Outline of Medicare Supplement Coverage – Benefit Plans A, D, and F
Corporate Office – Omaha, NE Administrative Services – PO Box 10386 Des Moines, IA 50306 www.gomedico.com Toll-Free 1-800-228-6080
This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan "A" and
either Plan “C“or Plan ”F“. 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
$4800; paid
at 100% after
limit reached
Out-of-pocket
$2400; 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 $2110 deductible.
Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2110. 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.
MI9F-4363(KY)-C 01012013
MONTHLY PREMIUMS FOR MEDICARE SUPPLEMENT INSURANCE POLICY SERIES A20 – PLANS A, D AND F Zip Codes: 400, 401, 403, 404, 406, 407, 409, 410, 411, 412, 413, 414, 419, 420, 421, 422, 423, 424, 425, 426, 427
Female Male
Attained Age
Preferred Standard Preferred Standard
Plan A Plan D Plan F Plan A Plan D Plan F Plan A Plan D Plan F Plan A Plan D Plan F
Disabled
(under 65) $168.31 $169.92 $173.23 $193.46 $195.31 $199.12 $198.01 $195.42 $199.37 $227.60 $224.62 $229.16 65 84.15 113.28 123.74 96.73 130.20 142.23 99.00 130.28 142.41 113.80 149.75 163.69 66 84.15 113.28 123.74 96.73 130.20 142.23 99.00 130.28 142.41 113.80 149.75 163.69 67 84.15 113.28 123.74 96.73 130.20 142.23 99.00 130.28 142.41 113.80 149.75 163.69 68 87.81 118.71 129.19 100.94 136.45 148.49 103.31 136.46 148.68 118.75 156.85 170.90 69 91.42 124.13 134.63 105.08 142.68 154.74 107.55 142.63 154.93 123.62 163.94 178.08 70 94.95 129.51 140.03 109.14 148.86 160.96 111.71 148.74 161.13 128.40 170.97 185.21 71 98.51 135.25 145.82 113.23 155.46 167.61 115.37 154.22 166.66 132.60 177.26 191.56 72 101.97 140.90 151.52 117.21 161.95 174.16 119.04 159.73 172.21 136.83 183.60 197.95 73 105.24 146.35 157.03 120.96 168.22 180.49 122.75 165.32 177.84 141.09 190.03 204.41 74 108.21 151.53 162.26 124.38 174.17 186.50 126.51 171.03 183.57 145.42 196.58 211.00 75 110.80 156.32 167.12 127.35 179.68 192.09 130.35 176.89 189.43 149.83 203.32 217.74 76 112.93 160.68 171.55 129.81 184.69 197.18 134.25 182.91 195.44 154.31 210.24 224.65 77 114.70 164.70 175.63 131.84 189.31 201.87 138.11 188.96 201.47 158.75 217.20 231.58 78 116.22 168.48 179.48 133.59 193.65 206.30 141.80 194.89 207.37 162.99 224.01 238.36 79 117.60 172.15 183.21 135.17 197.87 210.59 145.19 200.53 212.99 166.89 230.49 244.81 80 118.97 175.83 186.95 136.74 202.10 214.88 148.16 205.71 218.17 170.30 236.45 250.77 81 120.41 179.62 190.77 138.40 206.46 219.27 150.62 210.34 222.81 173.12 241.77 256.10 82 121.92 183.48 194.66 140.13 210.90 223.75 152.65 214.49 226.99 175.46 246.54 260.90 83 123.46 187.39 198.57 141.91 215.39 228.25 154.39 218.30 230.83 177.46 250.92 265.33 84 125.00 191.28 202.47 143.68 219.86 232.73 155.97 221.89 234.47 179.27 255.05 269.51 85 126.51 195.10 206.31 145.42 224.25 237.14 157.52 225.41 238.04 181.06 259.09 273.60 86 127.96 198.82 210.04 147.08 228.53 241.43 159.13 228.94 241.61 182.91 263.16 277.71 87 129.31 202.39 213.64 148.63 232.64 245.56 160.77 232.45 245.15 184.79 267.18 281.78 88 130.54 205.80 217.06 150.04 236.55 249.49 162.34 235.83 248.56 186.59 271.07 285.71 89 131.61 209.00 220.28 151.28 240.23 253.20 163.76 239.01 251.77 188.23 274.73 289.39 90 132.50 211.96 223.27 152.30 243.64 256.63 164.95 241.90 254.68 189.60 278.05 292.74 91 133.19 214.68 226.00 153.09 246.76 259.77 165.86 244.44 257.24 190.65 280.97 295.68 92 133.71 217.19 228.52 153.69 249.64 262.67 166.52 246.68 259.50 191.40 283.54 298.27 93 134.09 219.54 230.88 154.13 252.34 265.38 166.99 248.69 261.53 191.94 285.85 300.60 94 134.40 221.78 233.14 154.48 254.92 267.98 167.33 250.55 263.40 192.34 287.99 302.76 95 & Over 134.66 223.97 235.34 154.78 257.44 270.51 167.62 252.33 265.20 192.66 290.04 304.83
*Premium rates shown above were approved for use in your state on April 18, 2012, and are effective August 1, 2012.
Premiums payable other than by the monthly bank withdrawal mode may be determined by the following factors (monthly direct bill is not available):
Monthly Quarterly Semi-Annual Annual Automatic Bank Withdrawal N/A 3 N/A N/A
Direct Billed N/A 3.24 6.24 12 Credit/Debit Card 1.091 3.24 6.24 12 Note: Due to rounding, premium amounts you calculate may differ by a few cents from the actual premium you will be charged.
MI9F-4363(KY)-C 2
MONTHLY PREMIUMS FOR MEDICARE SUPPLEMENT INSURANCE POLICY SERIES A20 – PLANS A, D AND F Zip Codes: 402, 405 and 408
Female Male
Attained Age
Preferred Standard Preferred Standard
Plan A Plan D Plan F Plan A Plan D Plan F Plan A Plan D Plan F Plan A Plan D Plan F
Disabled
(under 65) $177.05 $178.74 $182.23 $203.51 $205.45 $209.46 $208.30 $205.57 $209.73 $239.42 $236.29 $241.07 65 88.52 119.16 130.16 101.75 136.97 149.61 104.15 137.05 149.80 119.71 157.53 172.19 66 88.52 119.16 130.16 101.75 136.97 149.61 104.15 137.05 149.80 119.71 157.53 172.19 67 88.52 119.16 130.16 101.75 136.97 149.61 104.15 137.05 149.80 119.71 157.53 172.19 68 92.38 124.87 135.90 106.18 143.53 156.20 108.68 143.55 156.40 124.92 165.00 179.77 69 96.17 130.58 141.62 110.54 150.09 162.78 113.14 150.03 162.98 130.05 172.46 187.33 70 99.88 136.24 147.31 114.81 156.60 169.32 117.51 156.47 169.51 135.07 179.85 194.83 71 103.63 142.28 153.40 119.11 163.54 176.32 121.36 162.23 175.31 139.49 186.47 201.51 72 107.27 148.22 159.39 123.30 170.36 183.20 125.22 168.03 181.16 143.94 193.14 208.23 73 110.70 153.95 165.18 127.24 176.96 189.87 129.13 173.91 187.08 148.42 199.90 215.03 74 113.83 159.40 170.69 130.84 183.22 196.19 133.09 179.91 193.10 152.97 206.80 221.96 75 116.55 164.44 175.80 133.97 189.02 202.07 137.12 186.08 199.27 157.61 213.88 229.05 76 118.80 169.03 180.46 136.55 194.29 207.42 141.22 192.41 205.59 162.33 221.16 236.32 77 120.66 173.25 184.75 138.69 199.14 212.36 145.28 198.78 211.94 166.99 228.48 243.61 78 122.26 177.23 188.80 140.53 203.71 217.02 149.17 205.01 218.14 171.46 235.65 250.74 79 123.71 181.09 192.73 142.20 208.15 221.53 152.74 210.94 224.05 175.56 242.46 257.53 80 125.15 184.96 196.66 143.85 212.60 226.04 155.86 216.40 229.50 179.15 248.74 263.79 81 126.66 188.95 200.68 145.59 217.18 230.66 158.44 221.27 234.38 182.12 254.33 269.40 82 128.25 193.02 204.77 147.41 221.86 235.37 160.58 225.63 238.78 184.57 259.35 274.46 83 129.87 197.12 208.89 149.28 226.58 240.11 162.41 229.64 242.82 186.68 263.95 279.11 84 131.49 201.21 212.99 151.14 231.28 244.82 164.07 233.42 246.65 188.59 268.30 283.51 85 133.08 205.24 217.03 152.97 235.90 249.46 165.70 237.12 250.40 190.46 272.55 287.82 86 134.61 209.15 220.95 154.72 240.40 253.97 167.40 240.84 254.16 192.41 276.83 292.14 87 136.03 212.91 224.73 156.35 244.72 258.32 169.12 244.52 257.88 194.39 281.06 296.42 88 137.32 216.49 228.34 157.84 248.84 262.45 170.77 248.08 261.48 196.29 285.15 300.55 89 138.45 219.85 231.72 159.14 252.71 266.35 172.27 251.43 264.85 198.01 289.00 304.42 90 139.38 222.97 234.86 160.21 256.29 269.96 173.52 254.47 267.91 199.45 292.49 307.95 91 140.11 225.83 237.74 161.04 259.58 273.27 174.48 257.14 270.60 200.55 295.56 311.04 92 140.65 228.47 240.39 161.67 262.61 276.32 175.17 259.49 272.98 201.34 298.27 313.77 93 141.06 230.94 242.88 162.14 265.45 279.17 175.66 261.61 275.11 201.91 300.70 316.22 94 141.38 233.30 245.25 162.51 268.17 281.90 176.03 263.56 277.08 202.33 302.95 318.49 95 & Over 141.65 235.61 247.57 162.82 270.81 284.56 176.32 265.44 278.98 202.67 305.10 320.66
*Premium rates shown above were approved for use in your state on April 18, 2012, and are effective August 1, 2012.
Premiums payable other than by the monthly bank withdrawal mode may be determined by the following factors (monthly direct bill is not available):
Monthly Quarterly Semi-Annual Annual Automatic Bank Withdrawal N/A 3 N/A N/A
Direct Billed N/A 3.24 6.24 12 Credit/Debit Card 1.091 3.24 6.24 12 Note: Due to rounding, premium amounts you calculate may differ by a few cents from the actual premium you will be charged.
MI9F-4363(KY)-C 3
MONTHLY PREMIUMS FOR MEDICARE SUPPLEMENT INSURANCE POLICY SERIES A20 – PLANS A, D AND F Zip Codes: 415, 416, 417 and 418
Female Male
Attained Age
Preferred Standard Preferred Standard
Plan A Plan D Plan F Plan A Plan D Plan F Plan A Plan D Plan F Plan A Plan D Plan F
Disabled
(under 65) $209.84 $211.84 $215.98 $241.20 $243.50 $248.25 $246.87 $243.65 $248.57 $283.76 $280.05 $285.71 65 104.92 141.23 154.27 120.60 162.33 177.32 123.43 162.43 177.55 141.88 186.70 204.08 66 104.92 141.23 154.27 120.60 162.33 177.32 123.43 162.43 177.55 141.88 186.70 204.08 67 104.92 141.23 154.27 120.60 162.33 177.32 123.43 162.43 177.55 141.88 186.70 204.08 68 109.48 148.00 161.07 125.84 170.12 185.13 128.80 170.14 185.37 148.05 195.56 213.07 69 113.98 154.76 167.85 131.01 177.88 192.93 134.09 177.82 193.16 154.13 204.39 222.03 70 118.38 161.47 174.59 136.07 185.60 200.68 139.27 185.44 200.90 160.09 213.15 230.92 71 122.82 168.63 181.80 141.17 193.82 208.97 143.83 192.27 207.78 165.33 221.00 238.83 72 127.13 175.66 188.90 146.13 201.91 217.13 148.41 199.15 214.71 170.59 228.90 246.79 73 131.20 182.47 195.77 150.81 209.73 225.03 153.04 206.12 221.72 175.91 236.92 254.85 74 134.91 188.92 202.29 155.07 217.15 232.52 157.73 213.23 228.86 181.30 245.09 263.06 75 138.14 194.90 208.35 158.78 224.02 239.49 162.52 220.54 236.18 186.80 253.49 271.47 76 140.80 200.33 213.88 161.84 230.27 245.84 167.38 228.05 243.67 192.39 262.12 280.08 77 143.01 205.34 218.97 164.38 236.02 251.69 172.19 235.59 251.19 197.92 270.80 288.72 78 144.90 210.05 223.77 166.55 241.44 257.21 176.79 242.98 258.54 203.21 279.29 297.17 79 146.62 214.63 228.42 168.53 246.70 262.56 181.02 250.01 265.54 208.07 287.37 305.22 80 148.32 219.22 233.08 170.49 251.98 267.91 184.72 256.48 272.00 212.32 294.80 312.65 81 150.12 223.94 237.84 172.55 257.40 273.38 187.78 262.24 277.79 215.84 301.43 319.29 82 152.00 228.76 242.69 174.71 262.95 278.96 190.32 267.42 283.00 218.76 307.38 325.28 83 153.92 233.63 247.57 176.92 268.54 284.57 192.49 272.16 287.79 221.25 312.83 330.80 84 155.85 238.47 252.44 179.13 274.11 290.16 194.45 276.65 292.33 223.51 317.99 336.01 85 157.73 243.24 257.22 181.30 279.59 295.66 196.39 281.03 296.77 225.73 323.03 341.12 86 159.53 247.88 261.87 183.37 284.92 301.00 198.40 285.44 301.23 228.05 328.09 346.24 87 161.22 252.34 266.35 185.31 290.04 306.15 200.44 289.81 305.64 230.39 333.11 351.31 88 162.75 256.58 270.62 187.07 294.92 311.06 202.39 294.02 309.90 232.64 337.96 356.21 89 164.09 260.57 274.64 188.61 299.51 315.67 204.17 297.99 313.90 234.68 342.52 360.80 90 165.20 264.27 278.36 189.88 303.76 319.95 205.66 301.59 317.53 236.39 346.66 364.97 91 166.05 267.66 281.77 190.87 307.65 323.87 206.79 304.76 320.72 237.69 350.30 368.64 92 166.70 270.78 284.91 191.61 311.24 327.49 207.61 307.55 323.53 238.63 353.50 371.87 93 167.18 273.71 287.86 192.17 314.61 330.87 208.19 310.05 326.06 239.31 356.38 374.78 94 167.56 276.51 290.67 192.60 317.83 334.10 208.63 312.37 328.40 239.80 359.05 377.47 95 & Over 167.89 279.24 293.41 192.97 320.97 337.26 208.98 314.60 330.64 240.21 361.61 380.05
*Premium rates shown above were approved for use in your state on April 18, 2012, and are effective August 1, 2012.
Premiums payable other than by the monthly bank withdrawal mode may be determined by the following factors (monthly direct bill is not available):
Monthly Quarterly Semi-Annual Annual Automatic Bank Withdrawal N/A 3 N/A N/A
Direct Billed N/A 3.24 6.24 12 Credit/Debit Card 1.091 3.24 6.24 12 Note: Due to rounding, premium amounts you calculate may differ by a few cents from the actual premium you will be charged.
MI9F-4363(KY)-C 4
Premium Information
We, Medico Insurance Company, can only raise your premium if we raise the premium for all
policies like yours in this state. The premiums change automatically on the policy renewal
date that follows the date you turn a new age.
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 your insurance company.
Right To Return Policy
If you find that you are not satisfied with your policy, you may return it to PO Box 10386, Des
Moines, IA 50306. 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 Medico Insurance Company nor its producers 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. The 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.
MI9F-4363(KY)-C 5
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 $1,184 $0 $1,184 (Part A
Deductible)
61st thru 90th day All but $296 a day $296 a day $0
91st day and after:
-While using 60 lifetime reserve days
-Once lifetime reserve days are used:
-Additional lifetime maximum of 365
days
-Beyond the additional 365 days
All but $592 a day
$0
$0
$592 a day
100% of Medicare
eligible expense
$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 All approved
amounts
$0 $0
21st thru 100th day All but $148 a day $0 Up to $148 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
copayment and
coinsurance for
outpatient drugs
and inpatient respite
care
Medicare
copayment and
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.
MI9F-4363(KY)-C 6
Plan A
Medicare (Part B) - Medical Services - Per Calendar Year
*Once you have been billed $147 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 $147 of Medicare-Approved
Amounts*
$0 $0 $147 (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 $147 of Medicare-Approved
Amounts*
$0 $0 $147 (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 $147 of Medicare-Approved
Amounts*
$0 $0 $147 (Part B
Deductible)
-Remainder of Medicare-Approved
Amounts
80% 20% $0
MI9F-4363(KY)-C 7
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 $1,184 $1,184 (Part A
Deductible)
$0
61st thru 90th day All but $296 a day $296 a day $0
91st day and after:
-While using 60 lifetime reserve days
-Once lifetime reserve days are used:
-Additional lifetime maximum of 365
days
-Beyond the additional 365 days
All but $592 a day
$0
$0
$592 a day
100% of Medicare
eligible expense
$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 All approved
amounts
$0 $0
21st thru 100th day All but $148 a day Up to $148 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 and
coinsurance for
outpatient drugs
and inpatient respite
care
Medicare
copayment and
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.
MI9F-4363(KY)-C 8
Plan D
Medicare (Part B) - Medical Services - Per Calendar Year
*Once you have been billed $147 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 $147of Medicare-Approved
Amounts*
$0 $0 $147 (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 $147 of Medicare-Approved
Amounts*
$0 $0 $147 (Part B
Deductible)
Remainder of Medicare-Approved
Amounts
80% 20% $0
Clinical Laboratory Services – Tests For
Diagnostic Services 100% $0 $0
MI9F-4363(KY)-C 9
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 $147 of Medicare-Approved
Amounts*
$0 $0 $147 (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
MI9F-4363(KY)-C 10
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 $1,184 $1,184 (Part A
Deductible)
$0
61st thru 90th day All but $296 a day $296 a day $0
91st day and after:
-While using 60 lifetime reserve days
-Once lifetime reserve days are used:
-Additional lifetime maximum of 365
days
-Beyond the additional 365 days
All but $592 a day
$0
$0
$592 a day
100% of Medicare
eligible expense
$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 All approved
amounts
$0 $0
21st thru 100th day All but $148 a day Up to $148 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 and
coinsurance for
outpatient drugs
and inpatient respite
care
Medicare
copayment and
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.
MI9F-4363(KY)-C 11
Plan F
Medicare (Part B) - Medical Services - Per Calendar Year
*Once you have been billed $147 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 $147 of Medicare-Approved
Amounts*
$0 $147 (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 $147 of Medicare-Approved
Amounts*
$0 $147 (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 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 $147 of Medicare-Approved
Amounts*
$0 $147 (Part B
Deductible)
$0
-Remainder of Medicare-Approved
Amounts
80% 20% $0
MI9F-4363(KY)-C 12
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
Printed Name of Producer, if any:
First Middle Initial Last
Address:
Street Address, Rural Route or Box Number
City State Zip
Phone Number Date Producer/Home Office Employee Signature
MI9F-4363(KY)-C 13
