Hawaii Administrative Rules › Title 16 - DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS › Chapter 12 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Exhibit A - Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or after June 1, 2010

Current through June, 2024
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.
Plan E, H, I, and J are no longer available for sale. [This
				sentence shall 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
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance
Basic, Including 100% Part B coinsurance*
Basic, including 100% Part B coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Part A Deductible
Part A Deductible
Part A Deductible
Part A Deductible
Part A Deductible
Part B Deductible
Part B Deductible
Part B Excess (100%)
Part B Excess (100%)
Foreign Travel Emergency
Foreign Travel Emergency
Foreign Travel Emergency
Foreign Travel Emergency
K
L
M
N
Hospitalization and preventive care paid at 100%; other
						  basic benefits paid at 50%
Hospitalization and preventive care paid at 100%; other
						  basic benefits paid at 75%
Basic, Including 100% Part B coinsurance
Basic, Including 100% Part B coinsurance, except up to
						  $20 copayment for office visit, and up to $50 copayment for ER
50% Skilled Nursing Facility Coinsurance
75% Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
50% Part A Deductible
75% Part A Deductible
50% Part A Deductible
Part A Deductible
Foreign Travel Emergency
Foreign Travel Emergency
Out-of-pocket limit $[4620]; paid at 100% after limit
						  reached
Out-of-pocket limit $[2310]; paid at 100% after limit
						  reached
*Plan F also has an option called a high deductible plan F.
				This high deductible plan pays the same benefits as Plan F after one has paid a
				calendar year [$2000] deductible. Benefits from high_deductible plan F will not
				begin until out-of-pocket expenses exceed [$2000]. Out-of-pocket expenses for
				this deductible are expenses that would ordinarily be paid by the policy. These
				expenses_include the Medicare deductibles for Part A and Part B, but do not
				include the plan's separate foreign travel emergency deductible.
PREMIUM INFORMATION
(Boldface Type)
We (insert issuer'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 when premiums
				will change).
DISCLOSURES
(Boldface Type)
Use this outline to compare benefits and premiums among
				policies.
This outline shows benefits and premiums of policies
				sold for effective dates on or after June 1, 2010. Policies sold for effective
				dates prior to June 1, 2010 have different benefits and premiums. Plans E, H,
				I, and J are no longer available for sale. [This paragraph shall not appear
				after June 1, 2011].
READ YOUR POLICY VERY CAREFULLY
(Boldface
				Type)
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 policy.
RIGHT TO RETURN POLICY
(Boldface Type)
If you find that you are not satisfied with your policy, you
				may return it to (insert issuer'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
(Boldface Type)
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
(Boldface Type)
This policy may not fully cover all of your medical
				costs.
(for agents:)
Neither (insert company's name) nor its agents are connected
				with Medicare.
(for direct response:)
(insert company's name) is not connected with Medicare.
This outline of coverage does not give all the details of
				Medicare coverage. Contact your local Social Security Office or consult
Medicare and You
for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT
(Boldface
				Type)
When you fill out the application for the new policy, be sure
				to answer truthfully and completely all questions about your medical and health
				history. The company may cancel your policy and refuse to pay any claims if you
				leave out or falsify important medical information. (If the policy or
				certificate is guaranteed issue, this paragraph need not appear.)
Review the application carefully before you sign it. Be
				certain that all information has been properly recorded.
(Include for each plan prominently identified in the cover
				page, a chart showing the services, Medicare payments, plan payments and
				insured payments for each plan, using the same language, in the same order,
				using uniform layout and format as shown in the charts below. No more than four
				plans may be shown on one chart. For purposes of illustration, charts for each
				plan are included in this regulation. An issuer may use additional benefit plan
				designations on these charts pursuant to section
				16-12-6.05(e) of
				this regulation.)
(Include an explanation of any innovative benefits on the
				cover page and in the chart, in a manner approved by the commissioner.)
PLAN A
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT
				PERIOD
*A benefit period begins on the first day you receive service
				as an inpatient in a hospital and ends after you have been out of the hospital
				and have not received skilled care in any other facility for 60 days in a
				row.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION*
Semiprivate room and
						  board, general nursing and miscellaneous services and supplies.
First 60 days
All but [$1,068][DAGGER]
$0
[$1,068][DOUBLE DAGGER] (Part A Deductible)
61st thru 90th day
All but [$267][DAGGER] a day
[$267][DOUBLE DAGGER] a day
$0
91st day and after:
--While using 60 lifetime reserve days
All but [$534][DAGGER] a day
[$534][DOUBLE DAGGER] a day
$0
--Once lifetime reserve days are used:
--Additional 365 days
$0
100% of Medicare Eligible Expenses
$0**
--Beyond the Additional 365 days
$0
$0
All Costs
SKILLED NURSING FACILITY CARE*
You must
						  meet Medicare's requirements, including having been in a hospital for at least
						  3 days and entered a Medicare-approved facility within 30 days after leaving
						  the hospital.
First 20 days
All approved amounts
$0
$0
21st thru 100th day
All but [$133.50][DAGGER] a day
$0
Up to [$133.50][DOUBLE DAGGER] a day
101st day and after
$0
$0
All Costs
BLOOD
First 3 pints
$0
3 pints
$0
Additional Amounts
100%
$0
$0
HOSPICE CARE
You must meet Medicare's
						  requirements, including a doctor's certification of terminal illness.
All but very limited copayment/coinsurance for
						  out-patient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
[DAGGER] Medicare redetermines deductibles on an annual
				basis.
[DOUBLE DAGGER] Plan Payments and your payments are adjusted
				annually based on medicare deductibles.
**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 [$135] 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 [$135] of Medicare Approved Amounts*
$0
$0
[$135] (Part B Deductible)
Remainder of Medicare Approved Amounts
Generally 80%
Generally 20%
$0
Part B Excess Charges
(Above Medicare
						  Approved Amounts)
$0
$0
All costs
BLOOD
First 3 pints
$0
All Costs
$0
Next [$135] Medicare Approved Amounts*
$0
$0
[$135] (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 [$135] of Medicare
						  Approved Amounts*
$0
$0
[$135] (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 [$1,068][DAGGER]
[$1,068][DOUBLE DAGGER] (Part A Deductible)
$0
61st thru 90th day
All but [$267][DAGGER] a day
[$267][DOUBLE DAGGER] a day
$0
91st day and after:
--While using 60 lifetime reserve days
All but [$534][DAGGER] a day
[$534][DOUBLE DAGGER] a day
$0
--Once lifetime reserve days are used:
--Additional 365 days
$0
100% of Medicare Eligible Expenses
$0**
--Beyond the Additional 365 days
$0
$0
All Costs
SKILLED NURSING FACILITY CARE*
You must
						  meet Medicare's requirements, including having been in a hospital for at least
						  3 days and entered a Medicare-approved facility within 30 days after leaving
						  the hospital.
First 20 days
All approved amounts
$0
$0
21st thru 100th day
All but [$133.50][DAGGER] a day
$0
Up to [$133.50[DOUBLE DAGGER] a day
101st day and after
$0
$0
All Costs
BLOOD
First 3 pints
$0
3 pints
$0
Additional Amounts
100%
$0
$0
HOSPICE CARE
You must meet Medicare's
						  requirements, including a doctor's certification of terminal illness
All but very limited copayment/ coinsurance for
						  outpatient drugs and inpatient respite care
Medicare copayment/coinsurance
$0
[DAGGER] Medicare redetermines deductibles on an annual
				basis.
[DOUBLE DAGGER] Plan Payments and your payments are adjusted
				annually based on medicare deductibles.
**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 [$135] 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 [$135] of Medicare Approved Amounts*
$0
$0
[$135] (Part B Deductible)
Remainder of Medicare Approved Amounts
Generally 80%
Generally 20%
$0
Part B Excess Charges
(Above Medicare
						  Approved Amounts)
$0
$0
All Costs
BLOOD
First 3 pints
$0
All Costs
$0
Next [$135] Medicare Approved Amounts*
$0
$0
[$135] (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 [$135] of Medicare
						  Approved Amounts*
$0
$0
[$135] (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 [$1,068][DAGGER]
[$1,068[DOUBLE DAGGER] (Part A Deductible)
$0
61st thru 90th day
All but [$267][DAGGER] a day
[$267][DOUBLE DAGGER] a day
$0
91st day and after:
--While using 60 lifetime reserve days
All but [$534][DAGGER] a day
[$534][DOUBLE DAGGER] a day
$0
--Once lifetime reserve days are used:
--Additional 365 days
$0
100% of Medicare Eligible Expenses
$0**
--Beyond the Additional 365 days
$0
$0
All Costs
SKILLED NURSING FACILITY CARE*
You must
						  meet Medicare's requirements, including having been in a hospital for at least
						  3 days and entered a Medicare-approved facility within 30 days after leaving
						  the hospital.
First 20 days
All approved amounts
$0
$0
21st thru 100th day
All but [$133.50][DAGGER] a day
Up to [$133.50][DOUBLE DAGGER] 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
[DAGGER] Medicare redetermines deductibles on an annual
				basis.
[DOUBLE DAGGER] Plan payments and your payments are adjusted
				annually based on medicare deductibles.
**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 [$135] 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 [$135] of Medicare Approved Amounts*
$0
[$135] (Part B Deductible)
$0
Remainder of Medicare Approved Amounts
Generally 80%
Generally 20%
$0
Part B Excess Charges
(Above Medicare
						  Approved Amounts)
$0
$0
All Costs
BLOOD
First 3 pints
$0
All Costs
$0
Next [$135] Medicare Approved Amounts*
$0
[$135] (Part B Deductible)
$0
Remainder of Medicare Approved Amounts
80%
20%
$0
CLINICAL LABORATORY SERVICES
- TESTS FOR
						  DIAGNOSTIC SERVICES
100%
$0
$0
PARTS A & B
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
--Medically necessary skilled care services and medical
						  supplies
100%
$0
$0
--Durable medical equipment First [$135] of Medicare
						  Approved Amounts*
$0
[$135] (Part B Deductible)
$0
Remainder of Medicare Approved Amounts
80%
20%
$0
OTHER BENEFITS - NOT COVERED BY MEDICARE
FOREIGN TRAVEL
- NOT COVERED BY MEDICARE
						  Medically necessary emergency care services beginning during the first 60 days
						  of each trip outside the USA.
First $250 each calendar year
$0
$0
$250
Remainder of Charges
$0
80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
PLAN D
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT
				PERIOD
*A benefit period begins on the first day you receive service
				as an inpatient in a hospital and ends after you have been out of the hospital
				and have not received skilled care in any other facility for 60 days in a
				row.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION*
Semiprivate room and
						  board, general nursing and miscellaneous services and supplies.
First 60 days
All but [$1,068][DAGGER]
[$1,068][DOUBLE DAGGER] (Part A Deductible)
$0
61st thru 90th day
All but [$267][DAGGER] a day
[$267][DOUBLE DAGGER] a day
$0
91st day and after:
--While using 60 lifetime reserve days
All but [$534][DAGGER] a day
[$534][DOUBLE DAGGER] a day
$0
--Once lifetime reserve days are used:
--Additional 365 days
$0
100% of Medicare Eligible Expenses
$0**
--Beyond the Additional 365 days
$0
$0
All Costs
SKILLED NURSING FACILITY CARE*
You must
						  meet Medicare's requirements, including having been in a hospital for at least
						  3 days and entered a Medicare-approved facility within 30 days after leaving
						  the hospital.
First 20 days
All approved amounts
$0
$0
21st thru 100th day
All but [$133.50][DAGGER] a day
Up to [$133.50][DOUBLE DAGGER] 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
[DAGGER] Medicare redetermines deductibles on an annual
				basis.
[DOUBLE DAGGER] Plan payments and your payments are adjusted
				annually based on medicare deductibles.
**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 [$135] 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 [$135] of Medicare Approved Amounts*
$0
$0
[$135] (Part B Deductible)
Remainder of Medicare Approved Amounts)
Generally 80%
Generally 20%
$0
Part B Excess Charges
(Above Medicare
						  Approved Amounts)
$0
$0
All Costs
BLOOD
First 3 pints
$0
All Costs
$0
Next [$135] Medicare Approved Amounts*
$0
$0
[$135] (Part B Deductible)
Remainder of Medicare Approved Amounts
80%
20%
$0
CLINICAL LABORATORY SERVICES
- TESTS FOR
						  DIAGNOSTIC SERVICES
100%
$0
$0
PARTS A & B
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE
-MEDICARE APPROVED SERVICES
--Medically necessary skilled care services and medical
						  supplies
100%
$0
$0
--Durable medical equipment First [$135] of Medicare
						  Approved Amounts*
$0
$0
[$135] (Part B Deductible)
Remainder of Medicare Approved Amounts
80%
20%
$0
OTHER BENEFITS - NOT COVERED BY MEDICARE
FOREIGN TRAVEL
- NOT COVERED BY MEDICARE
						  Medically necessary emergency care services beginning during the first 60 days
						  of each trip outside the USA
First $250 each calendar year
$0
$0
$250
Remainder of Charges
$0
80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
PLAN 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 one has paid a calendar year [$2,000] deductible. Benefits from
				the high deductible Plan F will not begin until out-of-pocket expenses are
				[$2,000]. Out-of-pocket expenses for this deductible are expenses that would
				ordinarily be paid by the policy. This includes the Medicare deductibles for
				Part A and Part B, but does not include the plan's separate foreign travel
				emergency deductible.]
SERVICES
MEDICARE PAYS
[AFTER YOU PAY [$2,000] DEDUCTIBLE,**] PLAN
						  PAYS
[IN ADDITION TO [$2,000] DEDUCTIBLE,**] YOU PAY
HOSPITALIZATION*
Semiprivate room and
						  board, general nursing and miscellaneous services and supplies.
First 60 days
All but [$1,068][DAGGER]
[$1,068][DOUBLE DAGGER] (Part A Deductible)
$0
61st thru 90th day
All but [$267][DAGGER] a day
[$267][DOUBLE DAGGER] a day
$0
91st day and after:
--While using 60 lifetime reserve days
All but [$534][DAGGER] a day
[$534][DOUBLE DAGGER] a day
$0
--Once lifetime reserve days are used:
--Additional 365 days
$0
100% of Medicare Eligible Expenses
$0***
--Beyond the Additional 365 days
$0
$0
All Costs
SKILLED NURSING FACILITY CARE*
You must
						  meet Medicare's requirements, including having been in a hospital for at least
						  3 days and entered a Medicare-approved facility within 30 days after leaving
						  the hospital.
First 20 days
All approved amounts
$0
$0
21st thru 100th day
All but [$133.50][DAGGER] a day
Up to [$133.50][DOUBLE DAGGER] 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
[DAGGER] Medicare redetermines deductibles on an annual
				basis.
[DOUBLE DAGGER] Plan payments and your payments are adjusted
				annually based on medicare deductibles.
***
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.
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR
				YEAR
*Once you have been billed [$135] 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 one has paid a calendar year [$2,000] deductible. Benefits from
				the high deductible Plan F will not begin until out-of-pocket expenses are
				[$2,000]. Out-of-pocket expenses for this deductible are expenses that would
				ordinarily be paid by the policy. This includes the Medicare deductibles for
				Part A and Part B, but does not include the plan's separate foreign travel
				emergency deductible.]
SERVICES
MEDICARE PAYS
[AFTER YOU PAY [$2,000] DEDUCTIBLE,**] PLAN PAYS
[IN ADDITION TO [$2,000] DEDUCTIBLE,**] YOU PAY
MEDICAL EXPENSES
-IN OR OUT OF THE HOSPITAL
						  AND OUTPATIENT HOSPITAL TREATMENT, such as Physician's services, inpatient and
						  outpatient medical and surgical services and supplies, physical and speech
						  therapy, diagnostic tests, durable medical equipment.
First [$135] of Medicare Approved Amounts*
$0
[$135] (Part B Deductible)
$0
Remainder of Medicare Approved Amounts
Generally 80%
Generally 20%
$0
Part B Excess Charges
(Above Medicare
						  Approved Amounts)
$0
100%
$0
BLOOD
First 3 pints
$0
All Costs
$0
Next [$135] Medicare Approved Amounts*
$0
[$135] (Part B Deductible)
$0
Remainder of Medicare Approved Amounts
80%
20%
$0
CLINICAL LABORATORY SERVICES
- BLOOD TESTS
						  FOR DIAGNOSTIC SERVICES
100%
$0
$0
PARTS A & B
SERVICES
MEDICARE PAYS
[AFTER YOU PAY [$2,000] DEDUCTIBLE,**] PLAN
						  PAYS
[IN ADDITION TO [$2,000] DEDUCTIBLE,**] YOU
						  PAY
HOME HEALTH CARE
-MEDICARE APPROVED
						  SERVICES
--Medically necessary skilled care services and medical
						  supplies
100%
$0
$0
--Durable medical equipment First [$135] of Medicare
						  Approved Amounts*
$0
[$135] (Part B Deductible)
$0
Remainder of Medicare Approved Amounts
80%
20%
$0
OTHER BENEFITS - NOT COVERED BY MEDICARE
SERVICES
MEDICARE PAYS
[AFTER YOU PAY [$2,000] DEDUCTIBLE,**] PLAN
						  PAYS
[IN ADDITION TO [$2,000] DEDUCTIBLE,**] YOU
						  PAY
FOREIGN TRAVEL
- NOT COVERED BY MEDICARE
						  Medically necessary emergency care services beginning during the first 60 days
						  of each trip outside the USA
First $250 each calendar year
$0
$0
$250
Remainder of Charges
$0
80% to a
						  lifetime maximum benefit of $50,000
20% and amounts over the $50,000
						  lifetime maximum
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.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION*
Semiprivate room and
						  board, general nursing and miscellaneous services and supplies.
First 60 days
All but [$1,068][DAGGER]
[$1,068][DOUBLE DAGGER] (Part A Deductible)
$0
61st thru 90th day
All but [$267][DAGGER] a day
[$267][DOUBLE DAGGER] a day
$0
91st day and after:
--While using 60 lifetime reserve days
All but [$534][DAGGER] a day
[$534][DOUBLE DAGGER] a day
$0
--Once lifetime reserve days are used:
--Additional 365 days
$0
100% of Medicare Eligible Expenses
$0**
--Beyond the Additional 365 days
$0
$0
All Costs
SKILLED NURSING FACILITY CARE*
You must
						  meet Medicare's requirements, including having been in a hospital for at least
						  3 days and entered a Medicare-approved facility within 30 days after leaving
						  the hospital.
First 20 days
All approved amounts
$0
$0
21st thru 100th day
All but [$133.50][DAGGER] a day
Up to [$133.50][DOUBLE DAGGER] 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
[DAGGER] Medicare redetermines deductibles on an annual
				basis.
[DOUBLE DAGGER] Plan payments and your payments are adjusted
				annually based on medicare deductibles.
**
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
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR
				YEAR
*Once you have been billed [$135] 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 [$135] of Medicare Approved Amounts*
$0
$0
[$135] (Part B Deductible)
Remainder of Medicare Approved Amounts
Generally 80%
Generally 20%
$0
Part B Excess Charges
(Above Medicare
						  Approved Amounts)
$0
100%
$0
BLOOD
First 3 pints
$0
All Costs
$0
Next [$135] of Medicare Approved Amounts*
$0
$0
[$135] (Part B Deductible)
Remainder of Medicare Approved Amounts
80%
20%
$0
CLINICAL LABORATORY SERVICES
- TESTS FOR
						  DIAGNOSTIC SERVICES
100%
$0
$0
PARTS A & B
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE
-MEDICARE APPROVED
						  SERVICES
--Medically necessary skilled care services and medical
						  supplies
100%
$0
$0
--Durable medical equipment First [$135] of Medicare
						  Approved Amounts*
$0
$0
[$135] (Part B Deductible)
Remainder of Medicare Approved Amounts
80%
20%
$0
OTHER BENEFITS - NOT COVERED BY MEDICARE
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
FOREIGN TRAVEL
- NOT COVERED BY MEDICARE
						  Medically necessary emergency care services beginning during the first 60 days
						  of each trip outside the USA
First $250 each calendar year
$0
$0
$250
Remainder of Charges
$0
80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
HCFA DEDUCTIBLES FOR PLANS F AND J
Calendar Year Beginning
Federal Register
January 1, 1999
$1,500
January 1, 2000
$1,530
Monday, April 10, 2000
January 1, 2001
$1,580
Thursday, December 21, 2000
January 1, 2002
$1,620
Friday, December 28, 2001
January 1, 2003
$1,650
January 1, 2004
$1,690
January 1, 2005
$1,730
January 1, 2006
$1,790
January 1, 2007
$1,860
January 1, 2008
$1,900
January 1, 2009
$2,000
PLAN K
*You will pay half the cost-sharing of some covered services
				until you reach the annual out-of-pocket
limit
of [$4,620] each
				calendar year. The amounts
that count toward your annual limit
are
				noted with diamonds (*) in the chart below. Once you reach the annual limit,
				the plan pays 100% of your Medicare copayment and coinsurance for the rest of
				the calendar year.
However, this limit does NOT include charges from your
				provider that exceed Medicare-approved amounts (these are called "Excess
				Charges") and you will be responsible for paying this difference in the amount
				charged by your provider and the amount paid by Medicare for the item or
				service.
MEDICARE (PART A)------HOSPITAL SERVICES-PER BENEFIT
				PERIOD
**A benefit period begins on the first day you receive service
				as an inpatient in a hospital and ends after you have been out of the hospital
				and have not received skilled care in any other facility for 60 days in a
				row.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY*
HOSPITALIZATION**
Semiprivate room and
						  board, general nursing and miscellaneous services and supplies.
First 60 days
All but [$1,068][DAGGER]
[$534][DOUBLE DAGGER] (50% Part A Deductible)
[$534][DOUBLE DAGGER] (50% of Part A Deductible)*
61st thru 90th day
All but [$267][DAGGER] a day
[$267][DOUBLE DAGGER] a day
$0
91st day and after:
--While using 60 lifetime reserve days
All but [$534][DAGGER] a day
[$534][DOUBLE DAGGER] a day
$0
--Once lifetime reserve days are used:
--Additional 365 days
$0
100% of Medicare eligible expenses
$0***
--Beyond the Additional 365 days
$0
$0
All Costs
SKILLED NURSING FACILITY CARE**
You must
						  meet Medicare's requirements, including having been in a hospital for at least
						  3 days and entered a Medicare-approved facility within 30 days after leaving
						  the hospital.
First 20 days
All approved amounts
$0
$0
21st thru 100th day
All but [$133.50][DAGGER] a day
Up to [$66.75][DOUBLE DAGGER] a day
Up to [$66.75][DOUBLE DAGGER] a day*
101st day and after
$0
$0
All Costs
BLOOD
First 3 pints
$0
50%
50%*
Additional Amounts
100%
$0
$0
HOSPICE CARE
You must meet Medicare's
						  requirements, including a doctor's certification of terminal illness
All but very limited copayment/coinsurance for
						  outpatient drugs and inpatient respite care.
50% of copayment/coinsurance
50% of Medicare copayment/coinsurance [or copayments]*
[DAGGER] Medicare redetermines deductibles on an annual
				basis.
[DOUBLE DAGGER] Plan payments and your payments are adjusted
				annually based on medicare deductibles.
***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 [$135] 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 [$135] of Medicare Approved Amounts****
$0
$0
[$135] (Part B Deductible)*****
Preventive Benefits for Medicare covered services
Generally 75% or more of Medicare approved amounts
Remainder of Medicare approved amounts
All costs above Medicare approved amounts
Remainder of Medicare Approved amounts
Generally 80%
Generally 10%
Generally 10%*
Part B Excess Charges (Above Medicare Approved Amounts)
$0
$0
All costs (and they do not count toward annual
						  out-of-pocket limit of [$4,620)*
BLOOD
First 3 pints
$0
50%
50%*
Next [$135] of Medicare Approved Amounts****
$0
$0
[$135] (Part B Deductible)*****
Remainder of Medicare Approved Amounts
Generally 80%
Generally 10%
Generally 10%*
CLINICAL LABORATORY SERVICES
- TESTS FOR
						  DIAGNOSTIC SERVICES
100%
$0
$0
*This plan limits your annual out-of-pocket payments for
				Medicare-approved amounts to [$4,620] 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.
PLAN K
PARTS A & B
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY*
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
--Medically necessary skilled care services and medical
						  supplies
100%
$0
$0
--Durable medical equipment First [$135] of Medicare
						  Approved amounts*****
$0
$0
[$135] (Part B Deductible)*
Remainder of Medicare approved amounts
80%
10%
10%*
*****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
				[$2,310] each calendar year. The amounts
that count toward your annual
				limit
are noted with diamonds (*) in the chart below. Once you reach the
				annual limit, the plan pays 100% of your Medicare copayment and coinsurance for
				the rest of the calendar year.
However, this limit does NOT include
				charges from your provider that exceed Medicare-approved amounts (these are
				called "Excess Charges") and you will be responsible for paying this difference
				in the amount charged by your provider and the amount paid by Medicare for the
				item or service.
MEDICARE (PART A)------HOSPITAL SERVICES-PER BENEFIT
				PERIOD
**A benefit period begins on the first day you receive service
				as an inpatient in a hospital and ends after you have been out of the hospital
				and have not received skilled care in any other facility for 60 days in a
				row.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY*
HOSPITALIZATION**
Semiprivate room and
						  board, general nursing and miscellaneous services and supplies.
First 60 days
All but [$1,068][DAGGER]
[$801][DOUBLE DAGGER] (75% Part A Deductible)
[$267][DOUBLE DAGGER] (25% of Part A Deductible)*
61st thru 90th day
All but [$267][DAGGER] a day
[$267][DOUBLE DAGGER] a day
$0
91st day and after:
--While using 60 lifetime reserve days
All but [$534][DAGGER] a day
[$534][DOUBLE DAGGER] a day
$0
--Once lifetime reserve days are used:
--Additional 365 days
$0
100% OF Medicare eligible expenses
$0***
--Beyond the additional 365 days
$0
$0
All Costs
SKILLED NURSING FACILITY CARE**
You must
						  meet Medicare's requirements, including having been in a hospital for at least
						  3 days and entered a Medicare-approved facility within 30 days after leaving
						  the hospital.
First 20 days
All approved amounts
$0
$0
21st thru 100th day
All but [$133.50][DAGGER] a day
Up to [$100.13][DOUBLE DAGGER] a day
Up to [$33.37][DOUBLE DAGGER] a day*
101st day and after
$0
$0
All Costs
BLOOD
First 3 pints
$0
75%
25%*
Additional Amounts
100%
$0
$0
HOSPICE CARE
You must meet Medicare's
						  requirements, including a doctor's certification of terminal illness
All but very limited copayment/coinsurance for
						  outpatient drugs and inpatient respite care
75% of copayment/coinsurance [or copayments]
25% of copayment/coinsurance*
[DAGGER] Medicare redetermines deductibles on an annual
				basis.
[DOUBLE DAGGER] Plan payments and your payments are adjusted
				annually based on medicare deductibles.
***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 [$135] 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 [$135] of Medicare Approved Amounts****
$0
$0
[$135] (Part B Deductible)*****
Preventive Benefits for Medicare covered services
Generally 75% or more of Medicare approved amounts
Remainder of Medicare approved amounts
All costs above Medicare approved amounts
Remainder of Medicare Approved amounts
Generally 80%
Generally 15%
Generally 5%*
Part B Excess Charges
(Above Medicare
						  Approved Amounts)
$0
$0
All costs (and they do not count toward annual
						  out-of-pocket limit of [$2,310])*
BLOOD
First 3 pints
$0
75%
25%*
Next [$135] of Medicare Approved Amounts****
$0
$0
[$135] (Part B deductible)*
Remainder of Medicare Approved Amounts
Generally 80%
Generally 15%
Generally 5%*
CLINICAL LABORATORY SERVICES
- TESTS FOR
						  DIAGNOSTIC SERVICES
100%
$0
$0
*This plan limits your annual out-of-pocket payments for
				Medicare-approved amounts to [$2,310] per year. However, this limit does NOT
				include charges from your provider that exceed Medicare-approved amounts (these
				are called "Excess Charges"), and you will be responsible for paying this
				difference in the amount charged by your provider and the amount paid by
				Medicare for the item or service.
PLAN L
PARTS A & B
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY*
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
--Medically necessary skilled care services and medical
						  supplies
100%
$0
$0
--Durable medical equipment First [$135] of Medicare
						  Approved amounts*****
$0
$0
[$135] (Part B Deductible)*
Remainder of Medicare approved amounts
80%
15%
5%*
*****Medicare benefits are subject to change. Please consult
				the latest
Guide to Health Insurance for People with
				Medicare.
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 [$1,068]
[$534](50% of Part A deductible)
[$534](50% of Part A deductible)
61st thru
						  90th day
All but $[267] a day
$[$267] a day
$0
91st day and after -While
						  using 60 lifetime reserve days
All but [$534] a day
[$534] a day
$0
-Once lifetime reserve days are used:
--Additional 365 days
$0
100% of Medicare eligible expenses
$0**
--Beyond the additional 365 days
$0
$0
All costs
SKILLED NURSING FACILITY CARE*
You must
						  meet Medicare's requirements, including having been in a hospital for at least
						  3 days and entered a Medicare-approved facility within 30 days after leaving
						  the hospital
First 20 days
All approved amounts
$0
$0
21st thru
						  100th day
All but [$133.50] a day
Up to [$133.50] a day
$0
101st day and after
$0
$0
All Costs
BLOOD
First 3 pints
$0
3 pints
$0
Additional amounts
100%
$0
$0
HOSPICE CARE
You must meet Medicare's
						  requirements, including a doctor's certification of terminal illness
All but very limited copayment/coinsurance for
						  outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
0
**NOTICE:
When your Medicare Part A hospital
				benefits are exhausted, the insurer stands in the place of Medicare and will
				pay whatever amount Medicare would have paid for up to an additional 365 days
				as provided in the policy's " Core Benefits." During this time the hospital is
				prohibited from billing you for the balance based on any difference between its
				billed charges and the amount Medicare would have paid.
[DAGGER] Medicare redetermines deductibles on an annual
				basis.
[DOUBLE DAGGER] Plan payments and your payments are adjusted
				annually based on medicare deductibles.
MEDICARE (PART B) - MEDICARE SERVICES - PER CALENDAR
				YEAR
*Once you have been billed $[135] 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
MEDICAR 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 [$135] of Medicare Approved Amounts*
$0
$0
[$135] (Part B deductible)
Remainder of Medicare Approved Amounts
Generally 80%
Generally 20%
$0
Part B Excess Charges
(Above Medicare
						  Approved Amounts)
$0
$0
All costs
BLOOD
First 3 pints
$0
All Costs
$0
Next [$135] of Medicare Approved Amounts*
$0
$0
[$135] (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 [$135] of Medicare Approved Amounts*
$0
$0
$[135] ( Part B deductible)
Remainder of Medicare Approved
						  Amounts
80%
20%
$0
OTHER BENEFITS - NOT COVERED BY
				MEDICARE
FOREIGN TRAVEL
- NOT COVERED BY MEDICARE
						  Medically necessary emergency care services beginning during the first 60 days
						  of each trip outside the USA
First $250 each calendar year
$0
$0
$250
Remainder of Charges
$0
80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
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 [$1,068]
[$1,068] ( Part A deductible)
$0
61st thru
						  90th day
All but [$267] a day
[$267] a day
$0
91st day and after
--While using 60 lifetime reserve days
All but [$534] a day
[$534] a day
$0
-Once lifetime reserve days are used:
--Additional 365 days
$0
100% of Medicare eligible expenses
$0**
--Beyond the additional 365 days
$0
$0
All costs
SKILLED NURSING FACILITY CARE*
You must
						  meet Medicare's requirements, including having been in a hospital for at least
						  3 days and entered a Medicare-approved facility within 30 days after leaving
						  the hospital
First 20 days
All approved amounts
$0
$0
21st thru
						  100th day
All but $[133.50] a day
Up to $[133.50] a day
$0
101st day and after
$0
$0
All costs
BLOOD
First 3 pints
$0
3 pints
$0
Additional amounts
100%
$0
$0
HOSPICE CARE
You must meet Medicare's
						  requirements, including a doctor's certification of terminal illness
All but very limited copayment/coinsurance for
						  outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**NOTICE:
When your Medicare Part A hospital
				benefits are exhausted, the insurer stands in the place of Medicare and will
				pay whatever amount Medicare would have paid for up to an additional 365 days
				as provided in the policy's "Core Benefits." During this time the hospital is
				prohibited from billing you for the balance based on any difference between its
				billed charges and the amount Medicare would have paid.
[DAGGER] Medicare redetermines deductibles on an annual
				basis.
[DOUBLE DAGGER] Plan payments and your payments are adjusted
				annually based on medicare deductibles.
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR
				YEAR
*Once you have been billed [$135] 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 [$135] of Medicare Approved Amounts*
$0
$0
[$135] (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 [$135] of Medicare Approved Amounts*
$0
$0
[$135] (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
MEDICAL APPROVED SERVICES
-Medically necessary skilled care services and medical
						  supplies
100%
$0
$0
-Durable medical equipment First [$135] of Medicare
						  Approved Amounts*
$0
%0
[$135] (Part B deductible)
Remainder of Medicare Approved Amounts
80%
20%
$0
OTHER BENEFITS - NOT COVERED BY
				MEDICARE
FOREIGN TRAVEL
- NOT COVERED BY MEDICARE
						  Medically necessary emergency care services beginning during the first 60 days
						  of each trip outside the USA
First $250 each calendar year
$0
$0
$250
Remainder of Charges
$0
80% to a lifetime maximum benefit of $50,000
20% and amounts over the 50,000 lifetime maximum
The amended
				version of this section by
				Hawaii
				Administrative Rules Listing of Filings, 2019-01, July, eff.
				8/1/2019 is not yet
				available.