MI Comp L § 500.3815 (2021)
2021 Michigan Compiled Laws|Chapter 500 - Insurance Code of 1956|Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302)|218-1956-38 - Chapter 38 Medicare Supplement Policies and Certificates (500.3801...500.3861)|Section 500.3815 - Outline of Coverage; Acknowledgment of Receipt; Compliance With Notice Requirements; Substitute; Language, Written or Electronic Format, and Required Items.

500.3815 Outline of coverage; acknowledgment of receipt; compliance with notice requirements; substitute; language, written or electronic format, and required items.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 Compiler's Notes: In Plans K and L, a superscript numeral "1" has been substituted wherever a diamond symbol should occur.Popular Name: Act 218