14VAC5-170 Rules Governing Minimum Standards for Medicare Supplement Policies

REGULATIONS
Vol. 25 Iss. 18 - May 11, 2009

TITLE 14. INSURANCE

STATE CORPORATION COMMISSION

Chapter 170

Final Regulation

REGISTRAR'S NOTICE: The State Corporation Commission is exempt from the Administrative Process Act in accordance with § 2.2-4002 A 2 of the Code of Virginia, which exempts courts, any agency of the Supreme Court, and any agency that by the Constitution is expressly granted any of the powers of a court of record.

Title of Regulation: 14VAC5-170. Rules Governing Minimum Standards for Medicare Supplement Policies (amending 14VAC5-170-20, 14VAC5-170-30, 14VAC5-170-50, 14VAC5-170-60, 14VAC5-170-70, 14VAC5-170-80, 14VAC5-170-150; adding 14VAC5-170-75, 14VAC5-170-85, 14VAC5-170-215).

Statutory Authority: §§ 12.1-13 and 38.2-223 of the Code of Virginia.

Effective Date: May 21, 2009.

Agency Contact: Althelia Battle, Principal Insurance Market Examiner, State Corporation Commission, Bureau of Insurance, 1300 East Main Street, P.O. Box 1157, Richmond, VA 23218, telephone (804) 371-9154, FAX (804) 371-9944, or email al.battle@scc.virginia.gov.

Summary:

The purpose of the amendments is to incorporate related provisions of the federal Medicare Improvements for Patients and Providers Act of 2008 (MIPAA) and the Genetic Information Nondiscrimination Act of 2008 (GINA). Amendments, including the addition of three new sections to accommodate these federal laws are necessary to maintain certification of Virginia's state regulatory programs. Amendments were also made to reflect the 2009 deductible and copayment amounts under Medicare. Technical amendments were made to the proposed regulations in sections 14VAC5-170-30, 14VAC5-170-70, 14VAC5-170-75, 14VAC5-170-80, 14VAC5-170-85 and 14VAC5-170-150 to include language that references policies "with an effective date for coverage on or after June 1, 2010." The purpose of these technical amendments is to clarify that issuers can sell policies to seniors with the new benefit packages prior to June 1, 2010, providing that those policies have an effective date on or after June 1, 2010. Amendments were also made in 14VAC5-170-70 and 14VAC5-170-150 to correct cross-references and to clarify plan applicability dates.

AT RICHMOND, APRIL 21, 2009

COMMONWEALTH OF VIRGINIA

At the relation of the

STATE CORPORATION COMMISSION

CASE NO. INS-2009-00034

Ex Parte: In the matter of adopting Revisions
to the Rules Governing Minimum Standards
for Medicare Supplement Policies

ORDER ADOPTING REVISIONS TO RULES

By Order entered herein March 10, 2009, all interested persons were ordered to take notice that subsequent to April 15, 2009, the State Corporation Commission ("Commission") would consider the entry of an order adopting revisions proposed by the Bureau of Insurance ("Bureau") to the Commission's Rules Governing Minimum Standards for Medicare Supplement Policies ("Rules"), set forth in Chapter 170 of Title 14 of the Virginia Administrative Code, unless on or before April 15, 2009, any person objecting to the adoption of the proposed revisions filed a request for hearing with the Clerk of the Commission (the "Clerk").

The Order to Take Notice also required all interested persons to file their comments in support of or in opposition to the proposed revisions on or before April 15, 2009.

No request for hearing was filed with the Clerk. Comments were filed on April 16, 2009, by America's Health Insurance Plans. These comments were not timely filed. Nonetheless, the Bureau considered these comments and filed Statements of Position on April 20, 2009, in response. The Bureau recommends that the proposed Rules be amended at 14 VAC 5-170-70 and 14 VAC 5-170-150 in response to these comments.

The Bureau also received some technical amendments from the National Association of Insurance Commissioners ("NAIC") which were incorporated into the NAIC Model Act. The NAIC recommended that these same technical amendments be incorporated into each state's regulations. The Bureau therefore recommends that the proposed Rules be amended at 14 VAC 5-170-30, 14 VAC 5-170-70, 14 VAC 5-170-75, 14 VAC 5-170-80, 14 VAC 5-170-85 and 14 VAC 5-170-150 to include language that references policies "with an effective date for coverage on or after June 1, 2010." The purpose of these technical amendments is to clarify that issuers can sell policies to seniors with the new benefit packages prior to June 1, 2010, provided that those policies have an effective date on or after June 1, 2010.

The revisions to the Rules are necessary as a result of the passage of the federal Medicare Improvements for Patients and Providers Act of 2008 and the Genetic Information Nondiscrimination Act of 2008. Revisions to accommodate these federal laws are necessary to maintain certification of Virginia's state regulatory programs.

THE COMMISSION, having considered the proposed revisions, filed comments, the Bureau's Statements of Position, and the Bureau's recommendation for additional amendments, is of the opinion that the attached revisions to the Rules should be adopted.

THEREFORE IT IS ORDERED THAT:

(1) The revisions to Chapter 170 of Title 14 of the Virginia Administrative Code entitled "Rules Governing Minimum Standards for Medicare Supplement Policies," amended at 14 VAC 5-170-20, 14 VAC 5-170-30, 14 VAC 5-170-50 through 14 VAC 170-80, and 14 VAC 5-170-150, and add new sections at 14 VAC 5-170-75, 14 VAC 5-170-85 and 14 VAC 5-170-215, which are attached hereto and made a part hereof, should be, and they are hereby, ADOPTED to be effective May 21, 2009.

(2) AN ATTESTED COPY hereof shall be sent by the Clerk of the Commission to Jacqueline K. Cunningham, Deputy Commissioner, Bureau of Insurance, State Corporation Commission, who forthwith shall give further notice of the adoption of the revisions to the Rules by mailing a copy of this Order, including a clean copy of the attached final revised Rules, to all insurers licensed by the Commission to write accident and sickness insurance in the Commonwealth of Virginia, and certain interested parties designated by the Bureau of Insurance.

(3) The Commission's Division of Information Resources forthwith shall cause a copy of this Order, including a copy of the attached revised Rules, to be forwarded to the Virginia Registrar of Regulations for appropriate publication in the Virginia Register of Regulations.

(4) The Commission's Division of Information Resources shall make available this Order and the attached revisions to the Rules available on the Commission's website, http://www.scc.virginia.gov/case.

(5) The Bureau of Insurance shall file with the Clerk of the Commission an affidavit of compliance with the notice requirements in paragraph (2) of this Order.

14VAC5-170-20. Applicability and scope.

A. Except as otherwise specifically provided in 14VAC5-170-60, 14VAC5-170-110, 14VAC5-170-120, 14VAC5-170-150 and 14VAC5-170-200, this chapter shall apply to:

1. All Medicare supplement policies delivered or issued for delivery in this Commonwealth on or after ~~January 1, 2006~~ May 21, 2009; and

2. All certificates issued under group Medicare supplement policies for which certificates have been delivered or issued for delivery in this Commonwealth.

B. This chapter shall not apply to a policy or contract of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.

14VAC5-170-30. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"1990 standardized Medicare supplement benefit plan," "1990 standardized benefit plan" or "1990 plan" means a group or individual policy of Medicare supplement insurance issued on or after July 30, 1992, and [ with an effective date for coverage ] prior to June 1, 2010, and includes Medicare supplement insurance policies and certificates renewed on or after that date that are not replaced by the issuer at the request of the insured.

"2010 standardized Medicare supplement benefit plan," "2010 standardized benefit plan" or "2010 plan" means a group or individual policy of Medicare supplement insurance issued [ with an effective date for coverage ] on or after June 1, 2010.

"Applicant" means:

1. In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits; and

2. In the case of a group Medicare supplement policy, the proposed certificateholder.

"Attained age rating" means a premium structure under which premiums are based on the covered individual's age at the time of application of the policy or certificate, and for which premiums increase based on the covered individual's increase in age during the life of the policy or certificate.

"Bankruptcy" means when a Medicare Advantage organization that is not an issuer has filed, or has had filed against it, a petition for declaration of bankruptcy and has ceased doing business in this Commonwealth.

"Certificate" means any certificate delivered or issued for delivery in this Commonwealth under a group Medicare supplement policy.

"Certificate form" means the form on which the certificate is delivered or issued for delivery by the issuer.

"Community rating" means a premium structure under which premium rates are the same for all covered individuals of all ages in a given area.

"Continuous period of creditable coverage" means the period during which an individual was covered by creditable coverage, if during the period of the coverage the individual did not have a break in coverage greater than 63 days.

"Creditable coverage" means, 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 of 1935 (Medicare) (42 USC § 1395 et seq.);

4. Title XIX of the Social Security Act of 1935 (Medicaid) (42 USC § 1396 et seq.), other than coverage consisting solely of benefits under § 1928;

5. Chapter 55 of Title 10 of the United States Code (CHAMPUS) (10 USC§§ 1071-1107);

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 the Federal Employees Health Benefits Act of 1959 (5 USC §§ 8901-8914);

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

10. A health benefit plan under § 5(e) of the Peace Corps Act of 1961 (22 USC § 2504(e)).

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

1. Coverage only for accident or 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 expense 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.

"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 long-term care, 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.

"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.

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

1. Medicare supplement health insurance as defined under § 1882(g)(1) of the Social Security Act of 1935 (42 USC § 1395ss);

2. Coverage supplemental to the coverage provided under Chapter 55 of Title 10 of the United States Code (10 USC §§ 1071-1107); and

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

"Employee welfare benefit plan" means a plan, fund or program of employee benefits as defined in the Employee Retirement Income Security Act of 1974 (29 USC § 1002).

"Insolvency" means when an issuer, duly licensed to transact an insurance business in this Commonwealth in accordance with the provisions of Chapter 10, 41, 42 or 43, respectively, of Title 38.2 of the Code of Virginia, is determined to be insolvent and placed under a final order of liquidation by a court of competent jurisdiction.

"Issue age rating" means a premium structure based upon the covered individual's age at the time of purchase of the policy or certificate. Under an issue age rating structure, premiums do not increase due to the covered individual's increase in age during the life of the policy or certificate.

"Issuer" includes insurance companies, fraternal benefit societies, corporations licensed pursuant to Chapter 42 of Title 38.2 of the Code of Virginia to offer health services plans, health maintenance organizations, and any other entity delivering or issuing for delivery in this Commonwealth Medicare supplement policies or certificates.

"Medicare" means the "Health Insurance for the Aged Act," Title XVIII of the Social Security Act (42 USC § 1395 et seq.), as then constituted or later amended.

"Medicare Advantage plan" means a plan of coverage for health benefits under Medicare Part C as defined in § 1859 (42 USC § 1395w-28(b)(1) of the Social Security Act, and includes:

1. Coordinated care plans which provide health care services, including but not limited to health maintenance organization plans (with or without a point-of-service option), plans offered by provider-sponsored organizations, and preferred provider organization plans;

2. Medical savings account plans coupled with a contribution into a Medicare Advantage medical savings account; and

3. Medicare Advantage private fee-for-service plans.

"Medicare supplement policy" means a group or individual policy of accident and sickness insurance or a subscriber contract of health service plans or health maintenance organizations, other than a policy issued pursuant to a contract under § 1876 of the federal Social Security Act of 1935 (42 USC § 1395 et seq.) or an issued policy under a demonstration project specified in 42 USC § 1395ss(g)(1), which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare. "Medicare supplement policy" does not include Medicare Advantage plans established under Medicare Part C, Outpatient Prescription Drug plans established under Medicare Part D, or any Health Care Prepayment Plan that provides benefits pursuant to an agreement under § 1833(a)(1)(A) of the Social Security Act.

"Policy form" means the form on which the policy is delivered or issued for delivery by the issuer.

"Prestandardized Medicare supplement benefit plan," "prestandardized benefit plan" or "prestandardized plan" means a group or individual policy of Medicare supplement insurance issued prior to July 30, 1992.

"Secretary" means the Secretary of the United States Department of Health and Human Services.

14VAC5-170-50. Policy provisions.

A. Except for permitted preexisting condition clauses as described in 14VAC5-170-60 B 1 ~~and~~ , 14VAC5-170-70 B 1 and 14VAC5-170-75 B 1, no policy or certificate may be advertised, solicited or issued for delivery in this Commonwealth as a Medicare supplement policy if the 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 this Commonwealth shall contain benefits which duplicate benefits provided by Medicare.

D. 1. Subject to 14VAC5-170-60 B 4, 5 and 7 and 14VAC5-170-70 B 4 and 5, 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 shall 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 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.

14VAC5-170-60. Minimum benefit standards for prestandardized Medicare supplement benefits plan policies or certificates issued for delivery prior to July 30, 1992.

A. No policy or certificate may be advertised, solicited or issued for delivery in this Commonwealth 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 which are not inconsistent with these standards.

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

1. A Medicare supplement policy or certificate shall not exclude or limit benefits for a loss incurred more than six months from the effective date of coverage because it involved a preexisting condition. The policy or certificate shall 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 six 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 ~~amount and copayment percentage factors~~ , 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. a. Except as authorized by the State Corporation Commission, 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 subdivision 5 d of this subsection, the issuer shall offer certificateholders an individual Medicare supplement policy. The issuer shall offer the certificateholder at least the following choices:

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

(2) An individual Medicare supplement policy which provides only such benefits as are required to meet the minimum standards as defined in ~~subsection C of this section~~ 14VAC5-170-75 C.

c. If membership in a group is terminated, the issuer shall:

(1) Offer the certificateholder the conversion opportunities described in subdivision 5 b of this subsection; or

(2) 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 is modified to eliminate an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 USC § 1395w-101), the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this subsection.

C. Minimum benefit standards.

1. Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th 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 three 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. Effective January 1, 1990, coverage under Medicare Part B for the reasonable cost of the first three 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 A, subject to the Medicare deductible amount.

14VAC5-170-70. Benefit standards for 1990 Medicare supplement policies ~~or certificates issued or~~ delivered on or after July 30, 1992, and prior to June 1, 2010.

A. The following standards are applicable to all Medicare supplement benefit plan policies or certificates delivered or issued for delivery in this Commonwealth on or after July 30, 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 Commonwealth as a Medicare supplement policy or certificate unless it complies with these benefit standards.

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

1. A Medicare supplement policy or certificate shall not exclude or limit benefits for a loss incurred more than six 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 six 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.

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 subdivision 5 e of this subsection, the issuer shall offer certificateholders an individual Medicare supplement policy which (at the option of the certificateholder):

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

(2) 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:

(1) Offer the certificateholder the conversion opportunity described in subdivision 5 c of this subsection; or

(2) 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.

f. If a Medicare supplement policy is modified to eliminate an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 USC § 1395w-101), the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this subdivision 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. 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 (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 of 1935 (42 USC § 1396 et seq.), 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 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 such 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.

c. Each Medicare supplement policy or certificate 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 or certificateholder is entitled to benefits under § 226 (b) of the Social Security Act (42 USC § 426) and is covered under a group health plan (as defined in § 1862(b)(1)(A)(v) of the Social Security Act (42 USC § 1395y)). 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 coverage) if the policyholder or certificateholder provides notice of loss of coverage within 90 days after the date of the loss.

d. Reinstitution of coverages as described in subdivisions 7 b and c of this subsection:

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

(2) Shall provide for reinstituted coverage that is substantially equivalent to coverage in effect before the date of such 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

(3) 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 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 1990 standardized plan (as described in [ ~~14VAC5-170-70~~ 14VAC5-170-80 ] ) to a 2010 standardized plan (as described in [ ~~14VAC5-170-75~~ 14VAC5-170-85 ] ), the offer and subsequent exchange shall comply with the following requirements:

a. An issuer need not provide justification to the commission 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 prefunding 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 shall be filed with the commission in accordance with § 38.2-316 of the Code of Virginia.

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 preexisting 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 preexisting condition limitations of no more than six 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 of issue would be in violation of state or federal law.

C. Standards for basic (core) benefits common to benefit plans A through 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 of it.

1. Coverage of Part A Medicare Eligible Expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th 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;

4. Coverage under Medicare Parts A and B for the reasonable cost of the first three 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.

D. Standards for additional benefits. The following additional benefits shall be included in Medicare Supplement Benefit Plans "B" through "J" only as provided by 14VAC5-170-80.

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 21st day through the 100th 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 basic 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 extended 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 an 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 subdivision 9 b of this subsection 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.

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:

"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.

"Care provider" means a duly qualified or licensed home health aide or 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.

"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.

"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 four hours in a 24-hour period of services provided by a care provider is one visit.

b. Coverage requirements and limitations:

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

(2) 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; and

(3) Coverage is limited to:

(a) 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;

(b) The actual charges for each visit up to a maximum reimbursement of $40 per visit;

(d) Seven visits in any one week;

(e) Care furnished on a visiting basis in the insured's home;

(f) Services provided by a care provider as defined in this section;

(g) At-home recovery visits while the insured is covered under the policy or certificate and not otherwise excluded;

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

c. Coverage is excluded for:

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

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

E. 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 61st through the 90th 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 91st through the 150th 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 lifetime maximum benefit of an additional 365 days;

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 subdivision 1 j of this subsection;

e. Skilled nursing facility care: Coverage for 50% of the coinsurance amount for each day used from the 21st day through the 100th 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 subdivision 1 j of this subsection;

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 subdivision 1 j of this subsection;

g. Coverage for 50%, under Medicare Part A or B, of the reasonable cost of the first three 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 subdivision 1 j of this subsection;

h. Except for coverage provided in subdivision 1 j of this subsection, 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 subdivision 1 j of this subsection;

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 $4,000 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 subdivisions 1 a, b, c and i of this subsection;

b. The benefit described in subdivisions 1 d, e, f, g and h of this subsection, but substituting 75% for 50%; and

c. The benefit described in subdivision 1 j of this subsection, but substituting $2,000 for $4,000 indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.

14VAC5-170-75. Benefit standards for 2010 Medicare supplement policies delivered on or after June 1, 2010.

A. The following standards are applicable to all Medicare supplement benefit plan policies or certificates delivered or issued for delivery in this Commonwealth [ 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 Commonwealth 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 [ ~~before~~ with an effective date for coverage prior to ] June 1, 2010, remain subject to the requirements of 14VAC5-170-70.

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

1. A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six 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 six 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.

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 in subdivision 5 e of this subsection, the issuer shall offer certificateholders an individual Medicare supplement policy which, at the option of the certificateholder:

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

(2) 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:

(1) Offer the certificateholder the conversion opportunity described in subdivision 5 c of this subsection; or

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

6. Termination of a Medicare supplement policy or certificate shall be without prejudice to any continuous loss that 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. 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 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, 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.

b. 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) as of the 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.

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 § 226 (b) of the Social Security Act and is covered under a group health plan as defined in § 1862 (b)(1)(A)(v) of the Social Security Act. 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 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.

d. Reinstitution of coverages as described in subdivisions 7 b and c of this subsection:

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

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

(3) 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 been applied to the policyholder or certificateholder had the coverage not been suspended.

C. 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 61st day through the 90th 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;

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; and

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

D. 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 14VAC5-170-85.

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 21st day through the 100th day in a Medicare benefit period for posthospital 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. 100% 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 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 an illness of sudden and unexpected onset.

14VAC5-170-80. Standard ~~Medicare supplement benefit~~ plans for 1990 Medicare supplement policies delivered on or after July 30, 1992, and prior to June 1, 2010.

A. The following standard Medicare supplement benefit plans are applicable to all Medicare supplement benefit plan policies or certificates delivered or issued for delivery in this Commonwealth on or after July 30, 1992, and [ with an effective date for coverage ] prior to June 1, 2010. 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 14VAC5-170-70 C.

B. No groups, packages or combinations of Medicare supplement benefits other than those listed in this section shall be offered for sale in this Commonwealth, except as may be permitted in subsection G of this section and 14VAC5-170-90.

C. Benefit plans shall be uniform in structure, language, designation, and format to the standard benefit plans "A" through "L" listed in this subsection and conform to the definitions in 14VAC5-170-30. Each benefit shall be structured in accordance with the format provided in 14VAC5-170-70 C, D, or E and list the benefits in the order shown in this subsection. 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, 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 14VAC5-170-70 C.

2. Standardized Medicare supplement benefit plan "B" shall include only the following: The core benefits as defined in 14VAC5-170-70 C, plus the Medicare Part A deductible as defined in 14VAC5-170-70 D 1.

3. Standardized Medicare supplement benefit plan "C" shall include only the following: The core benefits as defined in 14VAC5-170-70 C, 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 14VAC5-170-70 D 1, 2, 3, and 8 respectively.

4. Standardized Medicare supplement benefit plan "D" shall include only the following: The core benefits as defined in 14VAC5-170-70 C, 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 14VAC5-170-70 D 1, 2, 8, and 10 respectively.

5. Standardized Medicare supplement benefit plan "E" shall include only the following: The core benefits as defined in 14VAC5-170-70 C, 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 14VAC5-170-70 D 1, 2, 8, and 9 respectively.

6. Standardized Medicare supplement benefit plan "F" shall include only the following: The core benefits as defined in 14VAC5-170-70 C, 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 14VAC5-170-70 D 1, 2, 3, 5, and 8 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 benefits as defined in 14VAC5-170-70 C, 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 14VAC5-170-70 D 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 calendar year deductible shall be $1,500 for 1998 and 1999. 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 on August 31st 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 benefits as defined in 14VAC5-170-70 C, 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 14VAC5-170-70 D 1, 2, 4, 8, and 10 respectively.

9. Standardized Medicare supplement benefit plan "H" shall include only the following: The core benefits as defined in 14VAC5-170-70 C, 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 14VAC5-170-70 D 1, 2, 6, and 8 respectively. The basic 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 include only the following: The core benefits as defined in 14VAC5-170-70 C, 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 14VAC5-170-70 D 1, 2, 5, 6, 8, and 10 respectively. The basic 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 include only the following: The core benefits as defined in 14VAC5-170-70 C, 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 14VAC5-170-70 D 1, 2, 3, 5, 7, 8, 9, and 10 respectively. The extended 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 include only the following: 100% of covered expenses following the payment of the annual high deductible plan "J" deductible. The covered expenses include the core benefits as defined in 14VAC5-170-70 C, 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 14VAC5-170-70 D 1, 2, 3, 5, 7, 8, 9, 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 deductibles. The calendar year deductible shall be $1,500 for 1998 and 1999. 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 on August 31st of the preceding year and rounded to the nearest multiple of $10. The extended outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

F. Make-up of two Medicare supplement plans mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 USC § 1395w-101):

1. Standardized Medicare supplement benefit plan "K" shall consist of only those benefits described in 14VAC5-170-70 E 1.

2. Standardized Medicare supplement benefit plan "L" shall consist of only those benefits described in 14VAC5-170-70 E 2.

G. New or innovative benefits. An issuer may, with the prior approval of the State Corporation Commission, 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.

14VAC5-170-85. Standard plans for 2010 standardized Medicare supplement policies delivered on or after June 1, 2010.

A. The following standard plans are applicable to all Medicare supplement benefit plan policies or certificates delivered or issued for delivery in this Commonwealth [ 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 Commonwealth 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 14VAC5-170-80.

B. 1. 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 14VAC5-170-75 C.

2. If an issuer makes available any of the additional benefits described in 14VAC5-170-75 D, or offers standardized benefit Plans K or L (as described in subdivisions 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 subdivision 1 of this subsection, a policy form or certificate form containing either standardized benefit Plan C (as described in subdivision F 3 of this section) or standardized benefit Plan F (as described in subdivision F 5 of this section).

C. No groups, packages or combinations of Medicare supplement benefits other than those listed in this section shall be offered for sale in this Commonwealth, except as may be permitted in subsection G of this section and 14VAC5-170-90.

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 14VAC5-170-30. Each benefit shall be structured in accordance with the format provided in 14VAC5-170-75 C and D; or, in the case of plans K or L, in subdivision F 8 or 9 of this section and list the benefits in the order shown. For purposes of this section, the term "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 basic (core) benefits as defined in 14VAC5-170-75 C.

2. Standardized Medicare supplement benefit Plan B shall include only the basic (core) benefit as defined in 14VAC5-170-75 C, plus 100% of the Medicare Part A deductible as defined in 14VAC5-170-75 D 1.

3. Standardized Medicare supplement benefit Plan C shall include only the basic (core) benefit as defined in 14VAC5-170-75 C, 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 14VAC5-170-75 D 1, 3, 4 and 6, respectively.

4. Standardized Medicare supplement benefit Plan D shall include only the basic (core) benefit as defined in 14VAC5-170-75 C, plus 100% of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in an foreign country as defined in 14VAC5-170-75 D 1, 3 and 6, respectively.

5. Standardized Medicare supplement benefit Plan F shall include only the basic (core) benefit as defined in 14VAC5-170-75 C, 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 14VAC5-170-75 D 1, 3, 4, 5 and 6, respectively.

6. Standardized Medicare supplement benefit Plan F With High Deductible shall include only 100% of covered expenses following the payment of the annual deductible as defined in subdivision 6 b of this subsection.

a. The basic (core) benefit as defined in 14VAC5-170-75 C, 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 14VAC5-170-75 D 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 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 basic (core) benefit as defined in 14VAC5-170-75 C, 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 14VAC5-170-75 D 1, 3, 5 and 6, respectively.

8. Standardized Medicare supplement benefit 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 61st through 90th days: Coverage of 100% of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;

b. Part A hospital coinsurance, 91st through 150th days: Coverage of 100% of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th 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;

e. Skilled nursing facility care: Coverage for 50% of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subdivision 8 j of this subsection;

g. Blood: Coverage for 50%, under Medicare Part A or B, of the reasonable cost of the first three 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 subdivision 8 j of this subsection;

h. Part B cost sharing: Except for coverage provided in subdivision 8 i of this subsection, 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 subdivision 8 j of this subsection;

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 $4,000 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 benefit 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 subdivisions 8 a, b, c and i of this subsection;

b. The benefit described in subdivisions 8 d, e, f, g and h of this subsection, but substituting 75% for 50%; and

c. The benefit described in subdivision 8 j of this subsection, but substituting $2,000 for $4,000.

10. Standardized Medicare supplement benefit Plan M shall include only the basic (core) benefit as defined in 14VAC5-170-75 C, plus 50% of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in 14VAC5-170-75 D 2, 3 and 6, respectively.

11. Standardized Medicare supplement benefit Plan N shall include only the basic (core) benefit as defined in 14VAC5-170-75 C, plus 100% of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in 14VAC5-170-75 D 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 commission, 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.

14VAC5-170-150. 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 shall be consistent with the type of contract issued. The provision shall be appropriately captioned, 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. Medicare supplement policies or certificates which are attained age rated shall include a clear and prominent statement, in at least 14 point type, disclosing that premiums will increase due to changes in age and the frequency under which such changes will occur.

2. Except for riders or endorsements by which the issuer effectuates a request made in writing by the insured, 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 a signed acceptance by the insured. After the date of policy or certificate issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term shall be agreed to in writing signed by the insured, unless the benefits are required by the minimum standards for Medicare supplement policies, or 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, the 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 all premiums made for the policy refunded 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 which provide hospital or medical expense coverage on an expense incurred or indemnity basis to a person or persons eligible for Medicare shall provide to those applicants a Guide to Health Insurance for People with Medicare in the form developed jointly by the National Association of Insurance Commissioners and the Centers for Medicare and Medicaid Services and in a 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 chapter. 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.

For the purposes of this section, "form" means the language, format, type size, type proportional spacing, bold character, and line spacing.

B. Notice requirements.

1. As soon as practicable, but no later than 30 days prior to the annual effective date of any Medicare benefit changes, an issuer shall notify its policyholders and certificateholders of modifications it has made to Medicare supplement insurance policies or certificates in a format acceptable to the State Corporation Commission. The 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.

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

C. Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 USC § 1395w-101).

D. 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 the outline from the applicant; and

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. The outline of coverage provided to applicants pursuant to this section consists of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage shall be in the language and format prescribed below in no less than 12 point type. All plans ~~A through L~~ shall be shown on the cover page, and the plan(s) 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.

4. The following items shall be included in the outline of coverage in the order prescribed in the following table.

~~Rev. 8/05~~

~~[COMPANY NAME]~~

~~Outline of Medicare Supplement Coverage-Cover Page: 1 of 2 Benefit Plan(s) _________ [insert letter(s) of plan(s) being offered]~~

*These charts show the benefits included in each of the Standard Medicare Supplemental plans. Every company must make available Plan "A." Some plans may not be available in your state.

~~See outlines of coverages section 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 three pints of blood each year.~~

A	B	C	D	E	F	F*	G	H	I	J	J*
~~Basic Benefit~~	~~Basic Benefit~~	~~Basic Benefit~~	~~Basic Benefit~~	~~Basic Benefit~~	~~Basic Benefit~~		~~Basic Benefit~~	~~Basic Benefit~~	~~Basic Benefit~~	~~Basic Benefit~~
		~~Skilled Nursing Facility Coinsurance~~	~~Skilled Nursing Facility Coinsurance~~	~~Skilled Nursing Facility Coinsurance~~	~~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 A Deductible~~	~~Part A Deductible~~	~~Part A Deductible~~	~~Part A Deductible~~
		~~Part B 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~~	~~Foreign Travel Emergency~~	~~Foreign Travel Emergency~~	~~Foreign Travel Emergency~~
			~~At-Home Recovery~~				~~At-Home Recovery~~		~~At-Home Recovery~~	~~At-Home Recovery~~
				~~Preventive Care not covered by Medicare~~						~~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 $1,730 deductible. Benefits from high deductible Plans F and J will not begin until out-of-pocket expenses exceed $1,730. 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.

[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 three 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 three pints of blood~~ ~~75% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services~~
~~Skilled Nursing Facility 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~~
	$4,000 Out of Pocket Annual Limit***	$2,000 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.~~

Benefit Chart of Medicare Supplement Plans Sold [ with 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.

Plans E, H, I and J are no longer available for sale after June 1, 2010. [ [This sentence shall not appear after June 1, 2011.] ]

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 $4,620; paid at 100% after limit reached	Out-of-pocket limit $2,310; 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 $2,000 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,000. 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

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We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this Commonwealth. [If the premium is based on attained age of the insured, include the following information:

1. When premiums will change;

2. The current premium for all ages;

3. A statement that premiums for other Medicare Supplement policies that are issue age or community rated do not increase due to changes in your age; and

4. A statement that while the cost of this policy at the covered individual's present age may be lower than the cost of a Medicare supplement policy that is based on issue age or community rated, it is important to compare the potential cost of these policies over the life of the policy.]

DISCLOSURES

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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 are no longer available for sale after June 1, 2010. [ [This paragraph shall not appear after June 1, 2011.] ]

READ YOUR POLICY VERY CAREFULLY

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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

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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

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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

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

[for agents:]

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

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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 the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this regulation. An issuer may use additional benefit plan designations on these charts pursuant to ~~14VAC5-170-80~~ 14VAC5-170-85.]

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

~~Rev. 8/05~~

PLAN A
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 ~~$912~~ $1,068	$0	~~$912~~ $1,068 (Part A Deductible)
61st thru 90th day			All but ~~$228~~ $267 a day	~~$228~~ $267 a day	$0
91st day and after:
	While using 60 lifetime reserve days		All but ~~$456~~ $534 a day	~~$456~~ $534 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 ~~$114~~ $133.50 a day	$0	Up to ~~$114~~ $133.50 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~~ 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	$0 Medicare copayment/coinsurance	~~Balance~~ $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
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed ~~$110~~ $135 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B ~~Deductible~~ 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 ~~$110~~ $135 of Medicare-Approved Amounts*	$0	$0	~~$110~~ $135 (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 ~~$110~~ $135 of Medicare-Approved Amounts*	$0	$0	~~$110~~ $135 (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 ~~$110~~ $135 of Medicare-Approved Amounts*	$0	$0	~~$110~~ $135 (Part B Deductible)
	Remainder of Medicare-Approved Amounts	80%	20%	$0

~~Rev. 8/05~~

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

SERVICES			MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days			All but ~~$912~~ $1,068	~~$912~~ $1,068 (Part A Deductible)	$0
61st thru 90th day			All but ~~$228~~ $267 a day	~~$228~~ $267 a day	$0
91st day and after:
	While using 60 lifetime reserve days		All but ~~$456~~ $534 a day	~~$456~~ $534 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 ~~$114~~ $133.50 a day	$0	Up to ~~$114~~ $133.50 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~~ 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	$0 Medicare copayment/coinsurance	~~Balance~~ $0

PLAN B
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed ~~$110~~ $135 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 ~~$110~~ $135 of Medicare-Approved Amounts*	$0	$0	~~$110~~ $135 (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 ~~$110~~ $135 of Medicare-Approved Amounts*	$0	$0	~~$110~~ $135 (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 ~~$110~~ $135 of Medicare-Approved Amounts*	$0	$0	~~$110~~ $135 (Part B Deductible)
	Remainder of Medicare-Approved Amounts	80%	20%	$0

~~Rev. 8/05~~

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

SERVICES			MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days			All but ~~$912~~ $1,068	~~$912~~ $,1068 (Part A Deductible)	$0
61st thru 90th day			All but ~~$228~~ $267 a day	~~$228~~ $267 a day	$0
91st day and after:
	While using 60 lifetime reserve days		All but ~~$456~~ $534 a day	~~$456~~ $534 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 ~~$114~~ $133.50 a day	Up to ~~$114~~ $133.50 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~~ 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	$0 Medicare copayment/coinsurance	~~Balance~~ $0

PLAN C
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First ~~$110~~ $135 of Medicare-Approved Amounts*	$0	~~$110~~ $135 (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 ~~$110~~ $135 of Medicare-Approved Amounts*	$0	~~$110~~ $135 (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 ~~$110~~ $135 of Medicare-Approved Amounts*	$0	~~$110~~ $135 (Part B Deductible)	$0
	Remainder of Medicare-Approved Amounts	80%	20%	$0

OTHER BENEFITS—NOT COVERED BY MEDICARE

FOREIGN TRAVEL - NOT COVERED BY MEDICARE
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
	First $250 each calendar year	$0	$0	$250
	Remainder of Charges	$0	80% to a lifetime maximum benefit of $50,000	20% and amounts over the $50,000 lifetime maximum

~~Rev. 8/05~~

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

SERVICES			MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days			All but ~~$912~~ $1,068	~~$912~~ $1,068 (Part A Deductible)	$0
61st thru 90th day			All but ~~$228~~ $267 a day	~~$228~~ $267 a day	$0
91st day and after:
	While using 60 lifetime reserve days		All but ~~$456~~ $534 a day	~~$456~~ $534 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 ~~$114~~ $133.50 a day	Up to ~~$114~~ $133.50 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~~ 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	$0 Medicare copayment/coinsurance	~~Balance~~ $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
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed ~~$110~~ $135 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 ~~$110~~ $135 of Medicare-Approved Amounts*	$0	$0	~~$110~~ $135 (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 ~~$110~~ $135 of Medicare-Approved Amounts*	$0	$0	~~$110~~ $135 (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 ~~$110~~ $135 of Medicare-Approved Amounts*	$0	$0	~~$110~~ $135 (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

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

~~Rev. 8/05~~

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

~~SERVICES~~			~~MEDICARE PAYS~~	~~PLAN PAYS~~	~~YOU PAY~~
HOSPITALIZATION* ~~Semiprivate room and board, general nursing and miscellaneous services and supplies~~
~~First 60 days~~			~~All but $912~~	~~$912 (Part A Deductible)~~	$0
~~61st thru 90th day~~			~~All but $228 a day~~	~~$228 a day~~	$0
~~91st day and after:~~
	~~While using 60 lifetime reserve days~~		~~All but $456 a day~~	~~$456 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 $114 a day~~	~~Up to $114 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 outpatient drugs and inpatient respite care~~	$0	~~Balance~~

PLAN E
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $110 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 $110 of Medicare-Approved Amounts*	$0	$0	~~$110 (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 $110 of Medicare-Approved Amounts*	$0	$0	~~$110 (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 $110 of Medicare-Approved Amounts*	$0	$0	~~$110 (Part B Deductible)~~
	~~Remainder of Medicare-Approved Amounts~~	~~80%~~	~~20%~~	$0

~~Rev. 8/05~~

PLAN E
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~~
***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.

~~Rev. 8/05~~

PLAN F or HIGH DEDUCTIBLE PLAN F
MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year ~~$1730~~ $2,000 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are ~~$1730~~ $2,000. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.

SERVICES			MEDICARE PAYS	AFTER YOU PAY ~~$1730~~ $2,000 DEDUCTIBLE,** PLAN PAYS	IN ADDITION TO ~~$1730~~ $2,000 DEDUCTIBLE,** YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days			All but ~~$912~~ $1,068	~~$912~~ $1,068 (Part A Deductible)	$0
61st thru 90th day			All but ~~$228~~ $267 a day	~~$228~~ $267 a day	$0
91st day and after:
	While using 60 lifetime reserve days		All but ~~$456~~ $534 a day	~~$456~~ $534 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 ~~$114~~ $133.50 a day	Up to ~~$114~~ $133.50 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~~ 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	$0 Medicare copayment/coinsurance	~~Balance~~ $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 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
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed ~~$110~~ $135 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 ~~$1730~~ $2,000 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are ~~$1730~~ $2,000. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.

SERVICES	MEDICARE PAYS	AFTER YOU PAY ~~$1730~~ $2,000 DEDUCTIBLE,** PLAN PAYS	IN ADDITION TO ~~$1730~~ $2,000 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 ~~$110~~ $135 of Medicare-Approved amounts*	$0	~~$110~~ $135 (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 ~~$110~~ $135 of Medicare-Approved Amounts*	$0	~~$110~~ $135 (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 $2,000 DEDUCTIBLE,** PLAN PAYS	IN ADDITON TO $2,000 DEDUCTIBLE,** YOU PAY
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
Medically necessary skilled care services and medical supplies		100%	$0	$0
Durable medical equipment
	First ~~$110~~ $135 of Medicare-Approved Amounts*	$0	~~$110~~ $135 (Part B Deductible)	$0
	Remainder of Medicare-Approved Amounts	80%	20%	$0

OTHER BENEFITS - NOT COVERED BY MEDICARE

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

~~Rev. 8/05~~

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

SERVICES			MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days			All but ~~$912~~ $1,068	~~$912~~ $1,068 (Part A Deductible)	$0
61st thru 90th day			All but ~~$228~~ $267 a day	~~$228~~ $267 a day	$0
91st day and after:
	While using 60 lifetime reserve days		All but ~~$456~~ $534 a day	~~$456~~ $534 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 ~~$114~~ $133.50 a day	Up to ~~$114~~ $133.50 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~~ 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	$0 Medicare copayment/coinsurance	~~Balance~~ $0

PLAN G
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed ~~$110~~ $135 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 ~~$110~~ $135 of Medicare-Approved Amounts*	$0	$0	~~$110~~ $135 (Part B Deductible)
Remainder of Medicare-Approved Amounts	Generally 80%	Generally 20%	$0
PART B EXCESS CHARGES
(Above Medicare-Approved Amounts)	$0	~~80%~~ 100%	~~20%~~ $0
BLOOD
First 3 pints	$0	All costs	$0
Next ~~$110~~ $135 of Medicare-Approved Amounts*	$0	$0	~~$110~~ $135 (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 ~~$110~~ $135 of Medicare-Approved Amounts*	$0	$0	~~$110~~ $135 (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

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

~~Rev. 8/05~~

PLAN H
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

~~SERVICES~~			~~MEDICARE PAYS~~	~~PLAN PAYS~~	~~YOU PAY~~
HOSPITALIZATION* ~~Semiprivate room and board, general nursing and miscellaneous services and supplies~~
~~First 60 days~~			~~All but $912~~	~~$912 (Part A Deductible)~~	$0
~~61st thru 90th day~~			~~All but $228 a day~~	~~$228 a day~~	$0
~~91st day and after:~~
	~~While using 60 lifetime reserve days~~		~~All but $456 a day~~	~~$456 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 $114 a day~~	~~Up to $114 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 outpatient drugs and inpatient respite care~~	$0	~~Balance~~

PLAN H
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $110 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 $110 of Medicare-Approved Amounts*	$0	$0	~~$110 (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 $110 of Medicare-Approved Amounts*	$0	$0	~~$110 (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 $110 of Medicare-Approved Amounts*	$0	$0	~~$110 (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~~

~~Rev. 8/05~~

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

~~SERVICES~~			~~MEDICARE PAYS~~	~~PLAN PAYS~~	~~YOU PAY~~
HOSPITALIZATION* ~~Semiprivate room and board, general nursing and miscellaneous services and supplies~~
~~First 60 days~~			~~All but $912~~	~~$912 (Part A Deductible)~~	$0
~~61st thru 90th day~~			~~All but $228 a day~~	~~$228 a day~~	$0
~~91st day and after:~~
	~~While using 60 lifetime reserve days~~		~~All but $456 a day~~	~~$456 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 $114 a day~~	~~Up to $114 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 outpatient drugs and inpatient respite care~~	$0	~~Balance~~

PLAN I
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $110 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 $110 of Medicare-Approved Amounts*	$0	$0	~~$110 (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 $110 of Medicare-Approved Amounts*	$0	$0	~~$110 (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 $110 of Medicare-Approved Amounts*	$0	$0	~~$110 (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~~

~~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~~

~~Rev. 8/05~~

PLAN J or HIGH DEDUCTIBLE PLAN J
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

**This high deductible plan pays the same benefits as Plan J after one has paid a calendar year $1730 deductible. Benefits from high deductible plan J will not begin until out-of-pocket expenses are $1730. 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~~	~~PLAN PAYS~~	~~YOU PAY~~
HOSPITALIZATION* ~~Semiprivate room and board, general nursing and miscellaneous services and supplies~~
~~First 60 days~~			~~All but $912~~	~~$912 (Part A deductible)~~	$0
~~61st thru 90th day~~			~~All but $228 a day~~	~~$228 a day~~	$0
~~91st day and after:~~
	~~While using 60 lifetime reserve days~~		~~All but $456 a day~~	~~$456 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 $114 a day~~	~~Up to $114 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 outpatient drugs and inpatient respite care~~	$0	~~Balance~~

~~Rev. 8/05~~

PLAN J or HIGH DEDUCTIBLE PLAN J
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $110 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 $1730 DEDUCTIBLE,** PLAN PAYS~~	~~IN ADDITION TO $1730 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 $110 of Medicare-Approved Amounts*	$0	~~$110 (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 $110 of Medicare-Approved Amounts*	$0	~~$110 (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 $110 of Medicare-Approved Amounts*	$0	~~$110 (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~~

PLAN J or HIGH DEDUCTIBLE PLAN J
OTHER BENEFITS—NOT COVERED BY MEDICARE

~~SERVICES~~		~~MEDICARE PAYS~~	~~AFTER YOU PAY $1730 DEDUCTIBLE,** PLAN PAYS~~	~~IN ADDITION TO $1730 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.

~~Eff. 8/05~~

PLAN K

*You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of ~~$4000~~ $4,620 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 ~~$912~~ $1,068	~~$456~~ $534 (50% of Part A deductible)	~~$456~~ $534 (50% of Part A deductible)♦
61st thru 90th day			All but ~~$228~~ $267 a day	~~$228~~ $267 a day	$0
91st day and after:
	While using 60 lifetime reserve days		All but ~~$456~~ $534 a day	~~$456~~ $534 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 ~~$114~~ $133.50 a day	Up to ~~$57~~ $66.75 a day	Up to ~~$57~~ $66.75 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~~ You must meet Medicare's requirements, including a doctor's certification of terminal illness.			~~Generally, most Medicare-eligible expenses for out-patient drugs and inpatient respite care~~ All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	50% of copayment/coinsurance ~~or copayments~~	50% of Medicare copayment/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 the 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 ~~$110~~ $135 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 ~~$110~~ $135 of Medicare-Approved Amounts****	$0	$0	~~$110~~ $135 (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 $4000)* $4620)*
BLOOD
First 3 pints	$0	50%	50%♦
Next ~~$110~~ $135 of Medicare Approved Amounts****	$0	$0	~~$110~~ $135 (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 ~~$4000~~ $4,620 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.

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 ~~$110~~ $135 of Medicare-Approved Amounts*****	$0	$0	~~$110~~ $135 (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.

~~Eff. 8/05~~

PLAN L

*You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of ~~$2000~~ $2,310 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

SERVICES			MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days			All but ~~$912~~ $1,068	~~$684~~ $808.50 (75% of Part A deductible)	~~$228~~ $267 (25% of Part A deductible)♦
61st thru 90th day			All but ~~$228~~ $267 a day	~~$228~~ $267 a day	$0
91st day and after:
	While using 60 lifetime reserve days		All but ~~$456~~ $534 a day	~~$456~~ $534 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 ~~$114~~ $133.50 a day	Up to ~~$85.50~~ $100.13 a day	Up to ~~$28.50~~ $33.38 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~~ You must meet Medicare's requirements, including a doctor's certification of terminal illness.			~~Generally, most Medicare eligible expenses for out-patient drugs and inpatient respite care~~ All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	75% of copayment/coinsurance ~~or copayments~~	25% of copayment/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 charge and the amount Medicare would have paid.

PLAN L
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

****Once you have been billed ~~$110~~ $135 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 ~~$110~~ $135 of Medicare-Approved Amounts****	$0	$0	~~$110~~ $135 (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 $2000)* $2,310)*
BLOOD
First 3 pints	$0	75%	25%♦
Next ~~$110~~ $135 of Medicare Approved Amounts****	$0	$0	~~$110~~ $135 (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 ~~$2000~~ $2,310 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.

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 ~~$110~~ $135 of Medicare-Approved Amounts*****	$0	$0	~~$110~~ $135 (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.

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

SERVICES			MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days			All but $1,068	$534 (50% of Part A deductible)	$534 (50% of Part A deductible)
61st thru 90th day			All but $267 a day	$267 a day	$0
91st day and after:
	While using 60 lifetime reserve days		All but $534 a day	$534 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 $133.50 a day	Up to $133.50 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

PLAN M
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $135 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 $135 of Medicare-Approved Amounts*	$0	$0	$135 (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 $135 of Medicare Approved Amounts*	$0	$0	$135 (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 $135 of Medicare-Approved Amounts*	$0	$0	$135 (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

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

SERVICES			MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days			All but $1,068	$1,068 (Part A deductible)	$0
61st thru 90th day			All but $267 a day	$267 a day	$0
91st day and after:
	While using 60 lifetime reserve days		All but $534 a day	$534 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 $133.50 a day	Up to $133.50 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

PLAN N
MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

*Once you have been billed $135 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 $135 of Medicare-Approved Amounts*	$0	$0	$135 (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 visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency room 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 $135 of Medicare Approved Amounts*	$0	$0	$135 (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 $135 of Medicare-Approved Amounts*	$0	$0	$135 (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

E. Notice regarding policies or certificates which are not Medicare supplement policies.

1. Any accident and sickness insurance policy or certificate issued for delivery in this Commonwealth to persons eligible for Medicare, other than a Medicare supplement policy, a policy issued pursuant to a contract under § 1876 of the federal Social Security Act (42 USC § 1395 et seq.), a disability income policy, or other policy identified in 14VAC5-170-20 B, 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 CONTRACT]. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company."

2. Applications provided to persons eligible for Medicare for the health insurance policies or certificates described in subdivision 1 of this subsection shall disclose, using the applicable statement in Appendix C, the extent to which the policy duplicates Medicare. The disclosure statement shall be provided as a part of, or together with, the application for the policy or certificate.

F. Notice requirements for attained age rated Medicare supplement policies or certificates. Issuers of Medicare supplement policies or certificates which use attained age rating shall provide a notice to all prospective applicants at the time the application is presented, and except for direct response policies or certificates, shall obtain an acknowledgement of receipt of the notice from the applicant. The notice shall be in no less than 12 point type and shall contain the information included in Appendix D. The notice shall be provided as part of, or together with, the application for the policy or certificate.

14VAC5-170-215. Prohibition against use of genetic information and requests for genetic testing.

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 preexisting 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 of this section 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 such individual to undergo a genetic test.

D. Subsection C of this section 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 and § 264 of the Health Insurance Portability and Accountability Act of 1996) and consistent with subsection A of this section.

E. For purposes of carrying out subsection D of this section, 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 of this section, 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 Part 46, 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 such child, to whom the request is made that:

a. Compliance with the request is voluntary; and

b. Noncompliance will have no effect on enrollment status or premium or contribution amounts.

3. No genetic information collected or acquired under this subsection 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 U.S. Secretary of Health and Human Services in writing that the issuer is conducting activities pursuant to the exception provided for under this subsection, including a description of the activities conducted.

5. The issuer complies with such other conditions as the U.S. Secretary of Health and Human Services may by regulation require for activities conducted under this subsection.

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 such individual’s enrollment under the policy in connection with such 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, such request, requirement, or purchase shall not be considered a violation of subsection H of this section if such request, requirement, or purchase is not in violation of subsection G of this section.

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 such 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 such individual.

3. "Genetic information" means, with respect to any individual, information about such individual’s genetic tests, the genetic tests of family members of such individual, and the manifestation of a disease or disorder in family members of such individual. Such term includes, with respect to any individual, any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by such individual or any family member of such 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 a 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 preexisting 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.

VA.R. Doc. No. R09-1737; Filed April 22, 2009, 11:43 a.m.

Document Information

Rules:: 14VAC5-170-20
14VAC5-170-30
14VAC5-170-50
14VAC5-170-60
14VAC5-170-70
14VAC5-170-75
14VAC5-170-80
14VAC5-170-85
14VAC5-170-150
14VAC5-170-215

14VAC5-170 Rules Governing Minimum Standards for Medicare Supplement Policies

REGULATIONSVol. 25 Iss. 18 - May 11, 2009

Document Information

REGULATIONS
Vol. 25 Iss. 18 - May 11, 2009