NAC687B.250. Outline of coverage; assistance in understanding health insurance.

     1. Each issuer shall provide an outline of coverage to each applicant at the time the application is presented to the applicant and, except in the case of a direct response policy, shall obtain an acknowledgment from the applicant that he or she has received the outline.

     2. If an outline of coverage is provided at the time of application and the policy to supplement Medicare or the certificate is issued on a basis that would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany the policy or certificate when it is delivered. The substitute outline must contain the following statement, in not less than 12-point type, immediately above the name of the company:

     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 the applicant must consist of:

     (a) A cover page;

     (b) Information regarding premiums;

     (c) Disclosure pages; and

     (d) Charts displaying the features of each benefit plan offered by the issuer as set forth in subsection 7.

     4. All plans must be shown on the cover page and the plans offered by the issuer must be prominently identified.

     5. Information regarding premiums for benefit plans to supplement Medicare offered by the issuer must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and mode must be stated for all plans that are offered to the applicant. All possible premiums must be illustrated.

     6. An insured may contact the Commissioner of Insurance or the Nevada State Health Insurance Assistance Program (SHIP) of the Aging and Disability Services Division of the Department of Health and Human Services for help in understanding his or her health insurance.

     7. The outline of coverage must be printed in not less than 12-point type, using the following language and format:

Benefit Chart of Medicare Supplement Plans Sold with an Effective Date for Coverage On or After June 1, 2010

This chart shows the benefits included in each of the Standard Medicare Supplement Plans. Every company must make Plan “A” available. Some plans may not be available in your state.

Basic Benefits:

Hospitalization - Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

Medical Expenses - Part B coinsurance (generally 20 percent 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 *** copayment for office visit, and up to *** 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**; paid at 100% after limit reached	Out-of-pocket limit**; 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 deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses exceed the deductible. 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.

** Out-of-pocket limit will increase each year for inflation.

*** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an insurer to an applicant pursuant to NAC 687B.240.

PREMIUM INFORMATION (Boldface type)

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

DISCLOSURES (Boldface type)

Use this outline to compare benefits and premiums among policies.

READ YOUR POLICY VERY CAREFULLY

(Boldface type)

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

RIGHT TO RETURN POLICY (Boldface type)

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

POLICY REPLACEMENT (Boldface type)

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

NOTICE (Boldface type)

This policy may not 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

(Boldface type)

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

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

(Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, and the same uniform layout and format as shown in the charts set forth in this subsection. No more than four plans may be shown on one chart. An issuer may use additional designations for benefit plans on these charts as authorized by subsection 4 of NAC 687B.295.)

(Include an explanation of any innovative benefits on the cover page and in the chart, in the manner approved by the Commissioner.)

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 consecutive days.

** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

*** 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.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies:       First 60 days       61st thru 90th day       91st day and after:              While using 60 lifetime reserve days              Once lifetime reserve days are used:                    Additional 365 days                    Beyond the additional 365 days	All but ** All but ** a day All but ** a day $0 $0	$0 ** a day ** a day 100% of Medicare Eligible Expenses $0	(Part A Deductible) $0 $0 $0*** All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but ** a day $0	$0 $0 $0	$0 Up to ** a day All costs
BLOOD       First 3 pints       Additional amounts	$0 100%	3 pints $0	$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 A

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

* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (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 portion of Medicare-approved amounts *       Remainder of Medicare-approved amounts	$0 Generally 80%	$0 Generally 20%	(Part B Deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD       First 3 pints       Next portion of Medicare-approved amounts *       Remainder of Medicare-approved amounts	$0 $0 80%	All costs $0 20%	$0 (Part B Deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PLAN A

PARTS A & B

* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (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
HOME HEALTH CARE MEDICARE-APPROVED SERVICES       Medically necessary skilled care services and medical supplies       Durable medical equipment:              First portion of Medicare-approved amounts *              Remainder of Medicare-approved amounts	100% $0 80%	$0 $0 20%	$0 (Part B Deductible) $0

PLAN B

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 consecutive days.

** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

*** 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.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies:       First 60 days       61st thru 90th day       91st day and after:              While using 60 lifetime reserve days              Once lifetime reserve days are used:                    Additional 365 days                    Beyond the additional 365 days	All but ** All but ** a day All but ** a day $0 $0	(Part A Deductible) ** a day ** a day 100% of Medicare Eligible Expenses $0	$0 $0 $0 $0*** All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but ** a day $0	$0 $0 $0	$0 Up to ** a day All costs
BLOOD       First 3 pints       Additional amounts	$0 100%	3 pints $0	$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 B

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

* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (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 portion of Medicare-approved amounts *       Remainder of Medicare-approved amounts	$0 Generally 80%	$0 Generally 20%	(Part B Deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD       First 3 pints       Next portion of Medicare-approved amounts*       Remainder of Medicare-approved amounts	$0 $0 80%	All costs $0 20%	$0 (Part B Deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PLAN B

PARTS A & B

* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (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
HOME HEALTH CARE MEDICARE-APPROVED SERVICES       Medically necessary skilled care services and       medical supplies       Durable medical equipment:              First portion of Medicare-approved amounts *              Remainder of Medicare-approved amounts	100% $0 80%	$0 $0 20%	$0 (Part B Deductible) $0

PLAN C

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 consecutive days.

** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

*** 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.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies:       First 60 days       61st thru 90th day       91st day and after:              While using 60 lifetime reserve days              Once lifetime reserve days are used:                    Additional 365 days                    Beyond the additional 365 days	All but ** All but ** a day All but ** a day $0 $0	(Part A Deductible) ** a day ** a day 100% of Medicare Eligible Expenses $0	$0 $0 $0 $0*** All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but ** a day $0	$0 Up to ** a day $0	$0 $0 All costs
BLOOD       First 3 pints       Additional amounts	$0 100%	3 pints $0	$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 C

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

* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (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 portion of Medicare-approved amounts *       Remainder of Medicare-approved amounts	$0 Generally 80%	(Part B Deductible) Generally 20%	$0 $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD       First 3 pints       Next portion of Medicare-approved amounts *       Remainder of Medicare-approved amounts	$0 $0 80%	All costs (Part B Deductible) 20%	$0 $0 $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PLAN C

PARTS A & B

* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (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
HOME HEALTH CARE MEDICARE-APPROVED SERVICES       Medically necessary skilled care services and medical supplies       Durable medical equipment:              First portion of Medicare-approved amounts *              Remainder of Medicare-approved amounts	100% $0 80%	$0 (Part B Deductible) 20%	$0 $0 $0

PLAN C

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 United States:       First $250 each calendar year       Remainder of charges	$0 $0	$0 80% to a lifetime maximum benefit of $50,000	$250 20% and amounts over the $50,000 lifetime maximum

PLAN D

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 consecutive days.

** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

*** 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.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies:       First 60 days       61st thru 90th day       91st day and after:              While using 60 lifetime reserve days              Once lifetime reserve days are used:                    Additional 365 days                    Beyond the additional 365 days	All but ** All but ** a day All but ** a day $0 $0	(Part A Deductible) ** a day ** a day 100% of Medicare Eligible Expenses $0	$0 $0 $0 $0*** All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but ** a day $0	$0 Up to ** a day $0	$0 $0 All costs
BLOOD       First 3 pints       Additional amounts	$0 100%	3 pints $0	$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 D

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

* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (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 portion of Medicare-approved amounts *       Remainder of Medicare-approved amounts	$0 Generally 80%	$0 Generally 20%	(Part B Deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD       First 3 pints       Next portion of Medicare-approved amounts *       Remainder of Medicare-approved amounts	$0 $0 80%	All costs $0 20%	$0 (Part B Deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PLAN D

PARTS A & B

* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (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
HOME HEALTH CARE MEDICARE-APPROVED SERVICES       Medically necessary skilled care services and medical supplies       Durable medical equipment:              First portion of Medicare-approved amounts *              Remainder of Medicare-approved amounts	100% $0 80%	$0 $0 20%	$0 (Part B Deductible) $0

PLAN D

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 United States:       First $250 each calendar year       Remainder of charges	$0 $0	$0 80% to a lifetime maximum benefit of $50,000	$250 20% and amounts over the $50,000 lifetime maximum

PLAN F

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 consecutive days.

** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

*** 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.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies:       First 60 days       61st thru 90th day       91st day and after:              While using 60 lifetime reserve days              Once lifetime reserve days are used:                    Additional 365 days                    Beyond the additional 365 days	All but ** All but ** a day All but ** a day $0 $0	(Part A Deductible) ** a day ** a day 100% of Medicare Eligible Expenses $0	$0 $0 $0 $0*** All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but ** a day $0	$0 Up to ** a day $0	$0 $0 All costs
BLOOD       First 3 pints       Additional amounts	$0 100%	3 pints $0	$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 F

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

* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (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 portion of Medicare-approved amounts *       Remainder of Medicare-approved amounts	$0 Generally 80%	(Part B Deductible) Generally 20%	$0 $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	100%	$0
BLOOD       First 3 pints       Next portion of Medicare-approved amounts *       Remainder of Medicare-approved amounts	$0 $0 80%	All costs (Part B Deductible) 20%	$0 $0 $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PLAN F

PARTS A & B

* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (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
HOME HEALTH CARE MEDICARE-APPROVED SERVICES       Medically necessary skilled care services and       medical supplies       Durable medical equipment:              First portion of Medicare-approved amounts *              Remainder of Medicare-approved amounts	100% $0 80%	$0 (Part B Deductible) 20%	$0 $0 $0

PLAN F

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 United States:       First $250 each calendar year       Remainder of charges	$0 $0	$0 80% to a lifetime maximum benefit of $50,000	$250 20% and amounts over the $50,000 lifetime maximum

HIGH DEDUCTIBLE BENEFIT PLAN F

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 consecutive days.

** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

*** 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.

**** The High Deductible Benefit Plan F pays the same benefits as the Standardized Benefit Plan F after one has paid a calendar year deductible. The annual deductible for the High Deductible Benefit Plan F is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. Benefits from the High Deductible Benefit Plan F will not begin until out-of-pocket expenses are equal to the calendar year deductible. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes, without limitation, 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 THE DEDUCTIBLE, PLAN PAYS****	IN ADDITION TO THE DEDUCTIBLE, YOU PAY****
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies:       First 60 days       61st thru 90th day       91st day and after:              While using 60 lifetime reserve days              Once lifetime reserve days are used:                    Additional 365 days                    Beyond the additional 365 days	All but ** All but ** a day All but ** a day $0 $0	(Part A Deductible) ** a day ** a day 100% of Medicare Eligible Expenses $0	$0 $0 $0 $0*** All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but ** a day $0	$0 Up to ** a day $0	$0 $0 All costs
BLOOD       First 3 pints       Additional amounts	$0 100%	3 pints $0	$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

HIGH DEDUCTIBLE BENEFIT PLAN F

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

* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. The Part B Deductible will be applied toward the annual deductible for the calendar year set forth in NAC 687B.311.

** The High Deductible Benefit Plan F pays the same benefits as the Standardized Benefit Plan F after one has paid a calendar year deductible. The annual deductible for the High Deductible Benefit Plan F is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. Benefits from the High Deductible Benefit Plan F will not begin until out-of-pocket expenses are equal to the calendar year deductible. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes, without limitation, 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 THE DEDUCTIBLE, PLAN PAYS**	IN ADDITION TO THE 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 portion of Medicare-approved amounts *       Remainder of Medicare-approved amounts	$0 Generally 80%	(Part B Deductible) Generally 20%	$0 $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	100%	$0
BLOOD       First 3 pints       Next portion of Medicare-approved amounts *       Remainder of Medicare-approved amounts	$0 $0 80%	All costs (Part B Deductible) 20%	$0 $0 $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

HIGH DEDUCTIBLE BENEFIT PLAN F

MEDICARE (PARTS A & B)

* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. The Part B Deductible will be applied toward the annual deductible for the calendar year set forth in NAC 687B.311.

** The High Deductible Benefit Plan F pays the same benefits as the Standardized Benefit Plan F after one has paid a calendar year deductible. The annual deductible for the High Deductible Benefit Plan F is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. Benefits from the High Deductible Benefit Plan F will not begin until out-of-pocket expenses are equal to the calendar year deductible. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes, without limitation, 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 THE DEDUCTIBLE, PLAN PAYS**	IN ADDITION TO THE DEDUCTIBLE, YOU PAY**
HOME HEALTH CARE MEDICARE-APPROVED SERVICES       Medically necessary skilled care services and       medical supplies       Durable medical equipment:              First portion of Medicare-approved amounts *              Remainder of Medicare-approved amounts	100% $0 80%	$0 (Part B Deductible) 20%	$0 $0 $0

HIGH DEDUCTIBLE BENEFIT PLAN F

OTHER BENEFITS - NOT COVERED BY MEDICARE

* The High Deductible Benefit Plan F pays the same benefits as the Standardized Benefit Plan F after one has paid a calendar year deductible. The annual deductible for the High Deductible Benefit Plan F is subject to change. For the current deductible, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240. The cover page of the outline of coverage which must be provided to an applicant by an issuer pursuant to this section must specify the current amount of the deductible. Benefits from the High Deductible Benefit Plan F will not begin until out-of-pocket expenses are equal to the calendar year deductible. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes, without limitation, 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 THE DEDUCTIBLE, PLAN PAYS*	IN ADDITION TO THE DEDUCTIBLE, YOU PAY*
FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States:       First $250 each calendar year       Remainder of charges	$0 $0	$0 80% to a lifetime maximum benefit of $50,000	$250 20% and amounts over the $50,000 lifetime maximum

PLAN G

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 consecutive days.

** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

*** 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.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies:       First 60 days       61st thru 90th day       91st day and after:              While using 60 lifetime reserve days              Once lifetime reserve days are used:                    Additional 365 days                    Beyond the additional 365 days	All but ** All but ** a day All but ** a day $0 $0	(Part A Deductible) ** a day ** a day 100% of Medicare Eligible Expenses $0	$0 $0 $0 $0*** All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but ** a day $0	$0 Up to ** a day $0	$0 $0 All costs
BLOOD       First 3 pints       Additional amounts	$0 100%	3 pints $0	$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 G

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

* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (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 portion of Medicare-approved amounts *       Remainder of Medicare-approved amounts	$0 Generally 80%	$0 Generally 20%	(Part B Deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	100%	$0
BLOOD       First 3 pints       Next portion of Medicare-approved amounts *       Remainder of Medicare-approved amounts	$0 $0 80%	All costs $0 20%	$0 (Part B Deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PLAN G

PARTS A & B

* Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (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
HOME HEALTH CARE MEDICARE-APPROVED SERVICES       Medically necessary skilled care services and       medical supplies       Durable medical equipment:              First portion of Medicare-approved amounts *              Remainder of Medicare-approved amounts	100% $0 80%	$0 $0 20%	$0 (Part B Deductible) $0

PLAN G

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 United States:       First $250 each calendar year       Remainder of charges	$0 $0	$0 80% to a lifetime maximum benefit of $50,000	$250 20% and amounts over the $50,000 lifetime maximum

PLAN K

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

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

** 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 consecutive days.

*** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

**** 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.

¿ 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.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies:       First 60 days       61st thru 90th day       91st day and after:              While using 60 lifetime reserve days              Once lifetime reserve days are used:                    Additional 365 days                    Beyond the additional 365 days	All but *** All but *** a day All but *** a day $0 $0	(50% of Part A Deductible) *** a day *** a day 100% of Medicare Eligible Expenses $0	(50% of Part A Deductible)¿ $0 $0 $0**** All costs
SKILLED NURSING FACILITY CARE** You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but *** a day $0	$0 Up to 50% of *** a day (50% of Part A Coinsurance) $0	$0 Up to 50% of *** a day (50% of Part A Coinsurance) ¿ All costs
BLOOD       First 3 pints       Additional amounts	$0 100%	50% $0	50%¿ $0
HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness	All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	50% of coinsurance or copayments	50% of Medicare copayment/coinsurance ¿

PLAN K

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

* This plan limits your annual out-of-pocket payments for Medicare-approved amounts 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.

** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

**** Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the 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.

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 portion of Medicare-approved amounts****       Preventive Benefits for Medicare-covered services       Remainder of Medicare-approved amounts	$0 Generally 80% or more of Medicare-approved amounts Generally 80%	$0 Remainder of Medicare-approved amounts Generally 10%	(Part B Deductible) ****¿ All costs above Medicare-approved amounts 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)
BLOOD       First 3 pints       Next portion of Medicare-approved amounts ****       Remainder of Medicare-approved amounts	$0 $0 Generally 80%	50% $0 Generally 10%	50%¿ (Part B Deductible) ****¿ Generally 10%¿
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PLAN K

PARTS A & B

* This plan limits your annual out-of-pocket payments for Medicare-approved amounts 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.

** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

***** Medicare benefits are subject to change. For the current Medicare benefits, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

¿ 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.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOME HEALTH CARE MEDICARE-APPROVED SERVICES       Medically necessary skilled care services and       medical supplies       Durable medical equipment:              First portion of Medicare-approved amounts *****              Remainder of Medicare-approved amounts	100% $0 80%	$0 $0 10%	$0 (Part B Deductible)¿ 10%¿

PLAN L

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

* You will pay one-fourth of the cost sharing of some covered services until you reach the annual out-of-pocket limit each calendar year.

** 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 consecutive days.

*** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

**** 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.

¿ 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.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies:       First 60 days       61st thru 90th day       91st day and after:              While using 60 lifetime reserve days              Once lifetime reserve days are used:                    Additional 365 days                    Beyond the additional 365 days	All but *** All but *** a day All but *** a day $0 $0	(75% of Part A Deductible) *** a day *** a day 100% of Medicare Eligible Expenses $0	(25% of Part A Deductible)¿ $0 $0 $0**** All costs
SKILLED NURSING FACILITY CARE** You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but *** a day $0	$0 Up to 75% of *** a day (75% of Part A Coinsurance) $0	$0 Up to 25% of *** a day (25% of Part A Coinsurance) ¿ All costs
BLOOD       First 3 pints       Additional amounts	$0 100%	75% $0	25%¿ $0
HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness	All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care	75% of copayment/ coinsurance	25% of copayment/ coinsurance ¿

PLAN L

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

* This plan limits your annual out-of-pocket payments for Medicare-approved amounts 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.

** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

**** Once you have been billed a portion of Medicare-approved amounts for covered services equal to the Part B Deductible (which are noted with an asterisk), your Part B Deductible will have been met for the 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.

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 portion of Medicare-approved amounts ****       Preventive Benefits for Medicare-covered services       Remainder of Medicare-approved amounts	$0 Generally 80% or more of Medicare-approved amounts Generally 80%	$0 Remainder of Medicare-approved amounts Generally 15%	(Part B Deductible) ****¿ All costs above Medicare-approved amounts 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)*
BLOOD       First 3 pints       Next portion of Medicare-approved amounts ****       Remainder of Medicare-approved amounts	$0 $0 Generally 80%	75% $0 Generally 15%	25%¿ (Part B Deductible)¿ Generally 5%¿
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PLAN L

PARTS A & B

* This plan limits your annual out-of-pocket payments for Medicare-approved amounts 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.

** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

***** Medicare benefits are subject to change. For the current Medicare benefits, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

¿ 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.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY*
HOME HEALTH CARE MEDICARE-APPROVED SERVICES       Medically necessary skilled care services and       medical supplies       Durable medical equipment:              First portion of Medicare-approved amounts *****              Remainder of Medicare-approved amounts	100% $0 80%	$0 $0 15%	$0 (Part B Deductible)¿ 5%¿

PLAN M

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

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

** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

*** 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.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies:       First 60 days       61st thru 90th day       91st day and after:              While using 60 lifetime reserve days              Once lifetime reserve days are used:                    Additional 365 days                    Beyond the additional 365 days	All but ** All but ** a day All but ** a day $0 $0	(50% of Part A Deductible) ** a day ** a day 100% of Medicare Eligible Expenses $0	(50% of Part A Deductible) $0 $0 $0*** All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but ** a day $0	$0 Up to ** a day $0	$0 $0 All costs
BLOOD       First 3 pints       Additional amounts	$0 100%	3 pints $0	$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 a portion of Medicare-approved amounts (equal to the Part B Deductible) 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 portion of Medicare-approved amounts*       Remainder of Medicare-approved amounts	$0 Generally 80%	$0 Generally 20%	(Part B Deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD       First 3 pints       Next portion of Medicare-approved amounts*       Remainder of Medicare-approved amounts	$0 $0 80%	All costs $0 20%	$0 (Part B Deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PLAN M

PARTS A & B

* Once you have been billed a portion of Medicare-approved amounts (equal to the Part B Deductible) 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
HOME HEALTH CARE MEDICARE-APPROVED SERVICES       Medically necessary skilled care services and medical supplies       Durable medical equipment:              First portion of Medicare-approved amounts *              Remainder of Medicare-approved amounts	100% $0 80%	$0 $0 20%	$0 (Part B Deductible) $0

PLAN M

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 United States:       First $250 each calendar year       Remainder of charges	$0 $0	$0 80% to a lifetime maximum benefit of $50,000	$250 20% and amounts over the $50,000 lifetime maximum

PLAN N

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

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

** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

*** 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.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies:       First 60 days       61st thru 90th day       91st day and after:              While using 60 lifetime reserve days              Once lifetime reserve days are used:                    Additional 365 days                    Beyond the additional 365 days	All but ** All but ** a day All but ** a day $0 $0	(Part A Deductible) ** a day ** a day 100% of Medicare Eligible Expenses $0	$0 $0 $0 $0*** All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but ** a day $0	$0 Up to ** a day $0	$0 $0 All costs
BLOOD       First 3 pints       Additional amounts	$0 100%	3 pints $0	$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 a portion of Medicare-approved amounts (equal to the Part B Deductible) for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

** The amount that Medicare does not pay is subject to change. For the current amount that Medicare does not pay, please consult the most current version of the Guide to Health Insurance for People with Medicare, which must be provided by an issuer to an applicant pursuant to NAC 687B.240.

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 portion of Medicare-approved amounts*       Remainder of Medicare-approved amounts	$0 Generally 80%	$0 Balance, other than up to ** per office visit and up to ** per emergency room visit. The copayment of up to ** is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.	(Part B Deductible) Up to ** per office visit and up to ** per emergency room visit. The copayment of up to ** is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD       First 3 pints       Next portion of Medicare-approved amounts*       Remainder of Medicare-approved amounts	$0 $0 80%	All costs $0 20%	$0 (Part B Deductible) $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PLAN N

PARTS A & B

* Once you have been billed a portion of Medicare-approved amounts (equal to the Part B Deductible) 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
HOME HEALTH CARE MEDICARE-APPROVED SERVICES       Medically necessary skilled care services and medical supplies       Durable medical equipment:              First portion of Medicare-approved amounts*              Remainder of Medicare-approved amounts	100% $0 80%	$0 $0 20%	$0 (Part B Deductible) $0

PLAN N

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 United States:       First $250 each calendar year       Remainder of charges	$0 $0	$0 80% to a lifetime maximum benefit of $50,000	$250 20% and amounts over the $50,000 lifetime maximum

     (Added to NAC by Comm’r of Insurance, 2-21-89, eff. 3-15-89; A 5-27-92, 7-16-92, eff. 7-30-98; 8-2-94; R110-98, 2-23-99; R075-02, 9-20-2002; R027-04, 8-2-2004; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R066-07, 1-30-2008; R049-09, 10-27-2009; R087-10, 12-16-2010, eff. 6-2-2011)