Chapter 12 - Exhibit A effective on or after January 1, 2020

Exhibit A

Benefit Chart of Medicare Supplement Plans Sold for Effective 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.

Basic Benefits:

• Hospitalization - Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

• Medical Expenses - Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or copayments.

• Blood - First three pints of blood each year.

• Hospice - Part A coinsurance.

A

B

C

D

F

F*

G

K

L

M

N

Basic, including 100% Part B coinsurance

Basic, including

100% Part B

coinsurance

Basic, including

100% Part B

coinsurance

Basic, including

100% Part B

coinsurance

Basic, Including

100% Part B

coinsurance

Basic, including

100% Part B

coinsurance

Hospitalization and preventive care paid at 100%; other basic benefits paid at 50%

Hospitalization and preventive care paid at

100%; other

basic benefits paid at 75%

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 Coinsura nce

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 [$2,240] deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed [$2,240]. 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 [$5,240]; paid at 100% after limit reached

Out-of-pocket limit [$2,620]; paid at 100% after limit reached

PREMIUM INFORMATION

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 when premiums will change).

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 policy.

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 16-12-6.05(e) 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.]

Benefit Chart of Medicare Supplement Plan sold on or after January 1, 2020.

This chart shows the benefits included in each of the standard Medicare supplement plans. Some plans may not be available. Only applicants' first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F.

Note: A P means 100% of the benefit is paid.

Plans Available to All Applicants

Medicare first eligible before 202

Benefits

A

B

D

G

K

L

M

N

C

F1

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)

Medicare Part B coinsurance or Copayment

50%

75%

copays apply3

Blood (first three pints)

50%

75%

Part A hospice care coinsurance or copayment

50%

75%

Skilled nursing facility coinsurance

50%

75%

Medicare Part A deductible

50%

75%

50%

Medicare Part B deductible

Medicare Part B

excess charges

Foreign travel emergency (up to plan limits)

Out-of-pocket limit in [2018]2

[$5,240]2

[$2,620]2

1 Plans F and G also have a high deductible option which require first paying a plan deductible of [$2,240] before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible Plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.

2 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.

3 Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that do not result in an inpatient admission.

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 [$1,340]t

All but [$335]t a day

All but [$670]t a day

$0

$0

$0

[$335]tt a day

[$670]tt a day

100% of Medicare Eligible Expenses

$0

[$1,340]tt (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 [$167.50]t a day

$0

$0

$0

$0

$0

Up to [$167.50]tt a day

All Costs

BLOOD

First 3 pints

Additional Amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

You must meet Medicare's

requirements, including a doctor's

certification of terminal illness.

All but very limited

copayment/coinsurance

for out-patient drugs and inpatient respite care

Medicare copayment/ coinsurance

$0

t Medicare redetermines deductibles on an annual basis.

tt Plan Payments and your payments are adjusted annually based on Medicare deductibles.

** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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

* Once you have been billed [$183] 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 [$183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

$0

Generally 80%

$0

Generally 20%

[$183] (Part B Deductible)

$0

Part B Excess Charges

(Above Medicare Approved Amounts)

$0

$0

All Costs

BLOOD

First 3 pints

Next [$183] Medicare Approved

Amounts* Remainder of Medicare Approved

Amounts

$0

$0

80%

All Costs

$0

20%

$0

[$183] (Part B Deductible)

$0

CLINICAL LABORATORY SERVICES -

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 [$183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

100%

$0

80%

$0

$0

20%

$0

[$183] (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 [$1,340]t All but [$335]t a day

All but [$670]t a day

$0 $0

[$1,340]tt (Part A Deductible)

[$335]tt a day

[$670]tt 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 [$167.50]t a day

$0

$0 $0 $0

$0

Up to [$167.50]tt a day

All Costs

BLOOD

First 3 pints Additional Amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited copayment/

coinsurance for outpatient drugs and inpatient respite care

Medicare

copayment/coinsurance

$0

t Medicare redetermines deductibles on an annual basis.

tt Plan Payments and your payments are adjusted annually based on Medicare deductibles.

** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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

* Once you have been billed [$183] 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 [$183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

$0

Generally 80%

$0

Generally 20%

[$183] (Part B Deductible)

$0

Part B Excess Charges

(Above Medicare Approved Amounts)

$0

$0

All Costs

BLOOD

First 3 pints

Next [$183] Medicare Approved

Amounts* Remainder of Medicare Approved

Amounts

$0

$0

80%

All Costs

$0

20%

$0

[$183] (Part B Deductible)

$0

CLINICAL LABORATORY SERVICES -

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 [$183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

100%

$0

80%

$0

$0

20%

$0

[$183] (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 [$1,340]t All but [$335]t a day

All but [$670]t a day

$0 $0

[$1,340]tt (Part A Deductible)

[$335]tt a day

[$670]tt 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 [$167.50]t a day

$0

$0

Up to [$167.50]tt a day

$0

$0 $0

All Costs

BLOOD

First 3 pints Additional Amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited copayment/

coinsurance for outpatient drugs and inpatient respite care

Medicare

copayment/coinsurance

$0

t Medicare redetermines deductibles on an annual basis.

tt Plan payments and your payments are adjusted annually based on Medicare deductibles.

** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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

* Once you have been billed [$183] 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 [$183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

$0

Generally 80%

[$183] (Part B Deductible) Generally 20%

$0 $0

Part B Excess Charges

(Above Medicare Approved Amounts)

$0

$0

All Costs

BLOOD

First 3 pints

Next [$183] Medicare Approved

Amounts* Remainder of Medicare Approved

Amounts

$0

$0

80%

All Costs

[$183] (Part B Deductible)

20%

$0

$0

$0

CLINICAL LABORATORY SERVICES -

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 [$183] of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

100%

$0

80%

$0

[$183] (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 maximum

benefit of $50,000

$250

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 [$1,340]t All but [$335]t a day

All but [$670]t a day

$0 $0

[$1,340]tt (Part A Deductible)

[$335]tt a day

[$670]tt 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 [$167.50]t a day

$0

$0

Up to [$167.50]tt a day

$0

$0 $0

All Costs

BLOOD

First 3 pints Additional Amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare

copayment/coinsurance

$0

t Medicare redetermines deductibles on an annual basis.

tt Plan payments and your payments are adjusted annually based on Medicare deductibles.

** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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

* Once you have been billed [$183] 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 [$183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts)

$0

Generally 80%

$0

Generally 20%

[$183] (Part B Deductible)

$0

Part B Excess Charges

(Above Medicare Approved Amounts)

$0

$0

All Costs

BLOOD

First 3 pints

Next [$183] Medicare Approved

Amounts* Remainder of Medicare Approved

Amounts

$0

$0

80%

All Costs

$0

20%

$0

[$183] (Part B Deductible)

$0

CLINICAL LABORATORY SERVICES -

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 [$183] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts

100%

$0 80%

$0

$0

20%

$0

[$183] (Part B Deductible) $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 maximum benefit of $50,000

$250

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 [$2,240] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are [$2,240]. 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 [$2,240] DEDUCTIBLE,**] PLAN PAYS

[IN ADDITION TO [$2,240] 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 [$1,340]t All but [$335]t a day

All but [$670]t a day

$0 $0

[$1,340]tt (Part A Deductible)

[$335]tt a day

[$670]tt 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 [$167.50]t a day

$0

$0

Up to [$167.50]tt a day

$0

$0 $0

All Costs

BLOOD

First 3 pints Additional Amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care

Medicare

copayment/coinsurance

$0

t Medicare redetermines deductibles on an annual basis.

tt Plan payments and your payments are adjusted annually based on Medicare deductibles.

*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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

* Once you have been billed [$183] 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 [$2,240] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are [$2,240]. 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 [$2,240] DEDUCTIBLE,**] PLAN PAYS

[IN ADDITION TO [$2,240] 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 [$183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

$0

Generally 80%

[$183] (Part B Deductible)

Generally 20%

$0 $0

Part B Excess Charges

(Above Medicare Approved Amounts)

$0

100%

$0

BLOOD

First 3 pints

Next [$183] Medicare Approved

Amounts* Remainder of Medicare Approved

Amounts

$0

$0

80%

All Costs

[$183] (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 [$183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

100%

$0 80%

$0

[$183] (Part B Deductible) 20%

$0

$0 $0

FOREIGN TRAVEL -

NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside

the USA

First $250 each calendar year Remainder of Charges

$0 $0

$0

80% to a lifetime maximum benefit of $50,000

$250

20% and amounts over the $50,000 lifetime maximum

PLAN G OR HIGH DEDUCTIBLE PLAN G
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

** This high deductible plan pays the same benefits as Plan G after you have paid a calendar year [$2,240] deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are [$2,240]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

AFTER YOU PAY [$2,240] DEDUCTIBLE,**] PLAN PAYS

[IN ADDITION TO [$2,240] 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 [$1,340]t

All but [$335]t a day

All but [$670]t a day

$0

$0

[$1,340]tt (Part A Deductible)

[$335]tt a day

[$670]tt 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 [$167.50]t a day

$0

$0

Up to [$167.50]tt a day

$0

$0

$0

All Costs

BLOOD

First 3 pints

Additional Amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

You must meet Medicare's

requirements, including a doctor's

certification of terminal illness

All but very limited

copayment/

coinsurance for outpatient drugs and inpatient respite care

Medicare

copayment/coinsurance

$0

t Medicare redetermines deductibles on an annual basis.

tt Plan payments and your payments are adjusted annually based on Medicare deductibles.

*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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

* Once you have been billed [$183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

** This high deductible plan pays the same benefits as Plan G after you have paid a calendar year [$2,240] deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are [$2,240]. Out-of-pocket expenses for this deductible includes expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

AFTER YOU PAY [$2,240] DEDUCTIBLE,** PLAN PAYS

IN ADDITION TO [$2,240] 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 [$183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

$0

Generally 80%

$0

Generally 20%

[$183] (Unless Part B Deductible has been met)

$0

Part B Excess Charges

(Above Medicare Approved Amounts)

$0

100%

$0

BLOOD

First 3 pints

Next [$183] of Medicare Approved

Amounts* Remainder of Medicare Approved

Amounts

$0

$0

80%

All Costs $0

20%

$0

[$183] (Unless Part B Deductible has been met)

$0

CLINICAL LABORATORY SERVICES -

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 [$183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

100%

$0 80%

$0

$0

20%

$0

[$183] (Unless Part B

Deductible has been met)

$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 maximum benefit of $50,000

$250

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 [$5,240] 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 [$1,340]t

All but [$335]t a day

All but [$670]t a day

$0

$0

[$670]tt (50% Part A Deductible)

[$335]tt a day

[$670]tt a day

100% of Medicare Eligible

Expenses

$0

[$670]tt (50% of Part A Deductible)^

$0

$0

$0***

All Costs

SKILLED NURSING FACILITY

CARE**

You must meet Medicare's

requirements, including having

been in a hospital for at least 3

days and entered a Medicare-

approved facility within 30 days

after leaving the hospital.

First 20 days

21st thru 100th day

101st day and after

All approved amounts

All but [$167.50]t a day

$0

$0

Up to [$83.75]tt a day

(50% of Part A Coinsurance)

$0

$0

Up to [$83.75]tt a day^

(50% of Part A Coinsurance)

All Costs

BLOOD

First 3 pints

Additional Amounts

$0

100%

50%

$0

50% ♦

$0

HOSPICE CARE

You must meet Medicare's

requirements, including a doctor's

certification of terminal illness

All but very limited

copayment/coinsurance for

outpatient drugs and inpatient

respite care.

50% of

copayment/coinsurance

50% of Medicare copayment/coinsurance [or copayments] ♦

t Medicare redetermines deductibles on an annual basis.

tt Plan payments and your payments are adjusted annually based on Medicare deductibles.

*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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

**** Once you have been billed [$183] 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 [$183] 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%

[$183] (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 [$5,240]*

BLOOD

First 3 pints

Next [$183] of Medicare Approved Amounts****

Remainder of Medicare Approved Amounts

$0

$0

Generally 80%

50%

$0

Generally 10%

50% ♦

[$183] (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 [$5,240] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges"), and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

HOME HEALTH CARE

MEDICARE APPROVED SERVICES

--Medically necessary skilled care

services and medical supplies

--Durable medical equipment First

[$183] of Medicare Approved

Amounts*****

--Remainder of Medicare

Approved Amounts

100%

$0

80%

$0

$0

10%

$0

[$183] (Part B Deductible)*

10% ♦

*****Medicare benefits are subject to change. Please consult the latest Guide to Hea/th 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 [$2,620] 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 [$1,340]t All but [$335]t a day All but [$670]t a day

$0

$0

[$1,005]tt (75% Part A Deductible)

[$335]tt a day

[$670]tt a day

100% ofMedicare Eligible Expenses

$0

[$335]tt (25% of Part A

Deductible)^

$0

$0

$0***

All Costs

SKILLED NURSING FACILITY CARE**

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital. First 20 days 21st thru 100th day

101st day and after

All approved amounts All but [$167.50]t a day

$0

$0

Up to [$125.63]tt a day (75% of Part A Coinsurance)

$0

$0

Up to [$41.88]tt a day^ (25% of Part A Coinsurance) All Costs

BLOOD

First 3 pints Additional Amounts

$0

100%

75%

$0

25% ♦

$0

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

75% of copayment/coinsurance

25% of

copayment/coinsurance ♦

t Medicare redetermines deductibles on an annual basis.

tt Plan payments and your payments are adjusted annually based on Medicare deductibles.

*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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

**** Once you have been billed [$183] 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 [$183] 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%

[$183] (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 [$2,620])*

BLOOD

First 3 pints

Next [$183] of Medicare Approved Amounts****

Remainder of Medicare Approved Amounts

$0

$0

Generally 80%

75% $0

Generally 15%

25% ♦

[$183] (Part B deductible)* Generally 5%*

CLINICAL LABORATORY SERVICES -

TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

HOME HEALTH CARE

MEDICARE APPROVED SERVICES

--Medically necessary skilled care

services and medical supplies --Durable medical equipment First [$183] of Medicare

Approved Amounts***** Remainder of Medicare Approved Amounts

100%

$0 80%

$0

$0 15%

$0

[$183] (Part B Deductible)* 5%*

* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to [$2,620] 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.

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

PLAN M
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

61st thru 90th day

All but [$1,340] All but [$335] a day

[$670] (50% of Part A deductible) [$335] a day

[$670] (50% of Part A

deductible)

$0

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 [$670] a day

$0 $0

[$670] (a day

100% of Medicare Eligible

Expenses

$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 [$167.50] a day

$0

$0

Up to [$167.50] a day $0

$0 $0

All Costs

BLOOD

First 3 pints Additional amounts

$0

100%

3 pints $0

$0

$0

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/ coinsurance

0

t Medicare redetermines deductibles on an annual basis.

tt Plan payments and your payments are adjusted annually based on Medicare deductibles.

** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's " Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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

*Once you have been billed [$183] 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 [$183] of Medicare

Approved Amounts*

Remainder of Medicare Approved Amounts

$0

Generally 80%

$0

Generally 20%

[$183] (Part B deductible)

$0

Part B Excess Charges

(Above Medicare Approved Amounts)

$0

$0

All Costs

BLOOD

First 3 pints

Next [$183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

$0

$0

80%

All Costs

$0

20%

$0

[$183] (Part B deductible)

$0

CLINICAL LABORATORY SERVICES -

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 [[$183] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

100% $0

80%

$0 $0

20%

$0

[$183] (Part B deductible)

$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 maximum benefit of $50,000

$250

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

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 [$1,340]

All but [$335] a day

All but [$670] a day

$0

$0

[$1,340] (Part A deductible)

[$335] a day

[$670] 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 [$167.50] a day

$0

$0

Up to$167.50] a day

$0

$0

$0

All Costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

You must meet Medicare's

requirements, including a doctor's

certification of terminal illness

All but very limited

copayment/coinsurance

for outpatient drugs and

inpatient respite care

Medicare copayment/

coinsurance

$0

t Medicare redetermines deductibles on an annual basis.

tt Plan payments and your payments are adjusted annually based on Medicare deductibles.

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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

*Once you have been billed [$183] 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 [$183] of Medicare

Approved Amounts* Remainder of Medicare

Approved Amounts

$0

Generally 80%

$0

Balance, other than up to [$20] per office visit and up to [$50] per emergency room visit. The copayment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

[$183] (Part B deductible)

Up to [$20] per office visit and up to [$50] per emergency room visit. The copayment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Part B Excess Charges

(Above Medicare Approved Amounts)

$0

$0

All Costs

BLOOD

First 3 pints

Next [$183] of Medicare Approved

Amounts* Remainder of Medicare Approved

Amounts

$0

$0

80%

All Costs $0

20%

$0

[$183] (Part B deductible)

$0

CLINICAL LABORATORY

SERVICES-TESTS FOR

DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

HOME HEALTH CARE

MEDICAL APPROVED SERVICES

-Medically necessary skilled care services and medical supplies

-Durable medical equipment First [$183] of Medicare

Approved Amounts* Remainder of Medicare

Approved Amounts

100%

$0 80%

$0

$0 20%

$0

[$183] (Part B deductible) $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 maximum benefit of $50,000

$250

20% and amounts over the 50,000 lifetime maximum


The following state regulations pages link to this page.