Section 2008.45  Creditable coverage

 

Creditable coverage means:

 

a)         With respect to an individual, coverage of the individual provided under any of the following:

 

1)         A group health plan;

 

2)         Health insurance coverage;

 

3)         Part A or Part B of Title XVIII of the Social Security Act (Medicare);

 

4)         Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under Section 1928;

 

5)         Chapter 55 (CHAMPUS) (10 USC);

 

6)         A medical care program of the Indian Health Service or of a tribal organization;

 

7)         A state health benefits risk pool;

 

8)         A health plan offered under Chapter 89 (Federal Employees Health Benefits Program) (5 USC);

 

9)         A public health plan as defined in federal regulation; and

 

10)         A health benefit plan under Section 5(e) of the Peace Corps Act (22 USC 2504(e)).

 

b)         Creditable coverage shall not include one or more, or any combination, of the following:

 

1)         Coverage only for accident and disability income insurance, or any combination thereof;

 

2)         Coverage issued as a supplement to liability insurance;

 

3)         Liability insurance, including general liability insurance and automobile liability insurance;

 

4)         Workers' compensation or similar insurance;

 

5)         Automobile medical payment insurance;

 

6)         Credit-only insurance;

 

7)         Coverage for on-site medical clinics; and

 

8)         Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

 

c)         Creditable coverage shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:

 

1)         Limited scope dental or vision benefits;

 

2)         Benefits for traditional long-term care or long-term care partnership insurance, nursing home care, home health care, community-based care, or any combination thereof; and

 

3)         Such other similar, limited benefits as are specified in federal regulations.

 

d)         Creditable coverage shall not include the following benefits if offered as independent, noncoordinated benefits:

 

1)         Coverage only for a specified disease or illness; and

 

2)         Hospital indemnity or other fixed indemnity insurance.

 

e)         Creditable coverage shall not include the following if it is offered as a separate policy, certificate or contract of insurance:

 

1)         Medicare supplemental health insurance as defined under section 1882(g)(1) of the Social Security Act (42 USC 1395ss(g)(1));

 

2)         Coverage supplemental to the coverage provided under Chapter 55 (10 USC); and

 

3)         Similar supplemental coverage provided under a group health plan.

 

(Source:  Amended at 42 Ill. Reg. 21625, effective November 26, 2018)

 

Section 2008.50  Policy Definitions and Terms

 

No policy or certificate may be advertised, solicited or issued for delivery in this State as a Medicare supplement policy or certificate unless that policy or certificate contains definitions or terms that conform to the requirements of this Section.

 

"Accident", "Accidental Injury" or "Accidental Means" shall be defined to employ "result" language and shall not include words which establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization.

 

The definition shall not be more restrictive than the following:  "Injury or injuries for which benefits are provided means accidental bodily injury sustained by the insured person that is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while the insurance is in force."

 

That definition may provide that injuries shall not include injuries for which benefits are provided or available under any workers' compensation, employer's liability or similar law, or motor vehicle no fault plan, unless prohibited by law.

 

"Benefit Period" or "Medicare Benefit Period" shall not be defined more restrictively than as defined in the Medicare program.

 

"Convalescent Nursing Home", "Extended Care Facility" or "Skilled Nursing Facility" shall not be defined more restrictively than as defined in the Medicare program.

 

"Duplication of Insurance" means a transaction in which new accident and health insurance is to be purchased and it is known to the producer or should be known to the producer or the issuer, in the case of a direct response solicitation, that the new insurance will provide some of the benefits or coverages which the proposed insured already has under existing accident and health insurance.

 

"Health Care Expenses", for purposes of Section 2008.80, means expenses of a nonprofit health, hospital or medical service corporation, prepaid health plan or similar organization associated with the delivery of health care services in which providers of the health care services are reimbursed for such services on an other than fee for service basis that are analogous to incurred losses of insurers. 

 

"Hospital" may be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission but not more restrictively than as defined in the Medicare program.

 

"Medicare" shall be defined in the policy and certificate as "The Health Insurance for the Aged and Disabled Act, Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended", or "Title I, Part I of Public Law 89-97, as enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged and Disabled Act, as then constituted and any later amendments or substitutes thereof", or words of similar import.

 

"Medicare Eligible Expenses" shall mean expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.

 

"Over-Insurance" means duplication of insurance to such extent that the combination of the existing insurance and the proposed insurance would substantially exceed any loss reasonably expected to be incurred.

 

"Physician" shall not be defined more restrictively than as defined in the Medicare program.

 

"Sickness" shall not be defined more restrictively than the following:  "Sickness means illness or disease of an insured person which first manifests itself after the effective date of insurance and while the insurance is in force."  The definition may be further modified to exclude sicknesses or diseases for which benefits are provided under any workers' compensation, occupational disease, employer's liability or similar law.

 

(Source:  Amended at 42 Ill. Reg. 21625, effective November 26, 2018)

 

Section 2008.60  Policy Provisions

 

a)         Except for permitted preexisting condition clauses as described in Section 2008.70(a)(1), Section 2008.71(a)(1), and Section 2008.64(a)(1) of this Part, no policy or certificate may be advertised, solicited or issued for delivery in this State as a Medicare supplement policy if such policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.

 

b)         No Medicare supplement policy or certificate may use waivers to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions.

 

c)         No Medicare supplement policy or certificate in force in the State shall contain benefits which duplicate benefits provided by Medicare.

 

d)         Subject to Sections 2008.70(a)(4), (5) and (7) and 2008.71(a)(4) and (5):

 

1)         A Medicare supplement policy with benefits for outpatient prescription drugs in existence prior to January 1, 2006 shall be renewed for current policyholders who do not enroll in Part D at the option of the policyholder.

 

2)         A Medicare supplement policy with benefits for outpatient prescription drugs shall not be issued after December 31, 2005.

 

3)         After December 31, 2005, a Medicare supplement policy with benefits for outpatient prescription drugs will not be renewed after the policyholder enrolls in Medicare Part D unless:

 

A)        The policy is modified to eliminate outpatient prescription coverage for expenses of outpatient prescription drugs incurred after the effective date of the individual's coverage under a Part D plan; and

 

B)        Premiums are adjusted to reflect the elimination of outpatient prescription drug coverage at the time of Medicare Part D enrollment, accounting for any claims paid, if applicable.

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)

 

Section 2008.61  Benefit Conversion Requirements During Transition (Repealed)

 

(Source:  Repealed at 16 Ill. Reg. 2766, effective February 11, 1992; corrected at 16 Ill. Reg. 3590)

 

Section 2008.63  Standard Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals Newly Eligible for Medicare on or after January 1, 2020

 

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10, added 42 USC 1395ss(z)), which imposes the following standards on all Medicare supplement policies or certificates delivered or issued for delivery in this State to individuals newly eligible for Medicare on or after January 1, 2020.  No policy or certificate that provides coverage of the Medicare Part B deductible may be advertised, solicited, delivered, or issued for delivery in this State as a Medicare supplement policy or certificate to individuals newly eligible for Medicare on or after January 1, 2020.  All policies must comply with the following benefit plan standards.  Benefit plan standards applicable to Medicare supplement policies and certificates issued to individuals eligible for Medicare before January 1, 2020 remain subject to the requirements of Section 2008.70 for Pre-Standardized Plans, Section 2008.71 for 1990 Plans, or Section 2008.64 for 2010 Plans.

 

a)         Benefit Requirement. The standards and requirements of Section 2008.67 shall apply to all Medicare supplement policies or certificates delivered or issued for delivery to individuals newly eligible for Medicare on or after January 1, 2020, with the following exceptions:

 

1)         Standardized Medicare Supplement Benefit Plan C is redesignated as Plan D and shall provide the benefits contained in Section 2008.67(f)(3) but shall not provide coverage for 100% or any portion of the Medicare Part B deductible.

 

2)         Standardized Medicare Supplement Benefit Plan F is redesignated as Plan G and shall provide the benefits contained in Section 2008.67(f)(5) but shall not provide coverage for 100% or any portion of the Medicare Part B deductible.

 

3)         Standardized Medicare Supplement Benefit Plans C, F and F with High Deductible may not be offered to individuals newly eligible for Medicare on or after January 1, 2020.

 

4)         Standardized Medicare Supplement Benefit Plan F with High Deductible is redesignated as Plan G with High Deductible and shall provide the benefits contained in Section 2008.67(f)(6) but shall not provide coverage for 100% or any portion of the Medicare Part B deductible. In addition, the Medicare Part B deductible paid by the beneficiary shall be considered an out-of-pocket expense in meeting the annual high deductible.

 

5)         The reference to Plans C or F contained in Section 2008.67(b) is deemed a reference to Plans D or G, respectively, for purposes of this Section.

 

b)         Applicability to Certain Individuals. This Section applies only to individuals that are newly eligible for Medicare on or after January 1, 2020:

 

1)         By reason of attaining age 65 on or after January 1, 2020; or

 

2)         By reason of entitlement to benefits under Part A pursuant to section 226(b) or 226A of the Social Security Act or being deemed eligible for benefits under section 226(a) of the Social Security Act on or after January 1, 2020.

 

c)         Guaranteed Issue for Eligible Persons. For purposes of Section 2008.75(e), in the case of any individual newly eligible for Medicare on or after January 1, 2020, any reference to a Medicare supplement policy C or F (including F with High Deductible) shall be deemed to be a reference to Medicare supplement policy D or G (including G with High Deductible), respectively, that meets the requirements of this Section.

 

d)         Offer of Redesignated Plans to Individuals Other Than Newly Eligible.  On or after January 1, 2020, the standardized benefit plans described in subsection (a)(4) may be offered to any individual who was eligible for Medicare prior to January 1, 2020, in addition to the standardized plans described in Section 2008.67(f).

 

(Source:  Amended at 47 Ill. Reg. 5701, effective April 4, 2023)

 

Section 2008.64  Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date for Coverage on or after June 1, 2010

 

The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this State with an effective date for coverage on or after June 1, 2010.  No policy or certificate may be advertised, solicited, delivered, or issued for delivery in this State as a Medicare supplement policy or certificate unless it complies with these benefit standards.  No issuer may offer any 1990 Standardized Medicare supplement benefit plan for sale on or after June 1, 2010.  Benefit standards applicable to Medicare supplement policies and certificates issued with an effective date for coverage before June 1, 2010 remain subject to the requirements of Section 2008.70 for Pre-Standardized Plans or Section 2008.71 for 1990 Plans. 

 

a)         General Standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this Part.

 

1)         A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than 6 months from the effective date of coverage because it involved a preexisting condition. The policy or certificate may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.

 

2)         A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.

 

3)         A Medicare supplement policy or certificate shall provide that benefits designed to cover cost sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible, copayment, or coinsurance amounts.  Premiums may be modified to correspond with such changes.

 

4)         No Medicare supplement policy or certificate shall provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premium.

 

5)         Each Medicare supplement policy shall be guaranteed renewable.

 

A)        The issuer shall not cancel or nonrenew the policy solely on the ground of health status of the individual.

 

B)        The issuer shall not cancel or nonrenew the policy for any reason other than nonpayment of premium or material misrepresentation.

 

C)        If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under subsection (a)(5)(E), the issuer shall offer certificateholders an individual Medicare supplement policy which, at the option of the certificateholder:

 

i)          Provides for continuation of the benefits contained in the group policy; or

 

ii)         Provides for benefits that otherwise meet the requirements of this subsection.

 

D)        If an individual is a certificateholder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall:

 

i)          Offer the certificateholder the conversion opportunity described in subsection (a)(5)(C); or

 

ii)         At the option of the group policyholder, offer the certificateholder continuation of coverage under the group policy.

 

E)        If a group Medicare supplement policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced.

 

6)         Termination of a Medicare supplement policy or certificate shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be conditioned upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.

 

7)         A Medicare supplement policy or certificate shall provide that benefits and premiums under the policy or certificate shall be suspended at the request of the policyholder or certificateholder for the period in which the policyholder or certificateholder has applied for, and is determined to be entitled to medical assistance under Title XIX of the Social Security Act (42 USC 1901-1941), but only if the policyholder or certificateholder notifies the issuer of the policy or certificate within 90 days after the date the individual becomes entitled to assistance.  In no case shall the suspension exceed 24 months.

 

A)        If suspension occurs and if the policyholder or certificateholder loses entitlement to medical assistance, the policy or certificate shall be automatically reinstituted, effective as of the date of termination of entitlement, if the policyholder or certificateholder provides notice of loss of entitlement within 90 days after the date of loss and pays the premium attributable to the period, effective as of the date of termination of entitlement.

 

B)        Each Medicare supplement policy shall provide that benefits and premiums under the policy shall be suspended for any period that may be provided by federal regulation at the request of the policyholder if the policyholder is entitled to benefits under section 226(b) of the Social Security Act (42 USC 426(b)) and is covered under a group health plan (as defined in section 1862(b)(1)(A)(v) of the Social Security Act (42 USC 1395y(b)(1)(A)(v)). If suspension occurs and if the policyholder or certificate holder loses coverage under the group health plan, the policy shall be automatically reinstituted, effective as of the date of loss of coverage, if the policyholder provides notice of loss of coverage within 90 days after the date of the loss and pays the premium attributable to the period, effective as of the date of termination of enrollment in the group health plan.

 

C)        Reinstitution of coverages as described in subsections (a)(7)(A) and (B):

 

i)          Shall not provide for any waiting period with respect to treatment of preexisting conditions;

 

ii)         Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension; and

 

iii)        Shall provide for classification of premiums on terms at least as favorable to the policyholder or certificateholder as the premium classification terms that would have applied to the policyholder or certificateholder had the coverage not been suspended.

 

b)         Standards for Basic (Core) Benefits Common to Medicare Supplement Insurance Benefit Plans A, B, C, D, F, F with High Deductible, G, M and N.  Every issuer of Medicare supplement insurance benefit plans shall make available a policy or certificate including only the following basic "core" package of benefits to each prospective insured. An issuer may make available to prospective insureds any of the other Medicare Supplement Insurance Benefit Plans in addition to the basic core package, but not in lieu of it.

 

1)         Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61^st day through the 90^th day in any Medicare benefit period;

 

2)         Coverage of Part A Medicare eligible expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used;

 

3)         Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance;

 

4)         Coverage under Medicare Parts A and B for the reasonable cost of the first 3 pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations;

 

5)         Coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible;

 

6)         Hospice Care: Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses.

 

c)         Standards for Additional Benefits. The following additional benefits shall be included in Medicare supplement benefit Plans B, C, D, F, F with High Deductible, G, M and N as provided by Section 2008.67. 

 

1)         Medicare Part A Deductible:  Coverage for 100% of the Medicare Part A inpatient hospital deductible amount per benefit period.

 

2)         Medicare Part A Deductible:  Coverage for 50% of the Medicare Part A inpatient hospital deductible amount per benefit period.

 

3)         Skilled Nursing Facility Care:  Coverage for the actual billed charges up to the coinsurance amount from the 21^st day through the 100^th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A.

 

4)         Medicare Part B Deductible:  Coverage for 100% of the Medicare Part B deductible amount per calendar year regardless of hospital confinement.

 

5)         One Hundred Percent of the Medicare Part B Excess Charges:  Coverage for all of the difference between the actual Medicare Part B charges as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge.

 

6)         Medically Necessary Emergency Care in a Foreign Country:  Coverage to the extent not covered by Medicare for 80% of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during the 60 consecutive days of each trip outside the United States, subject to a calendar year deductible of $250, and a lifetime maximum benefit of $50,000. For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset.

 

(Source:  Amended at 42 Ill. Reg. 21625, effective November 26, 2018)

 

Section 2008.67  Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date for Coverage on or after June 1, 2010

 

The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this State with an effective date for coverage on or after June 1, 2010.  No policy or certificate may be advertised, solicited, delivered or issued for delivery in this State as a Medicare supplement policy or certificate unless it complies with these benefit plan standards.  Benefit plan standards applicable to Medicare supplement policies and certificates issued with an effective date for coverage before June 1, 2010 remain subject to the requirements of Section 2008.70 for Pre-Standardized Plans or Section 2008.71 for 1990 Plans. 

 

a)         An issuer shall make available to each prospective policyholder and certificateholder a policy form or certificate form containing only the basic (core) benefits, as defined in Section 2008.64(b).

 

b)         If an issuer makes available any of the additional benefits described in Section 2008.64(c), or offers standardized benefit Plans K or L as described in subsections (f)(8) and (9) of this Section, then the issuer shall make available to each prospective policyholder and certificateholder, in addition to a policy form or certificate form with only the basic (core) benefits as described in subsection (a), a policy form or certificate form containing either standardized benefit Plan C as described in subsection (f)(3) or standardized benefit Plan F as described in subsection (f)(5). 

 

c)         No groups, packages or combinations of Medicare supplement benefits other than those listed in this Section shall be offered for sale in this State, except as may be permitted in subsection (g) and in Section 2008.73.

 

d)         Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans listed in this subsection and conform to the definitions in Sections 2008.40 and 2008.50. Each benefit shall be structured in accordance with the format provided in Section 2008.64(b) and (c); or, in the case of plans K or L, in subsection (f)(8) or (f)(9) and list the benefits in the order shown. For purposes of this Section, "structure, language, and format" means style, arrangement and overall content of a benefit.

 

e)         In addition to the benefit plan designations required in subsection (d) of this Section, an issuer may use other designations to the extent permitted by law.

 

f)         Make-up of 2010 Standardized Benefit Plans:

 

1)         Standardized Medicare supplement benefit Plan A shall include only the following:  The basic (core) benefits as defined in Section 2008.64(b).

 

2)         Standardized Medicare supplement benefit Plan B shall include only the following: The basic (core) benefit as defined in Section 2008.64(b), plus 100% of the Medicare Part A deductible as defined in Section 2008.64(c)(1).

 

3)         Standardized Medicare supplement benefit Plan C shall include only the following: The basic (core) benefit as defined in Section 2008.64(b), plus 100% of the Medicare Part A deductible, skilled nursing facility care, 100% of the Medicare Part B deductible, and medically necessary emergency care in a foreign country as defined in Section 2008.64(c)(1), (3), (4), and (6), respectively.

 

4)         Standardized Medicare supplement benefit Plan D shall include only the following: The basic (core) benefit (as defined in Section 2008.64(b) of this Part), plus 100% of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in an foreign country as defined in Section 2008.64(c)(1), (3), and (6), respectively.

 

5)         Standardized Medicare supplement (regular) Plan F shall include only the following: The basic (core) benefit as defined in Section 2008.64(b), plus 100% of the Medicare Part A deductible, the skilled nursing facility care, 100% of the Medicare Part B deductible, 100% of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in Section 2008.64(c)(1), (3), (4), (5), and (6), respectively.

 

6)         Standardized Medicare supplement Plan F With High Deductible shall include only the following: 100% of covered expenses following the payment of the annual deductible set forth in subsection (f)(6)(B).

 

A)        The basic (core) benefit as defined in Section 2008.64(b), plus 100% of the Medicare Part A deductible, skilled nursing facility care, 100% of the Medicare Part B deductible, 100% of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in Section 2008.64(c)(1), (3), (4), (5), and (6), respectively.

 

B)        The annual deductible in Plan F With High Deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by (regular) Plan F, and shall be in addition to any other specific benefit deductibles. The basis for the deductible shall be $1,500 and shall be adjusted annually from 1999 by the Secretary of the U.S. Department of Health and Human Services to reflect the change in the Consumer Price Index for all urban consumers for the 12-month period ending with August of the preceding year, and rounded to the nearest multiple of $10.

 

7)         Standardized Medicare supplement benefit Plan G shall include only the following: The basic (core) benefit as defined in Section 2008.64(b), plus 100% of the Medicare Part A deductible, skilled nursing facility care, 100% of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in Section 2008.64(c)(1), (3), (5), and (6), respectively. Effective January 1, 2020, the standardized benefit plans described in Section 2008.63(a)(4) (Redesignated Plan G with High Deductible) may be offered to any individual who was eligible for Medicare prior to January 1, 2020.

 

8)         Standardized Medicare supplement Plan K is mandated by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:

 

A)        Part A Hospital Coinsurance 61^st through 90^th days: Coverage of 100% of the Part A hospital coinsurance amount for each day used from the 61^st through the 90^th day in any Medicare benefit period;

 

B)        Part A Hospital Coinsurance, 91^st through 150^th days: Coverage of 100% of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91^st through the 150^th day in any Medicare benefit period;

 

C)        Part A Hospitalization After 150 Days: Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance;

 

D)        Medicare Part A Deductible: Coverage for 50% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subsection (f)(8)(J);

 

E)        Skilled Nursing Facility Care: Coverage for 50% of the coinsurance amount for each day used from the 21^st day through the 100^th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subsection (f)(8)(J);

 

F)         Hospice Care: Coverage for 50% of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subsection (f)(8)(J);

 

G)        Blood: Coverage for 50%, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations until the out-of-pocket limitation is met as described in subsection (f)(8)(J);

 

H)        Part B Cost Sharing: Except for coverage provided in subsection (f)(8)(I), coverage for 50% of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in subsection (f)(8)(J);

 

I)         Part B Preventive Services: Coverage of 100% of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and

 

J)         Cost Sharing After Out-of-Pocket Limits: Coverage of 100% of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $4000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.

 

9)         Standardized Medicare supplement Plan L is mandated by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:

 

A)        The benefits described in subsections (f)(8)(A), (B), (C) and (I);

 

B)        The benefit described in subsections (f)(8)(D), (E), (F), (G) and (H), but substituting 75% for 50%; and

 

C)        The benefit described in subsection (f)(8)(J), but substituting $2000 for $4000.

 

10)         Standardized Medicare supplement Plan M shall include only the following: The basic (core) benefit as defined in Section 2008.64(b), plus 50% of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in Section 2008.64(c)(2), (3) and (6), respectively.

 

11)         Standardized Medicare supplement Plan N shall include only the following: The basic (core) benefit as defined in Section 2008.64(b), plus 100% of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in Section 2008.64(c)(1), (3) and (6), respectively, with copayments in the following amounts: 

 

A)        the lesser of $20 or the Medicare Part B coinsurance or copayment for each covered health care provider office visit (including visits to medical specialists); and

 

B)        the lesser of $50 or the Medicare Part B coinsurance or copayment for each covered emergency room visit; however, this copayment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense. 

 

g)         New or Innovative Benefits: An issuer may, with the prior approval of the Director, offer policies or certificates with new or innovative benefits, in addition to the standardized benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits shall include only benefits that are appropriate to Medicare supplement insurance, are new or innovative, are not otherwise available, and are cost-effective.  Approval of new or innovative benefits must not adversely impact the goal of Medicare supplement simplification.  New or innovative benefits shall not include an outpatient prescription drug benefit.  New or innovative benefits shall not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized plan.

 

(Source:  Amended at 42 Ill. Reg. 21625, effective November 26, 2018)

 

Section 2008.70  Minimum Benefit Standards for Pre-Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery Prior to February 11, 1992

 

The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this State prior to February 11, 1992.  No policy or certificate may be advertised, solicited, or issued for delivery in this State as a Medicare supplement policy or certificate unless it meets or exceeds the following minimum standards. These are minimum standards and do not preclude the inclusion of other provisions or benefits that are not inconsistent with these standards.

 

a)         General Standards

The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this Part.

 

1)         A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than 6 months after the effective date of coverage because the losses involved a preexisting condition.  The policy or certificate shall not define a preexisting condition more restrictively than as a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.

 

2)         A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.

 

3)         A Medicare supplement policy or certificate shall provide that benefits designed to cover cost sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible, copayment, or coinsurance amounts.  Premiums may be modified to correspond with such changes.

 

4)         A "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewable" Medicare supplement policy shall not:

 

A)        Provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premium, or

 

B)        Be cancelled or nonrenewed by the issuer solely on the grounds of deterioration of health.

 

5)         An insurer shall:

 

A)        Except as authorized by the Director, an issuer shall neither cancel nor nonrenew a Medicare supplement policy or certificate for any reason other than nonpayment of premium or material misrepresentation.

 

B)        If a group Medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in subsection (a)(5)(D), the issuer shall offer certificateholders an individual Medicare supplement policy. The issuer shall offer the certificateholder at least the following choices:

 

i)          an individual Medicare supplement policy currently offered by the issuer having comparable benefits to those contained in the terminated group Medicare supplement policy; and

 

ii)         an individual Medicare supplement policy that provides only such benefits as are required to meet the minimum standards as defined in Section 2008.71(b).

 

C)        If a membership in a group is terminated, the issuer shall:

 

i)          offer the certificateholder such conversion opportunities as are described in subsection (a)(5)(B); or

 

ii)         at the option of the group policyholder, offer the certificateholder continuation of coverage under the group policy.

 

D)        If a group Medicare supplement policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new group policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced.

 

6)         Termination of a Medicare supplement policy or certificate shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or to payment of the maximum benefits.  Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.

 

7)         If a Medicare supplement policy eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this subsection (a).

 

b)         Minimum Benefit Standards.

 

1)         Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61^st day through the 90^th day in any Medicare benefit period;

 

2)         Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount;

 

3)         Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days;

 

4)         Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of 90% of all Medicare Part A eligible expenses for hospitalization not covered by Medicare subject to a lifetime maximum benefit of an additional 365 days;

 

5)         Coverage under Medicare Part A for the reasonable cost of the first 3 pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations or already paid for under Part B;

 

6)         Coverage for the coinsurance amount or, in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount equal to the Medicare Part B deductible ($100);

 

7)         Coverage under Medicare Part B for the reasonable cost of the 3 pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) (42 CFR 409.87(a) (1997), no subsequent dates or editions) unless replaced in accordance with federal regulations (42 CFR 409.87(b) (1997), no subsequent dates or editions) or already paid for under Part A, subject to the Medicare deductible amount.

 

(Source:  Amended at 47 Ill. Reg. 5701, effective April 4, 2023)

 

Section 2008.71  Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery after February 11, 1992 and Prior to June 1, 2010

 

The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this State on or after February 11, 1992 and with an effective date for coverage prior to June 1, 2010.  No policy or certificate may be advertised, solicited, delivered or issued for delivery in this State as a Medicare supplement policy or certificate unless it complies with these benefit standards.

 

a)         General Standards

The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this Part.

 

1)         A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than 6 months from the effective date of coverage because the losses involved a preexisting condition.  The policy or certificate may not define a preexisting condition more restrictively than as a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.

 

2)         A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.

 

3)         A Medicare supplement policy or certificate shall provide that benefits designed to cover cost sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible, copayment, or coinsurance amounts.  Premiums may be modified to correspond with such changes.

 

4)         No Medicare supplement policy or certificate shall provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premium.

 

5)         Each Medicare supplement policy shall be guaranteed renewable and:

 

A)        The issuer shall not cancel or nonrenew the policy solely on the ground of health status of the individual;

 

B)        The issuer shall not cancel or nonrenew the policy for any reason other than nonpayment of premium or material misrepresentation;

 

C)        If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under subsection (a)(5)(E), the issuer shall offer certificateholders an individual Medicare supplement policy which (at the option of the certificateholder):

 

i)          Provides for continuation of the benefits contained in the group policy, or

 

ii)         Provides for such benefits as otherwise meet the requirements of this subsection;

 

D)        If an individual is a certificateholder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall:

 

i)          Offer the certificateholder the conversion opportunity described in subsection (a)(5)(C), or

 

ii)         At the option of the group policyholder, offer the certificateholder continuation of coverage under the group policy;

 

E)        If a group Medicare supplement policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the old policy on its date of termination.  Coverage under the new policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced; and

 

F)         If a Medicare supplement policy eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this subsection (a)(5).

 

6)         Termination of a Medicare supplement policy or certificate shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be conditioned upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits.  Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.

 

7)         A Medicare supplement policy or certificate shall provide:

 

A)        That benefits and premiums under the policy or certificate shall be suspended at the request of the policyholder or certificateholder for the period (not to exceed 24 months) in which the policyholder or certificateholder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act (42 USC 1901-1941), but only if the policyholder or certificateholder notifies the issuer of such policy or certificate within 90 days after the date the individual becomes entitled to such assistance.

 

B)        If such suspension occurs and if the policyholder or certificateholder loses entitlement to such medical assistance, such policy or certificate shall be automatically reinstituted (effective as of the date of termination of such entitlement) as of the termination of such entitlement if the policyholder or certificateholder provides notice of loss of such entitlement within 90 days after the date of such loss and pays the premium attributable to the period, effective as of the date of termination of such entitlement.

 

C)        Each Medicare supplement policy shall provide that benefits and premiums under the policy shall be suspended (for any period that may be provided by federal regulation) at the request of the policyholder if the policyholder is entitled to benefits under section 226(b) of the Social Security Act (42 USC 426(b)) and is covered under a group health plan as defined in section 1862(b)(1)(A)(v) of the Social Security Act (42 USC 1395y(b)(1)(A)(v)).  If suspension occurs and if the policyholder or certificateholder loses coverage under the group health plan, the policy shall be automatically reinstituted (effective as of the date of loss of such coverage) if the policyholder provides notice of loss of coverage within 90 days after the date of such loss.

 

D)        Reinstitution of such coverages as described in subsections (a)(7)(B) and (C):

 

i)          Shall not provide for any waiting period with respect to treatment of preexisting conditions;

 

ii)         Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of the suspension.  If the suspended Medicare supplement policy provided coverage for outpatient prescription drugs, reinstitution of the policy for Medicare Part D enrollees shall be without coverage for outpatient prescription drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension; and

 

iii)        Shall provide for classification of premiums on terms at least as favorable to the policyholder or certificateholder as the premium classification terms that would have applied to the policyholder or certificateholder had the coverage not been suspended.

 

8)         If, after June 1, 2010, an issuer makes a written offer to the Medicare Supplement policyholders or certificateholders of one or more of its plans, to exchange during a specified period from his or her 1990 Standardized plan (as described in Section 2008.72 of this Part) to a 2010 Standardized plan (as described in Section 2008.67 of this Part), the offer and subsequent exchange shall comply with the following requirements:

 

A)        An issuer need not provide justification to the Director if the insured replaces a 1990 Standardized policy or certificate with an issue age rated 2010 Standardized policy or certificate at the insured's original issue age and duration.  If an insured's policy or certificate to be replaced is priced on an issue age rate schedule at the time of such offer, the rate charged to the insured for the new exchanged policy shall recognize the policy reserve buildup, due to the pre-funding inherent in the use of an issue age rate basis, for the benefit of the insured.  The method proposed to be used by an issuer must be filed with the Director. 

 

B)        The rating class of the new policy or certificate shall be the class closest to the insured's class of the replaced coverage.

 

C)        An issuer may not apply new pre-existing condition limitations or a new incontestability period to the new policy for those benefits contained in the exchanged 1990 Standardized policy or certificate of the insured, but may apply pre-existing condition limitations of no more than 6 months to any added benefits contained in the new 2010 Standardized policy or certificate not contained in the exchanged policy.

 

D)        The new policy or certificate shall be offered to all policyholders or certificateholders within a given plan, except where the offer or issue would be in violation of state or federal law.

 

b)         Standards for Basic (Core) Benefits Common to Benefit Plans A-J

Every issuer shall make available a policy or certificate including only the following basic "core" package of benefits to each prospective insured. An issuer may make available to prospective insureds any of the other Medicare Supplement Insurance Benefit Plans in addition to the basic core package, but not in lieu thereof.

 

1)         Coverage of Part A Medicare Eligible Expenses for hospitalization to the extent not covered by Medicare from the 61^st day through the 90^th day in any Medicare benefit period;

 

2)         Coverage of Part A Medicare Eligible Expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used;

 

3)         Upon exhaustion of the Medicare hospital inpatient coverage including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days.  The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance;

 

4)         Coverage under Medicare Parts A and B for the reasonable cost of the first 3 pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations;

 

5)         Coverage for the coinsurance amount (or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount) of Medicare Eligible Expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible.

 

c)         Standards for Additional Benefits

The following additional benefits shall be included in Medicare Supplement Benefit Plans "B" through "J" only as provided by Section 2008.72 of this Part.

 

1)         Medicare Part A Deductible:  Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.

 

2)         Skilled Nursing Facility Care:  Coverage for the actual billed charges up to the coinsurance amount from the 21^st day through the 100^th day in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare Part A.

 

3)         Medicare Part B Deductible:  Coverage for all of the Medicare Part B deductible amount per calendar year regardless of hospital confinement.

 

4)         Eighty Percent of the Medicare Part B Excess Charges:  Coverage for 80% of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program or State law, and the Medicare-approved Part B charge.

 

5)         One Hundred Percent of the Medicare Part B Excess Charges:  Coverage for all of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program or State law, and the Medicare-approved Part B charge.

 

6)         Basic Outpatient Prescription Drug Benefit:  Coverage for 50% of outpatient prescription drug charges, after a $250 calendar year deductible, to a maximum of $1,250 in benefits received by the insured per calendar year, to the extent not covered by Medicare.  The outpatient prescription drug benefit may be included for sale or issuance in a Medicare supplement policy until January 1, 2006.

 

7)         Extended Outpatient Prescription Drug Benefit:  Coverage for 50% of outpatient prescription drug charges, after a $250 calendar year deductible to a maximum of $3,000 in benefits received by the insured per calendar year, to the extent not covered by Medicare.  The outpatient prescription drug benefit may be included for sale or issuance in a Medicare supplement policy until January 1, 2006.

 

8)         Medically Necessary Emergency Care in a Foreign Country:  Coverage to the extent not covered by Medicare for 80% of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during the first 60 consecutive days of each trip outside the United States, subject to a calendar year deductible of $250, and a lifetime maximum benefit of $50,000.  For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or illness of sudden and unexpected onset.

 

9)         Preventive Medical Care Benefit:  Coverage for the following preventive health services not covered by Medicare:

 

A)        An annual clinical preventive medical history and physical examination that may include tests and services from subsection (c)(9)(B) and patient education to address preventive health care measures;

 

B)        Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician;

 

C)        Reimbursement shall be for the actual charges up to 100% of the Medicare-approved amount for each service, as if Medicare were to cover the service as identified in American Medical Association Current Procedural Terminology (AMA CPT) codes, to a maximum of $120 annually under this benefit.  This benefit shall not include payment for any procedure covered by Medicare.

 

10)         At-Home Recovery Benefit:  Coverage for services to provide short term, at-home assistance with activities of daily living for those recovering from an illness, injury or surgery.

 

A)        For purposes of this benefit, the following definitions shall apply:

 

i)          "Activities of daily living" include but are not limited to bathing, dressing, personal hygiene, transferring, eating, ambulating, assistance with drugs that are normally self-administered, and changing bandages or other dressings.

 

ii)         "Care provider" means a duly qualified or licensed home health aide/homemaker, personal care aide or nurse provided through a licensed home health care agency or referred by a licensed referral agency or licensed nurses registry.

 

iii)        "Home" shall mean any place used by the insured as a place of residence, provided that such place would qualify as a residence for home health care services covered by Medicare.  A hospital or skilled nursing facility shall not be considered the insured's place of residence.

 

iv)        "At-home recovery visit" means the period of a visit required to provide at home recovery care, without limit on the duration of the visit, except each consecutive 4 hours in a 24-hour period of services provided by a care provider is one visit.

 

B)        Coverage Requirements and Limitations

 

i)          At-home recovery services provided must be primarily services which assist in activities of daily living.

 

ii)         The insured's attending physician must certify that the specific type and frequency of at-home recovery services are necessary because of a condition for which a home care plan of treatment was approved by Medicare.

 

iii)        Coverage is limited to:

No more than the number and type of at-home recovery visits certified as necessary by the insured's attending physician.  The total number of at-home recovery visits shall not exceed the number of Medicare approved home health care visits under a Medicare approved home care plan of treatment.

 

The actual charges for each visit up to a maximum reimbursement of $40 per visit.

 

$1,600 per calendar year.

 

7 visits in any one week.

 

Care furnished on a visiting basis in the insured's home.

 

Services provided by a care provider as defined in this Section.

 

At-home recovery visits while the insured is covered under the policy or certificate and not otherwise excluded.

 

At-home recovery visits received during the period the insured is receiving Medicare approved home care services or no more than 8 weeks after the service date of the last Medicare approved home health care visit.

 

C)        Coverage is excluded for:

 

i)          Home care visits paid for by Medicare or other government programs; and

 

ii)         Care provided by family members, unpaid volunteers or providers who are not care providers.

 

d)        Standards for Plans K and L

 

1)         Standardized Medicare supplement benefit Plan "K" shall consist of the following:

 

A)        Coverage of 100% of the Part A hospital coinsurance amount for each day used from the 61^st through the 90^th day in any Medicare benefit period;

 

B)        Coverage of 100% of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91^st through the 150^th day in any Medicare benefit period;

 

C)        Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days.  The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance;

 

D)        Medicare Part A Deductible:  Coverage for 50% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subsection (d)(1)(J);

 

E)        Skilled Nursing Facility Care:  Coverage for 50% of the coinsurance amount for each day used from the 21^st day through the 100^th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subsection (d)(1)(J);

 

F)         Hospice Care:  Coverage for 50% of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subsection (d)(1)(J);

 

G)        Coverage for 50%, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations until the out-of-pocket limitation is met as described in subsection (d)(1)(J);

 

H)        Except for coverage provided in subsection (d)(1)(J), coverage for 50% of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in subsection (d)(1)(J);

 

I)         Coverage of 100% of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and

 

J)         Coverage of 100% of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $4000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.

 

2)         Standardized Medicare supplement benefit Plan "L" shall consist of the following:

 

A)        The benefits described in subsections (d)(1)(A), (B), (C) and (J);

 

B)        The benefits described in subsections (d)(1)(D), (E), (F), (G) and (H), but substituting 75% for 50%; and

 

C)        The benefit described in subsection (d)(1)(J), but substituting $2000 for $4000.

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)

 

Section 2008.72  Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or after February 11, 1992 and Prior to June 1, 2010

 

a)         An issuer shall make available to each prospective policyholder and certificateholder a policy form or certificate form containing only the basic "core" benefits, as defined in Section 2008.71 of this Part.

 

b)         No groups, packages or combinations of Medicare supplement benefits other than those listed in this Section shall be offered for sale in this State, except as may be permitted in subsection (g) and Section 2008.73 of this Part.

 

c)         Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans listed in subsection (e) of this Section and conform to the definitions in Section 2008.40 of this Part.  Each benefit shall be structured in accordance with the format provided in Section 2008.71(b) and (c) and list the benefits in the order shown in Appendix B of this Part.  For purposes of this Section, "structure, language, and format" means style, arrangement and overall content of a benefit.

 

d)         An issuer may use, in addition to the benefit plan designations required in subsection (c) of this Section, other designations to the extent permitted by law.

 

e)         Make-up of benefit plans:

 

1)         Standardized Medicare supplement benefit Plan "A" shall be limited to the Basic (Core) Benefits Common to all Benefit Plans, as defined in Section 2008.71(b) of this Part.

 

2)         Standardized Medicare supplement benefit Plan "B" shall include only the following:  The Core Benefit as defined in Section 2008.71(b) of this Part, plus the Medicare Part A Deductible as defined in Section 2008.71(c)(1) of this Part.

 

3)         Standardized Medicare supplement benefit Plan "C" shall include only the following:  The Core Benefit as defined in Section 2008.71(b) of this Part, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medicare Part B Deductible and Medically Necessary Emergency Care in a Foreign Country as defined in Section 2008.71(c)(1), (2), (3) and (8) of this Part respectively.

 

4)         Standardized Medicare supplement benefit Plan "D" shall include only the following:  The Core Benefit as defined in Section 2008.71(b) of this Part, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medically Necessary Emergency Care in a Foreign Country and the At-Home Recovery Benefit as defined in Section 2008.71(c)(1), (2), (8) and (10) of this Part respectively.

 

5)         Standardized Medicare supplement benefit Plan "E" shall include only the following:  The Core Benefit as defined in Section 2008.71(b) of this Part, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medically Necessary Emergency Care in a Foreign Country and Preventive Medical Care as defined in Section 2008.71(c)(1), (2), (8) and (9) of this Part respectively.

 

6)         Standardized Medicare supplement benefit Plan "F" shall include only the following:  The Core Benefit as defined in Section 2008.71(b) of this Part, plus the Medicare Part A Deductible, the Skilled Nursing Facility Care, the Part B Deductible, 100% of the Medicare Part B Excess Charges, and Medically Necessary Emergency Care in a Foreign Country as defined in Section 2008.71(c)(1), (2), (3), (5) and (8) of this Part respectively.

 

7)         Standardized Medicare supplement benefit high deductible Plan "F" shall include only the following:  100% of covered expenses following the payment of the annual high deductible Plan "F" deductible.  The covered expenses include the Core Benefit as defined in Section 2008.71(b) of this Part, plus the Medicare Part A deductible, Skilled Nursing Facility Care, the Medicare Part B deductible, 100% of the Medicare Part B Excess Charges, and Medically Necessary Emergency Care in a Foreign Country as defined in Section 2008.71(c)(1), (2), (3), (5) and (8) respectively.  The annual high deductible Plan "F" deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement Plan "F" policy, and shall be in addition to any other specific benefit deductibles.  The annual high deductible Plan "F" deductible shall be $1500 for 1998 and 1999, and shall be based on the calendar year.  It shall be adjusted annually thereafter by the Secretary to reflect the change in the Consumer Price Index for all urban consumers for the 12 month period ending with August of the preceding year, and rounded to the nearest multiple of $10.

 

8)         Standardized Medicare supplement benefit Plan "G" shall include only the following:  The Core Benefit as defined in Section 2008.71(b) of this Part, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, 80% of the Medicare Part B Excess Charges, Medically Necessary Emergency Care in a Foreign Country, and the At-Home Recovery Benefit as defined in Section 2008.71(c)(1), (2), (4), (8) and (10) of this Part respectively.

 

9)         Standardized Medicare supplement benefit Plan "H" shall consist of only the following:  The Core Benefit as defined in Section 2008.71(b) of this Part, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Basic Prescription Drug Benefit and Medically Necessary Emergency Care in a Foreign Country as defined in Section 2008.71(c)(1), (2), (6) and (8) of this Part respectively.  The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

 

10)         Standardized Medicare supplement benefit Plan "I" shall consist of only the following:  The Core Benefit as defined in Section 2008.71(b) of this Part, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, 100% of the Medicare Part B Excess Charges, Basic Prescription Drug Benefit, Medically Necessary Emergency Care in a Foreign Country and At-Home Recovery Benefit as defined in Section 2008.71(c)(1), (2), (5), (6), (8) and (10) of this Part respectively.  The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

 

11)         Standardized Medicare supplement benefit Plan "J" shall consist of only the following:  The Core Benefit as defined in Section 2008.71(b) of this Part, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medicare Part B Deductible, 100% of the Medicare Part B Excess Charges, Extended Prescription Drug Benefit, Medically Necessary Emergency Care in a Foreign Country, Preventive Medical Care and At-Home Recovery Benefit as defined in Section 2008.71(c)(1), (2), (3), (5), (7), (8), (9) and (10) of this Part respectively.  The outpatient prescription drug benefit shall not be included in a Medicare Supplement policy sold after December 31, 2005.

 

12)         Standardized Medicare supplement benefit high deductible Plan "J" shall consist of only the following:  100% of covered expenses following the payment of the annual high deductible Plan "J" deductible.  The covered expenses include the Core Benefit as defined in Section 2008.71(b) of this Part, plus the Medicare Part A deductible, Skilled Nursing Facility Care, Medicare Part B deductible, 100% of the Medicare Part B Excess Charges, Extended Outpatient Prescription Drug Benefit, Medically Necessary Emergency Care in a Foreign Country, Preventive Medical Care Benefit and At-Home Recovery Benefit as defined in Section 2008.71(c)(1), (2), (8) and (10) respectively. The annual high deductible Plan "J" deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement Plan "J" policy, and shall be in addition to any other specific benefit deductible.  The annual deductible shall be $1500 for 1998 and 1999, and shall be based on a calendar year.  It shall be adjusted annually thereafter by the Secretary to reflect the change in the Consumer Price Index for all urban consumers for the 12 month period ending with August of the preceding year, and rounded to the nearest multiple of $10.

 

f)         Make-up of two Medicare supplement plans mandated by the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA);

 

1)         Standardized Medicare supplement benefit Plan "K" shall consist of only those benefits described in Section 2008.71(d)(1).

 

2)         Standardized Medicare supplement benefit Plan "L" shall consist of only those benefits described in Section 2008.71(d)(2).

 

g)        New or Innovative Benefits: An issuer may, with the prior approval of the Director, offer policies or certificates with new or innovative benefits in addition to the benefits provided in a policy or certificate that otherwise complies with the applicable standards.  The new or innovative benefits may include benefits that are appropriate to Medicare supplement insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner that is consistent with the goal of simplification of Medicare supplement policies.  After December 31, 2005, the innovative benefit shall not include an outpatient prescription drug benefit.

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)

 

Section 2008.73  Medicare Select Policies and Certificates

 

a)         This Section shall apply to Medicare Select policies and certificates, as defined in this Section.  No policy or certificate may be advertised as a Medicare Select policy or certificate unless it meets the requirements of this Section.

 

b)         For the purposes of this Section:

 

1)         "Complaint" means any dissatisfaction expressed by an individual concerning a Medicare Select issuer or its network providers.

 

2)         "Grievance" means dissatisfaction expressed in writing by an individual insured under a Medicare Select policy or certificate with the administration, claims practices, or provision of services concerning a Medicare Select issuer or its network providers.

 

3)         "Medicare Select Issuer" means an issuer offering, or seeking to offer, a Medicare Select policy or certificate.

 

4)         "Medicare Select Policy" or "Medicare Select Certificate" means respectively a Medicare supplement policy or certificate that contains restricted network provisions.

 

5)         "Network Provider" means a provider of health care, or a group of providers of health care, which has entered into a written agreement with the issuer to provide benefits insured under a Medicare Select policy.

 

6)         "Restricted Network Provision" means any provision which conditions the payment of benefits, in whole or in part, on the use of network providers.

 

7)         "Service Area" means the geographic area approved by the Director within which an issuer is authorized to offer a Medicare Select policy.

 

c)         The Director may authorize an issuer to offer a Medicare Select policy or certificate, pursuant to this Section and Section 4358 of the Omnibus Budget Reconciliation Act (OBRA) of 1990 if the Director finds that the issuer has satisfied all of the requirements of this Part.

 

d)         A Medicare Select issuer shall not issue a Medicare Select policy or certificate in this State until its plan of operation has been approved by the Director.

 

e)         A Medicare Select issuer shall file a proposed plan of operation with the Director in a format prescribed by the Director.  The plan of operation shall contain at least the following information:

 

1)         Evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration that:

 

A)        Such services can be provided by network providers with reasonable promptness with respect to geographic location, hours of operation and after-hour care.  The hours of operation and availability of after-hour care shall reflect usual practice in the local area.  Geographic availability shall reflect the usual travel times within the community.

 

B)        The number of network providers in the service area is sufficient, with respect to current and expected policyholders, either:

 

i)          To deliver adequately all services that are subject to a restricted network provision; or

 

ii)         To make appropriate referrals.

 

C)        There are written agreements with network providers describing specific responsibilities.

 

D)        Emergency care is available 24 hours per day and 7 days per week.

 

E)        In the case of covered services that are subject to a restricted network provision and are provided on a prepaid basis, there are written agreements with network providers prohibiting such providers from billing or otherwise seeking reimbursement from or recourse against any individual insured under a Medicare Select policy or certificate.  This subsection shall not apply to supplemental charges or coinsurance amounts as stated in the Medicare Select policy or certificate.

 

2)         A statement or map providing a clear description of the service area.

 

3)         A description of the grievance procedure to be utilized.

 

4)         A description of the quality assurance program, including:

 

A)        The formal organizational structure;

 

B)        The written criteria for selection, retention and removal of network providers; and

 

C)        The procedures for evaluating quality of care provided by network providers, and the process to initiate corrective action when warranted.

 

5)         A list and description, by specialty, of the network providers.

 

6)         Copies of the written information proposed to be used by the issuer to comply with subsection (i).

 

7)         Any other information requested by the Director.

 

f)         A Medicare Select issuer shall:

 

1)         File any proposed changes to the plan of operation, except for changes to the list of network providers, with the Director prior to implementing such changes.  Such changes shall be considered approved by the Director after 30 days unless specifically disapproved.

 

2)         An updated list of network providers shall be filed with the Director  at least quarterly.

 

g)         A Medicare Select policy or certificate shall not restrict payment for covered services provided by non-network providers if:

 

1)         The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury or condition; and

 

2)         It is not reasonable to obtain such services through a network provider.

 

h)         A Medicare Select policy or certificate shall provide payment for full coverage under the policy for covered services that are not available through network providers.

 

i)          A Medicare Select issuer shall make full and fair disclosure in writing of the provisions, restrictions, and limitations of the Medicare Select policy or certificate to each applicant.  This disclosure shall include at least the following:

 

1)         An outline of coverage sufficient to permit the applicant to compare the coverage and premiums of the Medicare Select policy or certificate with:

 

A)        Other Medicare supplement policies or certificates offered by the issuer; and

 

B)        Other Medicare Select policies or certificates.

 

2)         A description (including address, phone number and hours of operation) of the network providers, including primary care physicians, specialty physicians, hospitals, and other providers.

 

3)         A description of the restricted network provisions, including payments for coinsurance and deductibles when providers other than network providers are utilized.  Except to the extent specified in the policy or certificate, expenses incurred when using out-of-network providers do not count toward the out-of-pocket annual limit contained in Plans K and L.

 

4)         A description of coverage for emergency and urgently needed care and other out of service area coverage.

 

5)         A description of limitations on referrals to restricted network providers and to other providers.

 

6)         A description of the policyholder's right to purchase any other Medicare supplement policy or certificate otherwise offered by the issuer.

 

7)         A description of the Medicare Select issuer's quality assurance program and grievance procedure.

 

j)          Prior to the sale of a Medicare Select policy or certificate, a Medicare Select issuer shall obtain from the applicant a signed and dated form stating that the applicant has received the information provided pursuant to subsection (i) and that the applicant understands the restrictions of the Medicare Select policy or certificate.

 

k)         A Medicare Select issuer shall have and use procedures for hearing complaints and resolving written grievances from the subscribers.  Such procedures shall be aimed at mutual agreement for settlement and may include arbitration procedures.

 

1)         The grievance procedure shall be described in the policy and certificates and in the outline of coverage.

 

2)         At the time the policy or certificate is issued, the issuer shall provide detailed information to the policyholder describing how a grievance may be registered with the issuer.

 

3)         Grievances shall be considered in a timely manner and shall be transmitted to decision makers who have authority to investigate the issue and take corrective action.

 

4)         If a grievance is found to be valid, corrective action shall be taken promptly.

 

5)         All concerned parties shall be notified about the results of a grievance.

 

6)         The issuer shall report no later than each March 31^st to the Director regarding its grievance procedure.  The report shall be in a format prescribed by the Director and shall contain the number of grievances filed in the past year and a summary of the subject, nature and resolution of such grievances.

 

l)          At the time of initial purchase, a Medicare Select issuer shall make available to each applicant for a Medicare Select policy or certificate the opportunity to purchase any Medicare supplement policy or certificate otherwise offered by the issuer.

 

m)        At the request of an individual insured under a Medicare Select policy or certificate, a Medicare Select issuer shall make available to the individual insured the opportunity to purchase a Medicare supplement policy or certificate offered by the issuer which has comparable or lesser benefits and which does not contain a restricted network provision.  The issuer shall make such policies or certificates available without requiring evidence of insurability after the Medicare Select policy or certificate has been in force for 6 months.

 

1)         For the purposes of this subsection (m), a Medicare supplement policy or certificate will be considered to have "comparable or lesser" benefits unless it contains one or more significant benefits not included in the Medicare Select policy or certificate being replaced.

 

2)         For the purposes of subsection (m)(1), a "significant benefit" means coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Part B excess charges.

 

n)         Medicare Select policies and certificates shall provide for continuation of coverage in the event the Secretary of Health and Human Services determines that Medicare Select policies and certificates issued pursuant to this Section should be discontinued due to either the failure of the Medicare Select Program to be reauthorized under law or its substantial amendment.

 

1)         Each Medicare Select issuer shall make available to each individual insured under a Medicare Select policy or certificate the opportunity to purchase any Medicare supplement policy or certificate offered by the issuer which has comparable or lesser benefits and which does not contain a restricted network provision.  The issuer shall make such policies and certificates available without requiring evidence of insurability.

 

2)         For the purposes of this subsection (n), a Medicare supplement policy or certificate will be considered to have "comparable or lesser" benefits unless it contains one or more significant benefits not included in the Medicare Select policy or certificate being replaced.  For the purposes of this subsection (n)(2), a "significant benefit" means coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Part B excess charges.

 

o)         A Medicare Select issuer shall comply with requests for data made by State or federal agencies, including the United States Department of Health and Human Services, for the purpose of evaluating the Medicare Select Program.

 

(Source:  Amended at 29 Ill. Reg. 14188, effective September 8, 2005)

SUBPART C: ENROLLMENT & ELIGIBILITY

 

Section 2008.74  Open Enrollment

 

a)         Notwithstanding any Medicare Part B late enrollment penalty, no issuer shall deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this State, nor discriminate in the pricing of such a policy or certificate because of the health status, claims experience, receipt of health care, or medical condition of an applicant in the case of an application for a policy or certificate that is submitted prior to or during the 6 month period beginning with the first day of the month in which an individual is both 65 years of age or older and is enrolled for benefits under Medicare Part B.  Each Medicare supplement policy and certificate currently available from an insurer shall be made available to all applicants who qualify under this subsection (a) without regard to age.

 

b)         If an applicant qualifies under subsection (a) and submits an application during the time period referenced in subsection (a) and, as of the date of application, has had a continuous period of creditable coverage:

 

1)         Of at least 6 months, the issuer shall not exclude benefits based on a preexisting condition, or

 

2)         That is less than 6 months, the issuer shall reduce the period of any preexisting condition exclusion by the aggregate of the period of creditable coverage applicable to the applicant as of the enrollment date.  The Secretary shall specify the manner of the reduction under this subsection (b)(2).

 

c)         Except as otherwise provided in subsection (b), Section 2008.75 or Section 2008.104, subsection (a) of this Section shall not be construed as preventing the exclusion of benefits under a policy, during the first 6 months, based on a preexisting condition for which the policyholder or certificateholder received treatment or was otherwise diagnosed during the 6 months before the coverage became effective.

 

d)         Sections 363(6)(a)(i), (b), and (c) of the Code shall apply to individuals who qualify under those provisions without regard for age or any Medicare Part B late enrollment penalty. 

 

(Source:  Amended at 47 Ill. Reg. 16454, effective November 1, 2023)

 

Section 2008.75  Guaranteed Issue for Eligible Persons

 

All Medicare supplement insurance policies shall be guaranteed issue to eligible persons who meet the requirements of this Section (see 42 U.S.C. 1395ss(s)).

 

a)         Guaranteed Issue

 

1)         Eligible persons are those individuals described in subsection (b) who seek to enroll under the policy during the period specified in subsection (c), and who submit evidence of the date of termination, disenrollment, or Medicare Part D enrollment with the application for a Medicare supplement policy.

 

2)         With respect to eligible persons, an issuer shall not deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate described in subsection (e) that is offered and is available for issuance to new enrollees by the issuer; shall not discriminate in the pricing of such a Medicare supplement policy because of health status, claims experience, receipt of health care, or medical condition; and shall not impose an exclusion of benefits based on a preexisting condition under such a Medicare supplement policy.

 

b)         Eligible person is an individual described in any of the following subsections:

 

1)         The individual is enrolled under an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare; and the plan terminates, or the plan ceases to provide all such supplemental health benefits to the individual or the individual is enrolled under an employee welfare benefit plan that is primary to Medicare and the plan terminates or the plan ceases to provide all health benefits to the individual because the individual leaves the plan;

 

2)         The individual is enrolled with a Medicare Advantage organization under a Medicare Advantage plan under Part C of Medicare, and any of the following circumstances apply, or the individual is 65 years of age or older and is enrolled with a Program of All-Inclusive Care for the Elderly (PACE) provider under Section 1894 of the Social Security Act, and there are circumstances similar to those described in subsections (b)(2), (3), (4), (5) and (6) that would permit discontinuance of the individual's enrollment with such provider if such individual were enrolled in a Medicare Advantage Plan:

 

A)        The certification of the organization or plan under this Part has been terminated;

 

B)        The organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides;

 

C)        The individual is no longer eligible to elect the plan because of a change in the individual's place of residence or other change in circumstances specified by the Secretary, but not including termination of the individual's enrollment on the basis described in Section 1851(g)(3)(B) of the federal Social Security Act (where the individual has not paid premiums on a timely basis or has engaged in disruptive behavior as specified in standards under Section 1856), or the plan is terminated for all individuals within a residence area;

 

D)        The individual demonstrates, in accordance with guidelines established by the Secretary, that:

 

i)          The organization offering the plan substantially violated a material provision of the organization's contract in relation to the individual, including the failure to provide an enrollee on a timely basis medically necessary care for which benefits are available under the plan or the failure to provide such covered care in accordance with applicable quality standards; or

 

ii)         The organization, or agent or other entity acting on the organization's behalf, materially misrepresented the plan's provisions in marketing the plan to the individual; or

 

E)        The individual meets such other exceptional conditions as the Secretary may provide;

 

3)         The individual's enrollment ceases under the same circumstances that would permit discontinuance of an individual's election of coverage under subsection (b)(2) and they enrolled under:

 

A)        An eligible organization under a contract under Section 1876 of the Social Security Act (Medicare cost);

 

B)        A similar organization operating under demonstration project authority, effective for periods before April 1, 1999;

 

C)        An organization under an agreement under Section 1833(a)(1)(A) of the Social Security Act (health care prepayment plan); or

 

D)        An organization under a Medicare Select policy;

 

4)         The individual is enrolled under a Medicare supplement policy and the enrollment ceases because:

 

A)        Of the insolvency of the issuer or bankruptcy of the nonissuer organization;

 

B)        Of other involuntary termination of coverage or enrollment under the policy;

 

C)        The issuer of the policy substantially violated a material provision of the policy; or

 

D)        The issuer, or an agent or other entity acting on the issuer's behalf, materially misrepresented the policy's provisions in marketing the policy to the individual;

 

5)         The individual was enrolled under a Medicare supplement policy and terminates enrollment and subsequently enrolls, for the first time, with any Medicare Advantage organization under a Medicare Advantage plan under Part C of Medicare, any eligible organization under a contract under Section 1876 of the Social Security Act (Medicare cost), any similar organization operating under demonstration project authority, any PACE provider under Section 1894 of the Social Security Act, or a Medicare Select policy; and the subsequent enrollment is voluntarily or involuntarily terminated during any period within the first 12 months of such subsequent enrollment;

 

6)         The individual, upon first enrolling under Part B of Medicare at age 65 or older, enrolls in a Medicare Advantage plan under Part C of Medicare or with a PACE provider under Section 1894 of the Social Security Act, and voluntarily or involuntarily disenrolls from the plan or program by not later than 12 months after the effective date of enrollment;

 

7)         The individual enrolls in a Medicare Part D plan during the initial enrollment period and, at the time of enrollment in Part D, was enrolled under a Medicare supplement policy that covers outpatient prescription drugs and the individual terminates enrollment in the Medicare supplement policy and submits evidence of enrollment in Medicare Part D along with the application for a policy described in subsection (e)(4); or

 

8)         The individual:

 

A)        is enrolled for benefits under Medicare Part B;

 

B)        was enrolled in the State's medical assistance program during the COVID-19 Public Health Emergency described in Section 5-1.5 of the Illinois Public Aid Code [305 ILCS 5/5-1.5];

 

C)        was terminated or disenrolled from the medical assistance program after the COVID-19 Public Health Emergency with the later of the effective date of the loss of benefits or receipt of notice of a claim denial due to termination occurring on, after, or no more than 63 days before the end of either, as applicable:

 

i)          the individual's Medicare supplement open enrollment period described in Section 2008.74; or

 

ii)         the 6-month period described in Section 363(6)(a)(i) of the Code; and

 

D)        submits evidence of the date of termination of benefits or notice of claim denial due to termination under the medical assistance program with the application for a Medicare supplement policy or certificate. [215 ILCS 5/363(9)]

 

c)         Guaranteed Issue Time Periods

 

1)         In the case of an individual described in subsection (b)(1), the guaranteed issue period begins on the later of:

 

A)        date the individual receives a notice of termination or cessation of all supplemental health benefits (or, if a notice is not received, notice that a claim has been denied because of termination or cessation) and ends 63 days thereafter; or

 

B)        the date that the applicable coverage terminates or ceases;

 

2)         In the case of an individual described in subsection (b)(2), (b)(3), (b)(5) or (b)(6) whose enrollment is terminated involuntarily, the guaranteed issue period begins on the date that the individual receives a notice of termination and ends 63 days after the date the applicable coverage is terminated;

 

3)         In the case of an individual described in subsection (b)(4)(A):

 

A)        the guaranteed issue period begins on the earlier of:

 

i)          the date that the individual receives a notice of termination, a notice of the issuer's bankruptcy or insolvency, or other such similar notice if any; or

 

ii)         the date that the applicable coverage is terminated; and

 

B)        ends on the date that is 63 days after the date the coverage is terminated;

 

4)         In the case of an individual described in subsection (b)(2), (b)(4)(B), (b)(4)(C), (b)(5) or (b)(6) who disenrolls voluntarily, the guaranteed issue period begins on the date that is 60 days before the effective date of the disenrollment and ends on the date that is 63 days after the effective date;

 

5)         In the case of an individual described in subsection (b)(7), the guaranteed issue period begins on the date the individual receives notice pursuant to Section 1882(v)(2)(B) of the Social Security Act from the Medicare supplement issuer during the 60-day period immediately preceding the initial Part D enrollment period and ends on the date that is 63 days after the effective date of the individual's coverage under Medicare Part D;

 

6)         In the case an individual described in subsection (b) but not described in the preceding provisions of this subsection (c), the guaranteed issue period begins on the effective date of the disenrollment and ends on the date that is 63 days after the effective date; and

 

7)         In the case of an individual described in subsection (b)(8), the guaranteed issue period:

 

A)        begins on the later of:

 

i)          the effective date of loss of benefits under the medical assistance program; or

 

ii)         receipt of notice of a claim denial due to termination; and

 

B)        ends on the date that is 63 days later.

 

d)         Extended Medigap Access for Interrupted Trial Periods

 

1)         In the case of an individual described in subsection (b)(5) whose enrollment with an organization or provider described in subsection (b)(5) is involuntarily terminated within the first 12 months of enrollment, and who, without an intervening enrollment, enrolls with another such organization or provider, the subsequent enrollment shall be deemed to be initial enrollment described in subsection (b)(5);

 

2)         In the case of an individual described in subsection (b)(6) whose enrollment with a plan or in a program described in subsection (b)(6) is involuntarily terminated within the first 12 months of enrollment, and who, without an intervening enrollment, enrolls in another such plan or program, the subsequent enrollment shall be deemed to be an initial enrollment described in subsection (b)(6); and

 

3)         For purposes of subsections (b)(5) and (b)(6), no enrollment of an individual with an organization or provider described in subsection (b)(5)(A), or with a plan or in a program described in subsection (b)(6), may be deemed to be an initial enrollment after the 2-year period beginning on the date on which the individual first enrolled with such an organization, provider, plan or program.

 

e)         Products to Which Eligible Persons are Entitled

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

 

1)         Subsection (b)(1), (2), (3), and (4) is a Medicare supplement policy which has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K or L offered by any issuer.

 

2)         Subject to subsection (e)(2)(B), subsection (b)(5) is the same Medicare supplement policy in which the individual was most recently previously enrolled, if available from the same issuer, or, if not available, a policy described in subsection (e)(1).  After December 31, 2005, if the individual was most recently enrolled in a Medicare supplement policy with an outpatient prescription drug benefit, a Medicare supplement policy described in this subsection (e)(2) is:

 

A)        The policy available from the same issuer but modified to remove outpatient prescription drug coverage; or

 

B)        At the election of the policyholder, an A, B, C, F (including F with a high deductible), K or L policy that is offered by any issuer.

 

3)         Subsections (b)(6) and (b)(8) shall include any Medicare supplement policy offered by any issuer.

 

4)         Subsection (b)(7) is a Medicare supplement policy that has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K or L, and that is offered and is available for issuance to new enrollees by the same issuer that issued the individual's Medicare supplement policy with outpatient prescription drug coverage.

 

f)         Notification Provisions

 

1)         At the time of an event described in subsection (b) other than subsection (b)(8), because of which an individual loses coverage or benefits due to the termination of a contract or agreement, policy, or plan, the organization that terminates the contract or agreement, the issuer terminating the policy, or the administrator of the plan being terminated, respectively, shall notify the individual of the individual's under this Section, and of the obligations of issuers of Medicare supplement policies under subsection (a). Such notice shall be communicated contemporaneously with the notification of termination.

 

2)         At the time of an event described in subsection (b) other than subsection (b)(8), because of which an individual ceases enrollment under a contract or agreement, policy, or plan, the organization that offers the contract or agreement, regardless of the basis for the cessation of enrollment, the issuer offering the policy, or the administrator of the plan, respectively, shall notify the individual of the individual's rights under this Section, and of the obligations of issuers of Medicare supplement policies under subsection (a). Such notice shall be communicated within 10 working days after the issuer receives notification of disenrollment.

 

g)         Nothing in this Section shall eliminate or reduce the time period during which Section 2008.74 of this Part or Section 363(6)(a)(i) of the Code applies except that provisions in this Section that completely prohibit the exclusion of benefits based on a preexisting condition shall control.

 

(Source:  Amended at 47 Ill. Reg. 16454, effective November 1, 2023)

SUBPART D: CLAIMS, REFUNDS & CREDITS

 

Section 2008.76  Standards for Claims Payment

 

a)         An issuer shall comply with Section 1882(c)(3) of the Social Security Act (as enacted by Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA) (P.L. 100-203)) by:

 

1)         Accepting a notice from a Medicare carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of any other claim form otherwise required and making a payment determination on the basis of the information contained in that notice;

 

2)         Notifying the participating physician or supplier and the beneficiary of the payment determination;

 

3)         Paying the participating physician or supplier directly;

 

4)         Furnishing, at the time of enrollment, each enrollee with a card listing the policy name, number, and a central mailing address to which notices from a Medicare carrier may be sent;

 

5)         Paying user fees for claim notices that are transmitted electronically or otherwise; and

 

6)         Providing to the Secretary of Health and Human Services, at least annually, a central mailing address to which all claims may be sent by Medicare carriers.

 

b)         Compliance with the requirements set forth in subsection (a) of this Section shall be certified on the Medicare supplement insurance experience reporting form found in Appendix P of this Part.

 

(Source:  Renumbered from Section 2008.75 and amended at 23 Ill. Reg. 3704, effective March 10, 1999)

 

Section 2008.80  Loss Ratio Standards and Refund or Credit of Premium

 

a)         Loss Ratio Standards.

 

1)         A Medicare supplement policy form or certificate form shall not be delivered or issued for delivery unless the policy form or certificate form:

 

A)        Can be expected, as estimated for the entire period for which rates are computed to provide coverage, to return to policyholders and certificateholders in the form of aggregate benefits (not including anticipated refunds or credits) provided under the policy form or certificate form:

 

i)         At least 75% of the aggregate amount of premiums earned in the case of group policies; or

 

ii)        At least 65% of the aggregate amount of premiums earned in the case of individual policies.

 

B)        Is calculated on the basis of incurred claims experience or incurred health care expenses, where coverage is provided by a health maintenance organization on a service rather than reimbursement basis, and on the basis of earned premiums for the period, in accordance with accepted actuarial principles and practices.  Incurred health care expenses where coverage is provided by a health maintenance organization shall not include:

 

i)          Home office and overhead cost;

 

ii)         Advertising costs;

 

iii)        Commissions and other acquisition costs;

 

iv)        Taxes;

 

v)         Capital costs;

 

vi)        Administrative costs; and

 

vii)       Claims processing costs.

 

2)         All filings of rates and rating schedules shall be made in compliance with 50 Ill. Adm. Code 916 and shall demonstrate that expected claims in relation to premiums comply with the requirements of this Section when combined with actual experience to date.  Filings of rate revisions shall also demonstrate that the anticipated loss ratio over the entire future period for which the revised rates are computed to provide coverage can be expected to meet the appropriate loss ratio standards.

 

3)         For purposes of applying subsection (a) and Section 2008.81(d)(2), policies issued as a result of solicitations of individuals through the mails or by mass media advertising (including both print and broadcast advertising) shall be deemed to be individual policies.

 

4)         For policies issued prior to April 28, 1996, expected claims in relation to premiums shall meet:

 

A)        The originally filed anticipated loss ratio when combined with the actual experience since inception;

 

B)        The appropriate loss ratio requirement from subsections (a)(1)(A) and (B) when combined with actual experience beginning April 28, 1996 to date; and

 

C)        The appropriate loss ratio requirement from subsections (a)(1)(A) and (B) over the entire future period for which the rates are computed to provide coverage.

 

b)         Refund or Credit Calculation

 

1)         An issuer shall collect and file with the Director by May 31 of each year the data contained in Appendix S for each type in a standard Medicare supplement benefit plan.

 

2)         If, on the basis of the experience as reported, the benchmark ratio since inception (ratio 1) exceeds the adjusted experience ratio since inception (ratio 3), then a refund or credit calculation is required.  The refund calculation shall be done on a statewide basis for each type in a standard Medicare supplement benefit plan.  For purposes of the refund or credit calculation, experience on policies issued within the reporting year shall be excluded.

 

3)         For the purposes of this Section, on policies or certificates issued prior to November 5, 1991, the issuer shall make the refund or credit calculation separately for all individual policies (including all group policies subject to an individual loss ratio standard when issued) combined and all other group policies combined for experience after April 28, 1996.  The first such report shall be due by May 31, 1998.

 

4)         A refund or credit shall be made only when the benchmark loss ratio exceeds the adjusted experience loss ratio and the amount to be refunded or credited exceeds a de minimis level.  The refund shall include interest from the end of the calendar year to the date of the refund or credit at a rate specified by the Secretary of Health and Human Services, but in no event shall it be less than the average rate of interest for 13-week Treasury notes.  A refund or credit against premiums due shall be made by September 30 following the experience year upon which the refund or credit is based.

 

c)         Annual Filing of Premium Rates

An issuer of Medicare supplement policies and certificates issued in this State before or after the effective date of this Part shall file annually its rates, rating schedule and supporting documentation including ratios of incurred losses to earned premiums by policy duration for approval by the Director in accordance with the filing requirements and procedures prescribed by the Director.  The supporting documentation shall also demonstrate, in accordance with actuarial standards of practice using reasonable assumptions, that the appropriate loss ratio standards can be expected to be met over the entire period for which rates are computed.  The demonstration shall exclude active life reserves.  An expected third-year loss ratio which is greater than or equal to the applicable percentage shall be demonstrated for policies or certificates in force less than 3 years.

 

d)         As soon as practicable, but prior to the effective date of revisions in Medicare benefits, every issuer of Medicare supplement policies or certificates in this State shall file with the Department:

 

1)         Appropriate premium adjustments necessary to produce loss ratios as anticipated for the current premium for the applicable policies or certificates.  The supporting documents necessary to justify the adjustment shall accompany the filing.

 

2)         An issuer shall make such premium adjustments as are necessary to produce an expected loss ratio under the applicable policy or certificate as will conform with minimum loss ratio standards for Medicare supplement policies and which are expected to result in a loss ratio at least as great as that originally anticipated in the rates used to produce current premiums by the issuer for such Medicare supplement policies or certificates.  No premium adjustment that would modify the loss ratio experience under the policy other than the adjustments described in this subsection (d)(2) shall be made with respect to a policy at any time other than upon its renewal date or anniversary date.

 

3)         If an issuer fails to make premium adjustments acceptable to the Director, the Director may order premium adjustments, refunds or premium credits deemed necessary to achieve the loss ratio required by this Section.

 

4)         Any appropriate riders, endorsements or policy forms needed to accomplish the Medicare supplement policy or certificate modifications necessary to eliminate benefit duplications with Medicare.  These riders, endorsements or policy forms shall provide a clear description of the Medicare supplement benefits provided by the policy or certificate.

 

e)         Public Hearings

The Director may conduct a public hearing to gather information concerning a request by an issuer for an increase in a rate for a policy form or certificate form issued before or after the effective date of this Part if the experience of the form for the previous reporting period is not in compliance with the applicable loss ratio standard.  The determination of compliance is made without consideration of any refund or credit for the reporting period.

 

(Source:  Amended at 42 Ill. Reg. 21625, effective November 26, 2018)

SUBPART E: RATES, COMPENSATION AGREEMENT, DISCLOSURE, REPLACEMENT & MARKETING

 

Section 2008.81  Filing and Approval of Policies and Certificates and Premium Rates

 

a)         An issuer shall not deliver or issue for delivery a policy or certificate to a resident of this State unless the policy form or certificate form has been filed with and approved by the Director pursuant to 50 Ill. Adm. Code 916.

 

b)         An issuer shall file any riders or amendments to policy or certificate forms to delete outpatient prescription drug benefits as required by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 only with the Director in the state in which the policy or certificate was issued.

 

c)          An issuer shall not use or change premium rates for a Medicare supplement policy or certificate unless the rates, rating schedule and supporting documentation have been filed with and approved by the Director pursuant to 50 Ill. Adm. Code 916.

 

d)         Except as provided in subsection (d)(1), an issuer shall not file for approval more than one form of a policy or certificate of each type for each standard Medicare supplement benefit plan.

 

1)         An issuer may offer, with the approval of the Director, up to four additional policy forms or certificate forms of the same type for the same standard Medicare supplement benefit plan, one for each of the following cases:

 

A)        The inclusion of new or innovative benefits;

 

B)        The addition of either direct response or producer marketing methods;

 

C)        The addition of either guaranteed issue or underwritten coverage;

 

D)        The offering of coverage to individuals eligible for Medicare by reason of disability.

 

2)         For the purposes of this Section, a "type" means an individual policy, a group policy, an individual Medicare Select policy, or a group Medicare Select policy.

 

e)         Except as provided in subsection (e)(1), an issuer shall continue to make available for purchase any policy form or certificate form issued after the effective date of this Part that has been approved by the Director.  A policy form or certificate form shall not be considered to be available for purchase unless the issuer has actively offered it for sale in the previous 12 months.

 

1)         An issuer may discontinue the availability of a policy form or certificate form if the issuer provides to the Director in writing its decision at least 30 days prior to discontinuing the availability of the form of the policy or certificate.  After receipt of the notice by the Director, the issuer shall no longer offer for sale the policy form or certificate form in this State.

 

2)         An issuer that discontinues the availability of a policy form or certificate form pursuant to subsection (e)(1) shall not file for approval a new policy form or certificate form of the same type for the same standard Medicare supplement benefit plan as the discontinued form for a period of five years after the issuer provides notice to the Director of the discontinuance.  The period of discontinuance may be reduced if the Director determines that a shorter period is appropriate.

 

3)         The sale or other transfer of Medicare supplement business to another issuer shall be considered a discontinuance for the purposes of subsection (e).

 

4)         A change in the rating structure or methodology shall be considered a discontinuance under subsections (e)(1) and (2) unless the issuer complies with the following requirements:

 

A)        The issuer provides an actuarial memorandum, in a form and manner prescribed by the Director, describing the manner in which the revised rating methodology and resultant rates differ from the existing rating methodology and existing rates.

 

B)        The issuer does not subsequently put into effect a change of rates or rating factors that would cause the percentage differential between the discontinued and subsequent rates as described in the actuarial memorandum to change.  The Director may approve a change to the differential that is in the public interest.

 

f)         Except as provided otherwise in this subsection, the experience of all policy forms or certificate forms of the same type in a standard Medicare supplement benefit plan shall be combined for purposes of the refund or credit calculation prescribed in Section 2008.80.  Forms assumed under an assumption reinsurance agreement shall not be combined with the experience of other forms for purposes of the refund or credit calculation.

 

g)         For ages 65 and older, the ratio between rates for successive ages shall be greater than or equal to 1.

 

(Source:  Amended at 42 Ill. Reg. 21625, effective November 26, 2018)

 

Section 2008.82  Permitted Compensation Arrangements

 

a)         An issuer or other entity may provide commission or other compensation to an insurance producer for the sale of a Medicare supplement policy or certificate only if the first year commission or other first year compensation is no more than 200% of the commission or other compensation paid for selling or servicing the policy or certificate in the second year or period.

 

b)         The commission or other compensation provided in subsequent (renewal) years must be the same as that provided in the second year or period and must be provided for no fewer than five renewal years.

 

c)         No issuer or other entity shall provide compensation to its insurance producers and no insurance producer shall receive compensation greater than the renewal compensation payable by the replacing issuer on renewal policies or certificates if an existing policy or certificate is replaced.

 

d)         For purposes of this Section, "compensation" includes pecuniary or non-pecuniary remuneration of any kind relating to the sale or renewal of the policy or certificate including but not limited to bonuses, gifts, prizes, awards and finders fees.

 

(Source:  Amended at 23 Ill. Reg. 3704, effective March 10, 1999)

 

Section 2008.90  Required Disclosure Provisions

 

a)         General Rules

 

1)         Medicare supplement policies and certificates shall include a renewal or continuation provision.  The language or specifications of such provision must be consistent with the type of contract issued.  Such provision shall be appropriately captioned and shall appear on the first page of the policy and shall include any reservation by the issuer of the right to change premiums and any automatic renewal premium increases based on the policyholder's age.

 

2)         Except for riders or endorsements by which the issuer effectuates a request made in writing by the insured or exercises a specifically reserved right under a Medicare supplement policy, or is required to reduce or eliminate benefits to avoid duplication of Medicare benefits, all riders or endorsements added to a Medicare supplement policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require signed acceptance by the insured.  After the date of policy or certificate issue, any rider or endorsement which increases benefits or coverage with an accompanying increase in premium during the policy term shall be agreed to in writing and signed by the insured, unless the benefits are required by the minimum standards for Medicare supplement policies, except if the increased benefits or coverage is required by law.  Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, such premium charge shall be set forth in the policy.

 

3)         Medicare supplement policies or certificates shall not provide for the payment of benefits based on standards described as "usual and customary," "reasonable and customary," or words of similar import.

 

4)         If a Medicare supplement policy or certificate contains any limitations with respect to preexisting conditions, such limitations shall appear as a separate paragraph of the policy and be labeled as "Preexisting Condition Limitations."

 

5)         Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the policyholder or certificateholder shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded directly to him or her in a timely manner if, after examination of the policy or certificate, the insured person is not satisfied for any reason.

 

6)         Issuers of accident and sickness policies or certificates that provide hospital or medical expense coverage on an expense incurred or indemnity basis to persons eligible for Medicare shall provide to those applicants a Guide to Health Insurance for People with Medicare approved by the Director and in type size no smaller than 12 point type.  Delivery of the Guide shall be made whether or not such policies or certificates are advertised, solicited or issued as Medicare supplement policies or certificates as defined in this Part.  Except in the case of direct response issuers, delivery of the Guide shall be made to the applicant at the time of application and acknowledgement of receipt of the Guide shall be obtained by the issuer.  Direct response issuers shall deliver the Guide to the applicant upon request but not later than at the time the policy is delivered.

 

b)         Identification Cards.  Identification cards provided to the policyholders must reflect the name of the issuer rather than a corporate name and must also identify which plan coverage is being provided to the policyholder.

 

c)         Policy Checklist

 

1)         In order to determine what policy or certificate is appropriate and nonduplicative, a policy checklist must be completed in the presence of the applicant at the point of sale.  Copies of the checklist, completed and duly signed are to be provided to the applicant and the issuer.  This requirement does not apply to direct response solicitations.

 

2)         The checklist required by subsection (c)(1) of this Section shall provide substantially the form prescribed in Appendix A of this Part.

 

3)         Issuers issuing Medicare supplement policies for delivery in this State shall not issue a Medicare supplement policy unless all information requested in the policy checklist is provided.

 

d)         Notice Requirements

 

1)         As soon as practicable, but no later than 30 days prior to the annual effective date of Medicare benefit changes, an insurer shall notify its policyholders and certificateholders of modifications it has made to Medicare supplement insurance policies or certificates in the format prescribed in Appendix T of this Part.  Such notice shall:

 

A)        Include a description of revisions to the Medicare program and a description of each modification made to the coverage provided under the Medicare supplement policy or certificate, and

 

B)        Inform each policyholder or certificateholder as to when any premium adjustment is to be made due to changes in Medicare.

 

2)         The notice of benefit modifications and any premium adjustments shall be in outline form and in clear and simple terms so as to facilitate comprehension.  This notice shall be plainly printed in no smaller than 12 point type.

 

3)         Such notices shall not contain or be accompanied by any solicitation.

 

e)         MMA Notice Requirements.  Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

 

f)         Outline of Coverage Requirements for Medicare Supplement Policies

 

1)         Issuers shall provide an outline of coverage to all applicants at the time the application is presented to the prospective applicant, and except for direct response policies, shall obtain an acknowledgement of receipt of such outline from the applicant.

 

2)         If an outline of coverage is provided at the time of application and the Medicare supplement policy or certificate is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate shall accompany such policy or certificate when it is delivered and contain the following statement, in no less than 12 point type, immediately above the company name:

 

NOTICE:  Read this outline of coverage carefully.  It is not identical to the outline of coverage provided upon application, and the coverage originally applied for has not been issued.

 

3)         In addition to the statement required by subsection (f)(2) of this Section, each revised outline of coverage accompanying a policy or certificate issued on a basis other than that originally applied for, shall contain the following notice appearing in no less than 12 point type:

 

WARNING:  The (policy or certificate) you have received is not the same as the one for which you made application.

 

4)         The outline of coverage provided to applicants pursuant to this subsection (f)(4) shall consist of four parts:  a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer.  Please see Appendix B of this Part.  The outline of coverage shall be in the language and format prescribed in Appendix B in no less than 12 point type.  All Plans A through L shall be shown on the cover page, and the plans that are offered by the issuer shall be prominently identified.  Premium information for plans that are offered shall be shown on the cover page or immediately following the cover page and shall be prominently displayed.  The premium and mode shall be stated for all plans that are offered to the prospective applicant.  All possible premiums for the prospective applicant shall be illustrated.

 

5)         The outline of coverage shall follow the format in Appendix B of this Part.  The term "certificate" should be substituted for the word "policy" throughout the outline of coverage where appropriate.

 

g)         Notice Regarding Policies or Certificates Which are Not Medicare Supplement Policies

 

1)         Any accident and sickness insurance policy or certificate, other than a Medicare supplement policy, a policy issued pursuant to a contract under Section 1876 of the Federal Social Security Act (42 USC, Section 1395 et seq.), disability income policy, or other policy identified in Section 2008.30(b)(3) of this Part issued for delivery in this State to persons eligible for Medicare, shall notify insureds under the policy that the policy is not a Medicare supplement policy or certificate.  The notice shall either be printed or attached to the first page of the outline of coverage delivered to insureds under the policy, or if no outline of coverage is delivered, to the first page of the policy or certificate delivered to insureds.  The notice shall be in no less than 12 point type and shall contain the following language:

 

THIS (POLICY OR CERTIFICATE) IS NOT A MEDICARE SUPPLEMENT (POLICY OR CERTIFICATE).  IT DOES NOT FULLY SUPPLEMENT YOUR FEDERAL MEDICARE HEALTH INSURANCE.  If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company.

 

2)         Using the applicable statement found in Appendix V of this Part, applications provided to persons eligible for Medicare for the health insurance policies or certificates described in subsection (g)(1) of this Section shall disclose the extent to which the policy duplicates Medicare.  The disclosure statement shall be provided as part of, or together with, the application for the policy or certificate.

 

h)         Filing Requirements for Advertising

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

 

(Source:  Amended at 29 Ill. Reg. 14188, effective September 8, 2005)

 

Section 2008.91  Instructions for Use of the Disclosure Statements for Health Insurance Policies Sold to Medicare Beneficiaries that Duplicate Medicare

 

a)         Section 1882(d) of the federal Social Security Act prohibits the sale of health insurance policies (the term policy or policies includes certificates) that duplicate Medicare benefits unless the policy will pay benefits without regard to other health coverage and the policy includes the prescribed disclosure statement on, or together with, the application.

 

b)         All types of health insurance policies that duplicate Medicare shall include one of the disclosure statements found in Appendix Q of this Part, according to the particular policy type involved, on the application or together with the application.  The disclosure statement may not vary from those found in Appendix Q of this Part in terms of language or format (type size, type proportional spacing, bold character, line spacing, and usage of boxes around text).

 

c)         State and Federal law prohibits insurers from selling a Medicare supplement policy to a person that already has a Medicare supplement policy except as a replacement.

 

d)         Property/Casualty and Life insurance policies are not considered health insurance.

 

e)         Disability income policies are not considered to provide benefits that duplicate Medicare.

 

f)         Traditional Long-Term Care or Long-Term Care Partnership insurance policies that coordinate with Medicare and other health insurance are not considered to provide benefits that duplicate Medicare.

 

g)         The Federal law does not preempt Illinois law.

 

h)         The Federal law does not preempt existing Illinois form filing requirements.

 

i)          Section 1882 of the federal Social Security Act was amended in subsection (d)(3)(A) to allow for alternative disclosure statements.  The disclosure statements already in Appendix Q remain.  Issuers may use either disclosure statements with the requisite insurance product.  However, issuers should use either the original disclosure statements found in Appendix Q of this Part or the alternative disclosure statements, not use both simultaneously.

 

(Source:  Amended at 23 Ill. Reg. 3704, effective March 10, 1999)

 

Section 2008.100  Requirements for Application Forms and Replacement Coverage

 

a)         Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant currently has Medicare supplement, Medicare Advantage, Medicaid coverage, or another health insurance policy or certificate in force or whether a Medicare supplement policy or certificate is intended to replace any other accident and sickness policy or certificate presently in force.  A supplementary application or other form to be signed by the applicant and insurance producer containing such questions and statements may be used.

 

1)         Statements

 

A)        You do not need more than one Medicare supplement policy.

 

B)         If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverages.

 

C)         You may be eligible for benefits under Medicaid and may not need a Medicare supplement policy.

 

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

 

E)         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 after 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.

 

F)         Counseling services may be available in this 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).

 

2)         Questions

 

If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplement insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplement plans.  Please include a copy of the notice from your prior insurer with your application.  PLEASE ANSWER ALL QUESTIONS.  Please mark Yes or No below with an "X".

 

To the best of your knowledge:
A)	Did you turn age 65 in the last 6 months?
	Yes             No
B)	Did you enroll in Medicare Part B in the last 6 months?
	Yes             No
C)	If yes, what is the effective date?

 

D)        Are you covered for medical assistance through the State Medicaid program?

 

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
If yes:
i)	Will Medicaid pay your premiums for this Medicare supplement policy?
	Yes             No
ii)	Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?
	Yes             No

 

E)        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 below.  If you are still covered under this plan, leave "END" blank.

 

START

/     /

END

/     /

 

i)          If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplement policy?

 

Yes             No

 

ii)         Was this your first time in this type of Medicare plan?

 

Yes             No

 

iii)        Did you drop a Medicare supplement policy to enroll in the Medicare plan?

 

Yes             No

 

F)         Do you have another Medicare supplement policy in force?

 

Yes             No

 

i)          If so, with what company, and what plan do you have (optional for Direct Mailers)?

 

 

ii)         If so, do you intend to replace your current Medicare supplement policy with this policy?

 

Yes             No

 

G)        Have you had coverage under any other health insurance within the past 63 days?  (For example, an employer, union, or individual plan)

 

Yes             No

 

i)          If so, with what company, and what kind of policy?

 

 

ii)         What are your dates of coverage under the other policy?

 

START

/     /

END

/     /

 

(If you are still covered under the other policy, leave "END" blank.)

 

b)         Insurance producers shall list any other health insurance policies they have sold to the applicant.

 

1)         List policies sold that are still in force.

 

2)         List policies sold in the past 5 years that are no longer in force.

 

c)         In the case of a direct response issuer, a copy of the application or supplemental form, signed by the applicant and acknowledged by the insurer, shall be returned to the applicant by the insurer upon delivery of the policy.

 

d)         Upon determining that a sale will involve replacement of Medicare supplement, an issuer, other than a direct response issuer, or its agent, shall furnish the applicant, prior to issuance or delivery of the Medicare supplement policy or certificate, a notice regarding replacement of accident and sickness coverage.  One copy of such notice signed by the applicant and the insurance producer shall be provided to the applicant and an additional signed copy shall be retained by the issuer.  A direct response issuer shall deliver to the applicant at the time of the issuance of the policy the notice regarding replacement of accident and sickness coverage in the form prescribed in Appendix R.

 

e)         The notice required by subsection (d) for an issuer, other than a direct response issuer, shall be provided in the form prescribed in Appendix R in no less than 12-point type.

 

f)         Subsections (1) and (2) of Appendix R (applicable to preexisting conditions) may be deleted by an issuer if the replacement does not involve application of a new preexisting condition limitation.

 

g)         Persons aged 65-75 who have an existing Medicare supplement policy shall be eligible commencing on their birthday for an open enrollment period of 45 days to select any of the same issuer’s other Medicare supplement policies that offer benefits equal to or lesser than the person’s existing coverage.  An issuer shall not deny or condition the issuance or effectiveness of coverage or discriminate in pricing based on the person’s health status, claims experience, receipt of healthcare, or medical condition, including any preexisting condition.

 

h)         The notice of this annual open enrollment period required by Section 363(8) of the Code shall be attached with or incorporated into the application for Medicare supplement insurance.  If the notice is attached separately with the application and not embedded into the application, then it must be filed in a form filing through the System for Electronic Rate and Form Filing (SERFF) for approval by the Department prior to issuance to the applicant.

 

(Source:  Amended at 47 Ill. Reg. 5701, effective April 4, 2023)

 

Section 2008.101  Standards for Marketing

 

a)         An issuer, directly or through its producers, shall:

 

1)         Establish fair and accurate marketing procedures which comply with the standards set forth in Section 363a(5) and (6) of the Code.

 

2)         Establish marketing procedures to assure duplicative insurance benefits are not sold or issued.

 

3)         Display prominently by type, stamp or other appropriate means, on the first page of the policy, the following:

 

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

 

4)         Inquire and otherwise make every reasonable effort to identify whether a prospective applicant or enrollee for Medicare supplement insurance already has accident and sickness insurance and the types and amounts of such insurance.

 

5)         Establish auditable procedures for verifying compliance with this subsection (a).

 

b)         The following acts and practices are prohibited:

 

1)         Twisting.  Knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or insurers for the purpose of inducing or tending to induce any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert any insurance policy or to take out a policy of insurance with another insurer.

 

2)         High pressure tactics.  Employing any method of marketing having the effect of inducing or tending to induce the purchase of insurance through force, fright, threat, whether explicit or implied, or undue pressure to purchase or recommend the purchase of insurance.

 

3)         Cold lead advertising.  Making use directly or indirectly of any method of marketing which fails to disclose in a conspicuous manner that a purpose of the method of marketing is solicitation of insurance and that contact will be made by an insurance agent or insurance company.

 

c)         The terms "Medicare Supplement," "Medigap," "Medicare Wrap-Around" and words of similar import shall not be used unless the policy is issued in compliance with this Part.

 

(Source:  Amended at 20 Ill. Reg. 6393, effective April 28, 1996)

 

Section 2008.102  Appropriateness of Recommended Purchase and Excessive Insurance

 

a)         In recommending the purchase or replacement of any Medicare supplement policy or certificate, an insurance producer shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement.  For purposes of this subsection the insurer will be deemed to make reasonable efforts to determine the appropriateness of the recommended purchase if the insurer complies with the standards set forth in Sections 363a(5) and (6) of the Code.

 

b)         Any sale of a Medicare supplement policy or certificate that will provide an individual more than one Medicare supplement policy or certificate is prohibited.

 

c)         An issuer shall not issue a Medicare supplement policy or certificate to an individual enrolled in Medicare Part C unless the effective date of the coverage is after the termination date of the individual's Part C coverage.

 

(Source:  Amended at 29 Ill. Reg. 14188, effective September 8, 2005)

SUBPART F: REPORTING & PROHIBITIONS

 

Section 2008.103  Reporting of Multiple Policies

 

a)         On or before March 1 of each year an issuer shall report the following information prescribed in Appendix P of this Part for every individual resident of this State for which the issuer has in force more than one Medicare supplement policy or certificate:

 

1)         Policy and certificate number, and

 

2)         Date of issuance.

 

b)         The items set forth above must be grouped by individual policyholder.

 

(Source:  Amended at 16 Ill. Reg. 15452, effective September 29, 1992)

 

Section 2008.104  Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies or Certificates

 

a)         If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate, the replacing issuer shall waive any time periods applicable to preexisting conditions, waiting periods, elimination periods and probationary periods in the new Medicare supplement policy or certificate for similar benefits to the extent such time was spent under the original policy.

 

b)         If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate which has been in effect for at least six months, the replacing policy shall not provide any time period applicable to preexisting conditions, waiting periods, elimination periods and probationary periods for benefits similar to those contained in the original policy or certificate.

 

(Source:  Amended at 20 Ill. Reg. 6393, effective April 28, 1996)

 

Section 2008.107  Prohibition Against Use of Genetic Information and Requests for Genetic Testing

 

This Section applies to all policies with policy years beginning on or after May 21, 2009. 

 

a)         An issuer of a Medicare supplement policy or certificate; 

 

1)         shall not deny or condition the issuance or effectiveness of the policy or certificate (including the imposition of any exclusion of benefits under the policy based on a pre-existing condition) on the basis of the genetic information with respect to such individual; and

 

2)         shall not discriminate in the pricing of the policy or certificate (including the adjustment of premium rates) of an individual on the basis of the genetic information with respect to such individual. 

 

b)         Nothing in subsection (a) shall be construed to limit the ability of an issuer, to the extent otherwise permitted by law, from:

 

1)         Denying or conditioning the issuance or effectiveness of the policy or certificate or increasing the premium for a group based on the manifestation of a disease or disorder of an insured or applicant; or 

 

2)         Increasing the premium for any policy issued to an individual based on the manifestation of a disease or disorder of an individual who is covered under the policy (in such case, the manifestation of a disease or disorder in one individual cannot also be used as genetic information about other group members and to further increase the premium for the group).

 

c)         An issuer of a Medicare supplement policy or certificate shall not request or require an individual or a family member of the individual to undergo a genetic test. 

 

d)         Subsection (c) shall not be construed to preclude an issuer of a Medicare supplement policy or certificate from obtaining and using the results of a genetic test in making a determination regarding payment (as defined for the purposes of applying the regulations promulgated under Part C of Title XI (42 USC 1320d-1320d-8) and Section 264 of the Health Insurance Portability and Accountability Act of 1996 (42 USC 1320d-2), as may be revised from time to time) and consistent with subsection (a). 

 

e)         For purposes of carrying out subsection (d), an issuer of a Medicare supplement policy or certificate may request only the minimum amount of information necessary to accomplish the intended purpose. 

 

f)         Notwithstanding subsection (c), an issuer of a Medicare supplement policy may request, but not require, that an individual or a family member of such individual undergo a genetic test if each of the following conditions is met: 

 

1)         The request is made pursuant to research that complies with 45 CFR 46 (2005) or equivalent federal regulations, and any applicable state or local law or regulations for the protection of human subjects in research. 

 

2)         The issuer clearly indicates to each individual, or in the case of a minor child, to the legal guardian of the child, to whom the request is made that:

 

A)        compliance with the request is voluntary; and

 

B)        non-compliance will have no effect on enrollment status or premium or contribution amounts. 

 

3)         No genetic information collected or acquired under this subsection (f) shall be used for underwriting, determination of eligibility to enroll or maintain enrollment status, premium rates, or the issuance, renewal, or replacement of a policy or certificate. 

 

4)         The issuer notifies the Secretary in writing that the issuer is conducting activities pursuant to the exception provided for under this subsection (f), including a description of the activities conducted. 

 

5)         The issuer complies with other conditions the Secretary may by regulation require for activities conducted under this subsection (f). 

 

g)         An issuer of a Medicare supplement policy or certificate shall not request, require, or purchase genetic information for underwriting purposes. 

 

h)         An issuer of a Medicare supplement policy or certificate shall not request, require, or purchase genetic information with respect to any individual prior to the individual's enrollment under the policy in connection with the enrollment. 

 

i)          If an issuer of a Medicare supplement policy or certificate obtains genetic information incidental to the requesting, requiring, or purchasing of other information concerning any individual, the request, requirement, or purchase shall not be considered a violation of subsection (h) if the request, requirement, or purchase is not in violation of subsection (g).

 

j)          For the purposes of this Section only:

 

1)         "Issuer of a Medicare supplement policy or certificate" includes third-party administrator, or other person acting for or on behalf of the issuer. 

 

2)         "Family member" means, with respect to an individual, any other individual who is a first-degree, second-degree, third-degree, or fourth-degree relative of the individual. 

 

3)         "Genetic information" means, with respect to any individual, information about the individual's genetic tests, the genetic tests of family members of the individual, and the manifestation of a disease or disorder in family members of the individual.  The term includes, with respect to any individual, any request for, or receipt of, genetic services, or participation in clinical research that includes genetic services, by the individual or any family member of the individual.  Any reference to genetic information concerning an individual or family member of an individual who is a pregnant woman, includes genetic information of any fetus carried by the pregnant woman, or with respect to an individual or family member utilizing reproductive technology, includes genetic information of any embryo legally held by an individual or family member.  The term "genetic information" does not include information about the sex or age of any individual. 

 

4)         "Genetic services" means a genetic test, genetic counseling (including obtaining, interpreting, or assessing genetic information), or genetic education. 

 

5)         "Genetic test" means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites that detect genotypes, mutations, or chromosomal changes.  The term "genetic test" does not mean an analysis of proteins or metabolites that does not detect genotypes, mutations, or chromosomal changes; or an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition that could reasonably be detected by a health care professional with appropriate training and expertise in the field of medicine involved. 

 

6)         "Underwriting purposes" means,

 

A)        rules for, or determination of, eligibility (including enrollment and continued eligibility) for benefits under the policy;

 

B)        the computation of premium or contribution amounts under the policy;

 

C)        the application of any pre-existing condition exclusion under the policy; and

 

D)        other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits.

 

(Source:  Added at 33 Ill. Reg. 8904, effective June 10, 2009)

SUBPART G: MISCELLANEOUS PROVISIONS

 

Section 2008.110  Severability

 

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

 

(Source:  Amended at 16 Ill. Reg. 2766, effective February 11, 1992; corrected at 16 Ill. Reg. 3590)

 

Section 2008.120  Effective Date (Repealed)

 

(Source:  Repealed at 14 Ill. Reg. 19243, effective November 27, 1990)







Section 2008.APPENDIX A  Policy Checklist

 

Applicant's Name
Policy Number
Name of Existing Insurer
Expiration Date of Existing Insurance
SERVICE	BENEFIT					MEDICARE PAYS	EXISTING COVERAGE		SUPPLEMENT PAYS	YOU PAY
Hospital Inpatient	First 60 Days					All But ($        )
	61st to 90th Day					All But ($        ) a Day
	91st to 150th Day (Lifetime Reserve)					($        ) a Day
	Beyond 150 Days					Nothing
Skilled Nursing Home Care	First 20 Days Additional 80 Days					100% of Cost All But ($        ) A Day
	Beyond 100 Days					Nothing
Medical Expense	Physician's Services in hospital, office or home, inpatient and out-patient medical services and supplies at a hospital, physical and speech therapy and ambulance					80% of Medicare Determined allowable charges after ($              ) Deductible
Prescription Drugs						Inpatient Prescription Drugs.  80% of allowable charges for immunosuppressive drugs during the first year following a covered transplant.

 

This policy does/does not comply with the minimum standards set forth in Section 363 of the Illinois Insurance Code.

 

DATE		SIGNATURE OF APPLICANT
		SIGNATURE OF INSURANCE PRODUCER

 

(Source:  Amended at 16 Ill. Reg. 2766, effective February 11, 1992; corrected at 16 Ill. Reg. 3590)




Section 2008.APPENDIX B   Outline of Medicare Supplement Coverage – Cover Page for Medicare Supplement Plans Sold Prior to June 1, 2010

 

[COMPANY NAME]

Outline of Medicare Supplement Coverage – Cover Page: 1 of 2

Benefit Plans ______ [insert letters of plans being offered]

 

These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan "A". Some plans may not be available in Illinois.

 

See Outlines of Coverage sections for details about all plans.

 

BASIC BENEFITS FOR PLANS A-J:

 

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.

 

Blood: First 3 pints of blood each year.

 

A	B	C	D	E
Basic Benefits	Basic Benefits	Basic Benefits	Basic  Benefits	Basic Benefits
		Skilled Nursing Facility Coinsurance	Skilled Nursing Facility Coinsurance	Skilled Nursing Facility Coinsurance
	Part A Deductible	Part A Deductible	Part A Deductible	Part A Deductible
		Part B Deductible
		Foreign Travel Emergency	Foreign Travel Emergency	Foreign Travel Emergency
			At-Home Recovery
				Preventive Care NOT Covered by Medicare




 

F             F*	G	H	I	J             J*
Basic Benefits	Basic  Benefits	Basic Benefits	Basic Benefits	Basic Benefits
Skilled Nursing Facility Coinsurance	Skilled Nursing Facility Coinsurance	Skilled Nursing Facility Coinsurance	Skilled Nursing Facility Coinsurance	Skilled Nursing Facility Coinsurance
Part A Deductible	Part A Deductible	Part A Deductible	Part A Deductible	Part A Deductible
Part B Deductible				Part B Deductible
Part B Excess (100%)	Part B Excess (80%)		Part B Excess (100%)	Part B Excess (100%)
Foreign Travel Emergency	Foreign Travel Emergency	Foreign Travel Emergency	Foreign Travel Emergency	Foreign Travel Emergency
	At-Home Recovery		At-Home Recovery	At-Home Recovery
				Preventive Care NOT Covered by Medicare

 

Plans F and J also have an option called a high deductible Plan F and a high deductible Plan J. These high deductible plans pay the same benefits as Plans F and J after one has paid a calendar year [$_____] deductible. Benefits from high deductible Plans F and J will not begin until out-of-pocket expenses are [$_____]. 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.

 

NOTE:

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear above. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.




[COMPANY NAME]

Outline of Medicare Supplement Coverage – Cover Page 2

 

Basic Benefits for Plans K and L include similar services as Plans A-J, but cost-sharing for the basic benefits is at different levels.

 

J	K**	L**
Basic Benefits	100% of Part A Hospitalization Coinsurance plus coverage for 365 days after Medicare benefits end 50% Hospice cost-sharing 50% of Medicare-eligible expenses for the first 3 pints of blood 50% Part B Coinsurance, except 100% coinsurance for Part B Preventive Services	100% of Part A Hospitalization Coinsurance plus coverage for 365 days after Medicare benefits end 75% Hospice cost-sharing 75% of Medicare-eligible expenses for the first 3 pints of blood 75% Part B Coinsurance, except 100% coinsurance for Part B Preventive Services
Skilled Nursing Coinsurance	50% Skilled Nursing Facility Coinsurance	75% Skilled Nursing Facility Coinsurance
Part A Deductible	50% Part A Deductible	75% Part A Deductible
Part B Deductible
Part B Excess (100%)
Foreign Travel Emergency
At-Home Recovery
Preventive Care NOT Covered by Medicare
	$[      ] Out of Pocket Annual Limit***	$[      ] Out of Pocket Annual Limit***

 

** Plans K and L provide for different cost-sharing for items and services than Plans A-J.

 

Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance, and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called "excess charges".  You will be responsible for paying excess charges.

 

***The out-of-pocket annual limit will increase each year for inflation.

 

See Outlines of Coverage for details and exceptions.




PREMIUM INFORMATION [Boldface Type]

 

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

 

DISCLOSURES [Boldface Type]

 

Use this outline to compare benefits and premiums among policies.

 

This outline shows benefits and premiums of policies sold for effective dates prior to June 1, 2010.

 

READ YOUR POLICY VERY CAREFULLY

 

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

 

RIGHT TO RETURN POLICY [Boldface Type]

 

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

 

POLICY REPLACEMENT [Boldface Type]

 

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

 

NOTICE [Boldface Type]

 

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

(for producers:)

Neither (insert company's name) nor its agents are connected with Medicare.

(for direct response:)

(insert company's name) is not connected with Medicare.

 

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security office or consult "Medicare & You" for more details.

 

COMPLETE ANSWERS ARE VERY IMPORTANT [Boldface Type]

 

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

 

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

 

[Include for each plan prominently identified on the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in Appendices C through N of this Part. No more than four plans may be shown on one chart.  For purposes of illustration, charts for each plan are included in this Appendix.  An issuer may use additional benefit plan designations on these charts pursuant to Section 2008.72(d) of this Part.]

 

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

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)




Section 2008.APPENDIX C   Plan A (for plans issued prior to June 1, 2010)

 

MEDICARE (PART A) − Hospital Services – Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below.  The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$________]	$0	[$________] (Part A Deductible)
61st thru 90th day	All but [$________] a day	[$________] a day	$0
91st day and after;
- While using 60 lifetime reserve days	All but [$________] a day	[$________] 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	$0
21st thru 100th day	All but [$________] a day	$0	Up to [$________] a day
101st day and after	$0	$0	All costs
BLOOD
First 3 pints	$0	3 pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE
Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

 

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

 




(Plan A Continued)

 

MEDICARE (PART B) – Medical Services-Per Calendar Year

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES-IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 [$100] of Medicare Approved Amounts*	$0	$0	[$100] (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 3 pints	$0	All costs	$0
Next $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved   Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES
TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
- Medically necessary skilled care services and medical supplies	100%	$0	$0
- Durable medical equipment
First $[100] of Medicare Approved Amounts*	$0	$0	$100 (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)




Section 2008.APPENDIX D   Plan B (for plans issued prior to June 1, 2010)

 

MEDICARE (PART A) – Hospital Services-Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$________]	[$________] (Part A Deductible)	$0
61st thru 90th day	All but [$________] a day	[$________] a day	$0
91st day and after;
- While using 60 lifetime reserve days	All but [$________] a day	[$________] 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	$0
21st thru 100th day	All but [$________] day	$0	Up to [$________] a day
101st day and after	$0	$0	All costs
BLOOD
First 3 pints	$0	3 pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE
Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

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

 

(Plan B Continued)

 

MEDICARE (PART B) – Medical Services – Per Calendar Year

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES-IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $[100] of Medicare Approved Amounts*	$0	$0	$[100] (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 3 pints	$0	All costs	$0
Next $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES
TEST FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
- Medically necessary skilled care services and medical supplies	100%	$0	$0
- Durable medical equipment
First $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved  Amounts	80%	20%	$0

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)




Section 2008.APPENDIX E   Plan C (for plans issued prior to June 1, 2010)

 

MEDICARE (PART A) – Hospital Services – Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$__________]	[$__________] (Part A Deductible)	$0
61st thru 90th day	All but [$__________] a day	[$__________] a day	$0
91st day and after;
- While using 60 lifetime reserve days	All but [$__________] a day	[$__________] a day	$0
- Once lifetime reserve day 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	$0
21st thru 100th day	All but [$__________] a day	Up to [$__________] a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 pints	$0	3 pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE
Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

 

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




(Plan C Continued)

 

MEDICARE (PART B) – Medical Services – Per Calendar Year

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES-IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $[100] of Medicare Approved Amounts*	$0	$[100] (Part B Deductible)	$0
Remainder of Medicare Approved Amounts	generally 80%	generally 20%	$0
Part B Excess Charges (Above Medicare Approved Amounts)	$0	$0	All costs
BLOOD
First 3 pints	$0	All costs	$0
Next $[100] of Medicare Approved Amounts	$0	$[100] (Part B Deductible)	$0
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES- TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
-  Medically necessary skilled care services and medical supplies	100%	$0	$0
-  Durable medical equipment
First $[100] of Medicare Approved Amounts*	$0	$[100] (Part B Deductible)	$0
Remainder of Medicare Approved Amounts	80%	20%	$0

 




(Plan C Continued)

 

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

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)




Section 2008.APPENDIX F   Plan D (for plans issued prior to June 1, 2010)

 

MEDICARE (PART A) – Hospital Services – Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$________]	[$________] (Part A Deductible)	$0
61st thru 90th day	All but [$________] a day	[$________] a day	$0
91st day and after;
-  While using 60 lifetime reserve days	All but [$________] a day	[$________] 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	$0
21st thru 100th day	All but [$________] a day	Up to [$________] a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 pints	$0	3 pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE
Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

 

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




(Plan D Continued)

 

MEDICARE (PART B) – Medical Services – Per Calendar Year

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES-IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $[100] of Medicare Approved Amounts*	$0	$0	$[100] (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 3 pints	$0	All costs	$0
Next $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES-
TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
-  Medically necessary skilled care services and medical supplies	100%	$0	$0
-  Durable medical equipment
First $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0
AT HOME RECOVERY SERVICES-NOT COVERD BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan
-  Benefit for each visit	$0	Actual Charges to $40 a visit	Balance
-  Number of visits covered (must be received within 8 weeks of last Medicare Approved visit	$0	Up to the number of Medicare Approved visits, not to exceed 7 each week
-  Calendar year maximum	$0	$1,600

 

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

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)




Section 2008.APPENDIX G   Plan E (not available after May 31, 2010)

 

MEDICARE (PART A) – Hospital Services – Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$__________]	[$__________] (Part A Deductible)	$0
61st thru 90th day	All but [$__________] a day	[$__________] a day	$0
91st day and after;
- While using 60 lifetime reserve days	All but [$__________] a day	[$__________] a day	$0
- Once lifetime reserve day 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	$0
21st thru 100th day	All but [$__________] a day	Up to [$__________] a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 pints	$0	3 pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE
Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

 

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




(Plan E Continued)

 

MEDICARE (PART B) – Medical Services – Per Calendar Year

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES-IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $[100] of Medicare Approved Amounts*	$0	$0	$[100] (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 3 pints	$0	All costs	$0
Next $[100] of Medicare Approved Amounts	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES-
TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
- Medically necessary skilled care services and medical supplies	100%	$0	$0
- Durable medical equipment
First $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0




(Plan E Continued)

 

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
**PREVENTIVE MEDICAL CARE BENEFIT-NOT COVERED BY MEDICARE   Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare
First $120 each calendar year	$0	$120	$0
Additional charges	$0	$0	All costs

 

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

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)




Section 2008.APPENDIX H   Plan F or High Deductible Plan F (for plans issued prior to June 1, 2010)

 

MEDICARE (PART A) – Hospital Services – Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

[**  This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$_____] deductible.  Benefits from high deductible Plan F will not begin until out-of-pocket expenses are [$_____]. 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 [$___] DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO [$___] DEDUCTIBLE**] YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$_______]	[$________] (Part A Deductible)	$0
61st thru 90th day	All but [$_______] a day	[$________] a day	$0
91st day and after;
-  While using 60 lifetime reserve days	All but [$_______] a day	[$________] 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	$0
21st thru 100th day	All but [$________] a day	Up to [$________] a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 pints	$0	3 pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE
Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and in-patient respite care	$0	Balance

 

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




(Plan F or High Deductible Plan F Continued)

 

MEDICARE (PART B) – Medical Services – Per Calendar Year

 

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

 

[**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$____] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are [$____]. 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 [$____] DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO [$___] DEDUCTIBLE**]  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 $[100] of Medicare Approved Amounts*	$0	$[100] (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 3 pints	$0	All costs	$0
Next $[100] of Medicare Approved Amounts*	$0	$[100] (Part B Deductible)	$0
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES-
TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

SERVICES	MEDICARE PAYS	[AFTER YOU PAY [$____] DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO [$___] DEDUCTIBLE**] YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
-  Medically necessary skilled care services and medical supplies	100%	$0	$0
-  Durable medical equipment
First $[100] of Medicare Approved Amounts*	$0	$[100] (Part B Deductible)	$0
Remainder of Medicare Approved Amounts	80%	20%	$0

 

OTHER BENEFITS – Not Covered By Medicare

 

SERVICES	MEDICARE PAYS	[AFTER YOU PAY THE [$_____] DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO THE [$_____] DEDUCTIBLE**]  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

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)




Section 2008.APPENDIX I   Plan G (for plans issued prior to June 1, 2010)

 

MEDICARE (PART A) – Hospital Services – Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$________]	[$________] (Part A Deductible)	$0
61st thru 90th day	All but [$________] a day	[$________] a day	$0
91st day and after;
-  While using 60 lifetime reserve days	All but [$________] a day	[$________] 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	$0
21st thru 100th day	All but [$________] a day	Up to [$________] a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 pints	$0	3 pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE
Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

 

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




(Plan G Continued)

 

MEDICARE (PART B) – Medical Services – Per Calendar Year

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES-IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	generally 80%	generally 20%	$0
Part B Excess Charges (Above Medicare Approved Amounts)	$0	80%	20%
BLOOD
First 3 pints	$0	All costs	$0
Next $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES
TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
-  Medically necessary skilled care services and medical supplies	100%	$0	$0
-  Durable medical equipment
First $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0
AT-HOME RECOVERY SERVICES-NOT COVERD BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan
-   Benefit for each visit	$0	Actual Charges to $40 a visit	Balance
-   Number of visits covered (must be received within 8 weeks of last Medicare Approved visit	$0	Up to the number of Medicare Approved visits, not to exceed 7 each week
-   Calendar year maximum	$0	$1,600

 

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

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)




Section 2008.APPENDIX J   Plan H (not available after May 31, 2010)

 

MEDICARE (PART A) – Hospital Services – Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

SERVICES		MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION*
Semiprivate room and board,  general nursing and miscellaneous services and supplies
	First 60 days	All but [$_____]	[$_____] (Part A Deductible)	$0
	61st thru 90th day	All but [$_____] a day	[$_____] a day	$0
	91st day and after;
	-While using 60 lifetime reserve days	All but [$_____] a day	[$_____] 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	$0
	21st thru 100th day	All but [$_____] a day	Up to [$_____] a day	$0
	101st day and after	$0	$0	All costs
BLOOD
First 3 pints		$0	3 pints	$0
Additional amounts		100%	$0	$0
HOSPICE CARE
Available as long as your doctor certifies you are terminally ill and you elect to receive these services		All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

 

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




 

(Plan H Continued)

 

MEDICARE (PART B) – Medical Services – Per Calendar Year

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREAMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment.
First $[100] of Medicare Approved Amounts*	$0	$0	$[100] (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 3 pints	$0	All costs	$0
Next $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES-
TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
-    Medically necessary skilled care services and medical supplies	100%	$0	$0
-    Durable medical equipment
First $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0

 

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

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)




Section 2008.APPENDIX K   Plan I (not available after May 31, 2010)

 

MEDICARE (PART A) – Hospital Services – Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$________]	[$________] (Part A Deductible)	$0
61st thru 90th day	All but [$________] a day	[$________] a day	$0
91st day and after;
-  While using 60 lifetime reserve days	All but [$________] a day	[$________] 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	$0
21st thru 100th day	All but [$________] a day	Up to [$________] a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 pints	$0	3 pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE
Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

 

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




(Plan I Continued)

 

MEDICARE (PART B) – Medical Services – Per Calendar Year

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	generally 80%	generally 20%	$0
Part B Excess Charges (Above Medicare Approved Amounts)	$0	100%	$0
BLOOD
First 3 pints	$0	All costs	$0
Next $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES-
TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
-  Medically necessary skilled care services and medical supplies	100%	$0	$0
-  Durable medical equipment
First $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0
AT-HOME RECOVERY SERVICES-NOT COVERED BY MEDICARE
Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan
-  Benefit for each visit	$0	Actual Charges to $40 a visit	Balance
-  Number of visits covered (must be received within 8 weeks of last Medicare Approved visit	$0	Up to the number of Medicare Approved visits, not to exceed 7 each week
-  Calendar year maximum	$0	$1,600

 

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

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)




Section 2008.APPENDIX L   Plan J or High Deductible Plan J (not available after May 31, 2010)

 

MEDICARE (PART A) – Hospital Services – Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

[** This high deductible plan pays the same benefits as Plan J after one has paid a calendar year [$_____] deductible.  Benefits from high deductible Plan J will not begin until out-of-pocket expenses are [$_____]. 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 [$___] DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO [$___] DEDUCTIBLE**] YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$_______]	[$________] (Part A Deductible)	$0
61st thru 90th day	All but [$_______] a day	[$________] a day	$0
91st day and after;
-  While using 60 lifetime reserve days	All but [$_______] a day	[$________] 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	$0
21st thru 100th day	All but [$________] a day	Up to [$________] a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 pints	$0	3 pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE
Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and in-patient respite care	$0	Balance

 

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




(Plan J or High Deductible Plan J Continued)

 

MEDICARE (PART B) – Medical Services – Per Calendar Year

 

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

 

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

 

SERVICES	MEDICARE PAYS	[AFTER YOU PAY [$____] DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO [$___] DEDUCTIBLE**] 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 $[100] of Medicare Approved Amounts*	$0	$[100] (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 3 pints	$0	All costs	$0
Next $[100] of Medicare Approved Amounts*	$0	$[100] (Part B Deductible)	$0
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES-
TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

 

SERVICES	MEDICARE PAYS	[AFTER YOU PAY [$____] DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO [$____] DEDUCTIBLE**] YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
-  Medically necessary skilled care services and medical supplies	100%	$0	$0
-  Durable medical equipment
First $[100] of Medicare Approved Amounts*	$0	$[100] (Part B Deductible)	$0
Remainder of Medicare Approved Amounts	80%	20%	$0
AT-HOME RECOVERY SERVICES-NOT COVERED BY MEDICARE
Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan
-  Benefit for each visit	$0	Actual charges to $40 a visit		Balance
-  Number of visits covered (must be received within 8 weeks of last Medicare Approved visit)	$0	Up to the number of Medicare Approved visits, not to exceed 7 each week
-  Calendar year maximum	$0	$1,600

 

OTHER BENEFITS – NOT COVERED BY MEDICARE

 

SERVICES	MEDICARE PAYS	[AFTER YOU PAY [$____] DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO [$____] DEDUCTIBLE**] 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
***PREVENTIVE MEDICAL CARE BENEFIT-NOT COVERED BY MEDICARE   Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare
First $120 each calendar year	$0	$120		$0
Additional charges	$0	$0		All costs

 

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

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)




Section 2008.APPENDIX M   Plan K (for plans issued prior to June 1, 2010)

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below.  The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

*    You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[___] 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, 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.

 

MEDICARE (PART A) – HOSPITAL SERVICES-PER BENEFIT PERIOD

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but $[    ]	$[    ] (50% of Part A deductible)	$[    ] (50% of Part A deductible)♦
61st thru 90th day	All but $[    ] a day	$[    ] a day	$0
91st day and after:
-  While using 60 lifetime reserve days	All but $[    ] a day	$[    ] 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 thru 100th day	All but $[___] a day	Up to $[    ] a day	Up to $[    ] a day ♦
101st day and after	$0	$0	All costs
BLOOD
First 3 pints	$0	50%	50%♦
Additional amounts	100%	$0	$0
HOSPICE CARE
Available as long as your doctor certifies you are terminally ill and you elect to receive these services	Generally, most Medicare eligible expenses for outpatient drugs and inpatient respite care	50% of coinsurance or copayments	50% of coinsurance or copayments♦

 

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




PLAN K

 

MEDICARE (PART B) – MEDICAL SERVICES-PER CALENDAR YEAR

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $[100] of Medicare Approved Amounts****	$0	$0	$[100] (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	$0	All costs (and they do not count toward annual out-of-pocket limit of [$__])*
BLOOD
First 3 pints	$0	50%	50% ♦
Next $[100] of Medicare Approved Amounts****	$0	$0	$[100] (Part B deductible)**** ♦
Remainder of Medicare Approved Amounts	Generally 80%	Generally 10%	Generally 10% ♦
CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[_] 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.

 

PLAN K

 

PARTS A & 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 $[100] of Medicare Approved Amounts*****	$0	$0	$[100] (Part B deductible) ♦
Remainder of Medicare Approved Amounts	80%	10%	10% ♦

 

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

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)




Section 2008.APPENDIX N   Plan L (for plans issued prior to June 1, 2010)

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below.  The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

*     You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[___] 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, 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.

 

MEDICARE (PART A) − HOSPITAL SERVICES-PER BENEFIT PERIOD

 

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

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but $[___]	$[___] (75% of Part A deductible)	$[___] (25% of Part A deductible)♦
61st thru 90th day	All but $[___] a day	$[___] a day	$0
91st day and after:
-  While using 60 lifetime reserve days	All but $[___] a day	$[___] 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 thru 100th day	All but $[___] a day	Up to $[___] a day	Up to $[___] a day♦
101st day and after	$0	$0	All costs
BLOOD
First 3 pints	$0	75%	25% ♦
Additional amounts	100%	$0	$0
HOSPICE CARE
Available as long as your doctor certifies you are terminally ill and you elect to receive these services	Generally, most Medicare eligible expenses for outpatient drugs and inpatient respite care	75% of coinsurance or copayments	25% of coinsurance or copayments ♦

 

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




PLAN L

 

MEDICARE (PART B) – MEDICAL SERVICES-PER CALENDAR YEAR

 

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

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $[100] of Medicare Approved Amounts****	$0	$0	$[100] (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	$0	All costs (and they do not count toward annual out-of-pocket limit of [$_____])*
BLOOD
First 3 pints	$0	75%	25% ♦
Next $[100] of Medicare Approved Amounts****	$0	$0	$[100] (Part B deductible) ♦
Remainder of Medicare Approved Amounts	Generally 80%	Generally 15%	Generally 5% ♦
CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

*  This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[__] 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.

 

PLAN L

 

PARTS A & 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 1st $[100] of Medicare Approved Amounts*****	$0	$0	$[100] (Part B deductible) ♦
Remainder of Medicare Approved Amounts	80%	15%	5% ♦

 

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

 

(Source:  Amended at 33 Ill. Reg. 8904, effective June 10, 2009)




Section 2008.APPENDIX O   NOTICE OF MEDICARE CHANGES (RENUMBERED)

 

(Source:  Appendix O renumbered to Appendix T at 29 Ill. Reg. 14188, effective September 8, 2005)




Section 2008.APPENDIX P   MEDICARE SUPPLEMENT POLICIES REPORT (RENUMBERED)

 

(Source:  Appendix P renumbered to Appendix U at 29 Ill. Reg. 14188, effective September 8, 2005)




Section 2008.APPENDIX Q   Disclosure Statements (Renumbered)

 

(Source:  Appendix Q renumbered to Appendix V at 29 Ill. Reg. 14188, effective September 8, 2005)




Section 2008.APPENDIX R   Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage

 

Insurance company's name and address

 

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

 

According to (your application) (information you have furnished) you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by (Company Name) Insurance Company. Your new policy will provide 30 days within which you may decide without cost whether you desire to keep the policy.

 

You should review this new coverage carefully.  Compare it with all accident and sickness coverage you now have.  If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage.  You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.

 

STATEMENT TO APPLICANT BY INSURANCE PRODUCER:

 

I have reviewed your current medical or health insurance coverage.  To the best of my knowledge, this Medicare supplement or, if applicable, policy will not duplicate your existing Medicare supplement coverage because you intend to terminate your existing Medicare supplement or leave your Medicare Advantage Plan.  The replacement policy is being purchased for the following reason (Check one):

 

	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 for disenrollment. (Optional only for Direct Mailers)
	Disenrollment from a Medicare Advantage plan.  Please explain reason.
	Other.  (Please specify)

 

Note:  If the issuer of the Medicare supplement policy being applied for does not, or is otherwise prohibited from imposing, pre-existing condition limitations, please skip to statement 2 below.

 

1)         Health conditions which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy.  This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.

 

2)         Section 363(7)(b) of the Illinois Insurance Code [215 ILCS 5/363(7)(b)] provides that your replacement policy or certificate may not contain new preexisting conditions, waiting periods, elimination periods or probationary periods.  The issuer will waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, or probationary periods in the new policy (or coverage) for  similar benefits to the extent such time was spent (depleted) under the original policy.

 

3)         If you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history.  Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force.  After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded.  [If the policy or certificate is guaranteed issue, this paragraph need not appear.]

 

 

Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.
(Signature of Insurance Producer or Other Representative)
Typed Name and Address of Issuer or Insurance Producer
(Applicant's Signature)
Date

 

* Signature not required for direct response sales.

 

(Source:  Appendix R renumbered from Appendix M and amended at 29 Ill. Reg. 14188, effective September 8, 2005)




Section 2008.APPENDIX S   Medicare Supplement Refund Calculation Format

 

Type (1)

SMSBP (2)

For the State of

Company Name

NAIC Group Code

NAIC Company Code

Address

Person Completing this Form

Title

Telephone Number

(a) Earned Premium (3)

(b) Incurred Claims (4)

Line

1.

Current Year's Experience

a.

Total (all policy years)

b.

Current year's issues (z)

c.

Net (for reporting purposes = 1a - 1b)

2.

Past Years' Experience (all policy years)

3.

Total Experience (net current year  +  past years' experience)

4.

Refunds last year (excluding interest)

5.

Previous since Inception (excluding interest)

6.

Refunds since Inception (excluding interest)

7.

Benchmark Ratio since Inception

(see worksheet for Ratio 1)

8.

Experienced Ratio since Inception

Total Actual Incurred Claims (line 3, col. b) / Total Premium After Refunds = Ratio 2

Where Total Earned Premium after Refunds = Total Earned Premiums (line 3, col. a)

− Refunds since Inception (line 6)

9.

Life Years Exposed Since Inception

If the Experienced Ratio is less than the Benchmark Ratio,

and there are more than 500 life years exposure, then

proceed to calculation of refund.

10.

Tolerance Permitted

(obtained from credibility table)




 

11.

Adjustment to Incurred Claims for Credibility

Ratio 3 = Ratio 2 + Tolerance

If ratio 3 is more than benchmark ratio (ratio 1), a refund

or credit to premium is not required.

If ratio 3 is less than the benchmark ratio, then proceed.

12.

Adjusted Incurred Claims = Total Earned Premiums (line 3, col. a) - Refunds since

Inception (line 6) x Ratio 3 (line 11).

13.

Refund = Total Earned Premium after Refunds – [Adjusted Incurred Claims (line 12)

/Benchmark Ratio (Ratio 1)]

Where Total Earned Premium after Refunds = Total Earned Premiums (line 3, col. a) –

Refunds since Inception (line 6)

If the amount on line 13 is less than .005 times the annualized premium in force as of

December  31 of the reporting year, then no refund is made.  Otherwise, the amount

on line 13 is to be refunded or credited, and a description of the refund and/or credit

against premiums to be used must be attached to this form.

Medicare Supplement Credibility Table

Life Years Exposed

Since Inception

Tolerance

10,000 +

0.0%

5,000 - 9,999

5.0%

2,500 - 4,999

7.5%

1,000 - 2,499

10.0%

500 – 999

15.0%

If less than 500, no credibility.

(1)

Individual, Group, Individual Medicare Select, or Group Medicare Only.

(2)

"SMSBP" = Standard Medicare Supplement Benefit Plan-Use "P" for prestandardized plans.

(3)

Includes modal loadings and fees charged

(4)

Excludes Active Life Reserves

(5)

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

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

Signature

Title – please type

Name − please type

Date




 

REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION
FOR GROUP POLICIES
For Calendar Year ________
Type (1)																	SMSBP (2)
For the State of
Company Name
NAIC Group Code																NAIC Company Code
Address
Person Completing Form
Title																Telephone Number
(a3)	(b4)				(c)					(d)		(e)			(f)			(g)			(h)				(i)			(j)	(o5)
Year	Earned Premium				Factor					(b4) x (c)		Cumulative Loss Ratio			(d) x (e)			Factor			(b4) x (g)				Cumulative Loss Ratio			(h) x (i)	Policy Year Loss Ratio
1					2.770							0.507						0.000							0.000				0.46
2					4.175							0.567						0.000							0.000				0.63
3					4.175							0.567						1.194							0.759				0.75
4					4.175							0.567						2.245							0.771				0.77
5					4.175							0.567						3.170							0.782				0.80
6					4.175							0.567						3.998							0.792				0.82
7					4.175							0.567						4.754							0.802				0.84
8					4.175							0.567						5.445							0.811				0.87
9					4.175							0.567						6.075							0.818				0.88
10					4.175							0.567						6.650							0.824				0.88
11					4.175							0.567						7.176							0.828				0.88
12					4.175							0.567						7.655							0.831				0.88
13					4.175							0.567						8.093							0.834				0.89
14					4.175							0.567						8.493							0.837				0.89
15					4.175							0.567						8.684							0.838				0.89
Total:									(k):					(l):						(m):							(n):

 

Benchmark Ratio Since Inception:  Ratio 1 = (l + n) / (k + m):
	(1):		Individual, Group, Individual Medicare Select, or Group Medicare Select Only.
	(2):		"SMSBP" = Standardized Medicare Supplement Benefit Plan – Use "P" for pre-standardized plans.
	(3):		Year 1 is the current calendar year-1
			Year 2 is the current calendar year-2 (etc.)
			(Example: If the current year is 2022, then Year 1 is 2021; Year 2 is 2020, etc.)
	(4):		For the calendar year on the appropriate line in column (a), the premium earned during that year for
			policies issued in that year.
		(5):	These loss ratios are not explicitly used in computing the benchmark loss ratios.  They are the loss
			ratios, on a policy year basis, which result in the cumulative loss ratios displayed on this worksheet.
			They are shown here for informational purposes only.
		(6):	To include the earned premium for all years prior to as well as the 15th year to the current year.




 

REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION
FOR INDIVIDUAL POLICIES
For Calendar Year ________
Type (1)																				SMSBP (2)
For the State of
Company Name
NAIC Group Code																			NAIC Company Code
Address
Person Completing Form
Title																			Telephone Number
(a3)	(b4)				(c)						(d)		(e)				(f)				(g)			(h)				(i)			(j)	(o5)
Year	Earned Premium				Factor						(b4) x (c)			Cumulative Loss Ratio				(d) x (e)			Factor			(b4) x (g)				Cumulative Loss Ratio			(h) x (i)	Policy Year Loss Ratio
1					2.770								0.442								0.000							0.000				0.4
2					4.175								0.493								0.000							0.000				0.55
3					4.175								0.493								1.194							0.659				0.65
4					4.175								0.493								2.245							0.669				0.67
5					4.175								0.493								3.170							0.678				0.69
6					4.175								0.493								3.998							0.686				0.71
7					4.175								0.493								4.754							0.695				0.73
8					4.175								0.493								5.445							0.702				0.75
9					4.175								0.493								6.075							0.708				0.76
10					4.175								0.493								6.650							0.713				0.76
11					4.175								0.493								7.176							0.717				0.76
12					4.175								0.493								7.655							0.720				0.77
13					4.175								0.493								8.093							0.723				0.77
14					4.175								0.493								8.493							0.725				0.77
15					4.175								0.493								8.684							0.725				0.77
Total:									(k):							(l):							(m):							(n):

 

Benchmark Ratio Since Inception:  Ratio 1 = (l + n) / (k + m):
	(1):		Individual, Group, Individual Medicare Select, or Group Medicare Only.
	(2):		"SMSBP" = Standardized Medicare Supplement Benefit Plan – Use "P" for pre-standardized plans.
	(3):		Year 1 is the current calendar year-1
			Year 2 is the current calendar year-2 (etc.)
			(Example: If the current year is 2022, then Year 1 is 2021; Year 2 is 2020, etc.)
	(4):		For the calendar year on the appropriate line in column (a), the premium earned during that year for
			policies issued in that year.
		(5):	These loss ratios are not explicitly used in computing the benchmark loss ratios.  They are the loss
			ratios, on a policy year basis, which result in the cumulative loss ratios displayed on this worksheet.
			They are shown here for informational purposes only.
		(6):	To include the earned premium for all years prior to as well as the 15th year to the current year.

 

(Source:  Amended at 47 Ill. Reg. 5701, effective April 4, 2023)




Section 2008.APPENDIX T   Notice of Medicare Changes

 

(Company Name)

NOTICE ON CHANGES IN MEDICARE AND

YOUR MEDICARE SUPPLEMENT INSURANCE

 

The following outline briefly describes the modifications in Medicare and in your Medicare supplement coverage.  Please read carefully!

 

(A brief description of the revisions to Medicare Parts A & B with a parallel description of supplemental benefits with subsequent changes, including dollar amounts, provided by the Medicare supplement coverage in substantially the following format).

 

Services	Medicare Benefits	Your Medicare Supplement Coverage
	Effective (insert current calendar year) Medicare Will Pay	Effective (insert current calendar year) Your Coverage Will Pay
MEDICARE PART A SERVICES AND SUPPLIES
Inpatient Hospital Services	All but _______ for first 60 days/benefit period
Semi-Private Room & Board	All but _______ a day for 61st -90th days/benefit period
Miscellaneous Hospital Service & Supplies, such as Drugs, X-Rays, Lab Tests & Operating Room	All but _____ a day for 91st-150th days (if individual chooses to use 60 nonrenewable lifetime reserve days)
BLOOD	Pays all costs except nonreplacement fees (blood deductible) for first 3 pints in each calendar year
SKILLED NURSING FACILITY CARE	100% of costs for first 20 days (after a 3 day prior hospital/ confinement/ benefit period)
	All but ______ a day for 21st-100th days /benefit period
	Beyond 100 days – Nothing /benefit period
MEDICARE PART B SERVICES AND SUPPLIES	80% of allowable charges (after ____ deductible/calendar year)
PRESCRIPTION DRUGS	Inpatient prescription drugs 80% of  allowable charges for immunosuppressive drugs during the first year following a covered transplant (after ____ deductible/ calendar year)
BLOOD	80% of costs except nonreplacement fees (blood deductible) for first 3 pints (after ___ deductible/calendar year

 

(Any other policy benefits not mentioned in this chart should be added to the chart in the order prescribed by the outline of coverage.  If there are corresponding Medicare benefits, they should be shown.)

 

(Describe any coverage provisions changing due to Medicare modifications.)

 

(Include information about when premium adjustments that may be necessary due to changes in Medicare benefits will be effective.)

 

THIS CHART SUMMARIZING THE CHANGES IN YOUR MEDICARE BENEFITS AND IN YOUR MEDICARE SUPPLEMENT PROVIDED BY (COMPANY) ONLY BRIEFLY DESCRIBES SUCH BENEFITS.  FOR INFORMATION ON YOUR MEDICARE BENEFITS CONTACT YOUR SOCIAL SECURITY OFFICE OR THE HEALTH CARE FINANCING ADMINISTRATION.  FOR INFORMATION ON YOUR MEDICARE SUPPLEMENT (POLICY) CONTACT: (COMPANY AND FOR AN INDIVIDUAL POLICY-NAME OF AGENT) (ADDRESS/PHONE NUMBER).

 

(Source:  Appendix T renumbered from Appendix O at 29 Ill. Reg. 14188, effective September 8, 2005)




Section 2008.APPENDIX U   Medicare Supplement Policies Report

 

Company Name:
Address:
Phone Number:

 

Due:  March 1, annually

 

The purpose of this report is to provide information on each resident of this State who has more than one Medicare supplement policy or certificate in force.  The information is to be grouped by individual policyholder.

 

 

Policy and Certificate #	Date of Issuance

 

 

 

 

 

Signature

Name and Title (please type)

Date

 

(Source:  Appendix U renumbered from Appendix P at 29 Ill. Reg. 14188, effective September 8, 2005)




Section 2008.APPENDIX V    Disclosure Statements

 

Companies shall provide one of the following disclosures as prescribed by the directions contained in paragraph (o).

 

a)         Original disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only:

 

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

 

This is not Medicare Supplement Insurance

 

This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury.  It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

 

This insurance duplicates Medicare benefits when it pays hospital medical expenses up to the maximum stated in the policy.

 

Medicare generally pays for most or all of these expenses.

 

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

 

–          hospitalization,

–          physician services,

–          [outpatient prescription drugs if you are enrolled in Medicare Part D],

–          other approved items and services.

 

Before You Buy This Insurance

 

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

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

–          For help in understanding your health insurance, contact your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP].

 

b)         Original disclosure statement for policies that provide benefits for specified limited services:

 

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

 

This is not Medicare Supplement Insurance

 

This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy.  It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

 

This insurance duplicates Medicare benefits when any of the services covered by the policy are also covered by Medicare.

 

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

 

−          hospitalization,

−          physician services,

−          [outpatient prescription drugs if you are enrolled in Medicare Part D],

–          other approved items and services.

 

Before You Buy This Insurance

 

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

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

–          For help in understanding your health insurance, contact your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP].

 

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

 

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

 

This is not Medicare Supplement Insurance

 

This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy.  It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

 

This insurance duplicates Medicare benefits when it pays hospital or medical expenses up to the maximum stated in the policy.

 

Medicare generally pays for most or all of these expenses.

 

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

 

–          hospitalization,

–          physician services,

–          hospice,

–          [outpatient prescription drugs if you are enrolled in Medicare Part D],

–          other approved items and services.

 

Before You Buy This Insurance

 

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

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

–          For help in understanding your health insurance, contact your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP].

 

d)         Original disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments.  This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy:

 

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

 

This is not Medicare Supplement Insurance

 

This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy.  It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

 

This insurance duplicates Medicare benefits because Medicare generally pays for most of the expenses for the diagnosis and treatment of the specific conditions or diagnoses named in the policy.

 

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

 

–          hospitalization,

–          physician services,

–          hospice,

–          [outpatient prescription drugs if you are enrolled in Medicare Part D],

–          other approved items and services.

 

Before You Buy This Insurance

 

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

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

–          For help in understanding your health insurance, contact your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP] .

 

e)         Original disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies:

 

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

 

This is not Medicare Supplement Insurance

 

This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions.  It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

 

This insurance duplicates Medicare benefits when any expenses or services covered by the policy are also covered by Medicare.

 

Medicare generally pays for most or all of these expenses.

 

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

 

–          hospitalization,

–          physician services,

–          hospice,

–          [outpatient prescription drugs if you are enrolled in Medicare Part D],

–          other approved items and services.

 

Before You Buy This Insurance

 

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

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

–          For help in understanding your health insurance, contact your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP].

 

f)         Original disclosure statement for policies that provide benefits for both expenses incurred and fixed indemnity basis:

 

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

 

This is not Medicare Supplement Insurance

 

This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy.  It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions.  It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

 

This insurance duplicates Medicare benefits when:

 

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

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

 

Medicare generally pays for most or all of these expenses.

 

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

 

–          hospitalization,

–          physician services,

–          hospice care,

–          [outpatient prescription drugs if you are enrolled in Medicare Part D],

–          other approved items and services.

 

Before You Buy This Insurance

 

 

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

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

–          For help in understanding your health insurance, contact your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP].

 

g)         Original disclosure statement for other health insurance policies not specifically identified in the previous statements:

 

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

 

This is not Medicare Supplement Insurance

 

This insurance provides limited benefits if you meet the conditions listed in the policy.  It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

 

This insurance duplicates Medicare benefits when it pays the benefits stated in the policy and coverage for the same event is provided by Medicare.

 

Medicare generally pays for most or all of these expenses.

 

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

 

–          hospitalization,

–          physician services,

–          hospice,

–          [outpatient prescription drugs if you are enrolled in Medicare Part D],

–          other approved items and services.

 

Before You Buy This Insurance

 

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

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

–          For help in understanding your health insurance, contact your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP].

 

h)         Alternative disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.

 

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE

 

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

 

This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury.  It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. 

 

Medicare generally pays for most or all of these expenses.

 

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

 

−          hospitalization,

−          physician services,

−          [outpatient prescription drugs if you are enrolled in Medicare Part D],

−          other approved items and services.

 

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

 

Before You Buy This Insurance

 

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

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

−         For help in understanding your health insurance, contact your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP].

 

i)          Alternate disclosure statement for policies that provide benefits for specified limited services:

 

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE

 

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

 

This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy.  It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. 

 

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

 

−          hospitalization,

−          physician services,

−          [outpatient prescription drugs if you are enrolled in Medicare Part D],

−          other approved items and services.

 

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

 

Before You Buy This Insurance

 

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

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

−          For help in understanding your health insurance, contract your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP].

 

j)          Alternative disclosure statement for policies that reimburse expenses incurred for specified diseases or other specified impairments.  This includes expense-incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions.

 

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE

 

Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.  Medicare generally pays for most or all of these expenses.

 

This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy.  It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. 

 

Medicare generally pays for most or all of these expenses.

 

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

 

−          hospitalization,

−          physician services,

−          hospice,

−          [outpatient prescription drugs if you are enrolled in Medicare Part D],

−          other approved items and services.

 

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

 

Before You Buy This Insurance

 

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

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

−          For help in understanding your health insurance, contract your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP].

 

k)         Alternative disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments.  This includes cancer, specified disease and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.

 

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE

 

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

 

This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy.  It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. 

 

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

 

−          hospitalization,

−          physician services,

−          hospice,

−          [outpatient prescription drugs if you are enrolled in Medicare Part D],

−          other approved items and services.

 

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

 

Before You Buy This Insurance

 

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

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

−          For help in understanding your health insurance, contract your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP].

 

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

 

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE

 

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

 

This insurance pays a fixed amount, regardless of your expenses, for each day you meet the policy conditions.  It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. 

 

Medicare generally pays for most or all of these expenses.

 

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

 

−          hospitalization,

−          physician services,

−          hospice,

−          [outpatient prescription drugs if you are enrolled in Medicare Part D],

−          other approved items and services.

 

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

 

Before You Buy This Insurance

 

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

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

−          For help in understanding your health insurance, contract your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP].

 

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

 

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE

 

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

 

This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy.  It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions.  It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. 

 

Medicare generally pays for most or all of these expenses.

 

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

 

−          hospitalization,

−          physician services,

−          hospice care,

−          [outpatient prescription drugs if you are enrolled in Medicare Part D],

−          other approved items and services.

 

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

 

Before You Buy This Insurance

 

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

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

−          For help in understanding your health insurance, contract your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP].

 

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

 

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE

 

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

 

This insurance provides limited benefits if you meet the conditions listed in the policy.  It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. 

 

Medicare generally pays for most or all of these expenses.

 

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

 

−          hospitalization,

−          physician services,

−          hospice,

−          [outpatient prescription drugs if you are enrolled in Medicare Part D],

−          other approved items and services.

 

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

 

Before You Buy This Insurance

 

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

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

−          For help in understanding your health insurance, contract your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP].

 

o)         Instructions for use of the disclosure statements for health insurance policies sold to Medicare beneficiaries that duplicate Medicare.

 

1)         Section 1882(d) of the federal Social Security Act (42 USC 1395ss) prohibits the sale of a health insurance policy (the term policy includes certificate) to Medicare beneficiaries that duplicates Medicare benefits unless it will pay benefits without regard to a beneficiary's other health coverage and it includes the prescribed disclosure statement on or together with the application for the policy. 

 

2)         All types of health insurance policies that duplicate Medicare shall include one of the attached disclosure statements, according to the particular policy type involved, on the application or together with the application.  The disclosure statement may not vary from the attached statements in terms of language or format type size, type proportional spacing, bold character, line spacing, and usage of boxes around text from those presented in the disclosure statements. 

 

3)         State and federal law prohibits insurers from selling a Medicare supplement policy to a person that already has a Medicare supplement policy except as a replacement policy. 

 

4)         Property/casualty and life insurance policies are not considered health insurance.

 

5)         Disability income policies are not considered to provide benefits that duplicate Medicare.

 

6)         Long-term care insurance policies that coordinate with Medicare and other health insurance are not considered to provide benefits that duplicate Medicare.

 

7)         The federal law does not preempt state laws that are more stringent than the federal requirements. 

 

8)         The federal law does not preempt existing state form filing requirements. 

 

9)         Section 1882 of the federal Social Security Act was amended in subsection (d)(3)(A) to allow for alternative disclosure statements.  The disclosure statements already in Appendix C remain.  Carriers may use either disclosure statement with the requisite insurance product.  However, carriers should use either the original disclosure statements or the alternative disclosure statements and not use both simultaneously.

 

10)         In the disclosure language included under the heading Before You Buy This Insurance, that reads: "For help in understanding your health insurance, contact your state insurance department or state [senior] [health] insurance [counseling] [assistance] program [SHIP]," insurers are to insert reference to the state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005. 

 

(Source:  Appendix V renumbered from Appendix Q and amended at 29 Ill. Reg. 14188, effective September 8, 2005)




Section 2008.APPENDIX W   Outline of Medicare Supplement Coverage – Cover Page for Medicare Supplement Plans Sold on or after June 1, 2010

 

Benefit Chart of Medicare Supplement Plans Sold

for Effective Dates on or After June 1, 2010

 

This chart shows the benefits included in each of the standard Medicare supplement plans.  Every company must make Plan "A" available.  Some plans may not be available in your state. 

 

 

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 three 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	Skilled Nursing Facility Coinsurance	Skilled Nursing Facility Coinsurance		Skilled Nursing Facility Coinsurance		50% Skilled Nursing Facility Coinsurance	75% Skilled Nursing Facility Coinsurance	Skilled Nursing Facility Coinsurance	Skilled Nursing Facility Coinsurance
	Part A Deductible	Part A Deductible	Part A Deductible	Part A Deductible		Part A Deductible		50% Part A Deductible	75% 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 $[4140]; paid at 100% after  limit reached	Out-of-pocket limit $[2070]; paid at 100% after  limit reached

 

 

*  Plan F also has an option called a high deductible Plan F.  This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$1860] deductible.  Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed [$1860].  Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy.  These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.

 

PREMIUM INFORMATION [Boldface Type]

 

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

 

DISCLOSURES [Boldface Type]

 

Use this outline to compare benefits and premiums among policies. 

 

This outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010.  Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums.  Plans E, H, I, and J will no longer be available for sale after May 31, 2010.   

 

READ YOUR POLICY VERY CAREFULLY [Boldface Type]

 

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

 

RIGHT TO RETURN POLICY [Boldface Type]

 

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

 

POLICY REPLACEMENT [Boldface Type]

 

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

 

NOTICE [Boldface Type]

 

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

 

[for producers:]

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

 

[for direct response:]

[insert company's name] is not connected with Medicare.

 

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

 

COMPLETE ANSWERS ARE VERY IMPORTANT [Boldface Type]

 

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

 

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

 

[Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in Appendices AA through JJ. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this Part. An issuer may use additional benefit plan designations on these charts pursuant to Section 2008.67(e).]

 

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

 

Benefit Chart of Medicare Supplement Plans Sold

On or After January 1, 2020

 

This chart shows the benefits included in each of the standard Medicare supplement plans.  Some plans may not be available.  Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F.

 

Note: A ü means 100% of the benefit is paid.

 

Benefits	Plans Available to All Applicants									Medicare first eligible before 2020 only
	A	B	D	G1	K	L	M	N		C	F1
Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)	ü	ü	ü	ü	ü	ü	ü	ü		ü	ü
Medicare Part B coinsurance or copayment	ü	ü	ü	ü	50%	75%	ü	ü copays apply3		ü	ü
Blood (first three pints)	ü	ü	ü	ü	50%	75%	ü	ü		ü	ü
Part A hospice care coinsurance or copayment	ü	ü	ü	ü	50%	75%	ü	ü		ü	ü
Skilled nursing facility coinsurance			ü	ü	50%	75%	ü	ü		ü	ü
Medicare Part A deductible		ü	ü	ü	50%	75%	50%	ü		ü	ü
Medicare Part B deductible										ü	ü
Medicare Part B excess charges				ü							ü
Foreign travel emergency (up to plan limits)			ü	ü			ü	ü		ü	ü
Out-of-pocket limit in [2017]2					[$5120]2	[$2560]2

 

¹  Plans F and G also have a high deductible option which require first paying a plan deductible of [$2200] before the plan begins to pay.  Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year.  High deductible plan G does not cover the Medicare Part B deductible.  However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.

 

²  Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.

 

³  Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that do not result in an inpatient admission.

 

(Source:  Amended at 42 Ill. Reg. 21625, effective November 26, 2018






 

Section 2008.APPENDIX AA   Plan A (for plans issued on or after June 1, 2010)

 

Section 2008.APPENDIX AA   Plan A (for plans issued on or after June 1, 2010)

MEDICARE (PART A) − Hospital Services – Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below.  The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$_______]	$0	[$______] (Part A Deductible)
61st thru 90th day	All but [$______] a day	[$_______] a day	$0
91st day and after:
− While using 60 lifetime reserve days	All but [$______] a day	[$_______] 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	$0
21st thru 100th day	All but [$______] a day	$0	Up to [$________] a day
101st day and after	$0	$0	All costs
BLOOD
First 3 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 out-patient 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.

 

(Plan A Continued)

 

MEDICARE (PART B) – Medical Services − Per Calendar Year

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES-IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 [$100] of Medicare Approved Amounts*	$0	$0	[$100] (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 3 pints	$0	All costs	$0
Next $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES
TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
− Medically necessary skilled care services and medical supplies	100%	$0	$0
− Durable medical equipment
First $[100] of Medicare Approved Amounts*	$0	$0	$100 (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0

 

(Source:  Added at 33 Ill. Reg. 8904, effective June 10, 2009)




 

Section 2008.APPENDIX BB   Plan B (for plans issued on or after June 1, 2010)

 

Section 2008.APPENDIX BB   Plan B (for plans issued on or after June 1, 2010)

MEDICARE (PART A) – Hospital Services-Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$________]	[$________] (Part A Deductible)	$0
61st thru 90th day	All but [$________] a day	[$________] a day	$0
91st day and after:
− While using 60 lifetime reserve days	All but [$________] a day	[$________] 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	$0
21st thru 100th day	All but [$________] day	$0	Up to [$________] a day
101st day and after	$0	$0	All costs
BLOOD
First 3 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 out-patient 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.

 

(Plan B Continued)

 

MEDICARE (PART B) – Medical Services – Per Calendar Year

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES-IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $[100] of Medicare Approved Amounts*	$0	$0	$[100] (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 3 pints	$0	All costs	$0
Next $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES
TEST FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
− Medically necessary skilled care services and medical supplies	100%	$0	$0
− Durable medical equipment
First $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved  Amounts	80%	20%	$0

 

(Source:  Added at 33 Ill. Reg. 8904, effective June 10, 2009)




 

Section 2008.APPENDIX CC   Plan C (for plans issued on or after June 1, 2010)

 

Section 2008.APPENDIX CC   Plan C (for plans issued on or after June 1, 2010)

MEDICARE (PART A) – Hospital Services – Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$__________]	[$__________] (Part A Deductible)	$0
61st thru 90th day	All but [$__________] a day	[$__________] a day	$0
91st day and after:
− While using 60 lifetime reserve days	All but [$__________] a day	[$__________] a day	$0
− Once lifetime reserve day 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	$0
21st thru 100th day	All but [$__________] a day	Up to [$__________] a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 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 out-patient 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.

 

(Plan C Continued)

 

MEDICARE (PART B) – Medical Services – Per Calendar Year

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES − IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $[100] of Medicare Approved Amounts*	$0	$[100] (Part B Deductible)	$0
Remainder of Medicare Approved Amounts	generally 80%	generally 20%	$0
Part B Excess Charges (Above Medicare Approved Amounts)	$0	$0	All costs
BLOOD
First 3 pints	$0	All costs	$0
Next $[100] of Medicare Approved Amounts	$0	$[100] (Part B Deductible)	$0
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
− Medically necessary skilled care services and medical supplies	100%	$0	$0
− Durable medical equipment
First $[100] of Medicare Approved Amounts*	$0	$[100] (Part B Deductible)	$0
Remainder of Medicare Approved Amounts	80%	20%	$0

 

(Plan C Continued)

 

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

 

(Source:  Added at 33 Ill. Reg. 8904, effective June 10, 2009)




 

Section 2008.APPENDIX DD   Plan D (for plans issued on or after June 1, 2010)

 

Section 2008.APPENDIX DD   Plan D (for plans issued on or after June 1, 2010)

MEDICARE (PART A) – Hospital Services – Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$________]	[$________] (Part A Deductible)	$0
61st thru 90th day	All but [$________] a day	[$________] a day	$0
91st day and after:
− While using 60 lifetime reserve days	All but [$________] a day	[$________] 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	$0
21st thru 100th day	All but [$________] a day	Up to [$________] a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 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 out-patient 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.

 

(Plan D Continued)

 

MEDICARE (PART B) – Medical Services – Per Calendar Year

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES − IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $[100] of Medicare Approved Amounts*	$0	$0	$[100] (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 3 pints	$0	All costs	$0
Next $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES
TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
− Medically necessary skilled care services and medical supplies	100%	$0	$0
− Durable medical equipment
First $[100] of Medicare Approved Amounts*	$0	$0	$[100] (Part B Deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0

 

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

 

(Source:  Added at 33 Ill. Reg. 8904, effective June 10, 2009)




 

Section 2008.APPENDIX EE   Plan F or High Deductible Plan F (for plans issued on or after June 1, 2010)

 

Section 2008.APPENDIX EE   Plan F or High Deductible Plan F (for plans issued on or after June 1, 2010)

MEDICARE (PART A) – Hospital Services – Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

[**  This high deductible plan pays the same benefits as Plan F after you have paid a calendar year [$_____] deductible.  Benefits from high deductible Plan F will not begin until out-of-pocket expenses are [$_____]. 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 [$___] DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO [$___] DEDUCTIBLE**] YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$_______]	[$________] (Part A Deductible)	$0
61st thru 90th day	All but [$_______] a day	[$________] a day	$0
91st day and after:
− While using 60 lifetime reserve days	All but [$_______] a day	[$________] 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	$0
21st thru 100th day	All but [$________] a day	Up to [$________] a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 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 out-patient drugs and in-patient 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.

 

(Plan F or High Deductible Plan F Continued)

 

MEDICARE (PART B) – Medical Services – Per Calendar Year

 

*     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 high deductible plan pays the same benefits as Plan F after you have paid a calendar year [$____] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are [$____]. 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 [$____] DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO [$___] DEDUCTIBLE**] 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 $[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 3 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 DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

 

SERVICES	MEDICARE PAYS	[AFTER YOU PAY [$____] DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO [$___] DEDUCTIBLE**] 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
Remainder of Medicare Approved Amounts	80%	20%	$0

 

OTHER BENEFITS – Not Covered By Medicare

 

SERVICES	MEDICARE PAYS	[AFTER YOU PAY THE [$_____] DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO THE [$_____] DEDUCTIBLE**]  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

 

(Source:  Amended at 42 Ill. Reg. 21625, effective November 26, 2018)




 

Section 2008.APPENDIX FF   Plan G or High Deductible Plan G (for plans issued on or after June 1, 2010)

 

Section 2008.APPENDIX FF   Plan G or High Deductible Plan G (for plans issued on or after June 1, 2010)

MEDICARE (PART A) – Hospital Services – Per Benefit Period

 

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

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

 

[**  This high deductible plan pays the same benefits as Plan G after you have paid a calendar year [$_____] deductible.  Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are [$_____]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.]

 

 

SERVICES	MEDICARE PAYS	[AFTER YOU PAY ($2240) DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO ($2240) DEDUCTIBLE**] YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but [$________]	[$________] (Part A Deductible)	$0
61st thru 90th day	All but [$________] a day	[$________] a day	$0
91st day and after:
− While using 60 lifetime reserve days	All but [$________] a day	[$________] 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	$0
21st thru 100th day	All but [$________] a day	Up to [$________] a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 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 out-patient 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.

 

(Plan G or High Deductible Plan G Continued)

 

MEDICARE (PART B) – Medical Services – Per Calendar Year

 

*    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 high deductible plan pays the same benefits as Plan G after you have paid a calendar year [$_____] deductible.  Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are [$_____]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.]

 

SERVICES	MEDICARE PAYS	[AFTER YOU PAY ($2240) DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO ($2240) DEDUCTIBLE**] 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 $[183] of Medicare Approved Amounts*	$0	$0	$[183] (Unless Part B Deductible has been met)
Remainder of Medicare Approved Amounts	generally 80%	generally 20%	$0
Part B Excess Charges (Above Medicare Approved Amounts)	$0	100%	$0
BLOOD
First 3 pints	$0	All costs	$0
Next $[183] of Medicare Approved Amounts*	$0	$0	$[183] (Unless Part B Deductible has been met)
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES
TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

 

SERVICES	MEDICARE PAYS	[AFTER YOU PAY ($2240) DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO ($2240) DEDUCTIBLE**] 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

 

OTHER BENEFITS – NOT COVERED BY MEDICARE

 

SERVICES	MEDICARE PAYS	[AFTER YOU PAY ($2240) DEDUCTIBLE**] PLAN PAYS	[IN ADDITION TO ($2240) DEDUCTIBLE**] 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

 

(Source:  Amended at 42 Ill. Reg. 21625, effective November 26, 2018)




 

Section 2008.APPENDIX GG   Plan K (for plans issued on or after June 1, 2010)

 

Section 2008.APPENDIX GG   Plan K (for plans issued on or after June 1, 2010)

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below.  The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

*    You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[___] 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, 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.

 

MEDICARE (PART A) – HOSPITAL SERVICES − PER BENEFIT PERIOD

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOSPITALIZATION**
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but $[    ]	$[    ] (50% of Part A deductible)	$[    ] (50% of Part A deductible)♦
61st thru 90th day	All but $[    ] a day	$[    ] a day	$0
91st day and after:
− While using 60 lifetime reserve days	All but $[    ] a day	$[    ] 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 thru 100th day	All but $[___] a day	Up to $[___] a day	Up to $[___] a day ♦
101st day and after	$0	$0	All costs
BLOOD
First 3 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 copayment/ coinsurance	50% of Medicare copayment/ coinsurance♦

 

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

 

PLAN K

 

MEDICARE (PART B) – MEDICAL SERVICES − PER CALENDAR YEAR

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $[100] of Medicare Approved Amounts****	$0	$0	$[100] (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	$0	All costs (and they do not count toward annual out-of-pocket limit of [$__])*
BLOOD
First 3 pints	$0	50%	50% ♦
Next $[100] of Medicare Approved Amounts****	$0	$0	$[100] (Part B deductible)**** ♦
Remainder of Medicare Approved Amounts	Generally 80%	Generally 10%	Generally 10% ♦
CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[__] 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.

 

PLAN K

 

PARTS A & 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 $[100] of Medicare Approved Amounts*****	$0	$0	$[100] (Part B deductible) ♦
Remainder of Medicare Approved Amounts	80%	10%	10% ♦

 

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

 

(Source:  Added at 33 Ill. Reg. 8904, effective June 10, 2009)




 

Section 2008.APPENDIX HH   Plan L (for plans issued on or after June 1, 2010)

 

Section 2008.APPENDIX HH   Plan L (for plans issued on or after June 1, 2010)

Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear below.  The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.

 

*     You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[___] 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, 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.

 

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

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOSPITALIZATION**
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but $[___]	$[___] (75% of Part A deductible)	$[___] (25% of Part A deductible)♦
61st thru 90th day	All but $[___] a day	$[___] a day	$0
91st day and after:
− While using 60 lifetime reserve days	All but $[___] a day	$[___] 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 thru 100th day	All but $[___] a day	Up to $[___] a day	Up to $[___] a day♦
101st day and after	$0	$0	All costs
BLOOD
First 3 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 copayment/ coinsurance	25% of copayment/ coinsurance♦

 

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

 

PLAN L

 

MEDICARE (PART B) – MEDICAL SERVICES − PER CALENDAR YEAR

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $[100] of Medicare Approved Amounts****	$0	$0	$[100] (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	$0	All costs (and they do not count toward annual out-of-pocket limit of [$_____])*
BLOOD
First 3 pints	$0	75%	25% ♦
Next $[100] of Medicare Approved Amounts****	$0	$0	$[100] (Part B deductible) ♦
Remainder of Medicare Approved Amounts	Generally 80%	Generally 15%	Generally 5% ♦
CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

*         This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[__] 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.

 

PLAN L

 

PARTS A & 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
1st $[100] of Medicare Approved Amounts*****	$0	$0	$[100] (Part B deductible) ♦
Remainder of Medicare Approved Amounts	80%	15%	5% ♦

 

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

 

(Source:  Added at 33 Ill. Reg. 8904, effective June 10, 2009)




 

Section 2008.APPENDIX II   Plan M (for plans issued on or after June 1, 2010)

 

Section 2008.APPENDIX II   Plan M (for plans issued on or after June 1, 2010)

PLAN M

 

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

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
61st thru 90th day	All but $[992]	$[496] (50% of Part A deductible)	$[496] (50% of Part A deductible)
91st day and after:
− While using 60 lifetime reserve days	All but $[248] a day	$[248] a day	$0
− Once lifetime reserve days are used:	All but $[496] a day	$[496] a day	$0
− 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 thru 100th day	All but $[124] a day	Up to $[124] a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 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

 

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

 

PLAN M

 

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

 

*   Once you have been billed $[131] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES − IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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
1st $[131] of Medicare Approved Amounts*	$0	$0	$[131] (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 3 pints	$0	All costs	$0
Next $[131] of Medicare Approved Amounts	$0	$0	$[131] (Part B deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY
SERVICES − TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

 

HOME HEALTH CARE MEDICARE APPROVED SERVICES
− Medically necessary skilled care services and medical supplies	100%	$0	$0
− Durable medical equipment
1st  $[131] of Medicare Approved Amounts*	$0	$0	$[131] (Part B deductible)
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

 

(Source:  Added at 33 Ill. Reg. 8904, effective June 10, 2009)




 

Section 2008.APPENDIX JJ   Plan N (for plans issued on or after June 1, 2010)

 

Section 2008.APPENDIX JJ   Plan N (for plans issued on or after June 1, 2010)

PLAN N

 

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

 

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

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days	All but $[992]	$[992](Part A deductible)	$0
61st thru 90th day	All but $[248] a day	$[248] a day	$0
91st day and after:
− While using 60 lifetime reserve days	All but $[496] a day	$[496] a day	$0
− Once lifetime reserve days are used:
− Additional 365 days	$0	100% of Medicare eligible expenses
− 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 thru 100th day	All but $[124] a day	Up to $[124] a day	$0
101st day and after	$0	$0	All costs
BLOOD
First 3 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

 

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

 

PLAN N

 

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

 

*   Once you have been billed $[131] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

 

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES − IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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
1st $[131] of Medicare Approved Amounts*	$0	$0	$[131] (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.  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.
Part B Excess Charges
(Above Medicare Approved Amounts)	$0	$0	All costs
BLOOD
First 3 pints	$0	All costs	$0
Next $[131] of Medicare Approved Amounts*	$0	$0	$[131] (Part B deductible)
Remainder of Medicare Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES − TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

 

PARTS A & B

 

HOME HEALTH CARE MEDICARE APPROVED SERVICES
− Medically necessary skilled care services and medical supplies	100%	$0	$0
− Durable medical equipment
1st $[131] of Medicare Approved Amounts*	$0	$0	$[131] (Part B deductible)
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 amount over the $50,000 lifetime maximum

 

(Source:  Added at 33 Ill. Reg. 8904, effective June 10, 2009)