Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart G - MISCELLANEOUS PROVISIONS › Appendix I - Plan G (for plans issued prior to 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.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and
							 miscellaneous services and supplies
First 60 days
All but [$________]
[$________] (Part A Deductible)
$0
61st thru
							 90th day
All but [$________] 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
$0
101st day and after
$0
$0
All costs
BLOOD
First 3 pints
$0
3 pints
$0
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
All but very limited coinsurance for out-patient
							 drugs and inpatient respite care
$0
Balance
** 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 Continued)
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)
Remainder of Medicare Approved
							 Amounts
generally 80%
generally 20%
$0
Part B Excess Charges
(Above Medicare Approved Amounts)
$0
80%
20%
BLOOD
First 3 pints
$0
All costs
$0
Next $[100] of Medicare Approved Amounts*
$0
$0
$[100] (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 $[100] of Medicare Approved
							 Amounts*
$0
$0
$[100] (Part B Deductible)
Remainder of Medicare Approved
							 Amounts
80%
20%
$0
AT-HOME RECOVERY SERVICES-NOT COVERD BY
							 MEDICARE
Home care certified by your doctor, for
							 personal care during recovery from an injury or sickness for which Medicare
							 approved a Home Care Treatment Plan
- Benefit for each visit
$0
Actual Charges to $40 a visit
Balance
- Number of visits covered (must be
							 received within 8 weeks of last Medicare Approved visit
$0
Up to the number of Medicare Approved visits, not to
							 exceed 7 each week
- Calendar year maximum
$0
$1,600
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