Mich. Comp. Laws § 500.3815 — MI Code / Chapter 500 / Act Act-218-of-1956 / Section 500.3815
Outline of coverage; acknowledgment of receipt; compliance with notice requirements; substitute; language, written or electronic format, and required items.
Status: in_force

Sec. 3815.

(1) An insurer that offers a Medicare supplement policy shall provide to the applicant at the time of application an outline of coverage in written or electronic format and, except for direct response solicitation policies, shall obtain an acknowledgment of receipt of the outline of coverage from the applicant in written or electronic format. The outline of coverage provided to applicants under this section must consist of the following 4 parts:

(a) A cover page.

(b) Premium information.

(c) Disclosure pages.

(d) Charts displaying the features of each benefit plan offered by the insurer.

(2) Insurers shall comply with any notice requirements of the Medicare prescription drug, improvement, and modernization act of 2003, Public Law 108-173.

(3) If an outline of coverage is provided at the time of application and the Medicare supplement policy or certificate is issued on a basis that would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany the policy or certificate when it is delivered and must contain the following statement, in not less than 12-point type, immediately above the company name:

NOTICE: Read this outline of coverage carefully.

It is not identical to the outline of coverage

provided on application and the coverage

originally applied for has not been issued.

(4) An outline of coverage under subsection (1) must be in the language and in a written or electronic format prescribed in this section and in not less than 12-point type. The letter designation of the plan must be shown on the cover page and the plans offered by the insurer must be prominently identified. Premium information must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and method of payment mode must be stated for all plans that are offered to the applicant. All possible premiums for the applicant must be illustrated. The following items must be included in the outline of coverage in the order prescribed below and in substantially the following form, as approved by the director:

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,

Basic,

Basic,

Basic,

Basic,

Basic,

including

including

including

including

including

including

100% Part

100% Part

100% Part

100% Part

100% Part

100% Part

B coin-

B coinsur-

B coinsur-

B coinsur-

B coinsur-

B coinsur-

surance

ance

ance

ance

ance

ance

Skilled

Skilled

Skilled

Skilled

Nursing

Nursing

Nursing

Nursing

Facility

Facility

Facility

Facility

Coinsur-

Coinsur-

Coinsur-

Coinsur-

ance

ance

ance

ance

Part A

Part A

Part A

Part A

Part A

Deductible

Deductible

Deductible

Deductible

Deductible

Part B

Part B

Deductible

Deductible

Part B

Part B

Excess

Excess

(100%)

(100%)

Foreign

Foreign

Foreign

Foreign

Travel

Travel

Travel

Travel

Emergency

Emergency

Emergency

Emergency

K

L

M

N

Hospitalization

Hospitalization

Basic,

Basic, includ-

and preventive

and preventive

including 100%

ing 100% Part B

care paid at

care paid at

Part B

coinsurance,

100%; other

100%; other

coinsurance

except up to

basic benefits

basic benefits

$20 copayment

paid at 50%

paid at 75%

for office

visit, and up

to $50 copay-

ment for ER

50% Skilled

75% Skilled

Skilled

Skilled

Nursing

Nursing

Nursing

Nursing

Facility

Facility

Facility

Facility

Coinsurance

Coinsurance

Coinsurance

Coinsurance

50% Part A

75% Part A

50% Part A

Part A

Deductible

Deductible

Deductible

Deductible

Foreign

Foreign

Travel

Travel

Emergency

Emergency

Out-of-pocket

Out-of-pocket

limit $5,240;

limit $2,620;

paid at 100%

paid at 100%

after limit

after limit

reached

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

$0

$1,340

$1,340

(Part A

Deductible)

61st thru 90th day

All but

$335

$0

$335 a day

a day

91st day and after:

-While using 60

lifetime reserve days

All but

$670

$0

$670 a day

a day

-Once lifetime reserve

days are used:

-Additional 365 days

$0

100% of

$0**

Medicare

Eligible

Expenses

-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

$0

Up to

$167.50 a day

$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

All but very

$0

Medicare's requirements

limited

Medicare

including a doctor's

copayment/

copayment/

certification of terminal

coinsurance

coinsurance

illness

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 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

$0

$0

$183

Amounts*

(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

$0

$0

$183

Approved Amounts*

(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

$0

$0

$183

Approved Amounts*

(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

$0

$1,340

(Part A

Deductible)

61st thru 90th day

All but

$335

$0

$335 a day

a day

91st day and after

-While using 60

lifetime reserve days

All but

$670

$0

$670 a day

a day

-Once lifetime reserve

days are used:

-Additional 365 days

$0

100% of

$0**

Medicare

Eligible

Expenses

-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

$0

Up to

$167.50 a day

$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

Medicare

$0

copayment/

copayment/

coinsurance

coinsurance

You must meet

for outpatient

Medicare's requirements,

drugs and

including a doctor's

inpatient

certification of

respite care

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

$0

$0

$183

Amounts*

(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

Remainder of Medicare

Deductible)

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

$0

$1,340

(Part A

Deductible)

61st thru 90th day

All but

$335

$0

$335 a day

a day

91st day and after

-While using 60

lifetime reserve days

All but

$670

$0

$670 a day

a day

-Once lifetime reserve

days are used:

-Additional 365 days

$0

100% of

$0**

Medicare

Eligible

Expenses

-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

Up to

$0

$167.50 a day

$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

$0

limited

Medicare

copayment/

copayment/

coinsurance

coinsurance

You must meet

for outpatient

Medicare's requirements,

drugs and

including a doctor's

inpatient

certification of

respite care

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 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

$0

$183

$0

Amounts*

(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

$183

$0

(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

$0

$183

$0

Amounts*

(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

20% and

lifetime

amounts

maximum

over the

benefit

$50,000

of $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

$0

$1,340

(Part A

Deductible)

61st thru 90th day

All but

$335

$0

$335 a day

a day

91st day and after

-While using 60

lifetime reserve days

All but

$670

$0

$670 a day

a day

-Once lifetime reserve

days are used:

-Additional 365 days

$0

100% of

$0**

Medicare

Eligible

Expenses

-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

Up to

$0

$167.50 a day

$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

Medicare

$0

limited

copayment/

copayment/

coinsurance

coinsurance

You must meet

for outpatient

Medicare's requirements,

drugs and

including a doctor's

inpatient

certification of

respite care

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

$0

$0

$183

Amounts*

(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

$0

$0

$183

Amounts*

(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

20% and

lifetime

amounts

maximum

over the

benefit

$50,000

of $50,000

lifetime

maximum

PLAN F OR HIGH-DEDUCTIBLE PLAN F

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

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

**This high-deductible plan pays the same benefits as plan F after you have paid a calendar year $2,240 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

AFTER YOU

IN ADDITION

PAYS

PAY

TO

$2,240

$2,240

DEDUCTIBLE**,

DEDUCTIBLE**,

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

$0

$335 a day

a day

91st day and after

-While using 60

lifetime reserve days

All but

$670

$0

$670 a day

a day

-Once lifetime reserve

days are used:

-Additional 365 days

$0

100% of

$0***

Medicare

Eligible

Expenses

-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

Up to

$0

$167.50 a day

$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

Medicare

$0

limited

copayment/

copayment/

coinsurance

coinsurance

You must

for

meet Medicare's

outpatient

requirements, including

drugs and

a doctor's certification

inpatient

of terminal illness

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 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

AFTER YOU

IN ADDITION

PAYS

PAY

TO

$2,240

$2,240

DEDUCTIBLE**,

DEDUCTIBLE**,

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

$0

$183

$0

Amounts*

(Part B

Deductible)

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

$0

$183

$0

Amounts*

(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

$0

$183

$0

Amounts*

(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

20% and

lifetime

amounts

maximum

over the

benefit

$50,000

of $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

IN ADDITION

PAY

TO

$2,240

$2,240

DEDUCTIBLE**,

DEDUCTIBLE**,

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

$0

$335 a day

a day

91st day and after

-While using 60

lifetime reserve days

All but

$670

$0

$670 a day

a day

-Once lifetime reserve

days are used:

-Additional 365 days

$0

100% of

$0***

Medicare

Eligible

Expenses

-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

Up to

$0

$167.50 a day

$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

$0

limited

Medicare

copayment/

copayment/

coinsurance

coinsurance

You must meet

for outpatient

Medicare's requirements,

drugs and

including a doctor's

inpatient

certification of

respite care

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

IN ADDITION

PAY

TO

$2,240

$2,240

DEDUCTIBLE**,

DEDUCTIBLE**,

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

$0

$0

$163

Amounts*

(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

$0

$0

$183

Amounts*

(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

$0

$0

$183

Amounts*

(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

20% and

lifetime

amounts

maximum

over the

benefit

$50,000

of $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

$670

$670

$1,340

(50%

(50% of

of Part A

Part A

Deducti-

Deductible) 1

ble)

61st thru 90th day

All but

$335

$0

$335 a day

a day

91st day and after:

-While using 60

lifetime reserve days

All but

$670

$0

$670 a day

a day

-Once lifetime reserve

days are used:

-Additional 365 days

$0

100% of

$0***

Medicare

Eligible

Expenses

-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

Up to

Up to

$167.50 a

$83.75

$83.75

day

a day

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

50% of

copayment/

Medicare

coinsur-

copayment/

ance

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

$0

$0

$183

Amounts****

(Part B

Deductible)

**** 1

Preventive Benefits for

Generally 75%

Remainder

All costs

Medicare covered

or more of

of Medi-

above Medi-

services

Medicare ap-

care

care

proved amounts

approved

approved

amounts

amounts

Remainder of Medicare

Generally 80%

Generally

Generally

Approved Amounts

10%

10% 1

Part B Excess Charges

$0

$0

All costs

(Above Medicare

(and they do

Approved Amounts)

not count

toward

annual out-

of-pocket

limit of

$5,240)*

BLOOD

First 3 pints

$0

50%

50% 1

Next $183 of

Medicare Approved

$0

$0

$183

Amounts****

(Part B

Deductible)

**** 1

Remainder of Medicare

Generally 80%

Generally

Generally

Approved Amounts

10%

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

$0

$0

$183

Amounts*****

(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

$1,005

$335

$1,340

(75% of

(25% of

Part A

Part A

Deducti-

Deductible) 1

ble)

61st thru 90th day

All but

$335

$0

$335 a day

a day

91st day and after:

-While using 60

lifetime reserve days

All but

$670

$0

$670 a day

a day

-Once lifetime reserve

days are used:

-Additional 365 days

$0

100% of

$0***

Medicare

Eligible

Expenses

-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

Up to

Up to

$167.50 a

$125.63

$41.88

day

a day

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

25% of

copayment/

copayment/

coinsur-

coinsurance 1

ance

You must meet

Medicare's requirements,

including a doctor's

certification of terminal

All

illness

but very

limited copay-

ment/coinsur-

ance 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

$0

$0

$183

Amounts****

(Part

B Deducti-

ble)**** 1

Preventive Benefits for

Generally 75%

Remainder

All costs

Medicare covered

or more of

of Medi-

above Medi-

services

Medicare

care

care

approved

approved

approved

amounts

amounts

amounts

Remainder of Medicare

Generally

Generally

Generally

Approved Amounts

80%

15%

5% 1

Part B Excess Charges

$0

$0

All costs

(Above Medicare

(and they do

Approved Amounts)

not count

toward

annual out-

of-pocket

limit of

$2,620)*

BLOOD

First 3 pints

$0

75%

25% 1

Next $183 of

Medicare Approved

$0

$0

$183

Amounts****

(Part B

Deductible) 1

Remainder of Medicare

Generally

Generally

Generally

Approved Amounts

80%

15%

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

$0

$0

$183

Amounts*****

(Part

B Deducti-

ble) 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%

$670 (50%

of Part A

of Part A

Deduc-

Deduc-

tible)

tible)

61st thru 90th day

All but $335

$335

$0

a day

a day

91st day and after:

-While using 60

lifetime reserve days

All but $670

$670

$0

a day

a day

-Once lifetime reserve

days are used:

-Additional 365 days

$0

100% of

$0**

Medicare

Eligible

Expenses

-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

Up to $167.50

$0

a day

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

All but very

Medicare

$0

requirements, including

limited

copayment/

a doctor's

copayment/

coinsurance

certification of

coinsurance

terminal illness

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 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

Deduc-

tible)

Remainder of Medicare

Approved Amounts

Generally

Generally

$0

80%

20%

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

Deduc-

tible)

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

Deduc-

tible)

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

20% and

lifetime

amounts

maximum

over the

benefit of

$50,000

$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

$0

(Part A

Deduc-

tible)

61st thru 90th day

All but $335

$335

$0

a day

a day

91st day and after:

-While using 60

lifetime reserve days

All but $670

$670

$0

a day

a day

-Once lifetime reserve

days are used:

-Additional 365 days

$0

100% of

$0**

Medicare

Eligible

Expenses

-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

Up to $167.50

$0

a day

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

All but very

Medicare

$0

requirements, including

limited

copayment/

a doctor's certification

copayment/

coinsurance

of terminal illness

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 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

Deduc-

tible)

Remainder of Medicare

Approved Amounts

Generally

Balance,

Up to $20

80%

other than

per office

up to $20

visit and

per office

up to $50

visit and

per

up to $50

emergency

per

room

emergency

visit. The

room visit.

copayment

The

of up to

copayment

$50 is

of up to

waived if

$50 is

the

waived if

insured is

the insured

admitted

is admitted

to any

to any

hospital

hospital

and the

and the

emergency

emergency

visit is

visit is

covered as

covered as

a Medicare

a Medicare

Part A

Part A

expense.

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

Deduc-

tible)

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

Deduc-

tible)

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

20% and

lifetime

amounts

maximum

over the

benefit of

$50,000

$50,000

lifetime

maximum

History: Add. 1992, Act 84, Imd. Eff. June 2, 1992; Am. 2002, Act 304, Imd. Eff. May 10, 2002; Am. 2006, Act 462, Imd. Eff. Dec. 20, 2006; Am. 2009, Act 220, Imd. Eff. Jan. 5, 2010; Am. 2018, Act 429, Eff. Mar. 20, 2019