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O u t l i n e O f C O v e r a g e
M E D I C A R E S U P P L E M E N T I N S U R A N C E
Underwritten by Genworth Life and Annuity Insurance Company
101 Continental PlaceBrentwood, Tennessee 37027
800 264.4000cont-life.com
GLA
MS
0367V
T
01012012
GE
NW
OR
TH
LIF
E A
ND
AN
NU
ITY
IN
SU
RA
NC
E C
OM
PA
NY
OU
TL
INE
OF
ME
DIC
AR
E S
UP
PL
EM
EN
T C
OV
ER
AG
E C
OV
ER
PA
GE
: P
ag
e 1
of
2
BE
NE
FIT
PL
AN
S A
VA
ILA
BL
E:
A,
B,
C,
D,
N
Th
ese
ch
art
s s
how
th
e b
en
efits
in
clu
de
d in
ea
ch
of
the s
tand
ard
Me
dic
are
su
pp
lem
en
t p
lans.
Eve
ry c
om
pa
ny m
ust
ma
ke
ava
ilable
Pla
n “
A”.
S
om
e p
lans m
ay n
ot
be a
va
ilable
in y
our
sta
te.
Se
e O
utl
ines
of
Co
ve
rag
e s
ec
tio
ns
fo
r d
eta
ils
ab
ou
t A
LL
Pla
ns
Ba
sic
Ben
efi
ts:
H
ospita
liza
tion
: P
art
A c
oin
sura
nce
plu
s c
ove
rag
e f
or
36
5 a
dd
itio
na
l d
ays a
fte
r M
edic
are
ben
efits
end
.
Me
dic
al E
xp
en
ses:
Pa
rt B
co
insura
nce
(g
ene
rally
20%
of
Me
dic
are
-Ap
pro
ve
d e
xp
en
ses)
or,
co
-paym
ents
fo
r h
osp
ita
l o
utp
atie
nt
se
rvic
es.
Pla
ns K
, L
, a
nd
N r
eq
uire
insu
red
s t
o p
ay a
po
rtio
n o
f co
insura
nce
or
co
pa
ym
ents
B
lood
: F
irst
thre
e p
ints
of
blo
od
ea
ch
ye
ar.
Ho
spic
e-P
art
A c
oin
sura
nce
A
B
C
D
F/F
* G
K
L
M
N
Basic
, in
clu
din
g
100%
Part
B
coin
sura
nce
Basic
, in
clu
din
g
100%
Part
B
coin
sura
nce
Basic
, in
clu
din
g
100%
Part
B
coin
sura
nce
Basic
, in
clu
din
g
100%
Part
B
coin
sura
nce
Basic
, in
clu
din
g
100%
Part
B
coin
sura
nce
Basic
, in
clu
din
g
100%
Part
B
coin
sura
nce
Hospitaliz
ation
and p
reventive
care
paid
at
100%
; oth
er
basic
benefits
paid
at 50%
Hospitaliz
ation
and p
reventive
care
paid
at
100%
; oth
er
basic
benefits
paid
at 75%
Basic
, in
clu
din
g
10
0%
Part
B
coin
sura
nce
Basic
, in
clu
din
g
100%
Part
B
coin
sura
nce, except
up to $
20 c
opaym
ent
for
off
ice v
isit, and
up to $
50 c
opaym
ent
for
ER
Skill
ed
Nurs
ing
Facili
ty
Coin
sura
nce
Skill
ed
Nurs
ing
Facili
ty
Coin
sura
nce
Skill
ed
Nurs
ing
Facili
ty
Coin
sura
nce
Skill
ed
Nurs
ing
Facili
ty
Coin
sura
nce
50%
Skill
ed
Nurs
ing
Facili
ty
Coin
sura
nce
75%
Skill
ed
Nurs
ing F
acili
ty
Coin
sura
nce
Skill
ed
Nurs
ing
Facili
ty
Coin
sura
nce
Skill
ed N
urs
ing
Facili
ty C
oin
sura
nce
P
art
A
Deductible
P
art
A
Deductible
P
art
A
Deductible
P
art
A
Deductible
P
art
A
Deductible
50%
Part
A
Deductible
75%
Part
A
Deductible
50%
Part
A
Deductible
P
art
A D
eductible
Part
B
Deductible
Part
B
Deductible
Part
B
Excess
(100%
)
Part
B
Excess
(100%
)
Fore
ign
Tra
vel
Em
erg
ency
Fore
ign
Tra
vel
Em
erg
ency
Fore
ign
Tra
vel
Em
erg
ency
Fore
ign
Tra
vel
Em
erg
ency
Fore
ign
Tra
vel
Em
erg
ency
Fore
ign T
ravel
Em
erg
ency
Out-
of-
limit $
[4660];
paid
at 100%
aft
er
limit
reached
Out-
of-
limit $
[2330];
paid
at 100%
aft
er
limit
reached
*Pla
ns F
als
o h
as a
n o
ptio
n c
alle
d a
hig
h d
ed
uctib
le p
lan F
. T
his
hig
h d
ed
uctib
le p
lan p
ays t
he s
am
e b
en
efits
as P
lan F
aft
er
one
has p
aid
a
ca
lend
ar
ye
ar
[$20
70
] d
ed
uctib
le.
Be
ne
fits
fro
m h
igh
ded
uctib
le p
lan F
will
not
beg
in u
ntil
out-
of-
exp
en
ses e
xce
ed
[$
20
70
].
Ou
t-of-
pocke
t e
xp
en
ses fo
r th
is d
ed
uctib
le a
re e
xp
en
ses th
at
wo
uld
o
rdin
arily
b
e p
aid
b
y th
e p
olic
y.
Th
ese
e
xp
en
ses in
clu
de
th
e M
edic
are
d
ed
uctib
les f
or
Pa
rt A
and
Pa
rt B
, b
ut
do n
ot
inclu
de
th
e p
lan’s
se
pa
rate
fo
reig
n t
rave
l e
me
rge
ncy d
ed
uctib
le.
GLA
MS
0367V
T
01012012
GLA
MS
0367V
T
01012012
ISSU
E A
GE
AB
CD
N
0-64
$1,977.00
$2,490.00
$2,749.00
$2,515.00
$2,011.00
65+
$1,127.00
$1,420.00
$1,568.00
$1,435.00
$1,147.00
AN
NU
AL
PR
EM
IUM
S
GE
NW
OR
TH
LIF
E &
AN
NU
ITY
IN
SU
RA
NC
E C
OM
PA
NY
AL
L P
LA
NS
AV
AIL
AB
LE
TO
TH
OS
E U
ND
ER
AG
E 6
5 A
ND
EL
IGIB
LE
FO
R M
ED
ICA
RE
DU
RIN
G M
ED
ICA
RE
OP
EN
EN
RO
LL
ME
NT
PE
RIO
D A
ND
GU
AR
AN
TE
E IS
SU
E P
ER
IOD
S
SO
ME
PL
AN
S M
AY
NO
T B
E A
VA
ILA
BL
E IN
YO
UR
ST
AT
E
TH
E R
AT
ES
AB
OV
E D
O N
OT
IN
CL
UD
E T
HE
ON
E T
IME
$20 P
OL
ICY
FE
E
PR
EM
IUM
S P
AY
AB
LE
OT
HE
R T
HA
N A
NN
UA
L M
AY
BE
DE
TE
RM
INE
D B
Y T
HE
FO
LL
OW
ING
FA
CT
OR
S:
Mo
dal F
acto
rs:
An
n:
1.0
000 S
em
i: 0
.5200 Q
rtly
: 0.2
650 M
thly
: 0.0
83
3
GLA
MS
0367V
T
P
RE
MIU
M I
NF
OR
MA
TIO
N
Ge
nw
ort
h L
ife
an
d A
nn
uity I
nsu
ran
ce
Com
pa
ny c
an
on
ly r
ais
e
yo
ur
pre
miu
m i
f w
e r
ais
e t
he
pre
miu
m f
or
all
po
licie
s l
ike
yo
urs
in
th
is s
tate
.
Pre
miu
ms
pa
ya
ble
o
the
r th
an
a
nn
ua
l w
ill
be
d
ete
rmin
ed
a
cco
rdin
g t
o t
he
fo
llow
ing f
acto
rs:
Se
mi-a
nn
ua
l: 0
.52
00
Q
ua
rterly:
0.2
65
0
Mo
nth
ly E
FT
: 0
.08
33
.
DIS
CL
OS
UR
ES
Use
th
is
ou
tlin
e
to
co
mp
are
b
en
efits
a
nd
p
rem
ium
a
mo
ng
po
licie
s.
[
RE
AD
YO
UR
PO
LIC
Y V
ER
Y C
AR
EF
UL
LY
Th
is i
s o
nly
an
ou
tlin
e d
escrib
ing y
ou
r p
olic
y’s
mo
st
imp
ort
an
t fe
atu
res.
Th
e p
olic
y i
s y
ou
r in
su
ran
ce
co
ntr
act.
Yo
u m
ust
rea
d
the
po
licy its
elf t
o u
nd
ers
tan
d a
ll o
f th
e r
igh
ts a
nd
du
tie
s o
f b
oth
yo
u a
nd
yo
ur
insu
ran
ce
co
mp
an
y.
RIG
HT
TO
RE
TU
RN
PO
LIC
Y
If y
ou
fin
d t
ha
t yo
u a
re n
ot
sa
tisfied
with
yo
ur
po
licy,
yo
u m
ay
retu
rn
it
to
Ge
nw
ort
h
Life
a
nd
A
nn
uity
Insu
ran
ce
C
om
pa
ny,
P.O
.Bo
x 2
36
8,
Bre
ntw
oo
d,
Te
nn
esse
e
37
02
4.
If y
ou
se
nd
th
e
po
licy b
ack t
o u
s w
ith
in 3
0 d
ays a
fte
r yo
u r
ece
ive
it, w
e w
ill t
rea
t th
e p
olic
y a
s if it h
ad
n
eve
r b
ee
n is
sue
d a
nd
re
turn
a
ll yo
ur
pa
ym
en
ts.
PO
LIC
Y R
EP
LA
CE
ME
NT
If yo
u a
re re
pla
cin
g a
no
the
r h
ea
lth
insu
ran
ce
po
licy,
do
N
OT
ca
nce
l it u
ntil
yo
u h
ave
actu
ally
rece
ive
d y
ou
r n
ew
po
licy a
nd
a
re s
ure
yo
u w
an
t to
ke
ep
it.
NO
TIC
E
Th
e p
olic
y m
ay n
ot
co
ve
r all
of
yo
ur
me
dic
al co
sts
.
Neith
er
Ge
nw
ort
h L
ife
an
d A
nn
uity I
nsu
ran
ce
Com
pa
ny n
or
its
age
nts
are
co
nn
ecte
d w
ith
Med
icare
.
Th
is
ou
tlin
e
of
co
ve
rage
d
oe
s
no
t giv
e
all
the
d
eta
ils
of
Me
dic
are
co
ve
rage
. C
on
tact
yo
ur
loca
l S
ocia
l S
ecu
rity
Off
ice o
r co
nsu
lt M
ed
icare
& Y
ou
fo
r m
ore
de
tails
.
CO
MP
LE
TE
AN
SW
ER
S A
RE
VE
RY
IM
PO
RT
AN
T
Wh
en
yo
u f
ill o
ut
the
ap
plic
atio
n f
or
the
ne
w p
olic
y,
be
su
re t
o
an
sw
er
truth
fully
a
nd
co
mp
lete
ly
an
y
qu
estio
ns
ab
ou
t yo
ur
me
dic
al
an
d
he
alth
h
isto
ry.
Th
e
co
mp
an
y
ma
y
ca
nce
l yo
ur
po
licy a
nd
refu
se
to
pa
y a
ny c
laim
s i
f yo
u l
ea
ve
ou
t o
r fa
lsify
imp
ort
an
t m
ed
ical in
form
atio
n.
Revie
w t
he
ap
plic
atio
n c
are
fully
be
fore
yo
u s
ign
it. B
e c
ert
ain
th
at
all
info
rma
tio
n h
as b
ee
n p
rop
erly r
eco
rde
d.
TH
E F
OL
LO
WIN
G C
HA
RT
S D
ES
CR
IBE
P
LA
NS
A
, B
, C
, D
an
d
N
OF
FE
RE
D
BY
G
EN
WO
RT
H
LIF
E
AN
D
AN
NU
ITY
INS
UR
AN
CE
CO
MP
AN
Y.
GLAMS0367VT
PLAN A
MEDICARE (PART A) – MEDICAL SERVICES – PER CALENDAR YEAR
*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 [$1156] $0 [$1156] (Part A Deductible)
61st thru 90th day All but [$289] a day [$289] a day $0 91st day and after
While using 60 lifetime reserve days All but[ $578] a day [$578] 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 [$144.50] a day
$0
Up to[$144.50] 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 copayment/ 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.
GLAMS0367VT
PLAN A
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed [$140] 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 test, durable medical equipment
First [$140] of Medicare-Approved amounts*
$0 $0 [$140] (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 [$140] of Medicare-Approved amounts*
$0 $0 [$140] (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 [$140] of Medicare Approved amounts*
$0 $0 [$140] (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
GLAMS0367VT
PLAN B
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 [$1156] [$1156] (Part A Deductible)
$0
61st thru 90th day All but [$289] a day [$289] a day $0 91st day and after
While using 60 lifetime reserve days All but [$578] a day [$578] 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 [$144.50] a day
$0 Up to [$144.50] 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 copayment/ 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 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.
GLAMS0367VT
PLAN B
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
* Once you have been billed [$140] 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 test, durable medical equipment
First [$140] of Medicare-Approved amounts*
$0 $0 [$140] (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 [$140] of Medicare-Approved amounts*
$0 $0 [$140] (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 [$140] of Medicare Approved amounts*
$0 $0 [$140] (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
GLAMS0367VT
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 [$1156] [$1156] (Part A Deductible)
$0
61st thru 90th day All but $289 a day [$289] a day $0 91st day and after
While using 60 lifetime reserve days All but [$578] a day [$578] 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[ $144.50] a day
Up to [$144.50] 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 copayment/ 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 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.
GLAMS0367VT
PLAN C
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed [$140] 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 test, durable medical equipment
First [$140] of Medicare-Approved amounts*
$0 [$140] (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 [$140] of Medicare-Approved amounts*
$0 [$140] (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 [$140] of Medicare Approved amounts*
$0 [$140] (Part B Deductible)
$0
Remainder of Medicare Approved amounts 80% 20% $0
GLAMS0367VT
PLAN C
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
GLAMS0367VT
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 [$1156] [$1156] (Part A Deductible)
$0
61st thru 90th day All but [$289] a day [$289] a day $0 91st day and after
While using 60 lifetime reserve days All but [$578] a day [$578] 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 [$144.50] a day
Up to [$144.50] 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 services
All but very limited copayment/ 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 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.
GLAMS0367VT
PLAN D
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed [$140] 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 test, durable medical equipment
First [$140] of Medicare-Approved amounts*
$0 $0 [$140] (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 [$140] of Medicare-Approved amounts*
$0 $0 [$140] (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 [$140] of Medicare Approved amounts*
$0 $0 [$140] (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
GLAMS0367VT
PLAN D
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
GLAMS0367VT
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 [$1156] [$1156] (Part A Deductible)
$0
61st thru 90th day All but [$289] a day [$289] a day $0 91st day and after
While using 60 lifetime reserve days All but [$578] a day [$578] 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 [$144.50] a day
Up to [$144.50] 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 services
All but very limited copayment/ 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 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.
GLAMS0367VT
PLAN N
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed [$140] 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 test, durable medical equipment
First [$140] of Medicare-Approved amounts*
$0 $0 [$140] (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 copayment 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 [$140] of Medicare-Approved amounts*
$0 $0 [$140] (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0
CLINICAL LABORATORY
SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
GLAMS0367VT
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 [$140] of Medicare Approved amounts*
$0 $0 [$140] (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
