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

Current through Register Vol. 48, No. 28, July 12, 2024
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.
* You will pay one-fourth of the cost-sharing of some covered
				  services until you reach the annual out-of-pocket limit of $[___] each calendar
				  year. The amounts that count toward your annual limit are noted with diamonds
				  ([DIAMOND]) 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 $[___]
$[___] (75% of Part A deductible)
$[___] (25% of Part A deductible)[DIAMOND]
61st thru
							 90th day
All but $[___] a day
$[___] a day
$0
91st day and after:
- While using 60 lifetime reserve days
All but $[___] a day
$[___] 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 $[___] a day
Up to $[___] a day
Up to $[___] a day[DIAMOND]
101st day and after
$0
$0
All costs
BLOOD
First 3 pints
$0
75%
25% [DIAMOND]
Additional amounts
100%
$0
$0
HOSPICE CARE
Available as long as your doctor certifies you are
							 terminally ill and you elect to receive these services
Generally, most Medicare eligible expenses for
							 outpatient drugs and inpatient respite care
75% of coinsurance or copayments
25% of coinsurance or copayments [DIAMOND]
*** 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 $[100] 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 $[100] of Medicare Approved
							 Amounts****
$0
$0
$[100] (Part B deductible)**** [DIAMOND]
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% [DIAMOND]
Part B Excess Charges
(Above Medicare Approved Amounts)
$0
$0
All costs (and they do not count toward annual
							 out-of-pocket limit of [$_____])*
BLOOD
First 3 pints
$0
75%
25% [DIAMOND]
Next $[100] of Medicare Approved Amounts****
$0
$0
$[100] (Part B deductible) [DIAMOND]
Remainder of Medicare Approved Amounts
Generally 80%
Generally 15%
Generally 5% [DIAMOND]
CLINICAL LABORATORY SERVICES -
TESTS FOR
							 DIAGNOSTIC SERVICES
100%
$0
$0
* This plan limits your annual out-of-pocket payments for
				  Medicare-approved amounts to $[__] 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 1st $[100] of Medicare
							 Approved Amounts*****
$0
$0
$[100] (Part B deductible) [DIAMOND]
Remainder of Medicare Approved Amounts
80%
15%
5% [DIAMOND]
***** Medicare benefits are subject to change. Please consult
				  the latest Guide to Health Insurance for People with
				  Medicare.