DEPARTMENT OF INSURANCE

Statutory Authority: 18 Delaware Code, Section 314, 2503 (18 Del.C. 314, 2503)

In the

Matter of: |

The Amendment of Insurance | Docket Number: 99-12

Department Regulation No. 41. |

FINAL

ORDER

Medicare Supplement Insurance Minimum Standards,

DONNA LEE WILLIAMS

Insurance CommissionerState of Delaware

PROPOSED ORDER AND RECOMMENDATION

The following is the Hearing Officer’s Proposed Order and Recommendation in the above-captioned matter.

I. Summary of the Evidence

The evidence in this matter consists of the following:

II. Findings of Fact and Conclusions of Law

Based on the evidence received in this matter, I find that:

III. Recommendation

Fred A. Townsend III, Hearing Officer

REGULATION 41

MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS

January 1, 1992

Amended Effective April 9, 1992

Amended Effective April 1, 1996

Amended Effective November 20, 1998

Table of Contents

Section 1. Purpose

Section 2. Authority

Section 3. Applicability Scope

Section 4. Definitions

Section 5. Policy Definitions and Terms

Section 6. Policy Provisions

Section 7. Minimum Benefit Standards for Policies or Certificates Issued for Delivery Prior to January 1, 1992

Section 8. Minimum Benefit Standards for Policies or Certificates Issued for Delivery After January 1, 1992

Section 9. Standard Medicare Supplement Benefit Plans

Section 10. Medicare Select Policies

Section 11. Open Enrollment

Section 12. Guaranteed Issue for Eligible Persons

Section 1213. Standards for Claims Payment

Section 1314. Loss Ratio Standards and Refund or Credit of Premiums

Section 1415. Filing and approval of Policies and Certificates and Premium Rates

Section 1516. Permitted Compensation Arrangements

Section 1617. Required Disclosure Provisions

Section 1718. Requirements for Application Forms and Replacement Coverage

Section 1819. Filing Requirements for Advertising

Section 1920. Standards for Marketing

Section 2021. Appropriateness of Recommended Purchase and Excessive Insurance

Section 2122. Reporting of Multiple Policies

Section 2322. Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies or Certificates

Section 2324. Separability

Section 2425. Effective Date

Appendix A Reporting Form for Calculation of Loss Ratios

Appendix B Form for Reporting Duplicate Policies

Appendix C Disclosure Statements

Section 1. Purpose

The purpose of this regulation is to provide for the reasonable standardization of coverage and simplification of terms and benefits of Medicare supplement policies or contracts; 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.

Section 2. Authority

Section 3. Applicability and Scope

Section 4. Definitions

For purposes of this regulation:

Section 5. Policy Definitions and Terms

Section 6. Policy Provisions

Section 7. Minimum Benefit Standards for Policies or Certificates Issued for Delivery Prior to January 1, 1992

Section 8. Benefit Standards for Policies or Certificates Issued or delivered on or after January 1, 1992.

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 of it:

Reimbursement shall be for the actual charges up to one hundred (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 one hundred twenty dollars ($120) annually under this benefit. This benefit shall not include payment for any procedure covered by Medicare.

Section 9. Standard Medicare Supplement Benefit Plans

Section 10. Medicare Select Policies and Certificates:

Editor's Note: Section 10, Medicare Select Policies and Certificates, of this Regulation is effective October 6, 1995, pursuant to President Clinton's signing H.R. 483 on July 7, 1995, permitting Medicare Select policies to be offered in all fifty states, and the Delaware Insurance Commissioner's amending this regulation pursuant to 29 Del. C. 10013(b)(5).

Section 11. Open Enrollment

Section 12. Guaranteed Issue for Eligible Persons

A. Guaranteed Issue

The Medicare supplement policy to which eligible persons are entitled under:

[1 Filing deadline set by adoption of Life and Health Bulletin No. 21 on October 6, 1998.]

Section 13. Standards for Claims Payment

Section 143. Loss Ratio Standards and Refund or Credit of Premium

Section 154. Filing and Approval of Policies and Certificates and Premium Rates

Section 165. Permitted Compensation Arrangements

Section 176. Required Disclosure Provisions

[COMPANY NAME]

Outline of Medicare Supplement Coverage Cover Page

Benefit Plan(s) _____ _____ [insert letters of plan(s) being offered]

Medicare supplement insurance can be sold in onlysix ten standard plans, plus two high deductible plans. This chart shows the benefits included in each plan. Every company must make available [Plan "A"] [Plans "A, B, C, and F"]. Some plans may not be available in your state. [Plans other than A, B, C and F may be offered on a voluntary basis.]

BASIC BENEFITS: Included in All Plans.

Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

Medical Expenses: Part B coinsurance ([generally] 20% of Medicare-approved expenses), [in the case of hospital outpatient department services] or, under a prospective payment system, applicable copayments.

Blood: First three pints of blood each year.

A

B

C

D

E

F F4

G

H

I

J J4

Basic Benefits

Basic Benefits

Basic Benefits

Basic Benefits

Basic Benefits

Basic Benefits

Basic Benefits

Basic Benefits

Basic Benefits

Basic Benefits

   

Skilled Nursing

Co-Insuran ce

Skilled Nursing Co-Insuran ce

Skilled Nursing Co-Insurance

Skilled Nursing Co-Insurance

Skilled Nursing Co-Insurance

Skilled Nursing Co-Insurance

Skilled Nursing Co-Insurance

Skilled Nursing Co-Insurance

 

Part A Deductibl e

Part A Deducti ble

Part A Deducti ble

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductibl e

Part A Deductible

Part A Deductible

   

Part B Deducti ble

   

Part B Deductible

     

Part B Deductible

         

Part B Excess (100%)

Part B Excess (80%)

 

Part B Excess (100%)

Part B Excess (100%)

   

Foreign Travel Emerge ncy

Foreign Travel Emerge ncy

Foreign Travel Emergency

Foreign Travel Emergency

Foreign Travel Emergency

Foreign Travel Emergenc y

Foreign Travel Emergency

Foreign Travel Emergency

     

At-Home Recover y

   

At-Home Recovery

 

At-Home Recovery

At-Home Recovery

             

Basic Drugs ($1,250 Limit)

Basic Drugs ($1,250 Limit)

Extended Drugs

($3,000 Limit)

       

Preventive Care

       

Preventive Care

PREMIUM INFORMATION [Boldface Type]

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

DISCLOSURES [Boldface Type]

Use this outline to compare benefits and premiums among policies.

READ YOUR POLICY VERY CAREFULLY [Boldface Type]

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

RIGHT TO RETURN POLICY [Boldface Type]

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

POLICY REPLACEMENT [Boldface Type]

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

NOTICE [Boldface Type]

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

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

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult "The Medicare Handbook" for more details.

COMPLETE ANSWERS ARE VERY IMPORTANT [Boldface Type]

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

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

[Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this regulation. An issuer may use additional benefit plan designations on these charts pursuant Section 9D of this Regulation.]

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

PLAN A

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

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

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous service and supplies

First 60 days

61st thru 90th day

91st day and after:

- While using 60 lifetime

reserve days

- Once lifetime reserve days

are used:

-Additional 365 days

- Beyond the Additional

365 days

All but $[764]

All but $[191] a day

All but $[382] a day

$0

$0

$0

$[191 a day

$[382] a day

100% of Medicare Eligible Expenses

$0

$716 (Part A Deductible)

$0

$0

$0**

All Costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

- First 20 days

- 21st thru 100th day

- 101st day and after

All approved amounts

All but $[95.50] a day

$0

$0

$0

$0

$0

Up to $[95.50] a day

All costs

BLOOD

First 3 pints

Additional

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsur-ance for out-patient drugs and in-patient respite care

$0

Balance

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

PLAN A

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

*Once you have been billed $100 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES — IN OR OUT OF THE HOSPITAL AND OUTPATIENT TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

- First 100 days of Medicare

Approved Amounts*

- Remainder of Medicare Approved

Amounts

- Part B Excess Charges (Above

Medicare Approved Amounts)

$0

Generally 80%

$0

$0

Generally 20%

$0

$100 (Part B Deductible)

$0

All Costs

BLOOD

- First 3 pints

- Next $100 of Medicare Approved

Amounts*

- Remainder of Medicare Approved

Amounts

$0

$0

80%

All Costs

$0

20%

$0

$100 (Part B Deductible)

$0

CLINICAL LABORATORY SERVICES — BLOOD TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

ARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES

— Medically necessary skilled care

services and medical supplies

— Durable medical equipment

First $100 of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

100%

$0

80%

$0

$0

20%

$0

$100 (Part B Deductible)

$0

PLAN B

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

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

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous service and supplies:

First 60 days

61st thru 90th day

91st day and after:

- While using 60 lifetime

reserve days

- Once lifetime reserve days

are used:

- Additional 365 days

- Beyond the Additional

365 days

All but $[764]

All but $[191] a day

All but $[382] a day

$0

$0

$[764] (Part A Deductible)

$[191] a day

$[382] a day

100% of Medicare Eligible Expenses

$0

$0

$0

$0

$0**

All Costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

- First 20 days

- 21st thru 100th day

- 101st day and after

All approved amounts

All but $[95.50] a day

$0

$0

$0

$0

$0

Up to $[95.50] a day

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsurance for out- patient drugs and in-patient respite care

$0

Balance

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

PLAN B

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

*Once you have been billed $100 of Medicare-Approved Amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES — IN OR OUT OF THE HOSPITAL AND OUT-PATIENT TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

- First 100 days of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

- Part B Excess Charges

(Above Medicare Approved

Amounts)

$0

Generally 80%

$0

$0

Generally 20%

$0

$100 (Part B Deductible)

$0

All Costs

BLOOD

- First 3 pints

- Next $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

$0

$0

80%

All Costs

$0

20%

$0

$100 (Part B Deductible)

$0

CLINICAL LABORATORY SERVICES — BLOOD TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES

Medically necessary skilled care

services and medical supplies

Durable medical equipment

First $100 of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

100%

$0

80%

$0

$0

20%

$0

$100 (Part B Deductible)

$0

PLAN C

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

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

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscel-laneous service and supplies:

First 60 days

61st thru 90th day

91st day and after:

- While using 60 lifetime

reserve days

- Once lifetime reserve days

are used:

- Additional 365 days

- Beyond the Additional

365 days

All but $7[64]

All but $[191] a day

All but $3[82] a day

$0

$0

$7[64] (Part A Deductible)

$[191] a day

$3[82] a day

100% of Medicare Eligible Expenses

$0

$0

$0

$0

$0**

All Costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

- First 20 days

- 21st thru 100th day

- 101st day and after

All approved amounts

All but $[95.50] a day

$0

$0

Up to $[95.50] a day

$0

$0

$0

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsu-rance for out-patient drugs and in-patient respite care

$0

Balance

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

PLAN C

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

*Once you have been billed $100 of Medicare-Approved Amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES — IN OR OUT OF THE HOSPITAL AND OUT-PATIENT TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

- First 100 days of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

- Part B Excess Charges

(Above Medicare Approved

Amounts)

$0

Generally 80%

$0

$100 (Part B deductible)

Generally 20%

$0

$0

$0

All Costs

BLOOD

- First 3 pints

- Next $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

$0

$0

80%

All Costs

$100 (Part B deductible)

20%

$0

$0

$0

CLINICAL LABORATORY SERVICES — BLOOD TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES

Medically necessary skilled care

services and medical supplies

Durable medical equipment

First $100 of Medicare

Approved Amounts*

Remainder of Medicare

Approved Amounts

100%

$0

80%

$0

$100 (Part B deductible)

20%

$0

$0

$0

OTHER BENEFITS — NOT COVERED BY MEDICARE

FOREIGN TRAVEL — NOT COVERED BY MEDICARE Medically necessary emer-gency care services beginning during the first 60 days of each trip outside the USA

- First $250 each calendar year

- Remainder of Charges

$0

$0

$0

80% to a lifetime maximum benefit of $50,000

$250

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

PLAN D

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

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

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscel-laneous service and supplies

First 60 days

61st thru 90th day

91st day and after:

- While using 60 lifetime

reserve days

- Once lifetime reserve days are used:

- Additional 365 days

- Beyond the Additional 365

days

All but $[764]

All but $[191] a day

All but $[382] a day

$0

$0

$[764] (Part A Deductible)

$[191] a day

$[382] a day

100% of Medicare Eligible Expenses

$0

$0

$0

$0

$0**

All Costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

- First 20 days

- 21st thru 100th day

- 101st day and after

All approved amounts

All but $[95.50] a day

$0

$0

Up to $[95.50] a day

$0

$0

$0

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsurance for out-patient drugs and in-patient respite care

$0

Balance

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

PLAN D

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

*Once you have been billed $100 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES — IN OR OUT OF THE HOSPITAL AND OUT-PATIENT TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

- First 100 days of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

- Part B Excess Charges

(Above Medicare Approved

Amounts)

$0

Generally 80%

$0

$0

Generally 20%

$0

$100 (Part B Deductible)

$0

All Costs

BLOOD

- First 3 pints

- Next $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

$0

$0

80%

All Costs

$0

20%

$0

$100 (Part B Deductible)

$0

CLINICAL LABORATORY SERVICES — BLOOD TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES

— Medically necessary skilled

care services and medical

supplies

— Durable medical equipment

- First $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

100%

$0

80%

$0

$0

20%

$0

$100 (Part B Deductible)

$0

AT-HOME RECOVERY SERVICES — NOT COVERED BY MEDICARE Home care certified by your doctors, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan

— Benefit for each visit

— Number of visits covered

(must be received within 8

weeks of last Medicare

Approved visit)

— Calendar year maximum

$0

$0

$0

Actual Charges to $40 a visit

Up to the number of Medicare Approved visits, not to exceed 7 each week

$1,600

Balance

OTHER BENEFITS — NOT COVERED BY MEDICARE

FOREIGN TRAVEL — NOT COVERED BY MEDICARE

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

- First $250 each calendar year

- Remainder of Charges

$0

$0

$0

80% to a lifetime maximum benefit of $50,000

$250

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

PLAN E

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

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

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscel-laneous service and supplies

First 60 days

61st thru 90th day

91st day and after:

- While using 60 lifetime

reserve days

- Once lifetime reserve days

are used:

- Additional 365 days

- Beyond the Additional 365

days

All but $[764

All but $[191] a day

All but $[382] a day

$0

$0

$[764] (Part A Deductible)

$[191] a day

$[382] a day

100% of Medicare Eligible Expenses

$0

$0

$0

$0

$0**

All Costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

- First 20 days

- 21st thru 100th day

- 101st day and after

All approved amounts

All but $[95.50] a day

$0

$0

Up to $[95.50] a day

$0

$0

$0

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsur-ance for out-patient drugs and in-patient respite care

$0

Balance

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

PLAN E

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

*Once you have been billed $100 of Medicare Approved Amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES — IN OR OUT OF THE HOSPITAL AND OUT-PATIENT TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

- First 100 days of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

- Part B Excess Charges

(Above Medicare Approved

Amounts)

$0

Generally 80%

$0

$0

Generally 20%

$0

$100 (Part B Deductible)

$0

All Costs

BLOOD

- First 3 pints

- Next $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

$0

$0

80%

All Costs

$0

20%

$0

$100 (Part B Deductible)

$0

CLINICAL LABORATORY SERVICES — BLOOD TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES

Medically necessary skilled

care services and medical

supplies

Durable medical equipment

- First $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

100%

$0

80%

$0

$0

20%

$0

$100 (Part B Deductible)

$0

(continued)

OTHER BENEFITS — NOT COVERED BY MEDICARE

* Medicare benefits are subject to change. Please consult the

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

FOREIGN TRAVEL — NOT COVERED BY MEDICARE

Medically necessary emer-gency care services beginning during the first 60 days of each trip outside the USA

- First $250 each calendar year

- Remainder of Charges

$0

$0

$0

80% to a lifetime maximum benefit of $50,000

$250

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

*PREVENTIVE MEDICAL CARE BENEFIT — NOT COVERED BY MEDICARE ASome annual physical and preventive tests and services such as: fecal occult blood test, digital rectal exam, mammogram, hearing screening, dipstick urinalysis, diabetes screening, thyroid function test, influenza shot, tetanus and diphtheria booster and education, administered or ordered by your doctor when not covered by Medicare

- First $120 each calendar year

- Additional charges

$0

$0

$120

$0

$0

All Costs

latest Guide to Health Insurance for People with Medicare.

PLAN F or HIGH DEDUCTIBLE PLAN F

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

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

**This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year [$1500] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are [$1500]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

AFTER YOU PAY $1500 DEDUCTIBLE,** PLAN PAYS

IN ADDITION TO $1500 DEDUCTIBLE,** YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscel-laneous service and supplies

First 60 days

61st thru 90th day

91st day and after:

- While using 60 lifetime

reserve days

- Once lifetime reserve days

are used:

- Additional 365 days

- Beyond the Additional 365

days

All but $[764]

All but $[191] a day

All but $[382] a day

$0

$0

$[764] (Part A Deductible)

$[191] a day

$[382] a day

100% of Medicare Eligible Expenses

$0

$0

$0

$0

$0**

All Costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

- First 20 days

- 21st thru 100th day

- 101st day and after

All approved amounts

All but $[95.50] a day

$0

$0

Up to $[95.50] a day

$0

$0

$0

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsur-ance for out-patient drugs and in-patient respite care

$0

Balance

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

PLAN F or HIGH DEDUCTIBLE PLAN F

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

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

**This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year [$1500] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are [$1500]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

AFTER YOU PAY $1500 DEDUCTIBLE,** PLAN PAYS

AFTER YOU PAY $1500 DEDUCTIBLE,** YOU PAY

MEDICAL EXPENSES — IN OR OUT OF THE HOSPITAL AND OUT-PATIENT TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

- First 100 days of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

- Part B Excess Charges

(Above Medicare Approved

Amounts)

$0

Generally 80%

$0

$100 (Part B Deductible)

Generally 20%

100%

$0

$0

$0

BLOOD

- First 3 pints

- Next $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

$0

$0

80%

All Costs

$100 (Part B Deductible)

20%

$0

$0

$0

CLINICAL LABORATORY SERVICES — BLOOD TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

ntinued)

PLAN F or HIGH DEDUCTIBLE PLAN F (cont.)

PARTS A & B

SERVICES

MEDICARE PAYS

AFTER YOU PAY $1500 DEDUCTIBLE,** PLAN PAYS

AFTER YOU PAY $1500 DEDUCTIBLE,** YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES

Medically necessary skilled

care services and medical

supplies

Durable medical equipment

- First $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

100%

$0

80%

$0

$100 (Part B Deductible)

20%

$0

$0

$0

THER BENEFITS — NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

AFTER YOU PAY $1500 DEDUCTIBLE,** PLAN PAYS

AFTER YOU PAY $1500 DEDUCTIBLE,** YOU PAY

FOREIGN TRAVEL — NOT COVERED BY MEDICARE

Medically necessary emer-gency care services beginning during the first 60 days of each trip outside the USA

- First $250 each calendar year

- Remainder of Charges

$0

$0

$0

80% to a lifetime maximum benefit of $50,000

$250

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

PLAN G

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

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

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscel-laneous service and supplies

First 60 days

61st thru 90th day

91st day and after:

- While using 60 lifetime

reserve days

- Once lifetime reserve days

are used:

- Additional 365 days

- Beyond the Additional 365

days

All but $[764]

All but $[191] a day

All but $[382] a day

$0

$0

$[764] (Part A Deductible)

$[191] a day

$[382] a day

100% of Medicare Eligible Expenses

$0

$0

$0

$0

$0**

All Costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

- First 20 days

- 21st thru 100th day

- 101st day and after

All approved amounts

All but $[95.50] a day

$0

$0

Up to $[95.50] a day

$0

$0

$0

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsur-ance for out-patient drugs and in-patient respite care

$0

Balance

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

PLAN G

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

*Once you have been billed $100 of Medicare Approved Amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES — IN OR OUT OF THE HOSPITAL AND OUT-PATIENT TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

- First 100 days of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

- Part B Excess Charges

(Above Medicare Approved

Amounts)

$0

Generally 80%

$0

$0

Generally 20%

80%

$100 (Part B Deductible)

$0

20%

BLOOD

- First 3 pints

- Next $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

$0

$0

80%

All Costs

$0

20%

$0

$100 (Part B Deductible)

$0

CLINICAL LABORATORY SERVICES — BLOOD TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

(continued)

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES

Medically necessary skilled

care services and medical

supplies

Durable medical equipment

- First $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

100%

$0

80%

$0

$0

20%

$0

$100 (Part B Deductible)

$0

AT-HOME RECOVERY SERVICES — NOT COVERED BY MEDICARE

Home care certified by your doctors, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan

Benefit for each visit

Number of visits covered

(must be received within 8

weeks of last Medicare

Approved visit)

Calendar year maximum

$0

$0

$0

Actual Charges to $40 a visit

Up to the number of Medicare Approved visits, not to exceed 7 each week

$1,600

Balance

OTHER BENEFITS — NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

FOREIGN TRAVEL — NOT COVERED BY MEDICARE

Medically necessary emer-gency care services beginning during the first 60 days of each trip outside the USA

- First $250 each calendar year

- Remainder of Charges

$0

$0

$0

80% to a lifetime maximum benefit of $50,000

$250

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

PLAN H

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

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

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscel-laneous service and supplies

First 60 days

61st thru 90th day

91st day and after:

- While using 60 lifetime

reserve days

- Once lifetime reserve days

are used:

- Additional 365 days

- Beyond the Additional 365

days

All but $[764]

All but $[191] a day

All but $[382] a day

$0

$0

$[764] (Part A Deductible)

$[191] a day

$[382] a day

100% of Medicare Eligible Expenses

$0

$0

$0

$0

$0**

All Costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

- First 20 days

- 21st thru 100th day

- 101st day and after

All approved amounts

All but $[95.50] a day

$0

$0

Up to $[95.50] a day

$0

$0

$0

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsur-ance for out-patient drugs and in-patient respite care

$0

Balance

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

PLAN H

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

*Once you have been billed $100 of Medicare Approved Amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES — IN OR OUT OF THE HOSPITAL AND OUTPATIENT TREAT-MENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

- First 100 days of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

- Part B Excess Charges

(Above Medicare Approved

Amounts)

$0

Generally 80%

$0

$0

Generally 20%

$0

$100 (Part B Deductible)

$0

All Costs

BLOOD

- First 3 pints

- Next $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

$0

$0

80%

All Costs

$0

20%

$0

$100 (Part B Deductible)

$0

CLINICAL LABORATORY SERVICES — BLOOD TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES

Medically necessary skilled

care services and medical

supplies

Durable medical equipment

- First $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

100%

$0

80%

$0

$0

20%

$0

$100 (Part B Deductible)

$0

(continued)

PLAN H (continued)

OTHER BENEFITS — NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

FOREIGN TRAVEL — NOT COVERED BY MEDICARE

Medically necessary emer-gency care services beginning during the first 60 days of each trip outside the USA

- First $250 each calendar year

- Remainder of Charges

$0

$0

$0

80% to a lifetime maximum benefit of $50,000

$250

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

BASIC OUTPATIENT PRE-SCRIPTION DRUGS — NOT COVERED BY MEDICARE

- First $250 each calendar year

- Next $2,500 each calendar

year

- Over $2,500 each calendar

year

$0

$0

$0

$0

50% — $1,250 calendar year maximum benefit

$0

$250

50%

All Costs

PLAN I

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

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

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous service and supplies

First 60 days

61st thru 90th day

91st day and after:

- While using 60 lifetime

reserve days

- Once lifetime reserve days are used:

- Additional 365 days

- Beyond the Additional 365

days

All but $[764]

All but $[191] a day

All but $[382] a day

$0

$0

$[764] (Part A Deductible)

$[191] a day

$[382] a day

100% of Medicare Eligible Expenses

$0

$0

$0

$0

$0**

All Costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

- First 20 days

- 21st thru 100th day

- 101st day and after

All approved amounts

All but $[95.50] a day

$0

$0

Up to $[95.50] a day

$0

$0

$0

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsurance for out- patient drugs and in- patient respite care

$0

Balance

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

PLAN I

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

*Once you have been billed $100 of Medicare-Approved Amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

MEDICAL EXPENSES — IN OR OUT OF THE HOSPITAL AND OUT-PATIENT TREATMENT, such as Physician's services, in-patient and out-patient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

- First 100 days of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

- Part B Excess Charges

(Above Medicare Approved

Amounts)

$0

Generally 80%

$0

$0

Generally 20%

100%

$100 (Part B Deductible)

$0

$0

BLOOD

- First 3 pints

- Next $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

$0

$0

80%

All Costs

$0

20%

$0

$100 (Part B Deductible)

$0

CLINICAL LABORATORY SERVICES — BLOOD TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

(continued)

PLAN I (continued)

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES

— Medically necessary skilled care services and medical supplies

— Durable medical equipment

- First $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

100%

$0

80%

$0

$0

20%

$0

$100 (Part B Deductible)

$0

AT-HOME RECOVERY SERVICES — NOT COVERED BY MEDICARE

Home care certified by your doctors, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan

— Benefit for each visit

— Number of visits covered

(must be received within 8

weeks of last Medicare

Approved visit)

— Calendar year maximum

$0

$0

$0

Actual Charges to $40 a visit

Up to the number of Medicare Approved visits, not to exceed 7 each week

$1,600

Balance

OTHER BENEFITS — NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

FOREIGN TRAVEL — NOT COVERED BY MEDICARE

Medically necessary emer-gency care services beginning during the first 60 days of each trip outside the USA

- First $250 each calendar year

- Remainder of Charges*

$0

$0

$0

80% to a lifetime maximum benefit of $50,000

$250

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

BASIC OUTPATIENT PRE-SCRIPTION DRUGS — NOT COVERED BY MEDICARE

- First $250 each calendar year

- Next $2,500 each calendar

year

- Over $2,500 each calendar

year

$0

$0

$0

$0

50% — $1,250 calendar year maximum benefit

$0

$250

50%

All Costs

PLAN J or HIGH DEDUCTIBLE PLAN J

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

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

**This high deductible plan pays the same or offers the same benefits as Plan J after one has paid a calendar year [$1500] deductible. Benefits from high deductible plan J will not begin until out-of-pocket expenses are [$1500]. 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 prescription drug deductible or the plan’s separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

AFTER YOU PAY $1500 DEDUCTIBLE,** PLAN PAYS

IN ADDITION TO $1500 DEDUCTIBLE,** YOU PAY

HOSPITALIZATION*

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

First 60 days

61st thru 90th day

91st day and after:

- While using 60 lifetime

reserve days

- Once lifetime reserve days are used:

- Additional 365 days

- Beyond the Additional 365

days

All but $[764]

All but $[191] a day

All but $[382] a day

$0

$0

$[764] (Part A Deductible)

$[191] a day

$[382] a day

100% of Medicare Eligible Expenses

$0

$0

$0

$0

$0**

All Costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

- First 20 days

- 21st thru 100th day

- 101st day and after

All approved amounts

All but $[95.50] a day

$0

$0

Up to $[95.50] a day

$0

$0

$0

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsurance for out-patient drugs and in-patient respite care

$0

Balance

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

PLAN J

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

*Once you have been billed $100 of Medicare-Approved Amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

AFTER YOU PAY $1500 DEDUCTIBLE,** PLAN PAYS

AFTER YOU PAY $1500 DEDUCTIBLE,** YOU PAY

MEDICAL EXPENSES — IN OR OUT OF THE HOSPITAL AND OUT-PATIENT TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,

- First 100 days of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

- Part B Excess Charges

(Above Medicare Approved

Amounts)

$0

Generally 80%

$0

$100 (Part B Deductible)

Generally 20%

100%

$0

$0

$0

BLOOD

- First 3 pints

- Next $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

$0

$0

80%

All Costs

$100 (Part B Deductible)

20%

$0

$0

$0

CLINICAL LABORATORY SERVICES — BLOOD TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

(continued)

PLAN J or HIGH DEDUCTIBLE PLAN J (cont.)

PARTS A & B

SERVICES

MEDICARE PAYS

AFTER YOU PAY $1500 DEDUCTIBLE,** PLAN PAYS

AFTER YOU PAY $1500 DEDUCTIBLE,** YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES

Medically necessary skilled care services and medical supplies

Durable medical equipment

- First $100 of Medicare

Approved Amounts*

- Remainder of Medicare

Approved Amounts

100%

$0

80%

$0

$100 (Part B Deductible)

20%

$0

$0

$0

AT-HOME RECOVERY SERVICES — NOT COVERED BY MEDICARE Home care certified by your doctors, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan

Benefit for each visit

Number of visits covered

(must be received within 8

weeks of last Medicare

Approved visit)

Calendar year maximum

$0

$0

$0

Actual Charges to $40 a visit

Up to the number of Medicare Approved visits, not to exceed7 each week

$1,600

Balance

(continued)

PLAN J or HIGH DEDUCTIBLE PLAN J (cont.)

OTHER BENEFITS—NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

AFTER YOU PAY $1500 DEDUCTIBLE,** PLAN PAYS

AFTER YOU PAY $1500 DEDUCTIBLE,** YOU PAY

FOREIGN TRAVEL — NOT COVERED BY MEDICARE

Medically necessary emer-gency care services beginning during the first 60 days of each trip outside the USA

- First $250 each calendar year

- Remainder of Charges

$0

$0

$0

80% to a lifetime maximum benefit of $50,000

$250

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

EXTENDED OUTPATIENT PRESCRIPTION DRUGS — NOT COVERED BY MEDICARE

- First $250 each calendar year

- Next $6,000 each calendar

year

- Over $6,000 each calendar

year

$0

$0

$0

$0

50% — $3,000 calendar year maximum benefit

$0

$250

50%

All Costs

***PREVENTIVE MEDI-CAL CARE BENEFIT — NOT COVERED BY MEDICARE

ASome annual physical and preventive tests and services such as: fecal occult blood test, digital rectal exam, mammogram, hearing screening, dipstick urinalysis, diabetes screening, thyroid function test, influenza shot, tetanus and diphtheria booster and education, administered or ordered by your doctor when not covered by Medicare

- First $120 each calendar year

- Additional charges

$0

$0

$120

$0

$0

All Costs

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

[Drafting Note: The term "certificate" should be substituted for the word "policy" throughout the outline of coverage where appropriate.]

"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."

Cross-reference to Section 16: See Appendix C, page ____.

Section 187. Requirements for Application Forms and Replacement Coverage

[Statements]

[Questions]

To the best of your knowledge.

NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE

[Insurance company's name and address]

SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE

According to [your application] [information you have furnished], you intend to terminate existing Medicare supplement 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.

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 coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.

STATEMENT TO APPLICANT BY ISSUER, AGENT [BROKER OR OTHER REPRESENTATIVE]:

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 coverage because you intend to terminate your existing Medicare supplement coverage. The replacement policy is being purchased for the following reason(s) (check one):

________Additional benefits.

1. 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.

2. State law provides that your replacement policy or certificate may not contain new preexisting conditions, waiting period, elimination periods or probationary periods.

3. 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.]

Do not cancel your present policy until you have received you new policy and are sure that your want to keep it.

________________________________________________

(Signature of Agent, Broker or Other Representative)

[Typed Name and Address of Issuer, Agent or Broker]

________________________________________________

(Applicant's Signature)

___________________________________

(Date)

*Signature not required for direct response sales.

Section 198. Filing Requirements for Advertising

An issuer shall provide a copy of any Medicare supplement advertisement intended for use in this State whether through written, radio or television medium to the Commissioner of Insurance of this State for review or approval by the Commissioner to the extent it may be required under state law.

Section 2019. Standards for Marketing

"Notice to buyer: This policy may not cover all of your medical expenses."

Section 210. Appropriateness of Recommended Purchase and Excessive Insurance

Section 221. Reporting of Multiple Policies

Section 232. Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies or Certificates

Section 243. Separability

If any provision of this regulation or the application thereof to any person or circumstances is for any reason held to be invalid, the remainder of the regulation and the application of such provision to other persons or circumstances shall not be affected thereby.

Section 254. Effective Date

This Regulation shall be effective on January 1, 1992.

David N. Levinson

November 8, 1991

APPENDIX A

MEDICARE SUPPLEMENT REFUND CALCULATION FORM

FOR CALENDAR YEAR _________________________

TYPE1 ____________________________ SMSBP2_________________________________________

FOR THE STATE OF ________________ COMPANY NAME ______________________________

NAIC Group Code ___________________ NAIC Company Code ______________________________

PERSON COMPLETING THIS EXHIBIT _________________________________________________

Title ______________________________ Telephone Number _________________________________

Line

1. Current Year's Experience

a. Total (all policy years)

b. Current year's issues (%)

c. Net (for reporting purposes = 1a - 1b) ______________ ______________

2. Past Years' Experience (All Policy Years) ______________ ______________

3. Total Experience

4. Refunds Last Year (Excluding Interest) ______________ ______________

5. Previous Since Inception (Excluding Interest) ______________ ______________

6. Refunds Since Inception (Excluding Interest) ______________ ______________

7. Benchmark Ratio Since Inception

(SEE WORKSHEET FOR RATIO 1) ______________ ______________

8. Experienced Ratio Since Inception ______________ ______________

Total Actual Incurred Claims (Line 3, Col. b) = Ratio 2

____________________________________________

Tot. Earned Prem. (Line 3, Col. a — Refunds Since Inception (line 6)

9. Life Years Exposed Since Inception ________________________

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.

APPENDIX A

MEDICARE SUPPLEMENT REFUND CALCULATION FORM

FOR CALENDAR YEAR _________________________

TYPE1 ____________________________ SMSBP2_________________________________________

FOR THE STATE OF ________________ COMPANY NAME ______________________________

NAIC Group Code ___________________ NAIC Company Code ______________________________

PERSON COMPLETING THIS EXHIBIT ________________________________________________Title ______________________________ Telephone Number _________________________________

10. Tolerance Permitted (obtained from credibility table) ________________________

11. Adjustment to Incurred Claim for Credibility ______________________

Ratio 3 = Ratio 2 + Tolerance

If Ratio 3 is more than benchmark ratio (ratio 1), a refund or credit to premium is not required.

12. Adjusted Incurred Claims = ___________________________

(Tot. Earned Premiums (line 3, col. a) — Refunds Since Inception (line 6) x Ratio 3 (line 11)

13. Refund = Total Earned Premium (line 3, col. a) —

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 and/or credit against premiums to be used must be attached to this form.

MEDICARE SUPPLEMENT CREDIBILITY TABLE

Life Years Exposed Since Inception Tolerance

10,000+ 0.0%

5,000 - 9,999 5.0%

2,500 - 4,999 7.5%

1,000 - 2,499 10.0%

500 - 999 15.0%

If less than 500, no credibility.

1Individual, group, individual Medicare Select, or group Medicare “Select only

2"SMSBP" = Standardized Medicare Supplement Benefit Plan

3Includes model Loadings and fees charged.

4Excludes Active Life Reserves.

5This is to be used as "Issue Year Earned Premium" for Year 1 of next year's "Worksheet for Calculation of Benchmark Ratios".

I certify that the above information and calculations are true and accurate to the best of my knowledge and belief.

___________________________________________

Signature

___________________________________________

Name — Please Type

___________________________________________

Title

___________________________________________

Date

APPENDIX A

REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION

FOR INDIVIDUAL POLICIES FOR CALENDAR YEAR __________________

TYPE1 ____________________________ SMSBP2_________________________________________

FOR THE STATE OF ________________ COMPANY NAME ______________________________

NAIC Group Code ___________________ NAIC Company Code ______________________________

PERSON COMPLETING THIS EXHIBIT _________________________________________________

Title ______________________________ Telephone Number _________________________________

(a)3

(b)4

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(j)

(o)5

Year

Earned Premium

Factor

(b) x (c)

Cumula-tive Loss Ratio

(d) x (e)

Factor

(b) x (g)

Cumula -tive Loss Ratio

(h) x (i)

Policy Year Loss Ratio

1

 

2.770

 

0.442

 

0.000

 

0.000

 

0.4

2

 

4.175

 

0.493

 

0.000

 

0.000

 

0.55

3

 

4.175

 

0.493

 

1.194

 

0.659

 

0.65

4

 

4.175

 

0.493

 

2.245

 

0.669

 

0.67

5

 

4.175

 

0.493

 

3.170

 

0.678

 

0.69

6

 

4.175

 

0.493

 

3.998

 

0.686

 

0.71

7

 

4.175

 

0.493

 

4.754

 

0.695

 

0.73

8

 

4.175

 

0.493

 

5.445

 

0.702

 

0.75

9

 

4.175

 

0.493

 

6.075

 

0.708

 

0.76

10

 

4.175

 

0.493

 

6.650

 

0.713

 

0.76

11

 

4.175

 

0.493

 

7.176

 

0.717

 

0.76

12

 

4.175

 

0.493

 

7.655

 

0.720

 

0.77

13

 

4.175

 

0.493

 

8.093

 

0.723

 

0.77

14

 

4.175

 

0.493

 

8.493

 

0.725

 

0.77

15

 

4.175

 

0.493

 

8.684

 

0.725

 

0.77

Total

   

(k):

 

(l):

 

(m):

 

(n):

 

enchmark Ratio Since Inception: (l n) / (k m): _________________________________________

1Individual, group, individual Medicare Select, or group Medicare “Select only

2"SMSBP" = Standardized Medicare Supplement Benefit Plan - Use “P” for pre-standardized plans

3Year 1 is the current calendar year - 1. Year 2 is the current calendar year - 2 (etc.) (Example: If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)

4For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.

5These 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.

APPENDIX A

REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION

FOR INDIVIDUAL POLICIES FOR CALENDAR YEAR __________________

TYPE1 ____________________________ SMSBP2_________________________________________

FOR THE STATE OF ________________ COMPANY NAME ______________________________

NAIC Group Code ___________________ NAIC Company Code ______________________________

PERSON COMPLETING THIS EXHIBIT ________________________________________________

Title ______________________________ Telephone Number _________________________________

(a)3

(b)4

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(j)

(o)5

Year

Earned Premiu m

Factor

(b) x (c)

Cumula-tive Loss Ratio

(d) x (e)

Factor

(b) x (g)

Cumula-tive Loss Ratio

(h) x (i)

Policy Year Loss Ratio

1

 

2.770

 

0.507

 

0.000

 

0.000

 

0.46

2

 

4.175

 

0.567

 

0.000

 

0.000

 

0.63

3

 

4.175

 

0.567

 

1.194

 

0.759

 

0.75

4

 

4.175

 

0.567

 

2.245

 

0.771

 

0.77

5

 

4.175

 

0.567

 

3.170

 

0.782

 

0.8

6

 

4.175

 

0.567

 

3.998

 

0.792

 

0.82

7

 

4.175

 

0.567

 

4.754

 

0.802

 

0.84

8

 

4.175

 

0.567

 

5.445

 

0.811

 

0.87

9

 

4.175

 

0.567

 

6.075

 

0.818

 

0.88

10

 

4.175

 

0.567

 

6.650

 

0.824

 

0.88

11

 

4.175

 

0.567

 

7.176

 

0.828

 

0.88

12

 

4.175

 

0.567

 

7.655

 

0.831

 

0.88

13

 

4.175

 

0.567

 

8.093

 

0.834

 

0.89

14

 

4.175

 

0.567

 

8.493

 

0.837

 

0.89

15

 

4.175

 

0.567

 

8.684

 

0.838

 

0.89

Total

   

(k):

 

(l):

 

(m):

 

(n):

 

Benchmark Ratio Since Inception: (l n) / (k m): _________________________________________

1Individual, group, individual Medicare Select, or group Medicare “Select only

2"SMSBP" = Standardized Medicare Supplement Benefit Plan - Use “P” for pre-standardized plans

3Year 1 is the current calendar year - 1. Year 2 is the current calendar year - 2 (etc.) (Example: If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)

4For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.

5These 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.

APPENDIX B

FORM FOR REPORTING

DUPLICATE MEDICARE SUPPLEMENT POLICIES

Company Name: ________________________________________________

Address: ________________________________________________

________________________________________________

Phone Number: ________________________________________________

Due March 1, annually

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.

___________________________________

Signature

____________________________________

Name and Title (please type)

____________________________________

Date

APPENDIX C

DISCLOSURE STATEMENTS

Instructions for Use of the Disclosure Statements for

Health Insurance Policies sold to Medicare Beneficiaries

that Duplicate Medicare

[Original disclosure statement fFor policies that provide benefits for expenses incurred for an accidental injury only]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

This is not Medicare Supplement Insurance

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.

This insurance duplicates Medicare benefits when it pays:

hospital or medical expenses up to the maximum stated in the policy

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

other approved items and services

Before You Buy This Insurance

4Check the coverage in all health insurance policies you already have.

4For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[Original disclosure statement Ffor policies that provide benefits for specified limited services]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

This is not Medicare Supplement Insurance

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.

This insurance duplicates Medicare benefits when:

any of the services covered by the policy are also covered by Medicare

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

other approved items and services

Before You Buy This Insurance

4Check the coverage in all health insurance policies you already have.

4For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[Original disclosure statement Ffor policies that reimburse expenses incurred for specified disease(s) or other specified impairment(s). This includes expense incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions.]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

This is not Medicare Supplement Insurance

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.

This insurance duplicates Medicare benefits when it pays:

hospital or medical expenses up to the maximum stated in the policy

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

other approved items and services

Before You Buy This Insurance

4Check the coverage in all health insurance policies you already have.

4For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[Original disclosure statement Ffor 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.]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

This is not Medicare Supplement Insurance

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.

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.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

hospice

other approved items and services

Before You Buy This Insurance

4Check the coverage in all health insurance policies you already have.

4For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[Original disclosure statement Ffor indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

This is not Medicare Supplement Insurance

This insurance pays a fixed 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.

This insurance duplicates Medicare benefits when:

any expenses or services covered by the policy are also covered by Medicare

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

hospice

other approved items and services

Before You Buy This Insurance

4Check the coverage in all health insurance policies you already have.

4For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[Original disclosure statement Ffor policies that provide benefits for both expenses incurred and fixed indemnity basis]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

This is not Medicare Supplement Insurance

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.

This insurance duplicates Medicare benefits when:

any expenses or services covered by the policy are also covered by Medicare; or

it pays the fixed dollar amount stated in the policy and Medicare covers the same event

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

hospice

other approved items and services

Before You Buy This Insurance

4Check the coverage in all health insurance policies you already have.

4For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[For long-term care policies providing both nursing home and noninstitutional coverage]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

This is not Medicare Supplement Insurance

Federal law requires us to inform you that this insurance duplicates Medicare benefits in some situations.

This is a long-term care insurance that provides benefits for covered nursing home and home care services.

In some situations Medicare pays for short periods of skilled nursing home care, limited home health services and hospice care.

This insurance does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

Neither Medicare nor Medicare Supplement insurance provides benefits for most long-term care expenses.

Before You Buy This Insurance

4 Check the coverage in all health insurance policies you already have.

4 For more information about long-term care insurance, review the Shopper's Guide to Long-Term Care Insurance, available from the insurance company.

4 For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4 For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[For policies providing nursing home benefits only]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

This is not Medicare Supplement Insurance

Federal law requires us to inform you that this insurance duplicates Medicare benefits in some situations.

This insurance provides benefits primarily for covered nursing home services.

In some situations Medicare pays for short periods of skilled nursing home care and hospice care.

This insurance does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

Neither Medicare nor Medicare Supplement insurance provides benefits for most nursing home expenses.

Before You Buy This Insurance

4 Check the coverage in all health insurance policies you already have.

4 For more information about long-term care insurance, review the Shopper's Guide to Long-Term Care Insurance, available from the insurance company.

4 For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4 For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[For policies providing home care benefits only]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

This is not Medicare Supplement Insurance

Federal law requires us to inform you that this insurance duplicates Medicare benefits in some situations.

This insurance provides benefits primarily for covered home care services.

In some situations Medicare will cover some health related services in your home and hospice care which may also be covered by this insurance.

This insurance does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

Neither Medicare nor Medicare Supplement insurance provides benefits for most services in your home.

Before You Buy This Insurance

4 Check the coverage in all health insurance policies you already have.

4 For more information about long-term care insurance, review the Shopper's Guide to Long-Term Care Insurance, available from the insurance company.

4 For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4 For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[Original disclosure statement Ffor other health insurance policies not specifically identified in the previous statements]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

This is not Medicare Supplement Insurance

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.

This insurance duplicates Medicare benefits when it pays:

the benefits stated in the policy and coverage for the same event is provided by Medicare

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

hospice

other approved items and services

Before You Buy This Insurance

4 Check the coverage in all health insurance policies you already have.

4For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[Alternative disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS IS NOT MEDICARE SUPPLEMENT INSURANCE

Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.

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.

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

other approved items and services

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

Before You Buy This Insurance

4 Check the coverage in all health insurance policies you already have.

4 For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4 For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[Alternative disclosure statement for policies that provide benefits for specified limited services.]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS IS NOT MEDICARE SUPPLEMENT INSURANCE

Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.

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.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

other approved items and services

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

Before You Buy This Insurance

4 Check the coverage in all health insurance policies you already have.

4 For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4 For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[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.]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS IS NOT MEDICARE SUPPLEMENT INSURANCE

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.

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.

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

hospice

other approved items and services

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

Before You Buy This Insurance

4 Check the coverage in all health insurance policies you already have.

4 For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4 For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[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.]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS IS NOT MEDICARE SUPPLEMENT INSURANCE

Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.

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.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

hospice

other approved items and services

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

Before You Buy This Insurance

4 Check the coverage in all health insurance policies you already have.

4 For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4 For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[Alternative disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS IS NOT MEDICARE SUPPLEMENT INSURANCE

Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.

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.

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

hospice

other approved items and services

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

Before You Buy This Insurance

4 Check the coverage in all health insurance policies you already have.

4 For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4 For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[Alternative disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis.]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS IS NOT MEDICARE SUPPLEMENT INSURANCE

Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.

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.

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

hospice

other approved items and services

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

Before You Buy This Insurance

4 Check the coverage in all health insurance policies you already have.

4 For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4 For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

[Alternative disclosure statement for other health insurance policies not specifically identified in the preceding statements.]

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS IS NOT MEDICARE SUPPLEMENT INSURANCE

Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.

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.

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

hospice

other approved items and services

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

Before You Buy This Insurance

4 Check the coverage in all health insurance policies you already have.

4 For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4 For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

2 DE Reg. 2055 (05/01/99) (Final)