Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart G - MISCELLANEOUS PROVISIONS › Appendix W - Outline of Medicare Supplement Coverage - Cover Page for Medicare Supplement Plans Sold on or after June 1, 2010

Current through Register Vol. 48, No. 28, July 12, 2024
Benefit Chart of Medicare Supplement
				  Plans Sold for Effective Dates 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.
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
K
L
M
N
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
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
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility
Coinsurance
50% Skilled Nursing
Facility
Coinsurance
75% 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
50% Part A Deductible
75% Part A Deductible
50% 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
Foreign
Travel Emergency
Foreign
Travel
Emergency
Out-of-pocket limit $[4140];
paid at 100%
after limit
reached
Out-of-pocket limit $[2070]; 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 [$1860] deductible. Benefits from high deductible Plan F will not
				  begin until out-of-pocket expenses exceed [$1860]. 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 specifying 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 will no longer be available for sale after May 31, 2010.
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 company.
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 producers:]
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 Appendices AA through JJ. No more
				  than four plans may be shown on one chart. For purposes of illustration, charts
				  for each plan are included in this Part. An issuer may use additional benefit
				  plan designations on these charts pursuant to Section
				  2008.67(e).]
[Include an explanation of any innovative benefits on the
				  cover page and in the chart, in a manner approved by the Director.]
Benefit Chart of Medicare Supplement
				  Plans Sold On or After January 1, 2020
This chart shows the benefits included in each of the
				  standard Medicare supplement plans. Some plans may not be available. Only
				  applicants
first
eligible for Medicare before 2020 may purchase
				  Plans C, F, and high deductible F.
Note: A ü means 100% of the benefit is paid.
Benefits
Plans Available to All
								Applicants
Medicare first eligible before 2020
								only
A
B
D
G1
K
L
M
N
C
F1
Medicare Part A coinsurance and hospital coverage
								(up to an additional 365 days after Medicare benefits are used up)
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
Medicare Part B coinsurance or copayment
ü
ü
ü
ü
50%
75%
ü
u
copays
apply3
ü
ü
Blood (first three pints)
ü
ü
ü
ü
50%
75%
ü
ü
ü
ü
Part A hospice care coinsurance or copayment
ü
ü
ü
ü
50%
75%
ü
ü
ü
ü
Skilled nursing facility coinsurance
ü
ü
50%
75%
ü
ü
ü
ü
Medicare Part A deductible
ü
ü
ü
50%
75%
50%
ü
ü
ü
Medicare Part B deductible
ü
ü
Medicare Part B excess charges
ü
ü
Foreign travel emergency (up to plan limits)
ü
ü
ü
ü
ü
ü
Out-of-pocket limit in
								[2017]2
[$5120]2
[$2560]2
1 Plans F and G also have a high
				  deductible option which require first paying a plan deductible of [$2200]
				  before the plan begins to pay. Once the plan deductible is met, the plan pays
				  100% of covered services for the rest of the calendar year. High deductible
				  plan G does not cover the Medicare Part B deductible. However, high deductible
				  plans F and G count your payment of the Medicare Part B deductible toward
				  meeting the plan deductible.
2 Plans K and L pay 100% of
				  covered services for the rest of the calendar year once you meet the
				  out-of-pocket yearly limit.
3 Plan N pays 100% of the Part B
				  coinsurance, except for a co-payment of up to $20 for some office visits and up
				  to a $50 co-payment for emergency room visits that do not result in an
				  inpatient admission.