Section 500.3815 - Outline of coverage; acknowledgment of receipt; compliance with notice requirements; substitute; language, format, and required items.

THE INSURANCE CODE OF 1956 (EXCERPT)
Act 218 of 1956

500.3815 Outline of coverage; acknowledgment of receipt; compliance with notice requirements; substitute; language, format, and required items.

Sec. 3815.

(1) An insurer that offers a medicare supplement policy shall provide to the applicant at the time of application an outline of coverage and, except for direct response solicitation policies, shall obtain an acknowledgment of receipt of the outline of coverage from the applicant. The outline of coverage provided to applicants pursuant to this section shall consist of the following 4 parts:

(a) A cover page.

(b) Premium information.

(c) Disclosure pages.

(d) Charts displaying the features of each benefit plan offered by the insurer.

(2) Insurers shall comply with any notice requirements of the medicare prescription drug, improvement, and modernization act of 2003, Public Law 108-173.

(3) If an outline of coverage is provided at the time of application and the medicare supplement policy or certificate is issued on a basis that would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate shall accompany the policy or certificate when it is delivered and shall contain the following statement, in no less than 12-point type, immediately above the company name:

  NOTICE: Read this outline of coverage carefully.     It is not identical to the outline of coverage     provided upon application and the coverage     originally applied for has not been issued.  

(4) An outline of coverage under subsection (1) shall be in the language and format prescribed in this section and in not less than 12-point type. The letter designation of the plan shall be shown on the cover page and the plans offered by the insurer shall be prominently identified. Premium information shall be shown on the cover page or immediately following the cover page and shall be prominently displayed. The premium and method of payment mode shall be stated for all plans that are offered to the applicant. All possible premiums for the applicant shall be illustrated. The following items shall be included in the outline of coverage in the order prescribed below and in substantially the following form, as approved by the commissioner:

BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD ON OR AFTER JUNE 1, 2010

This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan "A" available. Some plans may not be available in your state.

Plans E, H, I, and J are no longer available for sale. (This sentence shall not appear after June 1, 2011.)

BASIC BENEFITS: Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or copayments. Blood: First three pints of blood each year. Hospice: Part A coinsurance

A B C D F|F* G Basic, Basic, Basic, Basic, Basic, Basic, including including including including including including 100% Part 100% Part 100% Part 100% Part 100% Part 100% Part B coin- B coinsur- B coinsur- B coinsur- B coinsur- B coinsur- surance ance ance ance ance ance     Skilled Skilled Skilled Skilled     Nursing Nursing Nursing Nursing     Facility Facility Facility Facility     Coinsur- Coinsur- Coinsur- Coinsur-     ance ance ance ance   Part A Part A Part A Part A Part A   Deductible Deductible Deductible Deductible Deductible     Part B   Part B       Deductible   Deductible           Part B Part B         Excess Excess         (100%) (100%)     Foreign Foreign Foreign Foreign     Travel Travel Travel Travel     Emergency Emergency Emergency Emergency

 

K L M N Hospitalization Hospitalization Basic, Basic, includ- and preventive and preventive including 100% ing 100% Part B care paid at care paid at Part B coinsurance, 100%; other 100%; other coinsurance except up to basic benefits basic benefits   $20 copayment paid at 50% paid at 75%   for office       visit, and up       to $50 copay-       ment for ER 50% Skilled 75% Skilled Skilled Skilled Nursing Nursing Nursing Nursing Facility Facility Facility Facility Coinsurance Coinsurance Coinsurance Coinsurance 50% Part A 75% Part A 50% Part A Part A Deductible Deductible Deductible Deductible                     Foreign Foreign     Travel Travel     Emergency Emergency Out-of-pocket Out-of-pocket     limit $4,140; limit $2,070;     paid at 100% paid at 100%     after limit after limit     reached reached    

* Plan F also has an option called a high-deductible Plan F. This high-deductible plan pays the same benefits as Plan F after one has paid a calendar year $1,860 deductible. Benefits from high-deductible Plan F will not begin until out-of-pocket expenses exceed $1,860. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.

 PREMIUM INFORMATION

We (insert insurer's name) can only raise your premium if we raise the premium for all policies like yours in this state. (If the premium is based on the increasing age of the insured, include information specifying when premiums will change).

 DISCLOSURES

Use this outline to compare benefits and premiums among policies, certificates, and contracts.

This outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums. Plans E, H, I, and J are no longer available for sale. (This sentence shall not appear after June 1, 2011.)

 READ YOUR POLICY VERY CAREFULLY

This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.

 RIGHT TO RETURN POLICY

If you find that you are not satisfied with your policy, you may return it to (insert insurer's address). If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.

 POLICY REPLACEMENT

If you are replacing another health insurance policy, do not cancel it until you have actually received your new policy and are sure you want to keep it.

 NOTICE

This policy may not fully cover all of your medical costs.

[For agent issued policies]

Neither (insert insurer's name) nor its agents are connected with medicare.

[For direct response issued policies]

(Insert insurer's name) is not connected with medicare.

This outline of coverage does not give all the details of medicare coverage. Contact your local social security office or consult "the medicare handbook" for more details.

 COMPLETE ANSWERS ARE VERY IMPORTANT

When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. [If the policy or certificate is guaranteed issue, this paragraph need not appear.]

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

[Include for each plan offered by the insurer a chart showing the services, medicare payments, plan payments, and insured payments using the same language, in the same order, and using uniform layout and format as shown in the charts that follow. An insurer may use additional benefit plan designations on these charts pursuant to section 3809(1)(k). Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the commissioner. The insurer issuing the policy shall change the dollar amounts each year to reflect current figures. No more than 4 plans may be shown on 1 chart.] Charts for each plan are as follows:

PLAN A MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

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

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION*       Semiprivate room and       board, general nursing       and miscellaneous       services and supplies       First 60 days All but $0 $992   $992   (Part A       Deductible) 61st thru 90th day All but $248 $0   $248 a day a day   91st day and after:       —While using 60       lifetime reserve days All but $496 $0   $496 a day a day   —Once lifetime reserve       days are used:       —Additional 365 days $0 100% of $0**     Medicare       Eligible       Expenses   —Beyond the       Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY       CARE*       You must meet Medicare's       requirements, including       having been in a hospital       for at least 3 days and       entered a Medicare-       approved facility within       30 days after leaving the       hospital       First 20 days All approved       amounts $0 $0 21st thru 100th day All but $0 Up to   $124 a day   $124 a day 101st day and after $0 $0 All costs BLOOD       First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE       You must meet All but very   $0 Medicare's requirements limited Medicare   including a doctor's copayment/ copayment/   certification of terminal coinsurance coinsurance   illness for outpatient       drugs and       inpatient       respite care            

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

PLAN A MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $131 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES—       In or out of the hospital       and outpatient hospital       treatment, such as       Physician's services,       inpatient and outpatient       medical and surgical       services and supplies,       physical and speech       therapy, diagnostic       tests, durable medical       equipment,       First $131 of       Medicare Approved $0 $0 $131 Amounts*     (Part B       Deductible) Remainder of Medicare       Approved Amounts 80% 20% $0 Part B Excess Charges       (Above Medicare       Approved Amounts) $0 $0 All Costs BLOOD       First 3 pints $0 All Costs $0 Next $131 of       Medicare $0 $0 $131 Approved Amounts*     (Part B       Deductible) Remainder of Medicare       Approved Amounts 80% 20% $0 CLINICAL LABORATORY       SERVICES—       Tests for       diagnostic services 100% $0 $0

PARTS A & B

HOME HEALTH CARE       Medicare Approved       Services       —Medically necessary       skilled care services       and medical supplies 100% $0 $0 —Durable medical       equipment       First $131 of       Medicare $0 $0 $131 Approved Amounts*     (Part B       Deductible) Remainder of Medicare       Approved Amounts 80% 20% $0

PLAN B MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

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

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION*       Semiprivate room and       board, general nursing       and miscellaneous       services and supplies       First 60 days All but $992 $0   $992 (Part A       Deductible)   61st thru 90th day All but $248 $0   $248 a day a day   91st day and after       —While using 60       lifetime reserve days All but $496 $0   $496 a day a day   —Once lifetime reserve       days are used:       —Additional 365 days $0 100% of $0**     Medicare       Eligible       Expenses   —Beyond the       Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY       CARE*       You must meet Medicare's       requirements, including       having been in a hospital       for at least 3 days and       entered a Medicare-       approved facility within       30 days after leaving the       hospital       First 20 days All approved       amounts $0 $0 21st thru 100th day All but $0 Up to   $124 a day   $124 a day 101st day and after $0 $0 All costs BLOOD       First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE         All but very       limited Medicare $0   copayment/ copayment/     coinsurance coinsurance   You must meet for outpatient     Medicare's requirements, drugs and     including a doctor's inpatient     certification of respite care     terminal illness      

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

PLAN B MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $131 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES—       In or out of the hospital       and outpatient hospital       treatment, such as       Physician's services,       inpatient and outpatient       medical and surgical       services and supplies,       physical and speech       therapy, diagnostic       tests, durable medical       equipment,       First $131 of       Medicare Approved $0 $0 $131 Amounts*     (Part B       Deductible) Remainder of Medicare       Approved Amounts 80% 20% $0 Part B Excess Charges       (Above Medicare       Approved Amounts) $0 $0 All Costs BLOOD       First 3 pints $0 All Costs $0 Next $131 of Medicare       Approved Amounts* $0 $0 $131       (Part B Remainder of Medicare     Deductible) Approved Amounts 80% 20% $0 CLINICAL LABORATORY       SERVICES—       Tests for       diagnostic services 100% $0 $0

PARTS A & B

HOME HEALTH CARE       Medicare Approved       Services       —Medically necessary       skilled care services       and medical supplies 100% $0 $0 —Durable medical       equipment       First $131 of       Medicare       Approved Amounts* $0 $0 $131       (Part B       Deductible) Remainder of Medicare       Approved Amounts 80% 20% $0

PLAN C MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

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

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION*       Semiprivate room and       board, general nursing       and miscellaneous       services and supplies       First 60 days All but $992 $0   $992 (Part A       Deductible)   61st thru 90th day All but $248 $0   $248 a day a day   91st day and after       —While using 60       lifetime reserve days All but $496 $0   $496 a day a day   —Once lifetime reserve       days are used:       —Additional 365 days $0 100% of $0**     Medicare       Eligible       Expenses   —Beyond the       Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY       CARE*       You must meet Medicare's       requirements, including       having been in a hospital       for at least 3 days and       entered a Medicare-       approved facility within       30 days after leaving the       hospital       First 20 days All approved       amounts $0 $0 21st thru 100th day All but Up to $0   $124 a day $124 a day   101st day and after $0 $0 All costs BLOOD       First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE         All but very   $0   limited Medicare     copayment/ copayment/     coinsurance coinsurance   You must meet for outpatient     Medicare's requirements, drugs and     including a doctor's inpatient     certification of respite care     terminal illness      

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

PLAN C MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $131 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES—       In or out of the hospital       and outpatient hospital       treatment, such as       Physician's services,       inpatient and outpatient       medical and surgical       services and supplies,       physical and speech       therapy, diagnostic       tests, durable medical       equipment,       First $131 of       Medicare Approved $0 $131 $0 Amounts*   (Part B       Deductible)   Remainder of Medicare       Approved Amounts 80% 20% $0 Part B Excess Charges       (Above Medicare       Approved Amounts) $0 $0 All Costs BLOOD       First 3 pints $0 All Costs $0 Next $131 of Medicare       Approved Amounts* $0 $131 $0     (Part B       Deductible)   Remainder of Medicare       Approved Amounts 80% 20% $0 CLINICAL LABORATORY       SERVICES—       Tests for       diagnostic services 100% $0 $0

PARTS A & B

HOME HEALTH CARE       Medicare Approved       Services       —Medically necessary       skilled care services       and medical supplies 100% $0 $0 —Durable medical       equipment       First $131 of       Medicare Approved $0 $131 $0 Amounts*   (Part B       Deductible)   Remainder of Medicare       Approved Amounts 80% 20% $0

OTHER BENEFITS—NOT COVERED BY MEDICARE

FOREIGN TRAVEL—       Not covered by Medicare       Medically necessary       emergency care services       beginning during the       first 60 days of each       trip outside the USA       First $250 each       calendar year $0 $0 $250 Remainder of charges $0 80% to a 20% and     lifetime amounts     maximum over the     benefit $50,000     of $50,000 lifetime       maximum

PLAN D MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

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

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION*       Semiprivate room and       board, general nursing       and miscellaneous       services and supplies       First 60 days All but $992 $0   $992 (Part A       Deductible)   61st thru 90th day All but $248 $0   $248 a day a day   91st day and after       —While using 60       lifetime reserve days All but $496 $0   $496 a day a day   —Once lifetime reserve       days are used:       —Additional 365 days $0 100% of $0**     Medicare       Eligible       Expenses   —Beyond the       Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY       CARE*       You must meet Medicare's       requirements, including       having been in a hospital       for at least 3 days and       entered a Medicare-       approved facility within       30 days after leaving the       hospital       First 20 days All approved       amounts $0 $0 21st thru 100th day All but Up to $0   $124 a day $124 a day   101st day and after $0 $0 All costs BLOOD       First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE         All but very Medicare $0   limited copayment/     copayment/ coinsurance     coinsurance     You must meet for outpatient     Medicare's requirements, drugs and     including a doctor's inpatient     certification of respite care     terminal illness      

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

PLAN D MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $131 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES—       In or out of the hospital       and outpatient hospital       treatment, such as       Physician's services,       inpatient and outpatient       medical and surgical       services and supplies,       physical and speech       therapy, diagnostic       tests, durable medical       equipment,       First $131 of       Medicare Approved $0 $0 $131 Amounts*     (Part B       Deductible) Remainder of Medicare       Approved Amounts 80% 20% $0 Part B Excess Charges       (Above Medicare       Approved Amounts) $0 $0 All Costs BLOOD       First 3 pints $0 All Costs $0 Next $131 of Medicare       Approved Amounts* $0 $0 $131       (Part B       Deductible) Remainder of Medicare       Approved Amounts 80% 20% $0 CLINICAL LABORATORY       SERVICES—       Tests for       diagnostic services 100% $0 $0

PARTS A & B

HOME HEALTH CARE       Medicare Approved       Services       —Medically necessary       skilled care services       and medical supplies 100% $0 $0 —Durable medical       equipment       First $131 of       Medicare Approved $0 $0 $131 Amounts*     (Part B       Deductible) Remainder of Medicare       Approved Amounts 80% 20% $0

OTHER BENEFITS—NOT COVERED BY MEDICARE

FOREIGN TRAVEL—       Not covered by Medicare       Medically necessary       emergency care services       beginning during the       first 60 days of each       trip outside the USA       First $250 each       calendar year $0 $0 $250 Remainder of charges $0 80% to a 20% and     lifetime amounts     maximum over the     benefit $50,000     of $50,000 lifetime       maximum

PLAN F OR HIGH DEDUCTIBLE PLAN F MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

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

**This high deductible plan pays the same benefits as plan F after you have paid a calendar year ($1,860) deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $1,860. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes medicare deductibles for part A and part B, but does not include the plan's separate foreign travel emergency deductible.

SERVICES MEDICARE AFTER YOU IN ADDITION   PAYS PAY TO     $1,860 $1,860     DEDUCTIBLE**, DEDUCTIBLE**,     PLAN PAYS YOU PAY HOSPITALIZATION*       Semiprivate room and       board, general nursing       and miscellaneous       services and supplies       First 60 days All but $992 $0   $992 (Part A       Deductible)   61st thru 90th day All but $248 $0   $248 a day a day   91st day and after       —While using 60       lifetime reserve days All but $496 $0   $496 a day a day   —Once lifetime reserve       days are used:       —Additional 365 days $0 100% of $0***     Medicare       Eligible       Expenses   —Beyond the       Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY       CARE*       You must meet Medicare's       requirements, including       having been in a       hospital for at least       3 days and entered a       Medicare-approved       facility within 30 days       after leaving the       hospital       First 20 days All approved       amounts $0 $0 21st thru 100th day All but Up to $0   $124 a day $124 a day   101st day and after $0 $0 All costs BLOOD       First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE         All but very Medicare $0   limited copayment/     copayment/ coinsurance     coinsurance     You must for     meet Medicare's outpatient     requirements, including drugs and     a doctor's certification inpatient     of terminal illness respite care    

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

PLAN F MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $131 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

**This high deductible plan pays the same benefits as plan F after you have paid a calendar year ($1,860) deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $1,860. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes medicare deductibles for part A and part B, but does not include the plan's separate foreign travel emergency deductible.

SERVICES MEDICARE AFTER YOU IN ADDITION   PAYS PAY TO     $1,860 $1,860     DEDUCTIBLE**, DEDUCTIBLE**,     PLAN PAYS YOU PAY MEDICAL EXPENSES—       In or out of the hospital       and outpatient hospital       treatment, such as       Physician's services,       inpatient and outpatient       medical and surgical       services and supplies,       physical and speech       therapy, diagnostic       tests, durable medical       equipment,       First $131 of       Medicare Approved $0 $131 $0 Amounts*   (Part B       Deductible)   Remainder of Medicare       Approved Amounts 80% 20% $0 Part B Excess Charges       (Above Medicare       Approved Amounts) $0 100% $0 BLOOD       First 3 pints $0 All Costs $0 Next $131 of       Medicare Approved $0 $131 $0 Amounts*   (Part B       Deductible)   Remainder of Medicare       Approved Amounts 80% 20% $0 CLINICAL LABORATORY       SERVICES—       Tests for       diagnostic services 100% $0 $0

PARTS A & B

HOME HEALTH CARE       Medicare Approved       Services       —Medically necessary       skilled care services       and medical supplies 100% $0 $0 —Durable medical       equipment       First $131 of       Medicare Approved $0 $131 $0 Amounts*   (Part B       Deductible)   Remainder of Medicare       Approved Amounts 80% 20% $0

OTHER BENEFITS—NOT COVERED BY MEDICARE

FOREIGN TRAVEL—       Not covered by Medicare       Medically necessary       emergency care services       beginning during the       first 60 days of each       trip outside the USA       First $250 each       calendar year $0 $0 $250 Remainder of charges $0 80% to a 20% and     lifetime amounts     maximum over the     benefit $50,000     of $50,000 lifetime       maximum

PLAN G MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

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

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION*       Semiprivate room and       board, general nursing       and miscellaneous       services and supplies       First 60 days All but $992 $0   $992 (Part A       Deductible)   61st thru 90th day All but $248 $0   $248 a day a day   91st day and after       —While using 60       lifetime reserve days All but $496 $0   $496 a day a day   —Once lifetime reserve       days are used:       —Additional 365 days $0 100% of $0**     Medicare       Eligible       Expenses   —Beyond the       Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY       CARE*       You must meet Medicare's       requirements, including       having been in a hospital       for at least 3 days and       entered a Medicare-       approved facility within       30 days after leaving the       hospital       First 20 days All approved       amounts $0 $0 21st thru 100th day All but Up to $0   $124 a day $124 a day   101st day and after $0 $0 All costs BLOOD       First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE         All but very   $0   limited Medicare     copayment/ copayment/     coinsurance coinsurance   You must meet for outpatient     Medicare's requirements, drugs and     including a doctor's inpatient     certification of respite care     terminal illness      

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

PLAN G MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $131 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES—       In or out of the hospital       and outpatient hospital       treatment, such as       Physician's services,       inpatient and outpatient       medical and surgical       services and supplies,       physical and speech       therapy, diagnostic       tests, durable medical       equipment,       First $131 of       Medicare Approved $0 $0 $131 Amounts*     (Part B       Deductible) Remainder of Medicare       Approved Amounts 80% 20% $0 Part B Excess Charges       (Above Medicare       Approved Amounts) $0 100% 0% BLOOD       First 3 pints $0 All Costs $0 Next $131 of       Medicare Approved $0 $0 $131 Amounts*     (Part B       Deductible) Remainder of Medicare       Approved Amounts 80% 20% $0 CLINICAL LABORATORY       SERVICES—       Tests for       diagnostic services 100% $0 $0

PARTS A & B

HOME HEALTH CARE       Medicare Approved       Services       —Medically necessary       skilled care services       and medical supplies 100% $0 $0 —Durable medical       equipment       First $131 of       Medicare Approved $0 $0 $131 Amounts*     (Part B       Deductible) Remainder of Medicare       Approved Amounts 80% 20% $0

OTHER BENEFITS—NOT COVERED BY MEDICARE

FOREIGN TRAVEL—       Not covered by Medicare       Medically necessary       emergency care services       beginning during the       first 60 days of each       trip outside the USA       First $250 each       calendar year $0 $0 $250 Remainder of charges $0 80% to a 20% and     lifetime amounts     maximum over the     benefit $50,000     of $50,000 lifetime       maximum

PLAN K

*You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $4,140 each calendar year. The amounts that count toward your annual limit are noted with diamonds 1 in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

PLAN K MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

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

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOSPITALIZATION**       Semiprivate room and       board, general nursing       and miscellaneous       services and supplies       First 60 days All but $496 $496   $992 (50% (50% of     of Part A Part A     Deducti- Deductible) 1     ble)           61st thru 90th day All but $248 $0   $248 a day a day   91st day and after:       —While using 60       lifetime reserve days All but $496 $0   $496 a day a day   —Once lifetime reserve       days are used:       —Additional 365 days $0 100% of $0***     Medicare       Eligible       Expenses   —Beyond the       Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY       CARE**       You must meet Medicare's       requirements, including       having been in a hospital       for at least 3 days and       entered a Medicare-       approved facility within       30 days after leaving the       hospital       First 20 days All approved       amounts $0 $0 21st thru 100th day All but Up to Up to   $124 a $62 $62   day a day a day 1 101st day and after $0 $0 All costs BLOOD       First 3 pints $0 50% 50% 1 Additional amounts 100% $0 $0 HOSPICE CARE           50% of 50% of     copayment/ Medicare     coinsur- copayment/     ance coinsurance 1 You must meet       Medicare's requirements,       including a doctor's       certification of terminal       illness All but very       limited       copayment/       coinsurance for       outpatient       drugs and       inpatient       respite care    

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

PLAN K MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

****Once you have been billed $131 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* MEDICAL EXPENSES—       In or out of the hospital       and outpatient hospital       treatment, such as       Physician's services,       inpatient and outpatient       medical and surgical       services and supplies,       physical and speech       therapy, diagnostic       tests, durable medical       equipment,       First $131 of       Medicare Approved $0 $0 $131 Amounts****     (Part B       Deductible)       **** 1         Preventive Benefits for Generally 75% Remainder All costs Medicare covered or more of of Medi- above Medi- services Medicare ap- care care   proved amounts approved approved     amounts amounts Remainder of Medicare Generally 80% Generally Generally Approved Amounts   10% 10% 1         Part B Excess Charges $0 $0 All costs (Above Medicare     (and they do Approved Amounts)     not count       toward       annual out-       of-pocket       limit of       $4,140)* BLOOD       First 3 pints $0 50% 50% 1 Next $131 of       Medicare Approved $0 $0 $131 Amounts****     (Part B       Deductible)       **** 1 Remainder of Medicare Generally 80% Generally Generally Approved Amounts   10% 10% 1 CLINICAL LABORATORY       SERVICES—Tests for       diagnostic services 100% $0 $0

*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $4,140 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

PARTS A & B

HOME HEALTH CARE       Medicare Approved       Services       —Medically necessary       skilled care services       and medical supplies 100% $0 $0 —Durable medical       equipment       First $131 of       Medicare Approved $0 $0 $131 Amounts*****     (Part B       Deductible)1 Remainder of Medicare       Approved Amounts 80% 10% 10% 1

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

PLAN L

*You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2,070 each calendar year. The amounts that count toward your annual limit are noted with diamonds 1 in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

PLAN L MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

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

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOSPITALIZATION**       Semiprivate room and       board, general nursing       and miscellaneous       services and supplies       First 60 days All but $744 $248   $992 (75% of (25% of     Part A Part A     Deducti- Deductible) 1     ble)   61st thru 90th day All but $248 $0   $248 a day a day   91st day and after:       —While using 60       lifetime reserve days All but $496 $0   $496 a day a day   —Once lifetime reserve       days are used:       —Additional 365 days $0 100% of $0***     Medicare       Eligible       Expenses   —Beyond the       Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY       CARE**       You must meet Medicare's       requirements, including       having been in a hospital       for at least 3 days and       entered a Medicare-       approved facility within       30 days after leaving the       hospital       First 20 days All approved       amounts $0 $0 21st thru 100th day All but Up to Up to   $124 a $93 $31   day a day a day 1 101st day and after $0 $0 All costs BLOOD       First 3 pints $0 75% 25% 1 Additional amounts 100% $0 $0 HOSPICE CARE           75% of 25% of     copayment/ copayment/     coinsur- coinsurance 1     ance   You must meet       Medicare's requirements,       including a doctor's       certification of terminal All     illness but very       limited copay-       ment/coinsur-       ance for       outpatient       drugs and       inpatient       respite care    

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

PLAN L MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

****Once you have been billed $131 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* MEDICAL EXPENSES—       In or out of the hospital       and outpatient hospital       treatment, such as       Physician's services,       inpatient and outpatient       medical and surgical       services and supplies,       physical and speech       therapy, diagnostic       tests, durable medical       equipment,       First $131 of       Medicare Approved $0 $0 $131 Amounts****     (Part       B Deducti-       ble)**** 1 Preventive Benefits for Generally 75% Remainder All costs Medicare covered or more of of Medi- above Medi- services Medicare care care   approved approved approved   amounts amounts amounts Remainder of Medicare Generally Generally Generally Approved Amounts 80% 15% 5% 1         Part B Excess Charges $0 $0 All costs (Above Medicare     (and they do Approved Amounts)     not count       toward       annual out-       of-pocket       limit of       $2,070)* BLOOD       First 3 pints $0 75% 25% 1 Next $131 of       Medicare Approved $0 $0 $131 Amounts****     (Part B       Deductible) 1 Remainder of Medicare Generally Generally Generally Approved Amounts 80% 15% 5% 1 CLINICAL LABORATORY       SERVICES—Tests for       diagnostic services 100% $0 $0

*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2,070 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

PARTS A & B

HOME HEALTH CARE       Medicare Approved       Services       —Medically necessary       skilled care services       and medical supplies 100% $0 $0 —Durable medical       equipment       First $131 of       Medicare Approved $0 $0 $131 Amounts*****     (Part       B Deducti-       ble) 1 Remainder of Medicare       Approved Amounts 80% 15% 5% 1

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