[29 Pa.B. 172]

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   (5)  The following items shall be included in the outline of coverage in the order prescribed in this paragraph:

*      *      *      *      *

[COMPANY NAME]
Outline of Medicare Supplement Coverage-Cover Page:
 
Benefit Plans ______ (insert letters of plans being offered)

Medicare supplement insurance can be sold in only ten standard plans plus two high deductible plans. This chart shows the benefits included in each plan. Every company must make available Plan A & B.

Basic Benefits:  Included in All Plans.
Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
Medical Expenses:  Part B coinsurance (20% of Medicare-approved expenses).
Blood:  First three pints of blood each year.

A	B	C	D	E	F	F*	G	H	I	J	J*
Basic Benefits	Basic Benefits	Basic Benefits	Basic Benefits	Basic Benefits	Basic Benefits		Basic Benefits	Basic Benefits	Basic Benefits	Basic Benefits
		Skilled Nursing Co-Insurance	Skilled Nursing Co-Insurance	Skilled Nursing Co-Insurance	Skilled Nursing Co-Insurance		Skilled Nursing Co-Insurance	Skilled Nursing Co-Insurance	Skilled Nursing Co-Insurance	Skilled Nursing Co-Insurance
	Part A Deductible	Part A Deductible	Part A Deductible	Part A Deductible	Part A Deductible		Part A Deductible	Part A Deductible	Part A Deductible	Part A Deductible
		Part B Deductible			Part B Deductible					Part B Deductible
					Part B Excess (100%)		Part B Excess (80%)		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	Foreign Travel Emergency	Foreign Travel Emergency
			At-Home Recovery				At-Home Recovery	At-Home Recovery	At-Home Recovery
								Basic Drugs ($1,250 Limit)	Basic Drugs ($1,250 Limit)	Extended Drugs ($3,000 Limit)
				Preventive Care						Preventive Care

*Plans F and J also have an option called a high deductible plan F and a high deductible plan J. These high deductible plans pay the same or offer the same benefits as Plans F and J after one has paid a calendar year [$1,500] deductible. Benefits from high deductible plans F and J will not begin until out-of-pocket expenses are [$1,500]. Out-of-pocket expenses for this deductible ar expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but does not include, in plan J, the plan's separate prescription drug deductible or, in Plans F and J, the plan's separate foreign travel emergency deductible.

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    61st thru 90th day    91st day and after:    --  While using 60 lifetime reserve days    --  Once lifetime reserve days are used:       --  Additional 365 days       --  Beyond the additional 365 days	All but $760 All but $190 a day   All but $380 a day       $0 $0	$0 $190 a day   $380 a day     100% of Medicare eligible expenses $0	$760 (Part A deductible) $0   $0       $0 All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital    First 20 days    21st thru 100th day    101st day and after	All approved amounts All but $95 a day $0	$0 $0 $0	$0 Up to $95 a day All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

PLAN A

MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR

*Once you have been billed $100 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 $100 of Medicare approved       amounts*    Remainder of Medicare approved       amounts    Part B excess charges (Above Medicare       approved amounts)	$0   80% (50% outpatient psychiatric services) $0	$0   20% (50% outpatient psychiatric services) $0	$100 (Part B deductible)   $0   All costs
BLOOD First 3 pints Next $100 of Medicare approved    amounts* Remainder of Medicare approved    amounts	$0 $0   80%	All costs $0   20%	$0 $100 (Part B deductible)   $0
CLINICAL LABORATORY SERVICES--BLOOD TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PARTS A & B

HOME HEALTH CARE MEDICARE APPROVED SERVICES --  Medically necessary skilled care services and medical supplies --  Durable medical equipment      First $100 of Medicare approved         amounts*      Remainder of Medicare approved         amounts	100%     $0   80%	$0     $0   20%	$0     $100 (Part B deductible)   $0

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    61st thru 90th day    91st day and after:    --  While using 60 lifetime reserve days    --  Once lifetime reserve days are used:         --  Additional 365 days         --  Beyond the additional 365 days	All but $760 All but $190 a day     All but $380 a day   $0 $0	$760 (Part A deductible) $190 a day     $380 a day 100% of Medicare eligible expenses $0	$0 $0     $0   $0 All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital    First 20 days    21st thru 100th day    101st day and after	All approved amounts All but $95 a day $0	$0 $0 $0	$0 Up to $95 a day All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

PLAN B

MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR

*Once you have been billed $100 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 $100 of Medicare approved       amounts*    Remainder of Medicare approved       amounts    Part B excess charges (Above Medicare       approved amounts)	$0   80% (50% outpatient psychiatric services) $0	$0   20% (50% outpatient psychiatric services) $0	$100 (Part B deductible)   $0   All costs
BLOOD First 3 pints Next $100 of Medicare approved    amounts* Remainder of Medicare approved    amounts	$0 $0   80%	All costs $0   20%	$0 $100 (Part B deductible)   $0
CLINICAL LABORATORY SERVICES--BLOOD TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PARTS A & B

HOME HEALTH CARE MEDICARE APPROVED SERVICES    --  Medically necessary skilled care services and medical supplies    --  Durable medical equipment         First $100 of Medicare approved            amounts*         Remainder of Medicare approved            amounts	100%     $0   80%	$0     $0   20%	$0     $100 (Part B deductible)   $0

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    61st thru 90th day    91st day and after:    --  While using 60 lifetime reserve days    --  Once lifetime reserve days are used:         --  Additional 365 days         --  Beyond the additional 365 days	All but $760 All but $190 a day   All but $380 a day       $0 $0	$760 (Part A deductible) $190 a day   $380 a day     100% of Medicare eligible expenses $0	$0 $0   $0       $0 All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital    First 20 days    21st thru 100th day    101st day and after	All approved amounts All but $95 a day $0	$0 Up to $95 a day $0	$0 $0 All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

PLAN C

MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR

*Once you have been billed $100 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 $100 of Medicare approved       amounts*    Remainder of Medicare approved       amounts    Part B excess charges (Above Medicare       approved amounts)	$0   80% (50% outpatient psychiatric services) $0	$100 (Part B deductible)   20% (50% outpatient psychiatric services) $0	$0   $0   All costs
BLOOD First 3 pints Next $100 of Medicare approved    amounts* Remainder of Medicare approved    amounts	$0 $0   80%	All costs $100 (Part B deductible)   20%	$0 $0   $0
CLINICAL LABORATORY SERVICES--BLOOD TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PARTS A & B

HOME HEALTH CARE MEDICARE APPROVED SERVICES    --  Medically necessary skilled care services and medical supplies    --  Durable medical equipment         First $100 of Medicare approved            amounts*         Remainder of Medicare approved            amounts	100%     $0   80%	$0     $100 (Part B deductible)   20%	$0     $0   $0

OTHER BENEFITS--COVERED BY MEDICARE

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
FOREIGN TRAVEL-- NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA    First $250 each calendar year Remainder of charges	$0 $0	$0 80% to a lifetime maximum benefit of $50,000	$250 20% and amounts over the $50,000 life-time maximum

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    61st thru 90th day    91st day and after:    --  While using 60 lifetime reserve days    --  Once lifetime reserve days are used:         --  Additional 365 days         --  Beyond the additional 365 days	All but $760 All but $190 a day     All but $380 a day   $0 $0	$760 (Part A deductible) $190 a day     $380 a day 100% of Medicare eligible expenses $0	$0 $0     $0   $0 All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital    First 20 days    21st thru 100th day    101st day and after	All approved amounts All but $95 a day $0	$0 Up to $95 a day $0	$0 $0 All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

PLAN D

MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR

*Once you have been billed $100 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 $100 of Medicare approved       amounts*    Remainder of Medicare approved       amounts    Part B excess charges (Above Medicare       approved amounts)	$0   80% (50% outpatient psychiatric services) $0	$0   20% (50% outpatient psychiatric services) $0	$100 (Part B deductible)   $0   All costs
BLOOD First 3 pints Next $100 of Medicare approved    amounts* Remainder of Medicare approved    amounts	$0 $0   80%	All costs $0   20%	$0 $100 (Part B deductible)   $0
CLINICAL LABORATORY SERVICES--BLOOD TESTS FOR DIAGNOSTIC SERVICES	100%	0	$0

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