[29 Pa.B. 172]

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PLAN I

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

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) 100%	$100 (Part B deductible)   $0   $0
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

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
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   AT-HOME RECOVERY SERVICES-NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan    --  Benefit for each visit    --  Number of visits covered (must be received within 8 weeks of last Medicare approved visit)    --  Calendar year maximum	100%     $0   80%                 $0 $0     $0	$0     $0   20%               Actual charges to $40 a visit Up to the number of Medicare approved visits, not to exceed 7 each week $1,600	$0     $100 (Part B deductible)   $0                 Balance

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    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
BASIC OUTPATIENT PRE- SCRIPTION DRUGS--NOT COVERED BY MEDICARE First $250 each calendar year   Next $2,500 each calendar year   Over $2,500 each calendar year	$0 $0   $0	$0 50%--$1,250 calendar year maximum benefit $0	$250 50%   All costs

PLAN J or HIGH DEDUCTIBLE PLAN J

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.
**This high deductible plan pays the same or offers the same benefits as Plan J after one has paid a calendar year [$1,500] deductible. Benefits from high deductible Plan J will not begin until out-of-pocket expenses are [$1,500]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate prescription drug deductible or the plan's separate foreign travel emergency deductible.

SERVICES	MEDICARE PAYS	AFTER YOU PAY $1,500 DEDUCTIBLE,** PLAN PAYS	IN ADDITION TO $1,500 DEDUCTIBLE,** 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

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.
**This high deductible plan pays the same or offers the same benefits as Plan J after one has paid a calendar year $[1,500] deductible. Benefits from high deductible Plan J will not begin until out-of-pocket expenses are [$1,500]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate prescription drug deductible or the plan's separate foreign travel emergency deductible.

SERVICES	MEDICARE PAYS	AFTER YOU PAY $1,500 DEDUCTIBLE,** PLAN PAYS	IN ADDITION TO $1,500 DEDUCTIBLE,** 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) 100%	$0   $0   $0
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
HOME HEALTH CARE (cont'd) AT-HOME RECOVERY SERVICES--NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan    --  Benefit for each visit    --  Number of visits covered (Must be received within 8 weeks of last Medicare Approved visit) --Calendar year maximum	$0 $0     $0	Actual charges to $40 a visit Up to the number of Medicare Approved visits, not to exceed 7 each week $1,600	Balance

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    Remainder of charges	$0 $0	$0 80% to a lifetime maximum benefit of $50,000	$250 20% and amounts over the $50,000 lifetime maximum
EXTENDED OUTPATIENT PRESCRIPTION DRUGS--NOT COVERED BY MEDICARE    First $250 each calendar year    Next $6,000 each calendar year      Over $6,000 each calendar year	$0 $0   $0	$0 50%--$3,000 calendar year maximum benefit $0	$250 50%   All costs
***PREVENTIVE MEDICAL CARE BENEFIT--NOT COVERED BY MEDICARE Some annual physical and preventive tests and services such as: digital rectal exam, hearing screening, dipstick urinalysis, diabetes screening, thyroid function test, tetanus and diphtheria booster and education, administered or ordered by your doctor when not covered by Medicare    First $120 each calendar year    Additional charges	$0 $0	$120 $0	$0 All costs

***Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

*      *      *      *      *

§ 89.788.  Reporting of multiple policies

   (a)  On or before March 1 of each year, an issuer shall report the following information for every individual resident of this Commonwealth for which the issuer has in force more than one Medicare supplement policy or certificate. This information must only be submitted for those issuers having insureds with more than one policy:

   (1)  The policy and certificate number.

   (2)  The date of issuance.

   (b)  The items in subsection (a) shall be grouped by individual policyholder.

§ 89.790.  Guaranteed issue for eligible persons

   (a)  Guaranteed issue.

   (1)  Eligible persons are those individuals described in subsection (b) who apply to enroll under the policy not later than 63 days after the date of the termination of enrollment described in subsection (b), and who submit evidence of the date of termination or disenrollment with the application for a Medicare supplement policy.

   (2)  With respect to eligible persons, an issuer may not:

   (i)  Deny or condition the issuance or effectiveness of a Medicare supplement policy described in subsection (c) that is offered and is available for issuance to new enrollees by the issuer.

   (ii)  Discriminate in the pricing of such a Medicare supplement policy because of health status, claims experience, receipt of health care or medical condition.

   (iii)  Impose an exclusion of benefits based on a preexisting condition under such a Medicare supplement policy.

   (b)  Eligible persons. An eligible person is an individual described in paragraphs (1)--(6):

   (1)  The individual is enrolled under an employe welfare benefit plan that provides health benefits that supplement the benefits under Medicare; and the plan terminates, or the plan ceases to provide all supplemental Medicare health benefits to the individual; or the individual is enrolled under an employe welfare benefit plan that is primary to Medicare and the plan terminates, or the plan ceases to provide health benefits to the individual because the individual leaves the plan.

   (2)  The individual is enrolled with a Medicare+Choice organization under a Medicare+Choice plan under Part C of Medicare, and any of the following circumstances apply:

   (i)  The organization's or plan's certification has been terminated or the organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides.

   (ii)  The individual is no longer eligible to elect the plan because of a change in the individual's place of residence or other change in circumstances specified by the HHS Secretary, but not including termination of the individual's enrollment on the basis described in section 1851(g)(3)(B) of the Social Security Act (42 U.S.C.A. § 1395w-21(g)(3)(B)) (when the individual has not paid premiums on a timely basis or has engaged in disruptive behavior as specified in standards under section 1856 of the Social Security Act (42 U.S.C.A. § 1395w-26), or the plan is terminated for all individuals within a residence area).

   (iii)  The individual demonstrates, in accordance with guidelines established by the HHS Secretary, that one of the following applies:

   (A)  The organization offering the plan substantially violated a material provision of the organization's contract under this part in relation to the individual, including the failure to provide an enrollee on a timely basis medically necessary care for which benefits are available under the plan or the failure to provide the covered care in accordance with applicable quality standards.

   (B)  The organization, or agent or other entity acting on the organization's behalf, materially misrepresented the plan's provisions in marketing the plan to the individual.

   (iv)  The individual meets other exceptional conditions the HHS Secretary may provide.

   (3)  The individual's enrollment ceases under the same circumstances that would permit discontinuance of an individual's election of coverage under paragraph (2) and the individual is enrolled with one of the following:

   (i)  An eligible organization under a contract under section 1876 of the Social Security Act (42 U.S.C.A. § 1395mm) (Medicare risk or cost).

   (ii)  A similar organization operating under demonstration project authority, effective for periods before April 1, 1999.

   (iii)  An organization under an agreement under section 1833(a)(1)(A) of the Social Security Act (42 U.S.C.A. § 1395l(a)(1)(A)) (health care prepayment plan).

   (iv)  An organization under a Medicare Select policy.

   (4)  The individual is enrolled under a Medicare supplement policy and the enrollment ceases because one of the following applies:

   (i)  The insolvency of the issuer or bankruptcy of the nonissuer organization or of other involuntary termination of coverage or enrollment under the policy.

   (ii)  The issuer of the policy substantially violated a material provision of the policy.

   (iii)  The issuer, or an agent or other entity acting on the issuer's behalf, materially misrepresented the policy's provisions in marketing the policy to the individual.

   (5)  The individual was enrolled under a Medicare supplement policy and terminates enrollment and subsequently enrolls, for the first time, with any Medicare+Choice organization under a Medicare+Choice plan under Part C of Medicare, any eligible organization under a contract under section 1876 of the Social Security Act (Medicare risk or cost), any similar organization operating under demonstration project authority, any organization under an agreement under section 1833(a)(1)(A) of the Social Security Act (health care prepayment plan) or any Medicare Select policy and the subsequent enrollment under this paragraph is terminated by the enrollee during the first 12 months of the subsequent enrollment (during which the enrollee is permitted to terminate the subsequent enrollment under section 1851(e) of the Social Security Act).

   (6)  The individual, upon first becoming eligible for benefits under Part A or enrolled in Part B of Medicare at age 65 or older, enrolls in a Medicare+Choice plan under Part C of Medicare, and disenrolls from the plan within 12 months after the effective date of enrollment.

   (c)  Products to which eligible persons are entitled. The Medicare supplement policy to which eligible persons are entitled under:

   (1)  Subsection (b)(1)--(4) is a Medicare supplement policy which has a benefit package classified as Plan A, B, C or F offered by an issuer.

   (2)  Subsection (b)(5) is the same Medicare supplement policy in which the individual was most recently previously enrolled, if available from the same issuer, or, if not so available, a policy described in paragraph (1).

   (3)  Subsection (b)(6) includes any Medicare supplement policy offered by an issuer.

   (d)  Notification provisions.

   (1)  At the time of an event described in subsection (b) because of which an individual loses coverage or benefits due to the termination of a contract or agreement, policy or plan, the organization that terminates the contract or agreement, the issuer terminating the policy or the administrator of the plan being terminated, respectively, shall notify individuals of their rights under this section, and of the obligations of issuers of Medicare supplement policies under subsection (a). The notice shall be communicated contemporaneously with the notification of termination.

   (2)  At the time of an event described in subsection (b) because of which an individual ceases enrollment under a contract or agreement, policy or plan, the organization that offers the contract or agreement, regardless of the basis for the cessation of enrollment, the issuer offering the policy, or the administrator of the plan, respectively, shall notify individuals of their rights under this section, and of the obligations of issuers of Medicare supplement policies under subsection (a). The notice shall be communicated within 10 working days of the issuer receiving notification of disenrollment.

APPENDIX I

DISCLOSURE STATEMENTS

INSTRUCTIONS FOR USE OF THE DISCLOSURE STATEMENTS FOR HEALTH INSURANCE POLICIES SOLD TO MEDICARE BENEFICIARIES THAT DUPLICATE MEDICARE

   1.  Section 1882 (d) of the Federal Social Security Act (42 U.S.C.A. § 1395ss) prohibits the sale of health insurance policies (the term policy or policies includes certificates) that duplicate Medicare benefits unless it will pay benefits without regard to other health coverage and it includes the prescribed disclosure statement on or together with the application for the policy.

   2.  All types of health insurance policies that duplicate Medicare shall include one of the attached disclosure statements, according to the particular policy type involved, on the application or together with the application. The disclosure statement may not vary from the attached statements in terms of language or format (type size, type proportional spacing, bold character, line spacing, and usage of boxes around text).

   3.  State and Federal law prohibits insurers from selling a Medicare supplement policy to a person that already has a Medicare supplement policy except as a replacement.

   4.  Property/Casualty and Life insurance policies are not considered health insurance.

   5.  Disability income policies are not considered to provide benefits that duplicate Medicare.

   6.  Long-term care policies are insurance policies that coordinate with Medicare and other health insurance are not considered to provide benefits that duplicate Medicare.

   7.  The Federal law does not preempt state laws that are more stringent than the Federal requirements.

   8.  The Federal law does not preempt existing state form filing requirements.

   9.  Section 1882 of the Social Security Act was amended in subsection (d)(3)(A) to allow for alternative disclosure statements. The disclosure statements already in Appendix I remain. Carriers may use either disclosure statement with the requisite insurance product. However, carriers should use either the original disclosure statements or the alternative disclosure statements and not use both simultaneously.

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