Medicare Supplement Plan I

Choose a letter to see the plan summary.

Plan I 2010
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.

Service:

HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies:

MEDICARE PAYS

PLAN PAYS

YOU PAY

First 60 days

All but $1,100

$1,100 (Part A Deductible)

61st through 90th day

All but $275 a day

$275 a day

91st day and after:

While using 60 lifetime reserve days

All but $550 a day

$550 a day

Once lifetime reserve days are used:

Additional 365 days

100% of Medicare Eligible Expenses

$0**

Beyond the Additional 365 days

All costs

Service:

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

21st through 100th day

All but $137.50 a day

Up to $137.50 a day

101st day and after

All costs

Service:

BLOOD

First 3 pints

3 pints

Additional amounts

100%

Service:

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

Balance

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

Plan I 2010
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR*

* Once you have been billed $155 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Medicare Part B Deductible will have been met for the calendar year.

Service:

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:

MEDICARE PAYS

PLAN PAYS

YOU PAY

First $155 of Medicare Approved Amounts*

$155 (Part B Deductible)

Remainder of Medicare Approved Amounts

Generally 80%

Generally 20%

Part B Excess Charges (Above Medicare Approved Amounts)

100%

Service:

BLOOD

First 3 pints

All costs

Next $155 of Medicare Approved Amounts*

$155 (Part B Deductible)

Remainder of Medicare Approved Amounts

80%

20%

Service:

CLINICAL LABORATORY SERVICES

Tests for Diagnostic Services

100%

PARTS A & B

Service:

HOME HEALTH CARE
Medicare Approved Services:

MEDICARE PAYS

PLAN PAYS

YOU PAY

Medically necessary skilled care services and medical supplies

100%

Durable medical equipment:

First $155 of Medicare Approved Amounts*

$155 (Part B Deductible)

Remainder of Medicare Approved Amounts

80%

20%

Service:

AT HOME RECOVERY SERVICES
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

Actual charges up to $40 per visit

Balance

Number of visits covered (must be received within 8 weeks of last Medicare approved visit)

Up to the number of Medicare approved visits, not to exceed 7 each week

Balance

Calendar year maximum

$1,600

Balance

OTHER BENEFITS - NOT COVERED BY MEDICARE

Service:

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

$250

Remainder of charges

80% to a lifetime maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum