054.00.05 Ark. Code R. 003
The purpose of this rule is to provide for the reasonable standardization of coverage and simplification of terms and benefits of Medicare supplement policies; to facilitate public understanding and comparison of such policies; to eliminate provisions contained in such policies which may be misleading or confusing in connection with the purchase of such policies or with the settlement of claims; and to provide for full disclosures in the sale of accident and health insurance coverages to persons eligible for Medicare.
This rule is issued pursuant to the authority vested in the Commissioner under Act 72 of 1991 (First Extraordinary Session), Ark. Code Ann. § 23-61-108, § 23-66-201 through § 23-66-214, §§ 23-66-301, et seq., § 23-79-109, § 23-79-110, § 23-85-105, § 23-74-122, § 23-75-111, § 23-76-125 and §§ 25-15-202, et seq., known as the Arkansas Administrative Procedure Act, and Public Law 101-508.
For purposes of this rule:
No policy or certificate may be advertised, solicited or issued for delivery in this State as a Medicare supplement policy or certificate unless such policy or certificate contains definitions or terms which conform to the requirements of this section.
"Sickness means illness or disease of an insured person which first manifests itself after the effective date of insurance and while the insurance is in force." The definition may be further modified to exclude sicknesses or diseases for which benefits are provided under any workers compensation, occupational disease, employer's liability or similar law.
No policy or certificate may be advertised, solicited or issued for delivery in this State as a Medicare supplement policy or certificate unless it meets or exceeds the following minimum standards. These are minimum standards and do not preclude the inclusion of other provisions or benefits which are not inconsistent with these standards.
The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this State on or after May 1, 1992. No policy or certificate may be advertised, solicited, delivered or issued for delivery in this State as a Medicare supplement policy or certificate unless it complies with these benefit standards.
Every issuer shall make available a policy or certificate including only the following basic "core" package of benefits to each prospective insured. An issuer may make available to prospective insureds any of the other Medicare Supplement Insurance Benefit Plans in addition to the basic core package, but not in lieu of it.
An eligible person is an individual described in any of the following paragraphs:
and
The Medicare supplement policy to which eligible persons are entitled under:
An issuer of Medicare supplement policies and certificates issued before or after the effective date of this rule in this State shall file annually its rates, rating schedule and supporting documentation, including ratios of incurred losses to earned premiums by policy duration, for approval by the Commissioner in accordance with the filing requirements and procedures prescribed by the Commissioner. The supporting documentation shall also demonstrate, in accordance with actuarial standards of practice using reasonable assumptions that the appropriate loss ratio standards, can be expected to be met over the entire period for which rates are computed. Such demonstration shall exclude active life reserves. An expected third-year loss ratio which is greater than or equal to the applicable percentage (%) shall be demonstrated for policies or certificates in force less than three (3) years.
As soon as practicable, but prior to the effective date of enhancements in Medicare benefits, every issuer of Medicare supplement policies or certificates in this State shall file with the Commissioner, in accordance with the applicable filing procedures of this State:
The Commissioner may conduct a public hearing to gather information concerning a request by an issuer for an increase in a rate for a policy form or certificate form issued before or after the effective date of this rule, if the experience of the form for the previous reporting period is not in compliance with the applicable loss ratio standard. The determination of compliance is made without consideration of any refund or credit for such reporting period. Public notice of such hearing shall be furnished in a manner deemed appropriate by the Commissioner.
"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."
PREMIUM INFORMATION (Boldface Type)
We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this State.
DISCLOSURES [Boldface Type]
Use this outline to compare benefits and premiums among policies.
READ YOUR POLICY VERY CAREFULLY (Boldface Type)
This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.
RIGHT TO RETURN POLICY [Boldface Type]
If you find that you are not satisfied with your policy, you may return it to (insert issuer's address]. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.
POLICY REPLACEMENT [Boldface Type]
If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
NOTICE (Boldface Type)
This policy may not fully cover all of your medical costs.
(for agents/producers:]
Neither (insert company's name] nor its agents or producers are connected with Medicare.
[for direct response:)
[insert company's name) is not connected with Medicare.
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult "The Medicare Handbook" 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 (4) plans may be shown on one (1) chart. For purposes of illustration, charts for each plan are included in this rule. An issuer may use additional benefit plan designations on these charts pursuant to Section 9(D) of this rule.]
[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the Commissioner.]
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 thru 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 thru 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 |
** 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 in its bill charges and the amount Medicare would have paid.
PLAN A MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed [$110] 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 $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Part B Excess Charges (Above Medicare Approved Amounts) | $0 Generally 80% $0 | $0 Generally 20% $0 | $[110] (Part B deductible) $0 All costs |
BLOOD First 3 pints Next $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[110] (Part B deductible) $0 |
CLINICAL LABORATORY SERVICES-BLOOD TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B
HOME HEALTH CARE MEDICARE APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[110]of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 20% | $0 $[110] (Part B deductible) $0 |
PLAN B MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 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 thru 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 |
** 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 in its bill charges and the amount Medicare would have paid.
PLAN B
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[110] 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 $ [110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Part B Excess Charges (Above Medicare Approved Amounts) | $0 Generally 80% $0 | $0 Generally 20% $0 | $[110] (Part B deductible) $0 All costs |
BLOOD First 3 pints Next $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[110] (Part B deductible) $0 |
CLINICAL LABORATORY SERVICES-BLOOD TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B
HOME HEALTH CARE MEDICARE APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 20% | $0 $[110] (Part B deductible) $0 |
PLAN C MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 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 thru 100th day 101st day and after | All approved amounts All but $[ ] a day $0 | $0 Up to $[ ] a day $0 | $0 $0 All costs |
BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0 |
HOSPICE CARE 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 |
** 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 in its bill charges and the amount Medicare would have paid.
PLAN C MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[110] 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 $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Part B Excess Charges (Above Medicare Approved Amounts) | $0 Generally 80% $0 | $[110] (Part B deductible) Generally 20% $0 | $0 $0 All costs |
BLOOD First 3 pints Next $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $[110] (Part B deductible) 20% | $0 $0 $0 |
CLINICAL LABORATORY SERVICES-BLOOD TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B
HOME HEALTH CARE MEDICARE APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $[110] (Part B deductible) 20% | $0 $0 $0 |
OTHER BENEFITS-NOT COVERED BY MEDICARE
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 max-mum benefit of $50,000 | $0 20% and amounts over the $50,000 lifetime maximum |
PLAN D MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 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 $0 100% 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 thru 100th day 101st day and after | All approved amounts All but $[ ] a day $0 | $0 Up to $[ ] a day $0 | $0 $0 All costs |
BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0 |
HOSPICE CARE 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 |
** 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 in its bill charges and the amount Medicare would have paid.
PLAN D
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[110] 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 $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Part B Excess Charges (Above Medicare Approved Amounts) | $0 Generally 80% $0 | $0 Generally 20% $0 | $[110] (Part B deductible) $0 All costs |
BLOOD First 3 pints Next $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[110] (Part B deductible) $0 |
CLINICAL LABORATORY SERVICES-BLOOD 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 $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 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 | 100% $0 80% $0 $0 $0 | $0 $0 20% Actual charges to $40 a visit Up to the number of Medicare Approved visits, not to exceed 7 each week $1,600 | $0 $[110] (Part B deductible) $0 Balance |
OTHER BENEFITS-NOT COVERED BY MEDICARE
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 thru 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 thru 100th day 101st day and after | All approved amounts All but $[ ]a day $0 | $0 Up to $[ ]a day $0 | $0 $0 All costs |
BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0 |
HOSPICE CARE 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 |
** 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 in its bill charges and the amount Medicare would have paid.
PLAN E MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[110] 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 $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Part B Excess Charges (Above Medicare Approved Amounts) | $0 Generally 80% $0 | $0 Generally 20% $0 | $[110] (Part B deductible) $0 All costs |
BLOOD First 3 pints Next $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[110] (Part B deductible) $0 |
CLINICAL LABORATORY SERVICES-BLOOD TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B
HOME HEALTH CARE MEDICARE APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 20% | $0 $[110] (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, such as: digital rectal exam, hearing screening, dipstick urinalysis, diabetes screening, thyroid function test, tetanus and diphtheria booster and education, administered or ordered by your doctor when not covered by Medicare First $120 each calendar year Additional charges | $0 $0 | $120 $0 | $0 All costs |
*Medicare benefits are subject to change. Please consult the latest Choosing A Medigap Policy: Guide to Health Insurance for People with Medicare.
PLAN F or HIGH DEDUCTIBLE PLAN F MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on tiie first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and iiave not received stilled care in any other facility for 60 days in a row.
**This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year [$ ] 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 | AFTER YOU PAY $[ ] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[ ] DEDUCTIBLE,** YOU PAY |
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days Beyond the additional 365 days | All but $[ ] All but $[ ]aday 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 thru 100th day 101st 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 Available as long as your doctor certifies you are terminally ill and you elect to receive these services | All but very limited coinsurance for out-patient drugs and inpatient respite care | $0 | Balance |
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the poUcy's "Core Benefits". During this time the hospital is prohibited from billing you for the balance based on any difference in its bill charges and the amount Medicare would have paid.
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
*Once you have been billed $100 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
**This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year [$ ] 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 | [AFTER YOU PAY $[ ] DEDUCTIBLE,**] PLAN PAYS | [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 $[110] of Medicare approved amounts* Remainder of Medicare approved amounts Part B excess charges (Above Medicare approved amounts) | $0 Generally 80% $0 | $[110] (Part B deductible Generally 20% 100% | $0 $0 $0 |
BLOOD First 3 pints Next $[110] of Medicare approved amounts* Remainder of Medicare approved amounts | $0 $0 80% | All costs $[110] (Part B deductible 20% | $0 $0 $0 |
CLINICAL LABORATORY SERVICES--BLOOD TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B
HOME HEALTH CARE MEDICARE APPROVED SERVICES ---Medically necessary skilled care services and medical supplies ---Durable medical equipment First $[110] of Medicare approved amounts* Remainder of Medicare approved Amounts | 100% $0 80% | $0 $[110] (Part B deductible 20% | $0 $0 $0 |
OTHER BENEFITS - NOT COVERED BY MEDICARE
SERVICES | MEDICARE PAYS | [AFTER YOU PAY $[ ] DEDUCTIBLE,**] PLAN PAYS | [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 life-time maximum |
PLAN G MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 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 thru 100th day 101st day and after | All approved amounts All but $[ ] a day $0 | $0 Up to $[ ] a day $0 | $0 $0 All costs |
BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0 |
HOSPICE CARE 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 |
** 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 in its bill charges and the amount Medicare would have paid.
PLAN G MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[110] 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 $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Part B Excess Charges (Above Medicare Approved Amounts) | $0 Generally 80% $0 | $0 Generally 20% 80% | $[110] (Part B deductible) $0 20% |
BLOOD First 3 pints Next $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[110] (Part B deductible) $0 |
CLINICAL LABORATORY SERVICES-BLOOD TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B
HOME HEALTH CARE MEDICARE APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 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 | 100% $0 80% $0 $0 $0 | $0 $0 20% Actual charges to $40 a visit Up to the number of Medicare-approved visits, not to exceed 7 each week $1,600 | $0 $[110] (Part B deductible) $0 Balance |
OTHER BENEFITS-NOT COVERED BY MEDICARE
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 thru 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 thru 100th day 101st day and after | All approved amounts All but $[ ] a day $0 | $0 Up to $[ ]a day $0 | $0 $0 All costs |
BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0 |
HOSPICE CARE 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 |
** 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 in its bill charges and the amount Medicare would have paid.
PLAN H MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[110] 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 $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Part B Excess Charges (Above Medicare Approved Amounts) | $0 Generally 80% $0 | $0 Generally 20% 0% | $[110] (Part B deductible) $0 All Costs |
BLOOD First 3 pints Next $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[110] (Part B deductible) $0 |
CLINICAL LABORATORY SERVICES-BLOOD TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B
HOME HEALTH CARE MEDICARE APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 20% | $0 $[110] (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 max-mum benefit of $50,000 | $250 20% and amounts over the $50,000 lifetime maximum |
BASIC OUTPATIENT PRESCRIPTION DRUGS-NOT COVERED BY MEDICARE First $250 each calendar year Next $2,500 each calendar year Over $2,500 each calendar year | $0 $0 $0 | $0 50%-$1,250 calendar year maximum benefit $0 | $250 50% All costs |
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 thru 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 thru 100th day 101st day and after | All approved amounts All but $[ ]a day $0 | $0 Up to $[ ]a day $0 | $0 $0 All costs |
BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0 |
HOSPICE CARE 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 |
** 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 in its bill charges and the amount Medicare would have paid.
PLAN I MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[110] 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 $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Part B Excess Charges (Above Medicare Approved Amounts) | $0 Generally 80% $0 | $0 Generally 20% 100% | $[110] (Part B deductible) $0 $0 |
BLOOD First 3 pints Next $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[110] Part B deductible) $0 |
CLINICAL LABORATORY SERVICES-BLOOD TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B
HOME HEALTH CARE MEDICARE APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 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 | 100% $0 80% $0 $0 $0 | $0 $0 20% Actual charges to $40 a visit Up to the number of Medicare-approved visits, not to exceed 7 each week $1,600 | $0 $[110] (Part B deductible) $0 Balance |
OTHER BENEFITS-NOT COVERED BY MEDICARE
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 |
BASIC OUTPATIENT PRESCRIPTION DRUGS-NOT COVERED BY MEDICARE First $250 each calendar year Next $2500 each calendar year Over $2,500 each calendar year | $0 $0 $0 | $0 50%-$1,250 calendar year maximum benefit $0 | $250 50% All costs |
PLAN J or HIGH DEDUCTIBLE PLAN J MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
** This high deductible plan pays the same or offers the same benefits as Plan J after one has paid a calendar year [$ ] deductible. Benefits from 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 | [AFTER YOU PAY $[ ] DEDUCTIBLE,**] PLAN PAYS | [IN ADDITION TO $[ ] DEDUCTIBLE,**] YOU PAY |
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: ---While using 60 lifetime reserve days ---Once lifetime reserve days are used: ---Additional 365 days ---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 thru 100th day 101st day and after | All approved amounts All but $[ ] a day $0 | $0 Up to $[ ] a day $0 | $0 $0 All costs |
BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0 |
HOSPICE CARE 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 |
** 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 in its bill charges and the amount Medicare would have paid.
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[110] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
**This high deductible plan pays the same or offers the same benefits as Plan J after one has paid a calendar year [$ ] deductible. Benefits from 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 | [AFTER YOU PAY $[ ] DEDUCTIBLE,**] PLAN PAYS | [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 $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Part B Excess Charges (Above Medicare Approved Amounts) | $0 Generally 80% $0 | $[110] (Part B deductible) Generally 20% 100% | $0 $0 $0 |
BLOOD First 3 pints Next $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All Costs $[110] (Part B deductible) 20% | $0 $0 $0 |
CLINICAL LABORATORY SERVICES-BLOOD TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B
HOME HEALTH CARE MEDICARE APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[110] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $[110] (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 |
OTHER BENEFITS-NOT COVERED BY MEDICARE
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 |
EXTENDED OUTPATIENT PRESCRIPTION DRUGS-NOT COVERED BY MEDICARE First $250 each calendar year Next $6,000 each calendar Year Over $6,000 each calendar Year | $0 $0 $0 | $0 50%-$3,000 calendar year maximum benefit $0 | $250 50% All costs |
***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 |
***Medicare benefits are subject to change. Please consult the latest Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare.
PLANK
* You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[4000] 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 6l"thru 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 $[876] All but $[219] a day All but $[438] a day $0 $0 | $[438](50% of Part A deductible) $[219] a day $[438] a day 100% of Medicare eligible expenses $0 | $[438](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 21" thru 100th day 101st day and after | All approved amounts All but $[109.50] a day $0 | $0 Up to $[54.75] a day $0 | $0 Up to $[54.75] a day* All costs |
BLOOD First 3 pints Additional amounts | $0 100% | 50% $0 | 50%4 $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* |
*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN K MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
**** Once you have been billed $[100] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY* |
MEDICAL EXPENSES- IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $[110] 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% | $[110] (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 [$4000])* |
BLOOD First 3 pints Next $[110] of Medicare Approved Amounts**** Remainder of Medicare Approved Amounts | $0 $0 Generally 80% | 50% $0 Generally 10% | 50% $[110] (Part B deductible)**** Generally 10% |
CLINICAL LABORATORY SERVICES-TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[4000] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
PLAN K 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 $[110] of Medicare Approved Amounts***** Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 10% | $0 $[110] (Part B deductible) 10% |
*****Medicare benefits are subject to change. Please consult the latest Choosing a Medigap Policy: 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 $[2000] 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 thru 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 $[876] All but $[219] a day All but $[438] a day $0 $0 | $[657] (75% of Part A deductible) $[219] a day $[438] a day 100% of Medicare eligible expenses $0 | $[219] (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 21" thru 100th day 101st day and after | All approved amounts All but $[109.50] a day $0 | $0 Up to $[82.13] a day $0 | $0 Up to $[27.37] a day* All costs |
BLOOD First 3 pints Additional amounts | $0 100% | 75% $0 | 25%4 $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* |
*** 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.
PLANL
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
**** Once you have been billed $[110] 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 $[110]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% | $[110] (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 [$2000])* |
BLOOD First 3 pints Next $[110]of Medicare Approved Amounts**** Remainder of Medicare Approved Amounts | $0 $0 Generally 80% | 75% $0 Generally 15% | 25% $[110] (Part B deductible)* Generally 5%* |
CLINICAL LABORATORY SERVICES-TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[2000] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
PLAN L PARTS A & B
SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY* |
HOME HEALTH CARE MEDICARE APPROVED SERVICES -Medically necessary skilled care services and medical supplies -Durable medical equipment First $[110]of Medicare Approved Amounts***** Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 15% | $0 $[110] (Part B deductible) 5% |
*****Medicare benefits are subject to change. Please consult the latest Choosing a Medigap Policy: Guide to Health Insurance for People with Medicare.
*THIS (POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT [POLICY OR CONTRACT]. If you are eligible for Medicare, review the Choosing a Medigap Policy: a Guide to Health Insurance for People with Medicare, available from the company."
[Statements]
[Questions]
If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplement insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplement plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS. [Please mark Yes or No below with an "X"]
To the best of your knowledge,
Yes____ No____
Yes____ No____
[NOTE TO APPLICANT: If you are participating in a "Spend-Down Program" and have not met your "Share of Cost," please answer NO to this question.]
Yes____ No____
If yes,
Yes____ No____
Yes____ No____
START __/__/__ END __/__/__
Yes____ No____
Yes____ No____
Yes____ No____
Yes____ No____
__________________________________________________
Yes____ No____
Yes____ No____
________________________________________________
________________________________________________
________________________________________________
________________________________________________
(If you are still covered under the other policy, leave "END" blank.)
NOTICE TO APPLICANT REGARDING REPLACEMENT
OF MEDICARE SUPPLEMENT INSURANCE
OR MEDICARE ADVANTAGE
(Insurance company's name and address]
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.
According to [your application] (information you have furnished], you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by [Company Name) Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy.
You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.
STATEMENT TO APPLICANT BY ISSUER AGENT, [BROKER, PRODUCER OR OTHER REPRESENTATIVE]
I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason (check one):
_____ Additional benefits.
_____ No change in benefits, but lower premiums.
_____ Fewer benefits and lower premiums.
_____ My plan has outpatient prescription drug coverage and I am enrolling in Part D.
____ Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment.
[optional only for Direct Mailers. ] _____ Other. (Please specify)
Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.
___________________________________________
(Signature of Agent, Broker, Producer or Other Representative)* I [Typed Name and Address of Issuer, Agent or Broker or Producer]
___________________________________________
(Applicant's Signature)
_____________________________
(Date)
*Signature not required for direct response sales.
An issuer shall provide a copy of any Medicare supplement advertisement intended for use in this State whether through written, radio or television medium, or Internet to the Commissioner for review or approval by the Commissioner to the extent it may be required under State law.
"Notice to buyer: This policy may not cover all of your medical expenses."
If any provision of this rule or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the rule and the application of such provision to other persons or circumstances shall not be affected thereby.
Pursuant to Ark. Code Ann. §§ 25-15-201 et seq. and § 23-61-108 this rule shall be effective on September 1, 2005.
(signed by Julie Benafield Bowman)
__________________________________
JULIE BENAFIELD BOWMAN
INSURANCE COMMISSIONER
STATE OF ARKANSAS
(August 22, 2005)
__________________________________
DATE
Contact Person: Chief Counsel, Ms. Jean Langford, Legal Division, Arkansas Insurance Department, 1200 West Third Street, Little Rock, Arkansas 72201-1904; (501) 371-2820, or jean.langford@Arkansas.govor Ms. Marie Bennett, Senior Rate and Form Analyst, Life and Health Division, 501-371-2800 or marie.bennett@Arkansas.gov
Appendix A
MEDICARE SUPPLEMENT REFUND CALCULATION FORM
FOR CALENDAR YEAR _______________
ARKANSAS
REPORTING FORM FOR THE CALCULATION OF BENCHMARK
RATIO SINCE INCEPTION FOR GROUP POLICIES
FOR CALENDAR YEAR _______________
APPENDIX B ARKANSAS
FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES
APPENDIX C ARKANSAS
DISCLOSURE STATEMENTS
Instructions for Use of the Disclosure statement for
Health Insurance Policies Sold to Medicare Beneficiaries
That Duplicate Medicare
[Original disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS |
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
* Hospital or medical expenses up to the maximum stated in the policy
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* Hospitalization
* Physician services
* Other approved items and services
Before You Buy This Insurance |
/ Check the coverage in all health insurance policies you already have.
/ For more information about Medicare and Medicare Supplement insurance, review the Choosing a
Medigap Policy: AGuide to Health Insurance for People with Medicare, available from the insurance company.
/ For help in understanding your health insurance, contact your state insurance department
(website = www.accessarkansas.org/insurance) or state senior insurance counseling program (SHIP Division of Department at 800-224-6330, or email Insurance.seniors@Arkansas.gov).
[Original disclosure statement for policies that provide benefits for specified limited services.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS |
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
* Any of the services covered by the policy are also covered by Medicare
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* Hospitalization
* Physician services
* Other approved items and services
Before You Buy This Insurance |
/ Check the coverage in all health insurance policies you already have.
/ For more information about Medicare and Medicare Supplement insurance, review the Choosing a
Medigap Policy: AGuide to Health Insurance for People with Medicare, available from the insurance company.
/ For help in understanding your health insurance, contact your state insurance department
(website = www.accessarkansas.org/insurance) or state senior insurance counseling program (SHIP Division of Department at 800-224-6330, or email Insurance.Seniors@Arkansas.gov).
[Original disclosure statement for policies that reimburse expenses incurred for specified diseases or other specified impairments. This includes expense-incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS |
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one (1) of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
* Hospital or medical expenses up to the maximum stated in the policy
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* Hospitalization
* Physician services
* Hospice
* Other approved items and services
Before You Buy This Insurance |
/ Check the coverage in all health insurance policies you already have.
/ For more information about Medicare and Medicare Supplement insurance, review the Choosing a
Medigap Policy: AGuide to Health Insurance for People with Medicare, available from the insurance company.
/ For help in understanding your health insurance, contact your state insurance department
(website = www.accessarkansas.org/insurance) or state senior insurance counseling program (SHIP Division of Department at 800-224-6330 or email Insurance.Seniors@Arkansas.gov).
[Original disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS |
This is not Medicare Supplement Insurance
This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one (1) of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits because Medicare generally pays for most of the expenses for the diagnosis and treatment of the specific conditions or diagnoses named in the policy.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* Hospitalization
* Physician services
* Hospice
* Other approved items and services
Before You Buy This Insurance |
/ Check the coverage in all health insurance policies you already have.
/ For more information about Medicare and Medicare Supplement insurance, review the Choosing a
Medigap Policy: AGuide to Health Insurance for People with Medicare, available from the insurance company.
/ For help in understanding your health insurance, contact your state insurance department
(website = www.accessarkansas.org/insurance) or state senior insurance counseling program (SHIP Division of Department at 800-224-6330 or email Insurance.Seniors@Arkansas.gov).
[Original disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS |
This is not Medicare Supplement Insurance
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
* Any expenses or services covered by the policy, also covered by Medicare
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* Hospitalization
* Physician services
* Hospice
* Other approved items and services
Before You Buy This Insurance
/ Check the coverage in all health insurance policies you already have.
/ For more information about Medicare and Medicare Supplement insurance, review the Choosing a
Medigap Policy: A Guide to Health Insurance for People with Medicare, available from the insurance company.
/ For help in understanding your health insurance, contact your state insurance department
(website = www.accessarkansas.org/insurance) or state senior insurance counseling program (SHIP Division of Department at 800-224-6330 or email Insurance.Seniors@Arkansas.gov).
[Original disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS |
This is not Medicare Supplement Insurance
This insurance provides limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
* Any expenses or services covered by the policy, also covered by Medicare; or
* It pays the fixed dollar amount stated in the policy and Medicare covers the same event
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* Hospitalization
* Physician services
* Hospice care
* Other approved items and services
Before You Buy This Insurance |
/ Check the coverage in all health insurance policies you already have.
/ For more information about Medicare and Medicare Supplement insurance, review the Choosing a
Medigap Policy: AGuide to Health Insurance for People with Medicare, available from the insurance company.
/ For help in understanding your health insurance, contact your state insurance department
(website = www.accessarkansas.org/insurance) or state senior insurance counseling program (SHIP Division of Department at 800-224-6330 or email Insurance.Seniors@Arkansas.gov).
[Original disclosure statement for other health insurance policies not specifically identified in the preceding statements.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS |
This is not Medicare Supplement Insurance
This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
* The benefits stated in the policy and coverage for the same event is provided by Medicare
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* Hospitalization
* Physician services
* Hospice
* Other approved items and services
Before You Buy This Insurance |
/ Check the coverage in all health insurance policies you already have.
/ For more information about Medicare and Medicare Supplement insurance, review the Choosing a
Medigap Policy: AGuide to Health Insurance for People with Medicare, available from the insurance company.
/ For help in understanding your health insurance, contact your state insurance department
(website = www.accessarkansas.org/insurance) or state senior insurance counseling program (SHIP Division of Department at 800-224-6330 or email Insurance.Seniors@Arkansas.gov).
[Alternative disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE |
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* hospitalization
* physician services
* other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
Before You Buy This Insurance |
/ Check the coverage in all health insurance policies you already have.
/ For more information about Medicare and Medicare Supplement insurance, review the Choosing a
Medigap Policy: AGuide to Health Insurance for People with Medicare, available from the insurance company.
/ For help in understanding your health insurance, contact your state insurance department
(website = www.accessarkansas.org/insurance) or state senior insurance counseling program (SHIP Division of Department at 800-224-6330 or email Insurance.Seniors@Arkansas.gov).
[Alternative disclosure statement for policies that provide benefits for specified limited services.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE |
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* hospitalization
* physician services
* other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
Before You Buy This Insurance |
/ Check the coverage in all health insurance policies you already have.
/ For more information about Medicare and Medicare Supplement insurance, review the Choosing a
Medigap Policy: AGuide to Health Insurance for People with Medicare, available from the insurance company.
/ For help in understanding your health insurance, contact your state insurance department
(website = www.accessarkansas.org/insurance) or state senior insurance counseling program (SHIP Division of Department at 800-224-6330 or email Insurance.Seniors@Arkansas.gov).
[Alternative disclosure statement for policies that reimburse expenses incurred for specific diseases or other specified impairments. This includes expense-incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE |
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are tested for one (1) of the specified diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* hospitalization
* physician services
* hospice
* other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
Before You Buy This Insurance |
/ Check the coverage in all health insurance policies you already have.
/ For more information about Medicare and Medicare Supplement insurance, review the Choosing a
Medigap Policy: AGuide to Health Insurance for People with Medicare, available from the insurance company.
/ For help in understanding your health insurance, contact your state insurance department
(website = www.accessarkansas.org/insurance) or state senior insurance counseling program (SHIP Division of Department at 800-224-6330 or email Insurance.Seniors@Arkansas.gov).
[Alternative disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE |
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one (1) of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* hospitalization
* physician services
* hospice
* other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
Before You Buy This Insurance |
/ Check the coverage in all health insurance policies you already have.
/ For more information about Medicare and Medicare Supplement insurance, review the Choosing a
Medigap Policy: AGuide to Health Insurance for People with Medicare, available from the insurance company.
/ For help in understanding your health insurance, contact your state insurance department
(website = www.accessarkansas.org/insurance) or state senior insurance counseling program (SHIP Division of Department at 800-224-6330 or email Insurance.Seniors@Arkansas.gov).
[Alternative disclosure statement for indemnity policies that pay a fixed dollar amount per day, excluding long-term care policies.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE |
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* hospitalization
* physician services
* hospice
* other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
Before You Buy This Insurance |
/ Check the coverage in all health insurance policies you already have.
/ For more information about Medicare and Medicare Supplement insurance, review the Choosing a
Medigap Policy: AGuide to Health Insurance for People with Medicare, available from the insurance company.
/ For help in understanding your health insurance, contact your state insurance department
(website = www.accessarkansas.org/insurance) or state senior insurance counseling program (SHIP Division of Department at 800-224-6330 or email Insurance.Seniors@Arkansas.gov).
[Alternative disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE |
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* hospitalization
* physician services
* hospice care
* other approved items & services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
Before You Buy This Insurance |
/ Check the coverage in all health insurance policies you already have.
/ For more information about Medicare and Medicare Supplement insurance, review the Choosing a
Medigap Policy: AGuide to Health Insurance for People with Medicare, available from the insurance company.
/ For help in understanding your health insurance, contact your state insurance department
(website = www.accessarkansas.org/insurance) or state senior insurance counseling program (SHIP Division of Department at 800-224-6330 or email Insurance.Seniors@Arkansas.gov).
[Alternative disclosure statement for other health insurance policies not specifically identified in the preceding statements.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE |
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance provides limited benefits, if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* hospitalization
* physician services
* hospice
* other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
Before You Buy This Insurance |
/ Check the coverage in all health insurance policies you already have.
/ For more information about Medicare and Medicare Supplement insurance, review the Choosing a
Medigap Policy: AGuide to Health Insurance for People with Medicare, available from the insurance company.
/ For help in understanding your health insurance, contact your state insurance department
(website = www.accessarkansas.org/insurance) or state senior insurance counseling program (SHIP Division of Department at 800-224-6330 or email I nsurance.Seniors@Arkansas.gov).
054.00.05 Ark. Code R. 003