HB-6431, As Passed House, December 12, 2018
HB-6431, As Passed Senate, December 11, 2018
SUBSTITUTE FOR
HOUSE BILL NO. 6431
A bill to amend 1956 PA 218, entitled
"The insurance code of 1956,"
by amending sections 2266, 3801, 3803, 3811a, 3813, 3815, 3819a,
3827, 3829, 3831, 3835, 3843, and 3847 (MCL 500.2266, 500.3801,
500.3803, 500.3811a, 500.3813, 500.3815, 500.3819a, 500.3827,
500.3829, 500.3831, 500.3835, 500.3843, and 500.3847), section
2266 as added by 2018 PA 205, sections 3801, 3803, 3815, and 3831
as amended and sections 3811a and 3819a as added by 2009 PA 220,
sections 3813, 3843, and 3847 as added by 1992 PA 84, sections
3827 and 3835 as amended by 2006 PA 462, and section 3829 as
amended by 2002 PA 304, and by adding section 3811b; and to
repeal acts and parts of acts.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
1 Sec. 2266. (1) Subject to the requirements of this section,
1 a notice to a party or any other document that is required in an
2 insurance transaction or that is to serve as evidence of
3 insurance coverage may be delivered, stored, and presented by
4 electronic means if it meets both of the following:
5 (a) The the requirements of the uniform electronic
6 transactions act, 2000 PA 305, MCL 450.831 to 450.849.
7 (b) For a health insurer, the requirements of section
8 2236(9)(a)(ii).
9 (2) Electronic delivery of a notice or document as provided
10 in this section is equivalent to any delivery method otherwise
11 required by law, including delivery by first-class mail, first-
12 class mail postage prepaid, certified mail, or certificate of
13 mailing.
14 (3) If an insurer has reason to believe that a party is not
15 receiving notices or documents that the insurer attempts to
16 deliver by electronic means, including if the insurer attempts
17 delivery by electronic means and receives a notice that the
18 delivery by electronic means has failed, the insurer shall
19 deliver the notices or documents by first-class mail or by any
20 other delivery method required for the notices or documents.
21 (4) An insurer may use electronic delivery of a notice or a
22 document to a party under this section if the insurer meets the
23 requirements of subsection (5) and if all of the following
24 requirements are met:
25 (a) The party has affirmatively consented to the electronic
26 delivery method and has not withdrawn consent.
27 (b) Before obtaining consent, the insurer provides the party
1 with a clear and conspicuous statement informing the party of all
2 of the following:
3 (i) The right of the party at any time to have the notice or
4 the document provided or made available in paper form or by
5 another nonelectronic form.
6 (ii) The right of the party at any time to withdraw consent
7 to have a notice or document delivered by electronic means and
8 any conditions or consequences imposed if consent is withdrawn.
9 (iii) The specific notice or document or categories of notices
10 or documents that may be delivered by electronic means during the
11 course of the relationship between the insurer and the party.
12 (iv) The means, after consent is given, by which the party
13 may obtain a paper copy of a notice or document delivered by
14 electronic means.
15 (v) The procedures for the party to follow to update
16 information needed to contact the party electronically and to
17 withdraw consent to have a notice or a document delivered by
18 electronic means.
19 (c) Before obtaining consent, the insurer provides the party
20 with a statement of the hardware and software requirements for
21 access to and retention of a notice or document delivered by
22 electronic means. The party shall provide electronic consent to
23 the hardware and software requirements or confirm consent
24 electronically in a manner that reasonably demonstrates that the
25 party can access information in the electronic form that will be
26 used for notices or documents delivered by electronic means.
27 (5) After the party consents as provided in subsection (4),
1 if a change occurs in hardware or software needed to access or
2 retain a notice or document delivered by electronic means that
3 creates a material risk that the party will not be able to access
4 or retain a notice or document to which consent applies, the
5 insurer shall provide the party with a statement that includes
6 all of the following:
7 (a) Information regarding the revised hardware or software
8 requirements for access to and retention of a notice or document
9 delivered by electronic means.
10 (b) A description of the right of the party to withdraw
11 consent without the imposition of any condition or consequence
12 that was not disclosed under subsection (4)(b)(ii).
13 (6) Withdrawal of consent to electronic delivery does not
14 affect the legal effectiveness, validity, or enforceability of a
15 notice or a document that is delivered by electronic means to a
16 party before the withdrawal of consent is effective.
17 (7) Except as otherwise provided in this subsection,
18 withdrawal of consent by a party becomes effective 30 days after
19 the insurer receives notice of the withdrawal. Consent is
20 automatically withdrawn if the insurer learns that the electronic
21 delivery method currently used is no longer an effective delivery
22 mechanism.
23 (8) Failure by an insurer to comply with subsection (5) may
24 be treated, at the election of the party, as a withdrawal of
25 consent.
26 (9) This section must not be construed to modify, limit, or
27 supersede the federal electronic signatures in global national
1 commerce act, 15 USC 7001 to 7031.
2 (10) An insurance producer is not subject to civil liability
3 for any harm or injury to a party that occurs as a result of
4 either of the following:
5 (a) The party's consent under subsection (4) to receive a
6 notice or a document delivered by electronic means under this
7 section.
8 (b) An insurer's failure to deliver a notice or document by
9 electronic means unless the insurance producer causes the harm or
10 injury.
11 (11) This section does not apply to a health insurer or
12 health maintenance organization.
13 (12) (11) As
used in this section:
14 (a) "Delivered by electronic means", "delivery by electronic
15 means", or "electronic delivery" mean delivery by either of the
16 following methods:
17 (i) Delivery to an electronic mail address at which a party
18 has consented to receive notices or documents.
19 (ii) Both of the following:
20 (A) Posting on an electronic network or site accessible by
21 the internet through use of a mobile application, computer,
22 mobile device, tablet, or any other electronic device.
23 (B) Sending separate notice of the posting described in sub-
24 subparagraph (A) to the electronic mail address at which the
25 party consented to receive notice of the posting or using any
26 other delivery method to which the party has consented.
27 (b) "Party" means a recipient of a notice or document
1 required as part of an insurance transaction and includes an
2 applicant, insured, policy holder, or annuity contract holder.
3 Sec. 3801. As used in this chapter:
4 (a) "Applicant" means:
5 (i) For an
individual medicare Medicare
supplement policy,
6 the person who seeks to contract for benefits.
7 (ii) For a group
medicare Medicare supplement policy or
8 certificate, the proposed certificate holder.
9 (b) "Bankruptcy" means, when with respect to a medicare
10 Medicare advantage organization that is not an insurer, that the
11 organization has filed, or has had filed against it, a petition
12 for declaration of bankruptcy and has ceased doing business in
13 this state.
14 (c) "Certificate" means any certificate delivered or issued
15 for delivery in this state under a group medicare Medicare
16 supplement policy.
17 (d) "Certificate form" means the form on which the a
18 certificate is delivered or issued for delivery by the an
19 insurer.
20 (e) "Continuous period of creditable coverage" means the
21 period during which an individual was covered by creditable
22 coverage, if during the period of the coverage the individual had
23 no breaks in coverage greater than 63 days.
24 (f) "Creditable coverage" means coverage of an individual
25 provided under any of the following:
26 (i) A group health plan.
27 (ii) Health insurance coverage.
1 (iii) Part A or
part B of medicare.Medicare.
2 (iv) Medicaid other than coverage consisting solely of
3 benefits under section 1928 of medicaid, 42 USC 1396s.
4 (v) Chapter 55 of title 10 of the United States Code, 10 USC
5 1071 to 1110.1110b.
6 (vi) A medical
care program of the Indian health service
7 Health Service or of a tribal organization.
8 (vii) A state health benefits risk pool.
9 (viii) A health plan offered under chapter 89 of title 5 of
10 the United States Code, 5 USC 8901 to 8914.
11 (ix) A public health plan as defined in federal regulation.
12 (x) Health care
under section 5(e) of title I of the peace
13 corps act, 22 USC 2504.2504(e).
14 (g) "Direct response solicitation" means solicitation in
15 which an insurer representative does not contact the applicant in
16 person and explain the coverage available, such as, but not
17 limited to, solicitation through direct mail or through
18 advertisements in periodicals and other media.
19 (h) "Employee welfare benefit plan" means a plan, fund, or
20 program of employee benefits as defined in section 3 of subtitle
21 A of title I of the employee retirement income security act of
22 1974, 29 USC 1002.
23 (i) "Insolvency" means, when with respect to an insurer
24 licensed to transact the business of insurance in this state,
25 that the insurer has had a final order of liquidation entered
26 against it with a finding of insolvency by a court of competent
27 jurisdiction in the insurer's state of domicile.
1 (j) "Insurer" includes any entity, including a
health care
2 corporation operating pursuant to the nonprofit health care
3 corporation reform act, 1980 PA 350, MCL 550.1101 to 550.1704,
4 delivering person
that delivers or issuing issues for
delivery in
5 this state medicare Medicare
supplement policies.
6 (k) "Medicaid" means title subchapter XIX of the social
7 security act, 42 USC 1396 to 1396v.1396w-5.
8 (l)
"Medicare" means title subchapter XVIII of the
social
9 security act, 42 USC 1395 to 1395hhh.1395lll.
10 (m) "Medicare advantage" means a plan of coverage for health
11 benefits under medicare Medicare
part C as defined described in
12 section 12-2859 of part C of medicare, 42 USC 1395w-28, and
13 includes any of the following:
14 (i) Coordinated care plans that provide health care services,
15 including, but not limited to, health maintenance organization
16 plans with or without a point-of-service option, plans offered by
17 provider-sponsored organizations, and preferred provider
18 organization plans.
19 (ii) Medical savings account plans coupled with a
20 contribution into a medicare Medicare advantage medical
savings
21 account.
22 (iii) Medicare advantage private fee-for-service plans.
23 (n) "Medicare supplement buyer's guide" means the document
24 entitled, "guide to health insurance for people with
medicare",
25 "Choosing a Medigap Policy: A Guide to Health Insurance for
26
People with Medicare", developed
by the national association of
27 insurance commissioners National
Association of Insurance
1
Commissioners and the United States department
of health and
2 human services Department
of Health and Human Services, or a
3 substantially similar document as approved by the
4 commissioner.director.
5 (o) "Medicare supplement policy" means an individual ,
6 nongroup, or group policy
or certificate that is advertised,
7 marketed, or designed primarily as a supplement to reimbursements
8 under medicare Medicare
for the hospital, medical, or surgical
9 expenses of persons eligible for medicare Medicare and
medicare
10 Medicare select policies and certificates under section 3817.
11 Medicare supplement policy does not include a policy,
12 certificate, or contract of 1 or more employers or labor
13 organizations, or of the trustees of a fund established by 1 or
14 more employers or labor organizations, or both, for employees or
15 former employees, or both, or for members or former members, or
16 both, of the labor organizations. Medicare supplement policy does
17 not include medicare Medicare
advantage plans established under
18 medicare Medicare part C, outpatient prescription drug plans
19 established under medicare Medicare part D, or any
health care
20 prepayment plan that provides benefits pursuant to an agreement
21 under section 1833(a)(1)(A) of the social security act.42 USC
22 1395l(a)(1).
23 (p) "PACE" means a program of all-inclusive care for the
24 elderly as described in the social security act.
25 (q) "Prestandardized medicare Medicare supplement
benefit
26 plan", "prestandardized benefit plan", or "prestandardized plan"
27 means a group or individual policy of medicare Medicare
1 supplement insurance issued prior to before June
2, 1992.
2 (r) "1990 standardized medicare Medicare supplement
benefit
3 plan", "1990 standardized benefit plan", or "1990 plan" means a
4 group or individual policy of medicare Medicare supplement
5 insurance issued on or after June 2, 1992 with an effective date
6 for coverage prior to before
June 1, 2010 and includes medicare
7 Medicare supplement insurance policies and certificates renewed
8 on or after that date which that are not replaced by the
issuer
9 at the request of the insured.
10 (s) "2010 standardized medicare Medicare supplement
benefit
11 plan", "2010 standardized benefit plan", or "2010 plan" means a
12 group or individual policy of medicare Medicare supplement
13 insurance with an effective date for coverage on or after June 1,
14 2010.
15 (t) "Policy form" means the form on which the policy or
16 certificate is delivered or issued for delivery by the insurer.
17 (u) "Secretary" means the secretary of the United States
18 department of health and human services.Department of Health and
19 Human Services.
20 (v) "Social security act" means the social security act, 42
21 USC 301 to 1397jj.1397mm.
22 Sec. 3803. (1) Except as provided in subsections (2) and
23 (3), this chapter applies to a medicare Medicare supplement
24 policy delivered, issued for delivery, or renewed in this state.
25 (2) Sections 3807, 3809, 3811, and 3819 apply to a medicare
26 Medicare supplement policy delivered or issued for delivery in
27 this state on or after June 2, 1992 with an effective date for
1 coverage prior to before
June 1, 2010.
2 (3) Sections 3807a, 3809a, 3811a, and 3819a apply to a
3 medicare Medicare supplement policy delivered or issued for
4 delivery in this state with an effective date for coverage on or
5 after June 1, 2010.
6 Sec. 3811a. (1) This section applies to all medicare
7 Medicare supplement policies or certificates delivered or issued
8 for delivery with an effective date for coverage on or after June
9 1, 2010. A policy or certificate shall must not
be advertised,
10 solicited, delivered, or issued for delivery in this state as a
11 medicare Medicare supplement policy or certificate unless it
12 complies with these benefit standards. Benefit plan standards
13 applicable to medicare Medicare
supplement policies and
14 certificates issued before June 1, 2010 remain subject to the
15 requirements of section 3811.
16 (2) An insurer shall make available to each prospective
17 medicare Medicare supplement policyholder and certificate holder
18 a policy form or certificate form containing only the basic core
19 benefits as provided in section 3807a. If an insurer makes
20 available any of the additional benefits described in section
21 3809a or offers standardized benefit plans K or L, the insurer
22 shall make available to each prospective medicare Medicare
23 supplement policyholder and certificate holder a policy form or
24 certificate form containing either standardized benefit plan C or
25 standardized benefit plan F.
26 (3) Groups, packages, or combinations of medicare Medicare
27 supplement benefits other than those listed in this section shall
1 must not be offered for sale in this state except as may be
2 permitted in subsection (6)(k).
3 (4) Benefit plans shall must be uniform in
structure,
4 language, designation, and format to the standard benefit plans
5 in subsection (6) and shall must conform to the
definitions in
6 this chapter. Each benefit shall must be structured in
accordance
7 with sections 3807a and 3809a and list the benefits in the order
8 shown in subsection (6). For purposes of As used in this section,
9 "structure, language, designation, and format" means style,
10 arrangement, and overall content of a benefit.
11 (5) In addition to the benefit plan designations as provided
12 under subsection (6), an insurer may use other designations to
13 the extent permitted by law.
14 (6) A medicare Medicare
supplement insurance benefit plan
15 shall must conform to 1 of the following:
16 (a) A standardized medicare Medicare supplement benefit
plan
17 A shall must be limited to the basic core benefits common to all
18 benefit plans as defined in required under section
3807a.
19 (b) A standardized medicare Medicare supplement benefit
plan
20 B shall must include only the following: the core benefits as
21 defined in required
under section 3807a and 100% of the medicare
22 Medicare part A deductible as defined in section 3809a(2)(a).
23 (c) A standardized medicare Medicare supplement benefit
plan
24 C shall must include only the following: the core benefits as
25 defined in required
under section 3807a , and 100%
of the
26 medicare Medicare part A deductible, skilled nursing facility
27 care, 100% of the medicare Medicare part B deductible,
and
1 medically necessary emergency care in a foreign country as
2 defined in section 3809a(2)(a), (c), (d), and (f).
3 (d) A standardized medicare Medicare supplement benefit
plan
4 D shall must include only the following: the core benefits as
5 defined in required
under section 3807a , and 100%
of the
6 medicare Medicare part A deductible, skilled nursing facility
7 care, and medically necessary emergency care in a foreign country
8 as defined in section 3809a(2)(a), (c), and (f).
9 (e) A standardized medicare Medicare supplement benefit
plan
10 F shall must include only the following: the core benefits as
11 defined in required
under section 3807a , and 100%
of the
12 medicare Medicare part A deductible, skilled nursing facility
13 care, 100% of the medicare Medicare part B deductible,
100% of
14 the medicare Medicare
part B excess charges, and medically
15 necessary emergency care in a foreign country as defined in
16 section 3809a(2)(a), (c), (d), (e), and (f). A standardized
17 medicare Medicare supplement plan F high deductible shall must
18 include only the following: 100% of covered expenses following
19 the payment of the annual high deductible high-deductible plan F
20 deductible. The covered expenses include the core benefits as
21 defined in required
under section 3807a ,
plus and 100% of the
22 medicare Medicare part A deductible, skilled nursing facility
23 care, 100% of the medicare Medicare part B deductible,
100% of
24 the medicare Medicare
part B excess charges, and medically
25 necessary emergency care in a foreign country as defined in
26 section 3809a(2)(a), (c), (d), (e), and (f). The annual high
27 deductible high-deductible
plan F deductible shall must consist
1 of out-of-pocket expenses, other than premiums, for services
2 covered by the medicare Medicare
supplement plan F policy, and
3 shall must be in addition to any other specific benefit
4 deductibles. The annual high deductible high-deductible plan F
5 deductible is $1,500.00 for calendar year 1999, and the secretary
6 shall adjust it annually thereafter to reflect the change in the
7 consumer price index Consumer
Price Index for all urban consumers
8 for the 12-month period ending with August of the preceding year,
9 rounded to the nearest multiple of $10.00.
10 (f) A standardized medicare Medicare supplement benefit
plan
11 G shall must include only the following: the core benefits as
12 defined in required
under section 3807a , and 100%
of the
13 medicare Medicare part A deductible, skilled nursing facility
14 care, 100% of the medicare Medicare part B excess
charges, and
15 medically necessary emergency care in a foreign country as
16 defined in section 3809a(2)(a), (c), (e), and (f). Effective
17 January 1, 2020, the standardized plan F high deductible benefit
18 plan, redesignated in section 3811b(2)(d) as plan G high
19 deductible, may be offered to an individual who was eligible for
20 Medicare before January 1, 2020.
21 (g) Standardized medicare Medicare supplement benefit
plan K
22 shall must consist of the following:
23 (i) Coverage of 100% of the part A hospital coinsurance
24 amount for each day used from the sixty-first day through the
25 ninetieth day in any medicare Medicare benefit period.
26 (ii) Coverage of 100% of the part A hospital coinsurance
27 amount for each medicare Medicare lifetime inpatient
reserve day
1 used from the ninety-first day through the one hundred fiftieth
2 day in any medicare Medicare
benefit period.
3 (iii) Upon On exhaustion
of the medicare Medicare hospital
4 inpatient coverage, including the lifetime reserve days, coverage
5 of 100% of the medicare Medicare
part A eligible expenses for
6 hospitalization paid at the applicable prospective payment system
7 rate, or other appropriate medicare Medicare standard
of payment,
8 subject to a lifetime maximum benefit of an additional 365 days.
9 The provider shall accept the insurer's payment as payment in
10 full and may not bill the insured for any balance.
11 (iv) Medicare part A deductible: coverage for 50% of the
12 medicare Medicare part A inpatient hospital deductible amount per
13 benefit period until the out-of-pocket limitation is met as
14 described in subparagraph (x).
15 (v) Skilled nursing facility care: coverage for 50% of the
16 coinsurance amount for each day used from the twenty-first day
17 through the one hundredth day in a medicare Medicare benefit
18 period for posthospital skilled nursing facility care eligible
19 under medicare Medicare
part A until the out-of-pocket
limitation
20 is met as described in subparagraph (x).
21 (vi) Hospice care: coverage for 50% of cost sharing for all
22 part A medicare Medicare
eligible expenses and respite care
until
23 the out-of-pocket limitation is met as described in subparagraph
24 (x).
25 (vii) Coverage
for 50%, under medicare Medicare
part A or B,
26 of the reasonable cost of the first 3 pints of blood or
27 equivalent quantities of packed red blood cells, as defined under
1 federal regulations, unless replaced in accordance with federal
2 regulations until the out-of-pocket limitation is met as
3 described in subparagraph (x).
4 (viii) Except for coverage provided in subparagraph (ix),
5 below, coverage for 50% of
the cost sharing otherwise applicable
6 under medicare Medicare
part B after the policyholder pays the
7 part B deductible until the out-of-pocket limitation is met as
8 described in subparagraph (x).
9 (ix) Coverage of
100% of the cost sharing for medicare
10 Medicare part B preventive services after the policyholder pays
11 the part B deductible.
12 (x) Coverage of
100% of all cost sharing under medicare
13 Medicare parts A and B for the balance of the calendar year after
14 the individual has reached the out-of-pocket limitation on annual
15 expenditures under medicare Medicare parts A and B of
$4,000.00
16 in 2006, indexed each year by the appropriate inflation
17 adjustment specified by the secretary of the United States
18 department of health and human services.Department of Health and
19 Human Services.
20 (h) Standardized medicare Medicare supplement benefit
plan L
21 shall must consist of the following:
22 (i) The benefits described in subdivision (g)(i), (ii), (iii),
23 and (ix).
24 (ii) The benefits described in subdivision (g)(iv), (v), (vi),
25 (vii), and (viii), but substituting 75% for 50%.
26 (iii) The benefit described in subdivision (g)(x), but
27 substituting $2,000.00 for $4,000.00.
1 (i) A standardized medicare Medicare supplement benefit
plan
2 M shall must include only the following: the core benefits as
3 defined in required
under section 3807a and 50% of the medicare
4 Medicare part A deductible, skilled nursing care, and medically
5 necessary emergency care in a foreign country as defined in
6 section 3809a(2)(b), (c), and (f).
7 (j) A standardized medicare Medicare supplement benefit
plan
8 N shall must include only the following: the core benefits as
9 defined in required
under section 3807a , and 100%
of the
10 medicare Medicare part A deductible, skilled nursing facility
11 care, and medically necessary emergency care in a foreign country
12 as defined in section 3809a(2)(a), (c), and (f) with copayments
13 in the following amounts:
14 (i) The lesser
of $20.00 or the medicare Medicare
part B
15 coinsurance or copayment for each covered health care provider
16 office visit, including visits to medical specialists.
17 (ii) The lesser
of $50.00 or the medicare Medicare
part B
18 coinsurance or copayment for each covered emergency room visit.
19 The copayment shall must
be waived if the insured is admitted to
20 any hospital and the emergency visit is subsequently covered as a
21 medicare Medicare part A expense.
22 (k) New or innovative benefits: an insurer may, with the
23 prior approval of the commissioner, director, offer policies or
24 certificates with new or innovative benefits in addition to the
25 benefits provided in a policy or certificate that otherwise
26 complies with the applicable standards. The new or innovative
27 benefits may include benefits that are appropriate to medicare
1 Medicare supplement insurance, new or innovative, not otherwise
2 available, cost-effective, and offered in a manner that is
3 consistent with the goal of simplification of medicare Medicare
4 supplement policies. The innovative benefit shall must not
5 include an outpatient prescription drug benefit. New or
6 innovative benefits shall must not be used to change
or reduce
7 benefits, including a change of any cost-sharing provision, in
8 any standardized plan.
9 Sec. 3811b. (1) This section applies to all Medicare
10 supplement policies or certificates delivered or issued for
11 delivery in this state to individuals newly eligible for Medicare
12 after December 31, 2019. A policy or certificate that provides
13 coverage of the Medicare part B deductible must not be
14 advertised, solicited, delivered, or issued for delivery in this
15 state as a Medicare supplement policy or certificate to
16 individuals newly eligible for Medicare after December 31, 2019,
17 unless it complies with the benefit standards provided in this
18 section. Benefit plan standards applicable to Medicare supplement
19 policies and certificates issued to individuals eligible for
20 Medicare before January 1, 2020 remain subject to the
21 requirements of section 3811a.
22 (2) The standards and requirements of section 3811a apply to
23 all Medicare supplement policies or certificates delivered or
24 issued for delivery to individuals newly eligible for Medicare
25 after December 31, 2019, with the following exceptions:
26 (a) Standardized Medicare supplement benefit plan C is
27 redesignated as plan D and must provide the benefits contained in
1 section 3811a(6)(c), but must not provide coverage for 100% or
2 any portion of the Medicare part B deductible.
3 (b) Standardized Medicare supplement benefit plan F is
4 redesignated as plan G and must provide the benefits contained in
5 section 3811a(6)(e), as applicable, but must not provide coverage
6 for 100% or any portion of the Medicare part B deductible.
7 (c) Standardized Medicare supplement benefit plans C, F, and
8 F high deductible may not be offered to individuals newly
9 eligible for Medicare after December 31, 2019.
10 (d) Standardized Medicare supplement benefit plan F high
11 deductible is redesignated as plan G high deductible and must
12 provide the benefits in section 3811a(6)(e), as applicable, but
13 must not provide coverage for 100% or any portion of the Medicare
14 part B deductible. The Medicare part B deductible paid by the
15 beneficiary is considered an out-of-pocket expense in meeting the
16 annual high deductible.
17 (e) The reference to plan C or plan F contained in section
18 3811a(2) is deemed a reference to plan D or plan G, respectively,
19 for purposes of this section.
20 (3) This section only applies to individuals that are newly
21 eligible for Medicare after December 31, 2019 because of either
22 of the following:
23 (a) By reason of attaining age 65 after December 31, 2019.
24 (b) By reason of entitlement to benefits under Medicare part
25 A under section 226(b) or 226a of the social security act, or who
26 is deemed to be eligible for benefits under section 226a of the
27 social security act after December 31, 2019.
1 (4) For purposes of section 3830(5) to (8), for an
2 individual newly eligible for Medicare after December 31, 2019,
3 any reference to Medicare supplement policy or certificate plans
4 C, F, or F high deductible is deemed to be a reference to
5 Medicare supplement policy or certificate plans D, G, or G high
6 deductible, respectively, that meet the requirements of
7 subsection (2).
8 (5) After December 31, 2019, the standardized benefit plans
9 described in subsection (2)(d) may be offered to an individual
10 who was eligible for Medicare before January 1, 2020, in addition
11 to the standardized plans described in section 3811a(6).
12 Sec. 3813. An insurer that issues a policy that provides
13 disability health
insurance coverage to a person eligible
for
14 medicare Medicare by reason of age shall provide the prospective
15 policyholder with a medicare Medicare supplement buyer's
guide in
16
written or electronic format, which shall
must be furnished at
17 the time of application, and the insurer shall obtain, in written
18 or electronic format, acknowledgment of receipt of the buyer's
19 guide. shall be obtained by the insurer. However, for
direct
20 response solicitation policies, the guide shall must be
furnished
21 with the policy in written or electronic format and the insurer
22
need not obtain acknowledgment of
receipt. need not be obtained
23 by the insurer. This
section does not apply to policies that
24 provide accidental death benefits for travel or other accidents,
25 or if the medical expense or indemnity payments are only
26 incidental to the accidental death benefits for travel or other
27 accidents.
1 Sec. 3815. (1) An insurer that offers a medicare Medicare
2 supplement policy shall provide to the applicant at the time of
3 application an outline of coverage in written or electronic
4 format and, except for direct response solicitation policies,
5 shall obtain an acknowledgment of receipt of the outline of
6 coverage from the applicant in written or electronic format. The
7 outline of coverage provided to applicants pursuant to under this
8 section shall must
consist of the following 4 parts:
9 (a) A cover page.
10 (b) Premium information.
11 (c) Disclosure pages.
12 (d) Charts displaying the features of each benefit plan
13 offered by the insurer.
14 (2) Insurers shall comply with any notice requirements of
15 the medicare Medicare
prescription drug, improvement, and
16 modernization act of 2003, Public Law 108-173.
17 (3) If an outline of coverage is provided at the time of
18 application and the medicare Medicare supplement policy
or
19 certificate is issued on a basis that would require revision of
20 the outline, a substitute outline of coverage properly describing
21 the policy or certificate shall must accompany the policy or
22 certificate when it is delivered and shall must contain
the
23 following statement, in no not less than 12-point type,
24 immediately above the company name:
25 |
|
NOTICE: Read this outline of coverage carefully. |
|
26 |
|
It is not identical to the outline of coverage |
|
1 |
|
provided
|
|
2 |
|
originally applied for has not been issued. |
|
3 (4) An outline of coverage under subsection (1) shall must
4 be in the language and in a written or electronic format
5 prescribed in this section and in not less than 12-point type.
6 The letter designation of the plan shall must be
shown on the
7 cover page and the plans offered by the insurer shall must be
8 prominently identified. Premium information shall must be
shown
9 on the cover page or immediately following the cover page and
10 shall must be prominently displayed. The premium and method of
11 payment mode shall must
be stated for all plans that are
offered
12 to the applicant. All possible premiums for the applicant shall
13
must be illustrated. The following
items shall must be included
14 in the outline of coverage in the order prescribed below and in
15 substantially the following form, as approved by the
16 commissioner:director:
17 |
BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD |
18 |
ON OR AFTER JUNE 1, 2010 |
19 This chart shows the benefits included in each of the
20 standard Medicare supplement plans. Every company must make Plan
21 "A" available. Some plans may not be available in your state.
22 Plans E, H, I, and J are no longer available for sale. (This
23 sentence shall must
not appear after June 1, 2011.)
24 |
BASIC BENEFITS: |
1 |
Hospitalization: Part A coinsurance plus coverage for 365 |
2 |
additional days after Medicare benefits end. |
3 |
Medical Expenses: Part B coinsurance (generally 20% of |
4 |
Medicare-approved expenses) or copayments for hospital |
5 |
outpatient services. Plans K, L, and N require insureds |
6 |
to pay a portion of Part B coinsurance or copayments. |
7 |
Blood: First three pints of blood each year. |
8 |
Hospice: Part A coinsurance |
9 |
A |
B |
C** |
D |
F|F* ** |
G/G* |
10 |
Basic, |
Basic, |
Basic, |
Basic, |
Basic, |
Basic, |
11 |
including |
including |
including |
including |
including |
including |
12 |
100% Part |
100% Part |
100% Part |
100% Part |
100% Part |
100% Part |
13 |
B coin- |
B coinsur- |
B coinsur- |
B coinsur- |
B coinsur- |
B coinsur- |
14 |
surance |
ance |
ance |
ance |
ance |
ance |
15 |
|
|
Skilled |
Skilled |
Skilled |
Skilled |
16 |
|
|
Nursing |
Nursing |
Nursing |
Nursing |
17 |
|
|
Facility |
Facility |
Facility |
Facility |
18 |
|
|
Coinsur- |
Coinsur- |
Coinsur- |
Coinsur- |
19 |
|
|
ance |
ance |
ance |
ance |
20 |
|
Part A |
Part A |
Part A |
Part A |
Part A |
21 |
|
Deductible |
Deductible |
Deductible |
Deductible |
Deductible |
22 |
|
|
Part B |
|
Part B |
|
23 |
|
|
Deductible |
|
Deductible |
|
24 |
|
|
|
|
Part B |
Part B |
25 |
|
|
|
|
Excess |
Excess |
26 |
|
|
|
|
(100%) |
(100%) |
27 |
|
|
Foreign |
Foreign |
Foreign |
Foreign |
1 |
|
|
Travel |
Travel |
Travel |
Travel |
2 |
|
|
Emergency |
Emergency |
Emergency |
Emergency |
3
4 |
K |
L |
M |
N |
5 |
Hospitalization |
Hospitalization |
Basic, |
Basic, includ- |
6 |
and preventive |
and preventive |
including 100% |
ing 100% Part B |
7 |
care paid at |
care paid at |
Part B |
coinsurance, |
8 |
100%; other |
100%; other |
coinsurance |
except up to |
9 |
basic benefits |
basic benefits |
|
$20 copayment |
10 |
paid at 50% |
paid at 75% |
|
for office |
11 |
|
|
|
visit, and up |
12 |
|
|
|
to $50 copay- |
13 |
|
|
|
ment for ER |
14 |
50% Skilled |
75% Skilled |
Skilled |
Skilled |
15 |
Nursing |
Nursing |
Nursing |
Nursing |
16 |
Facility |
Facility |
Facility |
Facility |
17 |
Coinsurance |
Coinsurance |
Coinsurance |
Coinsurance |
18 |
50% Part A |
75% Part A |
50% Part A |
Part A |
19 |
Deductible |
Deductible |
Deductible |
Deductible |
20 |
|
|
|
|
21 |
|
|
|
|
22 |
|
|
Foreign |
Foreign |
23 |
|
|
Travel |
Travel |
24 |
|
|
Emergency |
Emergency |
25 |
Out-of-pocket |
Out-of-pocket |
|
|
26 |
limit
|
limit
|
|
|
27 |
paid at 100% |
paid at 100% |
|
|
1 |
after limit |
after limit |
|
|
2 |
reached |
reached |
|
|
3 * Plan Plans
F and G also has an option have options called
4 a high-deductible Plan F .
This and high-deductible Plan
G. These
5 high-deductible plan pays plans pay the same benefits
as Plan F
6 or Plan G, as applicable, after one has paid a calendar year
7 $1,860 $2,240 deductible. Benefits from high-deductible Plan F or
8 high-deductible Plan G will not begin until out-of-pocket
9 expenses exceed $1,860. $2,240.
Out-of-pocket expenses for this
10 deductible these
deductibles are expenses that would
ordinarily
11 be paid by the policy. These expenses include the Medicare
12 deductibles for Part A and Part B, but do not include the plan's
13 separate foreign travel emergency deductible.
14 ** Plan C, Plan F, and high-deductible Plan F are only
15 available to individuals eligible for Medicare before January 1,
16 2020.
17 |
PREMIUM INFORMATION |
18 We (insert insurer's name) can only raise your premium if we
19 raise the premium for all policies like yours in this state. (If
20 the premium is based on the increasing age of the insured,
21 include information specifying when premiums will change).
22 |
DISCLOSURES |
23 Use this outline to compare benefits and premiums among
1 policies, certificates, and contracts.
2 This outline shows benefits and premiums of policies sold
3 for effective dates on or after June 1, 2010. Policies sold for
4 effective dates prior to before June 1, 2010 have
different
5 benefits and premiums. Plans E, H, I, and J are no longer
6 available for sale. (This sentence shall must not
appear after
7 June 1, 2011.)
8 |
READ YOUR POLICY VERY CAREFULLY |
9 This is only an outline describing your policy's most
10 important features. The policy is your insurance contract. You
11 must read the policy itself to understand all of the rights and
12 duties of both you and your insurance company.
13 |
RIGHT TO RETURN POLICY |
14 If you find that you are not satisfied with your policy, you
15 may return it to (insert insurer's address). If you send the
16 policy back to us within 30 days after you receive it, we will
17 treat the policy as if it had never been issued and return all of
18 your payments.
19 |
POLICY REPLACEMENT |
20 If you are replacing another health insurance policy, do not
21 cancel it until you have actually received your new policy and
22 are sure you want to keep it.
1 |
NOTICE |
2 This policy may not fully cover all of your medical costs.
3 [For agent issued policies]
4 Neither (insert insurer's name) nor its agents are connected
5 with medicare.Medicare.
6 [For direct response issued policies]
7 (Insert insurer's name) is not connected with
8 medicare.Medicare.
9 This outline of coverage does not give all the details of
10 medicare Medicare coverage. Contact your local social security
11 office or consult "the medicare handbook" "The Medicare Handbook"
12 for more details.
13 |
COMPLETE ANSWERS ARE VERY IMPORTANT |
14 When you fill out the application for the new policy, be
15 sure to answer truthfully and completely all questions about your
16 medical and health history. The company may cancel your policy
17 and refuse to pay any claims if you leave out or falsify
18 important medical information. [If the policy or certificate is
19 guaranteed issue, this paragraph need not appear.]
20 Review the application carefully before you sign it. Be
21 certain that all information has been properly recorded.
22 [Include for each plan offered by the insurer a chart
23 showing the services, medicare Medicare payments, plan
payments,
24 and insured payments using the same language, in the same order,
25 and using uniform layout and format as shown in the charts that
1 follow. An insurer may use additional benefit plan designations
2 on these charts pursuant to under section 3809(1)(k).
Include an
3 explanation of any innovative benefits on the cover page and in
4 the chart, in a manner approved by the commissioner. director.
5 The insurer issuing the policy shall change the dollar amounts
6 each year to reflect current figures. No more than 4 plans may be
7 shown on 1 chart.] Charts for each plan are as follows:
8 |
PLAN A |
9 |
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD |
10 *A benefit period begins on the first day you receive
11 service as an inpatient in a hospital and ends after you have
12 been out of the hospital and have not received skilled care in
13 any other facility for 60 days in a row.
14 |
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
15 |
HOSPITALIZATION* |
|
|
|
16 |
Semiprivate room and |
|
|
|
17 |
board, general nursing |
|
|
|
18 |
and miscellaneous |
|
|
|
19 |
services and supplies |
|
|
|
20 |
First 60 days |
All but |
$0 |
|
21 |
|
|
|
(Part A |
22 |
|
|
|
Deductible) |
23 |
61st thru 90th day |
All but |
|
$0 |
24 |
|
|
a day |
|
25 |
|
a day |
|
|
1 |
91st day and after: |
|
|
|
2 |
—While using 60 |
|
|
|
3 |
lifetime reserve days |
All but |
|
$0 |
4 |
|
|
a day |
|
5 |
|
a day |
|
|
6 |
—Once lifetime reserve |
|
|
|
7 |
days are used: |
|
|
|
8 |
—Additional 365 days |
$0 |
100% of |
$0** |
9 |
|
|
Medicare |
|
10 |
|
|
Eligible |
|
11 |
|
|
Expenses |
|
12 |
—Beyond the |
|
|
|
13 |
Additional 365 days |
$0 |
$0 |
All Costs |
14 |
SKILLED NURSING FACILITY |
|
|
|
15 |
CARE* |
|
|
|
16 |
You must meet Medicare's |
|
|
|
17 |
requirements, including |
|
|
|
18 |
having been in a hospital |
|
|
|
19 |
for at least 3 days and |
|
|
|
20 |
entered a Medicare- |
|
|
|
21 |
approved facility within |
|
|
|
22 |
30 days after leaving the |
|
|
|
23 |
hospital |
|
|
|
24 |
First 20 days |
All approved |
|
|
25 |
|
amounts |
$0 |
$0 |
26 |
21st thru 100th day |
All but |
$0 |
Up to |
27 |
|
|
|
|
28 |
|
a day |
|
a day |
29 |
101st day and after |
$0 |
$0 |
All costs |
1 |
BLOOD |
|
|
|
2 |
First 3 pints |
$0 |
3 pints |
$0 |
3 |
Additional amounts |
100% |
$0 |
$0 |
4 |
HOSPICE CARE |
|
|
|
5 |
You must meet |
All but very |
|
$0 |
6 |
Medicare's requirements |
limited |
Medicare |
|
7 |
including a doctor's |
copayment/ |
copayment/ |
|
8 |
certification of terminal |
coinsurance |
coinsurance |
|
9 |
illness |
for outpatient |
|
|
10 |
|
drugs and |
|
|
11 |
|
inpatient |
|
|
12 |
|
respite care |
|
|
13 |
|
|
|
|
14 **NOTICE: When your Medicare Part A hospital benefits are
15 exhausted, the insurer stands in the place of Medicare and will
16 pay whatever amount Medicare would have paid for up to an
17 additional 365 days as provided in the policy's "Core Benefits."
18 During this time the hospital is prohibited from billing you for
19 the balance based on any difference between its billed charges
20 and the amount Medicare would have paid.
21 |
PLAN A |
22 |
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR |
23 *Once you have been billed $131 $183 of
Medicare-Approved
24 amounts for covered services (which are noted with an asterisk),
25 your Part B Deductible will have been met for the calendar year.
1 |
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
2 |
MEDICAL EXPENSES— |
|
|
|
3 |
In or out of the hospital |
|
|
|
4 |
and outpatient hospital |
|
|
|
5 |
treatment, such as |
|
|
|
6 |
Physician's services, |
|
|
|
7 |
inpatient and outpatient |
|
|
|
8 |
medical and surgical |
|
|
|
9 |
services and supplies, |
|
|
|
10 |
physical and speech |
|
|
|
11 |
therapy, diagnostic |
|
|
|
12 |
tests, durable medical |
|
|
|
13 |
equipment, |
|
|
|
14 |
First |
|
|
|
15 |
Medicare Approved |
$0 |
$0 |
|
16 |
Amounts* |
|
|
(Part B |
17 |
|
|
|
Deductible) |
18 |
Remainder of Medicare |
|
|
|
19 |
Approved Amounts |
80% |
20% |
$0 |
20 |
Part B Excess Charges |
|
|
|
21 |
(Above Medicare |
|
|
|
22 |
Approved Amounts) |
$0 |
$0 |
All Costs |
23 |
BLOOD |
|
|
|
24 |
First 3 pints |
$0 |
All Costs |
$0 |
25 |
Next
|
|
|
|
26 |
Medicare |
$0 |
$0 |
|
27 |
Approved Amounts* |
|
|
(Part B |
28 |
|
|
|
Deductible) |
29 |
Remainder of Medicare |
|
|
|
1 |
Approved Amounts |
80% |
20% |
$0 |
2 |
CLINICAL LABORATORY |
|
|
|
3 |
SERVICES— |
|
|
|
4 |
Tests for |
|
|
|
5 |
diagnostic services |
100% |
$0 |
$0 |
6 |
PARTS A & B |
7 |
HOME HEALTH CARE |
|
|
|
8 |
Medicare Approved |
|
|
|
9 |
Services |
|
|
|
10 |
—Medically necessary |
|
|
|
11 |
skilled care services |
|
|
|
12 |
and medical supplies |
100% |
$0 |
$0 |
13 |
—Durable medical |
|
|
|
14 |
equipment |
|
|
|
15 |
First |
|
|
|
16 |
Medicare |
$0 |
$0 |
|
17 |
Approved Amounts* |
|
|
(Part B |
18 |
|
|
|
Deductible) |
19 |
Remainder of Medicare |
|
|
|
20 |
Approved Amounts |
80% |
20% |
$0 |
21 |
PLAN B |
22 |
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD |
23 *A benefit period begins on the first day you receive
1 service as an inpatient in a hospital and ends after you have
2 been out of the hospital and have not received skilled care in
3 any other facility for 60 days in a row.
4 |
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
5 |
HOSPITALIZATION* |
|
|
|
6 |
Semiprivate room and |
|
|
|
7 |
board, general nursing |
|
|
|
8 |
and miscellaneous |
|
|
|
9 |
services and supplies |
|
|
|
10 |
First 60 days |
All but |
|
$0 |
11 |
|
|
(Part A |
|
12 |
|
|
Deductible) |
|
13 |
61st thru 90th day |
All but |
|
$0 |
14 |
|
|
a day |
|
15 |
91st day and after |
|
|
|
16 |
—While using 60 |
|
|
|
17 |
lifetime reserve days |
All but |
|
$0 |
18 |
|
|
a day |
|
19 |
—Once lifetime reserve |
|
|
|
20 |
days are used: |
|
|
|
21 |
—Additional 365 days |
$0 |
100% of |
$0** |
22 |
|
|
Medicare |
|
23 |
|
|
Eligible |
|
24 |
|
|
Expenses |
|
25 |
—Beyond the |
|
|
|
26 |
Additional 365 days |
$0 |
$0 |
All Costs |
27 |
SKILLED NURSING FACILITY |
|
|
|
28 |
CARE* |
|
|
|
1 |
You must meet Medicare's |
|
|
|
2 |
requirements, including |
|
|
|
3 |
having been in a hospital |
|
|
|
4 |
for at least 3 days and |
|
|
|
5 |
entered a Medicare- |
|
|
|
6 |
approved facility within |
|
|
|
7 |
30 days after leaving the |
|
|
|
8 |
hospital |
|
|
|
9 |
First 20 days |
All approved |
|
|
10 |
|
amounts |
$0 |
$0 |
11 |
21st thru 100th day |
All but |
$0 |
Up to |
12 |
|
|
|
|
13 |
|
|
|
$167.50 |
14 |
|
a day |
|
a day |
15 |
101st day and after |
$0 |
$0 |
All costs |
16 |
BLOOD |
|
|
|
17 |
First 3 pints |
$0 |
3 pints |
$0 |
18 |
Additional amounts |
100% |
$0 |
$0 |
19 |
HOSPICE CARE |
|
|
|
20 |
|
All but very |
|
|
21 |
|
limited |
Medicare |
$0 |
22 |
|
copayment/ |
copayment/ |
|
23 |
|
coinsurance |
coinsurance |
|
24 |
You must meet |
for outpatient |
|
|
25 |
Medicare's requirements, |
drugs and |
|
|
26 |
including a doctor's |
inpatient |
|
|
27 |
certification of |
respite care |
|
|
28 |
terminal illness |
|
|
|
1 **NOTICE: When your Medicare Part A hospital benefits are
2 exhausted, the insurer stands in the place of Medicare and will
3 pay whatever amount Medicare would have paid for up to an
4 additional 365 days as provided in the policy's "Core Benefits."
5 During this time the hospital is prohibited from billing you for
6 the balance based on any difference between its billed charges
7 and the amount Medicare would have paid.
8 |
PLAN B |
9 |
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR |
10 *Once you have been billed $131 $183 of
Medicare-Approved
11 amounts for covered services (which are noted with an asterisk),
12 your Part B Deductible will have been met for the calendar year.
13 |
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
14 |
MEDICAL EXPENSES— |
|
|
|
15 |
In or out of the hospital |
|
|
|
16 |
and outpatient hospital |
|
|
|
17 |
treatment, such as |
|
|
|
18 |
Physician's services, |
|
|
|
19 |
inpatient and outpatient |
|
|
|
20 |
medical and surgical |
|
|
|
21 |
services and supplies, |
|
|
|
22 |
physical and speech |
|
|
|
23 |
therapy, diagnostic |
|
|
|
24 |
tests, durable medical |
|
|
|
25 |
equipment, |
|
|
|
26 |
First |
|
|
|
1 |
Medicare Approved |
$0 |
$0 |
|
2 |
Amounts* |
|
|
(Part B |
3 |
|
|
|
Deductible) |
4 |
Remainder of Medicare |
|
|
|
5 |
Approved Amounts |
80% |
20% |
$0 |
6 |
Part B Excess Charges |
|
|
|
7 |
(Above Medicare |
|
|
|
8 |
Approved Amounts) |
$0 |
$0 |
All Costs |
9 |
BLOOD |
|
|
|
10 |
First 3 pints |
$0 |
All Costs |
$0 |
11 |
Next
|
|
|
|
12 |
Approved Amounts* |
$0 |
$0 |
|
13 |
|
|
|
(Part B |
14 |
Remainder of Medicare |
|
|
Deductible) |
15 |
Approved Amounts |
80% |
20% |
$0 |
16 |
CLINICAL LABORATORY |
|
|
|
17 |
SERVICES— |
|
|
|
18 |
Tests for |
|
|
|
19 |
diagnostic services |
100% |
$0 |
$0 |
20 |
PARTS A & B |
21 |
HOME HEALTH CARE |
|
|
|
22 |
Medicare Approved |
|
|
|
23 |
Services |
|
|
|
24 |
—Medically necessary |
|
|
|
25 |
skilled care services |
|
|
|
26 |
and medical supplies |
100% |
$0 |
$0 |
1 |
—Durable medical |
|
|
|
2 |
equipment |
|
|
|
3 |
First |
|
|
|
4 |
Medicare |
|
|
|
5 |
Approved Amounts* |
$0 |
$0 |
|
6 |
|
|
|
(Part B |
7 |
|
|
|
Deductible) |
8 |
Remainder of Medicare |
|
|
|
9 |
Approved Amounts |
80% |
20% |
$0 |
10 |
PLAN C |
11 |
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD |
12 *A benefit period begins on the first day you receive
13 service as an inpatient in a hospital and ends after you have
14 been out of the hospital and have not received skilled care in
15 any other facility for 60 days in a row.
16 |
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
17 |
HOSPITALIZATION* |
|
|
|
18 |
Semiprivate room and |
|
|
|
19 |
board, general nursing |
|
|
|
20 |
and miscellaneous |
|
|
|
21 |
services and supplies |
|
|
|
22 |
First 60 days |
All but |
|
$0 |
23 |
|
|
(Part A |
|
24 |
|
|
Deductible) |
|
25 |
61st thru 90th day |
All but |
|
$0 |
1 |
|
|
a day |
|
2 |
91st day and after |
|
|
|
3 |
—While using 60 |
|
|
|
4 |
lifetime reserve days |
All but |
|
$0 |
5 |
|
|
a day |
|
6 |
—Once lifetime reserve |
|
|
|
7 |
days are used: |
|
|
|
8 |
—Additional 365 days |
$0 |
100% of |
$0** |
9 |
|
|
Medicare |
|
10 |
|
|
Eligible |
|
11 |
|
|
Expenses |
|
12 |
—Beyond the |
|
|
|
13 |
Additional 365 days |
$0 |
$0 |
All Costs |
14 |
SKILLED NURSING FACILITY |
|
|
|
15 |
CARE* |
|
|
|
16 |
You must meet Medicare's |
|
|
|
17 |
requirements, including |
|
|
|
18 |
having been in a hospital |
|
|
|
19 |
for at least 3 days and |
|
|
|
20 |
entered a Medicare- |
|
|
|
21 |
approved facility within |
|
|
|
22 |
30 days after leaving the |
|
|
|
23 |
hospital |
|
|
|
24 |
First 20 days |
All approved |
|
|
25 |
|
amounts |
$0 |
$0 |
26 |
21st thru 100th day |
All but |
Up to |
$0 |
27 |
|
|
|
|
28 |
|
a day |
a day |
|
29 |
101st day and after |
$0 |
$0 |
All costs |
1 |
BLOOD |
|
|
|
2 |
First 3 pints |
$0 |
3 pints |
$0 |
3 |
Additional amounts |
100% |
$0 |
$0 |
4 |
HOSPICE CARE |
|
|
|
5 |
|
All but very |
|
$0 |
6 |
|
limited |
Medicare |
|
7 |
|
copayment/ |
copayment/ |
|
8 |
|
coinsurance |
coinsurance |
|
9 |
You must meet |
for outpatient |
|
|
10 |
Medicare's requirements, |
drugs and |
|
|
11 |
including a doctor's |
inpatient |
|
|
12 |
certification of |
respite care |
|
|
13 |
terminal illness |
|
|
|
14 **NOTICE: When your Medicare Part A hospital benefits are
15 exhausted, the insurer stands in the place of Medicare and will
16 pay whatever amount Medicare would have paid for up to an
17 additional 365 days as provided in the policy's "Core Benefits."
18 During this time the hospital is prohibited from billing you for
19 the balance based on any difference between its billed charges
20 and the amount Medicare would have paid.
21 |
PLAN C |
22 |
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR |
23 *Once you have been billed $131 $183 of
Medicare-Approved
24 amounts for covered services (which are noted with an asterisk),
25 your Part B Deductible will have been met for the calendar year.
1 |
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
2 |
MEDICAL EXPENSES— |
|
|
|
3 |
In or out of the hospital |
|
|
|
4 |
and outpatient hospital |
|
|
|
5 |
treatment, such as |
|
|
|
6 |
Physician's services, |
|
|
|
7 |
inpatient and outpatient |
|
|
|
8 |
medical and surgical |
|
|
|
9 |
services and supplies, |
|
|
|
10 |
physical and speech |
|
|
|
11 |
therapy, diagnostic |
|
|
|
12 |
tests, durable medical |
|
|
|
13 |
equipment, |
|
|
|
14 |
First |
|
|
|
15 |
Medicare Approved |
$0 |
|
$0 |
16 |
Amounts* |
|
(Part B |
|
17 |
|
|
Deductible) |
|
18 |
Remainder of Medicare |
|
|
|
19 |
Approved Amounts |
80% |
20% |
$0 |
20 |
Part B Excess Charges |
|
|
|
21 |
(Above Medicare |
|
|
|
22 |
Approved Amounts) |
$0 |
$0 |
All Costs |
23 |
BLOOD |
|
|
|
24 |
First 3 pints |
$0 |
All Costs |
$0 |
25 |
Next
|
|
|
|
26 |
Approved Amounts* |
$0 |
|
$0 |
27 |
|
|
(Part B |
|
28 |
|
|
Deductible) |
|
29 |
Remainder of Medicare |
|
|
|
1 |
Approved Amounts |
80% |
20% |
$0 |
2 |
CLINICAL LABORATORY |
|
|
|
3 |
SERVICES— |
|
|
|
4 |
Tests for |
|
|
|
5 |
diagnostic services |
100% |
$0 |
$0 |
6 |
PARTS A & B |
7 |
HOME HEALTH CARE |
|
|
|
8 |
Medicare Approved |
|
|
|
9 |
Services |
|
|
|
10 |
—Medically necessary |
|
|
|
11 |
skilled care services |
|
|
|
12 |
and medical supplies |
100% |
$0 |
$0 |
13 |
—Durable medical |
|
|
|
14 |
equipment |
|
|
|
15 |
First |
|
|
|
16 |
Medicare Approved |
$0 |
|
$0 |
17 |
Amounts* |
|
(Part B |
|
18 |
|
|
Deductible) |
|
19 |
Remainder of Medicare |
|
|
|
20 |
Approved Amounts |
80% |
20% |
$0 |
21 |
OTHER BENEFITS—NOT COVERED BY MEDICARE |
22 |
FOREIGN TRAVEL— |
|
|
|
1 |
Not covered by Medicare |
|
|
|
2 |
Medically necessary |
|
|
|
3 |
emergency care services |
|
|
|
4 |
beginning during the |
|
|
|
5 |
first 60 days of each |
|
|
|
6 |
trip outside the USA |
|
|
|
7 |
First $250 each |
|
|
|
8 |
calendar year |
$0 |
$0 |
$250 |
9 |
Remainder of charges |
$0 |
80% to a |
20% and |
10 |
|
|
lifetime |
amounts |
11 |
|
|
maximum |
over the |
12 |
|
|
benefit |
$50,000 |
13 |
|
|
of $50,000 |
lifetime |
14 |
|
|
|
maximum |
15 |
PLAN D |
16 |
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD |
17 *A benefit period begins on the first day you receive
18 service as an inpatient in a hospital and ends after you have
19 been out of the hospital and have not received skilled care in
20 any other facility for 60 days in a row.
21 |
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
22 |
HOSPITALIZATION* |
|
|
|
23 |
Semiprivate room and |
|
|
|
24 |
board, general nursing |
|
|
|
25 |
and miscellaneous |
|
|
|
1 |
services and supplies |
|
|
|
2 |
First 60 days |
All but |
|
$0 |
3 |
|
|
(Part A |
|
4 |
|
|
Deductible) |
|
5 |
61st thru 90th day |
All but |
|
$0 |
6 |
|
|
a day |
|
7 |
91st day and after |
|
|
|
8 |
—While using 60 |
|
|
|
9 |
lifetime reserve days |
All but |
|
$0 |
10 |
|
|
a day |
|
11 |
—Once lifetime reserve |
|
|
|
12 |
days are used: |
|
|
|
13 |
—Additional 365 days |
$0 |
100% of |
$0** |
14 |
|
|
Medicare |
|
15 |
|
|
Eligible |
|
16 |
|
|
Expenses |
|
17 |
—Beyond the |
|
|
|
18 |
Additional 365 days |
$0 |
$0 |
All Costs |
19 |
SKILLED NURSING FACILITY |
|
|
|
20 |
CARE* |
|
|
|
21 |
You must meet Medicare's |
|
|
|
22 |
requirements, including |
|
|
|
23 |
having been in a hospital |
|
|
|
24 |
for at least 3 days and |
|
|
|
25 |
entered a Medicare- |
|
|
|
26 |
approved facility within |
|
|
|
27 |
30 days after leaving the |
|
|
|
28 |
hospital |
|
|
|
29 |
First 20 days |
All approved |
|
|
1 |
|
amounts |
$0 |
$0 |
2 |
21st thru 100th day |
All but |
Up to |
$0 |
3 |
|
|
|
|
4 |
|
a day |
a day |
|
5 |
101st day and after |
$0 |
$0 |
All costs |
6 |
BLOOD |
|
|
|
7 |
First 3 pints |
$0 |
3 pints |
$0 |
8 |
Additional amounts |
100% |
$0 |
$0 |
9 |
HOSPICE CARE |
|
|
|
10 |
|
All but very |
Medicare |
$0 |
11 |
|
limited |
copayment/ |
|
12 |
|
copayment/ |
coinsurance |
|
13 |
|
coinsurance |
|
|
14 |
You must meet |
for outpatient |
|
|
15 |
Medicare's requirements, |
drugs and |
|
|
16 |
including a doctor's |
inpatient |
|
|
17 |
certification of |
respite care |
|
|
18 |
terminal illness |
|
|
|
19 **NOTICE: When your Medicare Part A hospital benefits are
20 exhausted, the insurer stands in the place of Medicare and will
21 pay whatever amount Medicare would have paid for up to an
22 additional 365 days as provided in the policy's "Core Benefits."
23 During this time the hospital is prohibited from billing you for
24 the balance based on any difference between its billed charges
25 and the amount Medicare would have paid.
26 |
PLAN D |
27 |
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR |
1 *Once you have been billed $131 $183 of
Medicare-Approved
2 amounts for covered services (which are noted with an asterisk),
3 your Part B Deductible will have been met for the calendar year.
4 |
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
5 |
MEDICAL EXPENSES— |
|
|
|
6 |
In or out of the hospital |
|
|
|
7 |
and outpatient hospital |
|
|
|
8 |
treatment, such as |
|
|
|
9 |
Physician's services, |
|
|
|
10 |
inpatient and outpatient |
|
|
|
11 |
medical and surgical |
|
|
|
12 |
services and supplies, |
|
|
|
13 |
physical and speech |
|
|
|
14 |
therapy, diagnostic |
|
|
|
15 |
tests, durable medical |
|
|
|
16 |
equipment, |
|
|
|
17 |
First |
|
|
|
18 |
Medicare Approved |
$0 |
$0 |
|
19 |
Amounts* |
|
|
(Part B |
20 |
|
|
|
Deductible) |
21 |
Remainder of Medicare |
|
|
|
22 |
Approved Amounts |
80% |
20% |
$0 |
23 |
Part B Excess Charges |
|
|
|
24 |
(Above Medicare |
|
|
|
25 |
Approved Amounts) |
$0 |
$0 |
All Costs |
26 |
BLOOD |
|
|
|
27 |
First 3 pints |
$0 |
All Costs |
$0 |
1 |
Next
|
|
|
|
2 |
Approved Amounts* |
$0 |
$0 |
|
3 |
|
|
|
(Part B |
4 |
|
|
|
Deductible) |
5 |
Remainder of Medicare |
|
|
|
6 |
Approved Amounts |
80% |
20% |
$0 |
7 |
CLINICAL LABORATORY |
|
|
|
8 |
SERVICES— |
|
|
|
9 |
Tests for |
|
|
|
10 |
diagnostic services |
100% |
$0 |
$0 |
11 |
PARTS A & B |
12 |
HOME HEALTH CARE |
|
|
|
13 |
Medicare Approved |
|
|
|
14 |
Services |
|
|
|
15 |
—Medically necessary |
|
|
|
16 |
skilled care services |
|
|
|
17 |
and medical supplies |
100% |
$0 |
$0 |
18 |
—Durable medical |
|
|
|
19 |
equipment |
|
|
|
20 |
First |
|
|
|
21 |
Medicare Approved |
$0 |
$0 |
|
22 |
Amounts* |
|
|
(Part B |
23 |
|
|
|
Deductible) |
24 |
Remainder of Medicare |
|
|
|
25 |
Approved Amounts |
80% |
20% |
$0 |
1 |
OTHER BENEFITS—NOT COVERED BY MEDICARE |
2 |
FOREIGN TRAVEL— |
|
|
|
3 |
Not covered by Medicare |
|
|
|
4 |
Medically necessary |
|
|
|
5 |
emergency care services |
|
|
|
6 |
beginning during the |
|
|
|
7 |
first 60 days of each |
|
|
|
8 |
trip outside the USA |
|
|
|
9 |
First $250 each |
|
|
|
10 |
calendar year |
$0 |
$0 |
$250 |
11 |
Remainder of charges |
$0 |
80% to a |
20% and |
12 |
|
|
lifetime |
amounts |
13 |
|
|
maximum |
over the |
14 |
|
|
benefit |
$50,000 |
15 |
|
|
of $50,000 |
lifetime |
16 |
|
|
|
maximum |
17 |
PLAN F OR |
18 |
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD |
19 *A benefit period begins on the first day you receive
20 service as an inpatient in a hospital and ends after you have
21 been out of the hospital and have not received skilled care in
22 any other facility for 60 days in a row.
23 **This high deductible high-deductible plan pays
the same
24 benefits as plan F after you have paid a calendar year ($1,860)
1
$2,240 deductible. Benefits from the high
deductible high-
2 deductible plan F will not begin until out-of-pocket expenses are
3 $1,860. $2,240. Out-of-pocket expenses for this deductible are
4 expenses that would ordinarily be paid by the policy. This
5 includes medicare Medicare
deductibles for part A and part B, but
6 does not include the plan's separate foreign travel emergency
7 deductible.
8 |
SERVICES |
MEDICARE |
AFTER YOU |
IN ADDITION |
9 |
|
PAYS |
PAY |
TO |
10 |
|
|
|
|
11 |
|
|
DEDUCTIBLE**, |
DEDUCTIBLE**, |
12 |
|
|
PLAN PAYS |
YOU PAY |
13 |
HOSPITALIZATION* |
|
|
|
14 |
Semiprivate room and |
|
|
|
15 |
board, general nursing |
|
|
|
16 |
and miscellaneous |
|
|
|
17 |
services and supplies |
|
|
|
18 |
First 60 days |
All but |
|
$0 |
19 |
|
|
(Part A |
|
20 |
|
|
Deductible) |
|
21 |
61st thru 90th day |
All but |
|
$0 |
22 |
|
|
a day |
|
23 |
|
a day |
|
|
24 |
91st day and after |
|
|
|
25 |
—While using 60 |
|
|
|
26 |
lifetime reserve days |
All but |
|
$0 |
27 |
|
|
a day |
|
28 |
|
a day |
|
|
1 |
—Once lifetime reserve |
|
|
|
2 |
days are used: |
|
|
|
3 |
—Additional 365 days |
$0 |
100% of |
$0*** |
4 |
|
|
Medicare |
|
5 |
|
|
Eligible |
|
6 |
|
|
Expenses |
|
7 |
—Beyond the |
|
|
|
8 |
Additional 365 days |
$0 |
$0 |
All Costs |
9 |
SKILLED NURSING FACILITY |
|
|
|
10 |
CARE* |
|
|
|
11 |
You must meet Medicare's |
|
|
|
12 |
requirements, including |
|
|
|
13 |
having been in a |
|
|
|
14 |
hospital for at least |
|
|
|
15 |
3 days and entered a |
|
|
|
16 |
Medicare-approved |
|
|
|
17 |
facility within 30 days |
|
|
|
18 |
after leaving the |
|
|
|
19 |
hospital |
|
|
|
20 |
First 20 days |
All approved |
|
|
21 |
|
amounts |
$0 |
$0 |
22 |
21st thru 100th day |
All but |
Up to |
$0 |
23 |
|
|
|
|
24 |
|
a day |
a day |
|
25 |
101st day and after |
$0 |
$0 |
All costs |
26 |
BLOOD |
|
|
|
27 |
First 3 pints |
$0 |
3 pints |
$0 |
28 |
Additional amounts |
100% |
$0 |
$0 |
29 |
HOSPICE CARE |
|
|
|
1 |
|
All but very |
Medicare |
$0 |
2 |
|
limited |
copayment/ |
|
3 |
|
copayment/ |
coinsurance |
|
4 |
|
coinsurance |
|
|
5 |
You must |
for |
|
|
6 |
meet Medicare's |
outpatient |
|
|
7 |
requirements, including |
drugs and |
|
|
8 |
a doctor's certification |
inpatient |
|
|
9 |
of terminal illness |
respite care |
|
|
10 ***NOTICE: When your Medicare Part A hospital benefits are
11 exhausted, the insurer stands in the place of Medicare and will
12 pay whatever amount Medicare would have paid for up to an
13 additional 365 days as provided in the policy's "Core Benefits."
14 During this time the hospital is prohibited from billing you for
15 the balance based on any difference between its billed charges
16 and the amount Medicare would have paid.
17 |
PLAN F |
18 |
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR |
19 *Once you have been billed $131 $183 of
Medicare-Approved
20 amounts for covered services (which are noted with an asterisk),
21 your Part B Deductible will have been met for the calendar year.
22 **This high deductible high-deductible plan pays
the same
23 benefits as plan F after you have paid a calendar year ($1,860)
24
$2,240 deductible. Benefits from the high
deductible high-
25 deductible plan F will not begin until out-of-pocket expenses are
26 $1,860. $2,240. Out-of-pocket expenses for this deductible are
1 expenses that would ordinarily be paid by the policy. This
2 includes medicare Medicare
deductibles for part A and part B, but
3 does not include the plan's separate foreign travel emergency
4 deductible.
5 |
SERVICES |
MEDICARE |
AFTER YOU |
IN ADDITION |
6 |
|
PAYS |
PAY |
TO |
7 |
|
|
|
|
8 |
|
|
DEDUCTIBLE**, |
DEDUCTIBLE**, |
9 |
|
|
PLAN PAYS |
YOU PAY |
10 |
MEDICAL EXPENSES— |
|
|
|
11 |
In or out of the hospital |
|
|
|
12 |
and outpatient hospital |
|
|
|
13 |
treatment, such as |
|
|
|
14 |
Physician's services, |
|
|
|
15 |
inpatient and outpatient |
|
|
|
16 |
medical and surgical |
|
|
|
17 |
services and supplies, |
|
|
|
18 |
physical and speech |
|
|
|
19 |
therapy, diagnostic |
|
|
|
20 |
tests, durable medical |
|
|
|
21 |
equipment, |
|
|
|
22 |
First |
|
|
|
23 |
Medicare Approved |
$0 |
|