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

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)	$0
61^st thru 90^th day	All but [$________] a day	[$________] a day	$0
91^st day and after:
− While using 60 lifetime reserve days	All but [$________] 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	$0
21^st thru 100^th day	All but [$________] a day	Up to [$________] a day	$0
101^st 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.

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)