Benefit Plans  A, B, C, D, F, G, K, L, M & N and Medicare Select Benefit Plans

These charts show the benefits included in each of the standard Medicare Supplement plans. Every Company must make available Plan "A". Some plans may not be available in your state.

See Outlines of Coverage sections for details about ALL plans. Basic Benefits for Plans A, B, C, D, F, G, K, L, M & N

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.

Blood: First three pints of blood each year.

•      Medicare Select Plans contains the same benefits as standardized Medicare Supplement Plans, except for restrictions on your
use of hospitals.

 

                                                                                                                

PLAN A	PLAN B	PLAN C	PLAN D	PLAN F	PLAN F*	PLAN G
Basic Benefits	Basic Benefits	Basic Benefits	Basic Benefits	Basic Benefits		Basic Benefits
		Skilled Nursing Facility Coinsurance	Skilled Nursing Facility Coinsurance	Skilled Nursing Facility Coinsurance		Skilled Nursing Facility Coinsurance
	Part A Deductible	Part A Deductible	Part A Deductible	Part A Deductible		Part A Deductible
		Part B Deductible		Part B Deductible
				Part B Excess (100%)		Part B Excess (80%)
		Foreign Travel Emergency	Foreign Travel Emergency	Foreign Travel Emergency		Foreign Travel Emergency

 

*Plan F also has an option called a high deductible plan F. The high deductible plan pays the same benefits as regular plan F after one has paid a calendar year $2,000 deductible. Benefits from high deductible plan F will not begin until out--of--pocket expenses exceed $2,000. 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.

Basic Benefits for Plans K and L include similar services as plans A--J,, but cost--sharing for the basic benefits is at different levels..

 

	Plan K**		Plan L**	Plan M	Plan N
100% 50% 50% 50%	of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End Hospice cost-sharing of Medicare-eligible expenses for the first three pints of blood Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services	100% 75% 75% 75%	of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End Hospice cost-sharing of Medicare-eligible expenses for the first three pints of blood Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services	Basic, including 100% Part B co-insurance	Basic, including100% Part B coinsurance, except up to $20copayment for office visit, and up to $50 copayment for ER
50%	Skilled Nursing Facility Coinsurance	75%	Skilled Nursing Facility Coinsurance	Skilled Nursing Facility Co-insurance	Skilled Nursing Facility Co-insurance
50%	Part A Deductible	75%	Part A Deductible	50% Part A Deductible	Part A Deductible
				Foreign Travel Emergency	Foreign Travel Emergency
	$4640 Out-of-Pocket Annual Limit***		$2320 Out-of-Pocket Annual Limit***

 

**Plans K and L provide for different cost--sharing for items and services than Plans A--J.

Once you reach the annual limit,, the plan pays 100% of the Medicare copayments,, coinsurance,, and deductibles for the rest of the calendar year. The out--of--pocket annual limit does NOT include charges from your provider that exceed Medicare--approved amounts,, called "Excess Charges". You will be responsible for paying excess charges.

***The out--of--pocket annual limit will increase each year for inflation.

See Outlines of Coverage for details and exceptions.

PREMIUM INFORMATION

You may keep your plan in force by paying the required monthly premium when due. Monthly rates shown reflect current premium levels and all rates are subject to change.

Any change will apply to all members of the same class insured under your plan who reside in your state. Your premium can only be changed with the approval of or your state insurance department.

DISCLOSURES

Use this outline to compare benefits and premiums among plans.

READ YOUR CERTIFICATE VERY CAREFULLY

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

RIGHT TO RETURN THE CERTIFICATE

If you find that you are not satisfied with your coverage, you may return the certificate to the insurance company.  If you send the certificate back within 30 days after you receive it, they will treat the certificate as if it had never been issued and return all of your premium payments. However, the insurance company has the right to recover any claims paid during that period. Any premium refund otherwise due to you will be reduced by the amount of any claims paid during this period. If you have received claims payment in excess of the amount of your premium, no refund of premium will be made.

POLICY REPLACEMENT

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

NOTICE

The certificate may not fully cover all of your medical costs.

COMPLETE ANSWERS ARE VERY IMPORTANT

When you fill out the enrollment application for the new certificate, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your certificate and refuse to pay any claims if you leave out or falsify important medical information.

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

GRIEVANCE PROCEDURE

Complaint and Grievance Procedure – The insurance company has established a formal procedure to respond to customer complaints and grievances. The insurance company desires to provide a fair, accessible and responsive method of evaluating and resolving complaints and grievances. If the insurance company determines that any prior action that it has taken was incorrect, corrective action will be taken. You may, at any time, submit a written complaint to the Department of Insurance in your state.

Complaints -- If you have a complaint, you may call or write the insurance company. They  will acknowledge all complaints within 15 days and will respond to all complaints within a reasonable period of time.

Grievances -- If you are dissatisfied with our handling of a complaint or a claim denial, or are dissatisfied for any other reason, you may submit a formal grievance. Grievances must be in writing and contain the words "this is a grievance" to ensure that the insurance company understand the purpose of the communication. You must clearly state the nature of the grievance and send it to the insurance company. They will acknowledge in writing all grievances within 15 days and respond to all grievances within a reasonable period of time. All grievances must be filed within 60 days or as soon as reasonably possible from the date of denial of benefits or other action giving rise to the grievance.