Medicare Supplement plans sold with effective dates for coverage on or after January 1, 2020

Outline of Coverage High Deductible 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 days in a row.

​**This high deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,340 deductible.  Benefits from the high deductible plan G will not begin until out-of-pocket expenses are $2,340.  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.

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Services	Medicare Pays	After You Pay $2,340 Deductible,  Plan Pays	After You Pay ​$2,340 Deductible, Plan Pays
HOSPITALIZATION* Semi-private room and board, general nursing & miscellaneous services and supplies ​ First 60 days 61st thru 90th day 91st day & after: -while using 60 lifetime reserve days Once lifetime reserve days are used:                                                               - additional 365 days ​ - beyond the additional 365 days	​ ​All but $1,408 All but $352 a day ​ All but $704 a day $0                           $0	​​$1,408 (Part A deductible) $352 a day ​ $704 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 $176 a day $0	​$0 Up to $176 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 co-payment/coinsurance for outpatient drugs and inpatient respite care	​Medicare               co-payment/coinsurance	$0

**Notice:  When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as   provided by 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.
 

Medicare (Part B) - Medical Services - Per Calendar Year

* Once you have been billed $198 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 $2,340 Deductible, Plan Pays	After You Pay $2,340 Deductible, Plan Pays
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 $198 of Medicare-approved amounts*   Remainder of Medicare-approved amounts ​	​ ​$0                           Generally 80%	​ ​$0 ​Generally 20%	​ ​$198 (Unless Part B deductible has not been met)                          $0
Part B Excess Charges  (above Medicare-approved amounts)	$0	​100%	$0
BLOOD First 3 pints ​ Next $198 of Medicare-approved amounts* Remainder of Medicare-approved amounts	​$0 $0 ​ ​80%	​All costs $0 ​ ​20%	​$0 $198 (Unless Part B deductible has not been met) ​  ​ ​$0
CLINICAL LABORATORY            SERVICES - TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

Parts A & B

Services	Medicare Pays	After You Pay $2,340 Deductible, ​Plan Pays	After You Pay $2,340 Deductible, Plan Pays
​HOME HEALTH CARE MEDICARE-APPROVED SERVICES ​ Medically necessary skilled care services and medical supplies Durable medical equipment                                 - First $198 of Medicare-approved amounts*                                                       - Remainder of Medicare-approved amounts	​ ​100% $0 ​ ​80%	​ ​​$0 $0 ​ ​20%	​ ​$0 $198 (Unless Part B deductible has been met) ​ ​$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                                                    - 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

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