044-35 Wyo. Code R. § 35-17
(a) General Rules.
(b) Notice Requirements.
(c) MMA Notice Requirements. Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement and Modernization Act of 2003.
(d) Outline of Coverage Requirements for Medicare Supplement Policies. 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." Benefit Chart of Medicare Supplement Plans Sold for Efective Dates on or After June 1, 2010 This chart shows the benefits included in each of the standard 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. [This sentence shall not appear after June 1, 2011.] 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 co-payments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or co-payments. . Blood -First three pints of blood each year. . Hospice- Part A coinsurance A B C D F F* 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 *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 [$2000] deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed [$2000]. Out-of-pocket 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. Out-of-pocket limit $[4620]; paid at 100% after limit reached Out-of-pocket limit $[2310]; paid at 100% after limit reached
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 prior to June 1, 2010 have different benefits and premiums. Plans E, H, I, and J are no longer available for sale. [This paragraph shall not appear after June 1, 2011.]
READ YOUR POLICY VERY CAREFULLY [Boldface Type]
This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.
RIGHT TO RETURN POLICY [Boldface Type]
If you find that you are not satisfied with your policy, you may return it to [insert issuer's address]. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.
POLICY REPLACEMENT [Boldface Type]
If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
NOTICE [Boldface Type]
This policy may not fully cover all of your medical costs.
[for agents:]
Neither [insert company's name] nor its agents are connected with Medicare.
[for direct response:]
[insert company's name] is not connected with Medicare.
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT [Boldface Type]
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 pursuant to Section 9.1 D of this regulation.]
[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 | All but $[1068] | $0 | $[1068](Part A deductible) |
| 61st thru 90th day | All but $[267] a day | $[267] a day | $0 |
| 91st day and after: -While using 60 lifetime reserve days | All but $[534] a day | $[534] a day | $0 |
| -Once lifetime reserve days are used: | $0 | 100% of Medicare eligible expenses | $0** |
| -Additional 365 days | $0 | $0 | All costs |
| -Beyond the additional 365 days | |||
| SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility Within 30 days after leaving the hospital First 20 days | All approved amounts | $0 | $0 |
| 21st thru 100th day | All but $[133.50] a day | $0 | Up to $[133.50] a day |
| 101st day and after | $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 co-payment/ coinsurance | $0 |
** 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 A
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[135] 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 $[135] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 Generally 80% | $0 Generally 20% | $[135] (Part B deductible) $0 |
| Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs |
| BLOOD First 3 pints Next $[135] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[135] (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 | 100% | $0 | $0 |
| First $[135] of Medicare Approved Amounts* | $0 | $0 | $[135] (Part B deductible) |
| Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
PLAN B
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
| SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
| HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days | All but $[1068] | $[1068](PartA deductible) | $0 |
| 61stthru 90th day | All but $[267] a day | $[267]a day | $0 |
| 91st day and after: -While using 60 lifetime reserve days | All but $[534] a day | $[534]a day | $0 |
| -Once lifetime reserve days are used: | $0 | 100% of Medicare eligible expenses | $0** |
| -Additional 365 days -Beyond the additional 365 days | $0 | $0 | All costs |
| SKILLED NURSING FACILITY CARE* | |||
| You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days | All approved amounts | $0 | $0 |
| 21st thru 100th day | All but $[133.50] a day | $0 | Up to $[133.50] a day |
| 101st day and after | $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 co-payment/ coinsurance | $0 |
** 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 B
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[135] 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, F First $[135] of Medicare Approved Amounts* | $0 | $0 | $[135] (Part B deductible) |
| Remainder of Medicare Approved Amounts | Generally 80% | Generally 20% | $0 |
| Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs |
| BLOOD First 3 pints | $0 | All costs | $0 |
| Next $[135] of Medicare Approved Amounts* | $0 | $0 | $[135] (Part B deductible) |
| Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
| CLINICAL LABORATORY SERVICES-TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B
| SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
| HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies -Durable medical equipment | 100% | $0 | $0 |
| First $[135] of Medicare Approved Amounts* | $0 | $0 | $[135] (Part B deductible) |
| Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
PLAN C
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
| SERVICES HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days | MEDICARE PAYS All but $[1068] | PLAN PAYS $[1068](Part A deductible) | YOU PAY $0 |
| 61st thru 90th day | All but $[267] a day | $[267] a day | $0 |
| 91st day and after: -While using 60 lifetime reserve days | All but $[534] a day | $[534] a day | $0 $0** |
| -Once lifetime reserve days are used: | $0 | 100% of Medicare eligible expenses | All costs |
| Additional 365 days -Beyond the additional 365 days | $0 | $0 | |
| SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days | All approved amounts | $0 | $0 |
| 21st thru 100th day | All but $[133.50] a day | Up to $[133.50] a day | $0 |
| 101st day and after | $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 co-payment/ coinsurance | $0 |
** 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 C
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[135] 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 $[135] of Medicare | $0 | $[135] (Part B deductible) | $0 |
| Approved Amounts* | Generally 80% | Generally 20% | $0 |
| Remainder of Medicare Approved Amounts | |||
| Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs |
| BLOOD First 3 pints | $0 | All costs | $0 |
| Next $[135] of Medicare Approved Amounts* | $0 | $[135] (Part B deductible) | $0 |
| Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
| CLINICAL LABORATORY SERVICES-TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B
| SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
| HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies -Durable medical equipment | 100% | $0 | $0 |
| First $[135] of Medicare Approved Amounts* | $0 | $[135](PartB deductible) | $0 |
| Remainder of Medicare Approved Amounts | 80% | 20% | $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 | $0 | $0 | $250 |
| Remainder of Charges | $0 | 80% to a lifetime maximum benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
PLAN D
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
| SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY | |
| HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days | All but $[1068] | $[1068] (Part A deductible) | $0 | |
| 61st thru 90th day | All but $[267] a day | $[267] a day | $0 | |
| 91st day and after: -While using 60 lifetime reserve days | All but $[534] a day | $[534] a day $0 | $0 | |
| -Once lifetime reserve days are used: | $0 | 100% of Medicare eligible expenses | $0** | |
| Additional 365 days -Beyond the additional 365 days | $0 | $0 | All costs | |
| SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days | All approved amounts | $0 | $0 | |
| 21st thru 100th day | All but $[133.50] a day | Up to $[133.50] a day | $0 | |
| 101st day and after | $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 co-payment/ coinsurance | $0 |
** 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 D
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[135] 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 $[135] of Medicare Approved Amounts* | $0 | $0 | $[135] (Part B |
| Remainder of Medicare Approved Amounts | Generally 80% | Generally 20% | $0 |
| Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs |
| BLOOD First 3 pints Next $[135] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[135] (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 | 100% | $0 | $0 |
| First $[135] of Medicare Approved Amounts* | $0 | $0 | $[135] (Part B deductible) |
| Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
OTHER BENEFITS-NOT COVERED BY MEDICARE
| SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
| FOREIGN TRAVEL-NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the | |||
| First $250 each calendar year | $0 | $0 | $250 |
| Remainder of charges | $0 | 80% to a lifetime maximum benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
PLAN 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.
. [**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2000] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are [$2000]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.]
| SERVICES | MEDICARE PAYS | [AFTER YOU PAY $[2000] DEDUCTIBLE,**] PLAN PAYS | [IN ADDITION TO $[2000] DEDUCTIBLE,**] YOU PAY |
| HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days | All but $[1068] | $[1068] (Part A deductible) | $0 |
| 61st thru 90th day | All but $[267] a day | $[267] a day | $0 |
| 91st day and after: -While using 60 Lifetime reserve days | All but $[534] a day | $[534] a day | $0 |
| Once lifetime reserve days are used: -Additional 365 days | $0 | 100% of Medicare eligible expenses | $0*** |
| Beyond the additional 365 days | $0 | $0 | All costs |
| SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days | All approved amounts | $0 | $0 |
| 21st thru 100th day 101st day and after | All but $[133.50] a day $0 | Up to $[133.50] a day $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 co-payment/ coinsurance | $0 |
*** 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 F or HIGH DEDUCTIBLE PLAN F
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
*Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
[**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2000] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are [$2000]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.]
| SERVICES | MEDICARE PAYS | [AFTER YOU PAY $[2000] DEDUCTIBLE,**] PLAN PAYS | [IN ADDITION TO $[2000] DEDUCTIBLE,**] YOU PAY |
| MEDICAL EXPENSES -IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, Such as physician's Services, inpatient and Outpatient medical and Surgical services and Supplies, physical and Speech therapy, Diagnostic tests, Durable medical Equipment, First $[135] of Medicare Approved amounts* | $0 | $[135] (Part B deductible) | $0 |
| Remainder of Medicare Approved amounts | Generally 80% | Generally 20% | $0 |
| Part B excess charges (Above Medicare Approved Amounts) | $0 | 100% | $0 |
| BLOOD First 3 pints | $0 | All costs | $0 |
| Next $[135] of Medicare Approved amounts* | $0 | $[135] (Part B deductible) | $0 |
| Remainder of Medicare Approved amounts | 80% | 20% | $0 |
| CLINICAL LABORATORY SERVICES--TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PLAN F or HIGH DEDUCTIBLE PLAN F
PARTS A & B
| SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2000] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2000] DEDUCTIBLE, ** YOU PAY |
| HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies -Durable medical equipment | 100% | $0 | $0 |
| First $[135] of Medicare Approved Amounts* | $0 | $[135] (Part B deductible) | $0 |
| Remainder of Medicare - Approved Amounts | 80% | 20% | $0 |
OTHER BENEFITS - NOT COVERED BY MEDICARE
| SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2000] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2000] DEDUCTIBLE, ** YOU PAY |
| FOREIGN TRAVEL -NOT COVERED BY MEDICARE Medically necessary Emergency care services Beginning during the first 60 days of each trip outside the USA First $250 each calendar year | $0 | $0 | $250 |
| Remainder of charges | $0 | 80% to a lifetime maximum benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
PLAN G
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
| SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
| HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days | All but $[1068] | $[1068] (Part A deductible) | $0 |
| 61st thru 90th day | All but $[267] a day | $[267] a day | $0 |
| 91st day and after: -While using 60 lifetime reserve days | All but $[534] a day | $[534] a day | $0 |
| -Once lifetime reserve days are used: | $0 | 100% of Medicare eligible expenses | $0** |
| -Additional 365 days -Beyond the additional 365 days | $0 | $0 | All costs |
| SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days | All approved amounts | $0 | $0 |
| 21st thru 100th day | All but $[133.50] a day | Up to $[133.50] a day | $0 |
| 101st day and after | $0 | $0 | All costs |
| BLOOD First 3 pints | $0 | 3 pints | $0 |
| Additional amounts | 100% | $0 | $0 |
| HOSPICE CARE 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 co-payment/ coinsurance | $0 |
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN G
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[133.50] 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 $[135] of Medicare Approved Amounts* Remainder of Medicare | $0 | $0 | $[135] (Part B deductible) |
| Approved Amounts | Generally 80% | Generally 20% | $0 |
| Part B Excess Charges (Above Medicare Approved Amounts) | $0 | 100% | $0 |
| BLOOD First 3 pints | $0 | All costs | $0 |
| Next $[135] of Medicare Approved Amounts* | $0 | $0 | $[135] (Part B deductible) |
| Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
| CLINICAL LABORATORY SERVICES-TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PLAN G
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 | 100% | $0 | $0 |
| First $[135] of Medicare Approved Amounts* | $0 | $0 | $[135] (Part B deductible) |
| Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
OTHER BENEFITS-NOT COVERED BY MEDICARE
| SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY* |
| FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year | $0 | $0 | $250 |
| Remainder of Charges | $0 | 80% to a lifetime maximum benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
PLAN K
* You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[4620] each calendar year. The amounts that count toward your annual limit are noted with diamonds (*) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare co-payment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD
** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
| SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY* |
| HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days | All but $[1068] | $[534](50% of Part A deductible) | $[534](50% of Part A deductible) |
| 61st thru 90th day | All but $[267] a day | $[267] a day | $0 |
| 91st day and after: -While using 60 lifetime reserve days | All but $[534] a day | $[534] a day | $0 |
| -Once lifetime reserve days are used: -Additional 365 days | $0 | 100% of Medicare eligible expenses | $0*** |
| -Beyond the additional 365 days | $0 | $0 | All costs |
| SKILLED NURSING FACILITY CARE** You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility Within 30 days after leaving the hospital First 20 days | All approved amounts. | $0 | $0 |
| 21st thru 100th day | All but $[133.50] a day $0 | Up to $[66.75] a day | Up to $[66.75] a day* |
| 101st day and after | $0 | All costs | |
| BLOOD First 3 pints | $0 | 50% | 50%* |
| Additional amounts | 100% | $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 | 50% of co-payment/ coinsurance | 50% of Medicare co-payment/coinsurance* |
*** 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 $[135] 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 $[135] of Medicare Approved Amounts**** | $0 | $0 | $[135] (Part B deductible)***** |
| Preventive Benefits for Medicare covered services | Generally 75% or more of Medicare approved amounts | Remainder of Medicare approved amounts | All costs above Medicare approved amounts |
| Remainder of Medicare Approved Amounts | Generally 80% | Generally 10% | 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 [$4620])* |
| BLOOD First 3 pints | $0 | 50% | 50%* |
| Next $[135] of Medicare Approved Amounts**** | $0 | $0 | $[135] (Part B deductible)***** |
| Remainder of Medicare Approved Amounts | Generally 80% | Generally 10% | 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 $[4620] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
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 | 100% | $0 | $0 |
| First $[135] of Medicare Approved Amounts***** | $0 | $0 | $[135] (Part B deductible)* |
| Remainder of Medicare Approved Amounts | 80% | 10% | 10%* |
*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
PLAN L
* You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[2310] each calendar year. The amounts that count toward your annual limit are noted with diamonds (*) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD
** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
| SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY* |
| HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days | All but $[1068] | $[808.50] (75% of Part A deductible) | $[267] (25% of Part A deductible)* |
| 61st thru 90th day | All but $[267] a day | $[267] a day | $0 |
| 91st day and after: -While using 60 lifetime reserve days | All but $[534] a day | $[534] a day | $0 |
| -Once lifetime reserve days are used: -Additional 365 days | $0 | 100% of Medicare eligible expenses | $0*** |
| -Beyond the additional 365 days | $0 | $0 | All costs |
| SKILLED NURSING FACILITY CARE** You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility Within 30 days after leaving the hospital First 20 days | All approved amounts | $0 | $0 |
| 21st thru 100th day | All but $[133.50] a day | Up to $[100.13] a day | Up to $[33.38] a day* |
| 101st day and after | $0 | $0 | All costs |
| BLOOD First 3 pints | $0 | 75% | 25%* |
| Additional amounts | 100% | $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 | 75% of co-payment/ coinsurance | 25% of co-payment/ coinsurance* |
*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN L
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
**** Once you have been billed $[135] 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 $[135] of Medicare Approved Amounts**** | $0 | $0 | $[135] (Part B deductible)***** |
| Preventive Benefits for Medicare covered services | Generally 75% or more of Medicare approved amounts | Remainder of Medicare approved amounts | All costs above Medicare approved amounts |
| Remainder of Medicare Approved Amounts | Generally 80% | Generally 15% | Generally 5%* |
| Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs (and they do not count toward annual out-of-pocket limit of [$2310])* |
| BLOOD First 3 pints | $0 | 75% | 25%* |
| Next $[135] of Medicare Approved Amounts**** | $0 | $0 | $[135] (Part B deductible)* |
| Remainder of Medicare Approved Amounts | Generally 80% | Generally 15% | 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 $[2310] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
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 | 100% | $0 | $0 |
| First $[135] of Medicare Approved Amounts***** | $0 | $0 | $[135] (Part B deductible)* |
| Remainder of Medicare Approved Amounts | 80% | 15% | 5%* |
*****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 | All but $[1068] | $[534](50% of Part A deductible) | $[534](50% of Part A deductible) |
| 61st thru 90th day | All but $[267] a day | $[267] a day | $0 |
| 91st day and after: -While using 60 lifetime reserve days | All but $[534] a day | $[534] a day | $0 |
| -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days | $0 $0 | 100% of Medicare eligible expenses | $0** |
| SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days | All approved amounts | $0 $0 | All costs $0 |
| 21st thru 100th day | All but $[133.50] a day $0 | Up to $[133.50] a day $0 | $0 $0 All costs |
| 101st day and after BLOOD First 3 pints | $0 | 3 pints | $0 |
| Additional amounts | 100% | $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 co-payment/ coinsurance | $0 |
** 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 M
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[135] 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 $[135] of Medicare Approved Amounts* | $0 | $0 | $[135] (Part B deductible) |
| Remainder of Medicare Approved Amounts | Generally 80% | Generally 20% | $0 |
| Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs |
| BLOOD First 3 pints | $0 | All costs | $0 |
| Next $[135] of Medicare Approved Amounts* | $0 | $0 | $[135] (Part B deductible) |
| Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
| CLINICAL LABORATORY SERVICES-TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B
| SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
| HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies -Durable medical equipment | 100% | $0 | $0 |
| First $[135] of Medicare Approved Amounts* | $0 | $0 | $[135](Part B deductible) |
| Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
OTHER BENEFITS-NOT COVERED BY MEDICARE
| SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
| FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA | |||
| First $250 each calendar year | $0 | $0 | $250 |
| Remainder of Charges | $0 | 80% to a lifetime maximum benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
PLAN 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 | All but $[1068] | $[1068](Part A deductible) | $0 |
| 61st thru 90th day | All but $[267] a day | $[267] a day | $0 |
| 91st day and after: -While using 60 lifetime reserve days | All but $[534] a day | $[534] a day | $0 |
| -Once lifetime reserve days are used: -Additional 365 days | $0 | 100% of Medicare eligible expenses | $0** |
| -Beyond the additional 365 days | $0 | $0 | All costs |
| SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days | All approved amounts | $0 | $0 |
| 21st thru 100th day 101st day and after | All but $[133.50] a day $0 | Up to $[133.50] a day $0 | $0 All costs |
| BLOOD First 3 pints | $0 | 3 pints | $0 |
| Additional amounts | 100% | $0 | $0 |
| HOSPICE CARE | MEDICARE PAYS | PLAN PAYS | YOU PAY |
| 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 co-payment/ coinsurance | $0 |
** 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 N
MEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR
* Once you have been billed $[135] 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 $[135] of Medicare Approved Amounts* | $0 | $0 | $[135] (Part B deductible) |
| Remainder of Medicare Approved Amounts | Generally 80% | Balance, other than up to [$20] per office visit and up to [$50] per emergency room visit. The co-payment 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. | up to [$20] per office visit and up to [$50] per emergency room visit. The co-payment 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 | $0 | All costs | $0 |
| Next $[135] of Medicare Approved Amounts* | $0 | $0 | $[135] (Part B deductible) |
| Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
| CLINICAL LABORATORY SERVICES-TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0 |
PARTS A & B
| SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
| HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies -Durable medical equipment | 100% | $0 | $0 |
| First $[135] of Medicare Approved Amounts* | $0 | $0 | $[135] (Part B deductible) |
| Remainder of Medicare Approved Amounts | 80% | 20% | $0 |
OTHER BENEFITS-NOT COVERED BY MEDICARE
| SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY |
| FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year | $0 | $0 | $250 |
| Remainder of Charges | $0 | 80% to a lifetime maximum benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
(e) Notice Regarding Policies or Certificates Which Are Not Medicare Supplement Policies. "THIS [POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT [POLICY OR CONTRACT]. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company."
044-35 Wyo. Code R. § 35-17