REGULATIONS
Vol. 33 Iss. 23 - July 10, 2017

TITLE 14. INSURANCE
STATE CORPORATION COMMISSION
Chapter 170
Proposed Regulation

TITLE 14. INSURANCE

STATE CORPORATION COMMISSION

Proposed Regulation

REGISTRAR'S NOTICE: The State Corporation Commission is claiming an exemption from the Administrative Process Act in accordance with § 2.2-4002 A 2 of the Code of Virginia, which exempts courts, any agency of the Supreme Court, and any agency that by the Constitution is expressly granted any of the powers of a court of record.

Title of Regulation: 14VAC5-170. Rules Governing Minimum Standards for Medicare Supplement Policies (amending 14VAC5-170-30, 14VAC5-170-60, 14VAC5-170-85, 14VAC5-170-150; adding 14VAC5-170-87).

Statutory Authority: §§ 12.1-13 and 38.2-223 of the Code of Virginia.

Public Hearing Information: A public hearing will be held upon request.

Public Comment Deadline: August 10, 2017.

Agency Contact: James Young, Policy Advisor, Policy and Compliance Division, Bureau of Insurance, State Corporation Commission, 1300 East Main Street, 6th Floor, Richmond, VA 23219, mailing address: P.O. Box 1157, Richmond, VA 23218, telephone (804) 371-9612, FAX (804) 371994, or email james.young@scc.virginia.gov.

Summary:

The proposed amendments (i) conform the regulations to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which prohibits the sale of Medigap policies that cover Part B deductibles to newly eligible Medicare beneficiaries, defined as those individuals who have attained age 65 years on or after January 1, 2020, or first become eligible for Medicare due to age, disability, or end-stage renal disease on or after January 1, 2020, and (ii) update deductible amounts.

AT RICHMOND, JUNE 20, 2017

COMMONWEALTH OF VIRGINIA, ex rel.

STATE CORPORATION COMMISSION

CASE NO. INS-2017-00141

Ex Parte: In the matter of Amending
the Rules Governing Minimum Standards
for Medicare Supplement Policies

ORDER TO TAKE NOTICE

Section 12.1-13 of the Code of Virginia ("Code") provides that the State Corporation Commission ("Commission") shall have the power to promulgate rules and regulations in the enforcement and administration of all laws within its jurisdiction, and § 38.2-223 of the Code provides that the Commission may issue any rules and regulations necessary or appropriate for the administration and enforcement of Title 38.2 of the Code.

The rules and regulations issued by the Commission pursuant to § 38.2-223 of the Code are set forth in Title 14 of the Virginia Administrative Code. A copy may also be found at the Commission's website: http://www.scc.virginia.gov/case.

The Bureau of Insurance ("Bureau") has submitted to the Commission proposed amendments to rules set forth in Chapter 170 of Title 14 of the Virginia Administrative Code entitled Rules Governing Minimum Standards for Medicare Supplement Policies, 14 VAC 5-170-10 et seq. ("Rules"), which amend the Rules at 14 VAC 5-170-30, 14 VAC 5-170-60, 14 VAC 5-170-85, and 14 VAC 5-170-150, and add a new Rule at 14 VAC 5-170-87.

The amendments to the Rules are necessary to conform to the Medicare Access and CHIP Reauthorization Act of 2015 ("MACRA"), which was signed into law on April 16, 2015. This piece of legislation prohibits the sale of Medigap policies that cover Part B deductibles to "newly eligible" Medicare beneficiaries, defined as those individuals who have attained age 65 on or after January 1, 2020, or first become eligible for Medicare due to age, disability, or end-stage renal disease on or after January 1, 2020. In addition to the changes made pursuant to MACRA, the proposed amendments include updated deductible amounts.

NOW THE COMMISSION is of the opinion that the proposed amendments submitted by the Bureau to amend the Rules at 14 VAC 5-170-30, 14 VAC 5-170-60, 14 VAC 5-170-85, and 14 VAC 5-170-150, and add a new Rule at 14 VAC 5-170-87, should be considered for adoption.

Accordingly, IT IS ORDERED THAT:

(1) The proposal to amend the Rules at 14 VAC 5-170-30, 14 VAC 5-170-60, 14 VAC 5-170-85, and 14 VAC 5-170-150, and add a new Rule at 14 VAC 5-170-87, is attached hereto and made a part hereof.

(2) All interested persons who desire to comment in support of or in opposition to, or request a hearing to consider the amendments to the Rules, shall file such comments or hearing request on or before August 10, 2017, with Joel H. Peck, Clerk, State Corporation Commission, c/o Document Control Center, P.O. Box 2118, Richmond, Virginia 23218. Interested persons desiring to submit comments electronically may do so by following the instructions at the Commission's website:  http://www.scc.virginia.gov/case. All comments shall refer to Case No. INS-2017-00141.

(3) If no written request for a hearing on the proposal to amend the Rules is received on or before August 10, 2017, the Commission, upon consideration of any comments submitted in support of or in opposition to the proposal, may amend the Rules.

(4) The Bureau forthwith shall provide notice to all health insurance issuers licensed to issue policies of accident and sickness insurance, subscription contracts, or evidences of coverage in this Commonwealth and to all interested persons.

(5) The Commission's Division of Information Resources forthwith shall cause a copy of this Order, together with the proposal to amend the Rules, to be forwarded to the Virginia Registrar of Regulations for appropriate publication in the Virginia Register of Regulations.

(6) The Commission's Division of Information Resources shall make available this Order and the attached proposed amendment to the Rules on the Commission's website: http://www.scc.virginia.gov/case.

(7) The Bureau shall file with the Clerk of the Commission an affidavit of compliance with the notice requirements of Ordering Paragraph (4) above.

(8) This matter is continued.

AN ATTESTED COPY hereof shall be sent by the Clerk of the Commission to:  Kiva B. Pierce, Assistant Attorney General, Division of Consumer Counsel, Office of the Attorney General, 202 N. 9th Street, 8th Floor, Richmond, Virginia 23219-3424; and a copy hereof shall be delivered to the Commission's Office of General Counsel and the Bureau of Insurance in care of Deputy Commissioner Julie S. Blauvelt.

14VAC5-170-30. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"1990 standardized Medicare supplement benefit plan," "1990 standardized benefit plan" or "1990 plan" means a group or individual policy of Medicare supplement insurance issued on or after July 30, 1992, and with an effective date for coverage prior to June 1, 2010, and includes Medicare supplement insurance policies and certificates renewed on or after that date that are not replaced by the issuer at the request of the insured.

"2010 standardized Medicare supplement benefit plan," "2010 standardized benefit plan" or "2010 plan" means a group or individual policy of Medicare supplement insurance issued with an effective date for coverage on or after June 1, 2010.

"Applicant" means:

1. In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits; and

2. In the case of a group Medicare supplement policy, the proposed certificateholder.

"Attained age rating" means a premium structure under which premiums are based on the covered individual's age at the time of application of the policy or certificate, and for which premiums increase based on the covered individual's increase in age during the life of the policy or certificate.

"Bankruptcy" means when a Medicare Advantage organization that is not an issuer has filed, or has had filed against it, a petition for declaration of bankruptcy and has ceased doing business in this Commonwealth.

"Certificate" means any certificate delivered or issued for delivery in this Commonwealth under a group Medicare supplement policy.

"Certificate form" means the form on which the certificate is delivered or issued for delivery by the issuer.

"Community rating" means a premium structure under which premium rates are the same for all covered individuals of all ages in a given area.

"Continuous period of creditable coverage" means the period during which an individual was covered by creditable coverage, if during the period of the coverage the individual did not have a break in coverage greater than 63 days.

"Creditable coverage" means, with respect to an individual, coverage of the individual provided under any of the following:

1. A group health plan;

2. Health insurance coverage;

3. Part A or Part B of Title XVIII of the Social Security Act of 1935 (Medicare) (42 USC § 1395 et seq.);

4. Title XIX of the Social Security Act of 1935 (Medicaid) (42 USC § 1396 et seq.), other than coverage consisting solely of benefits under § 1928;

5. Chapter 55 of Title 10 of the United States Code (CHAMPUS) (TRICARE) (10 USC§§ 1071-1107);

6. A medical care program of the Indian Health Service or of a tribal organization;

7. A state health benefits risk pool;

8. A health plan offered under the Federal Employees Health Benefits Act of 1959 (5 USC §§ 8901-8914);

9. A public health plan as defined in federal regulation; and

10. A health benefit plan under § 5(e) of the Peace Corps Act of 1961 (22 USC § 2504(e)).

"Creditable coverage" shall not include one or more, or any combination of, the following:

1. Coverage only for accident or disability income insurance, or any combination thereof;

2. Coverage issued as a supplement to liability insurance;

3. Liability insurance, including general liability insurance and automobile liability insurance;

4. Workers' compensation or similar insurance;

5. Automobile medical expense insurance;

6. Credit-only insurance;

7. Coverage for on-site medical clinics; and

8. Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

"Creditable coverage" shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:

1. Limited scope dental or vision benefits;

2. Benefits for long-term care, nursing home care, home health care, community-based care or any combination thereof; and

3. Such other similar, limited benefits as are specified in federal regulations.

"Creditable coverage" shall not include the following benefits if offered as independent, noncoordinated benefits:

1. Coverage only for a specified disease or illness; and

2. Hospital indemnity or other fixed indemnity insurance.

"Creditable coverage" shall not include the following if it is offered as a separate policy, certificate or contract of insurance:

1. Medicare supplement health insurance as defined under § 1882(g)(1) of the Social Security Act of 1935 (42 USC § 1395ss);

2. Coverage supplemental to the coverage provided under Chapter 55 of Title 10 of the United States Code (10 USC §§ 1071-1107); and

3. Similar supplemental coverage provided to coverage under a group health plan.

"Employee welfare benefit plan" means a plan, fund or program of employee benefits as defined in the Employee Retirement Income Security Act of 1974 (29 USC § 1002).

"Insolvency" means when an issuer, duly licensed to transact an insurance business in this Commonwealth in accordance with the provisions of Chapter 10, 41, 42 or 43, respectively, of Title 38.2 of the Code of Virginia, is determined to be insolvent and placed under a final order of liquidation by a court of competent jurisdiction.

"Issue age rating" means a premium structure based upon the covered individual's age at the time of purchase of the policy or certificate. Under an issue age rating structure, premiums do not increase due to the covered individual's increase in age during the life of the policy or certificate.

"Issuer" includes insurance companies, fraternal benefit societies, corporations licensed pursuant to Chapter 42 of Title 38.2 of the Code of Virginia to offer health services plans, health maintenance organizations, and any other entity delivering or issuing for delivery in this Commonwealth Medicare supplement policies or certificates.

"Medicare" means the "Health Insurance for the Aged Act," Title XVIII of the Social Security Act (42 USC § 1395 et seq.), as then constituted or later amended.

"Medicare Advantage plan" means a plan of coverage for health benefits under Medicare Part C as defined in § 1859 (42 USC § 1395w-28(b)(1) of the Social Security Act, and includes:

1. Coordinated care plans which that provide health care services, including but not limited to health maintenance organization plans (with or without a point-of-service option), plans offered by provider-sponsored organizations, and preferred provider organization plans;

2. Medical savings account plans coupled with a contribution into a Medicare Advantage medical savings account; and

3. Medicare Advantage private fee-for-service plans.

"Medicare supplement policy" means a group or individual policy of accident and sickness insurance or a subscriber contract of health service plans or health maintenance organizations, other than a policy issued pursuant to a contract under § 1876 of the federal Social Security Act of 1935 (42 USC § 1395 et seq.) or an issued policy under a demonstration project specified in 42 USC § 1395ss(g)(1), which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare. "Medicare supplement policy" does not include Medicare Advantage plans established under Medicare Part C, Outpatient Prescription Drug plans established under Medicare Part D, or any Health Care Prepayment Plan that provides benefits pursuant to an agreement under § 1833(a)(1)(A) of the Social Security Act.

"Policy form" means the form on which the policy is delivered or issued for delivery by the issuer.

"Prestandardized Medicare supplement benefit plan," "prestandardized benefit plan" or "prestandardized plan" means a group or individual policy of Medicare supplement insurance issued prior to July 30, 1992.

"Secretary" means the Secretary of the United States U.S. Department of Health and Human Services.

14VAC5-170-60. Minimum benefit standards for prestandardized Medicare supplement benefits plan policies or certificates issued for delivery prior to July 30, 1992.

A. No policy or certificate may be advertised, solicited or issued for delivery in this Commonwealth as a Medicare supplement policy or certificate unless it meets or exceeds the following minimum standards. These are minimum standards and do not preclude the inclusion of other provisions or benefits which that are not inconsistent with these standards.

B. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this chapter.

1. A Medicare supplement policy or certificate shall not exclude or limit benefits for a loss incurred more than six months from the effective date of coverage because it involved a preexisting condition. The policy or certificate shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage.

2. A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.

3. A Medicare supplement policy or certificate shall provide that benefits designed to cover cost sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible, copayment or coinsurance amounts. Premiums may be modified to correspond with such changes.

4. A "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewable" Medicare supplement policy shall not:

a. Provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premium; or

b. Be cancelled canceled or nonrenewed by the issuer solely on the grounds of deterioration of health.

5. a. Except as authorized by the State Corporation Commission, an issuer shall neither cancel nor nonrenew a Medicare supplement policy or certificate for any reason other than nonpayment of premium or material misrepresentation.

b. If a group Medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in subdivision 5 d of this subsection, the issuer shall offer certificateholders an individual Medicare supplement policy. The issuer shall offer the certificateholder at least the following choices:

(1) An individual Medicare supplement policy currently offered by the issuer having comparable benefits to those contained in the terminated group Medicare supplement policy; and

(2) An individual Medicare supplement policy which that provides only such benefits as are required to meet the minimum standards as defined in 14VAC5-170-75 C.

c. If membership in a group is terminated, the issuer shall:

(1) Offer the certificateholder the conversion opportunities described in subdivision 5 b of this subsection; or

(2) At the option of the group policyholder, offer the certificateholder continuation of coverage under the group policy.

d. If a group Medicare supplement policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new group policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced.

6. Termination of a Medicare supplement policy or certificate shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or to payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.

7. If a Medicare supplement policy is modified to eliminate an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 USC § 1395w-101), the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this subsection.

C. Minimum benefit standards.

1. Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period;

2. Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount;

3. Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days;

4. Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of 90% of all Medicare Part A eligible expenses for hospitalization not covered by Medicare subject to a lifetime maximum benefit of an additional 365 days;

5. Coverage under Medicare Part A for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations or already paid for under Part B;

6. Coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount of Medicare eligible expenses under Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount equal to the Medicare Part B deductible $100 established by the Centers for Medicare and Medicaid Services;

7. Effective January 1, 1990, coverage under Medicare Part B for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations), unless replaced in accordance with federal regulations or already paid for under Part A, subject to the Medicare deductible amount.

14VAC5-170-85. Standard plans for 2010 standardized Medicare supplement policies delivered on or after June 1, 2010.

A. The following standard plans are applicable to all Medicare supplement benefit plan policies or certificates delivered or issued for delivery in this Commonwealth with an effective date for coverage on or after June 1, 2010. No policy or certificate may be advertised, solicited, delivered or issued for delivery in this Commonwealth as a Medicare supplement policy or certificate unless it complies with these benefit plan standards. Benefit plan standards applicable to Medicare supplement policies and certificates issued with an effective date for coverage before June 1, 2010, remain subject to the requirements of 14VAC5-170-80.

B. 1. An issuer shall make available to each prospective policyholder and certificateholder a policy form or certificate form containing only the basic (core) benefits, as defined in 14VAC5-170-75 C.

2. If an issuer makes available any of the additional benefits described in 14VAC5-170-75 D, or offers standardized benefit Plans K or L (as described in subdivisions F 8 and F 9 of this section), then the issuer shall make available to each prospective policyholder and certificateholder, in addition to a policy form or certificate form with only the basic (core) benefits as described in subdivision 1 of this subsection, a policy form or certificate form containing either standardized benefit Plan C (as described in subdivision F 3 of this section) or standardized benefit Plan F (as described in subdivision F 5 of this section).

C. No groups, packages or combinations of Medicare supplement benefits other than those listed in this section shall be offered for sale in this Commonwealth, except as may be permitted in subsection G of this section and 14VAC5-170-90.

D. Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans listed in this subsection and conform to the definitions in 14VAC5-170-30. Each benefit shall be structured in accordance with the format provided in 14VAC5-170-75 C and D; or, in the case of plans K or L, in subdivision F 8 or F 9 of this section and list the benefits in the order shown. For purposes of this section, the term "structure, language, and format" means style, arrangement and overall content of a benefit.

E. In addition to the benefit plan designations required in subsection D of this section, an issuer may use other designations to the extent permitted by law.

F. Make-up of 2010 standardized benefit plans:

1. Standardized Medicare supplement benefit Plan A shall include only the basic (core) benefits as defined in 14VAC5-170-75 C.

2. Standardized Medicare supplement benefit Plan B shall include only the basic (core) benefit as defined in 14VAC5-170-75 C, plus 100% of the Medicare Part A deductible as defined in 14VAC5-170-75 D 1.

3. Standardized Medicare supplement benefit Plan C shall include only the basic (core) benefit as defined in 14VAC5-170-75 C, plus 100% of the Medicare Part A deductible, skilled nursing facility care, 100% of the Medicare Part B deductible, and medically necessary emergency care in a foreign country as defined in 14VAC5-170-75 D 1, 3, 4 and 6, respectively.

4. Standardized Medicare supplement benefit Plan D shall include only the basic (core) benefit as defined in 14VAC5-170-75 C, plus 100% of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in an foreign country as defined in 14VAC5-170-75 D 1, 3 and 6, respectively.

5. Standardized Medicare supplement benefit Plan F shall include only the basic (core) benefit as defined in 14VAC5-170-75 C, plus 100% of the Medicare Part A deductible, skilled nursing facility care, 100% of the Medicare Part B deductible, 100% of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in 14VAC5-170-75 D 1, 3, 4, 5 and 6, respectively.

6. Standardized Medicare supplement benefit Plan F With High Deductible shall include only 100% of covered expenses following the payment of the annual deductible as defined in subdivision 6 b of this subsection.

a. The basic (core) benefit as defined in 14VAC5-170-75 C, plus 100% of the Medicare Part A deductible, skilled nursing facility care, 100% of the Medicare Part B deductible, 100% of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in 14VAC5-170-75 D 1, 3, 4, 5 and 6, respectively.

b. The annual deductible in Plan F With High Deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by Plan F, and shall be in addition to any other specific benefit deductibles. The basis for the deductible shall be $1,500 and shall be adjusted annually from 1999 by the Secretary of the U.S. Department of Health and Human Services to reflect the change in the Consumer Price Index for all urban consumers for the 12-month period ending with August of the preceding year, and rounded to the nearest multiple of $10.

7. Standardized Medicare supplement benefit Plan G shall include only the basic (core) benefit as defined in 14VAC5-170-75 C, plus 100% of the Medicare Part A deductible, skilled nursing facility care, 100% of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in 14VAC5-170-75 D 1, 3, 5 and 6, respectively. Effective January 1, 2020, the standardized benefit plans described in 14VAC5-170-87 D 3(Plan G with High Deductible) may be offered to any individual who was eligible for Medicare prior to January 1, 2020.

8. Standardized Medicare supplement benefit Plan K is mandated by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:

a. Part A hospital coinsurance 61st through 90th days: Coverage of 100% of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;

b. Part A hospital coinsurance, 91st through 150th days: Coverage of 100% of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;

c. Part A hospitalization after 150 days: Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance;

d. Medicare Part A deductible: Coverage for 50% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subdivision 8 j of this subsection;

e. Skilled nursing facility care: Coverage for 50% of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subdivision 8 j of this subsection;

f. Hospice care: Coverage for 50% of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subdivision 8 j of this subsection;

g. Blood: Coverage for 50%, under Medicare Part A or B, of the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations until the out-of-pocket limitation is met as described in subdivision 8 j of this subsection;

h. Part B cost sharing: Except for coverage provided in subdivision 8 i of this subsection, coverage for 50% of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in subdivision 8 j of this subsection;

i. Part B preventive services: Coverage of 100% of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and

j. Cost sharing after out-of-pocket limits: Coverage of 100% of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $4,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.

9. Standardized Medicare supplement benefit Plan L is mandated by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:

a. The benefits described in subdivisions 8 a, b, c and i of this subsection;

b. The benefit described in subdivisions 8 d, e, f, g and h of this subsection, but substituting 75% for 50%; and

c. The benefit described in subdivision 8 j of this subsection, but substituting $2,000 for $4,000.

10. Standardized Medicare supplement benefit Plan M shall include only the basic (core) benefit as defined in 14VAC5-170-75 C, plus 50% of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in 14VAC5-170-75 D 2, 3 and 6, respectively.

11. Standardized Medicare supplement benefit Plan N shall include only the basic (core) benefit as defined in 14VAC5-170-75 C, plus 100% of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in 14VAC5-170-75 D 1, 3 and 6, respectively, with copayments in the following amounts:

a. The lesser of $20 or the Medicare Part B coinsurance or copayment for each covered health care provider office visit (including visits to medical specialists); and

b. The lesser of $50 or the Medicare Part B coinsurance or copayment for each covered emergency room visit; however, this copayment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.

G. New or innovative benefits. An issuer may, with the prior approval of the commission, offer policies or certificates with new or innovative benefits, in addition to the standardized benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits shall include only benefits that are appropriate to Medicare supplement insurance, are new or innovative, are not otherwise available, and are cost-effective. Approval of new or innovative benefits must not adversely impact the goal of Medicare supplement simplification. New or innovative benefits shall not include an outpatient prescription drug benefit. New or innovative benefits shall not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized plan.

14VAC5-170-87. Standard plans for 2020 standardized Medicare supplement policies delivered to individuals newly eligible for Medicare on or after January 1, 2020.

A. This section applies only to individuals who are newly eligible for Medicare on or after January 1, 2020:

1. By reason of attaining age 65 years on or after January 1, 2020; or

2. By reason of entitlement to benefits under part A pursuant to § 226(b) or 226A of the Social Security Act, or who is deemed to be eligible for benefits under § 226(a) of the Social Security Act on or after January 1, 2020.

B. No policy or certificate that provides coverage of the Medicare Part B deductible may be advertised, solicited, delivered, or issued for delivery in the Commonwealth as a Medicare supplement policy or certificate to individuals newly eligible for Medicare on or after January 1, 2020. All such policies must comply with the benefit standards contained in subsection D of this section. Benefit plan standards applicable to Medicare supplement policies and certificates issued to individuals eligible for Medicare before January 1, 2020, remain subject to the requirements of 14VAC5-170-75 and 14VAC5-170-85.

C. Standardized Medicare supplement benefit plans C, F, and F with High Deductible may not be offered to individuals newly eligible for Medicare on or after January 1, 2020. For purposes of this section, the reference to Plans C or F contained in 14VAC5-170-85 B 2 is deemed a reference to Plan D or G, respectively.

D. The standards and requirements of 14VAC5-170-85 shall apply to all Medicare supplement policies or certificates delivered or issued for delivery to individuals newly eligible for Medicare on or after January 1, 2020, with the following exceptions:

1. Standardized Medicare supplement benefit Plan D (previously Plan C) shall provide the benefits contained in 14VAC5-170-85 F 3 but shall not provide coverage for 100% or any portion of the Medicare Part B deductible.

2. Standardized Medicare supplement benefit Plan G (previously Plan F) shall provide the benefits contained in 14VAC5-170-85 F 5 but shall not provide coverage for 100% or any portion of the Medicare Part B deductible.

3. Standardized Medicare supplement benefit Plan G with High Deductible (previously Plan F with High Deductible) shall provide the benefits contained in 14VAC5-170-85 F 6 but shall not provide coverage for 100% or any portion of the Medicare Part B deductible; provided further that the Medicare Part B deductible paid by the beneficiary shall be considered an out-of-pocket expense in meeting the annual high deductible.

E. For purposes of 14VAC5-170-105 E, in the case of any individual newly eligible for Medicare on or after January 1, 2020, any reference to a Medicare supplement policy C or F (including F with High Deductible) shall be deemed to be a reference to Medicare supplement policy D or G (including G with High Deductible), respectively.

14VAC5-170-150. Required disclosure provisions.

A. General rules.

1. Medicare supplement policies and certificates shall include a renewal or continuation provision. The language or specifications of such provision shall be consistent with the type of contract issued. The provision shall be appropriately captioned, shall appear on the first page of the policy, and shall include any reservation by the issuer of the right to change premiums and any automatic renewal premium increases based on the policyholder's age. Medicare supplement policies or certificates which are attained age rated shall include a clear and prominent statement, in at least 14 point type, disclosing that premiums will increase due to changes in age and the frequency under which such changes will occur.

2. Except for riders or endorsements by which the issuer effectuates a request made in writing by the insured, exercises a specifically reserved right under a Medicare supplement policy, or is required to reduce or eliminate benefits to avoid duplication of Medicare benefits, all riders or endorsements added to a Medicare supplement policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require a signed acceptance by the insured. After the date of policy or certificate issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term shall be agreed to in writing signed by the insured, unless the benefits are required by the minimum standards for Medicare supplement policies, or if the increased benefits or coverage is required by law. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge shall be set forth in the policy.

**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 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 or HIGH DEDUCTIBLE PLAN F
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $135 $147 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 one has you have paid a calendar year $2,000 $2,180 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $2,000 $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2,000 $2,180 DEDUCTIBLE,** PLAN PAYS

IN ADDITION ADDITION TO $2,000 $2,180 DEDUCTIBLE,** 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 $135 $147 of Medicare-Approved amounts*

$0

$135 $147 (Part B Deductible)

$0

Remainder of Medicare-Approved amounts

Generally 80%

Generally 20%

$0

PART B EXCESS CHARGES

 

 

 

(Above Medicare Approved Amounts)

$0

100%

$0

BLOOD

 

 

 

First 3 pints

$0

All Costs

$0

Next $135 $147 of Medicare-Approved Amounts*

$0

$135 $147 (Part B Deductible)

$0

Remainder of Medicare-Approved Amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES

 

 

 

TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2,000 $2,180 DEDUCTIBLE,** PLAN PAYS

IN ADDITON ADDITION TO $2,000 $2,180 DEDUCTIBLE,** YOU PAY

HOME HEALTH CARE
MEDICARE-APPROVED SERVICES

 

 

 

Medically necessary skilled care services and medical supplies

100%

$0

$0

Durable medical equipment

 

 

 

 

First $135 $147 of Medicare-Approved Amounts*

$0

$135 $147 (Part B Deductible)

$0

 

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 lifetime maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum

PLAN G OR HIGH DEDUCTIBLE 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

AFTER YOU PAY $2,180 DEDUCTIBLE, PLAN PAYS

IN ADDITION TO $2,180 DEDUCTIBLE, YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

 

 

 

First 60 days

All but $1,068 $1,288

$1,068 $1,288 (Part A Deductible)

$0

61st thru 90th day

All but $267 $322 a day

$267 $322 a day

$0

91st day and after:

 

 

 

 

While using 60 lifetime reserve days

All but $534 $644 a day

$534 $644 a day

$0

 

Once lifetime reserve days are used:

 

 

 

 

Additional 365 days

$0

100% of Medicare Eligible Expenses

$0**

 

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 $133.50 $161 a day

Up to $133.50 $161 a day

$0

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 Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

$0

3. Medicare supplement policies or certificates shall not provide for the payment of benefits based on standards described as "usual and customary," "reasonable and customary" or words of similar import.

4. If a Medicare supplement policy or certificate contains any limitations with respect to preexisting conditions, such limitations shall appear as a separate paragraph of the policy and be labeled as "Preexisting Condition Limitations."

5. Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the policyholder or certificateholder shall have the right to return the policy or certificate within 30 days of its delivery and to have all premiums made for the policy refunded if, after examination of the policy or certificate, the insured person is not satisfied for any reason.

6. Issuers of accident and sickness policies or certificates which provide hospital or medical expense coverage on an expense incurred or indemnity basis to a person or persons eligible for Medicare shall provide to those applicants a Guide to Health Insurance for People with Medicare in the form developed jointly by the National Association of Insurance Commissioners and the Centers for Medicare and Medicaid Services and in a type size no smaller than 12 point type. Delivery of the guide shall be made whether or not such policies or certificates are advertised, solicited or issued as Medicare supplement policies or certificates as defined in this chapter. Except in the case of direct response issuers, delivery of the guide shall be made to the applicant at the time of application and acknowledgement of receipt of the guide shall be obtained by the issuer. Direct response issuers shall deliver the guide to the applicant upon request but not later than at the time the policy is delivered.

For the purposes of this section, "form" means the language, format, type size, type proportional spacing, bold character, and line spacing.

B. Notice requirements.

1. As soon as practicable, but no later than 30 days prior to the annual effective date of any Medicare benefit changes, an issuer shall notify its policyholders and certificateholders of modifications it has made to Medicare supplement insurance policies or certificates in a format acceptable to the State Corporation Commission. The notice shall:

a. Include a description of revisions to the Medicare program and a description of each modification made to the coverage provided under the Medicare supplement policy or certificate; and

b. Inform each policyholder or certificateholder as to when any premium adjustment is to be made due to changes in Medicare.

2. The notice of benefit modifications and any premium adjustments shall be in outline form and in clear and simple terms so as to facilitate comprehension.

3. Such notices shall not contain or be accompanied by any solicitation.

C. Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 USC § 1395w-101).

D. Outline of coverage requirements for Medicare Supplement Policies.

1. Issuers shall provide an outline of coverage to all applicants at the time the application is presented to the prospective applicant and, except for direct response policies, shall obtain an acknowledgement of receipt of the outline from the applicant; and

2. If an outline of coverage is provided at the time of application and the Medicare supplement policy or certificate is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate shall accompany such policy or certificate when it is delivered and 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."

3. The outline of coverage provided to applicants pursuant to this section consists of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage shall be in the language and format prescribed below in no less than 12 point type. All plans shall be shown on the cover page, and the plan(s) plans that are offered by the issuer shall be prominently identified. Premium information for plans that are offered shall be shown on the cover page or immediately following the cover page and shall be prominently displayed. The premium and mode shall be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant shall be illustrated.

4. The following items shall be included in the outline of coverage in the order prescribed in the following table.

Benefit Chart of Medicare Supplement Plans Sold with Effective Dates 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 after June 1, 2010. [This sentence shall not appear after June 1, 2011.]

Plans C, F, and high deductible F are no longer available for sale to those who are newly eligible, as defined in 14VAC5-170-87, on or after January 1, 2020.

Note that the numerical figures in the following charts, including out-of-pocket limits and deductible amounts, are current as of January 1, 2018, and are subject to change.

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

K

L

M

N

Basic,
including
100% Part B coinsurance

Basic,
including
100% Part B coinsurance

Basic,
including
100% Part B coinsurance

Basic,
including
100% Part B coinsurance

Basic,
including 100% Part B coinsurance*

Basic,
including
100% Part B coinsurance

Hospitalization and preventive care paid at 100%; other basic benefits paid at 50%

Hospitalization and preventive care paid at 100%; other basic benefits paid at 75%

Basic,
including 1
00% Part B coinsurance

Basic,
including
100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER

 

 

Skilled nursing facility coinsurance

Skilled nursing facility coinsurance

Skilled nursing facility coinsurance

Skilled nursing facility coinsurance

50% skilled nursing facility coinsurance

75% 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

50% Part A deductible

75% Part A deductible

50% Part A deductible

Part A deductible

 

 

Part B deductible

 

Part B deductible

 

 

 

 

 

 

 

 

 

Part B excess (100%)

Part B excess (100%)

 

 

 

 

 

 

Foreign travel emergency

Foreign travel emergency

Foreign travel emergency

Foreign travel emergency

 

 

Foreign travel emergency

Foreign travel emergency

 

 

 

 

 

 

Out-of-pocket limit $4,620$4,940; paid at 100% after limit reached

Out-of-pocket limit $2,310$2,470; paid at 100% after limit 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 $2,000 $2,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,000 $2,180. 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

Boldface Type

We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this Commonwealth. [If the premium is based on attained age of the insured, include the following information:

1. When premiums will change;

2. The current premium for all ages;

3. A statement that premiums for other Medicare Supplement policies that are issue age or community rated do not increase due to changes in your age; and

4. A statement that while the cost of this policy at the covered individual's present age may be lower than the cost of a Medicare supplement policy that is based on issue age or community rated, it is important to compare the potential cost of these policies over the life of the policy.]

DISCLOSURES

Boldface Type

Use this outline to compare benefits and premiums among policies.

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 after June 1, 2010. [This paragraph shall not appear after June 1, 2011.]

READ YOUR POLICY VERY CAREFULLY

Boldface Type

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

Boldface Type

If you find that you are not satisfied with your policy, you may return it to [insert issuer'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

Boldface Type

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

Boldface Type

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

[for agents:]

Neither [insert company's name] nor its agents are connected with Medicare.

[for direct response:]

[insert company'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 "Medicare & You" for more details.

COMPLETE ANSWERS ARE VERY IMPORTANT

Boldface Type

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 prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this regulation. An issuer may use additional benefit plan designations on these charts pursuant to 14VAC5-170-85.]

[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the State Corporation Commission.]

Benefit Chart of Medicare Supplement Plans Sold on or after January 1, 2020

This chart shows the benefits included in each of the standard Medicare supplement plans. Some plans may not be available. Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F.

Note: A means 100% of the benefit is paid.

 

Benefits

Plans Available to All Applicants

Medicare first eligible before 2020 only

A

B

D

G1

K

L

M

N

C

F1

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)

Medicare Part B coinsurance or copayment

50%

75%

copays apply3

Blood (first three pints)

50%

75%

Part A hospice care coinsurance or copayment

50%

75%

Skilled nursing facility coinsurance

50%

75%

Medicare Part A deductible

50%

75%

50%

Medicare Part B deductible

Medicare Part B excess charges

Foreign travel emergency (up to plan limits)

Out-of-pocket limit in 20162

$4,9602

$2,4802

1 Plans F and G also have a high deductible option that require first paying a plan deductible of $2,180 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible Plan G does not cover the Medicare Part B deductible. However, high deductible Plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible. High deductible Plan G is the same as high deductible Plan F except that where the annual out-of-pocket expenses are met with Medicare Part A expenses only, any subsequent Medicare Part B deductible expense incurred by the beneficiary after the required annual out-of-pocket expenses is met may not be paid for by the high deductible Plan G.

2 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.

3 Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission.

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 $1,068 $1,260

$0

$1,068 $1,260 (Part A Deductible)

61st thru 90th day

All but $267 $315 a day

$267 $315 a day

$0

91st day and after:

 

 

 

 

While using 60 lifetime reserve days

All but $534 $630 a day

$534 $630 a day

$0

 

Once lifetime reserve days are used:

 

 

 

 

Additional 365 days

$0

100% of Medicare Eligible Expenses

$0**

 

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 $133.50 $157.50 a day

$0

Up to $133.50 $157.50 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 Medicare's requirements, including a doctor's certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

$0

**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 $135 $147 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 $135 $147 of Medicare-Approved Amounts*

$0

$0

$135 $147 (Part B deductible)

Remainder of Medicare-Approved Amounts

Generally 80%

Generally 20%

$0

PART B EXCESS CHARGES

 

 

 

(Above Medicare-Approved Amounts)

$0

$0

All Costs

BLOOD

 

 

 

First 3 pints

$0

All Costs

$0

Next $135 $147 of Medicare-Approved Amounts*

$0

$0

$135 $147 (Part B Deductible)

Remainder of Medicare-Approved Amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES

 

 

 

TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE
MEDICARE-APPROVED SERVICES

 

 

 

Medically necessary skilled care services and medical supplies

100%

$0

$0

Durable medical equipment

 

 

 

 

First $135 $147 of Medicare-Approved Amounts*

$0

$0

$135 $147 (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 $1,068 $1,260

$1,068 $1,260 (Part A Deductible)

$0

61st thru 90th day

All but $267 $315 a day

$267 $315 a day

$0

91st day and after:

 

 

 

 

While using 60 lifetime reserve days

All but $534 $630 a day

$534 $630 a day

$0

 

Once lifetime reserve days are used:

 

 

 

 

Additional 365 days

$0

100% of Medicare Eligible Expenses

$0**

 

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 $133.50 $157.50 a day

$0

Up to $133.50 $157.50 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 Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

$0

**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 $135 $147 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 $135 $147 of Medicare-Approved Amounts*

$0

$0

$135 $147 (Part B Deductible)

Remainder of Medicare-Approved Amounts

Generally 80%

Generally 20%

$0

PART B EXCESS CHARGES

 

 

 

(Above Medicare-Approved Amounts)

$0

$0

All Costs

BLOOD

 

 

 

First 3 pints

$0

All Costs

$0

Next $135 $147 of Medicare-Approved Amounts*

$0

$0

$135 $147 (Part B Deductible)

Remainder of Medicare-Approved Amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES 

 

 

 

TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE
MEDICARE-APPROVED SERVICES

 

 

 

Medically necessary skilled care services and medical supplies

100%

$0

$0

Durable medical equipment

 

 

 

 

First $135 $147 of Medicare-Approved Amounts*

$0

$0

$135 $147 (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 $1,068 $1,260

$,1068 $1,260 (Part A Deductible)

$0

61st thru 90th day

All but $267 $315 a day

$267 $315 a day

$0

91st day and after:

 

 

 

 

While using 60 lifetime reserve days

All but $534 $630 a day

$534 $630 a day

$0

 

Once lifetime reserve days are used:

 

 

 

 

Additional 365 days

$0

100% of Medicare eligible expenses

$0**

 

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 $133.50 $157.50 a day

Up to $133.50 $157.50 a day

$0

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 Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

$0

**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 $135 $147 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 $135 $147 of Medicare-Approved Amounts*

$0

$135 $147 (Part B Deductible)

$0

Remainder of Medicare-Approved Amounts

Generally 80%

Generally 20%

$0

PART B EXCESS CHARGES

 

 

 

(Above Medicare-Approved Amounts)

$0

$0

All Costs

BLOOD

 

 

 

First 3 pints

$0

All Costs

$0

Next $135 $147 of Medicare-Approved Amounts*

$0

$135 $147 (Part B Deductible)

$0

Remainder of Medicare-Approved Amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES

 

 

 

TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE
MEDICARE-APPROVED SERVICES

 

 

 

Medically necessary skilled care services and medical supplies

100%

$0

$0

Durable medical equipment

 

 

 

 

First $135 $147 of Medicare-Approved Amounts*

$0

$135 $147 (Part B Deductible)

$0

 

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 lifetime maximum benefit of $50,000

20% and amounts over the $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 $1,068 $1,260

$1,068 $1,260 (Part A Deductible)

$0

61st thru 90th day

All but $267 $315 a day

$267 $315 a day

$0

91st day and after:

 

 

 

 

While using 60 lifetime reserve days

All but $534 $630 a day

$534 $630 a day

$0

 

Once lifetime reserve days are used:

 

 

 

 

Additional 365 days

$0

100% of Medicare Eligible Expenses

$0**

 

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 $133.50 $157.50a day

Up to $133.50 $157.50a day

$0

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 Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

$0

**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 $135 $147 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 $135 $147 of Medicare-Approved Amounts*

$0

$0

$135 $147 (Part B Deductible)

Remainder of Medicare-Approved Amounts

Generally 80%

Generally 20%

$0

PART B EXCESS CHARGES

 

 

 

(Above Medicare-Approved Amounts)

$0

$0

All Costs

BLOOD

 

 

 

First 3 pints

$0

All Costs

$0

Next $135 $147 of Medicare-Approved Amounts*

$0

$0

$135 $147 (Part B Deductible)

Remainder of Medicare-Approved Amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES

 

 

 

TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE
MEDICARE-APPROVED SERVICES

 

 

 

Medically necessary skilled care services and medical supplies

100%

$0

$0

Durable medical equipment

 

 

 

 

First $135 $147 of Medicare-Approved Amounts*

$0

$0

$135 $147 (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 lifetime maximum benefit of $50,000

20% and amounts over the $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 one has you have paid a calendar year $2,000 $2,180 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2,000 $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2,000 $2,180 DEDUCTIBLE,** PLAN PAYS

IN ADDITION TO $2,000 $2,180 DEDUCTIBLE,** YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

 

 

 

First 60 days

All but $1,068 $1,260

$1,068 $1,260 (Part A Deductible)

$0

61st thru 90th day

All but $267 $315 a day

$267 $315 a day

$0

91st day and after:

 

 

 

 

While using 60 lifetime reserve days

All but $534 $630 a day

$534 $630 a day

$0

 

Once lifetime reserve days are used:

 

 

 

 

Additional 365 days

$0

100% of Medicare Eligible Expenses

$0**

 

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 $133.50 $157.50 a day

Up to $133.50 $157.50 a day

$0

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 Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

$0

**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 OR HIGH DEDUCTIBLE PLAN G
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $135 $166 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 $135 $166 of Medicare-Approved Amounts*

$0

$0

$135 (Part B Deductible) $166 (Unless Part B Deductible has been met)

Remainder of Medicare-Approved Amounts

Generally 80%

Generally 20%

$0

PART B EXCESS CHARGES

 

 

 

(Above Medicare-Approved Amounts)

$0

100%

$0

BLOOD

 

 

 

First 3 pints

$0

All costs

$0

Next $135 $166 of Medicare-Approved Amounts*

$0

$0

$135 (Part B Deductible) $166 (Unless Part B Deductible has been met)

Remainder of Medicare-Approved Amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES

 

 

 

TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE
MEDICARE-APPROVED SERVICES

 

 

 

Medically necessary skilled care services and medical supplies

100%

$0

$0

Durable medical equipment

 

 

 

 

First $135 $166 of Medicare-Approved Amounts*

$0

$0

$135 (Part B deductible) $166 (Unless Part B Deductible has been met)

 

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 lifetime maximum benefit of $50,000

20% and amounts over the $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 $4,620 $4,940 each calendar year. The amounts that count toward your annual limit are noted with diamonds (♦) 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.

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 $1,068 $1,260

$534 $630 (50% of Part A deductible)

$534 $630 (50% of Part A deductible)♦

61st thru 90th day

All but $267 $315 a day

$267 $315 a day

$0

91st day and after:

 

 

 

 

While using 60 lifetime reserve days

All but $534 $630 a day

$534 $630 a day

$0

 

Once lifetime reserve days are used:

 

 

 

 

Additional 365 days

$0

100% of Medicare eligible expenses

$0***

 

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 $133.50 $157.50 a day

Up to $66.75 $78.75 a day (50% of Part A coinsurance)

Up to $66.75 $78.75 a day (50% of Part A coinsurance)

101st day and after

$0

$0

All costs

BLOOD

 

 

 

First 3 pints

$0

50%

50%♦

Additional amounts

100%

$0

$0

HOSPICE CARE

 

 

 

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

50% of copayment/coinsurance

50% of Medicare copayment/coinsurance ♦

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever the 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 $135 $147 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 $135 $147 of Medicare-Approved Amounts****

$0

$0

$135 $147 (Part B deductible)****♦

Preventive Benefits for Medicare covered services

Generally 75% 80% or more of Medicare-approved amounts

Remainder of Medicare-approved amounts

All costs above Medicare-approved amounts

Remainder of Medicare-Approved Amounts

Generally 80%

Generally 10%

Generally 10%♦

PART B EXCESS CHARGES

 

 

 

(Above Medicare-Approved Amounts)

$0

$0

All costs (and they do not count toward annual out-of-pocket limit of $4620)* $4,940)*

BLOOD

 

 

 

First 3 pints

$0

50%

50%♦

Next $135 $147 of Medicare Approved Amounts****

$0

$0

$135 $147 (Part B deductible)****♦

Remainder of Medicare-Approved Amounts

Generally 80%

Generally 10%

Generally 10%♦

CLINICAL LABORATORY SERVICES

 

 

 

TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $4,620 $4,940 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

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

HOME HEALTH CARE
MEDICARE-APPROVED SERVICES

 

 

 

Medically necessary skilled care services and medical supplies

100%

$0

$0

Durable medical equipment

 

 

 

 

First $135 $147 of Medicare-Approved Amounts*****

$0

$0

$135 $147 (Part B deductible)♦

 

Remainder of Medicare-Approved Amounts

80%

10%

10%♦

*****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 $2,310 $2,470 each calendar year. The amounts that count toward your annual limit are noted with diamonds (♦) 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.

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 $1,068 $1,260

$808.50 $945 (75% of Part A deductible)

$267 $315 (25% of Part A deductible)♦

61st thru 90th day

All but $267 $315 a day

$267 $315 a day

$0

91st day and after:

 

 

 

 

While using 60 lifetime reserve days

All but $534 $630 a day

$534 $630 a day

$0

 

Once lifetime reserve days are used:

 

 

 

 

Additional 365 days

$0

100% of Medicare eligible expenses

$0***

 

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 $133.50 $157.50 a day

Up to $100.13 $118.13 a day (75% of Part A coinsurance)

Up to $33.38 $39.38 a day (25% of Part A coinsurance)

101st day and after

$0

$0

All costs

BLOOD

 

 

 

First 3 pints

$0

75%

25%♦

Additional amounts

100%

$0

$0

HOSPICE CARE

 

 

 

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

75% of copayment/coinsurance

25% of copayment/coinsurance ♦

***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 charge and the amount Medicare would have paid.

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

****Once you have been billed $135 $147 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 $135 $147 of Medicare-Approved Amounts****

$0

$0

$135 $147 (Part B deductible)****♦

Preventive Benefits for Medicare covered services

Generally 75% 80% or more of Medicare-approved amounts

Remainder of Medicare-approved amounts

All costs above Medicare-approved amounts

Remainder of Medicare-Approved Amounts

Generally 80%

Generally 15%

Generally 5%♦

PART B EXCESS CHARGES

 

 

 

(Above Medicare-Approved Amounts)

$0

$0

All costs (and they do not count toward annual out-of-pocket limit of $2,310)* $2,470)*

BLOOD

 

 

 

First 3 pints

$0

75%

25%♦

Next $135 $147 of Medicare Approved Amounts****

$0

$0

$135 $147 (Part B deductible)♦

Remainder of Medicare-Approved Amounts

Generally 80%

Generally 15%

Generally 5%♦

CLINICAL LABORATORY SERVICES

 

 

 

TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2,310 $2,470 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

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

HOME HEALTH CARE
MEDICARE-APPROVED SERVICES

 

 

 

Medically necessary skilled care services and medical supplies

100%

$0

$0

Durable medical equipment

 

 

 

 

First $135 $147 of Medicare-Approved Amounts*****

$0

$0

$135 $147 (Part B deductible)♦

 

Remainder of Medicare-Approved Amounts

80%

15%

5%♦

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

PLAN M
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 $1,068 $1,260

$534 $630 (50% of Part A deductible)

$534 $630 (50% of Part A deductible)

61st thru 90th day

All but $267 $315 a day

$267 $315 a day

$0

91st day and after:

 

 

 

 

While using 60 lifetime reserve days

All but $534 $630 a day

$534 $630 a day

$0

 

Once lifetime reserve days are used:

 

 

 

 

Additional 365 days

$0

100% of Medicare eligible expenses

$0**

 

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 $133.50 $157.50 a day

Up to $133.50 $157.50 a day

$0

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 Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

$0

**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 charge and the amount Medicare would have paid.

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

*Once you have been billed $135 $147 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 $135 $147 of Medicare-Approved Amounts*

$0

$0

$135 $147 (Part B deductible)

Remainder of Medicare-Approved Amounts

Generally 80%

Generally 20%

$0

PART B EXCESS CHARGES

 

 

 

(Above Medicare-Approved Amounts)

$0

$0

All costs

BLOOD

 

 

 

First 3 pints

$0

All costs

$0

Next $135 $147 of Medicare Approved Amounts*

$0

$0

$135 $147 (Part B deductible)

Remainder of Medicare-Approved Amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES

 

 

 

TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE
MEDICARE-APPROVED SERVICES

 

 

 

Medically necessary skilled care services and medical supplies

100%

$0

$0

Durable medical equipment

 

 

 

 

First $135 $147 of Medicare-Approved Amounts*

$0

$0

$135 $147 (Part B deductible)

 

Remainder of Medicare-Approved Amounts

80%

20%

$0

OTHER BENEFITS—NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

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 lifetime maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum

PLAN N
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 $1,068 $1,260

$1,068 $1,260 (Part A deductible)

$0

61st thru 90th day

All but $267 $315 a day

$267 $315 a day

$0

91st day and after:

 

 

 

 

While using 60 lifetime reserve days

All but $534 $630 a day

$534 $630 a day

$0

 

Once lifetime reserve days are used:

 

 

 

 

Additional 365 days

$0

100% of Medicare eligible expenses

$0**

 

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 $133.50 $157.50 a day

Up to $133.50 $157.50 a day

$0

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 Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

$0

**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 charge and the amount Medicare would have paid.

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

*Once you have been billed $135 $147 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 $135 $147 of Medicare-Approved Amounts*

$0

$0

$135 $147 (Part B deductible)

Remainder of Medicare-Approved Amounts

Generally 80%

Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Up to$20 per office visit and up to $50 per emergency visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency room visit is covered as a Medicare Part A expense.

PART B EXCESS CHARGES

 

 

 

(Above Medicare-Approved Amounts)

$0

$0

All costs

BLOOD

 

 

 

First 3 pints

$0

All costs

$0

Next $135 $147 of Medicare Approved Amounts*

$0

$0

$135 $147 (Part B deductible)

Remainder of Medicare-Approved Amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES

 

 

 

TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE
MEDICARE-APPROVED SERVICES

 

 

 

Medically necessary skilled care services and medical supplies

100%

$0

$0

Durable medical equipment

 

 

 

 

First $135 $147 of Medicare-Approved Amounts*

$0

$0

$135 $147 (Part B deductible)

 

Remainder of Medicare-Approved Amounts

80%

20%

$0

OTHER BENEFITS—NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

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 lifetime maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum


E. Notice regarding policies or certificates which that are not Medicare supplement policies.

1. Any accident and sickness insurance policy or certificate issued for delivery in this Commonwealth to persons eligible for Medicare, other than a Medicare supplement policy, a policy issued pursuant to a contract under § 1876 of the federal Social Security Act (42 USC § 1395 et seq.), a disability income policy, or other policy identified in 14VAC5-170-20 B, shall notify insureds under the policy that the policy is not a Medicare supplement policy or certificate. The notice shall either be printed or attached to the first page of the outline of coverage delivered to insureds under the policy, or if no outline of coverage is delivered, to the first page of the policy, or certificate delivered to insureds. The notice shall be in no less than 12 point type and shall contain the following language:

"THIS [POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT [POLICY OR CONTRACT]. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company."

2. Applications provided to persons eligible for Medicare for the health insurance policies or certificates described in subdivision 1 of this subsection shall disclose, using the applicable statement in Appendix C, the extent to which the policy duplicates Medicare. The disclosure statement shall be provided as a part of, or together with, the application for the policy or certificate.

F. Notice requirements for attained age rated Medicare supplement policies or certificates. Issuers of Medicare supplement policies or certificates which that use attained age rating shall provide a notice to all prospective applicants at the time the application is presented, and except for direct response policies or certificates, shall obtain an acknowledgement of receipt of the notice from the applicant. The notice shall be in no less than 12 point type and shall contain the information included in Appendix D. The notice shall be provided as part of, or together with, the application for the policy or certificate.

VA.R. Doc. No. R17-5121; Filed June 20, 2017, 1:47 p.m.