3 Alaska Admin. Code § 28.490

Current through October 17, 2024

Section 3 AAC 28.490 - Required disclosure provisions

(a) Medicare supplement policies and certificates must include a renewal or continuation provision The language or specifications of the provisions must be consistent with the type of contract issued The provisions must be appropriately captioned, must appear on the first page of the policy, and must include any reservation by the issuer of the right to change premiums and any automatic renewal premium increases based on the policyholder's age.

(b) Except for riders or endorsements by which the issuer fulfills a request made in writing by the insured, exercises a specifically reserved right under a Medicare supplement policy, or is required to reduce or eliminate benefits to avoid duplication of Medicare benefits, all riders or endorsements added to a Medicare supplement policy after the date of issue or at reinstatement or renewal that reduce or eliminate benefits or coverage in the policy must require a signed acceptance by the insured. After the date of a policy or certificate issue, a rider or an endorsement that increases benefits or coverage with a concomitant increase in premium during the policy term must be agreed to in writing and signed by the insured, unless the benefits are required by the minimum standards for Medicare supplement policies or if the increased benefits or coverage are required by law. If a separate additional premium is charged for benefits provided in connection with a rider or an endorsement, the premium charge must be set out in the policy.

(c) A Medicare supplement policy or certificate may not provide for the payment of benefits based on standards described as "usual and customary," "reasonable and customary," or words of similar import.

(d) If a Medicare supplement policy or certificate contains a limitation with respect to a preexisting condition, the limitation must appear as a separate paragraph of the policy and be labeled "preexisting condition limitation."

(e) A Medicare supplement policy or certificate must have a notice prominently printed on the first page of the policy or certificate or attached to it stating in substance that the policyholder or certificate holder shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the insured person is not satisfied for any reason.

(f) An issuer of accident and sickness policies or certificates that provide hospital or medical expense coverage on an expense incurred or indemnity basis to a person eligible for Medicare must provide to the applicant a Guide to Health Insurance for People with Medicare in the form developed jointly by the National Association of Insurance Commissioners and the Centers for Medicare and Medicaid Services and in a type size no smaller than 12-point type. Delivery of the Guide must be made regardless of whether the policies or certificates are advertised, solicited, or issued as Medicare supplement policies or certificates under 3 AAC 28.410-3 AAC 28.510. Except for a direct response issuer, delivery of the Guide must be made to the applicant at the time of application and acknowledgment of receipt of the Guide must be obtained by the issuer. A direct response issuer shall deliver the Guide to the applicant upon request, but not later than at the time the policy is delivered.

(g) As soon as practicable, but not later than 30 days before the annual effective date of a Medicare benefit change, an issuer shall notify its policyholders and certificate holders of modifications that the issuer has made to Medicare supplement insurance policies or certificates in a format acceptable to the director. The notice must

(1) include a description of revisions to the Medicare program and a description of each modification made to the coverage provided under the Medicare supplement policy or certificate; and

(2) inform the policyholder or certificate holder when a premium adjustment is to be made due to changes in Medicare.

(h) The notice of benefit modifications and premium adjustments must be in outline format, in clear and simple terms, to facilitate comprehension.

(i) The notice may not contain or be accompanied by any solicitation.

(j) An issuer shall provide an outline of coverage to an applicant at the time the application is presented to the prospective applicant and, except for direct response policies, shall obtain an acknowledgment of receipt of the outline from the applicant.

(k) If an outline of coverage is provided at the time of application and the Medicare supplement policy or certificate is issued on a basis that would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany the policy or certificate when it is delivered and contain the following statement, in no smaller than 12-point type, immediately above the company name:

"NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued."

(l) For a Medicare supplement policy or certificate sold with an effective date of coverage before June 1, 2010, the outline of coverage provided to an applicant under this section consists of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage must be in the language and format set out in (t) of this section in no smaller than 12-point type. Plans "A" - "L" must be shown on the cover page and the plans offered by the issuer must be prominently identified. Premium information for plans that are offered must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and mode must be stated for each plan that is offered to the prospective applicant. Each possible premium for the prospective applicant must be illustrated.

(m) For a Medicare supplement policy or certificate sold with an effective date of coverage before June 1, 2010, as provided in 42 U.S.C. 1395e(b)(2), the dollar amount of the inpatient hospital deductible and all coinsurance amounts for plans "A" - "L" are determined annually by the secretary between September 1 and September 15 of the year preceding the year to which they will apply. As provided in 42 U.S.C. 1395/(b) and 1395r(a)(l), the dollar amount of the Medicare Part B deductible for plans "A" - "L" are determined annually by the secretary. Once determined, the figures are published in the Federal Register and may be obtained from the division.

(n) For a Medicare supplement policy or certificate sold with an effective date of coverage on or after June 1, 2010, the outline of coverage provided to an applicant under this section consists of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage must be in the language and format set out in (u) of this section in no smaller than 12-point type. Plans "A" - "D," plan "F," high deductible plan "F," and plans "G," "K," "L," "M," and "N" must be shown on the cover page and the plans offered by the issuer must be prominently identified. Premium information for plans that are offered must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and mode must be stated for each plan that is offered to the prospective applicant. Each possible premium for the prospective applicant must be illustrated.

(o) For a Medicare supplement policy or certificate sold with an effective date of coverage on or after June 1, 2010, as provided in 42 U.S.C. 1395e(b)(2), the dollar amount of the inpatient hospital deductible and all coinsurance amounts for plans "A" - "D," plan "F," high deductible plan "F," and plans "G," "K," "L," "M," and "N" are determined annually by the secretary between September 1 and September 15 of the year preceding the year to which they will apply. As provided in 42 U.S.C. 1395/(b) and 1395r(a)(l), the dollar amount of the Medicare Part B deductible for plans "A" - "D," plan "F," high deductible plan "F," and plans "G," "K," "L," "M," and "N" are determined annually by the secretary. Once determined, the figures are published in the Federal Register and may be obtained from the division.

(p) For a Medicare policy or certificate sold with an effective date of coverage on or after January 1, 2020, the outline of coverage provided to an applicant under this section consists of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage must be in the language and format set out in (w) of this section in no smaller than 12-point type. Plans "A" -"D," plan "F" high deductible plan "F," plan "G," high deductible plan "G," and plans "K," "L," "M," and "N" must be shown on the cover page and the plans offered by the issuer must be prominently identified. Premium information for plans that are offered must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and mode must be stated for each plan that is offered to the prospective applicant. Each possible premium for the prospective applicant must be illustrated.

(q) For a Medicare supplement policy or certificate sold with an effective date of coverage on or after January 1, 2020, as provided in 42 U.S.C. 1395e(b)(2), the dollar amount of the inpatient hospital deductible and all coinsurance amounts for plans "A" - "D," plan "F," high deductible plan "F," plan "G," high deductible plan "G," and plans "K," "L," "M," and "N" are determined annually by the secretary between September 1 and September 15 of the year preceding the year to which they will apply. As provided in 42 U.S.C. 1395/(b) and 1395r(a)(l), the dollar amount of the Medicare Part B deductible for plans "A" - "D," plan "F," high deductible plan "F," plan "G," high deductible plan "G," and plans "K," "L," "M," and "N" are determined annually by the secretary. Once determined, the figures are published in the Federal Register and may be obtained from the division.

(r) An issuer shall comply with the notice requirements of P.L. 108-173 (Medicare Prescription Drug, Improvement, and Modernization Act of 2003).

(s) For the purposes of this section, "form" means the language, format, type size, type proportional spacing, bold character, and line spacing.

(t) For a Medicare supplement policy or certificate sold with an effective date of coverage before June 1, 2010, the following items must be included in the outline of coverage in the order set out in this subsection.

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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. [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.

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.

A. [for agents]:

Neither [insert company's name] nor its agents are connected with Medicare.

B. [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 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 as set out in 3 AAC 28.455(e).]

[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the director.]

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* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$0 $[+] a day $[+]a day 100% of Medicare eligible expenses $0	$[+] (Part A deductible) $0 $0 $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- 100th day 101st dav and after	All approved amounts All but $[+] a day $0	$0 $0 $0	$0 Up to $[+] a day ' All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$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 outpatient drugs and inpatient respite care	$0	Balance

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (Parte deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $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 -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $0

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

PLANE 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 61st-90th day 91st day and after: --While using 60 lifetime reserve days --Once lifetime reserve days are used: --Additional 365 days --Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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- 100th day 101st day and after	All approved amounts All but $[+] a day $0	$0 $0 $0	$0 Up to $[+] a day All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$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 outpatient drugs and inpatient respite care	$0	Balance

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) -- MEDICAL SERVICES -- PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare- approved amounts* Remainder of Medicare -approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (Parte deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $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 -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $0

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

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 61st-90th day 91 st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+]a day $[+]a day 100% of Medicare eligible expenses $0	$0 $0 $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-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 Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for outpatient drugs and inpatient respite care	$0	Balance

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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 C

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare-approved amounts* Remainder of Medicare-approved amounts	$0 Generally 80%	$[+] (Part B deductible) Generally 20%	$0 $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	'$0	All costs
BLOOD First 3 pints Next $[+] of Medicare-approved amounts* Remainder of Medicare-approved amounts	$0 $0 80%	All costs $[+] (Part B deductible) 20%	$0 $0 $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE - APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare-approved amounts	100% $0 80%	$0 1 1 $[+] (Part B deductible) 20%	$0 $0 $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 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

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+]aday $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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- 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 Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for outpatient drugs and inpatient respite care	$0	Balance

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) -- MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare-approved amounts* Remainder of Medicare-approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE - APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare-approved amounts* Remainder of Medicare-approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $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 -Number of visits covered (Must be received within 8 weeks of last Medicare-approved visit) -Calendar year maximum	$0 $0 $0	Actual charges to $40 a visit Up to the number of Medicare-approved visits, not to exceed 7 each week $1,600	Balance

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

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 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

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $0 $0** All costs 1
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-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 Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for outpatient drugs and inpatient respite care	$0	Balance

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs '
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE - APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare -approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $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 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
*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 Additional charges	$0 $0	$120 $0	$0 All costs

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

*Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

[Indicate Plan F or High Deductible Plan F, depending on which plan is offered: PLAN F or 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.

[Language for High Deductible Plan F, if offered: **This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year $[+] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[+]. 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	[Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan F, if offered: IN ADDITION TO $[+] DEDUCTIBLE,**] YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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- 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 Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for outpatient drugs and inpatient respite care	$0	Balance

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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 lime 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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.

[Language for High Deductible Plan F, if offered: **This high deductible plan pays the same or offers the same beneflts as Plan F after one has paid a calendar year $[+] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[+]. 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 1	[Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan F, if offered: IN ADDITION TO $[+] 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 $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 Generally 80%	$[+] (Part B deductible) Generally 20%	$0 $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	100%	$0
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $[+] (Part B deductible) 20%	$0 $0 $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	[Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan F, if offered: IN ADDITION TO $[+] DEDUCTIBLE,**] YOU PAY
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare -approved amounts* Remainder of Medicare-approved amounts	100% $0 80%	$0 $[+] (Part B deductible) 20%	$0 $0 $0

OTHER BENEFITS-NOT COVERED BY MEDICARE

SERVICES	MEDICARE PAYS	[Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan F, if offered: IN ADDITION TO $[+] 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

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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- 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 Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for outpatient drugs and inpatient respite care	$0	Balance

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare -approved amounts* Remainder of Medicare -approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts')	$0	80%	20%
BLOOD First 3 pints Next$[+] of Medicare -approved amounts* Remainder of Medicare -approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare -approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $0
HOME HEALTH CARE (cont'd) 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 -Number of visits covered (Must be received within 8 weeks of last Medicare-approved visit) -Calendar year maximum	$0 $0 $0	Actual charges to $40 a visit Up to the number of Medicare-approved visits, not to exceed 7 each week $1,600	Balance

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

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 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

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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- 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 Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for outpatient drugs and inpatient respite care	$0	Balance

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $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 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

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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- 100th day 101 St 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 Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for outpatient drugs and inpatient respite care	$0	Balance

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	100%	$0
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare -approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $0
HOME HEALTH CARE (cont'd) 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 -Number of visits covered (Must be received within 8 weeks of last Medicare-approved visit) -Calendar year maximum	$0 $0 $0	Actual charges to $40 a visit Up to the number of Medicare-approved visits, not to exceed 7 each week $1,600	Balance

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

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 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

[Indicate Plan J or High Deductible Plan J, depending on which plan is offered: PLAN J or 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.

[Language for High Deductible Plan J, if offered: **This high deductible plan pays the same or offers the same benefits as Plan J after one has paid a calendar year $[+] deductible. Benefits from the high deductible Plan J will not begin until out-of-pocket expenses are $[+]. 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	[Language for High Deductible Plan J, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan J, if offered: IN ADDITION TO $[+] DEDUCTIBLE,**] YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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-1 approved facility within 30 days 1 after leaving the hospital First 20 days 21st- 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 Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for outpatient drugs and inpatient respite care	$0	Balance

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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.

[Language for High Deductible Plan J, if offered: **This high deductible plan pays the same or offers the same benefits as Plan J after one has paid a calendar year $[+] deductible. Benefits from the high deductible Plan J will not begin until out-of-pocket expenses are $[+]. 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	[Language for High Deductible Plan J, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan J, if offered: IN ADDITION TO $[+] 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 $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 Generally 80%	$[+] (Part B deductible) Generally 20%	$0 $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	100%	$0
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $[+] (Part B deductible) 20%	$0 $0 $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	[Language for High Deductible Plan J, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan J, if offered: IN ADDITION TO $[+] DEDUCTIBLE,**] YOU PAY
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $[+] (Part B deductible) 20%	$0 $0 $0
HOME HEALTH CARE (cont'd) 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 -Number of visits covered (Must be received within 8 weeks of last Medicare-approved visit) -Calendar year maximum	$0 $0 $0	Actual charges to $40 a visit Up to the number of Medicare-approved visits, not to exceed 7 each week $1,600	Balance

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

OTHER BENEFITS-NOT COVERED BY MEDICARE

SERVICES	MEDICARE PAYS	[Language for High Deductible Plan J, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan J, if offered: IN ADDITION TO $[+] 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
"'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 Additional charges	$0 $0	$120 $0	$0 All costs

[+ The dollar amount to be inserted is determined annually, as described in (m) of this section, and may be obtained from the division.]

***Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

PLAN K

*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 () 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 61st-90th day 91 St day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (50% of Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$[+] (50% of Part A deductible)* $0 $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- 100th day 101st day and after	All approved amounts All but $[+] a day $0	$0 Up to $[+] a day $0	$0 Up to $[+] a day* All costs
BLOOD First 3 pints Additional amounts	$0 100%	50% $0	50%* $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	50% of coinsurance or copayments	50% of coinsurance or copayments*

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

****Once you have been billed $[+] 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 $[+] of Medicare- approved amounts**** Preventive Benefits for Medicare covered services Remainder of Medicare- approved amounts	$0 Generally 75% or more of Medicare-approved amounts Generally 80%	$0 Remainder of Medicare-approved amounts Generally 10%	$[+] (Part B deductible) **** All costs above Medicare-approved amounts Generally 10%*
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 Next $[+] of Medicare-approved amounts**** Remainder of Medicare-approved amounts	$0 $0 Generally 80%	50% $0 Generally 10%	50%* $[+] (Part B deductible) ***** Generally 10%*
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

*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.

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare-approved amounts***** Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 10%	$0 $[+] (Part B deductible)* 10%*

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

*****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 $[+] each calendar year. The amounts that count toward your annual limit are noted with diamonds (*) 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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $ [+] All but $ [+] a day All but $ [+] a day $0 $0	$[+] (75% of Part A deductible)* $[+] a day $[+] a day 100 % of Medicare eligible expenses $0	$[+] (25% of Part A deductible)* $0 $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- 100th day 101st day and after	All approved amounts All but $[+] a day $0	$0 Up to $[+] a day $0	$0 Up to $[+] a day* All costs
BLOOD First 3 pints Additional amounts	$0 100%	75% $0	25%* $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*

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division at the address listed in the editor's note at the end of this section.]

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

****Once you have been billed $[+] 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 $[+] of Medicare-approved amounts**** Preventive Benefits for Medicare covered services Remainder of Medicare-approved amounts	$0 Generally 75% or more of Medicare-approved amounts Generally 80%	$0 Remainder of Medicare-approved amounts Generally 15%	$[+] (Part B deductible)***** All costs above Medicare-approved amounts Generally 5%*
Part B Excess Charges (Above Medicare-approved amounts)	$0	80%	All costs (and they do not count toward annual out-of-pocket limit of Sf+l)
BLOOD First 3 pints Next $[+] of Medicare-approved amounts**** Remainder of Medicare-approved amounts	$0 $0 Generally 80%	75% $0 Generally 15%	25%* $[+] (Part B deductible)***** Generally 5%*
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

*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.

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare-approved amounts***** Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 15%	$0 $[+](Part B deductible) 5%*

[+ The dollar amount to be inserted here is determined annually, as described in (m) of this section, and may be obtained from the division.]

*****

Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

(u) For a Medicare supplement policy or certificate sold with an effective date of coverage on or after June 1, 2010, the following items must be included in the outline of coverage in the order set out in this subsection. The benefit chart and the "DISCLOSURES" paragraph in this subsection may not be used on or after June 1, 2011.

Benefit Chart of Medicare Supplement Plans Sold With an Effective Date of Coverage On or After June 1, 2010

This chart shows the benefits included in each of the stand Medicare supplement plans. Every company must make plan "A" available. Some plans may not be available in your state. Plans E, H, I, and J are no longer available for sale.

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%o	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 $[+] paid at 100% after limit reached	Out-of-Pocket limit $[+] 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 [+] deductible. Benefits from high deductible plan F will not until out-of-pocket expense exceed [+]. Out-of-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.

[+ The dollar amount to be inserted is determined annually, as described in (o) of this section, and may be obtained from the division.]

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 before June 1, 2010 have different benefits and premiums. Plans E, H, I, and J are no longer available for sale.

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.

A. [for agents]:

Neither [insert company's name] nor its agents are connected with Medicare.

B. [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 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 as set out in 3 AAC 28.456(f).]

[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the director.]

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* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the -additional 365 days	All but $[+] All but $[+] a day All but$[+] a day $0 $0	$0 $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$[+] (Part A deductible) $0 $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-100th day 101st day and after	All approved amounts All but $[+] a day $0	$0 $0 $0	$0 Upto$[+]a day 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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare -approved amounts* Remainder of Medicare-approved amounts	$0 Generally 80%	1 $0 Generally 20%	$[+] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE - APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional -365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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-100th day 101st day and after	All approved amounts All but $[+] a day $0	$0 $0 $0	$0 Upto$[+]aday 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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted is determined annually, as described in (o) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES -- PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare -approved amounts* Remainder of Medicare-approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare -approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE - APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional -365 days	All but $[+] All but $[+] a day All but $[+]a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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-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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 Generally 80%	$[+] (Parte deductible) Generally 20%	$0 $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $[+] (Parte deductible) 20%	$0 $0 $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE - APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $[+] (Part B deductible) 20%	$0 $0 $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 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

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional -365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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-100th day 101 St day and after	All approved amounts All but $[+] a day $0	$0 Upto$[+]aday $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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare -approved amounts* Remainder of Medicare-approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE - APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $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 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

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

[Indicate Plan F or High Deductible Plan F, depending on which plan is offered: PLAN F or 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.

[Language for High Deductible Plan F, if offered: **This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year $[+] deductible. Benefits from the high deductible Flan F will not begin until out-of-pocket expenses are $[+]. 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	[Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan F, if offered: IN ADDITION TO $[+] DEDUCTIBLE,**] YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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- 100th day 101 St 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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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.

[Language for High Deductible Plan F, if offered: **This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year $[+] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[+]. 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	[Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan F, if offered: IN ADDITION TO $[+] 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 $[+] of Medicare- approved amounts* Remainder of Medicare-approved amounts	$0 Generally 80%	$[+] (Part B deductible) Generally 20%	$0 $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	100%	$0
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $[+] (Part B deductible) 20%	$0 $0 $0
CLINICAL LABORATORY SERVICES - TESTS FOR DL\GNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	[Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan F, if offered: IN ADDITION TO $[+] DEDUCTIBLE,**] YOU PAY
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $[+] (Part B deductible) 20%	$0 $0 $0

OTHER BENEFITS-NOT COVERED BY MEDICARE

SERVICES	MEDICARE PAYS	[Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan F, if offered: IN ADDITION TO $[+] DEDUCTIBLE,**] YOU PAY
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary 1 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

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

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 61st-90th day 91 St day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional -365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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-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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare- approved amounts* Remainder of Medicare-approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	100%	$0
BLOOD First 3 pints Next $[+] of Medicare-approved amounts* Remainder of Medicare-approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined armually, as described in (o) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare-approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $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 Remainder of charges	$0 , $0	$0 80% to a hfetime maximum benefit of $50,000	$250 20% and amounts over the $50,000 lifetime maximum

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

PLAN K

*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 () 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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	Allbut$[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (50% of PartA deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$[+] (50%of Part A deductible)* $0 $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 - 100th day 101st day and after	All approved amounts All but $[+] a day $0	$0 Up to $[+] a day $0	$0 Up to $[+]a day* All costs
BLOOD First 3 pints Additional amounts	$0 100%	50% $0	50%* $0
HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness	All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	50% of copayment/coinsurance	50% of Medicare copayment/coinsurance*

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

****Once you have been billed $[+] 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 $[+] of Medicare-approved amounts**** Preventive Benefits for Medicare covered services Remainder of Medicare- approved amounts	$0 Generally 75% or more of Medicare-approved amounts Generally 80%	$0 Remainder of Medicare-approved amounts Generally 10%	$[+] (Part B deductible)***** All costs above Medicare-approved amounts Generally 10%*
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 Next $[+] of Medicare-approved amounts**** Remainder of Medicare-approved amounts	$0 $0 Generally 80%	50% $0 Generally 10%	50%* $[+] (Part B deductible)***** Generally 10%*
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

*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.

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare-approved amounts***** Remainder of Medicare-approved amounts	100% $0 80%	$0 $0 10%	$0 $[+] (Part B deductible)* 10%*

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

*****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 $[+] each calendar year. The amounts that count toward your annual limit are noted with diamonds () 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 day.s 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 61st - 90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+](75% of Part A deductible) $[+]aday $[+] a day 100% of Medicare eligible expenses $0	$[+](25%ofPartA deductible)* $0 $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- 100th day 101st day and after	All approved amounts All but $[+] a day $0	$0 Upto$[+] a day $0	$0 Up to $[+] a day* All costs
BLOOD First 3 pints Additional amounts	$0 100%	75% $0	25%* $0
HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness	All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	75% of copayment/coinsurance	25% of copayment/coinsurance*

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

****Once you have been billed $[+] 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 $[+] of Medicare-approved amounts**** Preventive Benefits for Medicare covered services Remainder of Medicare- approved amounts	$0 Generally 75% or more of Medicare-approved amounts Generally 80%	$0 Remainder of Medicare-approved amounts Generally 15%	$[+] (Part B deductible)***** All costs above Medicare-approved amounts Generally 5%*
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs (and they do not count toward annual out-of-pocket limit of $M)*
BLOOD First 3 pints Next $[+] of Medicare-approved amounts**** Remainder of Medicare-approved amounts	$0 $0 Generally 80%	75% $0 Generally 15%	25%* $[+] (Part B deductible)* Generally 5%*
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

*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.

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts***** Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 15%	$0 $[+] (Part B deductible)* 5%*

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

*****Medicare benefits are subject to change. Please consuh the latest Guide to Health Insurance for People with Medicare.

PLAN M

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $ [+] All but $ [+] a day All but $[+] a day $0 $0	$[+] (50% Part A deductible) $[+] a day 1 $[+] a day 100% of Medicare eligible expenses $0	$[+] (50% Part A deductible) $0 $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-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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

****Once you have been billed $[+] 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 $[+] of Medicare-approved amounts**** Remainder of Medicare-approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[+] of Medicare-approved amounts**** Remainder of Medicare- approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $0
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

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

PLAN N

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used : -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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- 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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

****Once you have been billed $[+] 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 $[+] of Medicare- approved amounts**** Remainder of Medicare- approved amounts	$0 Generally 80%	$0 Balance, other than up to $[+] per office visit and up to $[+] per emergency room visit. The copayment of up to $[+] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.	$[+] (Part B deductible) Up to $[20] per office visit and up to $[50] per emergency room visit. The copayment of up to $[50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[+] of Medicare-approved amounts**** Remainder of Medicare-approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $0
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

[+ The dollar amount to be inserted here is determined annually, as described in (o) of this section, and may be obtained from the division.]

(v) For a Medicare supplement policy or certificate sold on or after June 1, 2011, the benefit chart and the "DISCLOSURES" paragraph in (u) of this section are replaced with the benefit chart and the "DISCLOSURES" paragraph in this subsection. All the rest of the items in the outline of coverage in the order set out in (u) of this section must be included.

Benefit Chart of Medicare Supplement Plans Sold With an Effective Date of Coverage On or After June 1, 2010

This chart shows the benefits included in each of the stand Medicare supplement plans. Every company must make plan "A" available in your state.

Basic Benefits:

* Hospitalization - Part A coinsurance plus coverage for 365 additional day

* Medical Expenses - Part B coinsurance (generally 20% of Medicare-appn 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 $[+] paid at 100% after limit reached	Out-of-Pocket limit $[+] 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 [+] deductible. Benefits from high deductible plan F will not until out-of-pocket expense exceed [+]. Out-of-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.

[+ The dollar amount to be inserted is determined annually, as described in (o) of this section, and may be obtained from the division.]

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.

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.

A. [for agents]:

Neither [insert company's name] nor its agents are connected with Medicare.

B. [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 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 as set out in 3 AAC 28.456(f).]

[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the director.]

(w) For a Medicare supplement policy or certificate with an effective date of coverage on or after January 1, 2020, the following items must be included in the outline of coverage in the order set out in this subsection.

Benefit Chart of Medicare Supplement Plans Sold With an Effective Date of Coverage On or After January 1, 2020

This chart shows the benefits include 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.

Benefits	Plans Available to All Applicants								Medicare eligible before 2020
	A	B	D	G*	K%	L%	M	N&	C	F*
Medicare Part A coinsurance and Hospital coverage (up to an additional 365 days after IVIedicare benefits are used up)	X	X	X	X	X	X	X	X	X	X
Medicare Part B coinsurance or Copayment	X	X	X	X	50%	75%	X	X copays apply	X	X
Blood (first three pints)	X	X	X	X	50%	75%	X	X	X	X
Part A hospice care coinsurance or copayment	X	X	X	X	50%	75%	X	X	X	X
Skilled nursing facility coinsurance	X	X	50%	75%	X	X	X	X
Medicare Part A deductible	X	X	X	50%	75%	50%	X	X	X
Medicare Part B deductible	X	X
Medicare Part B excess charges	X	X
Foreign travel emergency (up to plan limits)	X	X	X	X	X	X
Out-of-pocket limit	[+]	[+]

* Plans F and G also have a high deductible option which require first paying a plan deductible of [+] 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.

% 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.

& 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.

[+ The dollar amount to be inserted is determined annually, as described in (q) of this section, and may be obtained from the division.]

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.

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 folly cover all of your medical costs.

A. [for agents]:

Neither [insert company's name] nor its agents are connected with Medicare.

B. [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 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 as set out in 3 AAC 28.456(f).]

[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the director.]

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* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the -additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$0 $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$[+] (Part A deductible) $0 $0 $0** All costs
SKILLED NURSING FACILITY CARE* 1 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- 100th day 101st day and after	All approved amounts All but $[+] a day $0	$0 $0 $0	$0 Up to $[+] a day 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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES -- PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare-approved amounts* Remainder of Medicare-approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE - APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional -365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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-100th day 101st day and after	All approved amounts All but $[+] a day $0	$0 $0 $0	$0 Upto$[+] a day 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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted is determined annually, as described in (q) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare- approved amounts* Remainder of Medicare-approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next$[+] of Medicare-approved amounts* Remainder of Medicare-approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE - APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional -365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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-100th day 101st day and after	All approved amounts All but $[+] a day $0	$0 Upto$[+] 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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 Generally 80%	$[+] (Part B deductible) Generally 20%	$0 $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD 1 First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $[+] (Part B deductible) 20%	$0 $0 '$0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE - APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare -approved amounts* Remainder of Medicare -approved amounts	100% $0 80%	$0 $[+] (Part B deductible) 20%	$0 $0 $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 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

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional -365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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- 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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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 $[+] of Medicare- approved amounts* Remainder of Medicare-approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE - APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $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 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

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

[Indicate Plan F or High Deductible Plan F, depending on which plan is offered: PLAN F or 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.

[Language for High Deductible Plan F, if offered: **This high deductible plan pays the same or offers the same benefits as Plan F after you have paid a calendar year $[+] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[+]. 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	[Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan F, if offered: IN ADDITION TO $[+] DEDUCTIBLE,**] YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies 1 First 60 days 61st-90th day 91 st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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- 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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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.

[Language for High Deductible Plan F, if offered: **This high deductible plan pays the same or offers the same benefits as Plan F after you have paid a calendar year $[+] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[+]. 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	[Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan F, if offered: IN ADDITION TO $[+] 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 $[+] of Medicare- approved amounts* Remainder of Medicare-approved amounts	$0 Generally 80%	$[+] (Part B deductible) Generally 20%	$0 $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	100%	$0
BLOOD First 3 pints Next $[+] of Medicare- approved amounts* Remainder of Medicare- approved amounts	$0 $0 80%	All costs $[+] (Part B deductible) 20%	$0 $0 $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	[Language for High Deductible Plan F, if offered: AFTER YOU PAY $[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan F, if offered: IN ADDITION TO $[+] DEDUCTIBLE,**] YOU PAY
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts* Remainder of Medicare-approved amounts	100% $0 80%	$0 $[+] (Part B deductible) 20%	$0 $0 $0

OTHER BENEFITS-NOT COVERED BY MEDICARE

SERVICES	MEDICARE PAYS	[Language for High Deductible Plan F, if offered: AFTER YOU PAY$[+] DEDUCTIBLE,**] PLAN PAYS	[Language for High Deductible Plan F, if offered: IN ADDITION TO $[+] 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

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

[Indicate Plan G or High Deductible Plan G, depending on which plan is offered:

PLAN G or HIGH DEDUCTIBLE 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.

[**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	[Language for High Deductible Plan G, if offered: AFTER YOU PAY $[#] DEDUCTIBLE, PLAN PAYS	[Language for High Deductible Plan G, if offered: IN ADDITION TO $[#] DEDUCTIBLE, **] YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days 6P'-90*day 91" day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: - Additional 365 days -Beyond the additional 365 days	All but $[+] All but$[+] a day All but $[+]a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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 2P'-100* day 1 OP'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 co-payment/coinsurance for outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

***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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[+] 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	[[Language for High Deductible Plan G, if offered: AFTER YOU PAY $[#] DEDUCTIBLE, **] PLAN PAYS	[Language for High Deductible Plan G, if offered: IN ADDITION TO $[#] DEDUCTIBLE, **] YOU PAY
Medical Expenses - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[+] of Medicare Approved amounts* Remainder of Medicare Approved amounts	$0 Generally 80%	$0 Generally 20%	$[+] (unless Part B deductible has been met) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	100%	$0
BLOOD First 3 pints Next $[+] of Medicare Approved amounts* Remainder of Medicare Approved amounts	$0 $0 80%	All costs $0 20%	$0 [$+] (Unless Part B deductible has been met) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

SERVICES	MEDICARE PAYS	[[Language for High Deductible Plan G, if offered: AFTER YOU PAY $[#] DEDUCTIBLE, **] PLAN PAYS	[Language for High Deductible Plan G, if offered: IN ADDITION TO $[#] DEDUCTIBLE, **] YOU PAY
HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment - First $[+] of Medicare-approved amounts* Remainder of Medicare-approved amounts	100% $0 80%	$0 $0 20%	$0 [$+] (Unless Part B deductible has been met) $0

OTHER BENEFITS-NOT COVERED BY MEDICARE

SERVICES	MEDICARE PAYS	[[Language for High Deductible Plan G, if offered: AFTER YOU PAY $[#] DEDUCTIBLE, PLAN PAYS	[Language for High Deductible Plan G, if offered: IN ADDITION TO $[#] 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 lifefime maximum

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

PLAN K

*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 () 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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: 1 -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (50%of Part A deductible) $[+] a day $[+]a day 100% of Medicare eligible expenses $0	$[+] (50% of Part A deductible)* $0 $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-100th day 101st day and after	All approved amounts All but $[+] a day $0	$0 Up to $[+] a day $0	$0 Up to $[+] a day* All costs
BLOOD First 3 pints Additional amounts	$0 100%	50% $0	50%* $0
HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness	All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	50% of copayment/coinsurance	50% of Medicare copayment/coinsurance*

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

****Once you have been billed $[+] 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 $[+] of Medicare-approved amounts**** Preventive Benefits for Medicare covered services Remainder of Medicare-approved amounts	$0 Generally 75% or more of Medicare-approved amounts Generally 80%	$0 Remainder of Medicare-approved amounts Generally 10%	$[+] (Part B deductible)***** All costs above Medicare-approved amounts Generally 10%*
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 Next $[+] of Medicare-approved amounts**** Remainder of Medicare-approved amounts	$0 $0 Generally 80%	50% $0 Generally 10%	50%* $[+] (Part B deductible)***** Generally 10%*
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

*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.

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts***** Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 10%	$0 $[+] (Part B deductible)* 10%*

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

*****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 $[+] each calendar year. The amounts that count toward your annual limit are noted with diamonds () 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 hospilal 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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+](75% of Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$[+] (25% of Part A deductible)* $0 $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- 100th day 101st day and after	All approved amounts All but $[+] a day $0	$0 Up to $[+] a day $0	$0 Upto$[+]a day 4 All costs
BLOOD First 3 pints Additional amounts	$0 100%	75% $0	25%* $0
HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness	All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	75% of copayment/coinsurance	25% of copayment/coinsurance*

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

****Once you have been billed $[+] 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 $[+] of Medicare-approved amounts**** Preventive Benefits for Medicare covered services Remainder of Medicare- approved amounts	$0 Generally 75% or more of Medicare-approved amounts Generally 80%	$0 Remainder of Medicare-approved amounts Generally 15%	$[+](Part B deductible)***** All costs above Medicare-approved amounts Generally 5%*
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 Next $[+] of Medicare-approved amounts**** Remainder of Medicare-approved amounts	$0 $0 Generally 80%	75% $0 Generally 15%	25%* $[+] (Part B deductible)* Generally 5%*
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

*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.

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts***** Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 15%	$0 $[+] (Part B deductible)* 5%*

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

PLAN M

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (50% Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$ [+](50% Part A deductible) $0 $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- 100th day 101 st 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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

****Once you have been billed $[+] 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 $ [+] of Medicare- approved amounts**** Remainder of Medicare- approved amounts	$0 Generally 80%	$0 Generally 20%	$ [+] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[+] of Medicare-approved amounts**** Remainder of Medicare-approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare-approved amounts Remainder of Medicare-approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Parte deductible) $0
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

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

PLAN N

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 61st-90th day 91st day and after: -While using 60 lifetime reserve days -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days	All but $[+] All but $[+] a day All but $[+] a day $0 $0	$[+] (Part A deductible) $[+] a day $[+] a day 100% of Medicare eligible expenses $0	$0 $0 $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- 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 outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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.

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

****Once you have been billed $[+] 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 $[+] of Medicare -approved amounts**** Remainder of Medicare- approved amounts	$0 Generally 80%	$0 Balance, other than up to $[+] per office visit and up to $[+] per emergency room visit. The copayment of up to $[+] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.	1 $[+] (Part B deductible) Up to $[20] per office visit and up to $[50] per emergency room visit. The copayment of up to $[50] is | waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[+] of Medicare-approved amounts**** Remainder of Medicare-approved amounts	$0 $0 80%	All costs $0 20%	$0 $[+] (Part B deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[+] of Medicare- approved amounts Remainder of Medicare- approved amounts	100% $0 80%	$0 $0 20%	$0 $[+] (Part B deductible) $0
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

[+ The dollar amount to be inserted here is determined annually, as described in (q) of this section, and may be obtained from the division.]

3 AAC 28.490

Eff. 3/26/82, Register 81; am 8/8/90, Register 115; am 7/1/92, Register 122; am 12/4/94, Register 132; am 7/12/96, Register 139; am 4/21/99, Register 150; am 7/12/2000, Register 155; am 9/4/2005, Register 175; am 9/19/2009, Register 191; am 3/28/2019,Register 229, April 2019

The information contained in the Federal Register described in 3 AAC 28.490(m), (o), and (q) or a copy of the current Guide to Health Insurance for People with Medicare referenced in the outlines of coverage listed in 3 AAC 28.490(t) - (w) may be obtained by writing to the Division of Insurance, P.O. Box 110805, Juneau, Alaska 99811-0805.

In 2010 the revisor of statutes, acting under AS 01.05.031, renumbered former AS 21.89.060 as AS 21.96.060. As of Register 196 (January 2011), the regulations attorney made a conforming technical revision under AS 44.62.125(b)(6), to the authority citation that follows 3 AAC 28.490, so that the citation to former AS 21.89.060 now refers to the renumbered statute, AS 21.96.060.

Authority:AS 21.06.090

AS 21.42.130

AS 21.96.060