Plan F


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PLAN F (and HIGH DEDUCTIBLE PLAN F)

Medicare (Part A) — Hospital Services — Per Benefit Period*

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

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

First 60 days

All but $1,132

$1,132 (Part A deductible)

$0

61st through 90th day

All but $283 a day

$283 a day

$0

91st day and after: While using 60 lifetime reserve days

All but $566 a day

$566 a day

$0

Once lifetime reserve days are used — Additional 365 days

$0

100% of Medicare eligible expenses

$0**

Beyond the additional 365 days

$0

$0

All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare Approved facility within 30 days after leaving the hospital

First 20 days

All approved amounts

$0

$0

21st through 100th day

All but $141.50 a day

Up to $141.50 a day

$0

101st day and after

$0

$0

All costs

BLOOD First three pints

$0

3 pints

$0

Additional amounts

100%

$0

$0

HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.

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

Medicare copayment/ coinsurance

$0

* 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.

** 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.

Medicare (Part B) — Medical Services — Per Calendar Year

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

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

First $162 of Medicare Approved Amounts***

$0

$162 (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 $162 of Medicare Approved Amounts***

$0

$162 (Part B Deductible)

$0

Remainder of Medicare Approved Amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES Tests for Diagnostic Services

100%

$0

$0

Medicare Parts A and B

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies

100%

$0

$0

Durable medical equipment
First $162 of Medicare Approved Amounts***

$0

$162 (Part B Deductible)

$0

Remainder of Medicare Approved Amounts

80%

20%

$0

Other Benefits Not Covered By Medicare

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






First $250 each calendar year

$0

$0

$250

Remainder of Charges

$0

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

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

*** Once you have been billed $162 of Medicare Approved amounts for covered services your Part B Deductible will have been met for the calendar year.

HIGH DEDUCTIBLE PLAN F
Medicare (Part A) — Hospital Services — Per Calendar Year*

SERVICES

MEDICARE PAYS

After you pay $2000 deductible1 PLAN PAYS

In addition to $2000 deductible1 YOU PAY

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

First 60 days

All but $1,132

$1,132 (Part A deductible)

$0

61st through 90th day

All but $283 a day

$283 a day

$0

91st day and after: While using 60 lifetime reserve days

All but $566 a day

$566 a day

$0

Once lifetime reserve days are used — Additional 365 days

$0

100% of Medicare eligible expenses

$0**

Beyond the additional 365 days

$0

$0

All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare Approved facility within 30 days after leaving the hospital

First 20 days

All approved amounts

$0

$0

21st through 100th day

All but $141.50 a day

Up to $141.50 a day

$0

101st day and after

$0

$0

All costs

BLOOD First three pints

$0

3 pints

$0

Additional amounts

100%

$0

$0

HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.

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

Medicare copayment/ coinsurance

$0

* 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.

** 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.

Note:  This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,000 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2,000. 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.

Note: Medicare deductibles and copayments are effective through December 31, 2010.

Medicare (Part B) — Medical Services — Per Calendar Year

SERVICES

MEDICARE PAYS

After you pay $2000 deductible1 PLAN PAYS

In addition to $2000 deductible1 YOU PAY

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

First $162 of Medicare Approved Amounts***

$0

$162 (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 $162 of Medicare Approved Amounts2

$0

$162 (Part B Deductible)

$0

Remainder of Medicare Approved Amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES Tests for Diagnostic Services

100%

$0

$0

Medicare Parts A and B

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies

100%

$0

$0

Durable medical equipment
First $162 of Medicare Approved Amounts***

$0

$162 (Part B Deductible)

$0

Remainder of Medicare Approved Amounts

80%

20%

$0

Other Benefits Not Covered By Medicare

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






First $250 each calendar year

$0

$0

$250

Remainder of Charges

$0

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

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

*** Once you have been billed $162 of Medicare Approved amounts for covered services, your Part B Deductible will have been met for the calendar year.

Note:  The high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,000 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2,000. 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.