Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart G - MISCELLANEOUS PROVISIONS › Appendix JJ - Plan N (for plans issued on or after June 1, 2010)

Current through Register Vol. 48, No. 28, July 12, 2024
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 $[992]
$[992](Part A deductible)
$0
61st thru
							 90th day
All but $[248] a day
$[248] a day
$0
91st day and
							 after:
- While using 60 lifetime reserve
							 days
All but $[496] a day
- Once lifetime reserve days are
							 used:
$[496] a day
$0
- Additional 365 days
$0
100% of 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 $[124] a day
Up to $[124] a day
$0
101st day and
							 after
$0
$0
All costs
BLOOD
First 3 pints
$0
3 pints
$0
Additional Amounts
100%
$0
$0
HOSPICE CARE
You must meet Medicare's requirements, including a
							 doctor's certification of terminal illness
All but very limited copayment/coinsurance for
							 outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
** NOTICE:
When your Medicare Part A hospital
				  benefits are exhausted, the insurer stands in the place of Medicare and will
				  pay whatever amount Medicare would have paid for up to an additional 365 days
				  as provided in the policy's "Core Benefits." During this time the hospital is
				  prohibited from billing you for the balance based on any difference between its
				  billed charges and the amount Medicare would have paid.
PLAN N
MEDICARE (PART B) - MEDICAL SERVICES -
				  PER CALENDAR YEAR
* Once you have been billed $[131] 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
1st $[131] of
							 Medicare Approved Amounts*
$0
$0
$[131] (Part B deductible)
Remainder of Medicare Approved
							 Amounts
Generally 80%
Balance, other than up to [$20] per office visit and
							 up to [$50] per emergency room visit. The copayment of up to [$50] is waived if
							 the insured is admitted to any hospital and the emergency visit is covered as a
							 Medicare Part A expense.
Up to [$20] per office visit and up to [$50] per
							 emergency room visit. The copayment of up to [$50] is waived if the insured is
							 admitted to any hospital and the emergency visit is covered as a Medicare Part
							 A expense.
Part B Excess Charges
(Above Medicare Approved Amounts)
$0
$0
All costs
BLOOD
First 3 pints
$0
All costs
$0
Next $[131] of Medicare Approved Amounts*
$0
$0
$[131] (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
1st $[131] of
							 Medicare Approved Amounts*
$0
$0
$[131] (Part B deductible)
Remainder of Medicare Approved
							 Amounts
80%
20%
$0
OTHER BENEFITS - NOT COVERED BY
				  MEDICARE
FOREIGN TRAVEL -
NOT COVERED BY MEDICARE
Medically necessary emergency care services beginning
							 during the first 60 days of each trip outside the USA
First $250 each calendar year
$0
$0
$250
Remainder of Charges
$0
80% to a lifetime maximum benefit of $50,000
20% and amount over the $50,000 lifetime
							 maximum