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EVOC2017MI Effective: 02-13-2017 Page 1 of 18
EVEREST REINSURANCE COMPANY
Outline of Medicare Supplement Coverage Benefit Plans A, C, D, F, G, and N
Benefit Chart of Medicare Supplement Plans Sold for 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. 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 $5120 paid at 100% after limit reached
Out-of-pocket limit $2560 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 $2200 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2200. 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.
Rates Effective 02-13-2017 EVEREST REINSURANCE COMPANY One-Time Policy Fee $25
Plan C Plan C
65 1,692.37 2,093.32 1,616.91 2,114.37 1,635.45 1,404.83 65 1,878.54 2,323.60 1,794.77 2,346.95 1,815.34 1,559.3766 1,692.37 2,093.32 1,616.91 2,114.37 1,635.45 1,404.83 66 1,878.54 2,323.60 1,794.77 2,346.95 1,815.34 1,559.3767 1,692.37 2,093.32 1,616.91 2,114.37 1,635.45 1,404.83 67 1,878.54 2,323.60 1,794.77 2,346.95 1,815.34 1,559.3768 1,729.84 2,132.32 1,655.62 2,153.82 1,674.55 1,437.33 68 1,920.13 2,366.87 1,837.74 2,390.75 1,858.76 1,595.4369 1,799.26 2,214.44 1,727.86 2,236.81 1,747.55 1,497.63 69 1,997.17 2,458.03 1,917.92 2,482.85 1,939.78 1,662.3670 1,866.40 2,290.75 1,794.98 2,313.96 1,815.42 1,554.38 70 2,071.71 2,542.74 1,992.43 2,568.50 2,015.12 1,725.3571 1,922.26 2,364.78 1,860.11 2,388.73 1,881.20 1,611.36 71 2,133.70 2,624.91 2,064.72 2,651.50 2,088.13 1,788.6072 1,978.11 2,438.82 1,925.23 2,463.51 1,946.97 1,668.33 72 2,195.71 2,707.09 2,137.00 2,734.49 2,161.14 1,851.8573 2,033.97 2,512.85 1,990.36 2,538.27 2,012.75 1,725.31 73 2,257.71 2,789.26 2,209.30 2,817.49 2,234.14 1,915.0974 2,089.82 2,586.88 2,055.48 2,613.04 2,078.52 1,782.29 74 2,319.70 2,871.44 2,281.59 2,900.48 2,307.16 1,978.3475 2,147.46 2,663.13 2,122.37 2,690.05 2,146.08 1,840.80 75 2,383.69 2,956.07 2,355.84 2,985.96 2,382.15 2,043.2876 2,195.75 2,740.97 2,188.82 2,768.63 2,213.18 1,890.44 76 2,437.29 3,042.47 2,429.59 3,073.18 2,456.63 2,098.3877 2,244.76 2,820.00 2,256.31 2,848.42 2,281.33 1,941.42 77 2,491.68 3,130.20 2,504.50 3,161.74 2,532.28 2,154.9878 2,294.47 2,900.26 2,324.85 2,929.44 2,350.55 1,993.77 78 2,546.85 3,219.29 2,580.59 3,251.68 2,609.11 2,213.0979 2,346.83 2,984.21 2,396.44 3,014.19 2,422.84 2,047.54 79 2,604.99 3,312.49 2,660.05 3,345.75 2,689.35 2,272.7880 2,400.01 3,069.56 2,469.23 3,100.34 2,496.34 2,102.76 80 2,664.02 3,407.21 2,740.85 3,441.38 2,770.93 2,334.0781 2,446.88 3,158.51 2,544.97 3,189.95 2,572.66 2,159.48 81 2,716.04 3,505.94 2,824.91 3,540.83 2,855.64 2,397.0182 2,494.48 3,249.02 2,622.06 3,281.11 2,650.33 2,217.71 82 2,768.88 3,606.41 2,910.48 3,642.03 2,941.86 2,461.6683 2,542.83 3,341.12 2,700.52 3,373.89 2,729.39 2,277.52 83 2,822.55 3,708.64 2,997.58 3,745.02 3,029.62 2,528.0484 2,591.93 3,434.83 2,780.37 3,468.29 2,809.84 2,342.42 84 2,877.04 3,812.67 3,086.22 3,849.80 3,118.92 2,600.0885 2,641.79 3,530.19 2,861.64 3,564.34 2,891.72 2,409.15 85 2,932.39 3,918.51 3,176.43 3,956.41 3,209.81 2,674.1686 2,692.64 3,625.93 2,942.20 3,660.83 2,972.95 2,477.79 86 2,988.82 4,024.78 3,265.85 4,063.53 3,299.98 2,750.3587 2,744.40 3,723.74 3,024.55 3,759.43 3,055.98 2,548.39 87 3,046.29 4,133.36 3,357.24 4,172.97 3,392.13 2,828.7288 2,797.11 3,823.69 3,108.69 3,860.15 3,140.81 2,621.00 88 3,104.79 4,244.30 3,450.65 4,284.78 3,486.30 2,909.3189 2,848.45 3,922.56 3,192.06 3,959.80 3,224.86 2,695.68 89 3,161.79 4,354.04 3,543.19 4,395.38 3,579.60 2,992.2190 2,898.30 4,020.17 3,274.47 4,058.16 3,307.94 2,772.50 90 3,217.12 4,462.38 3,634.66 4,504.57 3,671.81 3,077.4791 2,932.61 4,100.36 3,342.17 4,138.79 3,376.03 2,834.33 91 3,255.20 4,551.39 3,709.82 4,594.06 3,747.39 3,146.1192 2,967.32 4,181.82 3,410.96 4,220.70 3,445.21 2,897.17 92 3,293.72 4,641.81 3,786.17 4,684.98 3,824.18 3,215.8593 3,002.43 4,264.56 3,480.84 4,303.89 3,515.49 2,961.04 93 3,332.70 4,733.65 3,863.74 4,777.32 3,902.20 3,286.7694 3,037.96 4,348.60 3,551.85 4,388.38 3,586.89 3,025.95 94 3,372.14 4,826.94 3,942.54 4,871.11 3,981.45 3,358.8095 3,073.91 4,433.96 3,623.97 4,474.21 3,659.43 3,091.92 95 3,412.04 4,921.70 4,022.60 4,966.38 4,061.96 3,432.0396 3,135.39 4,522.64 3,696.45 4,563.69 3,732.62 3,153.77 96 3,480.28 5,020.13 4,103.06 5,065.70 4,143.21 3,500.6797 3,198.09 4,613.09 3,770.38 4,654.97 3,807.27 3,216.84 97 3,549.88 5,120.53 4,185.12 5,167.02 4,226.07 3,570.7098 3,262.05 4,705.35 3,845.79 4,748.07 3,883.41 3,281.17 98 3,620.88 5,222.94 4,268.83 5,270.35 4,310.59 3,642.10
99+ 3,327.29 4,799.45 3,922.70 4,843.03 3,961.08 3,281.17 99+ 3,693.29 5,327.40 4,354.20 5,375.77 4,396.80 3,642.10
Modal Factors: Semi Annual: 0.50 Quarterly: 0.25 Monthly BSP: 0.08333Household Discount Factor: .93
Plan D Plan F Plan GPlan N Plan A
MICHIGAN Standard Plans MALE Rates - ANNUALFOR USE IN ZIP CODES: 480-485
Attained Age
Non-Tobacco Attained Age
Tobacco
Plan A Plan D Plan F Plan G Plan N
EVOC2017MI Rate Pg 1 of 6
Rates Effective 02-13-2017 EVEREST REINSURANCE COMPANY One-Time Policy Fee $25
Plan C Plan C
65 1,476.98 1,826.90 1,411.12 1,845.26 1,427.30 1,226.04 65 1,639.45 2,027.87 1,566.35 2,048.25 1,584.30 1,360.9166 1,476.98 1,826.90 1,411.12 1,845.26 1,427.30 1,226.04 66 1,639.45 2,027.87 1,566.35 2,048.25 1,584.30 1,360.9167 1,476.98 1,826.90 1,411.12 1,845.26 1,427.30 1,226.04 67 1,639.45 2,027.87 1,566.35 2,048.25 1,584.30 1,360.9168 1,509.68 1,860.93 1,444.91 1,879.70 1,461.43 1,254.39 68 1,675.75 2,065.63 1,603.84 2,086.47 1,622.19 1,392.3769 1,570.26 1,932.60 1,507.95 1,952.12 1,525.13 1,307.02 69 1,742.99 2,145.19 1,673.82 2,166.85 1,692.90 1,450.7970 1,628.86 1,999.20 1,566.53 2,019.46 1,584.36 1,356.55 70 1,808.04 2,219.12 1,738.85 2,241.60 1,758.65 1,505.7671 1,677.61 2,063.81 1,623.37 2,084.71 1,641.77 1,406.28 71 1,862.14 2,290.83 1,801.94 2,314.03 1,822.37 1,560.9672 1,726.35 2,128.43 1,680.20 2,149.97 1,699.17 1,455.99 72 1,916.26 2,362.55 1,865.02 2,386.46 1,886.08 1,616.1673 1,775.10 2,193.03 1,737.04 2,215.22 1,756.58 1,505.72 73 1,970.36 2,434.26 1,928.11 2,458.90 1,949.80 1,671.3574 1,823.85 2,257.64 1,793.88 2,280.47 1,813.98 1,555.45 74 2,024.47 2,505.98 1,991.20 2,531.33 2,013.52 1,726.5575 1,874.15 2,324.19 1,852.25 2,347.68 1,872.94 1,606.51 75 2,080.31 2,579.85 2,056.00 2,605.93 2,078.97 1,783.2376 1,916.29 2,392.12 1,910.25 2,416.26 1,931.50 1,649.84 76 2,127.09 2,655.24 2,120.37 2,682.05 2,143.97 1,831.3277 1,959.06 2,461.09 1,969.14 2,485.89 1,990.98 1,694.33 77 2,174.55 2,731.81 2,185.75 2,759.34 2,209.99 1,880.7178 2,002.44 2,531.14 2,028.96 2,556.60 2,051.39 1,740.02 78 2,222.71 2,809.56 2,252.15 2,837.83 2,277.04 1,931.4279 2,048.14 2,604.40 2,091.44 2,630.56 2,114.48 1,786.94 79 2,273.44 2,890.90 2,321.50 2,919.93 2,347.07 1,983.5180 2,094.56 2,678.89 2,154.96 2,705.75 2,178.62 1,835.14 80 2,324.97 2,973.56 2,392.01 3,003.39 2,418.27 2,037.0081 2,135.46 2,756.52 2,221.07 2,783.95 2,245.23 1,884.63 81 2,370.36 3,059.73 2,465.38 3,090.18 2,492.20 2,091.9482 2,177.00 2,835.50 2,288.34 2,863.52 2,313.01 1,935.46 82 2,416.47 3,147.41 2,540.05 3,178.50 2,567.44 2,148.3683 2,219.19 2,915.88 2,356.82 2,944.48 2,382.01 1,987.65 83 2,463.31 3,236.63 2,616.07 3,268.38 2,644.03 2,206.2984 2,262.05 2,997.67 2,426.51 3,026.87 2,452.22 2,044.29 84 2,510.87 3,327.42 2,693.42 3,359.83 2,721.96 2,269.1685 2,305.56 3,080.89 2,497.43 3,110.70 2,523.69 2,102.53 85 2,559.18 3,419.79 2,772.15 3,452.87 2,801.29 2,333.8186 2,349.94 3,164.45 2,567.74 3,194.91 2,594.57 2,162.44 86 2,608.43 3,512.53 2,850.19 3,546.36 2,879.98 2,400.3187 2,395.11 3,249.81 2,639.61 3,280.95 2,667.03 2,224.05 87 2,658.58 3,607.30 2,929.96 3,641.87 2,960.40 2,468.7088 2,441.12 3,337.04 2,713.04 3,368.86 2,741.07 2,287.42 88 2,709.64 3,704.11 3,011.47 3,739.44 3,042.59 2,539.0489 2,485.92 3,423.32 2,785.80 3,455.83 2,814.42 2,352.60 89 2,759.38 3,799.89 3,092.24 3,835.97 3,124.01 2,611.3890 2,529.43 3,508.51 2,857.72 3,541.67 2,886.93 2,419.63 90 2,807.66 3,894.44 3,172.07 3,931.26 3,204.49 2,685.7991 2,559.37 3,578.50 2,916.81 3,612.04 2,946.36 2,473.59 91 2,840.90 3,972.12 3,237.66 4,009.36 3,270.45 2,745.7092 2,589.66 3,649.58 2,976.84 3,683.52 3,006.73 2,528.44 92 2,874.52 4,051.04 3,304.29 4,088.71 3,337.47 2,806.5693 2,620.30 3,721.80 3,037.82 3,756.12 3,068.06 2,584.18 93 2,908.54 4,131.19 3,371.99 4,169.30 3,405.55 2,868.4494 2,651.31 3,795.14 3,099.79 3,829.86 3,130.38 2,640.83 94 2,942.96 4,212.60 3,440.76 4,251.15 3,474.72 2,931.3195 2,682.68 3,869.64 3,162.74 3,904.76 3,193.68 2,698.41 95 2,977.78 4,295.30 3,510.63 4,334.29 3,544.98 2,995.2396 2,736.34 3,947.03 3,225.99 3,982.86 3,257.56 2,752.38 96 3,037.33 4,381.20 3,580.85 4,420.97 3,615.89 3,055.1397 2,791.06 4,025.97 3,290.52 4,062.52 3,322.70 2,807.42 97 3,098.07 4,468.83 3,652.46 4,509.40 3,688.20 3,116.2598 2,846.88 4,106.49 3,356.32 4,143.77 3,389.16 2,863.56 98 3,160.04 4,558.20 3,725.52 4,599.58 3,761.97 3,178.56
99+ 2,903.82 4,188.61 3,423.45 4,226.64 3,456.94 2,863.56 99+ 3,223.24 4,649.37 3,800.03 4,691.58 3,837.21 3,178.56
Plan F Plan G Plan N
Modal Factors: Semi Annual: 0.50 Quarterly: 0.25 Monthly BSP: 0.08333Household Discount Factor: .93
Plan A Plan D Plan F Plan G Plan N Plan A Plan D
MICHIGAN Standard Plans MALE Rates - ANNUALFOR USE IN ZIP CODES: 486-489, 492
Attained Age
Attained Age Attained Age
Tobacco
EVOC2017MI Rate Pg 2 of 6
Rates Effective 02-13-2017 EVEREST REINSURANCE COMPANY One-Time Policy Fee $25
Plan C Plan C
65 1,353.90 1,674.66 1,293.53 1,691.49 1,308.36 1,123.87 65 1,502.83 1,858.88 1,435.82 1,877.56 1,452.27 1,247.5066 1,353.90 1,674.66 1,293.53 1,691.49 1,308.36 1,123.87 66 1,502.83 1,858.88 1,435.82 1,877.56 1,452.27 1,247.5067 1,353.90 1,674.66 1,293.53 1,691.49 1,308.36 1,123.87 67 1,502.83 1,858.88 1,435.82 1,877.56 1,452.27 1,247.5068 1,383.87 1,705.85 1,324.50 1,723.06 1,339.64 1,149.86 68 1,536.10 1,893.50 1,470.19 1,912.60 1,487.01 1,276.3469 1,439.41 1,771.55 1,382.29 1,789.44 1,398.04 1,198.10 69 1,597.74 1,966.42 1,534.33 1,986.28 1,551.83 1,329.8970 1,493.12 1,832.60 1,435.98 1,851.17 1,452.33 1,243.50 70 1,657.37 2,034.19 1,593.94 2,054.80 1,612.10 1,380.2871 1,537.81 1,891.82 1,488.09 1,910.98 1,504.96 1,289.09 71 1,706.96 2,099.93 1,651.78 2,121.20 1,670.50 1,430.8872 1,582.49 1,951.06 1,540.18 1,970.80 1,557.57 1,334.66 72 1,756.57 2,165.67 1,709.60 2,187.59 1,728.91 1,481.4873 1,627.17 2,010.28 1,592.29 2,030.62 1,610.20 1,380.24 73 1,806.16 2,231.41 1,767.44 2,253.99 1,787.32 1,532.0774 1,671.86 2,069.50 1,644.39 2,090.43 1,662.81 1,425.83 74 1,855.76 2,297.15 1,825.27 2,320.38 1,845.73 1,582.6775 1,717.97 2,130.51 1,697.90 2,152.04 1,716.86 1,472.64 75 1,906.95 2,364.86 1,884.67 2,388.77 1,905.72 1,634.6376 1,756.60 2,192.78 1,751.06 2,214.91 1,770.54 1,512.35 76 1,949.83 2,433.97 1,943.67 2,458.54 1,965.30 1,678.7177 1,795.81 2,256.00 1,805.05 2,278.73 1,825.07 1,553.14 77 1,993.34 2,504.16 2,003.60 2,529.39 2,025.82 1,723.9878 1,835.57 2,320.21 1,859.88 2,343.55 1,880.44 1,595.02 78 2,037.48 2,575.43 2,064.47 2,601.34 2,087.29 1,770.4779 1,877.46 2,387.37 1,917.15 2,411.35 1,938.27 1,638.03 79 2,083.99 2,649.99 2,128.04 2,676.60 2,151.48 1,818.2280 1,920.01 2,455.65 1,975.38 2,480.27 1,997.07 1,682.21 80 2,131.22 2,725.76 2,192.68 2,753.11 2,216.75 1,867.2581 1,957.51 2,526.81 2,035.98 2,551.96 2,058.13 1,727.58 81 2,172.83 2,804.75 2,259.93 2,832.67 2,284.52 1,917.6182 1,995.58 2,599.21 2,097.65 2,624.89 2,120.26 1,774.17 82 2,215.10 2,885.12 2,328.38 2,913.63 2,353.49 1,969.3383 2,034.26 2,672.89 2,160.42 2,699.11 2,183.51 1,822.01 83 2,258.04 2,966.91 2,398.06 2,996.01 2,423.70 2,022.4384 2,073.54 2,747.86 2,224.30 2,774.63 2,247.87 1,873.93 84 2,301.63 3,050.13 2,468.97 3,079.84 2,495.13 2,080.0685 2,113.43 2,824.15 2,289.31 2,851.47 2,313.38 1,927.32 85 2,345.91 3,134.81 2,541.14 3,165.13 2,567.85 2,139.3286 2,154.11 2,900.74 2,353.76 2,928.67 2,378.36 1,982.24 86 2,391.06 3,219.82 2,612.68 3,250.83 2,639.98 2,200.2887 2,195.52 2,978.99 2,419.64 3,007.54 2,444.78 2,038.71 87 2,437.03 3,306.69 2,685.80 3,338.38 2,713.70 2,262.9788 2,237.69 3,058.95 2,486.95 3,088.12 2,512.65 2,096.80 88 2,483.84 3,395.44 2,760.52 3,427.82 2,789.04 2,327.4589 2,278.76 3,138.04 2,553.65 3,167.84 2,579.89 2,156.55 89 2,529.43 3,483.23 2,834.55 3,516.30 2,863.68 2,393.7790 2,318.64 3,216.14 2,619.58 3,246.53 2,646.35 2,218.00 90 2,573.69 3,569.90 2,907.73 3,603.65 2,937.45 2,461.9891 2,346.09 3,280.29 2,673.74 3,311.04 2,700.83 2,267.46 91 2,604.16 3,641.11 2,967.85 3,675.25 2,997.91 2,516.8992 2,373.85 3,345.45 2,728.77 3,376.56 2,756.17 2,317.74 92 2,634.98 3,713.45 3,028.93 3,747.98 3,059.35 2,572.6893 2,401.94 3,411.65 2,784.67 3,443.11 2,812.39 2,368.83 93 2,666.16 3,786.92 3,090.99 3,821.86 3,121.76 2,629.4094 2,430.37 3,478.88 2,841.48 3,510.71 2,869.51 2,420.76 94 2,697.71 3,861.55 3,154.03 3,896.89 3,185.16 2,687.0495 2,459.12 3,547.17 2,899.18 3,579.36 2,927.54 2,473.54 95 2,729.63 3,937.36 3,218.08 3,973.10 3,249.57 2,745.6396 2,508.31 3,618.11 2,957.16 3,650.95 2,986.10 2,523.01 96 2,784.22 4,016.10 3,282.44 4,052.56 3,314.56 2,800.5497 2,558.47 3,690.47 3,016.31 3,723.98 3,045.81 2,573.47 97 2,839.90 4,096.43 3,348.09 4,133.62 3,380.85 2,856.5698 2,609.64 3,764.28 3,076.63 3,798.46 3,106.73 2,624.93 98 2,896.70 4,178.35 3,415.06 4,216.28 3,448.47 2,913.68
99+ 2,661.83 3,839.56 3,138.16 3,874.42 3,168.86 2,624.93 99+ 2,954.64 4,261.92 3,483.36 4,300.61 3,517.44 2,913.68
Plan D Plan F Plan G Plan N
Modal Factors: Semi Annual: 0.50 Quarterly: 0.25 Monthly BSP: 0.08333Household Discount Factor: .93
Non-Tobacco Attained AgePlan A Plan D Plan F Plan G Plan N Plan A
Tobacco
MICHIGAN Standard Plans MALE Rates - ANNUALFOR USE IN ZIP CODES: 490-491,493-499
Attained Age
EVOC2017MI Rate Pg 3 of 6
Rates Effective 02-13-2017 EVEREST REINSURANCE COMPANY One-Time Policy Fee $25
Plan C Plan C
65 1,484.54 1,836.25 1,418.34 1,854.71 1,434.60 1,232.31 65 1,647.83 2,038.23 1,574.36 2,058.73 1,592.40 1,367.8766 1,484.54 1,836.25 1,418.34 1,854.71 1,434.60 1,232.31 66 1,647.83 2,038.23 1,574.36 2,058.73 1,592.40 1,367.8767 1,484.54 1,836.25 1,418.34 1,854.71 1,434.60 1,232.31 67 1,647.83 2,038.23 1,574.36 2,058.73 1,592.40 1,367.8768 1,517.41 1,870.45 1,452.30 1,889.32 1,468.91 1,260.81 68 1,684.32 2,076.21 1,612.05 2,097.15 1,630.49 1,399.5069 1,578.29 1,942.49 1,515.66 1,962.11 1,532.94 1,313.71 69 1,751.90 2,156.17 1,682.38 2,177.95 1,701.57 1,458.2270 1,637.20 2,009.44 1,574.55 2,029.79 1,592.48 1,363.48 70 1,817.29 2,230.47 1,747.75 2,253.06 1,767.65 1,513.4771 1,686.19 2,074.37 1,631.67 2,095.38 1,650.18 1,413.47 71 1,871.67 2,302.55 1,811.16 2,325.87 1,831.69 1,568.9572 1,735.18 2,139.31 1,688.80 2,160.97 1,707.87 1,463.45 72 1,926.06 2,374.64 1,874.57 2,398.67 1,895.74 1,624.4373 1,784.18 2,204.26 1,745.93 2,226.55 1,765.57 1,513.42 73 1,980.44 2,446.72 1,937.98 2,471.48 1,959.78 1,679.9174 1,833.18 2,269.19 1,803.05 2,292.15 1,823.26 1,563.41 74 2,034.82 2,518.80 2,001.38 2,544.28 2,023.82 1,735.3875 1,883.74 2,336.08 1,861.73 2,359.70 1,882.53 1,614.73 75 2,090.96 2,593.05 2,066.52 2,619.27 2,089.60 1,792.3576 1,926.10 2,404.36 1,920.02 2,428.62 1,941.39 1,658.27 76 2,137.97 2,668.83 2,131.22 2,695.77 2,154.94 1,840.6977 1,969.08 2,473.69 1,979.22 2,498.62 2,001.18 1,703.00 77 2,185.68 2,745.80 2,196.93 2,773.46 2,221.30 1,890.3378 2,012.69 2,544.09 2,039.35 2,569.68 2,061.88 1,748.92 78 2,234.08 2,823.94 2,263.68 2,852.34 2,288.69 1,941.3179 2,058.63 2,617.74 2,102.14 2,644.03 2,125.30 1,796.09 79 2,285.07 2,905.68 2,333.38 2,934.87 2,359.08 1,993.6680 2,105.28 2,692.59 2,165.99 2,719.60 2,189.77 1,844.54 80 2,336.86 2,988.78 2,404.25 3,018.75 2,430.65 2,047.4381 2,146.39 2,770.61 2,232.43 2,798.19 2,256.72 1,894.28 81 2,382.49 3,075.38 2,477.99 3,105.99 2,504.95 2,102.6482 2,188.14 2,850.01 2,300.06 2,878.17 2,324.85 1,945.36 82 2,428.84 3,163.51 2,553.06 3,194.77 2,580.58 2,159.3683 2,230.55 2,930.81 2,368.87 2,959.55 2,394.19 1,997.82 83 2,475.91 3,253.20 2,629.45 3,285.11 2,657.56 2,217.5984 2,273.62 3,013.01 2,438.92 3,042.36 2,464.77 2,054.75 84 2,523.72 3,344.44 2,707.21 3,377.02 2,735.90 2,280.7785 2,317.36 3,096.65 2,510.21 3,126.61 2,536.60 2,113.29 85 2,572.27 3,437.29 2,786.33 3,470.53 2,815.63 2,345.7586 2,361.95 3,180.64 2,580.89 3,211.26 2,607.86 2,173.50 86 2,621.77 3,530.51 2,864.79 3,564.50 2,894.72 2,412.5987 2,407.37 3,266.45 2,653.11 3,297.75 2,680.68 2,235.43 87 2,672.18 3,625.75 2,944.95 3,660.49 2,975.56 2,481.3488 2,453.61 3,354.11 2,726.92 3,386.10 2,755.09 2,299.13 88 2,723.51 3,723.06 3,026.88 3,758.57 3,058.15 2,552.0389 2,498.64 3,440.84 2,800.05 3,473.51 2,828.83 2,364.64 89 2,773.50 3,819.33 3,108.05 3,855.60 3,139.99 2,624.7490 2,542.38 3,526.46 2,872.34 3,559.80 2,901.70 2,432.01 90 2,822.03 3,914.37 3,188.30 3,951.38 3,220.89 2,699.5391 2,572.46 3,596.80 2,931.73 3,630.53 2,961.43 2,486.25 91 2,855.44 3,992.45 3,254.22 4,029.88 3,287.19 2,759.7592 2,602.91 3,668.26 2,992.07 3,702.37 3,022.12 2,541.37 92 2,889.23 4,071.76 3,321.20 4,109.62 3,354.55 2,820.9393 2,633.71 3,740.84 3,053.37 3,775.34 3,083.76 2,597.40 93 2,923.42 4,152.32 3,389.24 4,190.63 3,422.98 2,883.1194 2,664.87 3,814.56 3,115.65 3,849.46 3,146.40 2,654.34 94 2,958.01 4,234.15 3,458.37 4,272.91 3,492.50 2,946.3295 2,696.41 3,889.44 3,178.92 3,924.75 3,210.02 2,712.22 95 2,993.01 4,317.27 3,528.60 4,356.47 3,563.13 3,010.5696 2,750.34 3,967.23 3,242.50 4,003.24 3,274.23 2,766.46 96 3,052.87 4,403.62 3,599.18 4,443.59 3,634.39 3,070.7797 2,805.34 4,046.57 3,307.35 4,083.31 3,339.71 2,821.79 97 3,113.94 4,491.70 3,671.16 4,532.47 3,707.08 3,132.1898 2,861.45 4,127.50 3,373.49 4,164.97 3,406.50 2,878.22 98 3,176.21 4,581.52 3,744.58 4,623.12 3,781.22 3,194.82
99+ 2,918.67 4,210.05 3,440.97 4,248.28 3,474.64 2,878.22 99+ 3,239.73 4,673.15 3,819.48 4,715.58 3,856.84 3,194.82
Modal Factors: Semi Annual: 0.50 Quarterly: 0.25 Monthly BSP: 0.08333Household Discount Factor: .93
Plan N Plan A Plan D Plan F Plan G
Attained Age
Non-Tobacco Attained Age
Tobacco
Plan A Plan D Plan F Plan G Plan N
MICHIGAN Standard Plans FEMALE Rates - ANNUALFOR USE IN ZIP CODES: 480-485
EVOC2017MI Rate Pg 4 of 6
Rates Effective 02-13-2017 EVEREST REINSURANCE COMPANY One-Time Policy Fee $25
Plan C Plan C
65 1,295.60 1,602.55 1,237.82 1,618.66 1,252.01 1,075.47 65 1,438.11 1,778.82 1,373.99 1,796.71 1,389.73 1,193.7866 1,295.60 1,602.55 1,237.82 1,618.66 1,252.01 1,075.47 66 1,438.11 1,778.82 1,373.99 1,796.71 1,389.73 1,193.7867 1,295.60 1,602.55 1,237.82 1,618.66 1,252.01 1,075.47 67 1,438.11 1,778.82 1,373.99 1,796.71 1,389.73 1,193.7868 1,324.28 1,632.39 1,267.46 1,648.86 1,281.96 1,100.34 68 1,469.95 1,811.96 1,406.88 1,830.24 1,422.97 1,221.3869 1,377.42 1,695.26 1,322.76 1,712.39 1,337.84 1,146.51 69 1,528.93 1,881.74 1,468.26 1,900.75 1,485.00 1,272.6270 1,428.83 1,753.69 1,374.15 1,771.45 1,389.80 1,189.95 70 1,586.00 1,946.59 1,525.31 1,966.31 1,542.67 1,320.8471 1,471.58 1,810.36 1,424.01 1,828.69 1,440.15 1,233.57 71 1,633.46 2,009.50 1,580.65 2,029.85 1,598.56 1,369.2772 1,514.34 1,867.04 1,473.86 1,885.94 1,490.51 1,277.19 72 1,680.92 2,072.41 1,635.98 2,093.39 1,654.46 1,417.6873 1,557.10 1,923.72 1,523.72 1,943.17 1,540.86 1,320.81 73 1,728.38 2,135.32 1,691.33 2,156.93 1,710.36 1,466.1074 1,599.87 1,980.38 1,573.57 2,000.42 1,591.21 1,364.43 74 1,775.85 2,198.23 1,746.66 2,220.46 1,766.25 1,514.5275 1,643.99 2,038.76 1,624.78 2,059.37 1,642.93 1,409.22 75 1,824.84 2,263.03 1,803.50 2,285.90 1,823.65 1,564.2376 1,680.96 2,098.35 1,675.65 2,119.53 1,694.30 1,447.22 76 1,865.87 2,329.16 1,859.97 2,352.67 1,880.68 1,606.4277 1,718.47 2,158.86 1,727.32 2,180.61 1,746.48 1,486.25 77 1,907.50 2,396.33 1,917.32 2,420.48 1,938.59 1,649.7478 1,756.53 2,220.30 1,779.79 2,242.63 1,799.46 1,526.33 78 1,949.74 2,464.53 1,975.57 2,489.32 1,997.40 1,694.2479 1,796.62 2,284.57 1,834.60 2,307.51 1,854.81 1,567.50 79 1,994.25 2,535.87 2,036.40 2,561.34 2,058.84 1,739.9280 1,837.33 2,349.90 1,890.32 2,373.47 1,911.07 1,609.78 80 2,039.44 2,608.39 2,098.25 2,634.55 2,121.29 1,786.8581 1,873.21 2,417.99 1,948.30 2,442.06 1,969.50 1,653.19 81 2,079.26 2,683.97 2,162.61 2,710.68 2,186.14 1,835.0382 1,909.65 2,487.28 2,007.32 2,511.86 2,028.96 1,697.77 82 2,119.72 2,760.88 2,228.12 2,788.17 2,252.14 1,884.5383 1,946.66 2,557.80 2,067.38 2,582.88 2,089.48 1,743.55 83 2,160.80 2,839.15 2,294.79 2,867.00 2,319.32 1,935.3584 1,984.25 2,629.54 2,128.51 2,655.15 2,151.07 1,793.23 84 2,202.52 2,918.78 2,362.66 2,947.22 2,387.69 1,990.4985 2,022.42 2,702.53 2,190.73 2,728.68 2,213.76 1,844.32 85 2,244.89 2,999.82 2,431.71 3,028.83 2,457.27 2,047.2086 2,061.34 2,775.83 2,252.41 2,802.56 2,275.95 1,896.87 86 2,288.09 3,081.17 2,500.18 3,110.83 2,526.30 2,105.5387 2,100.98 2,850.72 2,315.44 2,878.03 2,339.50 1,950.92 87 2,332.08 3,164.29 2,570.14 3,194.61 2,596.85 2,165.5388 2,141.33 2,927.22 2,379.86 2,955.14 2,404.44 2,006.52 88 2,376.88 3,249.22 2,641.64 3,280.20 2,668.93 2,227.2389 2,180.63 3,002.92 2,443.68 3,031.43 2,468.79 2,063.68 89 2,420.51 3,333.24 2,712.48 3,364.89 2,740.36 2,290.6890 2,218.80 3,077.64 2,506.77 3,106.73 2,532.39 2,122.48 90 2,462.86 3,416.18 2,782.51 3,448.47 2,810.96 2,355.9691 2,245.06 3,139.03 2,558.60 3,168.46 2,584.52 2,169.82 91 2,492.02 3,484.32 2,840.04 3,516.99 2,868.82 2,408.5192 2,271.63 3,201.39 2,611.26 3,231.16 2,637.48 2,217.93 92 2,521.51 3,553.54 2,898.50 3,586.58 2,927.61 2,461.9093 2,298.51 3,264.73 2,664.76 3,294.84 2,691.28 2,266.82 93 2,551.34 3,623.85 2,957.88 3,657.27 2,987.33 2,516.1794 2,325.71 3,329.07 2,719.11 3,359.53 2,745.95 2,316.52 94 2,581.54 3,695.26 3,018.21 3,729.08 3,048.00 2,571.3395 2,353.23 3,394.42 2,774.33 3,425.23 2,801.47 2,367.02 95 2,612.08 3,767.80 3,079.51 3,802.01 3,109.64 2,627.4096 2,400.30 3,462.31 2,829.82 3,493.74 2,857.51 2,414.36 96 2,664.33 3,843.16 3,141.10 3,878.04 3,171.83 2,679.9597 2,448.30 3,531.55 2,886.41 3,563.62 2,914.66 2,462.65 97 2,717.62 3,920.03 3,203.92 3,955.61 3,235.27 2,733.5498 2,497.27 3,602.18 2,944.14 3,634.89 2,972.95 2,511.90 98 2,771.96 3,998.42 3,267.99 4,034.73 3,299.97 2,788.20
99+ 2,547.21 3,674.23 3,003.02 3,707.59 3,032.41 2,511.90 99+ 2,827.40 4,078.39 3,333.36 4,115.41 3,365.97 2,788.20
Modal Factors: Semi Annual: 0.50 Quarterly: 0.25 Monthly BSP: 0.08333Household Discount Factor: .93
Plan A Plan D Plan F Plan G Plan N Plan A
Attained Age
Tobacco
Plan D Plan F Plan G Plan N
Attained Age
Attained Age
MICHIGAN Standard Plans FEMALE Rates - ANNUALFOR USE IN ZIP CODES: 486-489, 492
EVOC2017MI Rate Pg 5 of 6
Rates Effective 02-13-2017 EVEREST REINSURANCE COMPANY One-Time Policy Fee $25
Plan C Plan C
65 1,187.63 1,469.00 1,134.67 1,483.77 1,147.68 985.85 65 1,318.27 1,630.59 1,259.49 1,646.98 1,273.92 1,094.3066 1,187.63 1,469.00 1,134.67 1,483.77 1,147.68 985.85 66 1,318.27 1,630.59 1,259.49 1,646.98 1,273.92 1,094.3067 1,187.63 1,469.00 1,134.67 1,483.77 1,147.68 985.85 67 1,318.27 1,630.59 1,259.49 1,646.98 1,273.92 1,094.3068 1,213.92 1,496.36 1,161.84 1,511.45 1,175.13 1,008.65 68 1,347.46 1,660.96 1,289.64 1,677.72 1,304.39 1,119.6069 1,262.63 1,553.99 1,212.53 1,569.69 1,226.35 1,050.97 69 1,401.52 1,724.93 1,345.91 1,742.36 1,361.25 1,166.5770 1,309.76 1,607.55 1,259.64 1,623.83 1,273.98 1,090.79 70 1,453.83 1,784.38 1,398.20 1,802.45 1,414.12 1,210.7771 1,348.95 1,659.50 1,305.34 1,676.30 1,320.14 1,130.77 71 1,497.34 1,842.04 1,448.93 1,860.70 1,465.35 1,255.1672 1,388.15 1,711.45 1,351.04 1,728.78 1,366.30 1,170.76 72 1,540.84 1,899.71 1,499.65 1,918.94 1,516.59 1,299.5473 1,427.34 1,763.41 1,396.74 1,781.24 1,412.45 1,210.74 73 1,584.35 1,957.38 1,550.38 1,977.18 1,567.83 1,343.9374 1,466.55 1,815.35 1,442.44 1,833.72 1,458.61 1,250.73 74 1,627.86 2,015.04 1,601.11 2,035.42 1,619.06 1,388.3175 1,506.99 1,868.86 1,489.38 1,887.76 1,506.02 1,291.79 75 1,672.77 2,074.44 1,653.21 2,095.41 1,671.68 1,433.8876 1,540.88 1,923.49 1,536.01 1,942.90 1,553.11 1,326.62 76 1,710.38 2,135.06 1,704.97 2,156.62 1,723.96 1,472.5577 1,575.26 1,978.95 1,583.38 1,998.89 1,600.94 1,362.40 77 1,748.54 2,196.64 1,757.54 2,218.77 1,777.04 1,512.2678 1,610.15 2,035.27 1,631.48 2,055.74 1,649.51 1,399.14 78 1,787.26 2,259.15 1,810.94 2,281.88 1,830.95 1,553.0579 1,646.90 2,094.19 1,681.72 2,115.22 1,700.24 1,436.87 79 1,828.06 2,324.55 1,866.70 2,347.89 1,887.27 1,594.9380 1,684.22 2,154.07 1,732.79 2,175.68 1,751.82 1,475.63 80 1,869.49 2,391.02 1,923.40 2,415.00 1,944.52 1,637.9481 1,717.11 2,216.49 1,785.94 2,238.55 1,805.37 1,515.42 81 1,905.99 2,460.30 1,982.39 2,484.79 2,003.96 1,682.1182 1,750.51 2,280.01 1,840.04 2,302.54 1,859.88 1,556.29 82 1,943.08 2,530.81 2,042.44 2,555.82 2,064.46 1,727.4883 1,784.44 2,344.65 1,895.10 2,367.64 1,915.36 1,598.26 83 1,980.73 2,602.56 2,103.56 2,628.08 2,126.04 1,774.0784 1,818.90 2,410.41 1,951.14 2,433.89 1,971.82 1,643.80 84 2,018.98 2,675.55 2,165.77 2,701.62 2,188.72 1,824.6285 1,853.89 2,477.32 2,008.17 2,501.29 2,029.28 1,690.63 85 2,057.82 2,749.83 2,229.07 2,776.43 2,252.50 1,876.6086 1,889.56 2,544.51 2,064.71 2,569.01 2,086.29 1,738.80 86 2,097.42 2,824.40 2,291.83 2,851.60 2,315.77 1,930.0787 1,925.90 2,613.16 2,122.49 2,638.20 2,144.54 1,788.34 87 2,137.74 2,900.60 2,355.96 2,928.39 2,380.44 1,985.0788 1,962.88 2,683.29 2,181.54 2,708.88 2,204.07 1,839.31 88 2,178.81 2,978.45 2,421.50 3,006.85 2,446.52 2,041.6389 1,998.91 2,752.68 2,240.04 2,778.81 2,263.06 1,891.71 89 2,218.80 3,055.47 2,486.44 3,084.48 2,512.00 2,099.7990 2,033.90 2,821.17 2,297.87 2,847.84 2,321.36 1,945.61 90 2,257.62 3,131.50 2,550.64 3,161.10 2,576.71 2,159.6391 2,057.97 2,877.44 2,345.38 2,904.42 2,369.14 1,989.00 91 2,284.35 3,193.96 2,603.37 3,223.91 2,629.75 2,207.8092 2,082.33 2,934.61 2,393.65 2,961.90 2,417.69 2,033.10 92 2,311.38 3,257.41 2,656.96 3,287.70 2,683.64 2,256.7493 2,106.97 2,992.67 2,442.70 3,020.27 2,467.01 2,077.92 93 2,338.73 3,321.86 2,711.39 3,352.50 2,738.38 2,306.4994 2,131.90 3,051.65 2,492.52 3,079.57 2,517.12 2,123.48 94 2,366.41 3,387.32 2,766.69 3,418.32 2,794.00 2,357.0595 2,157.13 3,111.55 2,543.14 3,139.80 2,568.02 2,169.77 95 2,394.41 3,453.82 2,822.88 3,485.18 2,850.50 2,408.4596 2,200.27 3,173.78 2,594.00 3,202.59 2,619.38 2,213.16 96 2,442.30 3,522.90 2,879.34 3,554.87 2,907.51 2,456.6297 2,244.27 3,237.26 2,645.88 3,266.65 2,671.77 2,257.43 97 2,491.15 3,593.36 2,936.93 3,625.98 2,965.66 2,505.7598 2,289.16 3,302.00 2,698.79 3,331.98 2,725.20 2,302.57 98 2,540.96 3,665.22 2,995.66 3,698.50 3,024.97 2,555.85
99+ 2,334.94 3,368.04 2,752.77 3,398.62 2,779.71 2,302.57 99+ 2,591.78 3,738.52 3,055.58 3,772.46 3,085.47 2,555.85
Modal Factors: Semi Annual: 0.50 Quarterly: 0.25 Monthly BSP: 0.08333Household Discount Factor: .93
Plan A Plan D Plan F Plan G Plan N Plan A
Attained Age
Non-Tobacco Attained Age
Tobacco
Plan D Plan F Plan G Plan N
MICHIGAN Standard Plans FEMALE Rates - ANNUALFOR USE IN ZIP CODES: 490-491,493-499
EVOC2017MI Rate Pg 6 of 6
EVOC2017MI Effective: 02-13-2017 Page 2 of 18
PREMIUM INFORMATION Everest Reinsurance Company may change your premium on any premium due date if a new table of rates is applicable to the policy. The change in the table of rates will apply to all covered persons in the same class. Class is determined by attained age, gender, underwriting class, state, and zip code of your primary residence.
Premiums are based on your attained age and will change on your policy anniversary date.
DISCLOSURES Use this outline to compare benefits and premiums among policies.
READ YOUR POLICY VERY CAREFULLY 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 Everest Reinsurance Company.
RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to: Everest Reinsurance Company, Medicare Supplement Administration, P.O. Box 10879, Clearwater, Florida 33757-8879. 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 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 This policy may not fully cover all of your medical costs. Neither Everest Reinsurance Company nor its agents are 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 and You for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT 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. Everest Reinsurance Company may cancel your Policy and refuse to pay any claims if you leave out or falsify important medical information.
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
Please refer to your Policy for details.
EVOC2017MI Effective: 02-13-2017 Page 3 of 18
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 $1316 $0 $1316 (Part A deductible)
61st thru 90th day All but $329 a day $329 a day $0 91st day and after: — While using 60 lifetime
reserve days All but $658 a day $658 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 $164.50 a day $0 Up to $164.50 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
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 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.
EVOC2017MI Effective: 02-13-2017 Page 4 of 18
PLAN A 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.
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 $183 of Medicare Approved Amounts* $0 $0 $183 (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 $183 of Medicare Approved Amounts* $0 $0 $183 (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 $183 of Medicare Approved Amounts* $0 $0 $183 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0
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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 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 $1316 $1316 (Part A deductible) $0 61st thru 90th day All but $329 a day $329 a day $0 91st day and after: — While using 60 lifetime
reserve days All but $658 a day $658 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 $164.50 a day Up to $164.50 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 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 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.
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PLAN C 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.
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 $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 $0 All costs 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 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 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.
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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 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 $1316 $1316 (Part A deductible) $0 61st thru 90th day All but $329 a day $329 a day $0 91st day and after: — While using 60 lifetime
reserve days All but $658 a day $658 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 $164.50 a day Up to $164.50 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 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 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.
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PLAN D
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.
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 $183 of Medicare Approved Amounts* $0 $0 $183 (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 $183 of Medicare Approved Amounts* $0 $0 $183 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
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PLAN D 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 $183 of Medicare Approved Amounts* $0 $0 $183 (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.
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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 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 $1316 $1316 (Part A deductible) $0 61st thru 90th day All but $329 a day $329 a day $0 91st day and after: — While using 60 lifetime
reserve days All but $658 a day $658 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 $164.50 a day Up to $164.50 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 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 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.
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PLAN F
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.
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 $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
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PLAN F
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 $183 of Medicare Approved Amounts* $0 $183 (Part B deductible) $0 Remainder of Medicare Approved Amounts 80% 20% $0
OTHER SERVICES – 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
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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.
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1316 $1316 (Part A deductible) $0 61st thru 90th day All but $329 a day $329 a day $0 91st day and after: — While using 60 lifetime
reserve days All but $658 a day $658 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 $164.50 a day Up to $164.50 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 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 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.
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PLAN G
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.
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 $183 of Medicare Approved Amounts* $0 $0 $183 (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 $183 of Medicare Approved Amounts* $0 $0 $183 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
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PLAN G
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 $183 of Medicare Approved Amounts* $0 $0 $183 (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
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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 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 $1316 $1316 (Part A deductible) $0 61st thru 90th day All but $329 a day $329 a day $0 91st day and after: — While using 60 lifetime
reserve days All but $658 a day $658 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 $164.50 a day Up to $164.50 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 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 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.
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PLAN N
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.
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 $183of Medicare Approved Amounts*
$0 $0 $183 (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 co-payment 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 room visit. The co-payment 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.
PART B EXCESS CHARGES (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare Approved Amounts* $0 $0 $183 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
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PLAN N 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 $183 of Medicare Approved Amounts* $0 $0 $183 (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.