{"data":{"id":"us-mi/mich.-comp.-laws-500.3815","jurisdiction":"us-mi","citation":"Mich. Comp. Laws § 500.3815","heading":"Outline of coverage; acknowledgment of receipt; compliance with notice requirements; substitute; language, written or electronic format, and required items.","body":"Sec. 3815.\n\n(1) An insurer that offers a Medicare supplement policy shall provide to the applicant at the time of application an outline of coverage in written or electronic format and, except for direct response solicitation policies, shall obtain an acknowledgment of receipt of the outline of coverage from the applicant in written or electronic format. The outline of coverage provided to applicants under this section must consist of the following 4 parts:\n\n(a) A cover page.\n\n(b) Premium information.\n\n(c) Disclosure pages.\n\n(d) Charts displaying the features of each benefit plan offered by the insurer.\n\n(2) Insurers shall comply with any notice requirements of the Medicare prescription drug, improvement, and modernization act of 2003, Public Law 108-173.\n\n(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 must accompany the policy or certificate when it is delivered and must contain the following statement, in not less than 12-point type, immediately above the company name:\n\nNOTICE: Read this outline of coverage carefully.\n\nIt is not identical to the outline of coverage\n\nprovided on application and the coverage\n\noriginally applied for has not been issued.\n\n(4) An outline of coverage under subsection (1) must be in the language and in a written or electronic format prescribed in this section and in not less than 12-point type. The letter designation of the plan must be shown on the cover page and the plans offered by the insurer must be prominently identified. Premium information must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and method of payment mode must be stated for all plans that are offered to the applicant. All possible premiums for the applicant must be illustrated. The following items must be included in the outline of coverage in the order prescribed below and in substantially the following form, as approved by the director:\n\nBENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD\n\nON OR AFTER JUNE 1, 2010\n\nThis 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.\n\nPlans E, H, I, and J are no longer available for sale. (This sentence must not appear after June 1, 2011.)\n\nBASIC BENEFITS:\n\nHospitalization: Part A coinsurance plus coverage for 365\n\nadditional days after Medicare benefits end.\n\nMedical Expenses: Part B coinsurance (generally 20% of\n\nMedicare-approved expenses) or copayments for hospital\n\noutpatient services. Plans K, L, and N require insureds\n\nto pay a portion of Part B coinsurance or copayments.\n\nBlood: First three pints of blood each year.\n\nHospice: Part A coinsurance\n\nA\n\nB\n\nC**\n\nD\n\nF|F* **\n\nG/G*\n\nBasic,\n\nBasic,\n\nBasic,\n\nBasic,\n\nBasic,\n\nBasic,\n\nincluding\n\nincluding\n\nincluding\n\nincluding\n\nincluding\n\nincluding\n\n100% Part\n\n100% Part\n\n100% Part\n\n100% Part\n\n100% Part\n\n100% Part\n\nB coin-\n\nB coinsur-\n\nB coinsur-\n\nB coinsur-\n\nB coinsur-\n\nB coinsur-\n\nsurance\n\nance\n\nance\n\nance\n\nance\n\nance\n\nSkilled\n\nSkilled\n\nSkilled\n\nSkilled\n\nNursing\n\nNursing\n\nNursing\n\nNursing\n\nFacility\n\nFacility\n\nFacility\n\nFacility\n\nCoinsur-\n\nCoinsur-\n\nCoinsur-\n\nCoinsur-\n\nance\n\nance\n\nance\n\nance\n\nPart A\n\nPart A\n\nPart A\n\nPart A\n\nPart A\n\nDeductible\n\nDeductible\n\nDeductible\n\nDeductible\n\nDeductible\n\nPart B\n\nPart B\n\nDeductible\n\nDeductible\n\nPart B\n\nPart B\n\nExcess\n\nExcess\n\n(100%)\n\n(100%)\n\nForeign\n\nForeign\n\nForeign\n\nForeign\n\nTravel\n\nTravel\n\nTravel\n\nTravel\n\nEmergency\n\nEmergency\n\nEmergency\n\nEmergency\n\nK\n\nL\n\nM\n\nN\n\nHospitalization\n\nHospitalization\n\nBasic,\n\nBasic, includ-\n\nand preventive\n\nand preventive\n\nincluding 100%\n\ning 100% Part B\n\ncare paid at\n\ncare paid at\n\nPart B\n\ncoinsurance,\n\n100%; other\n\n100%; other\n\ncoinsurance\n\nexcept up to\n\nbasic benefits\nB\n\nExcess\n\nExcess\n\n(100%)\n\n(100%)\n\nForeign\n\nForeign\n\nForeign\n\nForeign\n\nTravel\n\nTravel\n\nTravel\n\nTravel\n\nEmergency\n\nEmergency\n\nEmergency\n\nEmergency\n\nK\n\nL\n\nM\n\nN\n\nHospitalization\n\nHospitalization\n\nBasic,\n\nBasic, includ-\n\nand preventive\n\nand preventive\n\nincluding 100%\n\ning 100% Part B\n\ncare paid at\n\ncare paid at\n\nPart B\n\ncoinsurance,\n\n100%; other\n\n100%; other\n\ncoinsurance\n\nexcept up to\n\nbasic benefits\n\nbasic benefits\n\n$20 copayment\n\npaid at 50%\n\npaid at 75%\n\nfor office\n\nvisit, and up\n\nto $50 copay-\n\nment for ER\n\n50% Skilled\n\n75% Skilled\n\nSkilled\n\nSkilled\n\nNursing\n\nNursing\n\nNursing\n\nNursing\n\nFacility\n\nFacility\n\nFacility\n\nFacility\n\nCoinsurance\n\nCoinsurance\n\nCoinsurance\n\nCoinsurance\n\n50% Part A\n\n75% Part A\n\n50% Part A\n\nPart A\n\nDeductible\n\nDeductible\n\nDeductible\n\nDeductible\n\nForeign\n\nForeign\n\nTravel\n\nTravel\n\nEmergency\n\nEmergency\n\nOut-of-pocket\n\nOut-of-pocket\n\nlimit $5,240;\n\nlimit $2,620;\n\npaid at 100%\n\npaid at 100%\n\nafter limit\n\nafter limit\n\nreached\n\nreached\n\n* Plans F and G also have options called high-deductible Plan F and high-deductible Plan G. These high-deductible plans pay the same benefits as Plan F or Plan G, as applicable, after one has paid a calendar year $2,240 deductible. Benefits from high-deductible Plan F or high-deductible Plan G will not begin until out-of-pocket expenses exceed $2,240. Out-of-pocket expenses for these deductibles 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.\n\n** Plan C, Plan F, and high-deductible Plan F are only available to individuals eligible for Medicare before January 1, 2020.\n\nPREMIUM INFORMATION\n\nWe (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).\n\nDISCLOSURES\n\nUse this outline to compare benefits and premiums among policies, certificates, and contracts.\n\nThis outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates before June 1, 2010 have different benefits and premiums. Plans E, H, I, and J are no longer available for sale. (This sentence must not appear after June 1, 2011.)\n\nREAD YOUR POLICY VERY CAREFULLY\n\nThis 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.\n\nRIGHT TO RETURN POLICY\n\nIf 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.\n\nPOLICY REPLACEMENT\n\nIf 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.\n\nNOTICE\n\nThis policy may not fully cover all of your medical costs.\n\n[For agent issued policies]\n\nNeither (insert insurer's name) nor its agents are connected with Medicare.\n\n[For direct response issued policies]\n\n(Insert insurer's name) is not connected with Medicare.\n\nThis 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.\n\nCOMPLETE ANSWERS ARE VERY IMPORTANT\n\nWhen 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.]\nils.\n\nCOMPLETE ANSWERS ARE VERY IMPORTANT\n\nWhen 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.]\n\nReview the application carefully before you sign it. Be certain that all information has been properly recorded.\n\n[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 under 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 director. 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:\n\nPLAN A\n\nMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD\n\n*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.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY\n\nHOSPITALIZATION*\n\nSemiprivate room and\n\nboard, general nursing\n\nand miscellaneous\n\nservices and supplies\n\nFirst 60 days\n\nAll but\n\n$0\n\n$1,340\n\n$1,340\n\n(Part A\n\nDeductible)\n\n61st thru 90th day\n\nAll but\n\n$335\n\n$0\n\n$335 a day\n\na day\n\n91st day and after:\n\n-While using 60\n\nlifetime reserve days\n\nAll but\n\n$670\n\n$0\n\n$670 a day\n\na day\n\n-Once lifetime reserve\n\ndays are used:\n\n-Additional 365 days\n\n$0\n\n100% of\n\n$0**\n\nMedicare\n\nEligible\n\nExpenses\n\n-Beyond the\n\nAdditional 365 days\n\n$0\n\n$0\n\nAll Costs\n\nSKILLED NURSING FACILITY\n\nCARE*\n\nYou must meet Medicare's\n\nrequirements, including\n\nhaving been in a hospital\n\nfor at least 3 days and\n\nentered a Medicare-\n\napproved facility within\n\n30 days after leaving the\n\nhospital\n\nFirst 20 days\n\nAll approved\n\namounts\n\n$0\n\n$0\n\n21st thru 100th day\n\nAll but\n\n$0\n\nUp to\n\n$167.50 a day\n\n$167.50 a day\n\n101st day and after\n\n$0\n\n$0\n\nAll costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n3 pints\n\n$0\n\nAdditional amounts\n\n100%\n\n$0\n\n$0\n\nHOSPICE CARE\n\nYou must meet\n\nAll but very\n\n$0\n\nMedicare's requirements\n\nlimited\n\nMedicare\n\nincluding a doctor's\n\ncopayment/\n\ncopayment/\n\ncertification of terminal\n\ncoinsurance\n\ncoinsurance\n\nillness\n\nfor outpatient\n\ndrugs and\n\ninpatient\n\nrespite care\n\n**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.\n\nPLAN A\n\nMEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR\n\n*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY\n\nMEDICAL EXPENSES-\n\nIn or out of the hospital\n\nand outpatient hospital\n\ntreatment, such as\n\nPhysician's services,\n\ninpatient and outpatient\n\nmedical and surgical\n\nservices and supplies,\n\nphysical and speech\n\ntherapy, diagnostic\n\ntests, durable medical\n\nequipment,\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nPart B Excess Charges\n\n(Above Medicare\n\nApproved Amounts)\n\n$0\n\n$0\n\nAll Costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\nAll Costs\n\n$0\n\nNext $183 of\n\nMedicare\n\n$0\n\n$0\n\n$183\n\nApproved Amounts*\n\n(Part B\n\nDeductible)\nand speech\n\ntherapy, diagnostic\n\ntests, durable medical\n\nequipment,\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nPart B Excess Charges\n\n(Above Medicare\n\nApproved Amounts)\n\n$0\n\n$0\n\nAll Costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\nAll Costs\n\n$0\n\nNext $183 of\n\nMedicare\n\n$0\n\n$0\n\n$183\n\nApproved Amounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nCLINICAL LABORATORY\n\nSERVICES-\n\nTests for\n\ndiagnostic services\n\n100%\n\n$0\n\n$0\n\nPARTS A \u0026 B\n\nHOME HEALTH CARE\n\nMedicare Approved\n\nServices\n\n-Medically necessary\n\nskilled care services\n\nand medical supplies\n\n100%\n\n$0\n\n$0\n\n-Durable medical\n\nequipment\n\nFirst $183 of\n\nMedicare\n\n$0\n\n$0\n\n$183\n\nApproved Amounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nPLAN B\n\nMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD\n\n*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.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY\n\nHOSPITALIZATION*\n\nSemiprivate room and\n\nboard, general nursing\n\nand miscellaneous\n\nservices and supplies\n\nFirst 60 days\n\nAll but\n\n$1,340\n\n$0\n\n$1,340\n\n(Part A\n\nDeductible)\n\n61st thru 90th day\n\nAll but\n\n$335\n\n$0\n\n$335 a day\n\na day\n\n91st day and after\n\n-While using 60\n\nlifetime reserve days\n\nAll but\n\n$670\n\n$0\n\n$670 a day\n\na day\n\n-Once lifetime reserve\n\ndays are used:\n\n-Additional 365 days\n\n$0\n\n100% of\n\n$0**\n\nMedicare\n\nEligible\n\nExpenses\n\n-Beyond the\n\nAdditional 365 days\n\n$0\n\n$0\n\nAll Costs\n\nSKILLED NURSING FACILITY\n\nCARE*\n\nYou must meet Medicare's\n\nrequirements, including\n\nhaving been in a hospital\n\nfor at least 3 days and\n\nentered a Medicare-\n\napproved facility within\n\n30 days after leaving the\n\nhospital\n\nFirst 20 days\n\nAll approved\n\namounts\n\n$0\n\n$0\n\n21st thru 100th day\n\nAll but\n\n$0\n\nUp to\n\n$167.50 a day\n\n$167.50 a day\n\n101st day and after\n\n$0\n\n$0\n\nAll costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n3 pints\n\n$0\n\nAdditional amounts\n\n100%\n\n$0\n\n$0\n\nHOSPICE CARE\n\nAll but very\n\nlimited\n\nMedicare\n\n$0\n\ncopayment/\n\ncopayment/\n\ncoinsurance\n\ncoinsurance\n\nYou must meet\n\nfor outpatient\n\nMedicare's requirements,\n\ndrugs and\n\nincluding a doctor's\n\ninpatient\n\ncertification of\n\nrespite care\n\nterminal illness\n\n**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.\n\nPLAN B\n\nMEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR\n\n*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY\n\nMEDICAL EXPENSES-\n\nIn or out of the hospital\n\nand outpatient hospital\n\ntreatment, such as\n\nPhysician's services,\n\ninpatient and outpatient\n\nmedical and surgical\n\nservices and supplies,\n\nphysical and speech\n\ntherapy, diagnostic\n\ntests, durable medical\n\nequipment,\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nPart B Excess Charges\n\n(Above Medicare\n\nApproved Amounts)\n\n$0\n\n$0\n\nAll Costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\nAll Costs\n\n$0\n\nNext $183 of Medicare\n\nApproved Amounts*\n\n$0\n\n$0\n\n$183\n\n(Part B\n\nRemainder of Medicare\n\nDeductible)\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nCLINICAL LABORATORY\n\nSERVICES-\n\nTests for\n\ndiagnostic services\n\n100%\n\n$0\n\n$0\n\nPARTS A \u0026 B\n\nHOME HEALTH CARE\n\nMedicare Approved\n\nServices\n\n-Medically necessary\n\nskilled care services\n\nand medical supplies\n\n100%\n\n$0\n\n$0\n\n-Durable medical\n\nequipment\n\nFirst $183 of\n\nMedicare\n$183 of Medicare\n\nApproved Amounts*\n\n$0\n\n$0\n\n$183\n\n(Part B\n\nRemainder of Medicare\n\nDeductible)\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nCLINICAL LABORATORY\n\nSERVICES-\n\nTests for\n\ndiagnostic services\n\n100%\n\n$0\n\n$0\n\nPARTS A \u0026 B\n\nHOME HEALTH CARE\n\nMedicare Approved\n\nServices\n\n-Medically necessary\n\nskilled care services\n\nand medical supplies\n\n100%\n\n$0\n\n$0\n\n-Durable medical\n\nequipment\n\nFirst $183 of\n\nMedicare\n\nApproved Amounts*\n\n$0\n\n$0\n\n$183\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nPLAN C\n\nMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD\n\n*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.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY\n\nHOSPITALIZATION*\n\nSemiprivate room and\n\nboard, general nursing\n\nand miscellaneous\n\nservices and supplies\n\nFirst 60 days\n\nAll but\n\n$1,340\n\n$0\n\n$1,340\n\n(Part A\n\nDeductible)\n\n61st thru 90th day\n\nAll but\n\n$335\n\n$0\n\n$335 a day\n\na day\n\n91st day and after\n\n-While using 60\n\nlifetime reserve days\n\nAll but\n\n$670\n\n$0\n\n$670 a day\n\na day\n\n-Once lifetime reserve\n\ndays are used:\n\n-Additional 365 days\n\n$0\n\n100% of\n\n$0**\n\nMedicare\n\nEligible\n\nExpenses\n\n-Beyond the\n\nAdditional 365 days\n\n$0\n\n$0\n\nAll Costs\n\nSKILLED NURSING FACILITY\n\nCARE*\n\nYou must meet Medicare's\n\nrequirements, including\n\nhaving been in a hospital\n\nfor at least 3 days and\n\nentered a Medicare-\n\napproved facility within\n\n30 days after leaving the\n\nhospital\n\nFirst 20 days\n\nAll approved\n\namounts\n\n$0\n\n$0\n\n21st thru 100th day\n\nAll but\n\nUp to\n\n$0\n\n$167.50 a day\n\n$167.50 a day\n\n101st day and after\n\n$0\n\n$0\n\nAll costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n3 pints\n\n$0\n\nAdditional amounts\n\n100%\n\n$0\n\n$0\n\nHOSPICE CARE\n\nAll but very\n\n$0\n\nlimited\n\nMedicare\n\ncopayment/\n\ncopayment/\n\ncoinsurance\n\ncoinsurance\n\nYou must meet\n\nfor outpatient\n\nMedicare's requirements,\n\ndrugs and\n\nincluding a doctor's\n\ninpatient\n\ncertification of\n\nrespite care\n\nterminal illness\n\n**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.\n\nPLAN C\n\nMEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR\n\n*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY\n\nMEDICAL EXPENSES-\n\nIn or out of the hospital\n\nand outpatient hospital\n\ntreatment, such as\n\nPhysician's services,\n\ninpatient and outpatient\n\nmedical and surgical\n\nservices and supplies,\n\nphysical and speech\n\ntherapy, diagnostic\n\ntests, durable medical\n\nequipment,\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$183\n\n$0\n\nAmounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nPart B Excess Charges\n\n(Above Medicare\n\nApproved Amounts)\n\n$0\n\n$0\n\nAll Costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\nAll Costs\n\n$0\n\nNext $183 of Medicare\n\nApproved Amounts*\n\n$0\n\n$183\n\n$0\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nCLINICAL LABORATORY\n\nSERVICES-\n\nTests for\n\ndiagnostic services\n\n100%\n\n$0\n\n$0\n\nPARTS A \u0026 B\n\nHOME HEALTH CARE\n\nMedicare Approved\n\nServices\n\n-Medically necessary\n\nskilled care services\n\nand medical supplies\n\n100%\n\n$0\n\n$0\n\n-Durable medical\n\nequipment\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$183\n\n$0\n\nAmounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nOTHER BENEFITS-NOT COVERED BY MEDICARE\n\nFOREIGN TRAVEL-\n\nNot covered by Medicare\n\nMedically necessary\n\nemergency care services\n\nbeginning during the\n\nfirst 60 days of each\n\ntrip outside the USA\n\nFirst $250 each\nl supplies\n\n100%\n\n$0\n\n$0\n\n-Durable medical\n\nequipment\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$183\n\n$0\n\nAmounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nOTHER BENEFITS-NOT COVERED BY MEDICARE\n\nFOREIGN TRAVEL-\n\nNot covered by Medicare\n\nMedically necessary\n\nemergency care services\n\nbeginning during the\n\nfirst 60 days of each\n\ntrip outside the USA\n\nFirst $250 each\n\ncalendar year\n\n$0\n\n$0\n\n$250\n\nRemainder of charges\n\n$0\n\n80% to a\n\n20% and\n\nlifetime\n\namounts\n\nmaximum\n\nover the\n\nbenefit\n\n$50,000\n\nof $50,000\n\nlifetime\n\nmaximum\n\nPLAN D\n\nMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD\n\n*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.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY\n\nHOSPITALIZATION*\n\nSemiprivate room and\n\nboard, general nursing\n\nand miscellaneous\n\nservices and supplies\n\nFirst 60 days\n\nAll but\n\n$1,340\n\n$0\n\n$1,340\n\n(Part A\n\nDeductible)\n\n61st thru 90th day\n\nAll but\n\n$335\n\n$0\n\n$335 a day\n\na day\n\n91st day and after\n\n-While using 60\n\nlifetime reserve days\n\nAll but\n\n$670\n\n$0\n\n$670 a day\n\na day\n\n-Once lifetime reserve\n\ndays are used:\n\n-Additional 365 days\n\n$0\n\n100% of\n\n$0**\n\nMedicare\n\nEligible\n\nExpenses\n\n-Beyond the\n\nAdditional 365 days\n\n$0\n\n$0\n\nAll Costs\n\nSKILLED NURSING FACILITY\n\nCARE*\n\nYou must meet Medicare's\n\nrequirements, including\n\nhaving been in a hospital\n\nfor at least 3 days and\n\nentered a Medicare-\n\napproved facility within\n\n30 days after leaving the\n\nhospital\n\nFirst 20 days\n\nAll approved\n\namounts\n\n$0\n\n$0\n\n21st thru 100th day\n\nAll but\n\nUp to\n\n$0\n\n$167.50 a day\n\n$167.50 a day\n\n101st day and after\n\n$0\n\n$0\n\nAll costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n3 pints\n\n$0\n\nAdditional amounts\n\n100%\n\n$0\n\n$0\n\nHOSPICE CARE\n\nAll but very\n\nMedicare\n\n$0\n\nlimited\n\ncopayment/\n\ncopayment/\n\ncoinsurance\n\ncoinsurance\n\nYou must meet\n\nfor outpatient\n\nMedicare's requirements,\n\ndrugs and\n\nincluding a doctor's\n\ninpatient\n\ncertification of\n\nrespite care\n\nterminal illness\n\n**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.\n\nPLAN D\n\nMEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR\n\n*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY\n\nMEDICAL EXPENSES-\n\nIn or out of the hospital\n\nand outpatient hospital\n\ntreatment, such as\n\nPhysician's services,\n\ninpatient and outpatient\n\nmedical and surgical\n\nservices and supplies,\n\nphysical and speech\n\ntherapy, diagnostic\n\ntests, durable medical\n\nequipment,\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nPart B Excess Charges\n\n(Above Medicare\n\nApproved Amounts)\n\n$0\n\n$0\n\nAll Costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\nAll Costs\n\n$0\n\nNext $183 of Medicare\n\nApproved Amounts*\n\n$0\n\n$0\n\n$183\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nCLINICAL LABORATORY\n\nSERVICES-\n\nTests for\n\ndiagnostic services\n\n100%\n\n$0\n\n$0\n\nPARTS A \u0026 B\n\nHOME HEALTH CARE\n\nMedicare Approved\n\nServices\n\n-Medically necessary\n\nskilled care services\n\nand medical supplies\n\n100%\n\n$0\n\n$0\n\n-Durable medical\n\nequipment\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nOTHER BENEFITS-NOT COVERED BY MEDICARE\n\nFOREIGN TRAVEL-\n\nNot covered by Medicare\n\nMedically necessary\n\nemergency care services\n\nbeginning during the\n\nfirst 60 days of each\nsary\n\nskilled care services\n\nand medical supplies\n\n100%\n\n$0\n\n$0\n\n-Durable medical\n\nequipment\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nOTHER BENEFITS-NOT COVERED BY MEDICARE\n\nFOREIGN TRAVEL-\n\nNot covered by Medicare\n\nMedically necessary\n\nemergency care services\n\nbeginning during the\n\nfirst 60 days of each\n\ntrip outside the USA\n\nFirst $250 each\n\ncalendar year\n\n$0\n\n$0\n\n$250\n\nRemainder of charges\n\n$0\n\n80% to a\n\n20% and\n\nlifetime\n\namounts\n\nmaximum\n\nover the\n\nbenefit\n\n$50,000\n\nof $50,000\n\nlifetime\n\nmaximum\n\nPLAN F OR HIGH-DEDUCTIBLE PLAN F\n\nMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD\n\n*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.\n\n**This high-deductible plan pays the same benefits as plan F after you have paid a calendar year $2,240 deductible. Benefits from the high-deductible plan F will not begin until out-of-pocket expenses are $2,240. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes Medicare deductibles for part A and part B, but does not include the plan's separate foreign travel emergency deductible.\n\nSERVICES\n\nMEDICARE\n\nAFTER YOU\n\nIN ADDITION\n\nPAYS\n\nPAY\n\nTO\n\n$2,240\n\n$2,240\n\nDEDUCTIBLE**,\n\nDEDUCTIBLE**,\n\nPLAN PAYS\n\nYOU PAY\n\nHOSPITALIZATION*\n\nSemiprivate room and\n\nboard, general nursing\n\nand miscellaneous\n\nservices and supplies\n\nFirst 60 days\n\nAll but\n\n$1,340\n\n$0\n\n$1,340\n\n(Part A\n\nDeductible)\n\n61st thru 90th day\n\nAll but\n\n$335\n\n$0\n\n$335 a day\n\na day\n\n91st day and after\n\n-While using 60\n\nlifetime reserve days\n\nAll but\n\n$670\n\n$0\n\n$670 a day\n\na day\n\n-Once lifetime reserve\n\ndays are used:\n\n-Additional 365 days\n\n$0\n\n100% of\n\n$0***\n\nMedicare\n\nEligible\n\nExpenses\n\n-Beyond the\n\nAdditional 365 days\n\n$0\n\n$0\n\nAll Costs\n\nSKILLED NURSING FACILITY\n\nCARE*\n\nYou must meet Medicare's\n\nrequirements, including\n\nhaving been in a\n\nhospital for at least\n\n3 days and entered a\n\nMedicare-approved\n\nfacility within 30 days\n\nafter leaving the\n\nhospital\n\nFirst 20 days\n\nAll approved\n\namounts\n\n$0\n\n$0\n\n21st thru 100th day\n\nAll but\n\nUp to\n\n$0\n\n$167.50 a day\n\n$167.50 a day\n\n101st day and after\n\n$0\n\n$0\n\nAll costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n3 pints\n\n$0\n\nAdditional amounts\n\n100%\n\n$0\n\n$0\n\nHOSPICE CARE\n\nAll but very\n\nMedicare\n\n$0\n\nlimited\n\ncopayment/\n\ncopayment/\n\ncoinsurance\n\ncoinsurance\n\nYou must\n\nfor\n\nmeet Medicare's\n\noutpatient\n\nrequirements, including\n\ndrugs and\n\na doctor's certification\n\ninpatient\n\nof terminal illness\n\nrespite care\n\n***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.\n\nPLAN F\n\nMEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR\n\n*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.\n\n**This high-deductible plan pays the same benefits as plan F after you have paid a calendar year $2,240 deductible. Benefits from the high-deductible plan F will not begin until out-of-pocket expenses are $2,240. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes Medicare deductibles for part A and part B, but does not include the plan's separate foreign travel emergency deductible.\n\nSERVICES\n\nMEDICARE\n\nAFTER YOU\n\nIN ADDITION\n\nPAYS\n\nPAY\n\nTO\n\n$2,240\n\n$2,240\n\nDEDUCTIBLE**,\n\nDEDUCTIBLE**,\n\nPLAN PAYS\n\nYOU PAY\n\nMEDICAL EXPENSES-\n\nIn or out of the hospital\n\nand outpatient hospital\ndeductible 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.\n\nSERVICES\n\nMEDICARE\n\nAFTER YOU\n\nIN ADDITION\n\nPAYS\n\nPAY\n\nTO\n\n$2,240\n\n$2,240\n\nDEDUCTIBLE**,\n\nDEDUCTIBLE**,\n\nPLAN PAYS\n\nYOU PAY\n\nMEDICAL EXPENSES-\n\nIn or out of the hospital\n\nand outpatient hospital\n\ntreatment, such as\n\nPhysician's services,\n\ninpatient and outpatient\n\nmedical and surgical\n\nservices and supplies,\n\nphysical and speech\n\ntherapy, diagnostic\n\ntests, durable medical\n\nequipment,\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$183\n\n$0\n\nAmounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nPart B Excess Charges\n\n(Above Medicare\n\nApproved Amounts)\n\n$0\n\n100%\n\n$0\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\nAll Costs\n\n$0\n\nNext $183 of\n\nMedicare Approved\n\n$0\n\n$183\n\n$0\n\nAmounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nCLINICAL LABORATORY\n\nSERVICES-\n\nTests for\n\ndiagnostic services\n\n100%\n\n$0\n\n$0\n\nPARTS A \u0026 B\n\nHOME HEALTH CARE\n\nMedicare Approved\n\nServices\n\n-Medically necessary\n\nskilled care services\n\nand medical supplies\n\n100%\n\n$0\n\n$0\n\n-Durable medical\n\nequipment\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$183\n\n$0\n\nAmounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nOTHER BENEFITS-NOT COVERED BY MEDICARE\n\nFOREIGN TRAVEL-\n\nNot covered by Medicare\n\nMedically necessary\n\nemergency care services\n\nbeginning during the\n\nfirst 60 days of each\n\ntrip outside the USA\n\nFirst $250 each\n\ncalendar year\n\n$0\n\n$0\n\n$250\n\nRemainder of charges\n\n$0\n\n80% to a\n\n20% and\n\nlifetime\n\namounts\n\nmaximum\n\nover the\n\nbenefit\n\n$50,000\n\nof $50,000\n\nlifetime\n\nmaximum\n\nPLAN G OR HIGH-DEDUCTIBLE PLAN G\n\nMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD\n\n*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.\n\n** This high-deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,240 deductible. Benefits from the high-deductible Plan G will not begin until out-of-pocket expenses are $2,240. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.\n\nSERVICES\n\nMEDICARE PAYS\n\nAFTER YOU\n\nIN ADDITION\n\nPAY\n\nTO\n\n$2,240\n\n$2,240\n\nDEDUCTIBLE**,\n\nDEDUCTIBLE**,\n\nPLAN PAYS\n\nYOU PAY\n\nHOSPITALIZATION*\n\nSemiprivate room and\n\nboard, general nursing\n\nand miscellaneous\n\nservices and supplies\n\nFirst 60 days\n\nAll but\n\n$1,340\n\n$0\n\n$1,340\n\n(Part A\n\nDeductible)\n\n61st thru 90th day\n\nAll but\n\n$335\n\n$0\n\n$335 a day\n\na day\n\n91st day and after\n\n-While using 60\n\nlifetime reserve days\n\nAll but\n\n$670\n\n$0\n\n$670 a day\n\na day\n\n-Once lifetime reserve\n\ndays are used:\n\n-Additional 365 days\n\n$0\n\n100% of\n\n$0***\n\nMedicare\n\nEligible\n\nExpenses\n\n-Beyond the\n\nAdditional 365 days\n\n$0\n\n$0\n\nAll Costs\n\nSKILLED NURSING FACILITY\n\nCARE*\n\nYou must meet Medicare's\n\nrequirements, including\n\nhaving been in a hospital\n\nfor at least 3 days and\n\nentered a Medicare-\n\napproved facility within\n\n30 days after leaving the\n\nhospital\n\nFirst 20 days\n\nAll approved\n\namounts\n\n$0\n\n$0\n\n21st thru 100th day\n\nAll but\n\nUp to\n\n$0\n\n$167.50 a day\n\n$167.50 a day\n\n101st day and after\n\n$0\n\n$0\n\nAll costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n3 pints\n\n$0\n\nAdditional amounts\n\n100%\n\n$0\n\n$0\n\nHOSPICE CARE\n\nAll but very\n\n$0\n\nlimited\n\nMedicare\n\ncopayment/\n\ncopayment/\n\ncoinsurance\n\ncoinsurance\n\nYou must meet\n\nfor outpatient\n\nMedicare's requirements,\n\ndrugs and\n\nincluding a doctor's\n\ninpatient\n\ncertification of\n\nrespite care\n\nterminal illness\no\n\n$0\n\n$167.50 a day\n\n$167.50 a day\n\n101st day and after\n\n$0\n\n$0\n\nAll costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n3 pints\n\n$0\n\nAdditional amounts\n\n100%\n\n$0\n\n$0\n\nHOSPICE CARE\n\nAll but very\n\n$0\n\nlimited\n\nMedicare\n\ncopayment/\n\ncopayment/\n\ncoinsurance\n\ncoinsurance\n\nYou must meet\n\nfor outpatient\n\nMedicare's requirements,\n\ndrugs and\n\nincluding a doctor's\n\ninpatient\n\ncertification of\n\nrespite care\n\nterminal illness\n\n***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.\n\nPLAN G OR HIGH-DEDUCTIBLE PLAN G\n\nMEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR\n\n*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.\n\n** This high-deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,240 deductible. Benefits from the high-deductible Plan G will not begin until out-of-pocket expenses are $2,240. Out-of-pocket expenses for this deductible include expenses for the Medicare part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.\n\nSERVICES\n\nMEDICARE PAYS\n\nAFTER YOU\n\nIN ADDITION\n\nPAY\n\nTO\n\n$2,240\n\n$2,240\n\nDEDUCTIBLE**,\n\nDEDUCTIBLE**,\n\nPLAN PAYS\n\nYOU PAY\n\nMEDICAL EXPENSES-\n\nIn or out of the hospital\n\nand outpatient hospital\n\ntreatment, such as\n\nPhysician's services,\n\ninpatient and outpatient\n\nmedical and surgical\n\nservices and supplies,\n\nphysical and speech\n\ntherapy, diagnostic\n\ntests, durable medical\n\nequipment,\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$163\n\nAmounts*\n\n(Unless\n\nPart B\n\nDeductible\n\nhas been\n\nmet)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nPart B Excess Charges\n\n(Above Medicare\n\nApproved Amounts)\n\n$0\n\n100%\n\n0%\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\nAll Costs\n\n$0\n\nNext $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts*\n\n(Unless\n\nPart B\n\nDeductible\n\nhas been\n\nmet)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nCLINICAL LABORATORY\n\nSERVICES-\n\nTests for\n\ndiagnostic services\n\n100%\n\n$0\n\n$0\n\nPARTS A \u0026 B\n\nHOME HEALTH CARE\n\nMedicare Approved\n\nServices\n\n-Medically necessary\n\nskilled care services\n\nand medical supplies\n\n100%\n\n$0\n\n$0\n\n-Durable medical\n\nequipment\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts*\n\n(Part B\n\nDeductible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nOTHER BENEFITS-NOT COVERED BY MEDICARE\n\nFOREIGN TRAVEL-\n\nNot covered by Medicare\n\nMedically necessary\n\nemergency care services\n\nbeginning during the\n\nfirst 60 days of each\n\ntrip outside the USA\n\nFirst $250 each\n\ncalendar year\n\n$0\n\n$0\n\n$250\n\nRemainder of charges\n\n$0\n\n80% to a\n\n20% and\n\nlifetime\n\namounts\n\nmaximum\n\nover the\n\nbenefit\n\n$50,000\n\nof $50,000\n\nlifetime\n\nmaximum\n\nPLAN K\n\n*You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $5,240 each calendar year. The amounts that count toward your annual limit are noted with diamonds 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.\n\nPLAN K\n\nMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD\ncoinsurance 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.\n\nPLAN K\n\nMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD\n\n**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.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY*\n\nHOSPITALIZATION**\n\nSemiprivate room and\n\nboard, general nursing\n\nand miscellaneous\n\nservices and supplies\n\nFirst 60 days\n\nAll but\n\n$670\n\n$670\n\n$1,340\n\n(50%\n\n(50% of\n\nof Part A\n\nPart A\n\nDeducti-\n\nDeductible) 1\n\nble)\n\n61st thru 90th day\n\nAll but\n\n$335\n\n$0\n\n$335 a day\n\na day\n\n91st day and after:\n\n-While using 60\n\nlifetime reserve days\n\nAll but\n\n$670\n\n$0\n\n$670 a day\n\na day\n\n-Once lifetime reserve\n\ndays are used:\n\n-Additional 365 days\n\n$0\n\n100% of\n\n$0***\n\nMedicare\n\nEligible\n\nExpenses\n\n-Beyond the\n\nAdditional 365 days\n\n$0\n\n$0\n\nAll Costs\n\nSKILLED NURSING FACILITY\n\nCARE**\n\nYou must meet Medicare's\n\nrequirements, including\n\nhaving been in a hospital\n\nfor at least 3 days and\n\nentered a Medicare-\n\napproved facility within\n\n30 days after leaving the\n\nhospital\n\nFirst 20 days\n\nAll approved\n\namounts\n\n$0\n\n$0\n\n21st thru 100th day\n\nAll but\n\nUp to\n\nUp to\n\n$167.50 a\n\n$83.75\n\n$83.75\n\nday\n\na day\n\na day 1\n\n101st day and after\n\n$0\n\n$0\n\nAll costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n50%\n\n50% 1\n\nAdditional amounts\n\n100%\n\n$0\n\n$0\n\nHOSPICE CARE\n\n50% of\n\n50% of\n\ncopayment/\n\nMedicare\n\ncoinsur-\n\ncopayment/\n\nance\n\ncoinsurance 1\n\nYou must meet\n\nMedicare's requirements,\n\nincluding a doctor's\n\ncertification of terminal\n\nillness\n\nAll but very\n\nlimited\n\ncopayment/\n\ncoinsurance for\n\noutpatient\n\ndrugs and\n\ninpatient\n\nrespite care\n\n***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.\n\nPLAN K\n\nMEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR\n\n****Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY*\n\nMEDICAL EXPENSES-\n\nIn or out of the hospital\n\nand outpatient hospital\n\ntreatment, such as\n\nPhysician's services,\n\ninpatient and outpatient\n\nmedical and surgical\n\nservices and supplies,\n\nphysical and speech\n\ntherapy, diagnostic\n\ntests, durable medical\n\nequipment,\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts****\n\n(Part B\n\nDeductible)\n\n**** 1\n\nPreventive Benefits for\n\nGenerally 75%\n\nRemainder\n\nAll costs\n\nMedicare covered\n\nor more of\n\nof Medi-\n\nabove Medi-\n\nservices\n\nMedicare ap-\n\ncare\n\ncare\n\nproved amounts\n\napproved\n\napproved\n\namounts\n\namounts\n\nRemainder of Medicare\n\nGenerally 80%\n\nGenerally\n\nGenerally\n\nApproved Amounts\n\n10%\n\n10% 1\n\nPart B Excess Charges\n\n$0\n\n$0\n\nAll costs\n\n(Above Medicare\n\n(and they do\n\nApproved Amounts)\n\nnot count\n\ntoward\n\nannual out-\n\nof-pocket\n\nlimit of\n\n$5,240)*\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n50%\n\n50% 1\n\nNext $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts****\n\n(Part B\n\nDeductible)\n\n**** 1\n\nRemainder of Medicare\n\nGenerally 80%\n\nGenerally\n\nGenerally\n\nApproved Amounts\n\n10%\n\n10% 1\n\nCLINICAL LABORATORY\n\nSERVICES-Tests for\n\ndiagnostic services\n\n100%\n\n$0\n\n$0\ne Medicare\n\n(and they do\n\nApproved Amounts)\n\nnot count\n\ntoward\n\nannual out-\n\nof-pocket\n\nlimit of\n\n$5,240)*\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n50%\n\n50% 1\n\nNext $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts****\n\n(Part B\n\nDeductible)\n\n**** 1\n\nRemainder of Medicare\n\nGenerally 80%\n\nGenerally\n\nGenerally\n\nApproved Amounts\n\n10%\n\n10% 1\n\nCLINICAL LABORATORY\n\nSERVICES-Tests for\n\ndiagnostic services\n\n100%\n\n$0\n\n$0\n\n*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $5,240 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called \"Excess Charges\") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.\n\nPARTS A \u0026 B\n\nHOME HEALTH CARE\n\nMedicare Approved\n\nServices\n\n-Medically necessary\n\nskilled care services\n\nand medical supplies\n\n100%\n\n$0\n\n$0\n\n-Durable medical\n\nequipment\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts*****\n\n(Part B\n\nDeductible)1\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n10%\n\n10% 1\n\n*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.\n\nPLAN L\n\n*You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2,620 each calendar year. The amounts that count toward your annual limit are noted with diamonds 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.\n\nPLAN L\n\nMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD\n\n**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.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY*\n\nHOSPITALIZATION**\n\nSemiprivate room and\n\nboard, general nursing\n\nand miscellaneous\n\nservices and supplies\n\nFirst 60 days\n\nAll but\n\n$1,005\n\n$335\n\n$1,340\n\n(75% of\n\n(25% of\n\nPart A\n\nPart A\n\nDeducti-\n\nDeductible) 1\n\nble)\n\n61st thru 90th day\n\nAll but\n\n$335\n\n$0\n\n$335 a day\n\na day\n\n91st day and after:\n\n-While using 60\n\nlifetime reserve days\n\nAll but\n\n$670\n\n$0\n\n$670 a day\n\na day\n\n-Once lifetime reserve\n\ndays are used:\n\n-Additional 365 days\n\n$0\n\n100% of\n\n$0***\n\nMedicare\n\nEligible\n\nExpenses\n\n-Beyond the\n\nAdditional 365 days\n\n$0\n\n$0\n\nAll Costs\n\nSKILLED NURSING FACILITY\n\nCARE**\n\nYou must meet Medicare's\n\nrequirements, including\n\nhaving been in a hospital\n\nfor at least 3 days and\n\nentered a Medicare-\n\napproved facility within\n\n30 days after leaving the\n\nhospital\n\nFirst 20 days\n\nAll approved\n\namounts\n\n$0\n\n$0\n\n21st thru 100th day\n\nAll but\n\nUp to\n\nUp to\n\n$167.50 a\n\n$125.63\n\n$41.88\n\nday\n\na day\n\na day 1\n\n101st day and after\n\n$0\n\n$0\n\nAll costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n75%\n\n25% 1\n\nAdditional amounts\n\n100%\n\n$0\n\n$0\n\nHOSPICE CARE\n\n75% of\n\n25% of\n\ncopayment/\n\ncopayment/\n\ncoinsur-\n\ncoinsurance 1\n\nance\n\nYou must meet\n\nMedicare's requirements,\n\nincluding a doctor's\n\ncertification of terminal\n\nAll\n\nillness\n\nbut very\n\nlimited copay-\n\nment/coinsur-\n\nance for\n\noutpatient\n\ndrugs and\n\ninpatient\n\nrespite care\n\n***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.\n\nPLAN L\nedicare 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.\n\nPLAN L\n\nMEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR\n\n****Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY*\n\nMEDICAL EXPENSES-\n\nIn or out of the hospital\n\nand outpatient hospital\n\ntreatment, such as\n\nPhysician's services,\n\ninpatient and outpatient\n\nmedical and surgical\n\nservices and supplies,\n\nphysical and speech\n\ntherapy, diagnostic\n\ntests, durable medical\n\nequipment,\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts****\n\n(Part\n\nB Deducti-\n\nble)**** 1\n\nPreventive Benefits for\n\nGenerally 75%\n\nRemainder\n\nAll costs\n\nMedicare covered\n\nor more of\n\nof Medi-\n\nabove Medi-\n\nservices\n\nMedicare\n\ncare\n\ncare\n\napproved\n\napproved\n\napproved\n\namounts\n\namounts\n\namounts\n\nRemainder of Medicare\n\nGenerally\n\nGenerally\n\nGenerally\n\nApproved Amounts\n\n80%\n\n15%\n\n5% 1\n\nPart B Excess Charges\n\n$0\n\n$0\n\nAll costs\n\n(Above Medicare\n\n(and they do\n\nApproved Amounts)\n\nnot count\n\ntoward\n\nannual out-\n\nof-pocket\n\nlimit of\n\n$2,620)*\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n75%\n\n25% 1\n\nNext $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts****\n\n(Part B\n\nDeductible) 1\n\nRemainder of Medicare\n\nGenerally\n\nGenerally\n\nGenerally\n\nApproved Amounts\n\n80%\n\n15%\n\n5% 1\n\nCLINICAL LABORATORY\n\nSERVICES-Tests for\n\ndiagnostic services\n\n100%\n\n$0\n\n$0\n\n*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2,620 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called \"Excess Charges\") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.\n\nPARTS A \u0026 B\n\nHOME HEALTH CARE\n\nMedicare Approved\n\nServices\n\n-Medically necessary\n\nskilled care services\n\nand medical supplies\n\n100%\n\n$0\n\n$0\n\n-Durable medical\n\nequipment\n\nFirst $183 of\n\nMedicare Approved\n\n$0\n\n$0\n\n$183\n\nAmounts*****\n\n(Part\n\nB Deducti-\n\nble) 1\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n15%\n\n5% 1\n\n*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.\n\nPLAN M\n\nMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD\n\n*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.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY\n\nHOSPITALIZATION*\n\nSemiprivate room and\n\nboard, general nursing\n\nand miscellaneous\n\nservices and supplies\n\nFirst 60 days\n\nAll but $1,340\n\n$670 (50%\n\n$670 (50%\n\nof Part A\n\nof Part A\n\nDeduc-\n\nDeduc-\n\ntible)\n\ntible)\n\n61st thru 90th day\n\nAll but $335\n\n$335\n\n$0\n\na day\n\na day\n\n91st day and after:\n\n-While using 60\n\nlifetime reserve days\n\nAll but $670\n\n$670\n\n$0\n\na day\n\na day\n\n-Once lifetime reserve\n\ndays are used:\n\n-Additional 365 days\n\n$0\n\n100% of\n\n$0**\n\nMedicare\n\nEligible\n\nExpenses\n\n-Beyond the\n\nAdditional 365 days\n\n$0\n\n$0\n\nAll Costs\n\nSKILLED NURSING FACILITY\n\nCARE*\n\nYou must meet Medicare's\n\nrequirements, including\n\nhaving been in a hospital\n\nfor at least 3 days and\n\nentered a Medicare-\n\napproved facility within\n\n30 days after leaving the\n\nhospital\n\nFirst 20 days\n\nAll approved\n\n$0\n\n$0\n\namounts\n\n21st thru 100th day\n\nAll but $167.50\n\nUp to $167.50\n\n$0\n\na day\n\na day\n\n101st day and after\n\n$0\n\n$0\n\nAll costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n3 pints\n\n$0\n\nAdditional amounts\n\n100%\n\n$0\n\n$0\n\nHOSPICE CARE\n\nYou must meet Medicare's\n\nAll but very\n\nMedicare\n\n$0\nt least 3 days and\n\nentered a Medicare-\n\napproved facility within\n\n30 days after leaving the\n\nhospital\n\nFirst 20 days\n\nAll approved\n\n$0\n\n$0\n\namounts\n\n21st thru 100th day\n\nAll but $167.50\n\nUp to $167.50\n\n$0\n\na day\n\na day\n\n101st day and after\n\n$0\n\n$0\n\nAll costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n3 pints\n\n$0\n\nAdditional amounts\n\n100%\n\n$0\n\n$0\n\nHOSPICE CARE\n\nYou must meet Medicare's\n\nAll but very\n\nMedicare\n\n$0\n\nrequirements, including\n\nlimited\n\ncopayment/\n\na doctor's\n\ncopayment/\n\ncoinsurance\n\ncertification of\n\ncoinsurance\n\nterminal illness\n\nfor outpatient\n\ndrugs and\n\ninpatient\n\nrespite care\n\n**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.\n\nPLAN M\n\nMEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR\n\n*Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY\n\nMEDICAL EXPENSES-\n\nIn or out of the\n\nhospital and outpatient\n\nhospital treatment, such\n\nas Physician's services,\n\ninpatient and outpatient\n\nmedical and surgical\n\nservices and supplies,\n\nphysical and speech\n\ntherapy, diagnostic\n\ntests, durable medical\n\nequipment\n\nFirst $183 of Medicare\n\nApproved Amounts*\n\n$0\n\n$0\n\n$183\n\n(Part B\n\nDeduc-\n\ntible)\n\nRemainder of Medicare\n\nApproved Amounts\n\nGenerally\n\nGenerally\n\n$0\n\n80%\n\n20%\n\nPart B Excess Charges\n\n(Above Medicare\n\nApproved Amounts)\n\n$0\n\n$0\n\nAll Costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\nAll costs\n\n$0\n\nNext $183 of Medicare\n\nApproved Amounts*\n\n$0\n\n$0\n\n$183\n\n(Part B\n\nDeduc-\n\ntible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nCLINICAL LABORATORY\n\nSERVICES-Tests for\n\ndiagnostic services\n\n100%\n\n$0\n\n$0\n\nPARTS A \u0026 B\n\nHOME HEALTH CARE\n\nMedicare Approved\n\nServices\n\n-Medically necessary\n\nskilled care services\n\nand medical supplies\n\n100%\n\n$0\n\n$0\n\n-Durable medical\n\nequipment\n\nFirst $183 of\n\nMedicare Approved\n\nAmounts\n\n$0\n\n$0\n\n$183\n\n(Part B\n\nDeduc-\n\ntible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nOTHER BENEFITS-NOT COVERED BY MEDICARE\n\nFOREIGN TRAVEL-Not\n\ncovered by Medicare\n\nMedically necessary\n\nemergency care services\n\nbeginning during the\n\nfirst 60 days of each\n\ntrip outside the USA\n\nFirst $250 each\n\ncalendar year\n\n$0\n\n$0\n\n$250\n\nRemainder of Charges\n\n$0\n\n80% to a\n\n20% and\n\nlifetime\n\namounts\n\nmaximum\n\nover the\n\nbenefit of\n\n$50,000\n\n$50,000\n\nlifetime\n\nmaximum\n\nPLAN N\n\nMEDICARE (PART A)-HOSPITAL SERVICES-PER BENEFIT PERIOD\n\n*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.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY*\n\nHOSPITALIZATION*\n\nSemiprivate room and\n\nboard, general nursing\n\nand miscellaneous\n\nservices and supplies\n\nFirst 60 days\n\nAll but $1,340\n\n$1,340\n\n$0\n\n(Part A\n\nDeduc-\n\ntible)\n\n61st thru 90th day\n\nAll but $335\n\n$335\n\n$0\n\na day\n\na day\n\n91st day and after:\n\n-While using 60\n\nlifetime reserve days\n\nAll but $670\n\n$670\n\n$0\n\na day\n\na day\n\n-Once lifetime reserve\n\ndays are used:\n\n-Additional 365 days\n\n$0\n\n100% of\n\n$0**\n\nMedicare\n\nEligible\n\nExpenses\n\n-Beyond the\n\nAdditional 365 days\n\n$0\n\n$0\n\nAll Costs\n\nSKILLED NURSING FACILITY\n\nCARE*\n\nYou must meet Medicare's\n\nrequirements, including\n\nhaving been in a hospital\n\nfor at least 3 days and\n\nentered a Medicare-\n\napproved facility within\n\n30 days after leaving the\n\nhospital\n\nFirst 20 days\n\nAll approved\n\n$0\n\n$0\n\namounts\n\n21st thru 100th day\n\nAll but $167.50\n\nUp to $167.50\n\n$0\n\na day\n\na day\n\n101st day and after\n\n$0\n\n$0\n\nAll costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n3 pints\n\n$0\n\nAdditional amounts\n\n100%\n\n$0\n\n$0\nedicare's\n\nrequirements, including\n\nhaving been in a hospital\n\nfor at least 3 days and\n\nentered a Medicare-\n\napproved facility within\n\n30 days after leaving the\n\nhospital\n\nFirst 20 days\n\nAll approved\n\n$0\n\n$0\n\namounts\n\n21st thru 100th day\n\nAll but $167.50\n\nUp to $167.50\n\n$0\n\na day\n\na day\n\n101st day and after\n\n$0\n\n$0\n\nAll costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\n3 pints\n\n$0\n\nAdditional amounts\n\n100%\n\n$0\n\n$0\n\nHOSPICE CARE\n\nYou must meet Medicare's\n\nAll but very\n\nMedicare\n\n$0\n\nrequirements, including\n\nlimited\n\ncopayment/\n\na doctor's certification\n\ncopayment/\n\ncoinsurance\n\nof terminal illness\n\ncoinsurance\n\nfor outpatient\n\ndrugs and\n\ninpatient\n\nrespite care\n\n**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.\n\nPLAN N\n\nMEDICARE (PART B)-MEDICAL SERVICES-PER CALENDAR YEAR\n\n*Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.\n\nSERVICES\n\nMEDICARE PAYS\n\nPLAN PAYS\n\nYOU PAY\n\nMEDICAL EXPENSES-\n\nIN OR OUT OF THE\n\nHOSPITAL AND OUTPATIENT\n\nHOSPITAL TREATMENT, such\n\nas Physician's services,\n\ninpatient and outpatient\n\nmedical and surgical\n\nservices and supplies,\n\nphysical and speech\n\ntherapy, diagnostic\n\ntests, durable medical\n\nequipment\n\nFirst $183 of Medicare\n\nApproved Amounts*\n\n$0\n\n$0\n\n$183\n\n(Part B\n\nDeduc-\n\ntible)\n\nRemainder of Medicare\n\nApproved Amounts\n\nGenerally\n\nBalance,\n\nUp to $20\n\n80%\n\nother than\n\nper office\n\nup to $20\n\nvisit and\n\nper office\n\nup to $50\n\nvisit and\n\nper\n\nup to $50\n\nemergency\n\nper\n\nroom\n\nemergency\n\nvisit. The\n\nroom visit.\n\ncopayment\n\nThe\n\nof up to\n\ncopayment\n\n$50 is\n\nof up to\n\nwaived if\n\n$50 is\n\nthe\n\nwaived if\n\ninsured is\n\nthe insured\n\nadmitted\n\nis admitted\n\nto any\n\nto any\n\nhospital\n\nhospital\n\nand the\n\nand the\n\nemergency\n\nemergency\n\nvisit is\n\nvisit is\n\ncovered as\n\ncovered as\n\na Medicare\n\na Medicare\n\nPart A\n\nPart A\n\nexpense.\n\nexpense.\n\nPart B Excess Charges\n\n(Above Medicare\n\nApproved Amounts)\n\n$0\n\n$0\n\nAll costs\n\nBLOOD\n\nFirst 3 pints\n\n$0\n\nAll Costs\n\n$0\n\nNext $183 of Medicare\n\nApproved Amounts*\n\n$0\n\n$0\n\n$183\n\n(Part B\n\nDeduc-\n\ntible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nCLINICAL LABORATORY\n\nSERVICES-Tests for\n\ndiagnostic services\n\n100%\n\n$0\n\n$0\n\nPARTS A \u0026 B\n\nHOME HEALTH CARE\n\nMedicare Approved\n\nServices\n\n-Medically necessary\n\nskilled care services\n\nand medical supplies\n\n100%\n\n$0\n\n$0\n\n-Durable medical\n\nequipment\n\nFirst $183 of\n\nMedicare Approved\n\nAmounts*\n\n$0\n\n$0\n\n$183\n\n(Part B\n\nDeduc-\n\ntible)\n\nRemainder of Medicare\n\nApproved Amounts\n\n80%\n\n20%\n\n$0\n\nOTHER BENEFITS-NOT COVERED BY MEDICARE\n\nFOREIGN TRAVEL-Not\n\ncovered by Medicare\n\nMedically necessary\n\nemergency care services\n\nbeginning during the\n\nfirst 60 days of each\n\ntrip outside the USA\n\nFirst $250 each\n\ncalendar year\n\n$0\n\n$0\n\n$250\n\nRemainder of Charges\n\n$0\n\n80% to a\n\n20% and\n\nlifetime\n\namounts\n\nmaximum\n\nover the\n\nbenefit of\n\n$50,000\n\n$50,000\n\nlifetime\n\nmaximum","path":["MI Code","Chapter 500","Act Act-218-of-1956"],"source_url":"https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-500-3815","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:31Z","sha256":"63f87643418ba8d3873281a0d95f3fd6d69b7e2915cda2b9e33db7225219d49f","source_id":"us-mi","stale":false,"prev":"us-mi/mich.-comp.-laws-500.3813","next":"us-mi/mich.-comp.-laws-500.3817"},"notice":"GroundRules: Original legal text. Not legal advice."}