21st thru 100th day | All but $167.50 a day | $0 | Up to $167.50 a day |
101st day and after | $0 | $0 | All costs |
BLOOD | |||
First 3 pints | $0 | 3 pints | $0 |
Additional amounts | 100% | $0 | $0 |
HOSPICE CARE | |||
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care | Medicare copayment/coinsurance | $0 | |
You must meet Medicare's requirements, including a doctor's certification of terminal illness |
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN B |
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR |
*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
MEDICAL EXPENSES- | |||
In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved Amounts* | $0 | $0 | $183 (Part B Deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All Costs |
BLOOD | |||
First 3 pints | $0 | All Costs | $0 |
Next $183 of Medicare Approved Amounts* | $0 | $0 | $183 (Part B Deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
Tests for diagnostic services | 100% | $0 | $0 |
PARTS A & B |
HOME HEALTH CARE | |||
Medicare Approved Services | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment First $183 of Medicare Approved Amounts* | $0 | $0 | $183 (Part B Deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
PLAN C |
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD |
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOSPITALIZATION* | |||
Semiprivate room and board, general nursing and miscellaneous services and supplies | |||
First 60 days | All but $1,340 | $1,340 (Part A Deductible) | $0 |
61st thru 90th day | All but $335 a day | $335 a day | $0 |
91st day and after - While using 60lifetime reserve days | All but $670 a day | $670 a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days | $0 | 100% of Medicare Eligible Expenses | $0** |
-Beyond the Additional 365 days | $0 | $0 | All Costs |
SKILLED NURSING FACILITY CARE* | |||
You must meet Medicare's requirements, including having been in a hospital for at least 3 days andentered a Medicare-approved facility within 30 days after leaving the hospital | |||
First 20 days | All approved amounts | $0 | $0 |
21st thru 100th day | All but $167.50 a day | Up to $167.50 a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD | |||
First 3 pints | $0 | 3 pints | $0 |
Additional amounts | 100% | $0 | $0 |
HOSPICE CARE | |||
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care | Medicare copayment/ coinsurance | $0 | |
You must meet Medicare's requirements, including a doctor's certification of terminal illness |
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN C |
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR |
*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
MEDICAL EXPENSES- | |||
In or out of the hospital and outpatient hospitaltreatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved Amounts* | $0 | $183 (Part B Deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All Costs |
BLOOD | |||
First 3 pints | $0 | All Costs | $0 |
Next $183 of Medicare Approved Amounts* | $0 | $183 (Part B Deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
Tests for diagnostic services | 100% | $0 | $0 |
PARTS A & B |
HOME HEALTH CARE | |||
Medicare Approved Services | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $183 of Medicare Approved Amounts* | $0 | $183 (Part B Deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
OTHER BENEFITS-NOT COVERED BY MEDICARE |
FOREIGN TRAVEL- | |||
Not covered by Medicare Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA | |||
First $250 each calendar year | $0 | $0 | $250 |
Remainder of charges | $0 | 80% to a lifetime maximum benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
PLAN D |
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD |
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOSPITALIZATION* | |||
Semiprivate room and board, general nursing and miscellaneous services and supplies | |||
First 60 days | All but $1,340 | $1,340 (Part A Deductible) | $0 |
61st thru 90th day | All but $335 a day | $335 a day | $0 |
91st day and after - While using 60 lifetime reserve days | All but $670 a day | $670 a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days | $0 | 100% of Medicare Eligible Expenses | $0** |
-Beyond the Additional 365 days | $0 | $0 | All Costs |
SKILLED NURSING FACILITY CARE* | |||
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital | |||
First 20 days | All approved amounts | $0 | $0 |
21st thru 100th day | All but $167.50 a day | Up to $167.50 a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD | |||
First 3 pints | $0 | 3 pints | $0 |
Additional amounts | 100% | $0 | $0 |
HOSPICE CARE | |||
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care | Medicare copayment/coinsurance | $0 | |
You must meet Medicare's requirements, including a doctor's certification of terminal illness |
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN D |
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR |
*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
MEDICAL EXPENSES- | |||
In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved Amounts* | $0 | $0 | $183 (Part B Deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All Costs |
BLOOD | |||
First 3 pints | $0 | All Costs | $0 |
Next $183 of Medicare Approved Amounts* | $0 | $0 | $183 (Part B Deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
Tests for diagnostic services | 100% | $0 | $0 |
PARTS A & B |
HOME HEALTH CARE | |||
Medicare Approved Services | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $183 of Medicare Approved Amounts* | $0 | $0 | $183 (Part B Deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
OTHER BENEFITS-NOT COVERED BY MEDICARE |
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 maximum | 20% and amounts over the $50,000 lifetime |
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 $2,240 deductible. Benefits from the high-deductible plan F will not begin until out-of-pocket expenses are $2,240. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes Medicare deductibles for part A and part B, but does not include the plan's separate foreign travel emergency deductible.
SERVICES | MEDICARE PAYS | AFTER YOU PAY $2,240 DEDUCTIBLE**, PLAN PAYS | IN ADDITION TO $2,240 DEDUCTIBLE** YOU PAY |
HOSPITALIZATION* | |||
Semiprivate room and board, general nursing and miscellaneous services and supplies | |||
First 60 days | All but $1,340 | $1,340 (Part A Deductible) | $0 |
61st thru 90th day | All but $335 a day | $335 a day | $0 |
91st day and after - While using 60 lifetime reserve days | All but $670 a day | $670 a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days | $0 | 100% of Medicare Eligible Expenses | $0*** |
-Beyond the Additional 365 days | $0 | $0 | All Costs |
SKILLED NURSING FACILITY CARE* | |||
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital | |||
First 20 days | All approved amounts | $0 | $0 |
21st thru 100th day | All but $167.50 a day | Up to $167.50 a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD | |||
First 3 pints | $0 | 3 pints | $0 |
Additional amounts | 100% | $0 | $0 |
HOSPICE CARE | |||
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care | Medicare copayment/coinsurance | $0 | |
You must meet Medicare's requirements, including a doctor's certification of terminal illness |
***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 |
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR |
*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
**This high-deductible plan pays the same benefits as plan F after you have paid a calendar year $2,240 deductible. Benefits from the high-deductible plan F will not begin until out-of-pocket expenses are $2,240. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes Medicare deductibles for part A and part B, but does not include the plan's separate foreign travel emergency deductible.
SERVICES | MEDICARE PAYS | AFTER YOU PAY $2,240 DEDUCTIBLE**, PLAN PAYS | IN ADDITION TO $2,240 DEDUCTIBLE**, YOU PAY |
MEDICAL EXPENSES- | |||
In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved Amounts* | $0 | $183 (Part B Deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | 100% | $0 |
BLOOD | |||
First 3 pints | $0 | All Costs | $0 |
Next $183 of Medicare Approved Amounts* | $0 | $183 (Part B Deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
Tests for diagnostic services | 100% | $0 | $0 |
PARTS A & B |
HOME HEALTH CARE | |||
Medicare Approved Services | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $183 of Medicare Approved Amounts* | $0 | $183 (Part B Deductible) | $0 |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
OTHER BENEFITS-NOT COVERED BY MEDICARE |
FOREIGN TRAVEL- | |||
Not covered by Medicare | |||
Medically necessary | |||
emergency care services | |||
beginning during the | |||
first 60 days of each | |||
trip outside the USA | |||
First $250 each calendar year | $0 | $0 | $250 |
Remainder of charges | $0 | 80% to a lifetime maximum benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
PLAN G OR HIGH-DEDUCTIBLE PLAN G |
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD |
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
** This high-deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,240 deductible. Benefits from the high-deductible Plan G will not begin until out-of-pocket expenses are $2,240. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.
SERVICES | MEDICARE PAYS | AFTER YOU PAY $2,240 DEDUCTIBLE**, PLAN PAYS | IN ADDITION TO $2,240 DEDUCTIBLE**, YOU PAY |
HOSPITALIZATION* | |||
Semiprivate room and board, general nursing and miscellaneous services and supplies | |||
First 60 days | All but $1,340 | $1,340 (Part A Deductible) | $0 |
61st thru 90th day | All but $335 a day | $335 a day | $0 |
91st day and after - While using 60 lifetime reserve days | All but $670 a day | $670 a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days | $0 | 100% of Medicare Eligible Expenses | $0*** |
-Beyond the Additional 365 days | $0 | $0 | All Costs |
SKILLED NURSING FACILITY CARE* | |||
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital | |||
First 20 days | All approved amounts | $0 | $0 |
21st thru 100th day | All but $167.50 a day | Up to $167.50 a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD | |||
First 3 pints | $0 | 3 pints | $0 |
Additional amounts | 100% | $0 | $0 |
HOSPICE CARE | |||
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care | Medicare copayment/coinsurance | $0 | |
You must meet Medicare's requirements, including a doctor's certification of terminal illness |
***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 $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
** This high-deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,240 deductible. Benefits from the high-deductible Plan G will not begin until out-of-pocket expenses are $2,240. Out-of-pocket expenses for this deductible include expenses for the Medicare part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.
SERVICES | MEDICARE PAYS | AFTER YOU PAY $2,240 DEDUCTIBLE**, PLAN PAYS | IN ADDITION TO $2,240 DEDUCTIBLE**, YOU PAY |
MEDICAL EXPENSES- | |||
In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved Amounts* | $0 | $0 | $163 (Unless Part B Deductible has been met) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | 100% | 0% |
BLOOD | |||
First 3 pints | $0 | All Costs | $0 |
Next $183 of Medicare Approved Amounts* | $0 | $0 | $183 (Unless Part B Deductible has been met) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES- | |||
Tests for diagnostic services | 100% | $0 | $0 |
PARTS A & B |
HOME HEALTH CARE | |||
Medicare Approved Services | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $183 of Medicare Approved Amounts* | $0 | $0 | $183 (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 K |
*You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $5,240 each calendar year. The amounts that count toward your annual limit are noted with diamonds 1 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.
PLAN K |
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD |
**A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY* |
HOSPITALIZATION** | |||
Semiprivate room and board, general nursing and miscellaneous services and supplies | |||
First 60 days | All but $1,340 | $670 (50% of Part A Deductible) | $670 (50% of Part A Deductible) 1 |
61st thru 90th day | All but $335 a day | $335 a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $670 a day | $670 a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days | $0 | 100% of Medicare Eligible Expenses | $0*** |
-Beyond the Additional 365 days | $0 | $0 | All Costs |
SKILLED NURSING FACILITY CARE** | |||
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital | |||
First 20 days | All approved amounts | $0 | $0 |
21st thru 100th day | All but $167.50 a day | Up to $83.75 a day | Up to $83.75 a day 1 |
101st day and after | $0 | $0 | All costs |
BLOOD | |||
First 3 pints | $0 | 50% | 50% 1 |
Additional amounts | 100% | $0 | $0 |
HOSPICE CARE | |||
50% of copayment/coinsurance | 50% of Medicare copayment/coinsurance 1 | ||
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 |
***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN K |
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR |
****Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY* |
MEDICAL EXPENSES- | |||
In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved Amounts**** | $0 | $0 | $183 (Part B Deductible) **** 1 |
Preventive Benefits for Medicare covered services | Generally 75% or more of Medicare approved amounts | Remainder of Medicare approved amounts | All costs above Medicare approved amounts |
Remainder of Medicare Approved Amounts | Generally 80% | Generally 10% | Generally 10% 1 |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs (and they do not count toward annual out-of-pocket limit of $5,240)* |
BLOOD | |||
First 3 pints | $0 | 50% | 50% 1 |
Next $183 of Medicare Approved Amounts**** | $0 | $0 | $183 (Part B Deductible) **** 1 |
Remainder of Medicare Approved Amounts | Generally 80% | Generally 10% | Generally 10% 1 |
CLINICAL LABORATORY SERVICES-Tests for diagnostic services | 100% | $0 | $0 |
*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $5,240 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
PARTS A & B |
HOME HEALTH CARE | |||
Medicare Approved Services | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $183 of Medicare Approved Amounts***** | $0 | $0 | $183 (Part B Deductible)1 |
Remainder of Medicare Approved Amounts | 80% | 10% | 10% 1 |
*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
PLAN L |
*You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2,620 each calendar year. The amounts that count toward your annual limit are noted with diamonds 1 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.
PLAN L |
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD |
**A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY* |
HOSPITALIZATION** | |||
Semiprivate room and board, general nursing and miscellaneous services and supplies | |||
First 60 days | All but $1,340 | $1,005 (75% of Part A Deductible) | $335 (25% of Part A Deductible) 1 |
61st thru 90th day | All but $335 a day | $335 a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $670 a day | $670 a day | $0 |
-Once lifetime reserve | |||
days are used: | |||
-Additional 365 days | $0 | 100% of Medicare Eligible Expenses | $0*** |
-Beyond the Additional 365 days | $0 | $0 | All Costs |
SKILLED NURSING FACILITY CARE** | |||
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital | |||
First 20 days | All approved amounts | $0 | $0 |
21st thru 100th day | All but $167.50 a day | Up to $125.63a day | Up to $41.88 a day 1 |
101st day and after | $0 | $0 | All costs |
BLOOD | |||
First 3 pints | $0 | 75% | 25% 1 |
Additional amounts | 100% | $0 | $0 |
HOSPICE CARE | |||
75% of copayment/coinsurance | 25% of copayment/coinsurance 1 | ||
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 |
***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN L |
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR |
****Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY* |
MEDICAL EXPENSES- | |||
In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $183 of Medicare Approved Amounts**** | $0 | $0 | $183 (Part B Deductible)**** 1 |
Preventive Benefits for Medicare covered services | Generally 75% or more of Medicare approved amounts | Remainder of Medicare approved amounts | All costs above Medicare approved amounts |
Remainder of Medicare Approved Amounts | Generally 80% | Generally 15% | Generally 5% 1 |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs (and they do not count toward annual out-of-pocket limit of $2,620)* |
BLOOD | |||
First 3 pints | $0 | 75% | 25% 1 |
Next $183 of Medicare Approved Amounts**** | $0 | $0 | $183 (Part B Deductible) 1 |
Remainder of Medicare Approved Amounts | Generally 80% | Generally 15% | Generally 5% 1 |
CLINICAL LABORATORY SERVICES-Tests for diagnostic services | 100% | $0 | $0 |
*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2,620 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
PARTS A & B |
HOME HEALTH CARE | |||
Medicare Approved Services | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $183 of Medicare Approved Amounts***** | $0 | $0 | $183 (Part B Deductible) 1 |
Remainder of Medicare Approved Amounts | 80% | 15% | 5% 1 |
*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
PLAN M |
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD |
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOSPITALIZATION* | |||
Semiprivate room and board, general nursing and miscellaneous services and supplies | |||
First 60 days | All but $1,340 | $670 (50% of Part A Deductible) | $670 (50% of Part A Deductible) |
61st thru 90th day | All but $335 a day | $335 a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $670 a day | $670 a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days | $0 | 100% of Medicare Eligible Expenses | $0** |
-Beyond the Additional 365 days | $0 | $0 | All Costs |
SKILLED NURSING FACILITY CARE* | |||
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital | |||
First 20 days | All approved amounts | $0 | $0 |
21st thru 100th day | All but $167.50 a day | Up to $167.50 a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD | |||
First 3 pints | $0 | 3 pints | $0 |
Additional amounts | 100% | $0 | $0 |
HOSPICE CARE | |||
You must meet Medicare's requirements, including a doctor's certification of terminal illness | All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care | Medicare copayment/coinsurance | $0 |
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits". During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN M |
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR |
*Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
MEDICAL EXPENSES- | |||
In or out of the hospital and outpatient hospital treatment, such as Physician's services inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment | |||
First $183 of Medicare Approved Amounts* | $0 | $0 | $183 (Part B Deductible) |
Remainder of Medicare Approved Amounts | Generally 80% | Generally 20% | $0 |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All Costs |
BLOOD | |||
First 3 pints | $0 | All costs | $0 |
Next $183 of Medicare Approved Amounts* | $0 | $0 | $183 (Part B Deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES-Tests for diagnostic services | 100% | $0 | $0 |
PARTS A & B |
HOME HEALTH CARE | |||
Medicare Approved Services | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $183 of Medicare Approved Amounts | $0 | $0 | $183 (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 N |
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD |
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY* |
HOSPITALIZATION* | |||
Semiprivate room and board, general nursing and miscellaneous services and supplies | |||
First 60 days | All but $1,340 | $1,340 (Part A Deductible) | $0 |
61st thru 90th day | All but $335 a day | $335 a day | $0 |
91st day and after: | |||
-While using 60 lifetime reserve days | All but $670 a day | $670 a day | $0 |
-Once lifetime reserve days are used: | |||
-Additional 365 days | $0 | 100% of Medicare Eligible Expenses | $0** |
-Beyond the Additional 365 days | $0 | $0 | All Costs |
SKILLED NURSING FACILITY CARE* | |||
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital | |||
First 20 days | All approved | $0 | $0 |
amounts | |||
21st thru 100th day | All but $167.50 a day | Up to $167.50 a day | $0 |
101st day and after | $0 | $0 | All costs |
BLOOD | |||
First 3 pints | $0 | 3 pints | $0 |
Additional amounts | 100% | $0 | $0 |
HOSPICE CARE | |||
You must meet Medicare's requirements, including a doctor's certification of terminal illness | All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care | Medicare copayment/coinsurance | $0 |
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits". During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN N |
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR |
*Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
MEDICAL EXPENSES- | |||
IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment | |||
First $183 of Medicare Approved Amounts* | $0 | $0 | $183 (Part B Deductible) |
Remainder of Medicare Approved Amounts | Generally 80% | Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. | Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. |
Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs |
BLOOD | |||
First 3 pints | $0 | All Costs | $0 |
Next $183 of Medicare Approved Amounts* | $0 | $0 | $183 (Part B Deductible) |
Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
CLINICAL LABORATORY SERVICES-Tests for diagnostic services | 100% | $0 | $0 |
PARTS A & B |
HOME HEALTH CARE | |||
Medicare Approved Services | |||
-Medically necessary skilled care services and medical supplies | 100% | $0 | $0 |
-Durable medical equipment | |||
First $183 of Medicare Approved Amounts* | $0 | $0 | $183 (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 |
MCL 500.3815