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IAC 3/14/18
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Insurance[191]
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Ch
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, p.
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Ch
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, p.
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Insurance[191]
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IAC 3/14/18
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\pard\keepn\sb57\qc\sl250
{\plain\f4\fs21\cf2
CHAPTER
}
{\plain\f4\fs21\cf2
37
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
MEDICARE SUPPLEMENT INSURANCE
}
\par
\pard\keepn\sb283\qc\sl180
{\plain\f4\fs16\cf2
DIVISION I
}
\par
\pard\keepn\qc\sl180
{\plain\f4\fs16\cf2
MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
1
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Purpose.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The purpose of this chapter is to provide for the reasonable standardization of coverage and simplification of terms and benefits of Medicare supplement policies; to facilitate public understanding and comparison of such policies; to eliminate provisions contained in such policies which may be misleading or confusing in connection with the purchase of such policies or with the settlement of claims; and to provide for full disclosures in the sale of accident and sickness insurance coverages to persons eligible for Medicare.
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
2
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Applicability and scope.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.2
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Except as otherwise specifically provided in rules
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.6.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.6
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D),
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.13.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.13
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D),
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.14.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.14
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D),
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.17.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.17
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D) and
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.21.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.21
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D), this chapter shall apply to:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
All Medicare supplement policies delivered or issued for delivery in this state on or after the effective date hereof, and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
All certificates issued under group Medicare supplement policies, which certificates have been delivered or issued for delivery in this state.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.2
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
This chapter shall not apply to a policy or contract of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof; for employees or former employees, or a combination thereof; or for members or former members, or a combination thereof, of the labor organizations.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
3
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Definitions.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
For purposes of this chapter:
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
1990 standardized Medicare supplement benefit plan,” “1990 standardized benefit plan
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
or
}
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
1990 plan
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means a group or individual policy of Medicare supplement insurance issued on or after January 1, 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 June 1, 2010, which are not replaced by the issuer at the request of the insured.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
2010 standardized Medicare supplement benefit plan,” “2010 standardized benefit plan
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
or
}
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
2010 plan
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means a group or individual policy of Medicare supplement insurance issued with an effective date for coverage on or after June 1, 2010.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Applicant
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits, and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
In the case of a group Medicare supplement policy, the proposed certificate holder.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Bankruptcy
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means 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 the state.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Certificate
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means any certificate delivered or issued for delivery in this state under a group Medicare supplement policy.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Certificate form
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means the form on which the certificate is delivered or issued for delivery by the issuer.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Continuous period of creditable coverage
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means the period during which an individual was covered by creditable coverage, if during the period of the coverage the individual had no breaks in coverage greater than 63 days.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Creditable coverage
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means, with respect to an individual, coverage of the individual provided under any of the following:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A group health plan;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Health insurance coverage;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
3.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Part A or Part B of Title XVIII of the Social Security Act (Medicare);
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
4.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under Section 1928;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
5.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Chapter 55 of Title 10, United States Code (CHAMPUS);
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
6.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A medical care program of the Indian Health Service or of a tribal organization;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
7.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A state health benefits risk pool;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
8.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A health plan offered under Chapter 89 of Title 5 United States Code (Federal Employees Health Benefits Program);
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
9.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A public health plan as defined in federal regulation;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
10.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A health benefit plan under Section 5(e) of the Peace Corps Act (22 United States Code 2504(e)); and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
11.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Short-term limited durational policy.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
“Creditable coverage” shall not include one or more, or any combination of, the following:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage only for accident or disability income insurance, or any combination thereof;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage issued as a supplement to liability insurance;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
3.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Liability insurance, including general liability insurance and automobile liability insurance;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
4.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Workers’ compensation or similar insurance;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
5.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Automobile medical payment insurance;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
6.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Credit-only insurance;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
7.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage for on-site medical clinics; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
8.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
“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:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Limited scope dental or vision benefits;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
3.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Such other similar, limited benefits as are specified in federal regulations.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
“Creditable coverage” shall not include the following benefits if offered as independent, noncoordinated benefits:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage only for a specified disease or illness; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Hospital indemnity or other fixed indemnity insurance.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
“Creditable coverage” shall not include the following if it is offered as a separate policy, certificate or contract of insurance:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Medicare supplemental health insurance as defined under Section 1882(g)(1) of the Social Security Act;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
3.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Similar supplemental coverage provided to coverage under a group health plan.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Employee welfare benefit plan
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means a plan, fund or program of employee benefits as defined in 29 U.S.C. Section 1002 (Employee Retirement Income Security Act).
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Insolvency
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means that an issuer, licensed to transact the business of insurance in this state, has had a final order of liquidation entered against it with a finding of insolvency by a court of competent jurisdiction in the issuer’s state of domicile.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Issuer
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
includes insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations, and any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Medicare
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means the “Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as Then Constituted or Later Amended.”
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Medicare Advantage plan
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means a plan of coverage for health benefits under Medicare Part C (as defined in 42 U.S.C. 1395w-28(b)(1)), and includes:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coordinated care plans which 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;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Medical savings account plans coupled with a contribution into a Medicare Advantage medical savings account; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
3.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Medicare Advantage private fee-for-service plans.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Medicare supplement policy
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
” means a group or individual policy of accident and sickness insurance or a subscriber contract of hospital and medical service associations or health maintenance organizations, other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act (42 U.S.C. Section 1395 et seq.) or an issued policy under a demonstration project specified in 42 U.S.C. Section 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 (HCPP) that provides benefits pursuant to an agreement under §1833(a)(1)(A) of the Social Security Act.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Policy form
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means the form on which the policy is delivered or issued for delivery by the issuer.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Prestandardized Medicare supplement benefit plan
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
or
}
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
prestandardized plan
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means a group or individual policy of Medicare supplement insurance issued prior to January 1, 1992.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Secretary
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means the Secretary of the United States Department of Health and Human Services.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09;
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/3682C.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 3682C
}
}}
{\plain\f4\fs16\cf2
, IAB 3/14/18, effective 4/18/18]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
4
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Policy definitions and terms.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
No policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate unless such policy or certificate contains definitions or terms which conform to the requirements of this rule.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Accident,” “accidental injury,
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
or
}
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
accidental means
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
shall be defined to employ “result” language and shall not include words which establish an accidental means test or use words such as “external, violent, visible wounds” or similar words of description or characterization.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The definition shall not be more restrictive than the following: “Injury or injuries for which benefits are provided means accidental bodily injury sustained by the insured person which is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while insurance coverage is in force.”
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Such definition may provide that injuries shall not include injuries for which benefits are provided or available under any workers’ compensation, employer’s liability or similar law, or motor vehicle no-fault plan, unless prohibited by law.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Benefit period
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
or
}
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Medicare benefit period
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
shall not be defined more restrictively than as defined in the Medicare program.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Convalescent nursing home,” “extended care facility,
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
or
}
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
skilled nursing facility
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
shall not be defined more restrictively than as defined in the Medicare program.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Health care expenses
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means, for purposes of rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.14.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.14
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D), expenses of health maintenance organizations associated with the delivery of health care services, which expenses are analogous to incurred losses of insurers.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Hospital
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
may be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals, but not more restrictively than as defined in the Medicare program.
}
\par
\pard\qj\fi340\sl250\tx40
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Medicare
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
shall be defined in the policy and certificate. Medicare may be substantially defined as “The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended,” or “Title I, Part I of Pub. L. No.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof,” or words of similar import.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Medicare eligible expenses
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
shall mean expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Physician
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
shall not be defined more restrictively than as defined in the Medicare program.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Sickness
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
shall not be defined to be more restrictive than the following: “Sickness means illness or disease of an insured person which first manifests itself after the effective date of insurance and while the insurance is in force.” The definition may be further modified to exclude sicknesses or diseases for which benefits are provided under any workers’ compensation, occupational disease, employer’s liability or similar law.
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
5
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Policy provisions.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.5
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Except for permitted preexisting condition clauses as described in
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.6.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.6(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“a,”
}
}}
{\plain\f4\fs21\cf2\ulc2
\~
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“a,”
}
}}
{\plain\f4\fs21\cf2\ulc2
and
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“a,”
}
}}
{\plain\f4\fs21\cf2\ulc2
no policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy if such policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.5
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
No Medicare supplement policy or certificate may use waivers to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.5
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
No Medicare supplement policy or certificate in force in the state shall contain benefits which duplicate benefits provided by Medicare.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.5
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Subject to paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.6.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.6(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“d,” “e,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“g”
}
}}
{\plain\f4\fs21\cf2\ulc2
and
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“d”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“e,”
}
}}
{\plain\f4\fs21\cf2\ulc2
a Medicare supplement policy with benefits for outpatient prescription drugs in existence prior to January 1, 2006, shall be renewed for current policyholders who do not enroll in Medicare Part D at the option of the policyholder.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.5
}
{\plain\f4\fs21\b\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
A Medicare supplement policy with benefits for outpatient prescription drugs shall not be issued after December 31, 2005.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.5
}
{\plain\f4\fs21\b\cf2\ulc2
(6)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
After December 31, 2005, a Medicare supplement policy with benefits for outpatient prescription drugs may not be renewed after the policyholder enrolls in Medicare Part D unless:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The policy is modified to eliminate outpatient prescription coverage for expenses of outpatient prescription drugs incurred after the effective date of the individual’s coverage under a Medicare Part D plan; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Premiums are adjusted to reflect the elimination of outpatient prescription drug coverage at the time of Medicare Part D enrollment, accounting for any claims paid, if applicable.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
6
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Minimum benefit standards for prestandardized Medicare supplement benefit plan policies or certificates issued for delivery prior to January 1, 1992.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
No policy or certificate may be advertised, solicited or issued for delivery in this state 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 are not inconsistent with these standards.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.6
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
General standards.
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this regulation.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A Medicare supplement policy or certificate shall not exclude or limit benefits for losses 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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A “noncancelable,” “guaranteed renewable,” or “noncancelable and guaranteed renewable” Medicare supplement policy shall not:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Be canceled or nonrenewed by the issuer solely on the grounds of deterioration of health.
}
\par
\pard\qj\sl250\tx340\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Except as authorized by the commissioner of this state, an issuer shall neither cancel nor nonrenew a Medicare supplement policy or certificate for any reason other than nonpayment of premium or material misrepresentation.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If a group Medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in subparagraph
}
{\plain\f4\fs21\i\cf2\ulc2
“e”
}
{\plain\f4\fs21\cf2\ulc2
(4) below, the issuer shall offer certificate holders an individual Medicare supplement policy. The issuer shall offer the certificate holder at least the following choices:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An individual Medicare supplement policy currently offered by the issuer having comparable benefits to those contained in the terminated group Medicare supplement policy; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An individual Medicare supplement policy which provides only such benefits as are required to meet the minimum standards as defined in 37.7(2).
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If membership in a group is terminated, the issuer shall:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Offer the certificate holder such conversion opportunities as are described in 37.6(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“e”
}
{\plain\f4\fs21\cf2\ulc2
(2); or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If a Medicare supplement policy eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this subrule.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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.
}
\par
\pard\keepn\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.6
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Minimum benefit standards.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the sixty-first day through the ninetieth day in any Medicare benefit period;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare’s lifetime hospital inpatient reserve days;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of 90 percent of all Medicare Part A eligible expenses for hospitalization not covered by Medicare subject to a lifetime maximum benefit of an additional 365 days;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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);
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
g.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
7
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Benefit standards for 1990 standardized Medicare supplement benefit plan policies or certificates issued for delivery on or after January 1, 1992, and with an effective date for coverage prior to June 1, 2010.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state on or after January 1, 1992, and with an effective date for coverage prior to June 1, 2010. No policy or certificate may be advertised, solicited, delivered or issued for delivery in this state as a Medicare supplement policy or certificate unless it complies with these benefit standards.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.7
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
General standards.
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this chapter.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six months from the effective date of coverage because it involved a preexisting condition. The policy or certificate may 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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
No Medicare supplement policy or certificate shall 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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Each Medicare supplement policy shall be guaranteed renewable and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The issuer shall not cancel or nonrenew the policy solely on the ground of health status of the individual; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The issuer shall not cancel or nonrenew the policy for any reason other than nonpayment of premium or material misrepresentation.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under subparagraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“e”
}
{\plain\f4\fs21\cf2\ulc2
(5)
}
}}
{\plain\f4\fs21\cf2\ulc2
, the issuer shall offer certificate holders an individual Medicare supplement policy which at the option of the certificate holder:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Provides for continuation of the benefits contained in the group policy, or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Provides for such benefits as otherwise meets the requirements of this subrule.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Offer the certificate holder the conversion opportunity described in subparagraph 37.7(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“e”
}
{\plain\f4\fs21\cf2\ulc2
(3), or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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 policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(6)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If a Medicare supplement policy eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this subrule.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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 conditioned upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.
}
\par
\pard\qj\sl250\tx340\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
g.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A Medicare supplement policy or certificate shall provide that benefits and premiums under the policy or certificate shall be suspended at the request of the policyholder or certificate holder for the period (not to exceed 24 months) in which the policyholder or certificate holder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act, but only if the policyholder or certificate holder notifies the issuer of such policy or certificate within 90 days after the date the individual becomes entitled to such assistance.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If such suspension occurs and if the policyholder or certificate holder loses entitlement to such medical assistance, such policy or certificate shall be automatically reinstituted (effective as of the date of termination of such entitlement) as of the termination of such entitlement if the policyholder or certificate holder provides notice of loss of such entitlement within 90 days after the date of such loss and pays the premium attributable to the period, effective as of the date of termination of such entitlement.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Reinstitution of such coverages:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Shall not provide for any waiting period with respect to treatment of preexisting conditions;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension. If the suspended Medicare supplement policy provided coverage for outpatient prescription drugs, reinstitution of the policy for Medicare Part D enrollees shall be without coverage for outpatient prescription drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
3.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Shall provide for classification of premiums on terms at least as favorable to the policyholder or certificate holder as the premium classification terms that would have applied to the policyholder or certificate holder had the coverage not been suspended.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Each Medicare supplement policy shall provide that benefits and premiums under the policy shall be suspended for the period provided by federal regulation at the request of the policyholder if the policyholder is entitled to benefits under Section 226(b) of the Social Security Act and is covered under a group health plan as defined in Section 1862(b)(1)(A)(v) of the Social Security Act. If suspension occurs and if the policyholder or certificate holder loses coverage under the group health plan, the policy shall be automatically reinstituted effective as of the date of loss of coverage if the policyholder provides notice of loss of coverage within 90 days after the date of such loss and pays the premium attributable to the period, effective as of the date of termination of entitlement.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
h.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If an issuer makes a written offer to an insured who holds one or more of the issuer’s 1990 Standardized Medicare supplement policies or certificates (as described in rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.9.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.9
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D)) to allow the insured to exchange that policy during a specified period of time for a 2010 standardized plan (as described in rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.10
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D)), the offer and subsequent exchange shall comply with the following requirements:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An issuer need not provide justification to the commissioner if the insured exchanges a 1990 standardized policy or certificate for an issue-age-rated 2010 standardized policy or certificate at the insured’s original issue age and duration. If an insured’s 1990 standardized policy or certificate to be exchanged is priced on an issue-age rate schedule at the time of such offer, the rate charged to the insured for the new 2010 exchanged standardized policy or certificate shall recognize the policy reserve buildup, due to the prefunding inherent in the use of an issue-age rate basis, for the benefit of the insured. The method proposed to be used by an issuer must be filed with the commissioner pursuant to rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.15.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.15
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D).
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The rating class of the new 2010 standardized policy or certificate shall be the class closest to the insured’s class of the replaced coverage.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An issuer may not apply new preexisting condition limitations or a new incontestability period to the new 2010 standardized policy or certificate for those benefits contained in the exchanged 1990 standardized policy or certificate of the insured, but may apply preexisting condition limitations of no more than six months to any added benefits contained in the new 2010 standardized policy or certificate not contained in the exchanged 1990 standardized policy or certificate.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The new 2010 standardized policy or certificate shall be offered to all policyholders or certificate holders within a given plan, except where the offer or issue would be in violation of state or federal law.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.7
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Standards for Basic (“Core”) Benefits Common to A-J Benefit Plans.
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Every issuer shall make available a policy or certificate including only the following basic “Core” package of benefits to each prospective insured. An issuer may make available to prospective insureds any of the other Medicare supplement insurance benefit plans in addition to the basic “Core” package, but not in lieu thereof.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage of Part A Medicare Eligible Expenses for hospitalization to the extent not covered by Medicare from the sixty-first day through the ninetieth day in any Medicare benefit period;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage of Part A Medicare Eligible Expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Upon exhaustion of the Medicare hospital inpatient coverage including the lifetime reserve days, coverage of 100 percent 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;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage under Medicare Parts A and 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;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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 the Medicare Part B deductible.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.7
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Standards for Additional Benefits.
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The following additional benefits shall be included in Medicare Supplement Benefit Plans “B” through “J” only as provided by rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.9.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.9
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D).
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Medicare Part A Deductible: Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Skilled Nursing Facility Care: Coverage for the actual billed charges up to the coinsurance amount from the twenty-first day through the one hundredth day in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare Part A.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Medicare Part B Deductible: Coverage for all of the Medicare Part B deductible amount per calendar year regardless of hospital confinement.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Eighty percent of the Medicare Part B Excess Charges: Coverage for 80 percent of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
One hundred percent of the Medicare Part B Excess Charges: Coverage for all of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Basic Outpatient Prescription Drug Benefit: Coverage for 50 percent of outpatient prescription drug charges, after a $250 calendar year deductible, to a maximum of $1,250 in benefits received by the insured per calendar year to the extent not covered by Medicare. The outpatient prescription drug benefit may be included for sale or issuance in a Medicare supplement policy until January 1, 2006.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
g.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Extended Outpatient Prescription Drug Benefit: Coverage for 50 percent of outpatient prescription drug charges, after a $250 calendar year deductible to a maximum of $3,000 in benefits received by the insured per calendar year, to the extent not covered by Medicare. The outpatient prescription drug benefit may be included for sale or issuance in a Medicare supplement policy until January 1, 2006.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
h.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Medically Necessary Emergency Care in a Foreign Country: Coverage to the extent not covered by Medicare for 80 percent of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during the first 60 consecutive days of each trip outside the United States, subject to a calendar year deductible of $250 and a lifetime maximum benefit of $50,000. For purposes of this benefit, “emergency care” shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
i.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Preventive Medical Care Benefit: Coverage for the following preventive health services not covered by Medicare:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An annual clinical preventive medical history and physical examination that may include tests and services from subparagraph (2) and patient education to address preventive health care measures.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
Reimbursement shall be for the actual charges up to 100 percent of the Medicare-approved amount for each service, as if Medicare were to cover the service as identified in American Medical Association Current Procedural Terminology (AMA CPT) codes, to a maximum of $120 annually under this benefit. This benefit shall not include payment for any procedure covered by Medicare.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
j.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
At-Home Recovery Benefit: Coverage for services to provide short-term, at-home assistance with activities of daily living for those recovering from an illness, injury or surgery.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
For purposes of this benefit, the following definitions shall apply:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
“Activities of daily living” include, but are not limited to, bathing, dressing, personal hygiene, transferring, eating, ambulating, assistance with drugs that are normally self-administered, and changing bandages or other dressings.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
“Care provider” means a duly qualified or licensed home health aide/homemaker, personal care aide or nurse provided through a licensed home health care agency or referred by a licensed referral agency or licensed nurses registry.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
3.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
“Home” shall mean any place used by the insured as a place of residence, provided that such place would qualify as a residence for home health care services covered by Medicare. A hospital or skilled nursing facility shall not be considered the insured’s place of residence.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
4.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
“At-home recovery visit” means the period of a visit required to provide at-home recovery care, without limit on the duration of the visit, except each consecutive 4 hours in a 24-hour period of services provided by a care provider is one visit.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage requirements and limitations.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
At-home recovery services provided must be primarily services which assist in activities of daily living.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The insured’s attending physician must certify that the specific type and frequency of at-home recovery services are necessary because of a condition for which a home care plan of treatment was approved by Medicare.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
3.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage is limited to:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
No more than the number and type of at-home recovery visits certified as necessary by the insured’s attending physician. The total number of at-home recovery visits shall not exceed the number of Medicare-approved home health care visits under a Medicare-approved home care plan of treatment.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The actual charges for each visit up to a maximum reimbursement of $40 per visit.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
One thousand six hundred dollars per calendar year.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Seven visits in any one week.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Care furnished on a visiting basis in the insured’s home.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Services provided by a care provider as defined in this paragraph
}
{\plain\f4\fs21\i\cf2\ulc2
“j.”
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
At-home recovery visits while the insured is covered under the policy or certificate and not otherwise excluded.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
At-home recovery visits received during the period the insured is receiving Medicare-approved home care services or no more than eight weeks after the service date of the last Medicare-approved home health care visit.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage is excluded for:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Home care visits paid for by Medicare or other government programs; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Care provided by family members, unpaid volunteers or providers who are not care providers.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
k.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Rescinded
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/bulletin/01-05-2005.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
IAB 1/5/05
}
}}
{\plain\f4\fs21\cf2\ulc2
, effective 2/9/05.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.7
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Standards for Plan “K.”
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit plan “K” shall consist of the following:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage of 100 percent of the Part A hospital coinsurance amount for each day used from the sixty-first through the ninetieth day in any Medicare benefit period;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage of 100 percent of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the ninety-first through the one hundred fiftieth day in any Medicare benefit period;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent 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 in full and may not bill the insured for any balances;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Medicare Part A Deductible: Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in paragraph
}
{\plain\f4\fs21\i\cf2\ulc2
“j”
}
{\plain\f4\fs21\cf2\ulc2
;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Skilled Nursing Facility Care: Coverage for 50 percent of the coinsurance amount for each day used from the twenty-first day through the one hundredth day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in paragraph
}
{\plain\f4\fs21\i\cf2\ulc2
“j”
}
{\plain\f4\fs21\cf2\ulc2
;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Hospice Care: Coverage for 50 percent of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in paragraph
}
{\plain\f4\fs21\i\cf2\ulc2
“j”
}
{\plain\f4\fs21\cf2\ulc2
;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
g.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage for 50 percent, 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 paragraph
}
{\plain\f4\fs21\i\cf2\ulc2
“j”
}
{\plain\f4\fs21\cf2\ulc2
;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
h.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Except for coverage provided in paragraph
}
{\plain\f4\fs21\i\cf2\ulc2
“i,”
}
{\plain\f4\fs21\cf2\ulc2
coverage for 50 percent 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 paragraph
}
{\plain\f4\fs21\i\cf2\ulc2
“j”
}
{\plain\f4\fs21\cf2\ulc2
;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
i.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
j.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage of 100 percent 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.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.7
}
{\plain\f4\fs21\b\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Standards for Plan “L.”
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit plan “L” shall consist of the following:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The benefits described in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(4)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “b,” “c,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“i”
}
{\plain\f4\fs21\cf2\ulc2
;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The benefits described in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(4)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“d,” “e,” “f,” “g,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“h”
}
{\plain\f4\fs21\cf2\ulc2
but substituting 75 percent for 50 percent; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The benefits described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(4)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“j”
}
{\plain\f4\fs21\cf2\ulc2
but substituting $2,000 for $4,000.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
8
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Benefit standards for 2010 standardized Medicare supplement benefit plan policies or certificates issued for delivery with an effective date for coverage on or after June 1, 2010.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state with an effective date for coverage on or after June 1, 2010. Insurers may begin submitting policies and certificates to the division for approval on or after January 1, 2010. No policy or certificate may be advertised, solicited, delivered, or issued for delivery in this state as a Medicare supplement policy or certificate unless it complies with these benefit standards. No issuer may offer any 1990 standardized Medicare supplement benefit plan for sale on or after June 1, 2010. Benefit standards applicable to Medicare supplement policies and certificates issued with an effective date for coverage prior to June 1, 2010, remain subject to the requirements of rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.7
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D).
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.8
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
General standards.
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this chapter.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six months from the effective date of coverage because the losses involved a preexisting condition. The policy or certificate may 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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
No Medicare supplement policy or certificate shall 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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Each Medicare supplement policy shall be guaranteed renewable.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The issuer shall not cancel or nonrenew the policy solely on the ground of health status of the individual.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The issuer shall not cancel or nonrenew the policy for any reason other than nonpayment of premium or material misrepresentation.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under subparagraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“e”
}
{\plain\f4\fs21\cf2\ulc2
(5)
}
}}
{\plain\f4\fs21\cf2\ulc2
, the issuer shall offer certificate holders an individual Medicare supplement policy which (at the option of the certificate holder):
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Provides for continuation of the benefits contained in the group policy; or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Provides for benefits that otherwise meet the requirements of paragraph 37.8(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“e.”
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Offer the certificate holder the conversion opportunity described in subparagraph 37.8(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“e”
}
{\plain\f4\fs21\cf2\ulc2
(3); or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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 group policy that is being replaced on that policy’s date of termination. Coverage under the new policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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 conditioned upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
g.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Suspension of benefits.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A Medicare supplement policy or certificate shall provide that benefits and premiums under the policy or certificate shall be suspended at the request of the policyholder or certificate holder for the period (not to exceed 24 months) in which the policyholder or certificate holder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act, but only if the policyholder or certificate holder notifies the issuer of the policy or certificate within 90 days after the date the individual becomes entitled to assistance.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If suspension occurs and if the policyholder or certificate holder loses entitlement to medical assistance, the policy or certificate shall be automatically reinstituted effective as of the date of termination of entitlement if the policyholder or certificate holder provides notice of loss of entitlement within 90 days after the date of loss and pays the premium attributable to the period, effective as of the date of termination of entitlement.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Each Medicare supplement policy shall provide that benefits and premiums under the policy shall be suspended (for any period that may be provided by federal regulation) at the request of the policyholder or certificate holder if the policyholder or certificate holder is entitled to benefits under Section 226(b) of the Social Security Act and is covered under a group health plan (as defined in Section 1862(b)(1)(A)(v) of the Social Security Act). If suspension occurs and if the policyholder or certificate holder loses coverage under the group health plan, the policy shall be automatically reinstituted (effective as of the date of loss of coverage) if the policyholder or certificate holder provides notice of loss of coverage within 90 days after the date of the loss.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Reinstitution of coverage as described in subparagraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“g”
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
and (3):
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Shall not provide for any waiting period with respect to treatment of preexisting conditions;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
3.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Shall provide for classification of premiums on terms at least as favorable to the policyholder or certificate holder as the premium classification terms that would have applied to the policyholder or certificate holder had the coverage not been suspended.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.8
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Standards for basic (core) benefits common to Medicare supplement insurance benefit plans A, B, C, D, F, F with high deductible, G, M, and N.
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Every issuer of Medicare supplement insurance benefit plans shall make available to each prospective insured a policy or certificate including only the following basic (core) package of benefits. An issuer may make available to prospective insureds any of the other Medicare supplement insurance benefit plans in addition to the basic core package, but not in lieu of it. The basic core package must provide:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the sixty-first day through the ninetieth day in any Medicare benefit period;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage of Part A Medicare eligible expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent 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;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Coverage under Medicare Parts A and 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;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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 the Medicare Part B deductible; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Hospice Care: Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.8
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Standards for additional benefits.
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The following additional benefits shall be included in Medicare supplement benefit Plans B, C, D, F, F with high deductible, G, M, and N as provided by rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.10
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D):
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Medicare Part A Deductible: Coverage for 100 percent of the Medicare Part A inpatient hospital deductible amount per benefit period;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Medicare Part A Deductible: Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Skilled Nursing Facility Care: Coverage for the actual billed charges up to the coinsurance amount from the twenty-first day through the one hundredeth day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Medicare Part B Deductible: Coverage for 100 percent of the Medicare Part B deductible amount per calendar year regardless of hospital confinement;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
One hundred percent of the Medicare Part B excess charges: Coverage for all of the difference between the actual Medicare Part B charges as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Medically necessary emergency care in a foreign country: Coverage to the extent not covered by Medicare for 80 percent of the billed charges for Medicare eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during the first 60 consecutive days of each trip outside the United States, subject to a calendar year deductible of $250, and a lifetime maximum benefit of $50,000. For purposes of this benefit, “emergency care” shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
9
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Standard Medicare supplement benefit plans for 1990 standardized Medicare supplement benefit plan policies or certificates with an effective date for coverage prior to June 1, 2010.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.9
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An issuer shall make available to each prospective policyholder and certificate holder a policy form or certificate form containing only the basic “Core” benefits as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.9
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
No groups, packages or combinations of Medicare supplement benefits other than those listed in this rule shall be offered for sale in this state, except as may be permitted in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.9.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.9(7)
}
}}
{\plain\f4\fs21\cf2\ulc2
and in rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.11.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.11
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D).
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.9
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans “A” through “L” listed in this rule and conform to the definitions in rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.3.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.3(514D)
}
}}
{\plain\f4\fs21\cf2\ulc2
. Each benefit shall be structured in accordance with the format provided in subrules
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
,
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(3)
}
}}
{\plain\f4\fs21\cf2\ulc2
,
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(4)
}
}}
{\plain\f4\fs21\cf2\ulc2
and
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(5)
}
}}
{\plain\f4\fs21\cf2\ulc2
and list the benefits in the order shown in this rule. For purposes of this rule, “structure, language, and format” means style, arrangement and overall content of a benefit.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.9
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An issuer may use, in addition to the benefit plan designations required in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(3)
}
}}
{\plain\f4\fs21\cf2\ulc2
, other designations to the extent permitted by law.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.9
}
{\plain\f4\fs21\b\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Makeup of benefit plans:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit plan “A” shall be limited to the Basic (“Core”) Benefits Common to All Benefit Plans, as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit plan “B” shall include only the following: The Core Benefit as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus the Medicare Part A Deductible as defined in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(3)
}
{\plain\f4\fs21\i\cf2\ulc2
“a.”
}
}}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit plan “C” shall include only the following: The Core Benefit as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medicare Part B Deductible and Medically Necessary Emergency Care in a Foreign Country as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “b,” “c,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“h,”
}
{\plain\f4\fs21\cf2\ulc2
respectively.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit plan “D” shall include only the following: The Core Benefit, as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medically Necessary Emergency Care in a Foreign Country and the At-Home Recovery Benefit as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “b,” “h,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“j,”
}
{\plain\f4\fs21\cf2\ulc2
respectively.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit plan “E” shall include only the following: The Core Benefit, as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medically Necessary Emergency Care in a Foreign Country and Preventive Medical Care as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “b,” “h,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“i,”
}
{\plain\f4\fs21\cf2\ulc2
respectively.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit plan “F” shall include only the following: The Core Benefit, as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus the Medicare Part A Deductible, the Skilled Nursing Facility Care, the Part B Deductible, 100 Percent of the Medicare Part B Excess Charges, and Medically Necessary Emergency Care in a Foreign Country as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “b,” “c,” “e,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“h,”
}
{\plain\f4\fs21\cf2\ulc2
respectively.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
g.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit plan “G” shall include only the following: The Core Benefit, as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, 80 Percent of the Medicare Part B Excess Charges, Medically Necessary Emergency Care in a Foreign Country, and the At-Home Recovery Benefit as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “b,” “d,” “h,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“j,”
}
{\plain\f4\fs21\cf2\ulc2
respectively.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
h.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit plan “H” shall consist of only the following: The Core Benefit, as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Basic Prescription Drug Benefit and Medically Necessary Emergency Care in a Foreign Country as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “b,” “f,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“h,”
}
{\plain\f4\fs21\cf2\ulc2
respectively. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
i.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit plan “I” shall consist of only the following: The Core Benefit, as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, 100 Percent of the Medicare Part B Excess Charges, Basic Prescription Drug Benefit, Medically Necessary Emergency Care in a Foreign Country and At-Home Recovery Benefit as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “b,” “e,” “f,” “h,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“j,”
}
{\plain\f4\fs21\cf2\ulc2
respectively. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
j.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit plan “J” shall consist of only the following: The Core Benefit, as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medicare Part B Deductible, 100 Percent of the Medicare Part B Excess Charges, Extended Prescription Drug Benefit, Medically Necessary Emergency Care in a Foreign Country, Preventive Medical Care and At-Home Recovery Benefit as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “b,” “c,” “e,” “g,” “h,” “i,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“j,”
}
{\plain\f4\fs21\cf2\ulc2
respectively. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
k.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit high deductible plan “F” shall include only the following: 100 percent of covered expenses following the payment of the annual high deductible plan “F” deductible. The covered expenses include the Core Benefit as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus the Medicare Part A Deductible Skilled Nursing Facility Care, the Medicare Part B Deductible, 100 percent of the Medicare Part B Excess Charges, and Medically Necessary Emergency Care in a Foreign Country as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “b,” “c,” “e,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“h,”
}
{\plain\f4\fs21\cf2\ulc2
respectively. The annual high deductible plan “F” deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare Supplement plan “F” policy, and shall be in addition to any other specific benefit deductibles. The annual high deductible plan “F” deductible shall be $1500 for 1998 and 1999, and shall be based on the calendar year. It shall be adjusted annually thereafter by the Secretary 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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
l.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit high deductible plan “J” shall consist only of the following: 100 percent of covered expenses following the payment of the annual high deductible plan “J” deductible. The covered expenses include the Core Benefit as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus the Medicare Part A deductible, Skilled Nursing Facility Care, Medicare Part B deductible, 100 percent of the Medicare Part B Excess Charges, Extended Outpatient Prescription Drug Benefit, Medically Necessary Emergency Care in a Foreign Country, Preventive Medical Care Benefit and At-Home Recovery Benefit as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “b,” “c,” “e,” “g,” “h,” “i,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“j,”
}
{\plain\f4\fs21\cf2\ulc2
respectively. The annual high deductible plan “J” deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan “J” policy, and shall be in addition to any other specific benefit deductibles. The annual deductible shall be $1,500 for 1998 and 1999, and shall be based on a calendar year. It shall be adjusted annually thereafter by the Secretary 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. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.9
}
{\plain\f4\fs21\b\cf2\ulc2
(6)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit plan “K” mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 shall consist of only those benefits described in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(4)
}
}}
{\plain\f4\fs21\cf2\ulc2
. Standardized Medicare supplement benefit plan “L” mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 shall consist of only those benefits described in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.7.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.7(5)
}
}}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.9
}
{\plain\f4\fs21\b\cf2\ulc2
(7)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
New or Innovative Benefits: An issuer may, with the prior approval of the commissioner, offer policies or certificates with new or innovative benefits in addition to the benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits may include benefits that are appropriate to Medicare supplement insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner which is consistent with the goal of simplification of Medicare supplement policies. After December 31, 2004, the innovative benefit shall not include an outpatient prescription drug benefit.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
10
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Standard Medicare supplement benefit plans for 2010 standardized Medicare supplement benefit plan policies or certificates with an effective date for coverage on or after June 1, 2010.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state 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 state 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 with an effective date for coverage before June 1, 2010, remain subject to the requirements of rules
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.6.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.6
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D) and
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.9.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.9
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D).
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.10
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Issuer to make form available.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An issuer shall make available to each prospective policyholder and certificate holder a policy form or certificate form containing only the basic (core) benefits, as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If an issuer makes available any of the additional benefits described in subrule 37.8(3) or offers standardized benefit Plans K or L (as described in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“h”
}
}}
{\plain\f4\fs21\cf2\ulc2
and
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\i\cf2\ulc2
“i”
}
}}
{\plain\f4\fs21\cf2\ulc2
), then the issuer shall make available to each prospective policyholder and certificate holder, in addition to a policy form or certificate form with only the basic (core) benefits as described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“a,”
}
}}
{\plain\f4\fs21\cf2\ulc2
a policy form or certificate form containing either standardized benefit Plan C (as described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“c”
}
}}
{\plain\f4\fs21\cf2\ulc2
) or standardized benefit Plan F (as described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“e”
}
}}
{\plain\f4\fs21\cf2\ulc2
).
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.10
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
No groups, packages or combinations of Medicare supplement benefits other than those listed in this rule shall be offered for sale in this state, except as may be permitted in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(6)
}
}}
{\plain\f4\fs21\cf2\ulc2
and rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.11.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.11
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D).
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.10
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans listed in rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.10
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D) and conform to the definitions in rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.3.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.3
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D). Each benefit plan shall be structured in accordance with the format provided in subrules
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
and
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(3)
}
}}
{\plain\f4\fs21\cf2\ulc2
, or, in the case of Plan K or L, each benefit plan shall be structured in accordance with the format provided in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“h”
}
}}
{\plain\f4\fs21\cf2\ulc2
and
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.19.pdf"}{\fldrslt
{\plain\f4\fs21\i\cf2\ulc2
“i.”
}
}}
{\plain\f4\fs21\cf2\ulc2
Each plan shall list the benefits in the order shown. For purposes of this rule, “structure, language, and format” means style, arrangement and overall content of a benefit.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.10
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
In addition to the benefit plan designations required in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(3)
}
}}
{\plain\f4\fs21\cf2\ulc2
, an issuer may use other designations to the extent permitted by law.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.10
}
{\plain\f4\fs21\b\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Makeup of 2010 standardized benefit plans.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit Plan A shall include only the following: The basic (core) benefits as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit Plan B shall include only the following: The basic (core) benefit as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus 100 percent of the Medicare Part A deductible as defined in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(3)
}
{\plain\f4\fs21\i\cf2\ulc2
“a.”
}
}}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit Plan C shall include only the following: The basic (core) benefit as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, 100 percent of the Medicare Part B deductible, and medically necessary emergency care in a foreign country as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “c,” “d,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“f,”
}
{\plain\f4\fs21\cf2\ulc2
respectively.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit Plan D shall include only the following: The basic (core) benefit as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “c,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“f,”
}
{\plain\f4\fs21\cf2\ulc2
respectively.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement (regular) Plan F shall include only the following: The basic (core) benefit as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, 100 percent of the Medicare Part B deductible, 100 percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “c,” “d,” “e,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“f,”
}
{\plain\f4\fs21\cf2\ulc2
respectively.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement Plan F with high deductible shall include only the following: 100 percent of covered expenses following the payment of the annual deductible set forth in subparagraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.19.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“f”
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The basic (core) benefit as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, 100 percent of the Medicare Part B deductible, 100 percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “c,” “d,” “e,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“f,”
}
{\plain\f4\fs21\cf2\ulc2
respectively.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The annual deductible in Plan F with high deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by (regular) 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 ten dollars.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
g.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement benefit Plan G shall include only the following: The basic (core) benefit as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, 100 percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “c,” “e,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“f,”
}
{\plain\f4\fs21\cf2\ulc2
respectively.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
h.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement Plan K is mandated by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Part A hospital coinsurance from the sixty-first through ninetieth day: Coverage of 100 percent of the Part A hospital coinsurance amount for each day used from the sixty-first through the ninetieth day in any Medicare benefit period;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Part A hospital coinsurance from the ninety-first through one hundred fiftieth day: Coverage of 100 percent of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the ninety-first through the one hundred fiftieth day in any Medicare benefit period;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Part A hospitalization after 150 days: Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent 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;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Medicare Part A deductible: Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subparagraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“h”
}
{\plain\f4\fs21\cf2\ulc2
(10)
}
}}
{\plain\f4\fs21\cf2\ulc2
;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Skilled nursing facility care: Coverage for 50 percent of the coinsurance amount for each day used from the twenty-first day through the one hundredeth day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subparagraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“h”
}
{\plain\f4\fs21\cf2\ulc2
(10)
}
}}
{\plain\f4\fs21\cf2\ulc2
;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(6)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Hospice care: Coverage for 50 percent of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subparagraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“h”
}
{\plain\f4\fs21\cf2\ulc2
(10)
}
}}
{\plain\f4\fs21\cf2\ulc2
;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(7)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Blood: Coverage for 50 percent, 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 subparagraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“h”
}
{\plain\f4\fs21\cf2\ulc2
(10)
}
}}
{\plain\f4\fs21\cf2\ulc2
;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(8)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Part B cost sharing: Except for coverage provided in subparagraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“h”
}
{\plain\f4\fs21\cf2\ulc2
(9)
}
}}
{\plain\f4\fs21\cf2\ulc2
, coverage for 50 percent of the cost sharing otherwise applicable under Medicare Part B after the policyholder or certificate holder pays the Part B deductible until the out-of-pocket limitation is met as described in subparagraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“h”
}
{\plain\f4\fs21\cf2\ulc2
(10)
}
}}
{\plain\f4\fs21\cf2\ulc2
;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(9)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Part B preventive services: Coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder or certificate holder pays the Part B deductible; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(10)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Cost sharing after out-of-pocket limits: Coverage of 100 percent 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 $4000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
i.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement Plan L is mandated by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The benefits described in subparagraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“h”
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
}}
{\plain\f4\fs21\cf2\ulc2
, (2), (3) and (9);
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The benefits described in subparagraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“h”
}
{\plain\f4\fs21\cf2\ulc2
(4)
}
}}
{\plain\f4\fs21\cf2\ulc2
, (5), (6), (7) and (8), but substituting 75 percent for 50 percent; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The benefit described in subparagraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“h”
}
{\plain\f4\fs21\cf2\ulc2
(10)
}
}}
{\plain\f4\fs21\cf2\ulc2
, but substituting $2000 for $4000.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
j.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement Plan M shall include only the following: The basic (core) benefit as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus 50 percent of the Medicare Part A deductible, 100 percent of skilled nursing facility care, and 100 percent of medically necessary emergency care in a foreign country as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“b,” “c,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“f,”
}
{\plain\f4\fs21\cf2\ulc2
respectively.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
k.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Standardized Medicare supplement Plan N shall include only the following: The basic (core) benefit as defined in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.8.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.8(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “c,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“f,”
}
{\plain\f4\fs21\cf2\ulc2
respectively, with copayments in the following amounts:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.10
}
{\plain\f4\fs21\b\cf2\ulc2
(6)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
New or innovative benefits. An issuer may, with the prior approval of the commissioner, 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. The commissioner shall use any guidelines issued by the National Association of Insurance Commissioners in determining whether to approve new or innovative benefits.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
11
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Medicare Select policies and certificates.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\~
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\~\~\~
}
{\plain\f4\fs21\cf2\ulc2
Rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.11.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.11
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D) shall apply to Medicare Select policies and certificates, as defined in this rule.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
No policy or certificate may be advertised as a Medicare Select policy or certificate unless it meets the requirements of this rule.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
For the purposes of this rule:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
“Complaint”
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
means any dissatisfaction expressed by an individual concerning a Medicare Select issuer or its network providers.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
“Grievance”
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
means dissatisfaction expressed in writing by an individual insured under a Medicare Select policy or certificate with the administration, claims practices, or provision of services concerning a Medicare Select issuer or its network providers.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
“Medicare Select Issuer”
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
means an issuer offering, or seeking to offer, a Medicare Select policy or certificate.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
“Medicare Select Policy”
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
or
}
{\plain\f4\fs21\i\cf2\ulc2
“Medicare Select Certificate”
}
{\plain\f4\fs21\cf2\ulc2
means respectively, a Medicare supplement policy or certificate that contains restricted network provisions.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
“Network Provider”
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
means a provider of health care, or a group of providers of health care, which has entered into a written agreement with the issuer to provide benefits insured under a Medicare Select policy.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
“Restricted Network Provision”
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
means any provision which conditions the payment of benefits, in whole or in part, on the use of network providers.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
g.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
“Service Area”
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
means the geographic area approved by the commissioner within which an issuer is authorized to offer a Medicare Select policy.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The commissioner may authorize an issuer to offer a Medicare Select policy or certificate, pursuant to this rule and Section 4358 of the Omnibus Budget Reconciliation Act (OBRA) of 1990, if the commissioner finds that the issuer has satisfied all of the requirements.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
A Medicare Select issuer shall not issue a Medicare Select policy or certificate in this state until its plan of operation has been approved by the commissioner.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
A Medicare Select issuer shall file a proposed plan of operation with the commissioner in a format prescribed by the commissioner. The plan of operation shall contain at least the following information:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration that:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Such services can be provided by network providers with reasonable promptness with respect to geographic location, hours of operation and after-hour care. The hours of operation and availability of after-hour care shall reflect usual practice in the local area. Geographic availability shall reflect the usual travel times within the community.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The number of network providers in the service area is sufficient, with respect to current and expected policyholders, either:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
To adequately deliver all services that are subject to a restricted network provision; or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
To make appropriate referrals.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
There are written agreements with network providers describing specific responsibilities.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Emergency care is available 24 hours per day and seven days per week.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
In the case of covered services that are subject to a restricted network provision and are provided on a prepaid basis, there are written agreements with network providers prohibiting such providers from billing or otherwise seeking reimbursement from or recourse against any individual insured under a Medicare Select policy or certificate. This paragraph shall not apply to supplemental charges or coinsurance amounts as stated in the Medicare Select policy or certificate.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A statement or map providing a clear description of the service area.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A description of the grievance procedure to be utilized.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A description of the quality assurance program, including:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The formal organizational structure;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The written criteria for selection, retention and removal of network providers; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The procedures for evaluating quality of care provided by network providers, and the process to initiate corrective action when warranted.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A list and description, by specialty, of the network providers.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Copies of the written information proposed to be used by the issuer to comply with subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.11.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.11(9)
}
}}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
g.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Any other information requested by the commissioner.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(6)
}
{\plain\f4\fs21\cf2\ulc2
\~
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\~\~\~
}
{\plain\f4\fs21\cf2\ulc2
A Medicare Select issuer shall file any proposed changes to the plan of operation, except for changes to the list of network providers, with the commissioner prior to implementing such changes. Such changes shall be considered approved by the commissioner after 30 days unless specifically disapproved.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An updated list of network providers shall be filed with the commissioner at least quarterly.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(7)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
A Medicare Select policy or certificate shall not restrict payment for covered services provided by nonnetwork providers if:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury or a condition; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
It is not reasonable to obtain such services through a network provider.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(8)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
A Medicare Select policy or certificate shall provide payment for full coverage under the policy for covered services that are not available through network providers.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(9)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
A Medicare Select issuer shall make full and fair disclosure in writing of the provisions, restrictions, and limitations of the Medicare Select policy or certificate to each applicant. This disclosure shall include at least the following:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An outline of coverage sufficient to permit the applicant to compare the coverage and premiums of the Medicare Select policy or certificate with:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Other Medicare supplement policies or certificates offered by the issuer; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Other Medicare Select policies or certificates.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A description (including address, telephone number and hours of operation) of the network providers, including primary care physicians, specialty physicians, hospitals and other providers.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A description of the restricted network provisions, including payments for coinsurance and deductibles, when providers other than network providers are utilized. Except to the extent specified in the policy or certificate, expenses incurred when using out-of-network providers do not count toward the out-of-pocket annual limit contained in plans “K” and “L.”
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A description of coverage for emergency and urgently needed care and other out-of-service area coverage.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A description of limitations on referrals to restricted network providers and to other providers.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A description of the policyholder’s rights to purchase any other Medicare supplement policy or certificate otherwise offered by the issuer.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
g.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A description of the Medicare Select issuer’s quality assurance program and grievance procedure.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(10)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Prior to the sale of a Medicare Select policy or certificate, a Medicare Select issuer shall obtain from the applicant a signed and dated form stating that the applicant has received the information provided pursuant to subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.11.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.11(9)
}
}}
{\plain\f4\fs21\cf2\ulc2
and that the applicant understands the restrictions of the Medicare Select policy or certificate.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(11)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
A Medicare Select issuer shall have and use procedures for hearing complaints and resolving written grievances from the subscribers. Such procedures shall be aimed at mutual agreement for settlement and may include arbitration procedures.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The grievance procedure shall be described in the policy and certificates and in the outline of coverage.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
At the time the policy or certificate is issued, the issuer shall provide detailed information to the policyholder describing how a grievance may be registered with the issuer.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Grievances shall be considered in a timely manner and shall be transmitted to appropriate decision makers who have authority to fully investigate the issue and take corrective action.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If a grievance is found to be valid, corrective action shall be taken promptly.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
All concerned parties shall be notified about the results of a grievance.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The issuer shall report no later than each March 31 to the commissioner regarding its grievance procedure. The report shall be in a format prescribed by the commissioner and shall contain the number of grievances filed in the past year and a summary of the subject, nature and resolution of such grievances.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(12)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
At the time of initial purchase, a Medicare Select issuer shall make available to each applicant for a Medicare Select policy or certificate the opportunity to purchase any Medicare supplement policy or certificate otherwise offered by the issuer.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(13)
}
{\plain\f4\fs21\cf2\ulc2
\~
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\~\~\~
}
{\plain\f4\fs21\cf2\ulc2
At the request of an individual insured under a Medicare Select policy or certificate, a Medicare Select issuer shall make available to the individual insured the opportunity to purchase a Medicare supplement policy or certificate offered by the issuer which has comparable or lesser benefits and which does not contain a restricted network provision. The issuer shall make such policies or certificates available without requiring evidence of insurability after the Medicare Select policy or certificate has been in force for six months.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
For the purposes of this subrule, a Medicare supplement policy or certificate will be considered to have comparable or lesser benefits unless it contains one or more significant benefits not included in the Medicare Select policy or certificate being replaced. For the purposes of this paragraph, a significant benefit means coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Part B excess charges.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(14)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Medicare Select policies and certificates shall provide for continuation of coverage in the event the Secretary of Health and Human Services determines that Medicare Select policies and certificates issued pursuant to this section should be discontinued due to either the failure of the Medicare Select program to be reauthorized under law or its substantial amendment.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Each Medicare Select issuer shall make available to each individual insured under a Medicare Select policy or certificate the opportunity to purchase any Medicare supplement policy or certificate offered by the issuer which has comparable or lesser benefits and which does not contain a restricted network provision. The issuer shall make such policies and certificates available without requiring evidence of insurability.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
For the purposes of this subrule, a Medicare supplement policy or certificate will be considered to have comparable or lesser benefits unless it contains one or more significant benefits not included in the Medicare Select policy or certificate being replaced. For the purposes of this paragraph, a significant benefit means coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Part B excess charges.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.11
}
{\plain\f4\fs21\b\cf2\ulc2
(15)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
A Medicare Select issuer shall comply with reasonable requests for data made by state or federal agencies, including the United States Department of Health and Human Services, for the purpose of evaluating the Medicare Select program.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
12
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Open enrollment.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.12
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
No issuer shall deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this state, nor discriminate in the pricing of such a policy or certificate because of the health status, claims experience, receipt of health care, or medical condition of an applicant in the case of an application for a policy or certificate that is submitted prior to or during the six-month period beginning with the first day of the first month in which an individual is both 65 years of age or older and is enrolled for benefits under Medicare Part B. Each Medicare supplement policy and certificate currently available from an insurer shall be made available to all applicants who qualify under this subrule without regard to age.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.12
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
If an applicant under subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.12.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.12(1)
}
}}
{\plain\f4\fs21\cf2\ulc2
submits an application during the time period referenced in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.12.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.12(1)
}
}}
{\plain\f4\fs21\cf2\ulc2
and, as of the date of application, has had a continuous period of creditable coverage of at least six months, the issuer shall not exclude benefits based on a preexisting condition.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
If the applicant qualifies under subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.12.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.12(1)
}
}}
{\plain\f4\fs21\cf2\ulc2
and submits an application during the time period referenced in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.12.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.12(1)
}
}}
{\plain\f4\fs21\cf2\ulc2
and, as of the date of application, has had a continuous period of creditable coverage that is less than six months, the issuer shall reduce the period of any preexisting condition exclusion by the aggregate of the period of creditable coverage applicable to the applicant as of the enrollment date. The secretary shall specify the manner of the reduction under this subrule.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.12
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Except as provided in rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.22.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.22
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D) or
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.25
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D), subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.12.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.12(1)
}
}}
{\plain\f4\fs21\cf2\ulc2
shall not be construed as preventing the exclusion of benefits under a policy, during the first six months, based on a preexisting condition for which the policyholder or certificate holder received treatment or was otherwise diagnosed during the six months before the coverage became effective.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
13
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Standards for claims payment.
}
\par
\pard\qj\sl250\tx340\tx40
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.13
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An issuer shall comply with Section 1882(c)(3) of the Social Security Act (as enacted by Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Pub. L. No.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
100-203) by:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Accepting a notice from a Medicare carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of any other claim form otherwise required and making a payment determination on the basis of the information contained in that notice;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Notifying the participating physician or supplier and the beneficiary of the payment determination;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Paying the participating physician or supplier directly;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Furnishing, at the time of enrollment, each enrollee with a card listing the policy name, number and a central mailing address to which notices from a Medicare carrier may be sent;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Paying user fees for claim notices that are transmitted electronically or otherwise; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Providing to the Secretary of Health and Human Services, at least annually, a central mailing address to which all claims may be sent by Medicare carriers.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.13
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Compliance with the requirements set forth in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.13.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.13(1)
}
}}
{\plain\f4\fs21\cf2\ulc2
shall be certified on the Medicare supplement insurance experience reporting form.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
14
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Loss ratio standards and refund or credit of premium.
}
\par
\pard\keepn\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.14
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Loss ratio standards.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A Medicare supplement policy form or certificate form shall not be delivered or issued for delivery unless the policy form or certificate form can be expected, as estimated for the entire period for which rates are computed to provide coverage, to return to policyholders and certificate holders in the form of aggregate benefits (not including anticipated refunds or credits) provided under the policy form or certificate form:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
At least 75 percent of the aggregate amount of premiums earned in the case of group policies, or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
At least 65 percent of the aggregate amount of premiums earned in the case of individual policies, calculated on the basis of incurred claims experience or incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis and earned premiums for such period and in accordance with accepted actuarial principles and practices. Incurred health care expenses where coverage is provided by a health maintenance organization shall not include:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Home office and overhead costs;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Advertising costs;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
3.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Commissions and other acquisition costs;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
4.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Taxes;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
5.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Capital costs;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
6.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Administrative costs; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
7.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Claims processing costs.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
All filings of rates and rating schedules shall demonstrate that expected claims in relation to premiums comply with the requirements of this rule when combined with actual experience to date. Filings of rate revisions shall also demonstrate that the anticipated loss ratio over the entire future period for which the revised rates are computed to provide coverage can be expected to meet the appropriate loss ratio standards.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
For all policies issued prior to January 1, 1992, expected claims in relation to premiums shall meet:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The originally filed anticipated loss ratio when combined with the actual experience from inception;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The appropriate loss ratio requirement from subparagraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.14.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.14(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“a”
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
}}
{\plain\f4\fs21\cf2\ulc2
and (2) when combined with actual experience beginning with January 1, 1996, to date; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The appropriate loss ratio requirement from subparagraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.14.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.14(1)
}
{\plain\f4\fs21\i\cf2\ulc2
“a”
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
}}
{\plain\f4\fs21\cf2\ulc2
and (2) over the entire future period for which rates are computed to provide coverage.
}
\par
\pard\keepn\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.14
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Refund or credit calculation.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An issuer shall collect and file with the commissioner by May 31 of each year the data contained in the reporting form contained in Appendix A for each type in a standard Medicare supplement benefit plan.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If, on the basis of the experience as reported, the benchmark ratio since inception (ratio 1) exceeds the adjusted experience ratio since inception (ratio 3), then a refund or credit calculation is required. The refund calculation shall be done on a statewide basis for each type in a standard Medicare supplement benefit plan. For purposes of the refund or credit calculation, experience on policies issued within the reporting year shall be excluded.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
For purposes of this subrule, policies or certificates issued prior to January 1, 1992, the issuer shall make the refund calculation separately for all individual policies (including all group policies subject to an individual loss ratio standard when issued) combined and all other group policies combined for experience after January 1, 1996. The first report shall be due May 31, 1998.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A refund or credit shall be made only when the benchmark loss ratio exceeds the adjusted experience loss ratio and the amount to be refunded or credited exceeds a de minimis level. Such refund shall include interest from the end of the calendar year to the date of the refund or credit at a rate specified by the Secretary of Health and Human Services, but in no event shall it be less than the average rate of interest for 13-week Treasury notes. A refund or credit against premiums due shall be made by September 30 following the experience year upon which the refund or credit is based.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.14
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Annual filing of premium rates.
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An issuer of Medicare supplement policies and certificates issued before or after the effective date of January 1, 1992, in this state shall file annually its rates, rating schedule and supporting documentation including ratios of incurred losses to earned premiums by policy duration for approval by the commissioner in accordance with the filing requirements and procedures prescribed by the commissioner. The supporting documentation shall also demonstrate in accordance with actuarial standards of practice using reasonable assumptions that the appropriate loss ratio standards can be expected to be met over the entire period for which rates are computed. Such demonstration shall exclude active life reserves. An expected third-year loss ratio which is greater than or equal to the applicable percentage shall be demonstrated for policies or certificates in force less than three years.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
As soon as practicable, but prior to the effective date of enhancements in Medicare benefits, every issuer of Medicare supplement policies or certificates in this state shall file with the commissioner in accordance with the applicable filing procedures of this state:
}
\par
\pard\qj\sl250\tx340\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Appropriate premium adjustments necessary to produce loss ratios as anticipated for the current premium for the applicable policies or certificates. Such supporting documents as necessary to justify the adjustment shall accompany the filing.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An issuer shall make such premium adjustments as are necessary to produce an expected loss ratio under such policy or certificate as will conform with minimum loss ratio standards for Medicare supplement policies and which are expected to result in a loss ratio at least as great as that originally anticipated in the rates used to produce current premiums by the issuer for such Medicare supplement policies or certificates. No premium adjustment which would modify the loss ratio experience under the policy other than the adjustments described herein shall be made with respect to a policy at any time other than upon its renewal date or anniversary date.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If an issuer fails to make premium adjustments acceptable to the commissioner, the commissioner may order premium adjustments, refunds or premium credits deemed necessary to achieve the loss ratio required by this rule.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Any appropriate riders, endorsements or policy forms needed to accomplish the Medicare supplement policy or certificate modifications necessary to eliminate benefit duplications with Medicare. Such riders, endorsements or policy forms shall provide a clear description of the Medicare supplement benefits provided by the policy or certificate.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.14
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Public hearings.
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The commissioner may conduct a public hearing to gather information concerning a request by an issuer for an increase in a rate for a policy form or certificate form issued before or after the effective date of January 1, 1992, if the experience of the form for the previous reporting period is not in compliance with the applicable loss ratio standard. The determination of compliance is made without consideration of any refund or credit for such reporting period. Public notice of such hearing shall be furnished in a manner deemed appropriate by the commissioner.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
15
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Filing and approval of policies and certificates and premium rates.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.15
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An issuer shall not deliver or issue for delivery a policy or certificate to a resident of this state unless the policy form or certificate form has been filed pursuant to rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.20.1.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—20.1
}
}}
{\plain\f4\fs21\cf2\ulc2
(505,509,514A,515,515A,515F) and approved by the commissioner.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.15
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An issuer shall file any riders or amendments to policy or certificate forms to delete outpatient prescription drug benefits as required by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 only with the commissioner in the state in which the policy or certificate was issued.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.15
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An issuer shall not use or change premium rates for a Medicare supplement policy or certificate unless the rates, rating schedule and supporting documentation have been filed with and approved by the commissioner in accordance with the filing requirements and procedures prescribed by the commissioner.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.15
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
\~
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\~\~\~
}
{\plain\f4\fs21\cf2\ulc2
Except as provided in paragraph
}
{\plain\f4\fs21\i\cf2\ulc2
“b”
}
{\plain\f4\fs21\cf2\ulc2
of this subrule, an issuer shall not file for approval more than one form of a policy or certificate of each type for each standard Medicare supplement benefit plan.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An issuer may offer, with the approval of the commissioner, up to four additional policy forms or certificate forms of the same type for the same standard Medicare supplement benefit plan, one for each of the following cases:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The inclusion of new or innovative benefits;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The addition of either direct response or agent marketing methods;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The addition of either guaranteed issue or underwritten coverage;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The offering of coverage to individuals eligible for Medicare by reason of disability.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
For the purposes of this section, a “type” means an individual policy, a group policy, an individual Medicare Select policy, or a group Medicare Select policy.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.15
}
{\plain\f4\fs21\b\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
\~
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\~\~\~
}
{\plain\f4\fs21\cf2\ulc2
Except as provided in subparagraph
}
{\plain\f4\fs21\i\cf2\ulc2
“a”
}
{\plain\f4\fs21\cf2\ulc2
(1) below, an issuer shall continue to make available for purchase any policy form or certificate form issued after January 1, 1992, that has been approved by the commissioner. A policy form or certificate form shall not be considered to be available for purchase unless the issuer has actively offered it for sale in the previous 12 months.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An issuer may discontinue the availability of a policy form or certificate form if the issuer provides to the commissioner in writing its decision at least 30 days prior to discontinuing the availability of the form of the policy or certificate. After receipt of the notice by the commissioner, the issuer shall no longer offer for sale the policy form or certificate form in this state.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An issuer that discontinues the availability of a policy form or certificate form pursuant to subparagraph
}
{\plain\f4\fs21\i\cf2\ulc2
“a”
}
{\plain\f4\fs21\cf2\ulc2
(1) above shall not file for approval of a new policy form or certificate form of the same type for the same standard Medicare supplement benefit plan as the discontinued form for a period of five years after the issuer provides notice to the commissioner of the discontinuance. The period of discontinuance may be reduced if the commissioner determines that a shorter period is appropriate.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The sale or other transfer of Medicare supplement business to another issuer shall be considered a discontinuance for the purposes of this subrule.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A change in the rating structure or methodology shall be considered a discontinuance under paragraph
}
{\plain\f4\fs21\i\cf2\ulc2
“a”
}
{\plain\f4\fs21\cf2\ulc2
of this subrule unless the issuer complies with the following requirements:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The issuer provides an actuarial memorandum, in a form and manner prescribed by the commissioner, describing the manner in which the revised rating methodology and resultant rates differ from the existing rating methodology and resultant rates.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The issuer does not subsequently put into effect a change of rates or rating factors that would cause the percentage differential between the discontinued and subsequent rates as described in the actuarial memorandum to change. The commissioner may approve a change to the differential which is in the public interest.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.15
}
{\plain\f4\fs21\b\cf2\ulc2
(6)
}
{\plain\f4\fs21\cf2\ulc2
\~
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\~\~\~
}
{\plain\f4\fs21\cf2\ulc2
Except as provided in paragraph
}
{\plain\f4\fs21\i\cf2\ulc2
“b”
}
{\plain\f4\fs21\cf2\ulc2
of this subrule, the experience of all policy forms or certificate forms of the same type in a standard Medicare supplement benefit plan shall be combined for purposes of the refund or credit calculation prescribed in rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.14.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.14(514D)
}
}}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Forms assumed under an assumption reinsurance agreement shall not be combined with the experience of other forms for purposes of the refund or credit calculation.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
16
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Permitted compensation arrangements.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.16
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An issuer or other entity may provide commission or other compensation to an agent or other representative for the sale of a Medicare supplement policy or certificate only if the first-year commission or other first-year compensation is no more than 200 percent of the commission or other compensation paid for selling or servicing the policy or certificate i n the second year or period.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.16
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The commission or other compensation provided in subsequent (renewal) years must be the same as that provided in the second year or period and must be provided for no fewer than five renewal years.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.16
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
No issuer or other entity shall provide compensation to its agents or other producers and no agent or producer shall receive compensation greater than the renewal compensation payable by the replacing issuer on renewal policies or certificates if an existing policy or certificate is replaced.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.16
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
For purposes of this rule, “compensation” includes pecuniary or nonpecuniary remuneration of any kind relating to the sale or renewal of the policy or certificate including, but not limited to, bonuses, gifts, prizes, awards and finders fees.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
17
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Required disclosure provisions.
}
\par
\pard\keepn\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.17
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
General rules.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Medicare supplement policies and certificates shall include a renewal or continuation provision. The language or specifications of such provisions shall be consistent with the type of contract issued. Such provision shall be appropriately captioned and 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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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, such premium charge shall be set forth in the policy.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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.”
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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 certificate holder shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the insured person is not satisfied for any reason.
}
\par
\pard\qj\sl250\tx340\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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(s) 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 CMS 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 acknowledgment 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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
For the purposes of this rule, “form” means the language, format, type size, type proportional spacing, bold character and line spacing.
}
\par
\pard\keepn\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.17
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Notice requirements.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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 certificate holders of modifications it has made to Medicare supplement insurance policies or certificates in a format acceptable to the commissioner.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Inform each policyholder or certificate holder as to when any premium adjustment is to be made due to changes in Medicare.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Such notices shall not contain or be accompanied by any solicitation.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.17
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
MMA notice requirements.
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
}
\par
\pard\keepn\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.17
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Outline of coverage requirements for Medicare supplement policies.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Issuers shall provide an outline of coverage to all applicants at the time application is presented to the prospective applicant and, except for direct response policies, shall obtain an acknowledgment of receipt of such outline from the applicant; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
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:
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
“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.”
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The outline of coverage provided to applicants pursuant to this subrule 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 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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The following items shall be included in the outline of coverage in the order prescribed below.
}
\par
\pard\qc\sl250
{\plain\f4\fs21\b\cf2\ulc2
Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Plans E, H, I, and J are no longer available for sale. [This sentence shall not appear after June 1, 2011.]
}
\par
\pard\pagebb\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
Basic Benefits:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
Hospitalization
}
{\plain\f4\fs21\cf2\ulc2
– Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
Medical Expenses
}
{\plain\f4\fs21\cf2\ulc2
– 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.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
Blood
}
{\plain\f4\fs21\cf2\ulc2
– First three pints of blood each year.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
Hospice
}
{\plain\f4\fs21\cf2\ulc2
– Part A coinsurance.
}
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\pard\plain\f0\fs14
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{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
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\~
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{\plain\f4\fs14\cf2\ulc2
A
}
\cell
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{\plain\f4\fs14\cf2\ulc2
B
}
\cell
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{\plain\f4\fs14\cf2\ulc2
C
}
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{\plain\f4\fs14\cf2\ulc2
D
}
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{\plain\f4\fs14\cf2\ulc2
F
}
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{\plain\f4\fs14\cf2\ulc2
F*
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{\plain\f4\fs14\cf2\ulc2
G
}
\cell
\pard\intbl
\cell
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{\plain\f4\fs14\cf2\ulc2
K
}
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{\plain\f4\fs14\cf2\ulc2
L
}
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{\plain\f4\fs14\cf2\ulc2
M
}
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{\plain\f4\fs14\cf2\ulc2
N
}
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{\plain\f4\fs14\cf2\ulc2
\~
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{\plain\f4\fs14\cf2\ulc2
\~
}
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Basic, including 100% Part B co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance
}
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Basic, including 100% Part B co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance
}
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Basic, including 100% Part B co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance
}
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Basic, including 100% Part B co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance
}
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Basic, including 100% Part B co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance*
}
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Basic, including 100% Part B co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance
}
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{\plain\f4\fs14\cf2\ulc2
Hospitali-
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{\plain\f4\fs14\cf2\ulc2
zation and preven-
}
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{\plain\f4\fs14\cf2\ulc2
tive care paid at 100%; other basic benefits paid at 50%
}
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Hospitali-
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{\plain\f4\fs14\cf2\ulc2
zation and preven-
}
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{\plain\f4\fs14\cf2\ulc2
tive care paid at 100%; other basic benefits paid at 75%
}
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Basic, including 100% Part B co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance
}
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Basic, including 100% Part B co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance, except up to $20 copay-
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{\plain\f4\fs14\cf2\ulc2
ment for office visit, and up to $50 copay-
}
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{\plain\f4\fs14\cf2\ulc2
ment for ER
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
Skilled Nursing Facility Co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance
}
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{\plain\f4\fs14\cf2\ulc2
Skilled Nursing Facility Co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance
}
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{\plain\f4\fs14\cf2\ulc2
Skilled Nursing Facility Co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance
}
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{\plain\f4\fs14\cf2\ulc2
Skilled Nursing Facility Co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance
}
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\pard\intbl
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{\plain\f4\fs14\cf2\ulc2
50% Skilled Nursing Facility Co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance
}
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{\plain\f4\fs14\cf2\ulc2
75% Skilled Nursing Facility Co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance
}
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{\plain\f4\fs14\cf2\ulc2
Skilled Nursing Facility Co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance
}
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{\plain\f4\fs14\cf2\ulc2
Skilled Nursing Facility Co-
}
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{\plain\f4\fs14\cf2\ulc2
insurance
}
\cell
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
Part A Deductible
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Part A Deductible
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Part A Deductible
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
Part A Deductible
}
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{\plain\f4\fs14\cf2\ulc2
Part A Deductible
}
\cell
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{\plain\f4\fs14\cf2\ulc2
50% Part A Deduc-
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{\plain\f4\fs14\cf2\ulc2
tible
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{\plain\f4\fs14\cf2\ulc2
75% Part A Deduc-
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{\plain\f4\fs14\cf2\ulc2
tible
}
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{\plain\f4\fs14\cf2\ulc2
50% Part A Deduc-
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{\plain\f4\fs14\cf2\ulc2
tible
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{\plain\f4\fs14\cf2\ulc2
Part A Deduc-
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{\plain\f4\fs14\cf2\ulc2
tible
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
Part B Deductible
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs14\cf2\ulc2
Part B Deductible
}
\cell
\pard\intbl\li80\ri90\sl160
{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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\~
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\~
}
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\~
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\~
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\~
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Part B
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(100%)
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\~
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\~
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\~
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gency
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Foreign Travel Emer-
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gency
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\~
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Foreign Travel Emer-
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gency
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gency
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\~
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\~
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pocket limit $[4140]; paid at 100% after limit reached
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pocket limit $[2070]; paid at 100% after limit reached
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\~
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\~
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\~
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\~
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\~
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\~
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\~
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
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\~
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{\plain\f4\fs14\cf2\ulc2
\~
}
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{\plain\f4\fs14\cf2\ulc2
\~
}
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\~
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{\plain\f4\fs18\cf2\ulc2
* 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 $[1860] deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $[1860]. 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PREMIUM INFORMATION
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
We [insert issuer’s name] can only raise your premium if we raise the premium for all policies like yours in this State. [If the premium is based on the increasing age of the insured, include information specifying when premiums will change.]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
DISCLOSURES
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
Use this outline to compare benefits and premiums among policies.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
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. [The last sentence of this paragraph shall not appear after June 1, 2011.]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
READ YOUR POLICY VERY CAREFULLY
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
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.
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
RIGHT TO RETURN POLICY
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
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.
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
POLICY REPLACEMENT
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
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.
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
NOTICE
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
This policy may not fully cover all of your medical costs.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
[for agents: ]
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
Neither [insert company’s name] nor its agents are connected with Medicare.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
[for direct response: ]
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
[Insert company’s name] is not connected with Medicare.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security office or consult “Medicare and You” for more details.
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
COMPLETE ANSWERS ARE VERY IMPORTANT
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
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.]
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
[Include for each plan prominently identified in the cover page a chart showing the services, Medicare payments, plan payments and insured payments, 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 subrule. An issuer may use additional benefit plan descriptions on these charts pursuant to subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.10.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.10(4)
}
}}
{\plain\f4\fs21\cf2\ulc2
.]
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the commissioner.]
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PLAN A
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
\par
\pard\plain\f0\fs16
\par
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{\plain\f4\fs16\cf2\ulc2
SERVICES
}
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
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\clpadfr3\clpadr80
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\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 60 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[992] (Part A deductible)
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0**
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl
\cell
\pard\intbl
\cell
\pard\intbl
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
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\clpadfl3\clpadl80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
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\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
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\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
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{\plain\f4\fs16\cf2\ulc2
SERVICES
}
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
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{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
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{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
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\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts***
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\keepn\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
\par
\pard\plain\f0\fs17
\par
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services
}
\par
\pard\intbl\li80\ri90\fi158\sl180
{\plain\f4\fs16\cf2\ulc2
and medical supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved
}
\par
\pard\intbl\li80\ri90\fi432\sl180
{\plain\f4\fs16\cf2\ulc2
Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved
}
\par
\pard\intbl\li80\ri90\fi432\sl180
{\plain\f4\fs16\cf2\ulc2
Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PLAN B
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
\par
\pard\plain\f0\fs16
\par
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\clpadft3\clpadt80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 60 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[992] (Part A deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0**
}
\cell
\row
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All costs
}
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{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts***
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
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{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
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\par
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
}
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{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
}
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{\plain\f4\fs16\cf2\ulc2
medical supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved
}
\par
\pard\intbl\li80\ri90\fi432\sl180
{\plain\f4\fs16\cf2\ulc2
Amounts***
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved
}
\par
\pard\intbl\li80\ri90\fi432\sl180
{\plain\f4\fs16\cf2\ulc2
Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PLAN C
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
\par
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\par
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{\plain\f4\fs16\cf2\ulc2
SERVICES
}
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 60 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[992] (Part A deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0**
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\fi65\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\fi65\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\keepn\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
\par
\pard\plain\f0\fs17
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
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\clpadft3\clpadt80
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{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
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{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
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{\plain\f4\fs16\cf2\ulc2
medical supplies
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{\plain\f4\fs16\cf2\ulc2
100%
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{\plain\f4\fs16\cf2\ulc2
$0
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\cell
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved
}
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{\plain\f4\fs16\cf2\ulc2
Amounts***
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{\plain\f4\fs16\cf2\ulc2
$0
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$[131] (Part B deductible)
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$0
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{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved
}
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{\plain\f4\fs16\cf2\ulc2
Amounts
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{\plain\f4\fs16\cf2\ulc2
80%
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{\plain\f4\fs16\cf2\ulc2
20%
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
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{\plain\f4\fs21\cf2\ulc2
OTHER BENEFITS—NOT COVERED BY MEDICARE
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
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{\plain\f4\fs16\b\cf2\ulc2
FOREIGN TRAVEL—NOT COVERED BY MEDICARE
}
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{\plain\f4\fs16\cf2\ulc2
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First $250 each calendar year
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$250
}
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{\plain\f4\fs16\cf2\ulc2
Remainder of charges
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
80% to a lifetime maximum benefit of $50,000
}
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{\plain\f4\fs16\cf2\ulc2
20% and amounts over the $50,000 lifetime maximum
}
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{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
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{\plain\f4\fs21\cf2\ulc2
PLAN D
}
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{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
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{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
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*
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{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First 60 days
}
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{\plain\f4\fs16\cf2\ulc2
All but $[992]
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{\plain\f4\fs16\cf2\ulc2
$[992] (Part A deductible)
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{\plain\f4\fs16\cf2\ulc2
$0
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\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0**
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
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MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
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SERVICES
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MEDICARE PAYS
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PLAN PAYS
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YOU PAY
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MEDICAL EXPENSES
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{\plain\f4\fs16\cf2\ulc2
—
}
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{\plain\f4\fs16\cf2\ulc2
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
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\~
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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First $[131] of Medicare-Approved Amounts***
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$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
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Remainder of Medicare-Approved Amounts
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Generally 80%
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{\plain\f4\fs16\cf2\ulc2
Generally 20%
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$0
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Part B Excess Charges
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(Above Medicare-Approved Amounts)
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$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
All costs
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BLOOD
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{\plain\f4\fs16\cf2\ulc2
\~
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First 3 pints
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$0
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{\plain\f4\fs16\cf2\ulc2
All costs
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{\plain\f4\fs16\cf2\ulc2
$0
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Next $[131] of Medicare-Approved Amounts***
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$0
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$0
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$[131] (Part B deductible)
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{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
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{\plain\f4\fs16\cf2\ulc2
80%
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{\plain\f4\fs16\cf2\ulc2
20%
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$0
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{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
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{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
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{\plain\f4\fs16\cf2\ulc2
100%
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{\plain\f4\fs16\cf2\ulc2
$0
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$0
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{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
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{\plain\f4\fs21\cf2\ulc2
PARTS A & B
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
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\clpadft3\clpadt80
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HOME HEALTH CARE
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{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
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\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
}
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{\plain\f4\fs16\cf2\ulc2
medical supplies
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{\plain\f4\fs16\cf2\ulc2
100%
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved
}
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{\plain\f4\fs16\cf2\ulc2
Amounts***
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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$[131] (Part B deductible)
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Remainder of Medicare-Approved
}
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{\plain\f4\fs16\cf2\ulc2
Amounts
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{\plain\f4\fs16\cf2\ulc2
80%
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{\plain\f4\fs16\cf2\ulc2
20%
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
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{\plain\f4\fs21\cf2\ulc2
OTHER BENEFITS—NOT COVERED BY MEDICARE
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
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{\plain\f4\fs16\b\cf2\ulc2
FOREIGN TRAVEL—NOT COVERED
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{\plain\f4\fs16\b\cf2\ulc2
BY MEDICARE
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{\plain\f4\fs16\cf2\ulc2
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First $250 each calendar year
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$250
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{\plain\f4\fs16\cf2\ulc2
Remainder of charges
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
80% to a lifetime maximum benefit of $50,000
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{\plain\f4\fs16\cf2\ulc2
20% and amounts over the $50,000 lifetime maximum
}
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{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
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{\plain\f4\fs21\cf2\ulc2
PLAN F or HIGH DEDUCTIBLE PLAN F
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{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
[AFTER YOU PAY $[1860] DEDUCTIBLE,**]
}
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
[IN ADDITION TO $[1860] DEDUCTIBLE,**] YOU PAY
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{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
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*
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{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First 60 days
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{\plain\f4\fs16\cf2\ulc2
All but $[992]
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{\plain\f4\fs16\cf2\ulc2
$[992] (Part A deductible)
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$0
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{\plain\f4\fs16\cf2\ulc2
61st through 90th day
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{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
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{\plain\f4\fs16\cf2\ulc2
$[248] a day
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
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\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
\cell
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\qj\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0***
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
[**This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $[1860] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[1860]. 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.]
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
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\clpadft3\clpadt80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
[AFTER YOU PAY $[1860] DEDUCTIBLE,**] PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
[IN ADDITION TO $[1860] DEDUCTIBLE,**] YOU PAY
}
\cell
\row
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\fi101\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\fi101\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
[**This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $[1860] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[1860]. 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.]
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
***Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\keepn\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
\par
\pard\plain\f0\fs17
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
[AFTER YOU PAY $[1860] DEDUCTIBLE,**] PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
[IN ADDITION TO $[1860] DEDUCTIBLE,**] YOU PAY
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services
}
\par
\pard\intbl\li80\ri90\fi158\sl180
{\plain\f4\fs16\cf2\ulc2
and medical supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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First $[131] of Medicare-Approved
}
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{\plain\f4\fs16\cf2\ulc2
Amounts***
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
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$0
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{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved
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{\plain\f4\fs16\cf2\ulc2
Amounts
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80%
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{\plain\f4\fs16\cf2\ulc2
20%
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs21\cf2\ulc2
[**This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $[1860] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[1860]. 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.]
}
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{\plain\f4\fs21\cf2\ulc2
***Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
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{\plain\f4\fs21\cf2\ulc2
OTHER BENEFITS—NOT COVERED BY MEDICARE
}
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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MEDICARE PAYS
}
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{\plain\f4\fs16\cf2\ulc2
[AFTER YOU PAY $[1860] DEDUCTIBLE,**] PLAN PAYS
}
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{\plain\f4\fs16\cf2\ulc2
[IN ADDITION TO $[1860] DEDUCTIBLE,**] YOU PAY
}
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{\plain\f4\fs16\b\cf2\ulc2
FOREIGN TRAVEL—NOT COVERED BY MEDICARE
}
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{\plain\f4\fs16\cf2\ulc2
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First $250 each calendar year
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$250
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{\plain\f4\fs16\cf2\ulc2
Remainder of charges
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
80% to a lifetime maximum benefit of $50,000
}
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{\plain\f4\fs16\cf2\ulc2
20% and amounts over the $50,000 lifetime maximum
}
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{\plain\f4\fs21\cf2\ulc2
[**This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $[1860] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[1860]. 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.]
}
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{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
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{\plain\f4\fs21\cf2\ulc2
PLAN G
}
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{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
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{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
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*
}
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{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First 60 days
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{\plain\f4\fs16\cf2\ulc2
All but $[992]
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{\plain\f4\fs16\cf2\ulc2
$[992] (Part A deductible)
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
61st through 90th day
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All but $[248] a day
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$[248] a day
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{\plain\f4\fs16\cf2\ulc2
$0
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91st day and after:
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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—While using 60 lifetime reserve days
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{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
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{\plain\f4\fs16\cf2\ulc2
$[496] a day
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{\plain\f4\fs16\cf2\ulc2
$0
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—Once lifetime reserve days are used:
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0**
}
\cell
\row
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadft3\clpadt80
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{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
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{\plain\f4\fs16\cf2\ulc2
SERVICES
}
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
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\clpadft3\clpadt80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
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\clpadfr3\clpadr80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\qj\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
0%
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\keepn\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
\par
\pard\plain\f0\fs17
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
}
\par
\pard\intbl\li80\ri90\fi158\sl180
{\plain\f4\fs16\cf2\ulc2
medical supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\keepn\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
OTHER BENEFITS—NOT COVERED BY MEDICARE
}
\par
\pard\plain\f0\fs17
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadft3\clpadt80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
FOREIGN TRAVEL—NOT COVERED BY MEDICARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First $250 each calendar year
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$250
}
\cell
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\clpadfl3\clpadl80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of charges
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80% to a lifetime maximum benefit of $50,000
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
20% and amounts over the $50,000 lifetime maximum
}
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\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PLAN K
}
\par
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{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
\par
\pard\plain\f0\fs16
\par
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY*
}
\cell
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
{\plain\f4\fs16\cf2\ulc2
**
}
\par
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{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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\clpadft3\clpadt80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 60 days
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] (50% of Part A deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] (50% of Part A deductible)\u9830?
}
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0***
}
\cell
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
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{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
**
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
First 20 days
}
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{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
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{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
Up to $[62] a day
}
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{\plain\f4\fs16\cf2\ulc2
Up to $[62] a day \u9830?
}
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{\plain\f4\fs16\cf2\ulc2
101st day and after
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
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{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
50%
}
\cell
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{\plain\f4\fs16\cf2\ulc2
50%\u9830?
}
\cell
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{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
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{\plain\f4\fs16\cf2\ulc2
100%
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
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{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
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{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
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{\plain\f4\fs16\cf2\ulc2
50% of copayment/
}
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{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
50% of Medicare copayment/
}
\par
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{\plain\f4\fs16\cf2\ulc2
coinsurance\u9830?
}
\cell
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\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*You will pay half the cost sharing of some covered services until you reach the annual out-of-pocket maximum of $[4000] each calendar year. The amounts that count toward your annual limit are noted with diamonds (
}
{\plain\f4\fs16\cf2\ulc2
\u9830?
}
{\plain\f4\fs21\cf2\ulc2
) in the chart above. Once you reach the annual maximum, 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
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{\plain\f4\fs16\cf2\ulc2
SERVICES
}
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
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{\plain\f4\fs16\cf2\ulc2
YOU PAY*
}
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{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts****
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)**** \u9830?
}
\cell
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
Preventive Benefits for Medicare-Covered Services
}
\cell
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{\plain\f4\fs16\cf2\ulc2
Generally 75% or more of Medicare-
}
\par
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{\plain\f4\fs16\cf2\ulc2
Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All costs above Medicare-Approved Amounts
}
\cell
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{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 10%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 10% \u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs (and they do not count toward annual out-of-pocket limit of $[4140])*****
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
50%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
50%\u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts****
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)**** \u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 10%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 10% \u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*You will pay half the cost sharing of some covered services until you reach the annual out-of-pocket maximum of $[4000] each calendar year. The amounts that count toward your annual limit are noted with diamonds (
}
{\plain\f4\fs16\cf2\ulc2
\u9830?
}
{\plain\f4\fs21\cf2\ulc2
) in the chart above. Once you reach the annual maximum, 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
**** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
***** This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[4140] 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.
}
\par
\pard\keepn\pagebb\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
\par
\pard\plain\f0\fs17
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY*
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
}
\par
\pard\intbl\li80\ri90\fi158\sl180
{\plain\f4\fs16\cf2\ulc2
medical supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\par
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved
}
\par
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Amounts****
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible) \u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
10%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
10%\u9830?
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*You will pay half the cost sharing of some covered services until you reach the annual out-of-pocket maximum of $[4000] each calendar year. The amounts that count toward your annual limit are noted with diamonds (
}
{\plain\f4\fs16\cf2\ulc2
\u9830?
}
{\plain\f4\fs21\cf2\ulc2
) in the chart above. Once you reach the annual maximum, 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
**** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PLAN L
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY*
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
{\plain\f4\fs16\cf2\ulc2
**
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 60 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[744] (75% of Part A deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[248] (25% of Part A deductible)\u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0***
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
**
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[93] a day
}
\cell
\pard\intbl\qj\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[31] a day\u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
75%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
25%\u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
75% of copayment/
}
\par
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\qj\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
25% of copayment/
}
\par
\pard\intbl\qj\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance\u9830?
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* You will pay one-fourth of the cost sharing of some covered services until you reach the annual out-of-pocket limit of $[2070] each calendar year. The amounts that count toward your annual limit are noted with diamonds (\u9830?) in the chart above. 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY*
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\fi86\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts****
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)**** \u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\fi86\sl180
{\plain\f4\fs16\cf2\ulc2
Preventive Benefits for Medicare-Covered Services
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 75% or more of Medicare-
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs above Medicare-Approved Amounts
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\fi86\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 15%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 5% \u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs (and they do not count toward annual out-of-pocket limit of $[2070])*****
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
75%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
25%\u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts****
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible) \u9830?
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 15%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 5%\u9830?
}
\cell
\row
\trowd\trleft5
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* You will pay one-fourth of the cost sharing of some covered services until you reach the annual out-of-pocket limit of $[2070] each calendar year. The amounts that count toward your annual limit are noted with diamonds (\u9830?) in the chart above. 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
**** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
***** This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[2070] 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.
}
\par
\pard\keepn\pagebb\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
\par
\pard\plain\f0\fs17
\par
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\clpadft3\clpadt80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY*
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
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\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
}
\par
\pard\intbl\li80\ri90\fi158\sl180
{\plain\f4\fs16\cf2\ulc2
medical supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clpadft3\clpadt80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\par
\pard\intbl\qj\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts****
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible) \u9830?
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
15%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
5%\u9830?
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* You will pay one-fourth of the cost sharing of some covered services until you reach the annual out-of-pocket limit of $[2070] each calendar year. The amounts that count toward your annual limit are noted with diamonds (\u9830?) in the chart above. 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
**** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PLAN M
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
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\clpadft3\clpadt80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
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\trowd\trleft5
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 60 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] (50% of Part A deductible)
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] (50% of Part A deductible)
}
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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\clpadft3\clpadt80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
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\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0**
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\fi65\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\fi65\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
0%
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\keepn\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
\par
\pard\plain\f0\fs17
\par
\trowd\trleft5\trhdr
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
}
\par
\pard\intbl\li80\ri90\fi158\sl180
{\plain\f4\fs16\cf2\ulc2
medical supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\par
\pard\intbl\qj\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
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{\plain\f4\fs21\cf2\ulc2
OTHER BENEFITS—NOT COVERED BY MEDICARE
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
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{\plain\f4\fs16\b\cf2\ulc2
FOREIGN TRAVEL—NOT COVERED
}
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{\plain\f4\fs16\b\cf2\ulc2
BY MEDICARE
}
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{\plain\f4\fs16\cf2\ulc2
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
First $250 each calendar year
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$250
}
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{\plain\f4\fs16\cf2\ulc2
Remainder of charges
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
80% to a lifetime maximum benefit of $50,000
}
\cell
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{\plain\f4\fs16\cf2\ulc2
20% and amounts over the $50,000 lifetime maximum
}
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{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
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{\plain\f4\fs21\cf2\ulc2
PLAN N
}
\par
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{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
}
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{\plain\f4\fs16\cf2\ulc2
SERVICES
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
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{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
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{\plain\f4\fs16\b\cf2\ulc2
HOSPITALIZATION
}
{\plain\f4\fs16\cf2\ulc2
*
}
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{\plain\f4\fs16\cf2\ulc2
Semiprivate room and board, general nursing and miscellaneous services and supplies
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
First 60 days
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{\plain\f4\fs16\cf2\ulc2
All but $[992]
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$[992] (Part A deductible)
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
61st through 90th day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All but $[248] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$[248] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
91st day and after:
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
\~
}
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\clpadft3\clpadt80
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{\plain\f4\fs16\cf2\ulc2
—While using 60 lifetime reserve days
}
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{\plain\f4\fs16\cf2\ulc2
All but $[496] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$[496] a day
}
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{\plain\f4\fs16\cf2\ulc2
$0
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{\plain\f4\fs16\cf2\ulc2
—Once lifetime reserve days are used:
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
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{\plain\f4\fs16\cf2\ulc2
—Additional 365 days
}
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
100% of Medicare eligible expenses
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0**
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{\plain\f4\fs16\cf2\ulc2
—Beyond the additional 365 days
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All costs
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\qj\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
SKILLED NURSING FACILITY CARE
}
{\plain\f4\fs16\cf2\ulc2
*
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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{\plain\f4\fs16\cf2\ulc2
First 20 days
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All approved amounts
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
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{\plain\f4\fs16\cf2\ulc2
21st through 100th day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All but $[124] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
Up to $[124] a day
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0**
}
\cell
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{\plain\f4\fs16\cf2\ulc2
101st day and after
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
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\clpadfl3\clpadl80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
3 pints
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
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\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Additional amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOSPICE CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
All but very limited copayment/
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
coinsurance for outpatient drugs and inpatient respite care
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medicare copayment/
}
\par
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{\plain\f4\fs16\cf2\ulc2
coinsurance
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
* 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.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
** 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.
}
\par
\pard\pagebb\qc\sl250
{\plain\f4\fs21\cf2\ulc2
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
}
\par
\pard\plain\f0\fs16
\par
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{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
MEDICAL EXPENSES
}
{\plain\f4\fs16\cf2\ulc2
—
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\pard\intbl\li80\ri90\fi65\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\fi65\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Generally 80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
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.
}
\cell
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{\plain\f4\fs16\b\cf2\ulc2
Part B Excess Charges
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
(Above Medicare-Approved Amounts)
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BLOOD
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
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\clpadfl3\clpadl80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First 3 pints
}
\cell
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{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
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{\plain\f4\fs16\cf2\ulc2
All costs
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Next $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
CLINICAL LABORATORY SERVICES
}
{\plain\f4\fs16\cf2\ulc2
— TESTS FOR DIAGNOSTIC SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
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{\plain\f4\fs21\cf2\ulc2
PARTS A & B
}
\par
\pard\plain\f0\fs17
\par
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
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{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
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{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
HOME HEALTH CARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE-APPROVED SERVICES
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Medically necessary skilled care services and
}
\par
\pard\intbl\li80\ri90\fi158\sl180
{\plain\f4\fs16\cf2\ulc2
medical supplies
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
100%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
—Durable medical equipment
}
\par
\pard\intbl\qj\li80\ri90\fi144\sl180
{\plain\f4\fs16\cf2\ulc2
First $[131] of Medicare-Approved Amounts***
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$[131] (Part B deductible)
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of Medicare-Approved Amounts
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80%
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
20%
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*** Once you have been billed $[131] of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
}
\par
\pard\keepn\sb170\qc\sl250
{\plain\f4\fs21\cf2\ulc2
OTHER BENEFITS—NOT COVERED BY MEDICARE
}
\par
\pard\plain\f0\fs17
\par
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\clpadft3\clpadt80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrt\brdrs\brdrw10\brdrcf2\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
SERVICES
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
MEDICARE PAYS
}
\cell
\pard\intbl\qc\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
PLAN PAYS
}
\cell
\pard\intbl\qc\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
YOU PAY
}
\cell
\row
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
FOREIGN TRAVEL—NOT COVERED
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\b\cf2\ulc2
BY MEDICARE
}
\par
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
\~
}
\cell
\row
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\clpadfr3\clpadr80
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\clpadfr3\clpadr80
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\clpadft3\clpadt80
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\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
First $250 each calendar year
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
$250
}
\cell
\row
\trowd\trleft5
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrl\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx3565
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx5325
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx6985
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\clbrdrr\brdrs\brdrw10\brdrcf2\cellx8645
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
Remainder of charges
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
$0
}
\cell
\pard\intbl\li80\ri90\sl180
{\plain\f4\fs16\cf2\ulc2
80% to a lifetime maximum benefit of $50,000
}
\cell
\pard\intbl\li80\ri80\sl180
{\plain\f4\fs16\cf2\ulc2
20% and amounts over the $50,000 lifetime maximum
}
\cell
\row
\pard\sb160\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Medicare benefits are subject to change. Please consult the latest
}
{\plain\f4\fs21\i\cf2\ulc2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\keepn\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.17
}
{\plain\f4\fs21\b\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\i\cf2\ulc2
Notice regarding policies or certificates which are not Medicare supplement policies.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Any accident and sickness insurance policy or certificate, other than a Medicare supplement policy
}
{\plain\f4\fs21\i\cf2\ulc2
,
}
{\plain\f4\fs21\cf2\ulc2
a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act (42 U.S.C. Section 1395 et seq.), disability income policy, or other policy identified in rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.2.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.2(514D)
}
}}
{\plain\f4\fs21\cf2\ulc2
issued for delivery in this state to persons eligible for Medicare 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:
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
“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.”
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Applications provided to persons eligible for Medicare for the health insurance policies or certificates described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.17.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.17(4)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a”
}
{\plain\f4\fs21\cf2\ulc2
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.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
18
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Requirements for application forms and replacement coverage.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.18
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant currently has Medicare supplement, Medicare Advantage, Medicaid coverage or another health insurance policy or certificate in force or whether a Medicare supplement policy or certificate is intended to replace any other accident and sickness policy or certificate presently in force. A supplementary application or other form to be signed by the applicant and agent containing such questions and statements may be used.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Statements.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
You do not need more than one Medicare supplement policy.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If you purchase this policy (certificate), you may want to evaluate your existing health coverage and decide if you need multiple coverages.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
You may be eligible for benefits under Medicaid and may not need a Medicare supplement policy.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your Medicaid eligibility. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If you are eligible for, and have enrolled in a Medicare supplement policy by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare supplement policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(6)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement insurance and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB).
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Questions.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplement insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplement plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
(Please mark Yes or No below with an “X”.)
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
To the best of your knowledge,
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(a) Did you turn age 65 in the last 6 months?
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
Yes____No____
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
(b) Did you enroll in Medicare Part B in the last 6 months?
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
Yes____No____
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
(c) If yes, what is the effective date? ____________________________
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Are you covered for medical assistance through the state Medicaid program?
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
(NOTE TO APPLICANT: If you are participating in a “Spend-Down Program” and have not
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
met your “Share of Cost,” please answer NO to this question.)
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
Yes____No____
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
If yes,
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
(a) Will Medicaid pay your premiums for this Medicare supplement policy?
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
Yes____No____
}
\par
\pard\qj\li810\fi-317\sl250
{\plain\f4\fs21\cf2\ulc2
(b) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
Yes____No____
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(a) If you had coverage from any Medicare plan other than original Medicare within the past 63
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates below. If you are still covered under this plan, leave “END” blank.
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
START __/__/__ END __/__/__
}
\par
\pard\qj\li810\fi-317\sl250
{\plain\f4\fs21\cf2\ulc2
(b) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplement policy?
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
Yes____No____
}
\par
\pard\qj\li821\fi-317\sl250
{\plain\f4\fs21\cf2\ulc2
(c) Was this your first time in this type of Medicare plan?
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
Yes____No____
}
\par
\pard\qj\li821\fi-317\sl250
{\plain\f4\fs21\cf2\ulc2
(d) Did you drop a Medicare supplement policy to enroll in this plan?
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
Yes____No____
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(a) Do you have another Medicare supplement policy in force?
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
Yes____No____
}
\par
\pard\qj\li821\fi-317\sl250
{\plain\f4\fs21\cf2\ulc2
(b) If so, with what company, and what plan do you have [optional for Direct Mailers]? ______________________________________________________________________
}
\par
\pard\qj\li821\fi-317\sl250
{\plain\f4\fs21\cf2\ulc2
(c) If so, do you intend to replace your current Medicare supplement policy with this policy?
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
Yes____No____
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Have you had coverage under any other health insurance within the past 63 days? (For example,
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
an employer, union, or individual plan)
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
Yes____No____
}
\par
\pard\qj\li821\fi-317\sl250
{\plain\f4\fs21\cf2\ulc2
(a) If so, with what company and what kind of policy?
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
_________________________________________________________________________
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
_________________________________________________________________________
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
_________________________________________________________________________
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
_________________________________________________________________________
}
\par
\pard\qj\li821\fi-317\sl250
{\plain\f4\fs21\cf2\ulc2
(b) What are your dates of coverage under the other policy?
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
START __/__/__ END __/__/__
}
\par
\pard\qj\li204\sl250
{\plain\f4\fs21\cf2\ulc2
(If you are still covered under the other policy, leave “END” blank.)
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.18
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Agents shall list any other health insurance policies they have sold to the applicant.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
List policies sold which are still in force.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
List policies sold in the past five years which are no longer in force.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.18
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
In the case of a direct response issuer, a copy of the application or supplemental form, signed by the applicant and acknowledged by the insurer, shall be returned to the applicant by the insurer upon delivery of the policy.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.18
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Upon determining that a sale will involve replacement of Medicare supplement coverage, any issuer, other than a direct response issuer, or its agent, shall furnish the applicant, prior to issuance or delivery of the Medicare supplement policy or certificate, a notice regarding replacement of Medicare supplement coverage. One copy of such notice signed by the applicant and the agent, except where the coverage is sold without an agent, shall be provided to the applicant and an additional signed copy shall be retained by the issuer. A direct response issuer shall deliver to the applicant at the time of the issuance of the policy the notice regarding replacement of Medicare supplement coverage.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.18
}
{\plain\f4\fs21\b\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The notice required by subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.18.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.18(4)
}
}}
{\plain\f4\fs21\cf2\ulc2
for an issuer shall be provided in substantially the following form in no less than 12-point type:
}
\par
\pard\qc\sl250
{\plain\f4\fs21\b\cf2\ulc2
NOTICE TO APPLICANT REGARDING REPLACEMENT
}
\par
\pard\qc\sl250
{\plain\f4\fs21\b\cf2\ulc2
OF MEDICARE SUPPLEMENT INSURANCE
}
\par
\pard\qc\sl250
{\plain\f4\fs21\b\cf2\ulc2
OR MEDICARE ADVANTAGE
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2\ulc2
[Insurance company’s name and address]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\b\cf2\ulc2
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
According to [your application] [information you have furnished], you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by [Company Name] Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
STATEMENT TO APPLICANT BY ISSUER, AGENT [BROKER OR OTHER REPRESENTATIVE]:
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason (check one):
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
____ Additional benefits.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
____ No change in benefits, but lower premiums.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
____ Fewer benefits and lower premiums.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
____ My plan has outpatient prescription drug coverage and I am enrolling in Part D.
}
\par
\pard\qj\li446\fi-446\sl250
{\plain\f4\fs21\cf2\ulc2
____ Disenrollment from a Medicare Advantage Plan. Please explain reason for disenrollment. [optional only for Direct Mailers]
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
____ Other. (Please specify.)________________________________________________________
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
Note:
}
{\plain\f4\fs21\cf2\ulc2
If the issuer of the Medicare supplement policy being applied for does not, or is otherwise prohibited from imposing preexisting condition limitations, please skip to statement 2 below. Health conditions which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
State law provides that your replacement policy or certificate may not contain new preexisting conditions, waiting periods, elimination periods or probationary periods. The insurer will waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
3.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
If you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded. [If the policy or certificate is guaranteed issue, this paragraph need not appear.]
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
____________________________________________________________________
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
(Signature of Agent, Broker or Other Representative)*
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
[Typed Name and Address of Issuer, Agent or Broker]
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
____________________________________________________________________
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
(Applicant’s Signature)
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
______________________________
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
(Date)
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2\ulc2
*Signature not required for direct response sales.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.18
}
{\plain\f4\fs21\b\cf2\ulc2
(6)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Statements 1 and 2 of the replacement notice (applicable to preexisting conditions) may be deleted by an issuer if the replacement does not involve application of a new preexisting condition limitation.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
19
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Standards for marketing.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.19
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An issuer, directly or through its producers, shall:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Establish marketing procedures to ensure that any comparison of policies by its agent or other producers will be fair and accurate.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Establish marketing procedures to ensure excessive insurance is not sold or issued.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Display prominently by type, stamp or other appropriate means, on the first page of the policy, the following:
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
“Notice to buyer: This policy may not cover all of your medical expenses.”
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Inquire and otherwise make every reasonable effort to identify whether a prospective applicant or enrollee for Medicare supplement insurance already has accident and sickness insurance and the types and amounts of any such insurance.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Establish auditable procedures for certifying compliance with this subrule.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
At solicitation, provide written notice to the prospective policyholder or certificate holder of the name, address, and telephone number of the senior insurance counseling program approved in Iowa by the commissioner of insurance. The written notice shall be in a form prescribed by the commissioner.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.19
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
In addition to the practices prohibited in Iowa Code chapter
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/ico/chapter/507B.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
507B
}
}}
{\plain\f4\fs21\cf2\ulc2
, the following acts and practices are prohibited:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
Twisting.
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or insurers for the purpose of inducing, or tending to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert any insurance policy or to take out a policy of insurance with another insurer.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
High-pressure tactics.
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Employing any method of marketing having the effect of or tending to induce the purchase of insurance through force, fright, threat, whether explicit or implied, or undue pressure to purchase or recommend the purchase of insurance.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
Cold-lead advertising.
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Making use directly or indirectly of any method of marketing which fails to disclose in a conspicuous manner that a purpose of the method of marketing is solicitation of insurance and that contact will be made by an insurance agent or insurance company.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.19
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The terms “Medicare Supplement,” “Medigap,” “Medicare Wrap-Around” and words of similar import shall not be used unless the policy is issued in compliance with this chapter.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
20
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Appropriateness of recommended purchase and excessive insurance.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.20
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
In recommending the purchase or replacement of any Medicare supplement policy or certificate an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.20
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Any sale of a Medicare supplement policy or certificate that will provide an individual more than one Medicare supplement policy or certificate is prohibited.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.20
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An issuer shall not issue a Medicare supplement policy or certificate to an individual enrolled in Medicare Part C unless the effective date of the coverage is after the termination date of the individual's Part C coverage.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
21
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Reporting of multiple policies.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.21
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
On or before March 1 of each year, an issuer shall report the following information for every individual resident of this state for which the issuer has in force more than one Medicare supplement policy or certificate:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Policy and certificate number, and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Date of issuance.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.21
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The items set forth above must be grouped by individual policyholder.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
22
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Prohibition against preexisting conditions, waiting periods, elimination periods and probationary periods in replacement policies or certificates.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.22
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate, the replacing issuer shall waive any time periods applicable to preexisting conditions, waiting periods, elimination periods and probationary periods in the new Medicare supplement policy or certificate to the extent such time was spent under the original policy.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.22
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate which has been in effect for at least six months, the replacing policy shall not provide any time period applicable to preexisting conditions, waiting periods, elimination periods and probationary periods.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
23
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Prohibition against use of genetic information and requests for genetic testing.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
This rule applies to all policies with policy years beginning on or after May 21, 2009.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.23
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
For the purposes of this rule only, the following definitions shall apply:
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Family member
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means, with respect to an individual, any other individual who is a first-degree, second-degree, third-degree, or fourth-degree relative of such individual.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Genetic information
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means, with respect to any individual, information about such individual’s genetic tests, the genetic tests of family members of such individual, and the manifestation of a disease or disorder in family members of such individual. “Genetic information” includes, with respect to any individual, any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by such individual or any family member of such individual. Any reference to genetic information concerning an individual or family member of an individual who is a pregnant woman includes genetic information of any fetus carried by such pregnant woman or, with respect to an individual or family member utilizing reproductive technology, includes genetic information of any embryo legally held by an individual or family member. The term “genetic information” does not include information about the sex or age of any individual.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Genetic services
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means a genetic test, genetic counseling (including obtaining, interpreting, or assessing genetic information), or genetic education.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Genetic test
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites that detects genotypes, mutations, or chromosomal changes. The term “genetic test” does not mean:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An analysis of proteins or metabolites that does not detect genotypes, mutations, or chromosomal changes; or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition that could reasonably be detected by a health care professional with appropriate training and expertise in the field of medicine involved.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Issuer of a Medicare supplement policy or certificate
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means the same as “issuer” as defined in rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.3.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.3
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D) and includes third-party administrator, or other person acting for or on behalf of such issuer.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Underwriting purposes
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Rules for or determination of eligibility (including enrollment and continued eligibility) for benefits under the policy;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The computation of premium or contribution amounts under the policy;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
3.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The application of any preexisting condition exclusion under the policy; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
4.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.23
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An issuer of a Medicare supplement policy or certificate:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Shall not deny or condition the issuance or effectiveness of the policy or certificate (including the imposition of any exclusion of benefits under the policy based on a preexisting condition) of an individual on the basis of the genetic information with respect to such individual; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Shall not discriminate in the pricing of the policy or certificate (including the adjustment of premium rates) of an individual on the basis of the genetic information with respect to such individual.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.23
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Nothing in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.23.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.23(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
shall be construed to limit the ability of an issuer, to the extent otherwise permitted by law, from:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Denying or conditioning the issuance or effectiveness of the policy or certificate or increasing the premium for a group based on the manifestation of a disease or disorder of an insured or applicant; or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Increasing the premium for any policy issued to an individual based on the manifestation of a disease or disorder of another individual who is covered under the policy. In such case, the manifestation of a disease or disorder in one individual cannot also be used as genetic information about other group members and to further increase the premium for the group.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.23
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An issuer of a Medicare supplement policy or certificate shall not request or require an individual or a family member of such individual to undergo a genetic test.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.23
}
{\plain\f4\fs21\b\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.23.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.23(4)
}
}}
{\plain\f4\fs21\cf2\ulc2
shall not be construed to preclude an issuer of a Medicare supplement policy or certificate from obtaining and using the results of a genetic test in making a determination regarding payment (as defined for the purposes of applying the regulations promulgated under Part C of Title XI and Section 264 of the Health Insurance Portability and Accountability Act of 1996, as may be revised from time to time) and consistent with subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.23.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.23(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.23
}
{\plain\f4\fs21\b\cf2\ulc2
(6)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
For purposes of carrying out subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.23.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.23(5)
}
}}
{\plain\f4\fs21\cf2\ulc2
, an issuer of a Medicare supplement policy or certificate may request only the minimum amount of information necessary to accomplish the intended purpose.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.23
}
{\plain\f4\fs21\b\cf2\ulc2
(7)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Notwithstanding subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.23.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.23(4)
}
}}
{\plain\f4\fs21\cf2\ulc2
, an issuer of a Medicare supplement policy may request, but not require, that an individual or a family member of such individual undergo a genetic test if each of the following conditions is met:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The request is made pursuant to research that complies with Part 46 of Title 45, Code of Federal Regulations, or equivalent federal regulations, and any applicable state or local law or regulations for the protection of human subjects in research.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The issuer clearly indicates to each individual, or in the case of a minor child, to the legal guardian of such child, to whom the request is made that:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Compliance with the request is voluntary; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Noncompliance will have no effect on enrollment status or premium or contribution amounts.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
No genetic information collected or acquired under this subrule shall be used for underwriting, determination of eligibility to enroll or maintain enrollment status, premium rates, or the issuance, renewal, or replacement of a policy or certificate.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The issuer notifies the Secretary of the U.S. Department of Health and Human Services in writing that the issuer is conducting activities pursuant to the exception provided for under this subrule, including a description of the activities conducted.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The issuer complies with such other conditions as the Secretary of the U.S. Department of Health and Human Services may by regulation require for activities conducted under this subrule.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.23
}
{\plain\f4\fs21\b\cf2\ulc2
(8)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An issuer of a Medicare supplement policy or certificate shall not request, require, or purchase genetic information for underwriting purposes.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.23
}
{\plain\f4\fs21\b\cf2\ulc2
(9)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An issuer of a Medicare supplement policy or certificate shall not request, require, or purchase genetic information with respect to any individual prior to such individual’s enrollment under the policy in connection with such enrollment.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.23
}
{\plain\f4\fs21\b\cf2\ulc2
(10)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
If an issuer of a Medicare supplement policy or certificate obtains genetic information incidental to the requesting, requiring, or purchasing of other information concerning any individual, such request, requirement, or purchase shall not be considered a violation of subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.23.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.23(9)
}
}}
{\plain\f4\fs21\cf2\ulc2
if such request, requirement, or purchase is not in violation of subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.23.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.23(8)
}
}}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
24
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Prohibition against using SHIIP prepared materials
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The Senior Health Insurance Information Program (SHIIP) may prepare a consumer Medicare supplement insurance premium guide and benefits comparison guide. This guide and the SHIIP name or logo shall not be used in the solicitation or sale of health insurance products. Violation of this provision shall be deemed an unfair trade practice under Iowa Code chapter
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/ico/chapter/507B.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
507B
}
}}
{\plain\f4\fs21\cf2\ulc2
.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
25
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Guaranteed issue for eligible persons.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.25
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Eligible persons are those individuals described in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
who seek to enroll under the policy during the period specified in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(3)
}
}}
{\plain\f4\fs21\cf2\ulc2
and who submit evidence of the date of termination, disenrollment, or Medicare Part D enrollment with the application for a Medicare supplement policy.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
With respect to eligible persons, an issuer shall not deny or condition the issuance or effectiveness of a Medicare supplement policy described in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(5)
}
}}
{\plain\f4\fs21\cf2\ulc2
that is offered and is available for issuance to new enrollees by issuer, shall not discriminate in the pricing of such Medicare supplement policy because of health status, claims experience, receipt of health care, or medical condition, and shall not impose an exclusion of benefits based on a preexisting condition under such Medicare supplement policy.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.25
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An eligible person is an individual described in any of the following paragraphs:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The individual is enrolled under an employee welfare benefit plan that provides health benefits that supplement benefits under Medicare and the plan terminates or the plan ceases to provide some or all such supplemental health benefits to the individual;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The individual is enrolled with a Medicare Advantage organization under Medicare Advantage under Part C of Medicare and any of the following circumstances apply, or the individual is 65 years of age or older and is enrolled with a Program of All-Inclusive Care for the Elderly (PACE) provider under Section 1894 of the Social Security Act and circumstances exist similar to those described below that would permit discontinuance of the individual’s enrollment with such a provider if such individual were enrolled in Medicare Advantage:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The certification of the organization or plan under this part has been terminated; or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides; or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The individual is no longer eligible to elect the plan because of a change in the individual’s place of residence or other change in circumstances specified by the Secretary, but not including termination of the individual’s enrollment on the basis described in Section 1851(g)(3)(B) of the federal Social Security Act (where the individual has not paid premiums on a timely basis or has engaged in disruptive behavior as specified in standards under Section 1856), or the plan is terminated for all individuals within a residence area; or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The individual demonstrates, in accordance with guidelines established by the Secretary, that:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The organization offering the plan substantially violated a material provision of the organization’s contract under this part in relation to the individual, including the failure to provide an enrollee on a timely basis medically necessary care for which benefits are available under the plan or the failure to provide such covered care in accordance with applicable quality standards; or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The organization, or agent or other entity acting on the organization’s behalf, materially misrepresented the plan’s provisions in marketing the plan to the individual; or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The individual meets such other exceptional conditions as the Secretary may provide;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The individual is enrolled with:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An eligible organization under a contract under Section 1876 of the Social Security Act (Medicare cost); or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
A similar organization operating under demonstration project authority, effective for periods before April 1, 1999; or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An organization operating under an agreement under Section 1833(a)(1)(A) of the Social Security Act (health care prepayment plan); or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An organization under Medicare Select policy; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The enrollment ceases under the same circumstances that would permit discontinuance of an individual’s election of coverage under paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
{\plain\f4\fs21\i\cf2\ulc2
“b”
}
}}
{\plain\f4\fs21\cf2\ulc2
;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The individual is enrolled under a Medicare supplement policy and the enrollment ceases because:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Of the insolvency of the issuer or bankruptcy of the nonissuer organization; or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The issuer of the policy substantially violated a material provision of the policy; or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The issuer, or an agent or other entity acting on the issuer’s behalf, materially misrepresented the policy’s provisions in marketing the policy to the individual;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The individual was enrolled under a Medicare supplement policy and terminated enrollment and subsequently enrolls, for the first time, with any Medicare Advantage organization under Medicare Advantage under Part C of Medicare, any eligible organization under a contract under Section 1876 of the Social Security Act (Medicare cost), any similar organization operating under demonstration project authority, any PACE provider under Section 1894 of the Social Security Act, or a Medicare Select policy; and the subsequent enrollment under paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
{\plain\f4\fs21\i\cf2\ulc2
“e”
}
}}
{\plain\f4\fs21\cf2\ulc2
was terminated by the enrollee during any period within the first 12 months of such subsequent enrollment (during which the enrollee is permitted to terminate such subsequent enrollment under Section 1851(e) of the federal Social Security Act); or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The individual upon first becoming enrolled for benefits under Part B of Medicare at age 65 or older enrolls in Medicare Advantage under Part C of Medicare or with a PACE provider under Section 1894 of the Social Security Act and disenrolls from the plan or program by no later than 12 months after the effective date of enrollment.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
g.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The individual enrolls in a Medicare Part D plan during the initial enrollment period, at the time of enrollment in Part D, was enrolled under a Medicare supplement policy that covers outpatient prescription drugs and the individual terminates enrollment in the Medicare supplement policy and submits evidence of enrollment in Medicare Part D along with the application for a policy described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(5)
}
{\plain\f4\fs21\i\cf2\ulc2
“e.”
}
}}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.25
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Guaranteed issue time periods.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
In the case of an individual described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
{\plain\f4\fs21\i\cf2\ulc2
“a,”
}
}}
{\plain\f4\fs21\cf2\ulc2
the guaranteed issue period begins on the later of: (1) the date the individual receives a notice of termination or cessation of some or all supplemental health benefits (or, if a notice is not received, notice that a claim has been denied because of such a termination or cessation); or (2) the date that the applicable coverage terminates or ceases; and ends 63 days thereafter.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
In the case of an individual described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“b,” “c,” “e”
}
{\plain\f4\fs21\cf2\ulc2
or
}
{\plain\f4\fs21\i\cf2\ulc2
“f”
}
{\plain\f4\fs21\cf2\ulc2
whose enrollment is terminated involuntarily, the guaranteed issue period begins on the date that the individual receives a notice of termination and ends 63 days after the date the applicable coverage is terminated.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
In the case of an individual described in subparagraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“d”
}
{\plain\f4\fs21\cf2\ulc2
(1), the guaranteed issue period begins on the earlier of (1) the date that the individual receives a notice of termination, a notice of the issuer’s bankruptcy or insolvency, or other such similar notice, if any, and (2) the date that the applicable coverage is terminated, and ends on the date that is 63 days after the date the coverage is terminated.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
In the case of an individual described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“b,”
}
{\plain\f4\fs21\cf2\ulc2
subparagraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“d”
}
{\plain\f4\fs21\cf2\ulc2
(2), subparagraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“e”
}
{\plain\f4\fs21\cf2\ulc2
(2), paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“e”
}
{\plain\f4\fs21\cf2\ulc2
or paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“f”
}
{\plain\f4\fs21\cf2\ulc2
who disenrolls voluntarily, the guaranteed issue period begins on the date that is 60 days before the effective date of the disenrollment and ends on the date that is 63 days after the effective date.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
In the case of an individual described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“g,”
}
{\plain\f4\fs21\cf2\ulc2
the guaranteed issue period begins on the date the individual receives notice pursuant to Section 1882(v)(2)(B) of the Social Security Act from the Medicare supplement issuer during the 60-day period immediately preceding the initial Part D enrollment period and ends on the date that is 63 days after the effective date of the individual’s coverage under Medicare Part D; and
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
f.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
In the case of an individual described in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
but not described in the preceding paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(3)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a”
}
{\plain\f4\fs21\cf2\ulc2
to
}
{\plain\f4\fs21\i\cf2\ulc2
“e,”
}
{\plain\f4\fs21\cf2\ulc2
the guaranteed issue period begins on the effective date of disenrollment and ends on the date that is 63 days after the effective date.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.25
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Extended Medigap access for interrupted trial periods.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
In the case of an individual described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“e”
}
{\plain\f4\fs21\cf2\ulc2
(or deemed to be so described pursuant to paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(4)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a”
}
{\plain\f4\fs21\cf2\ulc2
) whose enrollment with an organization or provider described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“e”
}
{\plain\f4\fs21\cf2\ulc2
is involuntarily terminated within the first 12 months of enrollment and who, without an intervening enrollment, enrolls with another such organization or provider, the subsequent enrollment shall be deemed to be an initial enrollment as described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“e.”
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
In the case of an individual described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“f”
}
{\plain\f4\fs21\cf2\ulc2
(or deemed to be so described pursuant to paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(4)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“b”
}
{\plain\f4\fs21\cf2\ulc2
) whose enrollment with a plan or in a program described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“f”
}
{\plain\f4\fs21\cf2\ulc2
is involuntarily terminated within the first 12 months of enrollment and who, without an intervening enrollment, enrolls in another such plan or program, the subsequent enrollment shall be deemed to be an initial enrollment as described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“f.”
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
For purposes of paragraphs
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“e”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“f,”
}
{\plain\f4\fs21\cf2\ulc2
no enrollment of an individual with an organization or provider described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“e,”
}
{\plain\f4\fs21\cf2\ulc2
or with a plan or in a program described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“f,”
}
{\plain\f4\fs21\cf2\ulc2
may be deemed to be an initial enrollment under paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(4)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“c”
}
{\plain\f4\fs21\cf2\ulc2
after the two-year period beginning on the date on which the individual first enrolled with such an organization, provider, plan or program.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.25
}
{\plain\f4\fs21\b\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Products to which eligible persons are entitled. The Medicare supplement policy to which eligible persons are entitled under:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
, paragraphs
}
{\plain\f4\fs21\i\cf2\ulc2
“a,” “b,” “c,”
}
{\plain\f4\fs21\cf2\ulc2
and
}
{\plain\f4\fs21\i\cf2\ulc2
“d,”
}
{\plain\f4\fs21\cf2\ulc2
is a Medicare supplement policy which has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K or L offered by any issuer.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Subject to paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(5)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“c,”
}
{\plain\f4\fs21\cf2\ulc2
paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“e”
}
{\plain\f4\fs21\cf2\ulc2
is the same Medicare supplement policy in which the individual was most recently previously enrolled if available from the same issuer, or, if not so available, a policy described in paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(5)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“a.”
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
After December 31, 2005, if the individual was most recently enrolled in a Medicare supplement policy with an outpatient prescription drug benefit, a Medicare supplement policy described in this paragraph is:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The policy available from the same issuer but modified to remove outpatient prescription drug coverage; or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
At the election of the policyholder, an A, B, C, F (including F with a high deductible), K or L policy that is offered by any issuer.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
d.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“f”
}
{\plain\f4\fs21\cf2\ulc2
shall include any Medicare supplement policy offered by any issuer.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
e.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Paragraph
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\i\cf2\ulc2
“g”
}
{\plain\f4\fs21\cf2\ulc2
is a Medicare supplement policy that has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K or L, and that is offered and is available for issuance to new enrollees by the same issuer that issued the individual’s Medicare supplement policy with outpatient prescription drug coverage.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.25
}
{\plain\f4\fs21\b\cf2\ulc2
(6)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Notification of provisions.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
At the time of an event described in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
because of which an individual loses coverage or benefits due to the termination or change of a contract or agreement, policy, or plan, the organization that terminates or changes the contract or agreement, the issuer terminating or changing the policy, or the administrator of the plan being terminated or changed, respectively, shall notify the individual of the individual’s rights under this rule and of the obligations of issuers of Medicare supplement policies under subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(1)
}
}}
{\plain\f4\fs21\cf2\ulc2
. Such notice shall be communicated contemporaneously with the notification of termination.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
At the time of an event described in subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(2)
}
}}
{\plain\f4\fs21\cf2\ulc2
because of which an individual ceases enrollment under a contract or agreement, policy, or plan, the organization that offers the contract or agreement, regardless of the basis for the cessation of enrollment, the issuer offering the policy, or the administrator of the plan, respectively, shall notify the individual of the individual’s rights under this rule and of the obligations of issuers of Medicare supplement policies under subrule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.25.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
37.25(1)
}
}}
{\plain\f4\fs21\cf2\ulc2
. Such notice shall be communicated within ten working days of the issuer receiving notification of the disenrollment.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
26
}
{\plain\f4\fs21\b\cf2\ulc2
(514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Severability.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
If any provisions of this chapter or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the chapter and the application of such provision to other persons or circumstances shall not be affected thereby.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.27
}
{\plain\f4\fs21\cf2\ulc2
to
}
{\plain\f4\fs21\b\cf2\ulc2
37.49
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Reserved.
}
\par
\pard\keepn\sb283\qc\sl180
{\plain\f4\fs16\cf2
DIVISION II
}
\par
\pard\keepn\qc\sl180
{\plain\f4\fs16\cf2
MEDICARE SUPPLEMENT ADVERTISING
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
50
}
{\plain\f4\fs21\b\cf2\ulc2
(507B,514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Purpose.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The purpose of the rules in this division is to provide prospective purchasers with clear and unambiguous statements in the advertisement of Medicare supplement insurance and to assure the clear and truthful disclosure of the benefits, limitations and exclusions of policies sold as Medicare supplement insurance. This purpose is intended to be accomplished by the establishment of guidelines and permissible and impermissible standards of conduct in the advertising of Medicare supplement insurance in a manner which prevents unfair, deceptive and misleading advertising and which is conducive to accurate presentation and description to the insurance-buying public through the advertising media and material used by insurance producers and companies.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
51
}
{\plain\f4\fs21\b\cf2\ulc2
(507B,514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Applicability.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.51
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
“Insurer,” for the purpose of these rules, shall include any individual, corporation, association, partnership, reciprocal exchange, inter-insurer, Lloyd’s, fraternal benefit society, health maintenance organization, hospital service corporation, medical service corporation, prepaid health plan and any other legal entity which is defined as an “issuer” in rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.3.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.3
}
}}
{\plain\f4\fs21\cf2\ulc2
(514D) and is engaged in the advertisement of itself, or Medicare supplement insurance.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
These rules shall apply to any “advertisement” of Medicare supplement insurance, as that term is defined in rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.37.52.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—37.52
}
}}
{\plain\f4\fs21\cf2\ulc2
(507B,514D), unless otherwise specified in Division II of this chapter, that the insurer or producer knows or reasonably should know is intended for presentation, distribution or dissemination in this state when the presentation, distribution or dissemination is made either directly or indirectly by or on behalf of an insurer or producer, as those terms are defined in rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.15.2.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—15.2
}
}}
{\plain\f4\fs21\cf2\ulc2
(507B).
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.51
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Advertising materials that are reproduced in quantity shall be identified by form numbers or other identifying means. The identification shall be sufficient to distinguish an advertisement from any other advertising materials, policies, applications or other materials used by the insurer.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.51
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The requirements of Iowa Code chapter
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/ico/chapter/507B.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
507B
}
}}
{\plain\f4\fs21\cf2\ulc2
and
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/chapter/191.15.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—Chapter 15
}
}}
{\plain\f4\fs21\cf2\ulc2
also shall apply to insurers and producers to which
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/chapter/191.37.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—Chapter 37
}
}}
{\plain\f4\fs21\cf2\ulc2
, Division II, applies, unless specifically exempted therein.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
52
}
{\plain\f4\fs21\b\cf2\ulc2
(507B,514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Definitions.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
In addition to the definitions in Iowa Code section
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/ico/section/507B.2.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
507B.2
}
}}
{\plain\f4\fs21\cf2\ulc2
and rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.15.2.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—15.2
}
}}
{\plain\f4\fs21\cf2\ulc2
(507B), the following definitions shall apply to
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/chapter/191.37.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—Chapter 37
}
}}
{\plain\f4\fs21\cf2\ulc2
, Division II. When there is a definition for a term in this rule and also in Iowa Code section
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/ico/section/507B.2.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
507B.2
}
}}
{\plain\f4\fs21\cf2\ulc2
or rule
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.15.2.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—15.2
}
}}
{\plain\f4\fs21\cf2\ulc2
(507B), the definition in this rule shall take precedence.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Advertisement
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
includes:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
1.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The definition of “advertisement” in rule 191—15.2(507B).
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
2.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Advertising material included with a policy when the policy is delivered and material used in the solicitation of renewals and reinstatements.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
3.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The definition of “advertisement” does not include:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Items excluded in the definition of “advertisement” in rule 191—15.2(507B).
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Correspondence between a prospective group or blanket policyholder and an insurer in the course of negotiating a group or blanket contract.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
\u9679?
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
Court-approved material ordered by a court to be disseminated to policyholders.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Certificate
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means any certificate issued under a group Medicare supplement policy, which certificate has been delivered or issued for delivery in this state.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Institutional advertisement
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means an advertisement having as its sole purpose the promotion of the reader’s, viewer’s or listener’s interest in the concept of Medicare supplement insurance, or the promotion of the insurer as a seller of Medicare supplement insurance.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Lead-generating device
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means any communication directed to the public that, regardless of form, content or stated purpose, is intended to result in the compilation or qualification of a list containing names and other personal information to be used to solicit residents of this state for the purchase of Medicare supplement insurance.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Limitation
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means any provision other than an exception or a reduction that restricts coverage under the policy.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Medicare
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means “The Health Insurance for the Aged Act, Title XVIII of The Social Security Amendments of 1965 as Then Constituted or Later Amended,” or Title I, Part I, of Public Law 89-97, as enacted by the Eighty-Ninth Congress of the United States of America, and also known as the “Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof,” or words of similar import.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Medicare supplement insurance
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means a group or individual policy of accident and sickness insurance or a subscriber contract of hospital and medical service associations or health maintenance organizations that 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 by reason of age.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Person
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means a natural person, association, organization, partnership, trust, group, discretionary group, corporation or any other entity.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\i\cf2\ulc2
“
}
{\plain\f4\fs21\i\cf2\ulc2
Reduction
}
{\plain\f4\fs21\i\cf2\ulc2
”
}
{\plain\f4\fs21\i\cf2\ulc2
\~
}
{\plain\f4\fs21\cf2\ulc2
means any provision that reduces the amount of the benefit; a risk of loss is assumed but payment upon the occurrence of the loss is limited to some amount or period less than would be otherwise payable had the reduction not been used.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
53
}
{\plain\f4\fs21\b\cf2\ulc2
(507B,514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Form and content of advertisements.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An insurer must clearly identify its Medicare supplement insurance policy as an insurance policy. A policy trade name must be followed by the words “Insurance Policy” or similar words clearly identifying the fact that an insurance policy or health benefits product (in the case of health maintenance organizations, prepaid health plans and other direct service organizations) is being offered.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
54
}
{\plain\f4\fs21\b\cf2\ulc2
(507B,514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Testimonials or endorsements by third parties.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
In addition to complying with
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.15.3.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—subrule 15.3(7)
}
}}
{\plain\f4\fs21\cf2\ulc2
, when a testimonial refers to benefits received under a Medicare supplement insurance policy, the insurer shall retain the specific claim data, including claim number, date of loss, and other pertinent information, for a period of four years or until the filing of the next regular report of examination of the insurer, whichever is the longer period of time. The use of testimonials that do not correctly reflect the present practices of the insurer or that are not applicable to the policy or benefit being advertised is not permissible.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
55
}
{\plain\f4\fs21\b\cf2\ulc2
(507B,514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Use of statistics; jurisdictional licensing; status of insurer.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Advertisements shall be in compliance with
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.15.3.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—subrule 15.3(5)
}
}}
{\plain\f4\fs21\cf2\ulc2
and with the following:
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.55
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An advertisement shall specifically identify the Medicare supplement insurance policy to which statistics relate and, where statistics are given which are applicable to a different policy, the advertisement shall state clearly that the data do not relate to the policy being advertised.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.55
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An advertisement that is intended to be seen or heard beyond the limits of the jurisdiction in which the insurer is licensed shall not imply licensing beyond those limits.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.55
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An advertisement shall not create the impression directly or indirectly that the insurer, the insurer’s financial condition or status, the insurer’s payment of its claims, or the merits, desirability or advisability of the insurer’s policy forms or kinds of plans of insurance are approved, endorsed or accredited by any division or agency of this state or of the United States government.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.55
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An advertisement shall not imply that approval, endorsement or accreditation of policy forms or advertising has been granted by any division or agency of this state or of the United States government. “Approval” of either policy forms or advertising shall not be used by an insurer to imply or state that a governmental agency has endorsed or recommended the insurer, its policies, its advertising or its financial condition.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
56
}
{\plain\f4\fs21\b\cf2\ulc2
(507B,514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Identity of insurer.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Advertisements shall be in compliance with
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/iac/rule/191.15.3.pdf"}{\fldrslt
{\plain\f4\fs21\cf2\ulc2
191—subrule 15.3(9)
}
}}
{\plain\f4\fs21\cf2\ulc2
and with the following:
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.56
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Advertisements, stationery or envelopes that employ words, letters, initials, symbols or other devices are not permitted if they are so similar to those used by governmental agencies or other insurers that they may lead the public to believe:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The advertised coverages are somehow provided by or are endorsed by the governmental agencies or the other insurers;
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
The advertiser is the same as, is connected with or is endorsed by the governmental agencies or the other insurers.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.56
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
No advertisement shall use the name of a state or political subdivision thereof in a policy name or description.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.56
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
No advertisement in the form of envelopes or stationery of any kind may use any name, service mark, slogan, symbol or any device in such a manner that implies that the insurer or the policy advertised, or that any producer who may call upon the consumer in response to the advertisement, is connected with a governmental agency, such as the Social Security Administration.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.56
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
No advertisement may incorporate the word “Medicare” in the title of the plan or policy being advertised unless, wherever it appears, the word is qualified by language differentiating the plan or policy from Medicare. Such an advertisement, however, shall not use the phrase “_____________ Medicare Department of the _________________ Insurance Company,” or language of similar import.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.56
}
{\plain\f4\fs21\b\cf2\ulc2
(5)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
No advertisement shall be used that fails to include a disclaimer to the effect of “Not connected with or endorsed by the U.S. government or the federal Medicare program.”
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.56
}
{\plain\f4\fs21\b\cf2\ulc2
(6)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
No advertisement may imply that the reader may lose a right, privilege or benefit under federal, state or local law if the reader fails to respond to the advertisement.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.56
}
{\plain\f4\fs21\b\cf2\ulc2
(7)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
No insurer may use, in the trade name of its insurance policy, any terminology or words so similar to the name of a governmental agency or governmental program as to have the tendency to confuse, deceive or mislead the prospective purchaser.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.56
}
{\plain\f4\fs21\b\cf2\ulc2
(8)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
All advertisements used by producers or solicitors of an insurer shall have prior written approval of the insurer before the advertisements may be used.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.56
}
{\plain\f4\fs21\b\cf2\ulc2
(9)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
A producer who makes contact with a consumer as a result of acquiring that consumer’s name from a lead-generating device shall disclose that fact in the initial contact with the consumer.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\keepn\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
57
}
{\plain\f4\fs21\b\cf2\ulc2
(507B,514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Introductory, initial or special offers.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.57
}
{\plain\f4\fs21\b\cf2\ulc2
(1)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Enrollment periods.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
a.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An advertisement of an individual policy shall not directly or by implication represent that a contract or combination of contracts is an introductory, initial or special offer, or that applicants will receive substantial advantages not available at a later date, or that the offer is available only to a specified group of individuals, unless such representation is true. An advertisement shall not contain phrases describing an enrollment period as “special,” “limited,” or similar words or phrases when the insurer uses such enrollment periods as the usual method of advertising Medicare supplement insurance.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
b.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
An enrollment period during which a particular insurance product may be purchased on an individual basis shall not be offered within this state unless there has been a lapse of not less than six months between the close of the immediately preceding enrollment period for the same product and the opening of the new enrollment period. The advertisement shall indicate the date by which the applicant must mail the application, which shall be not fewer than 10 days and not more than 40 days from the date that the enrollment period is advertised for the first time. This rule applies to all advertising media, e.g., mail, newspapers, electronic mail, websites, radio, television, magazines and periodicals, used by any one insurer. This rule is not applicable to solicitations of employees or members of a particular group or association that otherwise would be eligible for group, blanket or franchise insurance. The phrase “any one insurer” in this paragraph includes all the affiliated companies of a group of insurance companies under common management or control. The phrase “a particular insurance product” in this paragraph means an insurance policy that provides benefits substantially different from those contained in any other policy. Different terms of renewability, an increase or decrease in the dollar amounts of benefits, or an increase or decrease in any elimination period or waiting period from those available during an enrollment period for another policy shall not be sufficient to constitute the product’s being offered as a different product eligible for concurrent or overlapping enrollment periods.
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\i\cf2\ulc2
c.
}
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2\ulc2
This rule prohibits any statement or implication to the effect that only a specific number of policies will be sold, or that a time is fixed for the discontinuance of the sale of the particular policy advertised because of special advantages available in the policy, unless either is true.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.57
}
{\plain\f4\fs21\b\cf2\ulc2
(2)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An advertisement shall not offer a policy that utilizes a reduced initial premium rate in a manner that overemphasizes the availability and the amount of the initial reduced premium. When an insurer charges an initial premium that differs in amount from the amount of the renewal premium payable on the same mode, the advertisement shall not display the amount of the reduced initial premium either more frequently or more prominently than the renewal premium, and both the initial reduced premium and the renewal premium shall be stated in juxtaposition in each portion of the advertisement where the initial reduced premium appears. The term “juxtaposition” means side by side or immediately above or below.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.57
}
{\plain\f4\fs21\b\cf2\ulc2
(3)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Special awards, such as a “safe driver’s award,” shall not be used in connection with advertisements of Medicare supplement insurance.
}
\par
\pard\qj\sl250\tx340
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\b\cf2\ulc2
37.57
}
{\plain\f4\fs21\b\cf2\ulc2
(4)
}
{\plain\f4\fs21\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
An invitation to inquire, which means an advertisement having as its objective the creation of a desire to inquire further about Medicare supplement insurance that is limited to a brief description of coverage, shall contain a provision in the following or substantially similar form:
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2\ulc2
“This policy has [exclusions] [limitations] [reductions of benefits] [terms under which the policy may be continued in force or discontinued]. For costs and complete details of the coverage, call [or write] your insurance producer or the company [whichever is applicable].”
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
58
}
{\plain\f4\fs21\b\cf2\ulc2
(507B,514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Enforcement procedures—certificate of compliance.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
Each insurer required to file an annual statement which is now or which hereafter becomes subject to the provisions of these rules must file with the insurance division, with the insurer’s annual statement, a certificate of compliance executed by an authorized officer of the insurer wherein it is stated that, to the best of the authorized officer’s knowledge, information and belief, the advertisements that were disseminated by the insurer during the preceding statement year complied with or were made to comply in all respects with the provisions of these rules and the laws of this state as implemented and interpreted by these rules.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\sb210\qj\sl250
{\plain\f4\fs21\b\cf2\ulc2
191—37.
}
{\plain\f4\fs21\b\cf2\ulc2
59
}
{\plain\f4\fs21\b\cf2\ulc2
(507B,514D)
}
{\plain\f4\fs21\b\cf2\ulc2
Filing for prior review.
}
{\plain\f4\fs21\b\cf2\ulc2
}
{\plain\f4\fs21\cf2\ulc2
The commissioner may, at the commissioner’s discretion, require the filing with the insurance division, for review prior to use, of any Medicare supplement insurance advertising material.
}
\par
\pard\keep\sl180
{\plain\f4\fs16\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs16\b\cf2
ARC 7964B
}
}}
{\plain\f4\fs16\cf2
, IAB 7/15/09, effective 8/19/09]
}
\par
\pard\pagebb\qj\sl250
{\plain\f4\fs21\cf2
Appendix A
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
MEDICARE SUPPLEMENT REFUND CALCULATION FORM
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
FOR CALENDAR YEAR ______
}
\par
\pard\plain\f0\fs18
\par
\trowd\trleft0
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TYPE
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1
}
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\tab
}
\cell
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SMSBP
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2
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\tab
}
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{\plain\f4\fs18\cf2
For the State of
}
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\tab
}
\cell
\pard\intbl\li80\ri80\sl200\tlth\tx4320
{\plain\f4\fs18\cf2
Company Name
}
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\tab
}
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{\plain\f4\fs18\cf2
NAIC Group Code
}
{\plain\f4\fs18\cf2\ulc2
\tab
}
\cell
\pard\intbl\li80\ri80\sl200\tlth\tx4320
{\plain\f4\fs18\cf2
NAIC Company Code
}
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\tab
}
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{\plain\f4\fs18\cf2
Address
}
{\plain\f4\fs18\cf2\ulc2
\tab
}
\cell
\pard\intbl\li80\ri80\sl200\tlth\tx4320
{\plain\f4\fs18\cf2
Person Completing This Exhibit
}
{\plain\f4\fs18\cf2\ulc2
\tab
}
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\pard\intbl\li80\ri80\sl200\tlth\tx4320
{\plain\f4\fs18\cf2
Title
}
{\plain\f4\fs18\cf2\ulc2
\tab
}
\cell
\pard\intbl\li80\ri80\sl200\tlth\tx4320
{\plain\f4\fs18\cf2
Telephone Number
}
{\plain\f4\fs18\cf2\ulc2
\tab
}
\cell
\row
\pard\plain\f0\fs18
\par
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\clpadft3\clpadt80
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{\plain\f4\fs18\cf2
Line
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\cell
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\~
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\cell
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(a)
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\par
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Earned Premium
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3
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{\plain\f4\fs18\cf2
(b)
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{\plain\f4\fs18\cf2
Incurred Claims
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4
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{\plain\f4\fs18\cf2
1.
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\cell
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Current Year’s Experience
}
\cell
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{\plain\f4\fs18\cf2
\~
}
\cell
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\~
}
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\~
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\cell
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a. Total (all policy years)
}
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{\plain\f4\fs18\cf2
\~
}
\cell
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\~
}
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\~
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\cell
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b. Current year’s issues
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5
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{\plain\f4\fs18\cf2
\~
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\cell
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\~
}
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{\plain\f4\fs18\cf2
\~
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\cell
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c. Net (for reporting purposes = 1a - 1b)
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{\plain\f4\fs18\cf2
\~
}
\cell
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{\plain\f4\fs18\cf2
\~
}
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{\plain\f4\fs18\cf2
2.
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\cell
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Past Years’ Experience (all policy years)
}
\cell
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{\plain\f4\fs18\cf2
\~
}
\cell
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{\plain\f4\fs18\cf2
\~
}
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{\plain\f4\fs18\cf2
3.
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\cell
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Total Experience
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{\plain\f4\fs18\cf2
(Net Current Year + Past Year)
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{\plain\f4\fs18\cf2
\~
}
\cell
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{\plain\f4\fs18\cf2
\~
}
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4.
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{\plain\f4\fs18\cf2
Refunds Last Year (excluding interest)
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{\plain\f4\fs18\cf2
\~
}
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5.
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Previous Since Inception (excluding interest)
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{\plain\f4\fs18\cf2
\~
}
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6.
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Refunds Since Inception (excluding interest)
}
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{\plain\f4\fs18\cf2
\~
}
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7.
}
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{\plain\f4\fs18\cf2
Benchmark Ratio Since Inception (see worksheet for Ratio 1)
}
\cell
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{\plain\f4\fs18\cf2
\~
}
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8.
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Experienced Ratio Since Inception (Ratio 2)
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Total Actual Incurred Claims (line 3, col. b)
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Total Earned Prem. (line 3, col. a) - Refunds Since
}
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Inception (line 6)
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\~
}
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9.
}
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Life Years Exposed Since Inception
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\par
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{\plain\f4\fs18\cf2
If the Experienced Ratio is less than the Benchmark Ratio, and there are more than 500 life years exposure, then proceed to calculation of refund.
}
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\~
}
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10.
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Tolerance Permitted (obtained from credibility table)
}
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{\plain\f4\fs18\cf2
\~
}
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Medicare Supplement Credibility Table
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Life Years Exposed
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Since Inception
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Tolerance
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10,000 +
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0.0%
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5,000 - 9,999
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5.0%
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2,500 - 4,999
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7.5%
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1,000 - 2,499
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10.0%
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500 - 999
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15.0%
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If less than 500, no credibility.
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1
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{\plain\f4\fs21\cf2
Individual, Group, Individual Medicare Select, or Group Medicare Select only.
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\par
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{\plain\f4\fs16\super\cf2
2
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{\plain\f4\fs21\cf2
“SMSBP” = Standardized Medicare Supplement Benefit Plan – Use “P” for prestandardized plans.
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{\plain\f4\fs16\super\cf2
3
}
{\plain\f4\fs21\cf2
Includes Modal Loadings and Fees Charged.
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{\plain\f4\fs16\super\cf2
4
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{\plain\f4\fs21\cf2
Excludes Active Life Reserves.
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{\plain\f4\fs16\super\cf2
5
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{\plain\f4\fs21\cf2
This is to be used as “Issue Year Earned Premium” for Year 1 of next year’s “Worksheet for Calculation of Benchmark Ratios.”
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{\plain\f4\fs21\cf2
MEDICARE SUPPLEMENT REFUND CALCULATION FORM
}
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{\plain\f4\fs21\cf2
FOR CALENDAR YEAR ______
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TYPE
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1
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{\plain\f4\fs18\cf2\ulc2
\tab
}
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SMSBP
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2
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\tab
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{\plain\f4\fs18\cf2
For the State of
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\tab
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Company Name
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\tab
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NAIC Group Code
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\tab
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NAIC Company Code
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\tab
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Address
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\tab
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Person Completing This Exhibit
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\tab
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Title
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\tab
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{\plain\f4\fs18\cf2
Telephone Number
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{\plain\f4\fs18\cf2\ulc2
\tab
}
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\par
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{\plain\f4\fs18\cf2
11.
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{\plain\f4\fs18\cf2
Adjustment to Incurred Claims for Credibility
}
\cell
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{\plain\f4\fs18\cf2
\~
}
\cell
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{\plain\f4\fs18\cf2
\~
}
\cell
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{\plain\f4\fs18\cf2
Ratio 3 = Ratio 2 + Tolerance
}
\cell
\pard\intbl\li80\ri80\sl200
{\plain\f4\fs18\cf2
\~
}
\cell
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{\plain\f4\fs21\cf2
If Ratio 3 is more than Benchmark Ratio (Ratio 1), a refund or credit to premium is not required.
}
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{\plain\f4\fs21\cf2
If Ratio 3 is less than the Benchmark Ratio, then proceed.
}
\par
\pard\plain\f0\fs18
\par
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{\plain\f4\fs18\cf2
12.
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{\plain\f4\fs18\cf2
Adjusted Incurred Claims
}
\cell
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{\plain\f4\fs18\cf2
\~
}
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{\plain\f4\fs18\cf2
\~
}
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{\plain\f4\fs18\cf2
[Total Earned Premiums (line 3, col. a) - Refunds Since Inception (line 6)] × Ratio 3 (line 11)
}
\cell
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{\plain\f4\fs18\cf2
\~
}
\cell
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13.
}
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{\plain\f4\fs18\cf2
Refund =
}
\cell
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{\plain\f4\fs18\cf2
\~
}
\cell
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\~
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Total Earned Premiums (line 3, col. a) - Refunds Since Inception (line 6) - [Adjusted Incurred Claims (line 12) / Benchmark Ratio (Ratio 1)]
}
\cell
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{\plain\f4\fs18\cf2
\~
}
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If the amount on line 13 is less than .005 times the annualized premium in force as of December 31 of the reporting year, then no refund is made. Otherwise, the amount on line 13 is to be refunded or credited, and a description of the refund or credit against premiums to be used must be attached to this form.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
I certify that the above information and calculations are true and accurate to the best of my knowledge and belief.
}
\par
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{\plain\f4\fs18\cf2
\~
}
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\~
}
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\~
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Signature
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\~
}
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\~
}
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\~
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Name (Please type.)
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\~
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\~
}
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\~
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Title (Please type.)
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\~
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\~
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\~
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1
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Individual, Group, Individual Medicare Select, or Group Medicare Select only.
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2
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“SMSBP” = Standardized Medicare Supplement Benefit Plan – Use “P” for prestandardized plans.
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REPORTING FORM FOR THE CALCULATION OF
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BENCHMARK RATIO SINCE INCEPTION FOR GROUP POLICIES
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FOR CALENDAR YEAR _____
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TYPE
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1
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2
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For the State of
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Person Completing This Exhibit
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(b)
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(c)
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(d)
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(e)
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(f)
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(g)
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(h)
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(i)
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(j)
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(o)
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5
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Earned
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Premium
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(b) × (c)
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Cumulative
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Factor
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Cumulative
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Policy Year
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Loss Ratio
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Total:
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\~
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\~
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Benchmark Ratio Since Inception: (l + n)/(k + m): __________
}
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1
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Individual, Group, Individual Medicare Select, or Group Medicare Select only.
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2
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“SMSBP” = Standardized Medicare Supplement Benefit Plan – Use “P” for prestandardized plans.
}
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3
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Year 1 is the current calendar year
}
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-
}
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1. Year 2 is the current calendar year
}
{\plain\f4\fs19\cf2
-
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2 (etc.). (Example: If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)
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4
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For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.
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5
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These loss ratios are not explicitly used in computing the benchmark loss ratios. They are the loss ratios, on a policy year basis, which result in the cumulative loss ratios displayed on this worksheet. They are shown here for informational purposes only.
}
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6
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REPORTING FORM FOR THE CALCULATION OF
}
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BENCHMARK RATIO SINCE INCEPTION FOR INDIVIDUAL POLICIES
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FOR CALENDAR YEAR _____
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TYPE
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14
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6
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\~
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\~
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Total:
}
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\~
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\~
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(k):
}
\cell
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{\plain\f4\fs14\cf2
\~
}
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{\plain\f4\fs14\cf2
(l):
}
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\pard\intbl\li80\ri90\sl160
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\~
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(m):
}
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\pard\intbl\li80\ri90\sl160
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\~
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(n):
}
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\~
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\pard\sb140\qj\sl250
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Benchmark Ratio Since Inception: (l + n)/(k + m): _______
}
\par
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1
}
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Individual, Group, Individual Medicare Select, or Group Medicare Select only.
}
\par
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{\plain\f4\fs16\super\cf2
2
}
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“SMSBP” = Standardized Medicare Supplement Benefit Plan – Use “P” for prestandardized plans.
}
\par
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{\plain\f4\fs16\super\cf2
3
}
{\plain\f4\fs21\cf2
Year 1 is the current calendar year
}
{\plain\f4\fs19\cf2
-
}
{\plain\f4\fs21\cf2
1. Year 2 is the current calendar year
}
{\plain\f4\fs19\cf2
-
}
{\plain\f4\fs21\cf2
2 (etc.). (Example: If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)
}
\par
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4
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For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.
}
\par
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5
}
{\plain\f4\fs21\cf2
These loss ratios are not explicitly used in computing the benchmark loss ratios. They are the loss ratios, on a policy year basis, which result in the cumulative loss ratios displayed on this worksheet. They are shown here for informational purposes.
}
\par
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6
}
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To include the earned premium for all years prior to as well as the 15th year prior to the current year.
}
\par
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Appendix B
}
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FORM FOR REPORTING
}
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MEDICARE SUPPLEMENT POLICIES
}
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Company Name:
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\tab
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Address:
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\~
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Phone Number:
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Due March 1, annually
}
\par
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The purpose of this form is to report the following information on each resident of this state who has in force more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder.
}
\par
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\par
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Policy and Certificate #
}
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Date of Issuance
}
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\pard\intbl
\cell
\pard\intbl
\cell
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\pard\sb180\qj\sl250\tlth\tx4320
{\plain\f4\fs21\cf2\ulc2
\tab
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\par
\pard\qj\sl250\tlth\tx4320
{\plain\f4\fs21\cf2\ulc2
\tab
}
\par
\pard\qj\sl250\tlth\tx4320
{\plain\f4\fs21\cf2\ulc2
\tab
}
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\pard\qj\sl250\tlth\tx4320
{\plain\f4\fs21\cf2\ulc2
\tab
}
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\pard\qj\sl250\tlth\tx4320
{\plain\f4\fs21\cf2\ulc2
\tab
}
\par
\pard\qj\sl250\tlth\tx4320
{\plain\f4\fs21\cf2\ulc2
\tab
}
\par
\pard\plain\f0\fs18
\par
\trowd\trleft0
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\clvertalt
\cellx3200
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\cellx6400
\pard\intbl\li80\ri80\sl200
{\plain\f4\fs18\cf2
\~
}
\cell
\pard\intbl\li80\ri80\sl200
{\plain\f4\fs18\cf2
\~
}
\cell
\row
\trowd\trleft0
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\li80\ri80\sl200
{\plain\f4\fs18\cf2
\~
}
\cell
\pard\intbl\li80\ri80\sl200
{\plain\f4\fs18\cf2
Signature
}
\cell
\row
\trowd\trleft0
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\cellx3200
\clpadft3\clpadt80
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\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\cellx6400
\pard\intbl\li80\ri80\sl200
{\plain\f4\fs18\cf2
\~
}
\cell
\pard\intbl\li80\ri80\sl200
{\plain\f4\fs18\cf2
\~
}
\cell
\row
\trowd\trleft0
\clpadft3\clpadt80
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\cellx3200
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\clpadfr3\clpadr80
\clvertalt
\cellx6400
\pard\intbl\li80\ri80\sl200
{\plain\f4\fs18\cf2
\~
}
\cell
\pard\intbl\li80\ri80\sl200
{\plain\f4\fs18\cf2
Name and Title (please type)
}
\cell
\row
\trowd\trleft0
\clpadft3\clpadt80
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\clpadfl3\clpadl80
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\clvertalt
\clbrdrb\brdrs\brdrw10\brdrcf2\cellx6400
\pard\intbl\li80\ri80\sl200
{\plain\f4\fs18\cf2
\~
}
\cell
\pard\intbl\li80\ri80\sl200
{\plain\f4\fs18\cf2
\~
}
\cell
\row
\trowd\trleft0
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\cellx3200
\clpadft3\clpadt80
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{\plain\f4\fs18\cf2
\~
}
\cell
\pard\intbl\li80\ri80\sl200
{\plain\f4\fs18\cf2
Date
}
\cell
\row
\pard\pagebb\sb180\qc\sl250
{\plain\f4\fs21\cf2
APPENDIX C
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
DISCLOSURE STATEMENTS
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
Instructions for Use of the Disclosure Statements for Health Insurance Policies
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
Sold to Medicare Beneficiaries that Duplicate Medicare
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2
1. Section 1882(d) of the federal Social Security Act [42 U.S.C. 1395ss] prohibits the sale of a health insurance policy (the term policy includes certificate) to Medicare beneficiaries that duplicates Medicare benefits unless it will pay benefits without regard to a beneficiary’s other health coverage and it includes the prescribed disclosure statement on or together with the application for the policy.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2
2. All types of health insurance policies that duplicate Medicare shall include one of the attached disclosure statements, according to the particular policy type involved, on the application or together with the application. The disclosure statement may not vary from the attached statements in terms of language or format (type size, type proportional spacing, bold character, line spacing, and usage of boxes around text).
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2
3. State and federal law prohibits insurers from selling a Medicare supplement policy to a person that already has a Medicare supplement policy except as a replacement policy.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2
4. Property/casualty and life insurance policies are not considered health insurance.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2
5. Disability income policies are not considered to provide benefits that duplicate Medicare.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2
6. Long-term care insurance policies that coordinate with Medicare and other health insurance are not considered to provide benefits that duplicate Medicare.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2
7. The federal law does not preempt state laws that are more stringent than the federal requirements.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2
8. The federal law does not preempt existing state form filing requirements.
}
\par
\pard\qj\fi340\sl250
{\plain\f4\fs21\cf2
9. Section 1882 of the federal Social Security Act was amended in Subsection (d)(3)(A) to allow for alternative disclosure statements. The disclosure statements already in Appendix C remain. Carriers may use either disclosure statement with the requisite insurance product. However, carriers should use either the original disclosure statements or the alternative disclosure statements and not use both simultaneously.
}
\par
\pard\pagebb\qj\sl250
{\plain\f4\fs21\cf2
[Original disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.]
}
\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw40\brdrcf2\clbrdrb\brdrs\brdrw40\brdrcf2\clbrdrl\brdrs\brdrw40\brdrcf2\clbrdrr\brdrs\brdrw40\brdrcf2\cellx7220
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
IMPORTANT NOTICE TO PERSONS ON MEDICARE
}
\par
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS
}
\cell
\row
\pard\qc\sl250
{\plain\f4\fs21\cf2
This is not Medicare Supplement Insurance
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This insurance duplicates Medicare benefits when it pays:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Hospital or medical expenses up to the maximum stated in the policy
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare generally pays for most or all of these expenses.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Hospitalization
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Physician services
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
[Outpatient Prescription Drugs if you are enrolled in Medicare Part D]
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Other approved items and services
}
\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw40\brdrcf2\clbrdrb\brdrs\brdrw40\brdrcf2\clbrdrl\brdrs\brdrw40\brdrcf2\clbrdrr\brdrs\brdrw40\brdrcf2\cellx7220
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
Before You Buy This Insurance
}
\cell
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\par
\trowd\trleft0
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\clpadfb3\clpadb80
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{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
Check the coverage in all health insurance policies you already have.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For more information about Medicare and Medicare Supplement insurance, review the
}
{\plain\f4\fs18\i\cf2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs18\cf2
, available from the insurance company.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP).
}
\cell
\row
\pard\sb180\qj\sl250
{\plain\f4\fs21\cf2
Drafting Note: Insurers insert reference to: Outpatient Prescription Drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
}
\par
\pard\pagebb\qj\sl250
{\plain\f4\fs21\cf2
[Original disclosure statement for policies that provide benefits for specified limited services.]
}
\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw40\brdrcf2\clbrdrb\brdrs\brdrw40\brdrcf2\clbrdrl\brdrs\brdrw40\brdrcf2\clbrdrr\brdrs\brdrw40\brdrcf2\cellx7220
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
IMPORTANT NOTICE TO PERSONS ON MEDICARE
}
\par
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS
}
\cell
\row
\pard\qc\sl250
{\plain\f4\fs21\cf2
This is not Medicare Supplement Insurance
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This insurance duplicates Medicare benefits when:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Any of the services covered by the policy are also covered by Medicare
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Hospitalization
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Physician services
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
[Outpatient Prescription Drugs if you are enrolled in Medicare Part D]
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Other approved items and services
}
\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw40\brdrcf2\clbrdrb\brdrs\brdrw40\brdrcf2\clbrdrl\brdrs\brdrw40\brdrcf2\clbrdrr\brdrs\brdrw40\brdrcf2\cellx7220
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
Before You Buy This Insurance
}
\cell
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\par
\trowd\trleft0
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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\clvertalt
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{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
Check the coverage in all health insurance policies you already have.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For more information about Medicare and Medicare Supplement insurance, review the
}
{\plain\f4\fs18\i\cf2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs18\cf2
, available from the insurance company.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP).
}
\cell
\row
\pard\sb180\qj\sl250
{\plain\f4\fs21\cf2
Drafting Note: Insurers insert reference to: Outpatient Prescription Drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
}
\par
\pard\pagebb\qj\sl250
{\plain\f4\fs21\cf2
[Original disclosure statement for policies that reimburse expenses incurred for specified diseases or other specified impairments. This includes expense-incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions.]
}
\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw40\brdrcf2\clbrdrb\brdrs\brdrw40\brdrcf2\clbrdrl\brdrs\brdrw40\brdrcf2\clbrdrr\brdrs\brdrw40\brdrcf2\cellx7220
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
IMPORTANT NOTICE TO PERSONS ON MEDICARE
}
\par
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS
}
\cell
\row
\pard\qc\sl250
{\plain\f4\fs21\cf2
This is not Medicare Supplement Insurance
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This insurance duplicates Medicare benefits when it pays:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Hospital or medical expenses up to the maximum stated in the policy
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare generally pays for most or all of these expenses.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Hospitalization
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Physician services
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Hospice
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
[Outpatient Prescription Drugs if you are enrolled in Medicare Part D]
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Other approved items and services
}
\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw40\brdrcf2\clbrdrb\brdrs\brdrw40\brdrcf2\clbrdrl\brdrs\brdrw40\brdrcf2\clbrdrr\brdrs\brdrw40\brdrcf2\cellx7220
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
Before You Buy This Insurance
}
\cell
\row
\pard\plain\f0\fs20
\par
\trowd\trleft0
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\cellx8640
\pard\intbl\sb45\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
Check the coverage in all health insurance policies you already have.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For more information about Medicare and Medicare Supplement insurance, review the
}
{\plain\f4\fs18\i\cf2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs18\cf2
, available from the insurance company.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP).
}
\cell
\row
\pard\sb180\qj\sl250
{\plain\f4\fs21\cf2
Drafting Note: Insurers insert reference to: Outpatient Prescription Drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
}
\par
\pard\pagebb\qj\sl250
{\plain\f4\fs21\cf2
[Original disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.]
}
\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw40\brdrcf2\clbrdrb\brdrs\brdrw40\brdrcf2\clbrdrl\brdrs\brdrw40\brdrcf2\clbrdrr\brdrs\brdrw40\brdrcf2\cellx7220
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
IMPORTANT NOTICE TO PERSONS ON MEDICARE
}
\par
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS
}
\cell
\row
\pard\qc\sl250
{\plain\f4\fs21\cf2
This is not Medicare Supplement Insurance
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This insurance duplicates Medicare benefits because Medicare generally pays for most of the expenses for the diagnosis and treatment of the specific conditions or diagnoses named in the policy.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Hospitalization
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Physician services
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Hospice
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
[Outpatient Prescription Drugs if you are enrolled in Medicare Part D]
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Other approved items and services
}
\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw40\brdrcf2\clbrdrb\brdrs\brdrw40\brdrcf2\clbrdrl\brdrs\brdrw40\brdrcf2\clbrdrr\brdrs\brdrw40\brdrcf2\cellx7220
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
Before You Buy This Insurance
}
\cell
\row
\pard\plain\f0\fs20
\par
\trowd\trleft0
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
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{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
Check the coverage in all health insurance policies you already have.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For more information about Medicare and Medicare Supplement insurance, review the
}
{\plain\f4\fs18\i\cf2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs18\cf2
, available from the insurance company.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP).
}
\cell
\row
\pard\sb180\qj\sl250
{\plain\f4\fs21\cf2
Drafting Note: Insurers insert reference to: Outpatient Prescription Drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
}
\par
\pard\pagebb\qj\sl250
{\plain\f4\fs21\cf2
[Original disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.]
}
\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw40\brdrcf2\clbrdrb\brdrs\brdrw40\brdrcf2\clbrdrl\brdrs\brdrw40\brdrcf2\clbrdrr\brdrs\brdrw40\brdrcf2\cellx7220
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
IMPORTANT NOTICE TO PERSONS ON MEDICARE
}
\par
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS
}
\cell
\row
\pard\qc\sl250
{\plain\f4\fs21\cf2
This is not Medicare Supplement Insurance
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This insurance duplicates Medicare benefits when:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Any expenses or services covered by the policy are also covered by Medicare
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare generally pays for most or all of these expenses
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Hospitalization
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Physician services
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
[Outpatient Prescription Drugs if you are enrolled in Medicare Part D]
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Hospice
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Other approved items and services
}
\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw40\brdrcf2\clbrdrb\brdrs\brdrw40\brdrcf2\clbrdrl\brdrs\brdrw40\brdrcf2\clbrdrr\brdrs\brdrw40\brdrcf2\cellx7220
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
Before You Buy This Insurance
}
\cell
\row
\pard\plain\f0\fs20
\par
\trowd\trleft0
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\cellx8640
\pard\intbl\sb45\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
Check the coverage in all health insurance policies you already have.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For more information about Medicare and Medicare Supplement insurance, review the
}
{\plain\f4\fs18\i\cf2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs18\cf2
, available from the insurance company.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP).
}
\cell
\row
\pard\sb180\qj\sl250
{\plain\f4\fs21\cf2
Drafting Note: Insurers insert reference to: Outpatient Prescription Drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
}
\par
\pard\pagebb\qj\sl250
{\plain\f4\fs21\cf2
[Original disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis.]
}
\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw40\brdrcf2\clbrdrb\brdrs\brdrw40\brdrcf2\clbrdrl\brdrs\brdrw40\brdrcf2\clbrdrr\brdrs\brdrw40\brdrcf2\cellx7220
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
IMPORTANT NOTICE TO PERSONS ON MEDICARE
}
\par
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS
}
\cell
\row
\pard\qc\sl250
{\plain\f4\fs21\cf2
This is not Medicare Supplement Insurance
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This insurance duplicates Medicare benefits when:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Any expenses or services covered by the policy are also covered by Medicare; or
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
It pays the fixed dollar amount stated in the policy and Medicare covers the same event
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare generally pays for most or all of these expenses.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Hospitalization
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Physician services
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Hospice care
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
[Outpatient Prescription Drugs if you are enrolled in Medicare Part D]
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Other approved items and services
}
\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
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\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
Before You Buy This Insurance
}
\cell
\row
\pard\plain\f0\fs20
\par
\trowd\trleft0
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\sb45\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
Check the coverage in all health insurance policies you already have.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For more information about Medicare and Medicare Supplement insurance, review the
}
{\plain\f4\fs18\i\cf2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs18\cf2
, available from the insurance company.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP).
}
\cell
\row
\pard\sb180\qj\sl250
{\plain\f4\fs21\cf2
Drafting Note: Insurers insert reference to: Outpatient Prescription Drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
}
\par
\pard\pagebb\qj\sl250
{\plain\f4\fs21\cf2
[Original disclosure statement for other health insurance policies not specifically identified in the preceding statements.]
}
\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
\clvertalt
\clbrdrt\brdrs\brdrw40\brdrcf2\clbrdrb\brdrs\brdrw40\brdrcf2\clbrdrl\brdrs\brdrw40\brdrcf2\clbrdrr\brdrs\brdrw40\brdrcf2\cellx7220
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
IMPORTANT NOTICE TO PERSONS ON MEDICARE
}
\par
\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS
}
\cell
\row
\pard\qc\sl250
{\plain\f4\fs21\cf2
This is not Medicare Supplement Insurance
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This insurance duplicates Medicare benefits when it pays:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
The benefits stated in the policy and coverage for the same event is provided by Medicare
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare generally pays for most or all of these expenses.
}
\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Hospitalization
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Physician services
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Hospice
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
[Outpatient Prescription Drugs if you are enrolled in Medicare Part D]
}
\par
\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
}
{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Other approved items and services
}
\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
\clpadfb3\clpadb80
\clpadfl3\clpadl80
\clpadfr3\clpadr80
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\pard\intbl\qc\li80\ri80\sl220
{\plain\f4\fs20\cf2
Before You Buy This Insurance
}
\cell
\row
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\par
\trowd\trleft0
\clpadft3\clpadt80
\clpadfb3\clpadb80
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{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
Check the coverage in all health insurance policies you already have.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For more information about Medicare and Medicare Supplement insurance, review the
}
{\plain\f4\fs18\i\cf2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs18\cf2
, available from the insurance company.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP).
}
\cell
\row
\pard\sb180\qj\sl250
{\plain\f4\fs21\cf2
Drafting Note: Insurers insert reference to: Outpatient Prescription Drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
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{\plain\f4\fs21\cf2
[Alternative disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.]
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IMPORTANT NOTICE TO PERSONS ON MEDICARE
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THIS IS NOT MEDICARE SUPPLEMENT INSURANCE
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Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
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{\plain\f4\fs21\cf2
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
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Medicare generally pays for most or all of these expenses.
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Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
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\u9679?
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Hospitalization
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\u9679?
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\u9679?
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[Outpatient Prescription Drugs if you are enrolled in Medicare Part D]
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\u9679?
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\tab
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Other approved items and services
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This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
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Before You Buy This Insurance
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\u8730?
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Check the coverage in all health insurance policies you already have.
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\u8730?
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\tab
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For more information about Medicare and Medicare Supplement insurance, review the
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Guide to Health Insurance for People with Medicare
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, available from the insurance company.
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\u8730?
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\tab
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For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP).
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{\plain\f4\fs21\cf2
Drafting Note: Insurers insert reference to: Outpatient Prescription Drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
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{\plain\f4\fs21\cf2
[Alternative disclosure statement for policies that provide benefits for specified limited services.]
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IMPORTANT NOTICE TO PERSONS ON MEDICARE
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THIS IS NOT MEDICARE SUPPLEMENT INSURANCE
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Some health care services paid for by Medicare may also trigger the payment of benefits under this policy.
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{\plain\f4\fs21\cf2
This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
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{\plain\f4\fs21\cf2
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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Hospitalization
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{\plain\f4\fs21\cf2\ulc2
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{\plain\f4\fs21\cf2
\u9679?
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Physician services
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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\tab
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[Outpatient Prescription Drugs if you are enrolled in Medicare Part D]
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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\tab
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Other approved items and services
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{\plain\f4\fs21\cf2
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
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Before You Buy This Insurance
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\u8730?
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\tab
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Check the coverage in all health insurance policies you already have.
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{\plain\f4\fs18\cf2
\u8730?
}
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\tab
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For more information about Medicare and Medicare Supplement insurance, review the
}
{\plain\f4\fs18\i\cf2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs18\cf2
, available from the insurance company.
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{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
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{\plain\f4\fs18\cf2
For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP).
}
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{\plain\f4\fs21\cf2
Drafting Note: Insurers insert reference to: Outpatient Prescription Drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
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\par
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{\plain\f4\fs21\cf2
[Alternative disclosure statement for policies that reimburse expenses incurred for specified diseases or other specified impairments. This includes expense-incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions.]
}
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\par
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IMPORTANT NOTICE TO PERSONS ON MEDICARE
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THIS IS NOT MEDICARE SUPPLEMENT INSURANCE
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Some health care services paid for by Medicare may also trigger the payment of benefits from this policy. Medicare generally pays for most or all of these expenses.
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{\plain\f4\fs21\cf2
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
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{\plain\f4\fs21\cf2
Medicare generally pays for most or all of these expenses.
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{\plain\f4\fs21\cf2
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
}
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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\tab
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{\plain\f4\fs21\cf2
Hospitalization
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{\plain\f4\fs21\cf2\ulc2
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{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
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{\plain\f4\fs21\cf2
Physician services
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
\tab
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{\plain\f4\fs21\cf2
Hospice
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
\tab
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{\plain\f4\fs21\cf2
[Outpatient Prescription Drugs if you are enrolled in Medicare Part D]
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
\tab
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{\plain\f4\fs21\cf2
Other approved items and services
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{\plain\f4\fs21\cf2
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
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\pard\plain\f0\fs20
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Before You Buy This Insurance
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\u8730?
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\tab
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{\plain\f4\fs18\cf2
Check the coverage in all health insurance policies you already have.
}
\par
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{\plain\f4\fs18\cf2
\u8730?
}
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\tab
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For more information about Medicare and Medicare Supplement insurance, review the
}
{\plain\f4\fs18\i\cf2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs18\cf2
, available from the insurance company.
}
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{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
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{\plain\f4\fs18\cf2
For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP).
}
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{\plain\f4\fs21\cf2
Drafting Note: Insurers insert reference to: Outpatient Prescription Drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
}
\par
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{\plain\f4\fs21\cf2
[Alternative disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.]
}
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IMPORTANT NOTICE TO PERSONS ON MEDICARE
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{\plain\f4\fs20\cf2
THIS IS NOT MEDICARE SUPPLEMENT INSURANCE
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Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
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{\plain\f4\fs21\cf2
This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
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{\plain\f4\fs21\cf2
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
}
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
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{\plain\f4\fs21\cf2
Hospitalization
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
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{\plain\f4\fs21\cf2
Physician services
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
\tab
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{\plain\f4\fs21\cf2
Hospice
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\pard\qj\sl250\tx340\tx680
{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
\tab
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{\plain\f4\fs21\cf2
[Outpatient Prescription Drugs if you are enrolled in Medicare Part D]
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
\tab
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{\plain\f4\fs21\cf2
Other approved items and services
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{\plain\f4\fs21\cf2
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
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\par
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Before You Buy This Insurance
}
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{\plain\f4\fs18\cf2
\u8730?
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\tab
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{\plain\f4\fs18\cf2
Check the coverage in all health insurance policies you already have.
}
\par
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{\plain\f4\fs18\cf2
\u8730?
}
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\tab
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For more information about Medicare and Medicare Supplement insurance, review the
}
{\plain\f4\fs18\i\cf2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs18\cf2
, available from the insurance company.
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{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
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{\plain\f4\fs18\cf2
For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP).
}
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{\plain\f4\fs21\cf2
Drafting Note: Insurers insert reference to: Outpatient Prescription Drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
}
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\pard\pagebb\qj\sl250
{\plain\f4\fs21\cf2
[Alternative disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.]
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IMPORTANT NOTICE TO PERSONS ON MEDICARE
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{\plain\f4\fs20\cf2
THIS IS NOT MEDICARE SUPPLEMENT INSURANCE
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{\plain\f4\fs21\cf2
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
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{\plain\f4\fs21\cf2
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
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\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare generally pays for most or all of these expenses.
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\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
}
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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\tab
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{\plain\f4\fs21\cf2
Hospitalization
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\tab
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\u9679?
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\tab
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{\plain\f4\fs21\cf2
Physician services
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
\tab
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{\plain\f4\fs21\cf2
Hospice
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
\tab
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[Outpatient Prescription Drugs if you are enrolled in Medicare Part D]
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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\tab
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Other approved items and services
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This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
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Before You Buy This Insurance
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\u8730?
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Check the coverage in all health insurance policies you already have.
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\u8730?
}
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\tab
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For more information about Medicare and Medicare Supplement insurance, review the
}
{\plain\f4\fs18\i\cf2
Guide to Health Insurance for People with Medicare
}
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, available from the insurance company.
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\u8730?
}
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\tab
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For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP).
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Drafting Note: Insurers insert reference to: Outpatient Prescription Drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
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{\plain\f4\fs21\cf2
[Alternative disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis.]
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IMPORTANT NOTICE TO PERSONS ON MEDICARE
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THIS IS NOT MEDICARE SUPPLEMENT INSURANCE
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Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
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This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
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Medicare generally pays for most or all of these expenses.
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\tab
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\u9679?
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Hospitalization
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\u9679?
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\tab
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Physician services
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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Hospice care
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\u9679?
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[Outpatient Prescription Drugs if you are enrolled in Medicare Part D]
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{\plain\f4\fs21\cf2\ulc2
\tab
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\u9679?
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Other approved items and services
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{\plain\f4\fs21\cf2
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
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Before You Buy This Insurance
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\u8730?
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\tab
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{\plain\f4\fs18\cf2
Check the coverage in all health insurance policies you already have.
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{\plain\f4\fs18\cf2
\u8730?
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\tab
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For more information about Medicare and Medicare Supplement insurance, review the
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Guide to Health Insurance for People with Medicare
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, available from the insurance company.
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\u8730?
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{\plain\f4\fs18\cf2
For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP).
}
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{\plain\f4\fs21\cf2
Drafting Note: Insurers insert reference to: Outpatient Prescription Drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
}
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{\plain\f4\fs21\cf2
[Alternative disclosure statement for other health insurance policies not specifically identified in the preceding statements.]
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IMPORTANT NOTICE TO PERSONS ON MEDICARE
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{\plain\f4\fs20\cf2
THIS IS NOT MEDICARE SUPPLEMENT INSURANCE
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Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
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{\plain\f4\fs21\cf2
This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
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\pard\qj\sl250
{\plain\f4\fs21\cf2
Medicare generally pays for most or all of these expenses.
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{\plain\f4\fs21\cf2
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
}
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
Hospitalization
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{\plain\f4\fs21\cf2\ulc2
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{\plain\f4\fs21\cf2
\u9679?
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\tab
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{\plain\f4\fs21\cf2
Physician services
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
\tab
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{\plain\f4\fs21\cf2
Hospice
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{\plain\f4\fs21\cf2\ulc2
\tab
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{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
[Outpatient Prescription Drugs if you are enrolled in Medicare Part D]
}
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{\plain\f4\fs21\cf2\ulc2
\tab
}
{\plain\f4\fs21\cf2
\u9679?
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{\plain\f4\fs21\cf2
\tab
}
{\plain\f4\fs21\cf2
Other approved items and services
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\par
\pard\qj\sl250
{\plain\f4\fs21\cf2
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
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\par
\pard\plain\f0\fs20
\par
\trowd\trleft20
\clpadft3\clpadt80
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{\plain\f4\fs20\cf2
Before You Buy This Insurance
}
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{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
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{\plain\f4\fs18\cf2
Check the coverage in all health insurance policies you already have.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For more information about Medicare and Medicare Supplement insurance, review the
}
{\plain\f4\fs18\i\cf2
Guide to Health Insurance for People with Medicare
}
{\plain\f4\fs18\cf2
, available from the insurance company.
}
\par
\pard\intbl\li530\ri80\fi-450\sl200\tx530
{\plain\f4\fs18\cf2
\u8730?
}
{\plain\f4\fs18\cf2
\tab
}
{\plain\f4\fs18\cf2
For help in understanding your health insurance, contact your state insurance department or your state health insurance assistance program (SHIP).
}
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{\plain\f4\fs21\cf2
Drafting Note: Insurers insert reference to: Outpatient Prescription Drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
}
\par
\pard\pagebb\qj\fi340\sl250
{\plain\f4\fs21\cf2
These rules are intended to implement Iowa Code chapters
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/ico/chapter/507B.pdf"}{\fldrslt
{\plain\f4\fs21\cf2
507B
}
}}
{\plain\f4\fs21\cf2
and
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/ico/chapter/514D.pdf"}{\fldrslt
{\plain\f4\fs21\cf2
514D
}
}}
{\plain\f4\fs21\cf2
.
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed 11/5/81, Notice 9/2/81—published 11/25/81, effective 12/31/81
}
{\plain\f4\fs11\super\up13\cf2
1
}
{\plain\f4\fs21\cf2
]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Editorially transferred from [510] to [191] IAC Supp. 10/22/86; see
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/bulletin/07-30-1986.pdf"}{\fldrslt
{\plain\f4\fs21\cf2
IAB 7/30/86
}
}}
{\plain\f4\fs21\cf2
]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed emergency 12/9/88—published 12/28/88, effective 12/31/88]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed 8/31/90, Notice 7/25/90—published 9/19/90, effective 12/1/90]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed emergency 1/18/91—published 2/6/91, effective 1/18/91]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed 4/26/91, Notice 2/6/91—published 5/15/91, effective 6/19/91]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed 10/25/91, Notice 9/18/91—published 11/13/91, effective1/1/92]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed 6/4/92, Notice 4/1/92—published 6/24/92, effective 7/29/92]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed 5/2/94, Notice 3/16/94—published 5/25/94, effective 7/1/94]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed 2/8/96, Notice 1/3/96—published 2/28/96, effective 4/3/96]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed without Notice 5/14/96—published 6/5/96, effective 7/10/96]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed emergency 8/18/98—published 9/9/98, effective 8/18/98]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed emergency 2/3/99—published 2/24/99, effective 2/3/99]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed emergency 1/5/01—published 1/24/01, effective 1/5/01]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed 11/21/01, Notice 10/17/01—published 12/12/01, effective 1/16/02]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed 12/15/04, Notice 10/27/04—published 1/5/05, effective 2/9/05]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed without Notice 2/11/05—published 3/2/05, effective 4/6/05]
}
\par
\pard\qc\sl250
{\plain\f4\fs21\cf2
[Filed 3/9/07, Notice 1/31/07—published 3/28/07, effective 5/2/07]
}
\par
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{\plain\f4\fs21\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7964B.pdf"}{\fldrslt
{\plain\f4\fs21\cf2
Filed ARC 7964B
}
}}
{\plain\f4\fs21\cf2
(
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/7795B.pdf"}{\fldrslt
{\plain\f4\fs21\cf2
Notice ARC 7795B
}
}}
{\plain\f4\fs21\cf2
, IAB 5/20/09), IAB 7/15/09, effective 8/19/09]
}
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{\plain\f4\fs21\cf2
[
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/3682C.pdf"}{\fldrslt
{\plain\f4\fs21\cf2
Filed ARC 3682C
}
}}
{\plain\f4\fs21\cf2
(
}
{\field{\*\fldinst HYPERLINK "https://www.legis.iowa.gov/docs/aco/arc/3571C.pdf"}{\fldrslt
{\plain\f4\fs21\cf2
Notice ARC 3571C
}
}}
{\plain\f4\fs21\cf2
, IAB 1/17/18), IAB 3/14/18, effective 4/18/18]
}
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{\listtext
{\plain\f4\fs12\super\cf2
1
}
{\plain\f4\fs12\super\cf2
\tab
}
}
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Effective date of 12/31/81 delayed 70 days by Administrative Rules Review Committee.
}
\par
\pard\sect
}