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

Current through Register Vol. 48, No. 28, July 12, 2024
MEDICARE (PART A) - Hospital Services -
				  Per Benefit Period
Companies must add the current fixed dollar amount authorized
				  by Medicare where the brackets appear below. The dollar amount is updated
				  periodically by Medicare and companies must reflect these changes to their
				  outlines of coverage in a timely manner.
* 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 you have paid a calendar year [$_____] deductible. Benefits from the
				  high deductible Plan G will not begin until out-of-pocket expenses are
				  [$_____]. 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 PAY ($2240) DEDUCTIBLE**] PLAN
								PAYS
[IN ADDITION TO ($2240 DEDUCTIBLE**] YOU
								PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and
								miscellaneous services and supplies
First 60 days
61st thru
								90th day
91st day and
								after:
- While using 60 lifetime reserve
								days
- Once lifetime reserve days are
								used:
- Additional 365 days
All but [$
________
]
All but [$
________
] a day
All but [$
________
] a day
$0
[$ ] (Part A Deductible)
[$ ] a day [$ ] a day
100% of Medicare Eligible Expenses
$0
$0
$0
$0***
- Beyond the Additional 365 days
$0
$0
All costs
SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including
								having been in a hospital for at least 3 days and entered a Medicare-approved
								facility within 30 days after leaving the hospital
First 20 days
21st thru
								100th day
101st day and
								after
All approved amounts All but
								[$
________
] a day
$0
$0
Up to [$ ________ ] a day
$0
$0
$0
All costs
BLOOD
First 3 pints
Additional amounts
$0 100%
3 pints $0
$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
** 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
				  Continued)
MEDICARE (PART B) - Medical Services -
				  Per Calendar Year
* Once you have been billed $[183] of Medicare-Approved
				  amounts for covered services (which are noted with an asterisk), your Part B
				  Deductible will have been met for the calendar year.
[** This high deductible plan pays the same benefits as Plan
				  G after you have paid a calendar year [$_____] deductible. Benefits from the
				  high deductible Plan G will not begin until out-of-pocket expenses are
				  [$_____]. 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 PAY
($2240)
DEDUCTIBLE**]
PLAN PAYS
[IN ADDITION TO
($2240)
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 $[183] of Medicare Approved
								Amounts*
Remainder of Medicare Approved
								Amounts
$0
generally 80%
$0
generally 20%
$[183] (Unless Part B Deductible has been
								met)
$0
Part B Excess Charges
(Above Medicare Approved Amounts)
$0
100%
$0
BLOOD
First 3 pints
Next $[183] of Medicare Approved Amounts*
Remainder of Medicare Approved Amounts
$0 $0
80%
All costs $0
20%
$0
$[183] (Unless Part B Deductible has been
								met)
$0
CLINICAL LABORATORY SERVICES
TESTS FOR DIAGNOSTIC SERVICES
100%
$0
$0
PARTS A & B
SERVICES
MEDICARE PAYS
[AFTER YOU PAY
($2240)
DEDUCTIBLE**]
PLAN PAYS
[IN ADDITION TO
($2240)
DEDUCTIBLE**] YOU
PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
- Medically necessary skilled care
								services and medical supplies
- Durable medical equipment
First $[183] of Medicare Approved
								Amounts*
100%
$0
$0
$0
$0
$[183] (Part B Deductible)
Remainder of Medicare Approved
								Amounts
80%
20%
$0
OTHER BENEFITS - NOT COVERED BY
				  MEDICARE
SERVICES
MEDICARE PAYS
[AFTER YOU PAY ($2240)
DEDUCTIBLE**] PLAN
PAYS
[IN ADDITION TO
($2240)
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
Remainder of Charges
$0 $0
$0
80% to a lifetime maximum benefit of $50,000
$250
20% and amounts over the $50,000 lifetime
								maximum