TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2008 MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE
SECTION 2008.APPENDIX EE PLAN F OR HIGH DEDUCTIBLE PLAN F (FOR PLANS ISSUED ON OR AFTER JUNE 1, 2010)



 

Section 2008.APPENDIX EE   Plan F or High Deductible Plan F (for plans issued on or after June 1, 2010)

 

Section 2008.APPENDIX EE   Plan F or High Deductible Plan F (for plans issued on or after June 1, 2010)

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

 

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

 

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

 

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

 

SERVICES

MEDICARE PAYS

[AFTER YOU PAY [$___] DEDUCTIBLE**] PLAN PAYS

[IN ADDITION TO [$___] DEDUCTIBLE**] YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

 

 

 

First 60 days

All but [$_______]

[$________] (Part A Deductible)

$0

61st thru 90th day

All but [$_______] a day

[$________] a day

$0

91st day and after:

 

 

 

− While using 60 lifetime reserve days

All but [$_______] a day

[$________] a day

$0

− Once lifetime reserve days are used:

 

 

 

− Additional 365 days

$0

100% of Medicare Eligible Expenses

$0***

− Beyond the Additional 365 days

$0

$0

All costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

 

 

 

First 20 days

All approved amounts

$0

$0

21st thru 100th day

All but [$________] a day

Up to [$________] a day

$0

101st day and after

$0

$0

All costs

BLOOD

 

 

 

First 3 pints

$0

3 pints

$0

Additional amounts

100%

$0

$0

HOSPICE CARE

 

 

 

You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited copayment/coinsurance for out-patient drugs and in-patient respite care

Medicare copayment/coinsurance

$0

 

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

 

(Plan F or High Deductible Plan F Continued)

 

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

 

*     Once you have been billed $[183] of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.

 

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

 

SERVICES

MEDICARE PAYS

[AFTER YOU PAY [$____] DEDUCTIBLE**] PLAN PAYS

[IN ADDITION TO [$___] DEDUCTIBLE**] YOU PAY

MEDICAL EXPENSESIN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment.

 

 

 

First $[183] of Medicare Approved Amounts*

$0

$[183] (Part B Deductible)

$0

Remainder of Medicare Approved Amounts

generally 80%

generally 20%

$0

Part B Excess Charges

(Above Medicare Approved Amounts)

$0

100%

$0

BLOOD

 

 

 

First 3 pints

$0

All costs

$0

Next $[183] of Medicare Approved Amounts*

$0

$[183] (Part B Deductible)

$0

Remainder of Medicare Approved Amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES

 

 

 

TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

 

PARTS A & B

 

SERVICES

MEDICARE PAYS

[AFTER YOU PAY [$____] DEDUCTIBLE**] PLAN PAYS

[IN ADDITION TO [$___] DEDUCTIBLE**] YOU PAY

HOME HEALTH CARE

 

 

 

MEDICARE APPROVED SERVICES

 

 

 

− Medically necessary skilled care services and medical supplies

100%

$0

$0

− Durable medical equipment

 

 

 

First $[183] of Medicare Approved Amounts*

$0

$[183] (Part B Deductible)

$0

Remainder of Medicare Approved Amounts

80%

20%

$0

 

OTHER BENEFITS – Not Covered By Medicare

 

SERVICES

MEDICARE PAYS

[AFTER YOU PAY THE [$_____] DEDUCTIBLE**] PLAN PAYS

[IN ADDITION TO THE [$_____] DEDUCTIBLE**]  YOU PAY

FOREIGN TRAVEL − NOT COVERED BY MEDICARE

 

 

 

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

 

 

 

First $250 each calendar year

$0

$0

$250

Remainder of Charges

$0

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

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

 

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