Standardized Plan Description

12 Standard Medicare Supplement Benefit Plans
CORE BENEFITS PLAN A PLAN B PLAN C PLAN D PLAN E PLAN F PLAN G PLAN H PLAN I PLAN J PLAN K PLAN L
Part A Hospital
Days 61-90		 X X X X X X X X X X X X
Lifetime Reserve
Days 91-150		 X X X X X X X X X X X X
365 Life Hospital
Days 100%		 X X X X X X X X X X X X
Parts A and B Blood X X X X X X X X X X 50% 75%
Part B Coinsurance 20% X X X X X X X X X X 50% 75%
ADDED BENEFITS PLAN A PLAN B PLAN C PLAN D PLAN E PLAN F PLAN G PLAN H PLAN I PLAN J PLAN K PLAN L
Skilled Nursing Facility Coinsurance
Days 21-100		 X X X X X X X X 50% 75%
Deductibles Part A X X X X X X X X X 50% 75%
Deductibles Part B X X X
Excess Charges Part B 100% 80% 100% 100%
Foreign Travel Emergency X X X X X X X X
Recovery At Home X X X X
Preventative Medical Care X X X X
Hospice Cost-sharing Part A 50% 75%
Out-of-pocket Annual Limit $4000 $2000

** Plans K and L provide for different cost-sharing for items and services than Plans A - J.
Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance, and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called "Excess Charges". You will be responsible for paying excess charges.

The out-of-pocket annual limit will increase each year for inflation.

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