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Plan N Details

Medicare Supplement Insurance — Plan N

Get a no-obligation quote for Medicare Supplement coverage from Blue Cross and Blue Shield of Texas

If you are willing to share certain health care costs, this Medicare Supplement insurance plan can help you save on premiums while still receiving dependable coverage.

COST

Medicare Supplement insurance costs include monthly premium payments and may include deductibles, out-of-pocket expenses, copayments and coinsurance. Here are some of the costs you can expect to pay with Plan N:

Your Part B deductible
Part B excess charges
All hospitalization costs beyond the additional 365 days after the Lifetime Reserve are used
All skilled nursing facility costs after 101 days
A $20 copayment for office visits and $50 for emergency room visits – these copayments apply to Part B coinsurance only
Foreign travel: $250 per calendar year; 20 percent of costs within the first $50,000; all costs thereafter

For more information on costs, get a quick quote or see the Medicare Supplement Outline of Coverage.

WHAT’S INCLUDED

Basic benefits:
- Part A coinsurance for hospitalization services plus coverage for 365 additional days after Medicare benefits end
- Part B coinsurance for medical expenses (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services
- First three pints of blood each year
- Part A coinsurance for hospice care
Skilled nursing facility coinsurance
Part A deductible
Foreign travel emergency care*

It’s important to know the critical features of the Medicare Supplement insurance plan you are considering. The Outline of Medicare Supplement Coverage provides brief descriptions of the basic provisions of the Medicare Supplement insurance plans, as well as details on policy renewability, benefit exclusions and coverage limitations.

* Plans cover medically necessary emergency care services needed immediately because of an injury or illness of sudden and unexpected onset, beginning during the first 60 days of each trip outside the USA.

PLAN RENEWALS

Blue Cross and Blue Shield of Texas (BCBSTX) will never terminate or refuse to renew your Medicare Supplement Insurance policy because of the condition of your health. However, to protect you and the rights of all policy holders, there are situations when a Medicare Supplement insurance plan may be terminated or a renewal refused:

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	Plan Pays	You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	$1,316 (Part A deductible)	$0
61st through 90th day	All but $329 a day	$329 a day	$0
91st day and after: – While using 60 Lifetime Reserve Days – Once Lifetime Reserve Days are used: Additional 365 days	All but $658 a day$0	$658 a day 100% of Medicare eligible expenses	$0$0**
Beyond the additional 365 days	$0	$0	All costs
SKILLED NURSING FACILITY CARE*: You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	Up to $164.50 a day	$0
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	Three pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE: You must meet Medicare’s requirements, including a doctor’s certification of terminal illness
	All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	Medicare copayment/ coinsurance	$0

* A benefit period begins on the first day you receive services 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.

** 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.

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	Generally 80%	Balance, other than up to $20 per office visit and up to $50 per emergency room visit.**	Up to $20 per office visit and up to $50 per emergency room visit.**
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	$0	All costs
BLOOD
First three pints	$0	All costs	$0
Next $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES— TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

** 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.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
– Medically necessary skilled care services and medical supplies	100%	$0	$0
– Durable medical equipment First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	20%	$0

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

OTHER BENEFITS – NOT COVERED BY MEDICARE

Services	Medicare Pays	Plan Pays	You Pay
FOREIGN TRAVEL —NOT COVERED BY MEDICARE: Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year	$0	$0	$250
Remainder of charges	$0	maximum benefit of $50,000	over the $50,000 lifetime maximum

Plan L Details

Medicare Supplement Insurance — Plan L

Get a no-obligation quote for Medicare Supplement coverage from Blue Cross and Blue Shield of Texas

If you are willing to share certain health care costs, this Medicare Supplement insurance plan can help you save on premiums while still receiving dependable coverage.

COST

Your Part B deductible
Part B excess charges
25 percent of your Part A deductible
All hospitalization costs beyond the additional 365 days after the Lifetime Reserve are used
A portion of cost after 21 days in a skilled nursing facility, and all costs after 101 days
25 percent of the cost of the first three pints of blood

For more information on costs, get a quick quote or see the Medicare Supplement Outline of Coverage.

WHAT’S INCLUDED

Basic benefits:
- 75% of Part A deductible for hospitalization services
- 75% of the costs for the first three pints of blood each year
- 75% of Medicare coinsurance for hospice care
Skilled nursing facility coinsurance (75%)
Part A deductible (75%)

PLAN RENEWALS

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	Plan Pays	You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	75% of Part A deductible	25% of Part A deductible
61st through 90th day	All but $329 a day	$329 a day	$0
91st day and after: – While using 60 Lifetime Reserve Days – Once Lifetime Reserve Days are used: Additional 365 days	All but $658 a day $0	$658 a day 100% of Medicare eligible expenses	$0 $0**
Beyond the additional 365 days	$0	$0	All costs
SKILLED NURSING FACILITY CARE*: You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	Up to $123.38 a day	Up to $41.12 a day
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	75%	25%
Additional amounts	100%	$0	$0
HOSPICE CARE: You must meet Medicare’s requirements, including a doctor’s certification of terminal illness
	All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	75% of Medicare copayment/ coinsurance	25% of Medicare copayment/ coinsurance

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Preventive benefits for Medicare-covered services	Generally 75% or more of Medicare-approved amounts	Remainder of Medicare-approved amounts	All costs above Medicare-approved amounts
Remainder of Medicare-approved amounts	Generally 80%	Generally 15%	Generally 5%
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	$0	All costs (and they do not count toward annual out-of pocket limit of $2,560 )**
BLOOD
First three pints	$0	75%	25%
Next $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	Generally 80%	Generally 15%	Generally 5%
CLINICAL LABORATORY SERVICES— TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

** This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2,560 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (“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 services.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
– Medically necessary skilled care services and medical supplies	100%	$0	$0
– Durable medical equipment First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	15%	5%

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

Plan F High Deductible

Medicare Supplement Insurance — High Deductible Plan F

Get a no-obligation quote for Medicare Supplement coverage from Blue Cross and Blue Shield of Texas

If you are willing to share certain health care costs, this Medicare Supplement insurance plan can help you save on premiums while still receiving dependable coverage.

High Deductible Plan F includes cost-sharing features that allow you to save on premiums while still receiving dependable coverage. For more detailed information about cost, coverage and renewability, click on the sections below.

COST

Medicare Supplement insurance costs include monthly premium payments and may include deductibles, out-of-pocket expenses, copayments and coinsurance.

This high deductible Medicare Supplement insurance plan pays the same benefits as Plan F after you have paid a calendar-year $2,220 deductible.
Benefits from the High Deductible Plan F will not begin until out-of-pocket expenses are $2,220.
Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy, which includes the Medicare deductibles for Part A and Part B, but not the separate foreign travel emergency deductible.

Other costs you can expect to pay with High Deductible Plan F:

Part B deductible
All costs beyond the additional 365 days after the Lifetime Reserve are used
All costs after 101 days in a skilled nursing facility
Foreign travel: $250 per calendar year; 20 percent of costs within the first $50,000; all costs thereafter

For more information on costs, get a quick quote or see the Medicare Supplement Outline of Coverage.

WHAT’S INCLUDED

Basic benefits:

- Part A coinsurance for hospitalization services plus coverage for 365 additional days after Medicare benefits end
- Part B coinsurance for medical expenses (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services
- First three pints of blood each year
- Part A coinsurance for hospice care
Skilled nursing facility coinsurance
Part A deductible
Part B deductible
Part B excess charges (100%)
Foreign travel emergency care

PLAN RENEWALS

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	After you pay $2,180 Deductible**, Plan Pays	After you pay $2,180 Deductible, You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	$1,316 (Part A Deductible)	$0
61st through 90th day	All but $329	$329 a day	$0
91st day and after: — While using 60 Lifetime Reserve days — Once Lifetime Reserve days are used: Additional 365 days	All but $658$0	$658 a day 100% of Medicare eligible expenses	$0$0 **
Beyond the additional 365 days	$0	$0	All costs
SKILLED NURSING FACILITY CARE*: You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	Up to $164.50 a day	$0
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	Three pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE: You must meet Medicare’s requirements, including a doctor’s certification of terminal illness
	All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
Remainder of Medicare-approved amounts	Generally 80%	Generally 20%	$0
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	100%	$0
BLOOD
First three pints	$0	All costs	$0
Next $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
Remainder of Medicare-approved amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES—TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
— Medically necessary skilled care services and medical supplies	100%	$0	$0
— Durable medical equipment First $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
— Durable medical equipment Remainder of Medicare-approved amounts	80%	20%	$0

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

OTHER BENEFITS — NOT COVERED BY MEDICARE

Services	Medicare Pays	Plan Pays	You Pay
FOREIGN TRAVEL—NOT COVERED BY MEDICARE: Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year	$0	$0	$250
Remainder of charges	$0	80% to a lifetime maximum benefit of $50,000	20% and amounts over the $50,000 lifetime maximum

Plan K Details

COST

50 percent of your Part A deductible
100 percent of your Part B deductible
Part B excess charges
A portion of cost after 21 days in a skilled nursing facility, and all costs after 101 days
50 percent of the cost of the first three pints of blood

For more information on costs, get a quick quote or see the Medicare Supplement Outline of Coverage.

WHAT’S INCLUDED

Basic benefits:
- 50% of Part A deductible for hospitalization services
- 50% of the costs for the first three pints of blood each year
- 50% of Medicare coinsurance for hospice care
Skilled nursing facility coinsurance (50%)
Part A deductible (50%)

PLAN RENEWALS

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	Plan Pays	You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	50% of Part A deductible	50% of Part A deductible
61st through 90th day	All but $329 a day	$329 a day	$0
91st day and after: – While using 60 Lifetime Reserve Days – Once Lifetime Reserve Days are used: Additional 365 days	All but $658 a day$0	$658 a day 100% of Medicare eligible expenses	$0$0**
Beyond the additional 365 days	$0	$0	All costs
SKILLED NURSING FACILITY CARE*: You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	Up to $82.25 a day	Up to $82.25 a day
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	50%	50%
Additional amounts	100%	$0	$0
HOSPICE CARE: You must meet Medicare’s requirements, including a doctor’s certification of terminal illness
	All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	50% of Medicare copayment/ coinsurance	50% of Medicare copayment/ coinsurance

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Preventive benefits for Medicare-covered services	Generally 75% or more of Medicare-approved amounts	Remainder of Medicare-approved amounts	All costs above Medicare-approved amounts
Remainder of Medicare-approved amounts	Generally 80%	Generally 10%	Generally 10%
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	$0	All costs (and they do not count toward annual out-of pocket limit of $5,120 )**
BLOOD
First three pints	$0	50%	50%
Next $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	Generally 80%	Generally 10%	Generally 10%
CLINICAL LABORATORY SERVICES— TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

** This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $5,120 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (“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 services.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
– Medically necessary skilled care services and medical supplies	100%	$0	$0
– Durable medical equipment First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	10%	10%

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

Plan A Details

COST

Your Part A deductible
Your Part B deductible
Part B excess charges
All hospitalization costs beyond the additional 365 days after the Lifetime Reserve are used

For more information on costs, get a quick quote or see the Medicare Supplement Outline of Coverage.

WHAT’S INCLUDED

Basic benefits:

Part A coinsurance for hospitalization services plus coverage for 365 additional days after Medicare benefits end
Part B coinsurance for medical expenses (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services
First three pints of blood each year
Part A coinsurance for hospice care

PLAN RENEWALS

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	Plan Pays	You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	$0	$1,316 (Part A Deductible)
61st through 90th day	All but $329 a day	$329 a day	$0
91st day and after: – While using 60 Lifetime Reserve Days – Once Lifetime Reserve Days are used: Additional 365 days	All but $658 a day $0	$658 a day 100% of Medicare eligible expenses	$0 $0**
Beyond the additional 365 days	$0	$0	All costs
SKILLED NURSING FACILITY CARE*: You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	$0	Up to $164.50 a day
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	Three pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE: You must meet Medicare’s requirements, including a doctor’s certification of terminal illness
	All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	Medicare copayment/ coinsurance	$0

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	Generally 80%	Generally 20%	$0
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	$0	All costs
BLOOD
First three pints	$0	All costs	$0
Next $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES— TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
– Medically necessary skilled care services and medical supplies	100%	$0	$0
– Durable medical equipment First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	20%	$0

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

Plan G Details

COST

Medicare Supplement insurance costs include monthly premium payments and may include deductibles, out-of-pocket expenses, copayments and coinsurance. Here is what you can expect to pay with Plan G:

The Part B deductible
All hospitalization costs beyond the additional 365 days after the Lifetime Reserve are used
All costs after 101 days in a skilled nursing facility
Foreign travel: $250 per calendar year; 20 percent of costs within the first $50,000; all costs thereafter

For more information on costs, get a quick quote or see the Medicare Supplement Outline of Coverage.

WHAT’S INCLUDED

Basic benefits:
- Part A coinsurance for hospitalization services plus coverage for 365 additional days after Medicare benefits end
- Part B coinsurance for medical expenses (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services
- First three pints of blood each year
- Part A coinsurance for hospice care
Skilled nursing facility coinsurance
Part A deductible
Part B excess charges (100%)
Foreign travel emergency care

PLAN RENEWALS

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	Plan Pays	You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	$1,316 (Part A Deductible)	$0
61st through 90th day	All but $329 a day	$329 a day	$0
91st day and after: – While using 60 Lifetime Reserve Days – Once Lifetime Reserve Days are used: Additional 365 days	All but $658 a day$0	$658 a day 100% of Medicare eligible expenses	$0$0**
Beyond the additional 365 days	$0	$0	All costs
SKILLED NURSING FACILITY CARE*: You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	Up to $164.50 a day	$0
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	Three pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE: You must meet Medicare’s requirements, including a doctor’s certification of terminal illness
	All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	20%	$0
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	100%	$0
BLOOD
First three pints	$0	All costs	$0
Next $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES— TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
– Medically necessary skilled care services and medical supplies	100%	$0	$0
– Durable medical equipment First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	20%	$0

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

Plan F Details

COST

Medicare Supplement insurance costs include monthly premium payments and may include deductibles, out-of-pocket expenses, copayments and coinsurance. Here is what you can expect to pay with Plan F:

All hospitalization costs beyond the additional 365 days after the Lifetime Reserve are used
All costs after 101 days in a skilled nursing facility
Foreign travel: $250 per calendar year; 20 percent of costs within the first $50,000; all costs thereafter

For more information on costs, get a quick quote or refer to the Outline of Medicare Supplement Coverage.

WHAT’S INCLUDED

Basic benefits:
- Part A coinsurance for hospitalization services plus coverage for 365 additional days after Medicare benefits end
- Part B coinsurance for medical expenses (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services
- First three pints of blood each year
- Part A coinsurance for hospice care
Skilled nursing facility coinsurance
Part A deductible
Part B deductible
Part B excess charges (100%)
Foreign travel emergency care

More Plan Details

PLAN RENEWALS

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	Plan Pays	You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	$1,316 (Part A Deductible)	$0
61st through 90th day	All but $329	$329 a day	$0
91st day and after: — While using 60 Lifetime Reserve days — Once Lifetime Reserve days are used: Additional 365 days	All but $658 $0	$658 a day 100% of Medicare eligible expenses	$0 $0**
Beyond the additional 365 days	$0	$0	All costs
SKILLED NURSING FACILITY CARE*: You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	Up to $164.50 a day	$0
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	Three pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE: You must meet Medicare’s requirements, including a doctor’s certification of terminal illness
	All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

*A benefit period begins on the first day you receive services 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.

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
Remainder of Medicare-approved amounts	Generally 80%	Generally 20%	$0
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	100%	$0
BLOOD
First three pints	$0	All costs	$0
Next $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
Remainder of Medicare-approved amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES—TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
— Medically necessary skilled care services and medical supplies	100%	$0	$0
— Durable medical equipment First $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
— Durable medical equipment Remainder of Medicare-approved amounts	80%	20%	$0

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

OTHER BENEFITS — NOT COVERED BY MEDICARE

Services	Medicare Pays	Plan Pays	You Pay
FOREIGN TRAVEL—NOT COVERED BY MEDICARE: Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year	$0	$0	$250
Remainder of charges	$0	80% to a lifetime maximum benefit of $50,000	20% and amounts over the $50,000 lifetime maximum

Medicaid Plan F Details

COST

Medicare Supplement insurance costs include monthly premium payments and may include deductibles, out-of-pocket expenses, copayments and coinsurance. Here is what you can expect to pay with Plan F:

All hospitalization costs beyond the additional 365 days after the Lifetime Reserve are used
All costs after 101 days in a skilled nursing facility
Foreign travel: $250 per calendar year; 20 percent of costs within the first $50,000; all costs thereafter

For more information on costs, get a quick quote or refer to the Outline of Medicare Supplement Coverage.

WHAT’S INCLUDED

Basic benefits:
- Part A coinsurance for hospitalization services plus coverage for 365 additional days after Medicare benefits end
- Part B coinsurance for medical expenses (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services
- First three pints of blood each year
- Part A coinsurance for hospice care
Skilled nursing facility coinsurance
Part A deductible
Part B deductible
Part B excess charges (100%)
Foreign travel emergency care

More Plan Details

PLAN RENEWALS

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	Plan Pays	You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	$1,316 (Part A Deductible)	$0
61st through 90th day	All but $329	$329 a day	$0
91st day and after: — While using 60 Lifetime Reserve days — Once Lifetime Reserve days are used: Additional 365 days	All but $658 $0	$658 a day 100% of Medicare eligible expenses	$0 $0**
Beyond the additional 365 days	$0	$0	All costs
SKILLED NURSING FACILITY CARE*: You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	Up to $164.50 a day	$0
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	Three pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE: You must meet Medicare’s requirements, including a doctor’s certification of terminal illness
	All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

*A benefit period begins on the first day you receive services 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.

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
Remainder of Medicare-approved amounts	Generally 80%	Generally 20%	$0
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	100%	$0
BLOOD
First three pints	$0	All costs	$0
Next $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
Remainder of Medicare-approved amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES—TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
— Medically necessary skilled care services and medical supplies	100%	$0	$0
— Durable medical equipment First $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
— Durable medical equipment Remainder of Medicare-approved amounts	80%	20%	$0

* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

OTHER BENEFITS — NOT COVERED BY MEDICARE

Services	Medicare Pays	Plan Pays	You Pay
FOREIGN TRAVEL—NOT COVERED BY MEDICARE: Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year	$0	$0	$250
Remainder of charges	$0	80% to a lifetime maximum benefit of $50,000	20% and amounts over the $50,000 lifetime maximum