Application for Medicare Supplement Insurance Plan · 2013. 8. 30. · If eligible for a Medicare Select Plan, I have also read and understand the statements regarding Medicare Select

32126.1012

Requested Policy Effective Date MONTH DAY YEAR

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Blue Cross and Blue Shield of Illinois, P.O. Box 3003, Naperville, Illinois 60566-7003

Application for Medicare Supplement Insurance Plan

IL-MS-APP-2011

Instructions1. To be considered for coverage, you must have Medicare Parts A and B, reside in Illinois,

and be: a) age 65 or over or b) applying within 6 months of your Medicare Part B effective date.2. If submitting a paper application, please complete in ink. Be sure to sign and date on the

appropriate line(s) on pages 3 and 4. Send no money now! No payment is due until you have a chance to review your policy and make sure the coverage is right for you.

Plan Selection Check one box to apply for a Medicare Supplement Insurance plan.

HOME OFFICE USE ONLY

Applicant Information Preferred Method of Contact: ■ Mail ■ Phone ■ Email

Name (First) (Middle) (Last)

Home Address (No P.O. Boxes) City State Zip

Correspondence/Billing Address City State Zip

Primary Phone Secondary Phone

( ) ( )

Gender Social Security Number Email address Male ■ Female ■ ___ ___ ___ -___ ___ -___ ___ ___ ___

IL

Date of Birth ___ ___ /___ ___ /___ ___ ___ ___ Mo. Day Year

Age

1. ■ Premium deducted from bank account: (choose one): ■ Checking ■ Savings

Account holder name: __________________________________________________________________________

Bank name: ________________________________________________________________________________

Bank routing #: ____________________________ Bank account #: ____________________________________

Account Owner Signature (if different than applicant) X _________________________________________________

2. ■ Premium to be billed by mail

3. I will pay my premium: ■ Monthly ■ Bi-Monthly ■ Quarterly ■ Semi-Annually ■ Annually

Payment Option (Select one payment option)

Plan A Plan B

Standard Medicare Select

Plan C Standard Medicare Select

Plan F Standard Medicare Select Plan F High Deductible

Plan G Standard Medicare Select

Plan K Standard Medicare Select

Plan L Standard Medicare Select

Plan N Standard Medicare Select

— 2 — 32126.1012

Applicant Name __________________________________________

Consumer Protection InformationIf you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you wereeligible for guaranteed issue of a Medicare Supplement insurance policy, or that you had certain rights to buy such a policy,you may be guaranteed acceptance in one or more of our Medicare Supplement plans. Please include a copy of the noticefrom your prior insurer with your application.

Yes ■ No ■

Yes ■ No ■

Yes ■ No ■

Yes ■ No ■

Yes ■ No ■

Yes ■ No ■

__________________________________

Yes ■ No ■

Yes ■ No ■

Start: __ __ /__ __ /__ __ __ __

End: __ __ /__ __ /__ __ __ __

1. Did you turn age 65 in the last 6 months?

2. Did you enroll in Medicare Part B in the last 6 months?

If yes, what is the effective date?

3. Are you covered for medical assistance through the state Medicaid program?

a. If yes, will Medicaid pay your premiums for this Medicare Supplement policy?

b. If yes, do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?

4. If you had coverage from any Medicare plan other than original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates. (If you are still covered under this plan, leave “END” blank.)

a. If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare Supplement policy?

b. Was this your first time in this type of Medicare plan?

c. Did you drop a Medicare Supplement policy to enroll in the Medicare plan?

5. Do you have another Medicare Supplement or Medicare Advantage policy in force?

a. If so, with what company, and what plan do you have?

b. If so, do you intend to replace your current Medicare Supplement or Medicare Advantage policy with this policy?

6. Have you had coverage under any other health insurance within the past 63 days?

a. If so, with what company, and what kind of policy? (For example, an employer, union, or individual plan)

b. What are your dates of coverage under the other policy? (If you are still covered under the other policy, leave “END” blank.)

NOTE TO APPLICANT: If you are participating in a “Spend-Down Program” and have not met your “Share of Cost,” please answer NO to this question. Yes ■ No ■

Yes ■ No ■

Yes ■ No ■

Start: __ __ /__ __ /__ __ __ __

End: __ __ /__ __ /__ __ __ __

__________________________________

Please answer all questions. Please mark Yes or No below with an “X” to the best of your knowledge.

__ __ /__ __ /__ __ __ __

Medicare Claim Number

Please copy the Medicare Claim Number from your red, white and blue Medicare Card. This number must be provided to us to complete your application process.

Your Medicare Claim No. ■■■–■■–■■■■■■■■Part B Effective Date: ___ ___ /___ ___ /___ ___ ___ ___

Part A Effective Date: ___ ___ /___ ___ /___ ___ ___ ___

0 1

0 1

(if applicable)

— 3 — 32126.1012

Applicant Name __________________________________________Applicant Name __________________________________________

Questions? Call us at our Customer Service toll-free number 1-800-624-1723, call your insurance agent at the number listed on the next page,

or visit www.bcbsil.com.

Applicant Signature (optional): X _________________________________________________________________

Print Your Name as You Signed It: ____________________________________ Date: ___ ___ /___ ___ /___ ___ ___ ___

Proxy Statement: The undersigned hereby appoints the Board of Directors of Health Care Service Corporation, a Mutual Legal Reserve Company, or any successor thereof (“HCSC”), with full power of substitution, and such persons as the Board of Directors may designate by resolution, as the undersigned’s proxy to act on behalf of the undersigned at all meetings of members of HCSC (and at all meetings of members of any successor of HCSC) and any adjournments thereof, with full power to vote on behalf of the undersigned on all matters that may come before any such meeting and any adjournment thereof. The annual meeting of members shall be held each year in the corporate headquarters (300 E Randolph St., Chicago, IL 60601) on the last Tuesday of October at 12:30 p.m. Special meetings of members may be called pursuant to notice mailed to the member not less than 30 nor more than 60 days prior to such meetings. This proxy shall remain in effect until revoked in writing by the undersigned at least 20 days prior to any meeting of members, or by attending and voting in person at any annual or special meeting of members.

STATEMENTS

1. You do not need more than one Medicare Supplement policy.

2. If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need more than one type of coverage in addition to your Medicare benefits.

3. You may be eligible for benefits under Medicaid and may not need a Medicare Supplement policy.

4. If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare Supplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare Supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing Medicaid eligibility.*

5. If you are eligible for, and have enrolled in a Medicare Supplement policy by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare Supplement policy can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare Supplement policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare Supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or union-based group health plan.*

* If the Medicare Supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.

6. Counseling services may be available in your state to provide advice concerning your purchase of Medicare Supplement insurance and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB). For information on Medicaid eligibility, call your local Social Security office. For questions on Medicare Supplement insurance, call 1-800-MEDICARE (1-800-633-4227).

— 4 — 32126.1012

Applicant Name __________________________________________

Agent Information (If Applicable)

The following statements apply if you are purchasing coverage through an agent:

The undersigned acknowledges that any agent is acting on his/her behalf for purposes of purchasing the insurance, and that if the Company accepts this application and issues an individual policy, the Company may pay the agent a commission and/or other compensation in connection with the issuance of such individual policy.The undersigned further acknowledges that if he/she desires additional information regarding any commissions or other compensation paid to the agent by the Company in connection with the issuance of the individual policy, he/she should contact the agent.The applicant(s) have received a copy(s) of the Medicare Supplement Buyers Guide.

Any other health insurance policies or coverages sold to the applicant which are still in force:

___________________________________________________________________________________________

Any other health insurance policies or coverages sold to the applicant within the last five (5) years which are no longer in force:

___________________________________________________________________________________________

I have reaffirmed that the information supplied on this application is accurate and complete.

Agent Signature: X ___________________________________________ Date: ___ ___ /___ ___ /___ ___ ___ ___

Print name: ______________________________________________ Broker Code: ___________________________

Agency name (If Applicable): __________________________________ Phone: _______________________________( )

Acknowledgements and Signature1. I hereby apply for coverage and request a policy to review for the Medicare Supplement policy indicated. 2. I understand that once my first premium payment is received, I will be covered as of the date shown on the Company

identification card. Once coverage begins, I understand I have 30 days to return my policy materials and receive a full refund for any premiums paid. Services are covered only when received on or after the effective date of the policy chosen, except in the case of inpatient services, where the admission must occur on or after the effective date to be covered.

3. I hereby declare that the statements and answers on this application, including but not limited to those relating to age and medical history, are true and complete to the best of my knowledge and belief. I agree that the Company, believing them to be true, shall rely and act upon them accordingly. I hereby agree to furnish any additional information, if requested.

4. I understand that the Company has the right to reject my application. If the Company rejects my application, I will be notified in writing. If this application is accepted, it will become part of the insurance policy.

5. I acknowledge that I have read and understand the Statements section regarding Medicare Supplement coverage. If eligible for a Medicare Select Plan, I have also read and understand the statements regarding Medicare Select as described in the Outline of Coverage. WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information may be guilty of a felony.

SIGNATURE REQUIRED Must be signed in ink and dated to avoid processing delays. For Power of Attorney and Legal Guardianships, be sure to submit copies of the court documents with the application.

Applicant X _______________________________________________ Date: ___ ___ /___ ___ /___ ___ ___ ___

Please return completed application to your agent or:Blue Cross Blue Shield of Illinois, P.O. Box 3003, Naperville, IL 60566-7003

2013 Policy Checklist

SERVICE BENEFIT MEDICARE PAYS

EXISTING COVERAGE

PAYSSUPPLEMENT COVERS YOU PAY

HOSPITAL INPATIENT SERVICES

Days 1-60 All but $1,184 p $1,184 Part A Deductible* orp $0 Plan A Only

p $0 orp $1,184 Part A Deductible

Days 61-90 All but $296 a day $296 a day $0

Days 91-150 (Lifetime Reserve)

All but $592 a day $592 a day $0

Days 151 and beyond $0 All Medicare-approved amounts for an additional 365 days $0

SKILLED NURSING HOME CARE

Days 1-20 (All Plans) All costs $0 $0

Days 21-100 All but $148 a dayp $148 a day or p $0 Plans A, B

p $0 or p $148 a day

Days 101 and beyond (All Plans)

$0 $0 All costs

MEDICAL EXPENSES

Physician’s Services in hospital, office, or home; inpatient and outpatient medical services and supplies at a hospital; physical and speech therapy; and ambulance

80% of the Medicare- determined allowable changes after a $147 deductible per calendar year

p After $147 Medicare Part B Deductible per calendar year, 20% of Medicare-approved amounts for Plans A,B,C,F,High F,G

p After $147 Medicare Part B Deductible per calendar year Plan N pays the balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense

p $147 Part B deductible for Plans C, F, High Fp 100% Part B Excess Charges for Plans F, High F and G

Charges not covered by policy and Medicare

p $147 Part B deductible for Plans A, B, G, N

p Part B Excess Charges for Plans A, B, C, N

PRESCRIPTION DRUGS

Inpatient Prescription Drugs – 80% of allowable charges for immunosuppressive drugs during the first year following a covered transplant

No benefit All costs; outpatient drugs

Applicant’s Name_________________________________________________________________________________________

Name of Existing Insurer_______________________________________ Expiration Date of Existing Insurance______________

Medicare Supplement Plans: Important — You must indicate your choice of coverage. Mark only one box, please.

Plan A p StandardPlan B p Standard p Med-Select

Plan C p Standard p Med-Select Plan F p Standard p Med-Select

Plan F p Standard (High Deductible)**

Plan G p Standard p Med-Select Plan N p Standard p Med-Select

/ /

/ /Date ______________ Signature of Applicant ___________________________________________________________

Signature of Producer ___________________________________________________________

* Med-Select Plans require that you use Blue Cross and Blue Shield of Illinois participating Med-Select hospitals for non-emergency admissions to receive coverage for the Medicare Part A deductible.

** High Deductible Plan F offers the same benefits as Plan F after you have paid a $2,110 calendar-year deductible.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 31601.0113 IL APCKLIST.0113

This policy does comply with the minimum standards set forth in Section 363 of the Illinois Insurance Code.

X

X

2013 Policy Checklist

SERVICE BENEFIT MEDICARE PAYS

EXISTING COVERAGE

PAYSSUPPLEMENT COVERS YOU PAY

HOSPITAL INPATIENT SERVICES

Days 1-60 All but $1,184 Plan K: $592 Part A Deductible* Plan L: $888 Part A Deductible*

p Plan K: $592 Part A deductible

p Plan L: $296 Part A deductible

Days 61-90 All but $296 a day $296 a day $0

Days 91-150 (Lifetime Reserve)

All but $592 a day $592 a day $0

Days 151 and beyond $0 All Medicare-approved amounts for an additional 365 days $0

SKILLED NURSING HOME CARE

Days 1-20 All costs $0 $0

Days 21-100 All but $148 a dayp Plan K: $74 a day p Plan L: $111 a day

p Plan K: $74 a day p Plan L: $37 a day

Days 101 and beyond $0 $0 All costs

MEDICAL EXPENSES

Physician’s Services in hospital, office, or home; inpatient and outpatient medical services and supplies at a hospital; physical and speech therapy; and ambulance

80% of the Medicare- determined allowable changes after a $147 deductible per calendar year

p After $147 Medicare Calendar Year deductible, Plan K generally pays 10% and Plan L generally pays 15% of Medicare-approved amounts

Charges not covered by policy and Medicare

PRESCRIPTION DRUGS

Inpatient Prescription Drugs – 80% of allowable charges for immunosuppressive drugs during the first year following a covered transplant

No benefit All costs; outpatient drugs

Applicant’s Name_________________________________________________________________________________________

Name of Existing Insurer_______________________________________ Expiration Date of Existing Insurance______________

Medicare Supplement Plans: Important — You must indicate your choice of coverage. Mark only one box, please.

/ /

/ /Date ______________ Signature of Applicant ___________________________________________________________

Signature of Producer ___________________________________________________________

* Med-Select Plans require that you use Blue Cross and Blue Shield of Illinois participating Med-Select hospitals for non-emergency admissions to receive coverage for the Medicare Part A deductible.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 30346.0113 IL KLCKLIST.0113

This policy does comply with the minimum standards set forth in Section 363 of the Illinois Insurance Code.

X

X

Plan K p Standard p Med-Select (Annual out-of-pocket limit of $4,800)

Plan L p Standard p Med-Select (Annual out-of-pocket limit of $2,400)

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

According to your application, you intend to terminate existing Medicare supplement or Medicare Advantage coverage and replace it with a policy to be issued by Blue Cross and Blue Shield of Illinois. Your new policy will provide 30 days within which you may decide, without cost, whether you desire to keep the policy. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy.

You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, and acceptance by the replacing issuer, you find that purchase of this Medicare supplement or Medicare Advantage 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 BLUE CROSS AND BLUE SHIELD OF ILLINOIS:I have reviewed your current medical or health coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reasons: � Additional benefits. � No change in benefits, but lower premiums. � Fewer benefits and lower premiums. � My plan has outpatient prescription drug coverage and I am enrolling in Part D. � Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment: ________________________

_________________________________________________________________________________________

� Other (please specify): ________________________________________________________________________

1. Note: If the issuer of the Medicare supplement policy applied for does not, or is otherwise prohibited from imposing preexisting condition limitations, please skip to statement 2 below. Health conditions which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.

2. State law provides that your replacement policy or certificate may not contain new preexisting conditions, waiting periods, elimination periods or probationary periods. The insurer will waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, or probationary periods in the new policy (or coverage) to the extent such time was spent (depleted) under the original policy.

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 issuer to deny any future claims and to refund your premium as though the policy had never been in force. After the application has been completed and before you sign it, read and review it carefully to be certain that all information has been properly recorded.

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

Agent’s Signature Agent’s Number

Printed Name and Address of Agent

Applicant’s Signature Date

Notice to Applicant RegardingREPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE

23648.0911


IL-MS-NOR-2011

P.O. Box 3003Naperville, IL 60566-7003

Aledo Mercer County Hospital

Aurora Provena Mercy Center for Health CareRush-Copley Medical Center

Barrington Good Shepherd Hospital**

Berwyn MacNeal Memorial Hospital

Blue Island MetroSouth Medical Center

Bolingbrook Adventist Bolingbrook Hospital

Canton Graham Hospital

Chicago Chicago Lakeshore Hospital

Holy Cross Hospital

Illinois Masonic Medical Center**

Jackson Park Hospital

John H. Stroger Hospital of Cook County

Louis A. Weiss Memorial Hospital

Mercy Hospital and Medical Center

Mount Sinai Hospital

Neurologic and Orthopedic Institute of Chicago

Northwestern Memorial Hospital

Our Lady of the Resurrection Medical Center

Provident Hospital of Cook County

Rehabilitation Institute of Chicago

Resurrection Medical Center

RML Specialty Hospital

Roseland Community Hospital

Schwab Rehabilitation Hospital

St. Anthony Hospital

St. Elizabeth Hospital

St. Joseph Hospital

Saint Mary of Nazareth Hospital

Swedish Covenant Hospital

Thorek Memorial Hospital

Trinity Hospital**

University of Chicago Hospitals and Clinics

University of Illinois Medical Center

Medicare Select* Contracting Hospital Listing

See if a hospital you would use is in our listing.

You could save more money every month with our popular Medicare Select option!

Is Medicare Select right for you?

Medicare Select is a money-saving option that is not an HMO. It fills the gaps in Medicare like our standard option, but it costs less. With Medicare Select, you are fully covered for emergency care at any hospital, and you can stillchoose your own doctors and specialists. Sound too good to be true?

With Medicare Select, all you need to do is use any of our Medicare Select contracting hospitals for non-emergencyelective admissions. If you do not use one of these hospitals, you agree to pay the Part A deductible. It’s that simple!

See if a hospital you would use is in our listing. If so, our money-saving Medicare Select option may be right for you.

Occasionally there may be changes to the Medicare Select Contracting Hospital Network. If you have anyquestions about this listing, please call 1-800-624-1723.

ILLINOIS HOSPITALS

(continued)

Current as of 4/1/12.

Please visit bcbsil.com for an up to date listing.

ILLINOIS HOSPITALS Continued

Chicago Heights St. James Hospital & Health Center

Clinton Dr. John Warner Hospital

Danville Provena United Samaritan Medical Center

Decatur Decatur Memorial Hospital St. Mary’s Hospital

Des Plaines Holy Family Medical Center

Downers Grove Good Samaritan Hospital**

East St. Louis Kenneth Hall Regional Hospital

Touchette Regional Hospital

Elgin Provena St. Joseph Hospital

Elk Grove Village Alexian Brothers Medical Center

Evanston NorthShore University Hospital St. Francis Hospital

Evergreen Park Little Company of Mary Hospital

Forest Park Riveredge Hospital

Galesburg OSF St. Mary Medical Center

Glendale Heights Adventist GlenOaks Hospital

Glenview Glenbrook Hospital

Harvey Ingalls Memorial Hospital

Hazel Crest South Suburban Hospital**

Highland Park Highland Park Hospital

Hinsdale Adventist Hinsdale HospitalRML Specialty Hospital

Hoffman Estates St. Alexius Medical Center

Alexian Brothers Behavioral Health Hospital

Joliet Provena St. Joseph Hospital

Kankakee Provena St. Mary’s HospitalRiverside Medical Center

La Grange Adventist La Grange Memorial Hospital

Maywood Loyola University Medical Center

Melrose Park Gottlieb Memorial Hospital

Westlake Community Hospital

Moline Trinity Medical Center East Campus

Naperville Edward Hospital

New Lenox Silver Cross Hospital

Oak Forest Oak Forest Hospital

Oak Lawn Christ Hospital Medical Center**

Oak Park Rush Oak Park Hospital West Suburban Medical Center

Olympia Fields St. James Hospital and Health Centers Olympia Fields Campus

Palos Heights Palos Community Hospital

Park Ridge Lutheran General Hospital**

Pekin Pekin Hospital

Peoria Proctor Hospital

St. Francis Medical Center

Pontiac St. James Hospital

Rockford OSF St. Anthony Medical CenterVan Matre HealthSouth

Rehabilitation Hospital

Rock Island Trinity Medical Center West Campus

Silvis Illini Hospital

Skokie Skokie Hospital

Springfield Memorial Medical Center

St. John’s Hospital

Taylorville Taylorville Memorial Hospital

Urbana Provena Covenant Medical Center

Wheaton Marionjoy Rehabilitation Hospital and Clinic


*The Medicare Select option requires that you live within 30 miles of any Medicare Select contracting hospital listed here. **Advocate Health Care

30189.0312 IL

1MCOMOOC-0113

* Plan F also has an option called a high deductible Plan F. This high

deductible plan pays the same benefits as Plan F after one has paid

a calendar year $2,110 deductible. Benefits from high deductible

Plan F will not begin until out-of-pocket expenses exceed $2,110.

Out-of-pocket expenses for this deductible are expenses that would

ordinarily be paid by the policy. These expenses include the Medicare

deductibles for Part A and Part B, but do not include the plan’s

separate foreign travel emergency deductible.

Medicare Select Plans require that you use Blue Cross and Blue Shield

of Illinois contracting Medicare Select hospitals for non-emergency

admissions to receive coverage for the Medicare Part A deductible. In

an emergency the $1,184 deductible is covered at any hospital from

which you receive care.

This chart shows the benefits included in each of the standard Medicare supplement plans sold for effective dates on or after June 1, 2010.

Every company must make Plan “A” available. Blue Cross and Blue Shield of Illinois does not offer those plans shaded in gray below.

BASIC BENEFITS: • Hospitalization - Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.• Medical Expenses - Part B coinsurance (generally 20% of Medicare-approved expenses), or copayments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or copayments.• Blood - First 3 pints of blood each year.• Hospice - Part A coinsurance.

A B C D F F* G K L M N

Basic, including

100% Part B

Coinsurance

Basic, including

100% Part B

Coinsurance

Basic, including

100% Part B

Coinsurance

Basic, including

100% Part B

Coinsurance

Basic, including

100% Part B

Coinsurance*

Basic, including

100% Part B

Coinsurance

Hospitalization and preventive

care paid at 100%; other

basic benefits paid at 50%

Hospitalization and preventive

care paid at 100%; other

basic benefits paid at 75%

Basic, including

100% Part B

Coinsurance

Basic, including 100% Part B coinsurance, except up to

$20 copayment for office visit, and up to$50

copayment for ER

Skilled Nursing Facility

Coinsurance


Coinsurance


Coinsurance


Coinsurance

50% Skilled Nursing Facility

Coinsurance

75% Skilled Nursing Facility

Coinsurance


Coinsurance


Coinsurance

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

50% Part A Deductible



Part A Deductible

Part B Deductible

Part B Deductible

Part B Excess (100%)

Part B Excess (100%)

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Out-of-pocket limit $4,800; paid at 100%

after limit reached

Out-of-pocket limit $2,400; paid at 100%

after limit reached

Outline of Medicare Supplement Coverage — Standard Benefits for Plan A and High Deductible Plan F* and Standard and Medicare Select Benefits for Plans B, C, F, G, K, L and N

31547.0313 IL

2

Monthly Premium Rates

Rates shown are for Illinois residents living in Cook, DuPage, Kane, Lake, McHenry or Will Counties only.

If you’re an Illinois resident living outside of Cook, DuPage, Kane, Lake, McHenry or Will County, please call the toll-free number that appears on the application and throughout the information packet.

AGE OPTION A B C F F* G K L N

Age

65

Standard $75.00 $124.00 $155.00 $156.00 $51.00 $140.00 $78.00 $113.00 $109.00

Medicare Select N/A $103.00 $130.00 $137.00 N/A $125.00 $73.00 $105.00 $97.00

Age

66

Standard $79.00 $129.00 $161.00 $163.00 $54.00 $146.00 $82.00 $118.00 $114.00


Age

67

Standard $85.00 $137.00 $169.00 $174.00 $57.00 $156.00 $88.00 $125.00 $121.00


Age

68

Standard $92.00 $146.00 $177.00 $185.00 $60.00 $166.00 $94.00 $133.00 $129.00


Age

69

Standard $96.00 $153.00 $186.00 $196.00 $63.00 $176.00 $99.00 $141.00 $137.00


Age

70

Standard $99.00 $160.00 $196.00 $207.00 $66.00 $186.00 $105.00 $149.00 $145.00


Age

71

Standard $103.00 $168.00 $207.00 $219.00 $70.00 $197.00 $111.00 $157.00 $153.00


Age

72

Standard $107.00 $176.00 $218.00 $231.00 $73.00 $208.00 $117.00 $166.00 $162.00


Age

73

Standard $113.00 $186.00 $229.00 $243.00 $77.00 $219.00 $123.00 $174.00 $170.00


Age

74

Standard $118.00 $197.00 $239.00 $254.00 $81.00 $228.00 $129.00 $182.00 $178.00


Age

75

Standard $122.00 $204.00 $246.00 $261.00 $83.00 $235.00 $133.00 $188.00 $183.00


Age

76

Standard $126.00 $211.00 $252.00 $267.00 $86.00 $241.00 $136.00 $192.00 $187.00


3


Age 77

Standard $129.00 $218.00 $258.00 $274.00 $88.00 $247.00 $140.00 $197.00 $192.00


Age 78

Standard $134.00 $227.00 $266.00 $281.00 $90.00 $253.00 $143.00 $202.00 $197.00


Age 79

Standard $138.00 $234.00 $271.00 $285.00 $92.00 $257.00 $145.00 $205.00 $200.00


Age 80

Standard $143.00 $241.00 $277.00 $289.00 $93.00 $261.00 $147.00 $209.00 $203.00


Age 81

Standard $146.00 $246.00 $279.00 $291.00 $94.00 $262.00 $148.00 $210.00 $204.00


Age 82

Standard $150.00 $254.00 $285.00 $295.00 $95.00 $266.00 $150.00 $213.00 $207.00


Age 83

Standard $153.00 $260.00 $291.00 $302.00 $97.00 $272.00 $153.00 $218.00 $211.00


Age 84

Standard $157.00 $265.00 $298.00 $308.00 $100.00 $278.00 $157.00 $223.00 $216.00


Age 85

Standard $160.00 $271.00 $304.00 $315.00 $102.00 $284.00 $160.00 $228.00 $221.00


Age 86

Standard $163.00 $277.00 $311.00 $322.00 $104.00 $290.00 $163.00 $234.00 $225.00


Age 87

Standard $167.00 $283.00 $318.00 $329.00 $107.00 $296.00 $167.00 $239.00 $230.00


Age 88

Standard $168.00 $284.00 $319.00 $330.00 $107.00 $297.00 $168.00 $240.00 $231.00


Age

89

Standard $168.00 $285.00 $321.00 $332.00 $108.00 $298.00 $168.00 $241.00 $232.00


4


Age 90

Standard $169.00 $286.00 $322.00 $333.00 $108.00 $300.00 $169.00 $242.00 $233.00


Age 91

Standard $170.00 $288.00 $323.00 $334.00 $109.00 $301.00 $170.00 $243.00 $234.00


Age 92

Standard $170.00 $289.00 $325.00 $336.00 $109.00 $302.00 $170.00 $244.00 $235.00


Age 93

Standard $171.00 $290.00 $326.00 $337.00 $110.00 $303.00 $171.00 $245.00 $236.00


Age 94

Standard $172.00 $291.00 $327.00 $338.00 $110.00 $305.00 $172.00 $246.00 $237.00


Age 95

Standard $173.00 $292.00 $329.00 $340.00 $111.00 $306.00 $173.00 $247.00 $238.00


Age 96

Standard $173.00 $294.00 $330.00 $341.00 $111.00 $307.00 $173.00 $248.00 $239.00


Age 97

Standard $174.00 $295.00 $331.00 $343.00 $111.00 $308.00 $174.00 $249.00 $240.00


Age 98

Standard $175.00 $296.00 $333.00 $344.00 $112.00 $310.00 $175.00 $250.00 $241.00


Age 99+

Standard $175.00 $297.00 $334.00 $345.00 $112.00 $311.00 $175.00 $251.00 $242.00


You have the option to purchase any of the Medicare Supplement benefit plans shown on the front cover in white as Standard Plans or as Medicare Select Plans, with the exception of Plan A and High Deductible Plan F,* which are available as Standard Plans only. Medicare Select Plans require that you use a Blue Cross and Blue Shield of Illinois contracting Medicare Select hospital for non-emergency admissions to receive coverage for the Medicare Part A deductible.PREMIUM INFORMATIONBlue Cross and Blue Shield of Illinois can only raise your premium if we raise the premium for all policies like yours in the state. We will not change your premium or cancel your policy because of poor health. Premiums change at age 65 and every year thereafter up to age 100. If your premium changes, you will be notified at least 30 days in advance.* This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,110 deductible. Benefits from High

Deductible Plan F will not begin until out-of-pocket expenses are $2,110. 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.

5

DISCLOSURES

Use this outline to compare benefits and premiums among policies.

READ YOUR POLICY VERY CAREFULLYThis 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 YOUR POLICYIf you find that you are not satisfied with your policy, you may return it to Medicare Supplement Membership, P.O. Box 3004, Naperville, IL 60566. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and will return all of your payments.

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

NOTICEThis policy may not fully cover all of your medical costs. Neither Blue Cross and Blue Shield of Illinois nor its agents are connected with Medicare. This Outline of Coverage does not give you all the details of Medicare coverage. Contact your local Social Security Office or consult “Medicare & You” for more details.

COMPLETE ANSWERS ARE VERY IMPORTANTReview the application carefully before you sign it. Be certain that all information has been properly recorded.

MEDICARE SELECT ADDITIONAL DISCLOSURES

GRIEVANCE PROCEDURESOur goal is your 100% satisfaction with our processing of your coverage. Should you ever not be fully satisfied with any aspect of the services you receive, we want to know about it so we can correct it.

If you have any dissatisfaction with your Medicare Select coverage, please send all written grievances within 60 days of the occurrence of your dissatisfaction to: Medicare Supplement Grievance Committee, PO Box 3122, Naperville, IL 60566-9744 or fax (888) 235-2936.

Your grievance will be reviewed by our Grievance Committee. Upon review of your grievance, we will mail you a response within 30 days from the receipt of your written correspondence. If additional information from an outside source is required, we may require an additional 30 days to research, finalize and respond to your correspondence. In no case will a complete response from us take more than 60 days.

If you are dissatisfied with the decision of our Grievance Committee you may submit a written complaint to the Illinois Insurance Department, 320 Washington Street, 4th Floor, Springfield, Illinois 62766 or call (217) 782-4515.

QUALITY ASSURANCEAs part of our Quality Assurance program, all

contracted hospitals must meet Medicare standards. In addition, hospitals must meet the contract criteria stated in the Hospital Agreement.Each hospital must: agree to maintain its state licensure; agree to maintain its Blue Cross and Blue Shield of Illinois Plan Hospital status; agree to maintain its Medicare participating status; be accredited and maintain its accreditation by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) or the American Osteopathic Association (AOA); and agree to waive the Part A deductible.

MEDICARE SELECT HOSPITAL RESTRICTIONSPlans B, C, F, G, K, L and N are Medicare Select policies currently available. Part A benefits may be restricted if you receive services in a hospital that is not a Medicare Select Hospital.The full benefits of your coverage, excluding Plan K & L coinsurance, will be paid anywhere if:1. Services are provided in a Doctor’s office, another

office setting, or in a skilled nursing facility;2. The services are for symptoms requiring emergency

care or are immediately required for an unforeseen illness, injury or condition and it is not reasonable to obtain such services from a Medicare Select Hospital (such as while you are traveling); or

3. Covered services are not available through a Medicare Select Hospital.

6

Plan A

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

Services Medicare Pays Plan Pays You Pay

HOSPITALIZATION*

Semiprivate room and board, general nursing,

and miscellaneous services and supplies

First 60 days

61st through 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 $1,184

All but $296 a day

All but $592 a day

$0

$0

$0

$296 a day

$592 a day

100% of Medicare-

eligible expenses

$0

$1,184 (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


101st day and after

All approved amounts

All but $148 a day

$0

$0

$0

$0

$0

Up to $148 a day

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE


including a doctor’s certification of

terminal illness

All but very limited

copayment/coinsurance

for outpatient drugs and

inpatient respite care

Medicare copayment/

coinsurance

$0

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

7

Plan A

MEDICARE PART B MEDICAL SERVICES PER CALENDAR YEAR.

* Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.


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 $147 of Medicare-approved amounts*

Remainder of Medicare-approved amounts

$0

Generally 80%

$0

Generally 20%

$147 (Part B deductible)

$0

PART B EXCESS CHARGES (above Medicare-approved amounts)

$0 $0 All costs

BLOOD

First 3 pints

Next $147 of Medicare-approved amounts*


$0

$0

80%

All costs

$0

20%

$0


$0

CLINICAL LABORATORY SERVICES — TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

MEDICARE PARTS A & B

HOME HEALTH CARE

MEDICAREAPPROVED SERVICES

– Medically necessary skilled care

services and medical supplies

– Durable medical equipment

First $147 of

Medicare-approved amounts*

Remainder of

Medicare-approved amounts

100%

$0

80%

$0

$0

20%

$0


$0


8

Plan B

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

* 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.


HOSPITALIZATION*



First 60 days


91st day and after:





All but $1,184

All but $296 a day

All but $592 a day

$0

$0

$1,184 (Part A deductible)1

$296 a day

$592 a day

100% of Medicare-

eligible expenses

$0

$0

$0

$0

$0**

All costs


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


101st day and after


All but $148 a day

$0

$0

$0

$0

$0

Up to $148 a day

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE



terminal illness





Medicare copayment/

coinsurance

$0

1 Medicare Select Plans require that you use Blue Cross and Blue Shield of Illinois contracting Medicare Select hospitals for non-emergency admissions to

receive coverage for the Medicare Part A deductible. In an emergency, the $1,184 deductible is covered at any hospital from which you receive care.

** 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.

9

Plan B

MEDICARE PART B MEDICAL SERVICES PER CALENDAR YEAR.

* Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible

will have been met for the calendar year.










$0

Generally 80%

$0

Generally 20%


$0


$0 $0 All costs

BLOOD

First 3 pints



$0

$0

80%

All costs

$0

20%

$0


$0


100%

$0

$0



HOME HEALTH CARE

MEDICAREAPPROVED SERVICES

– Medically necessary skilled care

services and medical supplies


First $147 of

Medicare-approved amounts*


100%

$0

80%

$0

$0

20%

$0


$0

10

Plan C





HOSPITALIZATION*



First 60 days


91st day and after:





All but $1,184

All but $296 a day

All but $592 a day

$0

$0


$296 a day

$592 a day

100% of Medicare-

eligible expenses

$0

$0

$0

$0

$0**

All costs






First 20 days


101st day and after


All but $148 a day

$0

$0

Up to $148 a day

$0

$0

$0

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE



terminal illness





Medicare copayment/

coinsurance

$0



** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever

amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is


11

Plan C

MEDICARE PART B MEDICAL SERVICES PER CALENDAR YEAR

* Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B

deductible will have been met for the calendar year.










$0

Generally 80%


Generally 20%

$0

$0

PART B EXCESS CHARGES

(above Medicare-approved amounts)

$0 $0 All costs

BLOOD

First 3 pints



$0

$0

80%

All costs


20%

$0

$0

$0

CLINICAL LABORATORY SERVICES — TESTS FOR

DIAGONOSTIC SERVICES

100%

$0

$0



HOME HEALTH CARE MEDICAREAPPROVED SERVICES

– Medically necessary skilled care services

and medical supplies




100%

$0

80%

$0


20%

$0

$0

$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

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

12

Plan F





HOSPITALIZATION*



First 60 days


91st day and after:





All but $1,184

All but $296 a day

All but $592 a day

$0

$0


$296 a day

$592 a day

100% of Medicare-

eligible expenses

$0

$0

$0

$0

$0**

All costs






First 20 days


101st day and after


All but $148 a day

$0

$0

Up to $148 a day

$0

$0

$0

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE



terminal illness





Medicare copayment/

coinsurance

$0



** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount

Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited

from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

13

Plan F


* Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will

have been met for the calendar year.










$0

Generally 80%


Generally 20%

$0

$0


$0 100% $0

BLOOD

First 3 pints



$0

$0

80%

All costs


20%

$0

$0

$0


100%

$0

$0



HOME HEALTH CARE MEDICAREAPPROVED SERVICES – Medically necessary skilled care services


– Durable medical equipment First $147 of Medicare-approved amounts*


100%

$0

80%

$0


20%

$0

$0

$0


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



$0

$0

$0

80% to a lifetime

maximum benefit

of $50,000

$250

20% and amounts

over the $50,000

lifetime maximum

14

High Deductible Plan F

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

** This high deductible plan pays the same benefits as Plan F after one has paid a calendar-year $2,110 deductible.

Benefits from High Deductible Plan F will not begin until out-of-pocket expenses are $2,110. Out-of-pocket expenses for

this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A

and Part B, but does not include the plan’s separate foreign travel emergency deductible.

Services Medicare Pays After You Pay $2,110

Deductible**, Plan Pays

In addition To $2,110

Deductible**, You Pay

HOSPITALIZATION*



First 60 days


91st day and after:





All but $1,184

All but $296 a day

All but $592 a day

$0

$0

$1,184 (Part A deductible)

$296 a day

$592 a day

100% of Medicare- eligible expenses

$0

$0

$0

$0

$0***

All costs



First 20 days


101st day and after


All but $148 a day

$0

$0

Up to $148 a day

$0

$0

$0

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE



terminal illness





Medicare copayment/

coinsurance

$0

*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount

Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is


15

High Deductible Plan F


* Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

Services Medicare PaysAfter You Pay $2,110












$0

Generally 80%


Generally 20%

$0

$0


$0 100% $0

BLOOD

First 3 pints



$0

$0

80%

All costs


20%

$0

$0

$0


100%

$0

$0


Services Medicare PaysAfter You Pay $2,110




HOME HEALTH CARE MEDICAREAPPROVED SERVICES – Medically necessary skilled care services





100%

$0

80%

$0


20%

$0

$0

$0


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



$0

$0

$0

80% to a lifetime maximum

benefit of $50,000

$250

20% and amounts over the

$50,000 lifetime maximum

16

Plan G





HOSPITALIZATION*



First 60 days


91st day and after:





All but $1,184

All but $296 a day

All but $592 a day

$0

$0


$296 a day

$592 a day

100% of Medicare-

eligible expenses

$0

$0

$0

$0

$0**

All costs






First 20 days


101st day and after


All but $148 a day

$0

$0

Up to $148 a day

$0

$0

$0

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE



terminal illness





Medicare copayment/

coinsurance

$0






17

Plan G













$0

Generally 80%

$0

Generally 20%


$0


$0 100% $0

BLOOD

First 3 pints



$0

$0

80%

All costs

$0

20%

$0


$0


100%

$0

$0



HOME HEALTH CARE MEDICAREAPPROVED

SERVICES






100%

$0

80%

$0

$0

20%

$0


$0


FOREIGN TRAVEL —NOT COVERED BY MEDICARE



outside the USA



$0

$0

$0

80% to a lifetime

maximum benefit

of $50,000

$250

20% and amounts

over the $50,000

lifetime maximum

18

Plan K * You will pay half of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $4,800 each calendar year.

The amounts that count toward your annual limit are noted with diamonds (�) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, the limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.


** 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.

Services Medicare Pays Plan Pays You Pay*

HOSPITALIZATION**



First 60 days


91st day and after:





All but $1,184

All but $296 a day

All but $592 a day

$0

$0

$592 (50% of Part A

deductible)1

$296 a day

$592 a day

100% of Medicare-eligible

expenses

$0

$592 (50% of Part A

deductible)�

$0

$0

$0***

All costs

SKILLED NURSING FACILITY CARE**


First 20 days


101st day and after


All but $148 a day

$0

$0

Up to $74 a day

$0

$0

Up to $74 a day�

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

50%

$0

50%�

$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�


receive coverage for the Medicare Part A deductible. In an emergency, 50% of the $1,184 deductible is covered at any hospital from which you receive care.

*** 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.

19

Plan K


† This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $4,800 per year. However, this limit does NOT

include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be

responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or

service.








First $147 of Medicare-approved amounts****

Preventive benefits for

Medicare-covered services


$0

Generally 75% or more of


Generally 80%

$0

Remainder of


Generally 10%

$147 (Part B deductible)****�

All costs above Medicare-

approved amounts

Generally 10%�


$0 $0 All costs (and they do not count toward annual out-of- pocket limit of $4,800)†

BLOOD

First 3 pints

Next $147 of Medicare-approved amounts****


$0

$0

Generally 80%

50%

$0

Generally 10%

50%�


Generally 10%�


100%

$0

$0







First $147 of Medicare-approved amounts*****


100%

$0

80%

$0

$0

10%

$0

$147 (Part B deductible)�

Generally 10%�

**** Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with asterisks), your Part B deductible


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

20

Plan L* You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2,400 each calendar year. The

amounts that count toward your annual limit are noted with diamonds (�) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, the limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.


** 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.


HOSPITALIZATION**



First 60 days


91st day and after:





All but $1,184

All but $296 a day

All but $592 a day

$0

$0

$888 (75% of Part A

deductible)1

$296 a day

$592 a day

100% of Medicare-

eligible expenses

$0

$296�(25% of Part A

deductible)�

$0

$0

$0***

All costs

SKILLED NURSING FACILITY CARE**


First 20 days


101st day and after


All but $148 a day

$0

$0

Up to $111 a day

$0

$0

Up to $37 a day�

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

75%

$0

25%�

$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�


receive coverage for the Medicare Part A deductible. In an emergency, 75% of the $1,184 deductible is covered at any hospital from which you receive care.

*** 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.

21

Plan L


† This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2,400 per year. However, this limit does NOT

include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be

responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or

service.








First $147 of Medicare-approved amounts****

Preventive benefits for

Medicare-covered services


$0

Generally 75% or more of


Generally 80%

$0

Remainder of


Generally 15%


All costs above Medicare-

approved amounts

Generally 5%�


$0 $0 All costs (and they do not count toward annual out-of- pocket limit of $2,400)†

BLOOD

First 3 pints

Next $147 of Medicare-approved amounts****


$0

$0

Generally 80%

75%

$0

Generally 15%

25%�


Generally 5%�


100%

$0

$0







First $147 of Medicare-approved amounts*****


100%

$0

80%

$0

$0

15%

$0

$147 (Part B deductible)�

Generally 5%�

**** Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with asterisks), your Part B deductible


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

22

Plan N





HOSPITALIZATION*



First 60 days


91st day and after:





All but $1,184

All but $296 a day

All but $592 a day

$0

$0


$296 a day

$592 a day

100% of Medicare-

eligible expenses

$0

$0

$0

$0

$0**

All costs



First 20 days


101st day and after


All but $148 a day

$0

$0

Up to $148 a day

$0

$0

$0

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE



terminal illness





Medicare copayment/

coinsurance

$0






23

Plan N













$0

Generally 80%

$0

Balance, other than up to

$20 per office visit and up

to $50 per emergency room

visit. The copayment of

up to $50 is waived if the

insured is admitted to any

hospital and the emergency

visit is covered as a Medicare

Part A expense.


Up to $20 per office

visit and up to $50 per

emergency room visit.

The copayment of up to

$50 is waived if the insured

is admitted to any hospital

and the emergency visit is

covered as a Medicare Part

A expense.


$0 $0 All costs

BLOOD

First 3 pints



$0

$0

80%

All costs

$0

20%

$0


$0


100%

$0

$0

24

Plan N









100%

$0

80%

$0

$0

20%

$0


$0


FOREIGN TRAVEL — NOT COVERED BY MEDICARE



outside the USA



$0

$0

$0

80% to a lifetime

maximum benefit

of $50,000

$250

20% and amounts

over the $50,000

lifetime maximum


Documents

Application for Medicare Supplement Insurance Plan · 2013. 8. 30. · If eligible for a Medicare Select Plan, I have also read and understand the statements regarding Medicare Select