New York Codes, Rules and Regulations › Title 11 - INSURANCE › Appendices › Appendix 12A

Current through Register Vol. 46, No. 28, July 10, 2024
APPENDIX 12A
Required disclosure statement for policies and
							 certificates of Medicare supplement insurance meeting the standards of sections
							 52.11 and
							 52.14  of this Title and sections
							 58.1 and
							 58.2  of this Part issued with an
							 effective date for coverage prior to June 1, 2010. The appendix contains the
							 items that shall be included in the disclosure statement in the order
							 prescribed therein.
The disclosure statement shall consist of four parts:
							 a cover page, premium information, disclosure pages, and charts displaying the
							 features of each benefit plan offered by the issuer. The disclosure statement
							 shall be in the language and format prescribed below in no less than 12-point
							 type. All benefit plans "A" through "L" shall be shown on the cover page, and
							 the plan(s) that are offered by the issuer shall be prominently identified.
							 Premium information for plans that are offered shall be shown on the cover page
							 or immediately following the cover page and shall be prominently displayed. The
							 premium and mode shall be stated for all plans that are offered to the
							 prospective applicant. All possible premiums for the prospective applicant
							 shall be illustrated.
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				to view image
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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.
DISCLOSURES (Boldface Type)
Use this outline to compare benefits and premiums
							 among policies.
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.
DISCLOSURES (Boldface Type)
Use this outline to compare benefits and premiums
							 among policies.
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 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)
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
							 58.2(b)(4)of  this
							 Part.)
(Include an explanation of any innovative benefits on
							 the cover page and in the chart, in a manner approved by the
							 superintendent.)
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*
Semi-private room and board, general nursing and
							 miscellaneous services and supplies
First 60 days
All but $[1100]
$0
$[1100](Part A deductible)
61st thru 90th day
All but $[275] a day
$[275] a day
$0
91st day and after:
-While using 60 lifetime reserve days
All but $[550] day
$[550] a day
$0
-Once lifetime reserve days are used:
-Additional 365 days (lifetime)
$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 $[137.50] a day
$0
Up to $[137.50] a day
101st day and after
$0
$0
All costs
BLOOD (per calendar year)
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
PLAN A
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR
				YEAR
* Once you have been billed $[155]
				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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[1100]
$[1100] (Part A deductible)
$0
61st thru 90th day
All but $[275] a day
$[275] a day
$0
91st day and after:
-While using 60 lifetime reserve days
All but $[550]
$[550] a day
$0
-Once lifetime reserve days are used:
-Additional 365 days (lifetime)
$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 $[137.50] a day
$0
Up to $[137.50] a day
101st day and after
$0
$0
All costs
BLOOD (per calendar year)
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
PLAN B
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR
				YEAR
* Once you have been billed $[155]
				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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[1100]
$[1100] (Part A deductible)
$0
61st thru 90th day
All but $[275] a day
$[275] a day
$0
91st day and after:
-While using 60 lifetime reserve days
All but $[550] a day
$[550] a day
$0
-Once lifetime reserve days are used:
-Additional 365 days (lifetime)
$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 $[137.50] a day
Up to $[137.50] a day
$0
101st day and after
$0
$0
All costs
BLOOD (per calendar year)
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
PLAN C
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR
				YEAR
* Once you have been billed $[155]
				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 $[155] of Medicare Approved
							 Amounts*
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$[155] (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
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 $[155] of Medicare Approved
							 Amounts*
$0
$[155] (Part B deductible)
$0
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
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 $[1100]
$[1100] (Part A deductible)
$0
61st thru 90th day
All but $[275] a day
$[275] a day
$0
91st day and after:
-While using 60 lifetime reserve days
All but $[550] a day
$[550] a day
$0
-Once lifetime reserve days are used:
-Additional 365 days (lifetime)
$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 $[137.50] a day
Up to $[137.50] a day
$0
101st day and after
$0
$0
All costs
BLOOD (per calendar year)
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
PLAN D
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR
				YEAR
* Once you have been billed $[155]
				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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (Part B deductible)
Remainder of Medicare Approved Amounts
80%
20%
$0
AT-HOME RECOVERY SERVICES-NOT COVERED 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
PLAN E
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 $[1100]
$[1100] (Part A deductible)
$0
61st thru 90th day
All but $[275] a day
$[275] a day
$0
91st day and after:
-While using 60 lifetime reserve days
All but $[550] a day
$[550] a day
$0
-Once lifetime reserve days are used:
-Additional 365 days (lifetime)
$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 $[137.50] a day
Up to $[137.50] a day
$0
101st day and after
$0
$0
All costs
BLOOD (per calendar year)
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
PLAN E
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR
				YEAR
* Once you have been billed $[155]
				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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (Part B deductible)
Remainder of Medicare Approved Amounts
80%
20%
$0
PLAN E
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
***PREVENTIVE
							 MEDICAL CARE BENEFIT-NOT COVERED BY MEDICARE
Some annual physical and preventive tests and
							 services administered or ordered by your doctor when not covered by
							 Medicare
First $120 each calendar year
$0
$120
$0
Additional charges
$0
$0
All costs
***Medicare benefits are subject to
				change. Please consult the latest
Guide to Health Insurance for People
				with Medicare.
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.
SERVICES
MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and
							 miscellaneous services and supplies
First 60 days
All but $[1100]
$[1100] (Part A deductible)
$0
61st thru 90th day
All but $[275] a day
$[275] a day
$0
91st day and after:
-While using 60
Lifetime reserve days
All but $[550] a day
$[550] a day
$0
-Once lifetime reserve days are used:
-Additional 365 days (lifetime)
$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 $[137.50] a day
Up to $[137.50] a day
$0
101st day and after
$0
$0
All costs
BLOOD (per calendar year)
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
PLAN F
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR
				YEAR
* Once you have been billed $[155]
				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 $[155] of Medicare Approved
							 Amounts*
$0
$[155] (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 $[155] of Medicare Approved
							 amounts*
$0
$[155] (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
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 $[155] of Medicare Approved
							 Amounts*
$0
$[155] (Part B deductible)
$0
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
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 [$2000]
				deductible. Benefits from the high deductible Plan F will not begin until
				out-of-pocket expenses are [$2000]. 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 $[2000]
							 DEDUCTIBLE,** PLAN
							 PAYS
IN ADDITION TO $[2000]
							 DEDUCTIBLE,** YOU
							 PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and
							 miscellaneous services and supplies
First 60 days
All but $[1100]
$[1100] (Part A deductible)
$0
61st thru 90th day
All but $[275] a day
$[275] a day
$0
91st day and after:
-While using 60 lifetime reserve days
All but $[550] a day
$[550] a day
$0
-Once lifetime reserve days are used:
-Additional 365 days (lifetime)
$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 $[137.50] a day
Up to $[137.50] a day
$0
101st day and after
$0
$0
All costs
BLOOD (per calendar year)
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
HIGH DEDUCTIBLE PLAN F
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR
				YEAR
* Once you have been billed $[155]
				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 [$2000]
				deductible. Benefits from the high deductible Plan F will not begin until
				out-of-pocket expenses are [$2000]. 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
							 $[2000]DEDUCTIBLE,** PLAN PAYS
IN ADDITION TO
							 $[2000]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 $[155] of Medicare Approved
							 amounts*
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$[155] (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
SERVICES
MEDICARE PAYS
AFTER YOU PAY
							 $[2000]DEDUCTIBLE,** PLAN
							 PAYS
IN ADDITION TO
							 $[2000]DEDUCTIBLE,** YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED
							 SERVICES
-Medically necessary skilled care services and
							 medical supplies
100%
$0
$0
-Durable medical equipment
First $[155] of Medicare Approved
							 Amounts*
$0
$[155] (Part B deductible)
$0
Remainder of Medicare Approved Amounts
80%
20%
$0
OTHER BENEFITS-NOT COVERED BY MEDICARE
SERVICES
MEDICARE PAYS
AFTER YOU PAY $[2000]
							 DEDUCTIBLE,** PLAN PAYS
IN ADDITION TO $[2000]
							 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 $[1100]
$[1100] (Part A deductible)
$0
61st thru 90th day
All but $[275] a day
$[275] a day
$0
91st day and after:
-While using 60 lifetime reserve days
All but $[550] a day
$[550] a day
$0
-Once lifetime reserve days are used:
-Additional 365 days (lifetime)
$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 $[137.50] a day
Up to $[137.50] a day
$0
101st day and after
$0
$0
All costs
BLOOD (per calendar year)
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
PLAN G
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR
				YEAR
* Once you have been billed $[155]
				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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (Part B deductible)
Remainder of Medicare Approved Amounts
80%
20%
$0
AT-HOME RECOVERY SERVICES-NOT COVERED 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
PLAN H
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 $[1100]
$[1100] (Part A deductible)
$0
61st thru 90th day
All but $[275] a day
$[275] a day
$0
91st day and after:
-While using 60 lifetime reserve days
All but $[550] a day
$[550] a day
$0
-Once lifetime reserve days are used:
-Additional 365 days (lifetime)
$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 $[137.50] a day
Up to $[137.50] a day
$0
101st day and after
$0
$0
All costs
BLOOD (per calendar year)
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
PLAN H
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR
				YEAR
* Once you have been billed $[155]
				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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (Part B deductible)
Remainder of Medicare Approved Amounts
80%
20%
$0
PLAN H
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
PLAN I
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 $[1100]
$[1100] (Part A deductible)
$0
61st thru 90th day
All but $[275] a day
$[275] a day
$0
91st day and after:
-While using 60 lifetime reserve days
All but $[550] a day
$[550] a day
$0
-Once lifetime reserve days are used:
-Additional 365 days (lifetime)
$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 $[137.50] a day
Up to $[137.50] a day
$0
101st day and after
$0
$0
All costs
BLOOD (per calendar year)
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
PLAN I
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR
				YEAR
* Once you have been billed $[155]
				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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$0
$[155] (Part B deductible)
Remainder of Medicare Approved Amounts
80%
20%
$0
AT-HOME RECOVERY SERVICES-NOT COVERED 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
PLAN J
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 $[1100]
$[1100] (Part A deductible)
$0
61st thru 90th day
All but $[275] a day
$[275] a day
$0
91st day and after:
-While using 60 lifetime reserve days
All but $[550] a day
$[550] a day
$0
-Once lifetime reserve days are used:
-Additional 365 days (lifetime)
$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 $[137.50] a day
Up to $[137.50] a day
$0
101st day and after
$0
$0
All costs
BLOOD (per calendar year)
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
PLAN J
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR
				YEAR
* Once you have been billed $[155]
				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
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
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 $[155] of Medicare Approved
							 Amounts*
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$[155] (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
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 $[155] of Medicare Approved
							 Amounts*
$0
$[155] (Part B deductible)
$0
Remainder of Medicare Approved Amounts
80%
20%
$0
HOME HEALTH CARE AT-HOME RECOVERY SERVICES-NOT
							 COVERED 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
PARTS A &
							 B
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
***-PREVENTIVE
							 MEDICAL CARE BENEFIT-NOT COVERED BY MEDICARE
Some annual physical and preventive tests and
							 services administered or ordered by your doctor when not covered by
							 Medicare
First $120 each calendar year
$0
$120
$0
Additional charges
$0
$0
All costs
*** Medicare benefits are subject to
				change. Please consult the latest
Guide to Health Insurance for People
				with Medicare.
HIGH DEDUCTIBLE PLAN J
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 J after one has paid a calendar year [$2000]
				deductible. Benefits from high deductible Plan J will not begin until
				out-of-pocket expenses are [$2000]. 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 $[2000]
							 DEDUCTIBLE,** PLAN
							 PAYS
IN ADDITION TO $[2000]
							 DEDUCTIBLE,** YOU
							 PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and
							 miscellaneous services and supplies
First 60 days
All but $[1100]
$[1100] (Part A deductible)
$0
61st thru 90th day
All but $[275] a day
$[275] a day
$0
91st day and after:
-While using 60 lifetime reserve days
All but $[550] a day
$[550] a day
$0
-Once lifetime reserve days are used:
-Additional 365 days (lifetime)
$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 $[137.50] a day
Up to $[137.50] a day
$0
101st day and after
$0
$0
All costs
BLOOD (per calendar year)
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
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR
				YEAR
* Once you have been billed $[155]
				of Medicar-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 plans
				pays the same benefits as Plan J after one has paid a calendar year [$2000]
				deductible. Benefits from high deductible plan J will not begin until
				out-of-pocket expenses are [$2000]. 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 $[2000]
							 DEDUCTIBLE,** PLAN
							 PAYS
IN ADDITION TO $[2000]
							 DEDUCTIBLE,** YOU
							 PAY
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
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 $[155] of Medicare Approved
							 Amounts*
$0
$[155] (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 $[155] of Medicare Approved
							 Amounts*
$0
$[155] (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
SERVICES
MEDICARE PAYS
AFTER YOU PAY $[2000] DEDUCTIBLE, 
							 ** PLAN
							 PAYS
IN ADDITION TO $[2000] DEDUCTIBLE, 
							 **
							 YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
-Medically necessary skilled care services and
							 medical supplies
100%
$0
$0
-Durable medical equipment
First $[155] of Medicare Approved
							 Amounts*
$0
$[155] (Part B deductible)
$0
Remainder of Medicare Approved Amounts
80%
20%
$0
HOME HEALTH CARE AT-HOME RECOVERY SERVICES-NOT
							 COVERED 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
PARTS A &
							 B
OTHER BENEFITS-NOT COVERED BY
							 MEDICARE
SERVICES
MEDICARE PAYS
AFTER YOU PAY $[2000] DEDUCTIBLE, 
							 ** PLAN
							 PAYS
IN ADDITION TO $[2000] 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
***PREVENTIVE
							 MEDICAL CARE BENEFIT-NOT COVERED BY MEDICARE
Some annual physical and preventive tests and
							 services administered or ordered by your doctor when not covered by
							 Medicare
First $120 each calendar year
$0
$120
$0
Additional charges
$0
$0
All costs
*** Medicare benefits are subject to
				change. Please consult the latest
Guide to Health Insurance for People
				with Medicare.
PLAN K
* You will pay half the cost-sharing
				of some covered services until you reach the annual out-of-pocket limit of
				$[4620] each calendar year. The amounts that count toward your annual limit are
				noted with diamonds (A) in the chart below. Once you reach the annual limit,
				the plan pays 100% of your Medicare copayments 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 $[1100]
$[550] (50% of Part A deductible)
$[550] (50% of Part A deductible)A
61st thru 90th day
All but $[275] a day
$[275] a day
$0
91st day and after:
-While using 60 lifetime reserve days
All but $[550] a day
$[550] a day
$0
-Once lifetime reserve days are used:
-Additional 365 days (lifetime)
$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 $[137.50] a day
Up to $[68.75] a day
Up to $[68.75] a day A
101st day and after
$0
$0
All costs
BLOOD (per calendar year)
First 3 pints
$0
50%
50%A
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
							 out-patient drugs and inpatient respite care
50% of coinsurance or copayments
50% of coinsurance or copaymentsA
PLAN K
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR
				YEAR
**** Once you have been billed
				$[155] 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 $[155] of Medicare Approved
							 Amounts****
$0
$0
$[155] (Part B
							 deductible)****A
Preventive Benefits for Medicare covered
							 services
Generally 80% 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%A
Part B Excess Charges
(Above Medicare
							 Approved Amounts)
$0
$0
All cost (and they do not count toward annual
							 out-of-pocket limit of [$4620])*
BLOOD
First 3 pints
$0
50%
50%A
Next $[155] of Medicare Approved
							 Amounts****
$0
$0
$[155] (Part B
							 deductible)****A
Remainder of Medicare Approved Amounts
Generally 80%
Generally 10%
Generally 10%A
CLINICAL LABORATORY
							 SERVICES-
TESTS FOR DIAGNOSTIC SERVICES
100%
$0
$0
* This plan limits
						  your annual out-of-pocket payments for Medicare-approved amounts to $[4620] 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.
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 $[155] of Medicare
							 Approved Amounts******
$0
$0
$[155] (Part B deductible)A
Remainder of Medicare Approved Amounts
80%
10%
10%A
****** 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 $[2310] each calendar year. The amounts that count toward your annual
				limit are noted with diamonds (A) in the chart below. Once you reach the annual
				limit, the plan pays 100% of your Medicare copayments 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 $[1100]
$[825] (75% of Part A deductible)
$[275] (25% of Part A deductible)A
61st thru 90th day
All but $[275] a day
$[275] a day
$0
91st day and after:
-While using 60 lifetime reserve days
All but $[550] a day
$[550] a day
$0
-Once lifetime reserve days are used:
-Additional 365 days (lifetime)
$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 $[137.50] a day
Up to $[103.13] a day
Up to $[34.38] a day A
101st day and after
$0
$0
All costs
BLOOD (per calendar year)
First 3 pints
$0
75%
25%A
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
							 out-patient drugs and inpatient respite care
75% of coinsurance or copayments
25% of coinsurance or copaymentsA
PLAN L
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR
				YEAR
****Once you have been billed $[155]
				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 $[155] of Medicare Approved
							 Amounts****
$0
$0
$[155] (Part B
							 deductible)**** A
Preventive Benefits for Medicare covered
							 services
Generally 80% 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% A
Part B Excess Charges
(Above Medicare
							 Approved Amounts)
$0
$0
All cost (and they do not count toward annual
							 out-of-pocket limit of [$2310])*
BLOOD
First 3 pints
$0
75%
25% A
Next $[155] of Medicare Approved
							 Amounts****
$0
$0
$[155] (Part B deductible)A
Remainder of Medicare Approved Amounts
Generally 80%
Generally 15%
Generally 5% A
CLINICAL LABORATORY SERVICES
- TESTS FOR
							 DIAGNOSTIC SERVICES
100%
$0
$0
* This plan limits
						  your annual out-of-pocket payments for Medicare-approved amounts to $[2310] 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.
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 $[155] of Medicare
							 Approved Amounts*****
$0
$0
$[155] (Part B deductible)A
Remainder of Medicare Approved Amounts
80%
15%
5% A
*****Medicare benefits are subject
				to change. Please consult the latest
Guide to Health Insurance for
				People with Medicare.