HOUSE BILL No. 6431

 

 

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 upon on application and the coverage
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