October 4, 2018, Introduced by Rep. Vaupel and referred to the Committee on Health Policy.
A bill to amend 1956 PA 218, entitled
"The insurance code of 1956,"
by amending sections 3801, 3803, 3807a, 3809, 3809a, 3811a, 3813,
3815, 3819a, 3827, 3829, 3831, 3835, 3839, 3843, and 3847 (MCL
500.3801, 500.3803, 500.3807a, 500.3809, 500.3809a, 500.3811a,
500.3813, 500.3815, 500.3819a, 500.3827, 500.3829, 500.3831,
500.3835, 500.3839, 500.3843, and 500.3847), sections 3801, 3803,
3809, 3815, 3831, and 3839 as amended and sections 3807a, 3809a,
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. 3801. As used in this chapter:
2 (a) "Applicant" means:
3 (i) For an
individual medicare Medicare
supplement policy,
4 the person who seeks to contract for benefits.
5 (ii) For a group
medicare Medicare supplement policy or
6 certificate, the proposed certificate holder.
7 (b) "Bankruptcy" means, when with respect to a medicare
8 Medicare advantage organization that is not an insurer, that the
9 organization has filed, or has had filed against it, a petition
10 for declaration of bankruptcy and has ceased doing business in
11 this state.
12 (c) "Certificate" means any certificate delivered or issued
13 for delivery in this state under a group medicare Medicare
14 supplement policy.
15 (d) "Certificate form" means the form on which the a
16 certificate is delivered or issued for delivery by the an
17 insurer.
18 (e) "Continuous period of creditable coverage" means the
19 period during which an individual was covered by creditable
20 coverage, if during the period of the coverage the individual had
21 no breaks in coverage greater than 63 days.
22 (f) "Creditable coverage" means coverage of an individual
23 provided under any of the following:
24 (i) A group health plan.
25 (ii) Health insurance coverage.
26 (iii) Part A or
part B of medicare.Medicare.
27 (iv) Medicaid other than coverage consisting solely of
1 benefits under section 1928 of medicaid, 42 USC 1396s.
2 (v) Chapter 55 of title 10 of the United States Code, 10 USC
3 1071 to 1110.1110b.
4 (vi) A medical
care program of the Indian health service
5 Health Service or of a tribal organization.
6 (vii) A state health benefits risk pool.
7 (viii) A health plan offered under chapter 89 of title 5 of
8 the United States Code, 5 USC 8901 to 8914.
9 (ix) A public health plan as defined in federal regulation.
10 (x) Health care
under section 5(e) of title I of the peace
11 corps act, 22 USC 2504.2504(e).
12 (g) "Direct response solicitation" means solicitation in
13 which an insurer representative does not contact the applicant in
14 person and explain the coverage available, such as, but not
15 limited to, solicitation through direct mail or through
16 advertisements in periodicals and other media.
17 (h) "Employee welfare benefit plan" means a plan, fund, or
18 program of employee benefits as defined in section 3 of subtitle
19 A of title I of the employee retirement income security act of
20 1974, 29 USC 1002.
21 (i) "Insolvency" means, when with respect to an insurer
22 licensed to transact the business of insurance in this state,
23 that the insurer has had a final order of liquidation entered
24 against it with a finding of insolvency by a court of competent
25 jurisdiction in the insurer's state of domicile.
26 (j) "Insurer" includes any entity, including a
health care
27 corporation operating pursuant to the nonprofit health care
1 corporation reform act, 1980 PA 350, MCL 550.1101 to 550.1704,
2 delivering person
that delivers or issuing issues for
delivery in
3 this state medicare Medicare
supplement policies.
4 (k) "Medicaid" means title subchapter XIX of the social
5 security act, 42 USC 1396 to 1396v.1396w-5.
6 (l)
"Medicare" means title subchapter XVIII of the
social
7 security act, 42 USC 1395 to 1395hhh.1395lll.
8 (m) "Medicare advantage" means a plan of coverage for health
9 benefits under medicare Medicare
part C as defined described in
10 section 12-2859 of part C of medicare, 42 USC 1395w-28, and
11 includes any of the following:
12 (i) Coordinated care plans that provide health care services,
13 including, but not limited to, health maintenance organization
14 plans with or without a point-of-service option, plans offered by
15 provider-sponsored organizations, and preferred provider
16 organization plans.
17 (ii) Medical savings account plans coupled with a
18 contribution into a medicare Medicare advantage medical
savings
19 account.
20 (iii) Medicare advantage private fee-for-service plans.
21 (n) "Medicare supplement buyer's guide" means the document
22 entitled, "guide to health insurance for people with
medicare",
23 "Choosing a Medigap Policy: A Guide to Health Insurance for
24
People with Medicare", developed
by the national association of
25 insurance commissioners National
Association of Insurance
26
Commissioners and the United States department
of health and
27 human services Department
of Health and Human Services, or a
1 substantially similar document as approved by the
2 commissioner.director.
3 (o) "Medicare supplement policy" means an individual ,
4 nongroup, or group policy
or certificate that is advertised,
5 marketed, or designed primarily as a supplement to reimbursements
6 under medicare Medicare
for the hospital, medical, or surgical
7 expenses of persons eligible for medicare Medicare and
medicare
8 Medicare select policies and certificates under section 3817.
9 Medicare supplement policy does not include a policy,
10 certificate, or contract of 1 or more employers or labor
11 organizations, or of the trustees of a fund established by 1 or
12 more employers or labor organizations, or both, for employees or
13 former employees, or both, or for members or former members, or
14 both, of the labor organizations. Medicare supplement policy does
15 not include medicare Medicare
advantage plans established under
16 medicare Medicare part C, outpatient prescription drug plans
17 established under medicare Medicare part D, or any
health care
18 prepayment plan that provides benefits pursuant to an agreement
19 under section 1833(a)(1)(A) of the social security act.42 USC
20 1395l(a)(1).
21 (p) "PACE" means a program of all-inclusive care for the
22 elderly as described in the social security act.
23 (q) "Prestandardized medicare Medicare supplement
benefit
24 plan", "prestandardized benefit plan", or "prestandardized plan"
25 means a group or individual policy of medicare Medicare
26 supplement insurance issued prior to before June
2, 1992.
27 (r) "1990 standardized medicare Medicare supplement
benefit
1 plan", "1990 standardized benefit plan", or "1990 plan" means a
2 group or individual policy of medicare Medicare supplement
3 insurance issued on or after June 2, 1992 with an effective date
4 for coverage prior to before
June 1, 2010 and includes medicare
5 Medicare supplement insurance policies and certificates renewed
6 on or after that date which that are not replaced by the
issuer
7 at the request of the insured.
8 (s) "2010 standardized medicare Medicare supplement
benefit
9 plan", "2010 standardized benefit plan", or "2010 plan" means a
10 group or individual policy of medicare Medicare supplement
11 insurance with an effective date for coverage on or after June 1,
12 2010.
13 (t) "Policy form" means the form on which the policy or
14 certificate is delivered or issued for delivery by the insurer.
15 (u) "Secretary" means the secretary of the United States
16 department of health and human services.Department of Health and
17 Human Services.
18 (v) "Social security act" means the social security act, 42
19 USC 301 to 1397jj.1397mm.
20 Sec. 3803. (1) Except as provided in subsections (2) and
21 (3), this chapter applies to a medicare Medicare supplement
22 policy delivered, issued for delivery, or renewed in this state.
23 (2) Sections 3807, 3809, 3811, and 3819 apply to a medicare
24 Medicare supplement policy delivered or issued for delivery in
25 this state on or after June 2, 1992 with an effective date for
26 coverage prior to before
June 1, 2010.
27 (3) Sections 3807a, 3809a, 3811a, and 3819a apply to a
1 medicare Medicare supplement policy delivered or issued for
2 delivery in this state with an effective date for coverage on or
3 after June 1, 2010.
4 Sec. 3807a. (1) This section applies to all medicare
5 Medicare supplement policies or certificates delivered or issued
6 for delivery with an effective date for coverage on or after June
7 1, 2010. A policy or certificate shall must not
be advertised,
8 solicited, delivered, or issued for delivery in this state as a
9 medicare Medicare supplement policy or certificate unless it
10 complies with these benefit standards. An issuer shall not offer
11 any 1990 plan for sale on or after June 1, 2010. Benefit
12 standards applicable to medicare Medicare supplement policies
and
13 certificates issued before June 1, 2010 remain subject to the
14 requirements of section 3807.
15 (2) Every insurer issuing a medicare Medicare supplement
16 insurance policy in this state shall make available a medicare
17 Medicare supplement insurance policy that includes a basic core
18 package of benefits to each prospective insured. An insurer
19 issuing a medicare Medicare
supplement insurance policy in this
20 state may make available to prospective insureds benefits
21 pursuant to under section 3809a that are in addition to, but not
22 instead of, the basic core package. The basic core package of
23 benefits shall must
include all of the following:
24 (a) Coverage of part A medicare eligible Medicare-eligible
25 expenses for hospitalization to the extent not covered by
26 medicare Medicare from the sixty-first day through the ninetieth
27 day in any medicare Medicare
benefit period.
1 (b) Coverage of part A medicare eligible Medicare-eligible
2 expenses incurred for hospitalization to the extent not covered
3 by medicare Medicare
for each medicare Medicare lifetime
4 inpatient reserve day used.
5 (c) Upon exhaustion of the medicare Medicare hospital
6 inpatient coverage including the lifetime reserve days, coverage
7 of 100% of the medicare Medicare
part A eligible expenses for
8 hospitalization paid at the applicable prospective payment system
9 rate or other appropriate medicare Medicare standard
of payment,
10 subject to a lifetime maximum benefit of an additional 365 days.
11 The provider shall accept the insurer's payment as payment in
12 full and may not bill the insured for any balance.
13 (d) Coverage under medicare Medicare parts A and B for
the
14 reasonable cost of the first 3 pints of blood or equivalent
15 quantities of packed red blood cells, as defined under federal
16 regulations unless replaced in accordance with federal
17 regulations.
18 (e) Coverage for the coinsurance amount, or the copayment
19 amount paid for hospital outpatient department services under a
20 prospective payment system, of medicare eligible Medicare-
21 eligible expenses under part B regardless of hospital
22 confinement, subject to the medicare Medicare part
B deductible.
23 (f) Coverage of cost sharing for all part A medicare
24 eligible Medicare-eligible
hospice care and respite care
25 expenses.
26 Sec. 3809. (1) In addition to the basic core package of
27 benefits required under section 3807, the following benefits may
1 be included in a medicare Medicare supplement
insurance policy
2 and if included shall must
conform to section 3811(5)(b) to (j):
3 (a) Medicare part A deductible: coverage for all of the
4 medicare Medicare part A inpatient hospital deductible amount per
5 benefit period.
6 (b) Skilled nursing facility care: coverage for the actual
7 billed charges up to the coinsurance amount from the 21st day
8 through the 100th day in a medicare Medicare benefit
period for
9 posthospital skilled nursing facility care eligible under
10 medicare Medicare part A.
11 (c) Medicare part B deductible: coverage for all of the
12 medicare Medicare part B deductible amount per calendar year
13 regardless of hospital confinement.
14 (d) Eighty percent of the medicare Medicare part
B excess
15 charges: coverage for 80% of the difference between the actual
16 medicare Medicare part B charge as billed, not to exceed any
17 charge limitation established by medicare Medicare or
state law,
18 and the medicare-approved Medicare-approved part B
charge.
19 (e) One hundred percent of the medicare Medicare part
B
20 excess charges: coverage for all of the difference between the
21 actual medicare Medicare
part B charge as billed, not to exceed
22 any charge limitation established by medicare Medicare or
state
23 law, and the medicare-approved Medicare-approved part B
charge.
24 (f) Basic outpatient prescription drug benefit: coverage for
25 50% of outpatient prescription drug charges, after a $250.00
26 calendar year deductible, to a maximum of $1,250.00 in benefits
27 received by the insured per calendar year, to the extent not
1 covered by medicare. Medicare.
The outpatient prescription drug
2 benefit may be included for sale or issuance in a medicare
3 Medicare supplement policy until January 1, 2006.
4 (g) Extended outpatient prescription drug benefit: coverage
5 for 50% of outpatient prescription drug charges, after a $250.00
6 calendar year deductible, to a maximum of $3,000.00 in benefits
7 received by the insured per calendar year, to the extent not
8 covered by medicare. Medicare.
The outpatient prescription drug
9 benefit may be included for sale or issuance in a medicare
10 Medicare supplement policy until January 1, 2006.
11 (h) Medically necessary emergency care in a foreign country:
12 coverage to the extent not covered by medicare Medicare for
80%
13 of the billed charges for medicare-eligible Medicare-eligible
14 expenses for medically necessary emergency hospital, physician,
15 and medical care received in a foreign country, which care would
16 have been covered by medicare Medicare if provided in the
United
17 States and which care began during the first 60 consecutive days
18 of each trip outside the United States, subject to a calendar
19 year deductible of $250.00, and a lifetime maximum benefit of
20 $50,000.00. For purposes of this benefit, "emergency care" means
21 care needed immediately because of an injury or an illness of
22 sudden and unexpected onset.
23 (i) Preventive medical care benefit: Coverage for the
24 following preventive health services not covered by
25 medicare:Medicare:
26 (i) An annual clinical preventive medical history and
27 physical examination that may include tests and services from
1 subparagraph (ii) and patient education to address preventive
2 health care measures.
3 (ii) Preventive screening tests or preventive services, the
4 selection and frequency of which is determined to be medically
5 appropriate by the attending physician.
6 (j) At-home recovery benefit: coverage for services to
7 provide short term, at-home assistance with activities of daily
8 living for those recovering from an illness, injury, or surgery.
9 At-home recovery services provided shall must be
primarily
10 services that assist in activities of daily living. The insured's
11 attending physician shall must certify that the
specific type and
12 frequency of at-home recovery services are necessary because of a
13 condition for which a home care plan of treatment was approved by
14 medicare. Medicare. Coverage is excluded for home care visits
15 paid for by medicare Medicare
or other government programs and
16 care provided by family members, unpaid volunteers, or providers
17 who are not care providers. Coverage is limited to:
18 (i) No more than the number of at-home recovery visits
19 certified as necessary by the insured's attending physician. The
20 total number of at-home recovery visits shall must not
exceed the
21 number of medicare Medicare
approved home health care visits
22 under a medicare Medicare
approved home care plan of treatment.
23 (ii) The actual charges for each visit up to a maximum
24 reimbursement of $40.00 per visit.
25 (iii) One thousand six hundred dollars per calendar year.
26 (iv) Seven visits in any 1 week.
27 (v) Care furnished on a visiting basis in the insured's
1 home.
2 (vi) Services provided by a care provider as defined in this
3 section.
4 (vii) At-home recovery visits while the insured is covered
5 under the insurance policy and not otherwise excluded.
6 (viii) At-home recovery visits received during the period the
7 insured is receiving medicare Medicare approved home care
8 services or no more than 8 weeks after the service date of the
9 last medicare Medicare
approved home health care visit.
10 (k) New or innovative benefits: an insurer may, with the
11 prior approval of the commissioner, director, offer policies or
12 certificates with new or innovative benefits in addition to the
13 benefits provided in a policy or certificate that otherwise
14 complies with the applicable standards. The new or innovative
15 benefits may include benefits that are appropriate to medicare
16 Medicare supplement insurance, new or innovative, not otherwise
17 available, cost-effective, and offered in a manner that is
18 consistent with the goal of simplification of medicare Medicare
19 supplement policies. After December 31, 2005, the innovative
20 benefit shall must
not include an outpatient prescription
drug
21 benefit.
22 (2) Reimbursement for the preventive screening tests and
23 services under subsection (1)(i)(ii) shall must be for the actual
24 charges up to 100% of the medicare-approved Medicare-approved
25 amount for each test or service, as if medicare Medicare were
to
26 cover the test or service as identified in the American medical
27 association Medical
Association current procedural
terminology
1 codes, to a maximum of $120.00 annually under this benefit. This
2 benefit shall does
not include payment for any procedure
covered
3 by medicare.Medicare.
4 (3) As used in subsection (1)(j):
5 (a) "Activities of daily living" include, but are not
6 limited to, bathing, dressing, personal hygiene, transferring,
7 eating, ambulating, assistance with drugs that are normally self-
8 administered, and changing bandages or other dressings.
9 (b) "Care provider" means a duly qualified or licensed home
10 health aide/homemaker, personal care aide, or nurse provided
11 through a licensed home health care agency or referred by a
12 licensed referral agency or licensed nurses registry.
13 (c) "Home" means any place used by the insured as a place of
14 residence, provided that if it qualifies as a
residence for home
15 health care services covered by medicare. Medicare. A hospital or
16 skilled nursing facility shall is not be considered
the insured's
17 home.
18 (d) "At-home recovery visit" means the period of a visit
19 required to provide at-home recovery care, without limit on the
20 duration of the visit, except each consecutive 4 hours in a 24-
21 hour period of services provided by a care provider is 1 visit.
22 (4) This section applies to medicare Medicare supplement
23 policies or certificates delivered or issued for delivery on or
24 after June 2, 1992 with an effective date for coverage prior to
25 before June 1, 2010.
26 Sec. 3809a. (1) This section applies to all medicare
27 Medicare supplement policies or certificates delivered or issued
1 for delivery with an effective date for coverage on or after June
2 1, 2010.
3 (2) In addition to the basic core package of benefits
4 required under section 3807a, the following benefits may be
5 included in a medicare Medicare
supplement insurance policy and
6 if included shall must
conform to section 3811a(6)(b) to
7 (j):3811a(7)(b) to
(j):
8 (a) Medicare part A deductible: coverage for 100% of the
9 medicare Medicare part A inpatient hospital deductible amount per
10 benefit period.
11 (b) Medicare part A deductible: coverage for 50% of the
12 medicare Medicare part A inpatient hospital deductible amount per
13 benefit period.
14 (c) Skilled nursing facility care: coverage for the actual
15 billed charges up to the coinsurance amount from the twenty-first
16 day through the one hundredth day in a medicare Medicare benefit
17 period for posthospital skilled nursing facility care eligible
18 under medicare Medicare
part A.
19 (d) Medicare part B deductible: coverage for 100% of the
20 medicare Medicare part B deductible amount per calendar year
21 regardless of hospital confinement.
22 (e) One hundred percent of the medicare Medicare part
B
23 excess charges: coverage for all of the difference between the
24 actual medicare Medicare
part B charge as billed, not to exceed
25 any charge limitation established by medicare Medicare or
state
26 law, and the medicare-approved Medicare-approved part B charge.
27 (f) Medically necessary emergency care in a foreign country:
1 coverage to the extent not covered by medicare Medicare for
80%
2 of the billed charges for medicare-eligible Medicare-eligible
3 expenses for medically necessary emergency hospital, physician,
4 and medical care received in a foreign country, which care would
5 have been covered by medicare Medicare if provided in the
United
6 States and which care began during the first 60 consecutive days
7 of each trip outside the United States, subject to a calendar
8 year deductible of $250.00, and a lifetime maximum benefit of
9 $50,000.00. For purposes of this benefit, "emergency care" means
10 care needed immediately because of an injury or an illness of
11 sudden and unexpected onset.
12 Sec. 3811a. (1) This section applies to all medicare
13 Medicare supplement policies or certificates delivered or issued
14 for delivery with an effective date for coverage on or after June
15 1, 2010. A policy or certificate shall must not
be advertised,
16 solicited, delivered, or issued for delivery in this state as a
17 medicare Medicare supplement policy or certificate unless it
18 complies with these benefit standards. Benefit plan standards
19 applicable to medicare Medicare
supplement policies and
20 certificates issued before June 1, 2010 remain subject to the
21 requirements of section 3811.
22 (2) An insurer shall make available to each prospective
23 medicare Medicare supplement policyholder and certificate holder
24 a policy form or certificate form containing only the basic core
25 benefits as provided in section 3807a. If an insurer makes
26 available any of the additional benefits described in section
27 3809a or offers standardized benefit plans K or L, the insurer
1 shall make available to each prospective medicare Medicare
2 supplement policyholder and certificate holder a policy form or
3 certificate form containing either standardized benefit plan C or
4 standardized benefit plan F.
5 (3) Beginning January 1, 2020, an insurer is no longer
6 required to offer standardized benefit plan C or standardized
7 benefit plan F. If an insurer makes available any of the
8 additional benefits described in section 3809a, the insurer shall
9 make available to each prospective Medicare supplement
10 policyholder and certificate holder a policy form or certificate
11 form that contains either standardized benefit plan D or
12 standardized benefit plan G.
13 (4) (3) Groups,
packages, or combinations of medicare
14 Medicare supplement benefits other than those listed in this
15 section shall must
not be offered for sale in this state
except
16 as may be permitted in subsection (6)(k).(7)(k).
17 (5) (4) Benefit
plans shall must be uniform in structure,
18 language, designation, and format to the standard benefit plans
19 in subsection (6) (7)
and shall must conform
to the definitions
20 in this chapter. Each benefit shall must be
structured in
21 accordance with sections 3807a and 3809a and list the benefits in
22 the order shown in subsection (6). For purposes of (7). As used
23 in this section, "structure, language, designation, and format"
24 means style, arrangement, and overall content of a benefit.
25 (6) (5) In
addition to the benefit plan designations as
26 provided under subsection (6), (7), an insurer may use
other
27 designations to the extent permitted by law.
1 (7) (6) A medicare
Medicare supplement insurance benefit
2 plan shall must conform to 1 of the following:
3 (a) A standardized medicare Medicare supplement benefit
plan
4 A shall must be limited to the basic core benefits common to all
5 benefit plans as defined in required under section
3807a.
6 (b) A standardized medicare Medicare supplement benefit
plan
7 B shall must include only the following: the core benefits as
8 defined in required
under section 3807a and 100% of the medicare
9 Medicare part A deductible as defined in section 3809a(2)(a).
10 (c) A standardized medicare Medicare supplement benefit
plan
11 C 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 deductible,
and
15 medically necessary emergency care in a foreign country as
16 defined in section 3809a(2)(a), (c), (d), and (f). Beginning
17 January 1, 2020, the standardized benefit plans described in
18 section 3811b may be offered to any individual who was eligible
19 for Medicare before January 1, 2020.
20 (d) A standardized medicare Medicare supplement benefit
plan
21 D shall must include only the following: the core benefits as
22 defined in required
under section 3807a , and 100%
of the
23 medicare Medicare part A deductible, skilled nursing facility
24 care, and medically necessary emergency care in a foreign country
25 as defined in section 3809a(2)(a), (c), and (f). Beginning
26 January 1, 2020, the standardized benefit plans described in
27 section 3811b may be offered to any individual who was eligible
1 for Medicare before January 1, 2020.
2 (e) A standardized medicare Medicare supplement benefit
plan
3 F shall must include only the following: the core benefits as
4 defined in required
under section 3807a , and 100%
of the
5 medicare Medicare part A deductible, skilled nursing facility
6 care, 100% of the medicare Medicare part B deductible,
100% of
7 the medicare Medicare
part B excess charges, and medically
8 necessary emergency care in a foreign country as defined in
9 section 3809a(2)(a), (c), (d), (e), and (f). A standardized
10 medicare Medicare supplement plan F high deductible shall must
11 include only the following: 100% of covered expenses following
12 the payment of the annual high deductible high-deductible plan F
13 deductible. The covered expenses include the core benefits as
14 defined in required
under section 3807a ,
plus and 100% of the
15 medicare Medicare part A deductible, skilled nursing facility
16 care, 100% of the medicare Medicare part B deductible,
100% of
17 the medicare Medicare
part B excess charges, and medically
18 necessary emergency care in a foreign country as defined in
19 section 3809a(2)(a), (c), (d), (e), and (f). The annual high
20 deductible high-deductible
plan F deductible shall must consist
21 of out-of-pocket expenses, other than premiums, for services
22 covered by the medicare Medicare
supplement plan F policy, and
23 shall must be in addition to any other specific benefit
24 deductibles. The annual high deductible high-deductible plan F
25 deductible is $1,500.00 for calendar year 1999, and the secretary
26 shall adjust it annually thereafter to reflect the change in the
27 consumer price index Consumer
Price Index for all urban consumers
1 for the 12-month period ending with August of the preceding year,
2 rounded to the nearest multiple of $10.00. Beginning January 1,
3 2020, the standardized benefit plans described in section 3811b
4 may be offered to any individual who was eligible for Medicare
5 before January 1, 2020.
6 (f) A standardized medicare Medicare supplement benefit
plan
7 G shall must include only the following: the core benefits as
8 defined in required
under section 3807a , and 100%
of the
9 medicare Medicare part A deductible, skilled nursing facility
10 care, 100% of the medicare Medicare part B excess
charges, and
11 medically necessary emergency care in a foreign country as
12 defined in section 3809a(2)(a), (c), (e), and (f). Beginning
13 January 1, 2020, the standardized benefit plans described in
14 section 3811b may be offered to any individual who was eligible
15 for Medicare before January 1, 2020.
16 (g) Standardized medicare Medicare supplement benefit
plan K
17 shall must consist of the following:
18 (i) Coverage of 100% of the part A hospital coinsurance
19 amount for each day used from the sixty-first day through the
20 ninetieth day in any medicare Medicare benefit period.
21 (ii) Coverage of 100% of the part A hospital coinsurance
22 amount for each medicare Medicare lifetime inpatient
reserve day
23 used from the ninety-first day through the one hundred fiftieth
24 day in any medicare Medicare
benefit period.
25 (iii) Upon On exhaustion
of the medicare Medicare hospital
26 inpatient coverage, including the lifetime reserve days, coverage
27 of 100% of the medicare Medicare
part A eligible expenses for
1 hospitalization paid at the applicable prospective payment system
2 rate, or other appropriate medicare Medicare standard
of payment,
3 subject to a lifetime maximum benefit of an additional 365 days.
4 The provider shall accept the insurer's payment as payment in
5 full and may not bill the insured for any balance.
6 (iv) Medicare part A deductible: coverage for 50% of the
7 medicare Medicare part A inpatient hospital deductible amount per
8 benefit period until the out-of-pocket limitation is met as
9 described in subparagraph (x).
10 (v) Skilled nursing facility care: coverage for 50% of the
11 coinsurance amount for each day used from the twenty-first day
12 through the one hundredth day in a medicare Medicare benefit
13 period for posthospital skilled nursing facility care eligible
14 under medicare Medicare
part A until the out-of-pocket
limitation
15 is met as described in subparagraph (x).
16 (vi) Hospice care: coverage for 50% of cost sharing for all
17 part A medicare Medicare
eligible expenses and respite care
until
18 the out-of-pocket limitation is met as described in subparagraph
19 (x).
20 (vii) Coverage
for 50%, under medicare Medicare
part A or B,
21 of the reasonable cost of the first 3 pints of blood or
22 equivalent quantities of packed red blood cells, as defined under
23 federal regulations, unless replaced in accordance with federal
24 regulations until the out-of-pocket limitation is met as
25 described in subparagraph (x).
26 (viii) Except for coverage provided in subparagraph (ix),
27 below, coverage for 50% of
the cost sharing otherwise applicable
1 under medicare Medicare
part B after the policyholder pays the
2 part B deductible until the out-of-pocket limitation is met as
3 described in subparagraph (x).
4 (ix) Coverage of
100% of the cost sharing for medicare
5 Medicare part B preventive services after the policyholder pays
6 the part B deductible.
7 (x) Coverage of
100% of all cost sharing under medicare
8 Medicare parts A and B for the balance of the calendar year after
9 the individual has reached the out-of-pocket limitation on annual
10 expenditures under medicare Medicare parts A and B of
$4,000.00
11 in 2006, indexed each year by the appropriate inflation
12 adjustment specified by the secretary of the United States
13 department of health and human services.Department of Health and
14 Human Services.
15 (h) Standardized medicare Medicare supplement benefit
plan L
16 shall must consist of the following:
17 (i) The benefits described in subdivision (g)(i), (ii), (iii),
18 and (ix).
19 (ii) The benefits described in subdivision (g)(iv), (v), (vi),
20 (vii), and (viii), but substituting 75% for 50%.
21 (iii) The benefit described in subdivision (g)(x), but
22 substituting $2,000.00 for $4,000.00.
23 (i) A standardized medicare Medicare supplement benefit
plan
24 M shall must include only the following: the core benefits as
25 defined in required
under section 3807a and 50% of the medicare
26 Medicare part A deductible, skilled nursing care, and medically
27 necessary emergency care in a foreign country as defined in
1 section 3809a(2)(b), (c), and (f).
2 (j) A standardized medicare Medicare supplement benefit
plan
3 N shall must include only the following: the core benefits as
4 defined in required
under section 3807a , and 100%
of the
5 medicare Medicare part A deductible, skilled nursing facility
6 care, and medically necessary emergency care in a foreign country
7 as defined in section 3809a(2)(a), (c), and (f) with copayments
8 in the following amounts:
9 (i) The lesser
of $20.00 or the medicare Medicare
part B
10 coinsurance or copayment for each covered health care provider
11 office visit, including visits to medical specialists.
12 (ii) The lesser
of $50.00 or the medicare Medicare
part B
13 coinsurance or copayment for each covered emergency room visit.
14 The copayment shall must
be waived if the insured is admitted to
15 any hospital and the emergency visit is subsequently covered as a
16 medicare Medicare part A expense.
17 (k) New or innovative benefits: an insurer may, with the
18 prior approval of the commissioner, director, offer policies or
19 certificates with new or innovative benefits in addition to the
20 benefits provided in a policy or certificate that otherwise
21 complies with the applicable standards. The new or innovative
22 benefits may include benefits that are appropriate to medicare
23 Medicare supplement insurance, new or innovative, not otherwise
24 available, cost-effective, and offered in a manner that is
25 consistent with the goal of simplification of medicare Medicare
26 supplement policies. The innovative benefit shall must not
27 include an outpatient prescription drug benefit. New or
1 innovative benefits shall must not be used to change
or reduce
2 benefits, including a change of any cost-sharing provision, in
3 any standardized plan.
4 Sec. 3811b. (1) Benefit plan standards applicable to
5 Medicare supplement policies and certificates issued to
6 individuals eligible before January 1, 2020 remain subject to the
7 requirements of section 3811 or 3811a, as applicable.
8 (2) This section applies to all Medicare supplement policies
9 or certificates delivered or issued for delivery to individuals
10 newly eligible for Medicare on or after January 1, 2020 because
11 of either of the following:
12 (a) By reason of attaining age 65 on or after January 1,
13 2020.
14 (b) By reason of entitlement to benefits under part A
15 pursuant to section 226(a) or (b) of the social security act, 42
16 USC 426, or who is deemed to be eligible for benefits under
17 section 226(a) of the social security act, 42 USC 426, on or
18 after January 1, 2020.
19 (3) The standards and requirements of section 3811 or 3811a,
20 as applicable, apply to all Medicare supplement policies or
21 certificates delivered or issued for delivery to individuals
22 newly eligible for Medicare on or after January 1, 2020, with the
23 following exceptions:
24 (a) Standardized Medicare supplement benefit plan C is
25 redesignated as plan D and must provide the benefits contained in
26 section 3811(5)(c) or 3811a(7)(c), as applicable, but must not
27 provide coverage for any portion of the Medicare part B
1 deductible.
2 (b) Standardized Medicare supplement benefit plan F is
3 redesignated as plan G and must provide the benefits contained in
4 section 3811(5)(f) or 3811a(7)(e), as applicable, but must not
5 provide coverage for any portion of the Medicare part B
6 deductible.
7 (c) Standardized Medicare supplement benefit plans C, F, and
8 F with high deductible may not be offered to individuals newly
9 eligible for Medicare on or after January 1, 2020.
10 (d) Standardized Medicare supplement benefit plan F with
11 high deductible is redesignated as plan G with high deductible
12 and must provide the benefits contained in section 3811(5)(f) or
13 3811a(7)(e), as applicable, but must not provide coverage for any
14 portion of the Medicare part B deductible. However, the Medicare
15 part B deductible paid by the beneficiary must be considered an
16 out-of-pocket expense in meeting the annual high-deductible.
17 (e) The reference to plans C or F contained in section
18 3811a(2) is deemed a reference to plans D or G for purposes of
19 this section.
20 (4) A policy or certificate must not provide coverage of the
21 Medicare part B deductible and may not be advertised, solicited,
22 delivered, or issued for delivery in this state as a Medicare
23 supplement policy or certificate unless it complies with the
24 benefit standards outlined in this section.
25 (5) On or after January 1, 2020, the standardized benefit
26 plans described in this section may be offered to any individual
27 who was eligible for Medicare before January 1, 2020.
1 Sec. 3813. An insurer that issues a policy that provides
2 disability health
insurance coverage to a person eligible
for
3 medicare Medicare by reason of age shall provide the prospective
4 policyholder with a medicare Medicare supplement buyer's
guide in
5
written or electronic format, which shall
must be furnished at
6 the time of application, and the insurer shall obtain, in written
7 or electronic format, acknowledgment of receipt of the buyer's
8 guide. shall be obtained by the insurer. However, for
direct
9 response solicitation policies, the guide shall must be
furnished
10 with the policy in written or electronic format and the insurer
11
need not obtain acknowledgment of
receipt. need not be obtained
12 by the insurer. This
section does not apply to policies that
13 provide accidental death benefits for travel or other accidents,
14 or if the medical expense or indemnity payments are only
15 incidental to the accidental death benefits for travel or other
16 accidents.
17 Sec. 3815. (1) An insurer that offers a medicare Medicare
18 supplement policy shall provide to the applicant at the time of
19 application an outline of coverage in written or electronic
20 format and, except for direct response solicitation policies,
21 shall obtain an acknowledgment of receipt of the outline of
22 coverage from the applicant in written or electronic format. The
23 outline of coverage provided to applicants pursuant to under this
24 section shall must
consist of the following 4 parts:
25 (a) A cover page.
26 (b) Premium information.
27 (c) Disclosure pages.
1 (d) Charts displaying the features of each benefit plan
2 offered by the insurer.
3 (2) Insurers shall comply with any notice requirements of
4 the medicare Medicare
prescription drug, improvement, and
5 modernization act of 2003, Public Law 108-173.
6 (3) If an outline of coverage is provided at the time of
7 application and the medicare Medicare supplement policy
or
8 certificate is issued on a basis that would require revision of
9 the outline, a substitute outline of coverage properly describing
10 the policy or certificate shall must accompany the policy or
11 certificate when it is delivered and shall must contain
the
12 following statement, in no not less than 12-point type,
13 immediately above the company name:
14 |
|
NOTICE: Read this outline of coverage carefully. |
|
15 |
|
It is not identical to the outline of coverage |
|
16 |
|
provided
|
|
17 |
|
originally applied for has not been issued. |
|
18 (4) An outline of coverage under subsection (1) shall must
19 be in the language and in a written or electronic format
20 prescribed in this section and in not less than 12-point type.
21 The letter designation of the plan shall must be
shown on the
22 cover page and the plans offered by the insurer shall must be
23 prominently identified. Premium information shall must be
shown
24 on the cover page or immediately following the cover page and
25 shall must be prominently displayed. The premium and method of
1 payment mode shall must
be stated for all plans that are
offered
2 to the applicant. All possible premiums for the applicant shall
3
must be illustrated. The following
items shall must be included
4 in the outline of coverage in the order prescribed below and in
5 substantially the following form, as approved by the
6 commissioner:director:
7 |
BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD |
8 |
ON OR AFTER JUNE 1, 2010 |
9 This chart shows the benefits included in each of the
10 standard Medicare supplement plans. Every company must make Plan
11 "A" available. Some plans may not be available in your state.
12 Plans E, H, I, and J are no longer available for sale. (This
13 sentence shall must
not appear after June 1, 2011.)
14 |
BASIC BENEFITS: |
15 |
Hospitalization: Part A coinsurance plus coverage for 365 |
16 |
additional days after Medicare benefits end. |
17 |
Medical Expenses: Part B coinsurance (generally 20% of |
18 |
Medicare-approved expenses) or copayments for hospital |
19 |
outpatient services. Plans K, L, and N require insureds |
20 |
to pay a portion of Part B coinsurance or copayments. |
21 |
Blood: First three pints of blood each year. |
22 |
Hospice: Part A coinsurance |
23 |
A |
B |
C** |
D |
F|F* ** |
G/G* |
24 |
Basic, |
Basic, |
Basic, |
Basic, |
Basic, |
Basic, |
1 |
including |
including |
including |
including |
including |
including |
2 |
100% Part |
100% Part |
100% Part |
100% Part |
100% Part |
100% Part |
3 |
B coin- |
B coinsur- |
B coinsur- |
B coinsur- |
B coinsur- |
B coinsur- |
4 |
surance |
ance |
ance |
ance |
ance |
ance |
5 |
|
|
Skilled |
Skilled |
Skilled |
Skilled |
6 |
|
|
Nursing |
Nursing |
Nursing |
Nursing |
7 |
|
|
Facility |
Facility |
Facility |
Facility |
8 |
|
|
Coinsur- |
Coinsur- |
Coinsur- |
Coinsur- |
9 |
|
|
ance |
ance |
ance |
ance |
10 |
|
Part A |
Part A |
Part A |
Part A |
Part A |
11 |
|
Deductible |
Deductible |
Deductible |
Deductible |
Deductible |
12 |
|
|
Part B |
|
Part B |
|
13 |
|
|
Deductible |
|
Deductible |
|
14 |
|
|
|
|
Part B |
Part B |
15 |
|
|
|
|
Excess |
Excess |
16 |
|
|
|
|
(100%) |
(100%) |
17 |
|
|
Foreign |
Foreign |
Foreign |
Foreign |
18 |
|
|
Travel |
Travel |
Travel |
Travel |
19 |
|
|
Emergency |
Emergency |
Emergency |
Emergency |
20
21 |
K |
L |
M |
N |
22 |
Hospitalization |
Hospitalization |
Basic, |
Basic, includ- |
23 |
and preventive |
and preventive |
including 100% |
ing 100% Part B |
24 |
care paid at |
care paid at |
Part B |
coinsurance, |
25 |
100%; other |
100%; other |
coinsurance |
except up to |
26 |
basic benefits |
basic benefits |
|
$20 copayment |
27 |
paid at 50% |
paid at 75% |
|
for office |
1 |
|
|
|
visit, and up |
2 |
|
|
|
to $50 copay- |
3 |
|
|
|
ment for ER |
4 |
50% Skilled |
75% Skilled |
Skilled |
Skilled |
5 |
Nursing |
Nursing |
Nursing |
Nursing |
6 |
Facility |
Facility |
Facility |
Facility |
7 |
Coinsurance |
Coinsurance |
Coinsurance |
Coinsurance |
8 |
50% Part A |
75% Part A |
50% Part A |
Part A |
9 |
Deductible |
Deductible |
Deductible |
Deductible |
10 |
|
|
|
|
11 |
|
|
|
|
12 |
|
|
Foreign |
Foreign |
13 |
|
|
Travel |
Travel |
14 |
|
|
Emergency |
Emergency |
15 |
Out-of-pocket |
Out-of-pocket |
|
|
16 |
limit $4,140; |
limit $2,070; |
|
|
17 |
paid at 100% |
paid at 100% |
|
|
18 |
after limit |
after limit |
|
|
19 |
reached |
reached |
|
|
20 * Plan Plans
F and G also has an option have options called
21 a high-deductible Plan F .
This and high-deductible Plan
G. These
22 high-deductible plan pays plans pay the same benefits
as Plan F
23 or Plan G, as applicable, after one has paid a calendar year
24 $1,860 $2,180 deductible. Benefits from high-deductible Plan F or
25 high-deductible Plan G will not begin until out-of-pocket
26 expenses exceed $1,860. $2,180.
Out-of-pocket expenses for this
27 deductible these
deductibles are expenses that would
ordinarily
28 be paid by the policy. These expenses include the Medicare
1 deductibles for Part A and Part B, but do not include the plan's
2 separate foreign travel emergency deductible.
3 ** Plan C, Plan F, and high-deductible Plan F are only
4 available to individuals eligible for Medicare before January 1,
5 2020.
6 |
PREMIUM INFORMATION |
7 We (insert insurer's name) can only raise your premium if we
8 raise the premium for all policies like yours in this state. (If
9 the premium is based on the increasing age of the insured,
10 include information specifying when premiums will change).
11 |
DISCLOSURES |
12 Use this outline to compare benefits and premiums among
13 policies, certificates, and contracts.
14 This outline shows benefits and premiums of policies sold
15 for effective dates on or after June 1, 2010. Policies sold for
16 effective dates prior to before June 1, 2010 have
different
17 benefits and premiums. Plans E, H, I, and J are no longer
18 available for sale. (This sentence shall must not
appear after
19 June 1, 2011.)
20 |
READ YOUR POLICY VERY CAREFULLY |
21 This is only an outline describing your policy's most
22 important features. The policy is your insurance contract. You
1 must read the policy itself to understand all of the rights and
2 duties of both you and your insurance company.
3 |
RIGHT TO RETURN POLICY |
4 If you find that you are not satisfied with your policy, you
5 may return it to (insert insurer's address). If you send the
6 policy back to us within 30 days after you receive it, we will
7 treat the policy as if it had never been issued and return all of
8 your payments.
9 |
POLICY REPLACEMENT |
10 If you are replacing another health insurance policy, do not
11 cancel it until you have actually received your new policy and
12 are sure you want to keep it.
13 |
NOTICE |
14 This policy may not fully cover all of your medical costs.
15 [For agent issued policies]
16 Neither (insert insurer's name) nor its agents are connected
17 with medicare.Medicare.
18 [For direct response issued policies]
19 (Insert insurer's name) is not connected with
20 medicare.Medicare.
21 This outline of coverage does not give all the details of
22 medicare Medicare coverage. Contact your local social security
23 office or consult "the medicare handbook" "The Medicare Handbook"
1 for more details.
2 |
COMPLETE ANSWERS ARE VERY IMPORTANT |
3 When you fill out the application for the new policy, be
4 sure to answer truthfully and completely all questions about your
5 medical and health history. The company may cancel your policy
6 and refuse to pay any claims if you leave out or falsify
7 important medical information. [If the policy or certificate is
8 guaranteed issue, this paragraph need not appear.]
9 Review the application carefully before you sign it. Be
10 certain that all information has been properly recorded.
11 [Include for each plan offered by the insurer a chart
12 showing the services, medicare Medicare payments, plan
payments,
13 and insured payments using the same language, in the same order,
14 and using uniform layout and format as shown in the charts that
15 follow. An insurer may use additional benefit plan designations
16 on these charts pursuant to under section 3809(1)(k).
Include an
17 explanation of any innovative benefits on the cover page and in
18 the chart, in a manner approved by the commissioner. director.
19 The insurer issuing the policy shall change the dollar amounts
20 each year to reflect current figures. No more than 4 plans may be
21 shown on 1 chart.] Charts for each plan are as follows:
22 |
PLAN A |
23 |
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD |
24 *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 |
$992 |
11 |
|
$992 |
|
(Part A |
12 |
|
|
|
Deductible) |
13 |
61st thru 90th day |
All but |
$248 |
$0 |
14 |
|
$248 a day |
a day |
|
15 |
91st day and after: |
|
|
|
16 |
—While using 60 |
|
|
|
17 |
lifetime reserve days |
All but |
$496 |
$0 |
18 |
|
$496 a day |
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 |
|
|
|
1 |
CARE* |
|
|
|
2 |
You must meet Medicare's |
|
|
|
3 |
requirements, including |
|
|
|
4 |
having been in a hospital |
|
|
|
5 |
for at least 3 days and |
|
|
|
6 |
entered a Medicare- |
|
|
|
7 |
approved facility within |
|
|
|
8 |
30 days after leaving the |
|
|
|
9 |
hospital |
|
|
|
10 |
First 20 days |
All approved |
|
|
11 |
|
amounts |
$0 |
$0 |
12 |
21st thru 100th day |
All but |
$0 |
Up to |
13 |
|
$124 a day |
|
$124 a day |
14 |
101st day and after |
$0 |
$0 |
All costs |
15 |
BLOOD |
|
|
|
16 |
First 3 pints |
$0 |
3 pints |
$0 |
17 |
Additional amounts |
100% |
$0 |
$0 |
18 |
HOSPICE CARE |
|
|
|
19 |
You must meet |
All but very |
|
$0 |
20 |
Medicare's requirements |
limited |
Medicare |
|
21 |
including a doctor's |
copayment/ |
copayment/ |
|
22 |
certification of terminal |
coinsurance |
coinsurance |
|
23 |
illness |
for outpatient |
|
|
24 |
|
drugs and |
|
|
25 |
|
inpatient |
|
|
26 |
|
respite care |
|
|
27 |
|
|
|
|
28 **NOTICE: When your Medicare Part A hospital benefits are
1 exhausted, the insurer stands in the place of Medicare and will
2 pay whatever amount Medicare would have paid for up to an
3 additional 365 days as provided in the policy's "Core Benefits."
4 During this time the hospital is prohibited from billing you for
5 the balance based on any difference between its billed charges
6 and the amount Medicare would have paid.
7 |
PLAN A |
8 |
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR |
9 *Once you have been billed $131 of Medicare-Approved amounts
10 for covered services (which are noted with an asterisk), your
11 Part B Deductible will have been met for the calendar year.
12 |
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
13 |
MEDICAL EXPENSES— |
|
|
|
14 |
In or out of the hospital |
|
|
|
15 |
and outpatient hospital |
|
|
|
16 |
treatment, such as |
|
|
|
17 |
Physician's services, |
|
|
|
18 |
inpatient and outpatient |
|
|
|
19 |
medical and surgical |
|
|
|
20 |
services and supplies, |
|
|
|
21 |
physical and speech |
|
|
|
22 |
therapy, diagnostic |
|
|
|
23 |
tests, durable medical |
|
|
|
24 |
equipment, |
|
|
|
25 |
First $131 of |
|
|
|
26 |
Medicare Approved |
$0 |
$0 |
$131 |
1 |
Amounts* |
|
|
(Part B |
2 |
|
|
|
Deductible) |
3 |
Remainder of Medicare |
|
|
|
4 |
Approved Amounts |
80% |
20% |
$0 |
5 |
Part B Excess Charges |
|
|
|
6 |
(Above Medicare |
|
|
|
7 |
Approved Amounts) |
$0 |
$0 |
All Costs |
8 |
BLOOD |
|
|
|
9 |
First 3 pints |
$0 |
All Costs |
$0 |
10 |
Next $131 of |
|
|
|
11 |
Medicare |
$0 |
$0 |
$131 |
12 |
Approved Amounts* |
|
|
(Part B |
13 |
|
|
|
Deductible) |
14 |
Remainder of Medicare |
|
|
|
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 $131 of |
|
|
|
4 |
Medicare |
$0 |
$0 |
$131 |
5 |
Approved Amounts* |
|
|
(Part B |
6 |
|
|
|
Deductible) |
7 |
Remainder of Medicare |
|
|
|
8 |
Approved Amounts |
80% |
20% |
$0 |
9 |
PLAN B |
10 |
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD |
11 *A benefit period begins on the first day you receive
12 service as an inpatient in a hospital and ends after you have
13 been out of the hospital and have not received skilled care in
14 any other facility for 60 days in a row.
15 |
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
16 |
HOSPITALIZATION* |
|
|
|
17 |
Semiprivate room and |
|
|
|
18 |
board, general nursing |
|
|
|
19 |
and miscellaneous |
|
|
|
20 |
services and supplies |
|
|
|
21 |
First 60 days |
All but |
$992 |
$0 |
22 |
|
$992 |
(Part A |
|
23 |
|
|
Deductible) |
|
24 |
61st thru 90th day |
All but |
$248 |
$0 |
25 |
|
$248 a day |
a day |
|
1 |
91st day and after |
|
|
|
2 |
—While using 60 |
|
|
|
3 |
lifetime reserve days |
All but |
$496 |
$0 |
4 |
|
$496 a day |
a day |
|
5 |
—Once lifetime reserve |
|
|
|
6 |
days are used: |
|
|
|
7 |
—Additional 365 days |
$0 |
100% of |
$0** |
8 |
|
|
Medicare |
|
9 |
|
|
Eligible |
|
10 |
|
|
Expenses |
|
11 |
—Beyond the |
|
|
|
12 |
Additional 365 days |
$0 |
$0 |
All Costs |
13 |
SKILLED NURSING FACILITY |
|
|
|
14 |
CARE* |
|
|
|
15 |
You must meet Medicare's |
|
|
|
16 |
requirements, including |
|
|
|
17 |
having been in a hospital |
|
|
|
18 |
for at least 3 days and |
|
|
|
19 |
entered a Medicare- |
|
|
|
20 |
approved facility within |
|
|
|
21 |
30 days after leaving the |
|
|
|
22 |
hospital |
|
|
|
23 |
First 20 days |
All approved |
|
|
24 |
|
amounts |
$0 |
$0 |
25 |
21st thru 100th day |
All but |
$0 |
Up to |
26 |
|
$124 a day |
|
$124 a day |
27 |
101st day and after |
$0 |
$0 |
All costs |
28 |
BLOOD |
|
|
|
29 |
First 3 pints |
$0 |
3 pints |
$0 |
1 |
Additional amounts |
100% |
$0 |
$0 |
2 |
HOSPICE CARE |
|
|
|
3 |
|
All but very |
|
|
4 |
|
limited |
Medicare |
$0 |
5 |
|
copayment/ |
copayment/ |
|
6 |
|
coinsurance |
coinsurance |
|
7 |
You must meet |
for outpatient |
|
|
8 |
Medicare's requirements, |
drugs and |
|
|
9 |
including a doctor's |
inpatient |
|
|
10 |
certification of |
respite care |
|
|
11 |
terminal illness |
|
|
|
12 **NOTICE: When your Medicare Part A hospital benefits are
13 exhausted, the insurer stands in the place of Medicare and will
14 pay whatever amount Medicare would have paid for up to an
15 additional 365 days as provided in the policy's "Core Benefits."
16 During this time the hospital is prohibited from billing you for
17 the balance based on any difference between its billed charges
18 and the amount Medicare would have paid.
19 |
PLAN B |
20 |
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR |
21 *Once you have been billed $131 of Medicare-Approved amounts
22 for covered services (which are noted with an asterisk), your
23 Part B Deductible will have been met for the calendar year.
24 |
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
1 |
MEDICAL EXPENSES— |
|
|
|
2 |
In or out of the hospital |
|
|
|
3 |
and outpatient hospital |
|
|
|
4 |
treatment, such as |
|
|
|
5 |
Physician's services, |
|
|
|
6 |
inpatient and outpatient |
|
|
|
7 |
medical and surgical |
|
|
|
8 |
services and supplies, |
|
|
|
9 |
physical and speech |
|
|
|
10 |
therapy, diagnostic |
|
|
|
11 |
tests, durable medical |
|
|
|
12 |
equipment, |
|
|
|
13 |
First $131 of |
|
|
|
14 |
Medicare Approved |
$0 |
$0 |
$131 |
15 |
Amounts* |
|
|
(Part B |
16 |
|
|
|
Deductible) |
17 |
Remainder of Medicare |
|
|
|
18 |
Approved Amounts |
80% |
20% |
$0 |
19 |
Part B Excess Charges |
|
|
|
20 |
(Above Medicare |
|
|
|
21 |
Approved Amounts) |
$0 |
$0 |
All Costs |
22 |
BLOOD |
|
|
|
23 |
First 3 pints |
$0 |
All Costs |
$0 |
24 |
Next $131 of Medicare |
|
|
|
25 |
Approved Amounts* |
$0 |
$0 |
$131 |
26 |
|
|
|
(Part B |
27 |
Remainder of Medicare |
|
|
Deductible) |
28 |
Approved Amounts |
80% |
20% |
$0 |
29 |
CLINICAL LABORATORY |
|
|
|
1 |
SERVICES— |
|
|
|
2 |
Tests for |
|
|
|
3 |
diagnostic services |
100% |
$0 |
$0 |
4 |
PARTS A & B |
5 |
HOME HEALTH CARE |
|
|
|
6 |
Medicare Approved |
|
|
|
7 |
Services |
|
|
|
8 |
—Medically necessary |
|
|
|
9 |
skilled care services |
|
|
|
10 |
and medical supplies |
100% |
$0 |
$0 |
11 |
—Durable medical |
|
|
|
12 |
equipment |
|
|
|
13 |
First $131 of |
|
|
|
14 |
Medicare |
|
|
|
15 |
Approved Amounts* |
$0 |
$0 |
$131 |
16 |
|
|
|
(Part B |
17 |
|
|
|
Deductible) |
18 |
Remainder of Medicare |
|
|
|
19 |
Approved Amounts |
80% |
20% |
$0 |
20 |
PLAN C |
21 |
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD |
22 *A benefit period begins on the first day you receive
23 service as an inpatient in a hospital and ends after you have
1 been out of the hospital and have not received skilled care in
2 any other facility for 60 days in a row.
3 |
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
4 |
HOSPITALIZATION* |
|
|
|
5 |
Semiprivate room and |
|
|
|
6 |
board, general nursing |
|
|
|
7 |
and miscellaneous |
|
|
|
8 |
services and supplies |
|
|
|
9 |
First 60 days |
All but |
$992 |
$0 |
10 |
|
$992 |
(Part A |
|
11 |
|
|
Deductible) |
|
12 |
61st thru 90th day |
All but |
$248 |
$0 |
13 |
|
$248 a day |
a day |
|
14 |
91st day and after |
|
|
|
15 |
—While using 60 |
|
|
|
16 |
lifetime reserve days |
All but |
$496 |
$0 |
17 |
|
$496 a day |
a day |
|
18 |
—Once lifetime reserve |
|
|
|
19 |
days are used: |
|
|
|
20 |
—Additional 365 days |
$0 |
100% of |
$0** |
21 |
|
|
Medicare |
|
22 |
|
|
Eligible |
|
23 |
|
|
Expenses |
|
24 |
—Beyond the |
|
|
|
25 |
Additional 365 days |
$0 |
$0 |
All Costs |
26 |
SKILLED NURSING FACILITY |
|
|
|
27 |
CARE* |
|
|
|
28 |
You must meet Medicare's |
|
|
|
1 |
requirements, including |
|
|
|
2 |
having been in a hospital |
|
|
|
3 |
for at least 3 days and |
|
|
|
4 |
entered a Medicare- |
|
|
|
5 |
approved facility within |
|
|
|
6 |
30 days after leaving the |
|
|
|
7 |
hospital |
|
|
|
8 |
First 20 days |
All approved |
|
|
9 |
|
amounts |
$0 |
$0 |
10 |
21st thru 100th day |
All but |
Up to |
$0 |
11 |
|
$124 a day |
$124 a day |
|
12 |
101st day and after |
$0 |
$0 |
All costs |
13 |
BLOOD |
|
|
|
14 |
First 3 pints |
$0 |
3 pints |
$0 |
15 |
Additional amounts |
100% |
$0 |
$0 |
16 |
HOSPICE CARE |
|
|
|
17 |
|
All but very |
|
$0 |
18 |
|
limited |
Medicare |
|
19 |
|
copayment/ |
copayment/ |
|
20 |
|
coinsurance |
coinsurance |
|
21 |
You must meet |
for outpatient |
|
|
22 |
Medicare's requirements, |
drugs and |
|
|
23 |
including a doctor's |
inpatient |
|
|
24 |
certification of |
respite care |
|
|
25 |
terminal illness |
|
|
|
26 **NOTICE: When your Medicare Part A hospital benefits are
27 exhausted, the insurer stands in the place of Medicare and will
28 pay whatever amount Medicare would have paid for up to an
1 additional 365 days as provided in the policy's "Core Benefits."
2 During this time the hospital is prohibited from billing you for
3 the balance based on any difference between its billed charges
4 and the amount Medicare would have paid.
5 |
PLAN C |
6 |
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR |
7 *Once you have been billed $131 of Medicare-Approved amounts
8 for covered services (which are noted with an asterisk), your
9 Part B Deductible will have been met for the calendar year.
10 |
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
11 |
MEDICAL EXPENSES— |
|
|
|
12 |
In or out of the hospital |
|
|
|
13 |
and outpatient hospital |
|
|
|
14 |
treatment, such as |
|
|
|
15 |
Physician's services, |
|
|
|
16 |
inpatient and outpatient |
|
|
|
17 |
medical and surgical |
|
|
|
18 |
services and supplies, |
|
|
|
19 |
physical and speech |
|
|
|
20 |
therapy, diagnostic |
|
|
|
21 |
tests, durable medical |
|
|
|
22 |
equipment, |
|
|
|
23 |
First $131 of |
|
|
|
24 |
Medicare Approved |
$0 |
$131 |
$0 |
25 |
Amounts* |
|
(Part B |
|
26 |
|
|
Deductible) |
|
1 |
Remainder of Medicare |
|
|
|
2 |
Approved Amounts |
80% |
20% |
$0 |
3 |
Part B Excess Charges |
|
|
|
4 |
(Above Medicare |
|
|
|
5 |
Approved Amounts) |
$0 |
$0 |
All Costs |
6 |
BLOOD |
|
|
|
7 |
First 3 pints |
$0 |
All Costs |
$0 |
8 |
Next $131 of Medicare |
|
|
|
9 |
Approved Amounts* |
$0 |
$131 |
$0 |
10 |
|
|
(Part B |
|
11 |
|
|
Deductible) |
|
12 |
Remainder of Medicare |
|
|
|
13 |
Approved Amounts |
80% |
20% |
$0 |
14 |
CLINICAL LABORATORY |
|
|
|
15 |
SERVICES— |
|
|
|
16 |
Tests for |
|
|
|
17 |
diagnostic services |
100% |
$0 |
$0 |
18 |
PARTS A & B |
19 |
HOME HEALTH CARE |
|
|
|
20 |
Medicare Approved |
|
|
|
21 |
Services |
|
|
|
22 |
—Medically necessary |
|
|
|
23 |
skilled care services |
|
|
|
24 |
and medical supplies |
100% |
$0 |
$0 |
25 |
—Durable medical |
|
|
|
26 |
equipment |
|
|
|
1 |
First $131 of |
|
|
|
2 |
Medicare Approved |
$0 |
$131 |
$0 |
3 |
Amounts* |
|
(Part B |
|
4 |
|
|
Deductible) |
|
5 |
Remainder of Medicare |
|
|
|
6 |
Approved Amounts |
80% |
20% |
$0 |
7 |
OTHER BENEFITS—NOT COVERED BY MEDICARE |
8 |
FOREIGN TRAVEL— |
|
|
|
9 |
Not covered by Medicare |
|
|
|
10 |
Medically necessary |
|
|
|
11 |
emergency care services |
|
|
|
12 |
beginning during the |
|
|
|
13 |
first 60 days of each |
|
|
|
14 |
trip outside the USA |
|
|
|
15 |
First $250 each |
|
|
|
16 |
calendar year |
$0 |
$0 |
$250 |
17 |
Remainder of charges |
$0 |
80% to a |
20% and |
18 |
|
|
lifetime |
amounts |
19 |
|
|
maximum |
over the |
20 |
|
|
benefit |
$50,000 |
21 |
|
|
of $50,000 |
lifetime |
22 |
|
|
|
maximum |
23 |
PLAN D |
24 |
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD |
1 *A benefit period begins on the first day you receive
2 service as an inpatient in a hospital and ends after you have
3 been out of the hospital and have not received skilled care in
4 any other facility for 60 days in a row.
5 |
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
6 |
HOSPITALIZATION* |
|
|
|
7 |
Semiprivate room and |
|
|
|
8 |
board, general nursing |
|
|
|
9 |
and miscellaneous |
|
|
|
10 |
services and supplies |
|
|
|
11 |
First 60 days |
All but |
$992 |
$0 |
12 |
|
$992 |
(Part A |
|
13 |
|
|
Deductible) |
|
14 |
61st thru 90th day |
All but |
$248 |
$0 |
15 |
|
$248 a day |
a day |
|
16 |
91st day and after |
|
|
|
17 |
—While using 60 |
|
|
|
18 |
lifetime reserve days |
All but |
$496 |
$0 |
19 |
|
$496 a day |
a day |
|
20 |
—Once lifetime reserve |
|
|
|
21 |
days are used: |
|
|
|
22 |
—Additional 365 days |
$0 |
100% of |
$0** |
23 |
|
|
Medicare |
|
24 |
|
|
Eligible |
|
25 |
|
|
Expenses |
|
26 |
—Beyond the |
|
|
|
27 |
Additional 365 days |
$0 |
$0 |
All Costs |
1 |
SKILLED NURSING FACILITY |
|
|
|
2 |
CARE* |
|
|
|
3 |
You must meet Medicare's |
|
|
|
4 |
requirements, including |
|
|
|
5 |
having been in a hospital |
|
|
|
6 |
for at least 3 days and |
|
|
|
7 |
entered a Medicare- |
|
|
|
8 |
approved facility within |
|
|
|
9 |
30 days after leaving the |
|
|
|
10 |
hospital |
|
|
|
11 |
First 20 days |
All approved |
|
|
12 |
|
amounts |
$0 |
$0 |
13 |
21st thru 100th day |
All but |
Up to |
$0 |
14 |
|
$124 a day |
$124 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 |
Medicare |
$0 |
21 |
|
limited |
copayment/ |
|
22 |
|
copayment/ |
coinsurance |
|
23 |
|
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 D |
9 |
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR |
10 *Once you have been billed $131 of Medicare-Approved amounts
11 for covered services (which are noted with an asterisk), your
12 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 $131 of |
|
|
|
1 |
Medicare Approved |
$0 |
$0 |
$131 |
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 $131 of Medicare |
|
|
|
12 |
Approved Amounts* |
$0 |
$0 |
$131 |
13 |
|
|
|
(Part B |
14 |
|
|
|
Deductible) |
15 |
Remainder of Medicare |
|
|
|
16 |
Approved Amounts |
80% |
20% |
$0 |
17 |
CLINICAL LABORATORY |
|
|
|
18 |
SERVICES— |
|
|
|
19 |
Tests for |
|
|
|
20 |
diagnostic services |
100% |
$0 |
$0 |
21 |
PARTS A & B |
22 |
HOME HEALTH CARE |
|
|
|
23 |
Medicare Approved |
|
|
|
24 |
Services |
|
|
|
25 |
—Medically necessary |
|
|
|
26 |
skilled care services |
|
|
|
1 |
and medical supplies |
100% |
$0 |
$0 |
2 |
—Durable medical |
|
|
|
3 |
equipment |
|
|
|
4 |
First $131 of |
|
|
|
5 |
Medicare Approved |
$0 |
$0 |
$131 |
6 |
Amounts* |
|
|
(Part B |
7 |
|
|
|
Deductible) |
8 |
Remainder of Medicare |
|
|
|
9 |
Approved Amounts |
80% |
20% |
$0 |
10 |
OTHER BENEFITS—NOT COVERED BY MEDICARE |
11 |
FOREIGN TRAVEL— |
|
|
|
12 |
Not covered by Medicare |
|
|
|
13 |
Medically necessary |
|
|
|
14 |
emergency care services |
|
|
|
15 |
beginning during the |
|
|
|
16 |
first 60 days of each |
|
|
|
17 |
trip outside the USA |
|
|
|
18 |
First $250 each |
|
|
|
19 |
calendar year |
$0 |
$0 |
$250 |
20 |
Remainder of charges |
$0 |
80% to a |
20% and |
21 |
|
|
lifetime |
amounts |
22 |
|
|
maximum |
over the |
23 |
|
|
benefit |
$50,000 |
24 |
|
|
of $50,000 |
lifetime |
25 |
|
|
|
maximum |
1 |
PLAN F OR |
2 |
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD |
3 *A benefit period begins on the first day you receive
4 service as an inpatient in a hospital and ends after you have
5 been out of the hospital and have not received skilled care in
6 any other facility for 60 days in a row.
7 **This high deductible high-deductible plan pays
the same
8 benefits as plan F after you have paid a calendar year ($1,860)
9
$1,860 deductible. Benefits from the high
deductible high-
10 deductible plan F will not begin until out-of-pocket expenses are
11 $1,860. Out-of-pocket expenses for this deductible are expenses
12 that would ordinarily be paid by the policy. This includes
13 medicare Medicare deductibles for part A and part B, but does not
14 include the plan's separate foreign travel emergency deductible.
15 |
SERVICES |
MEDICARE |
AFTER YOU |
IN ADDITION |
16 |
|
PAYS |
PAY |
TO |
17 |
|
|
$1,860 |
$1,860 |
18 |
|
|
DEDUCTIBLE**, |
DEDUCTIBLE**, |
19 |
|
|
PLAN PAYS |
YOU PAY |
20 |
HOSPITALIZATION* |
|
|
|
21 |
Semiprivate room and |
|
|
|
22 |
board, general nursing |
|
|
|
23 |
and miscellaneous |
|
|
|
24 |
services and supplies |
|
|
|
25 |
First 60 days |
All but |
$992 |
$0 |
26 |
|
$992 |
(Part A |
|
1 |
|
|
Deductible) |
|
2 |
61st thru 90th day |
All but |
$248 |
$0 |
3 |
|
$248 a day |
a day |
|
4 |
91st day and after |
|
|
|
5 |
—While using 60 |
|
|
|
6 |
lifetime reserve days |
All but |
$496 |
$0 |
7 |
|
$496 a day |
a day |
|
8 |
—Once lifetime reserve |
|
|
|
9 |
days are used: |
|
|
|
10 |
—Additional 365 days |
$0 |
100% of |
$0*** |
11 |
|
|
Medicare |
|
12 |
|
|
Eligible |
|
13 |
|
|
Expenses |
|
14 |
—Beyond the |
|
|
|
15 |
Additional 365 days |
$0 |
$0 |
All Costs |
16 |
SKILLED NURSING FACILITY |
|
|
|
17 |
CARE* |
|
|
|
18 |
You must meet Medicare's |
|
|
|
19 |
requirements, including |
|
|
|
20 |
having been in a |
|
|
|
21 |
hospital for at least |
|
|
|
22 |
3 days and entered a |
|
|
|
23 |
Medicare-approved |
|
|
|
24 |
facility within 30 days |
|
|
|
25 |
after leaving the |
|
|
|
26 |
hospital |
|
|
|
27 |
First 20 days |
All approved |
|
|
28 |
|
amounts |
$0 |
$0 |
29 |
21st thru 100th day |
All but |
Up to |
$0 |
1 |
|
$124 a day |
$124 a day |
|
2 |
101st day and after |
$0 |
$0 |
All costs |
3 |
BLOOD |
|
|
|
4 |
First 3 pints |
$0 |
3 pints |
$0 |
5 |
Additional amounts |
100% |
$0 |
$0 |
6 |
HOSPICE CARE |
|
|
|
7 |
|
All but very |
Medicare |
$0 |
8 |
|
limited |
copayment/ |
|
9 |
|
copayment/ |
coinsurance |
|
10 |
|
coinsurance |
|
|
11 |
You must |
for |
|
|
12 |
meet Medicare's |
outpatient |
|
|
13 |
requirements, including |
drugs and |
|
|
14 |
a doctor's certification |
inpatient |
|
|
15 |
of terminal illness |
respite care |
|
|
16 ***NOTICE: When your Medicare Part A hospital benefits are
17 exhausted, the insurer stands in the place of Medicare and will
18 pay whatever amount Medicare would have paid for up to an
19 additional 365 days as provided in the policy's "Core Benefits."
20 During this time the hospital is prohibited from billing you for
21 the balance based on any difference between its billed charges
22 and the amount Medicare would have paid.
23 |
PLAN F |
24 |
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR |
25 *Once you have been billed $131 of Medicare-Approved amounts
26 for covered services (which are noted with an asterisk), your
1 Part B Deductible will have been met for the calendar year.
2 **This high deductible high-deductible plan pays
the same
3 benefits as plan F after you have paid a calendar year ($1,860)
4
$1,860 deductible. Benefits from the high
deductible high-
5 deductible plan F will not begin until out-of-pocket expenses are
6 $1,860. Out-of-pocket expenses for this deductible are expenses
7 that would ordinarily be paid by the policy. This includes
8 medicare Medicare deductibles for part A and part B, but does not
9 include the plan's separate foreign travel emergency deductible.
10 |
SERVICES |
MEDICARE |
AFTER YOU |
IN ADDITION |
11 |
|
PAYS |