[30 Pa.B. 6886]

[Continued from previous Web Page]

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 $1,580 deductible. Benefits from high deductible Plan J will not begin until out-of-pocket expenses are $1,580. 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 $1,580 DEDUCTIBLE,** PLAN PAYS	IN ADDITION TO $1,580 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 $792 All but $198 a day     All but $396 a day     $0 $0	$792 (Part A deductible) $198 a day     $396 a day   100% of Medicare eli- gible expenses $0	$0 $0     $0     $0 All costs
SKILLED NURSING FACILITY CARE*   You must meet Medicare's require- ments, including having been in a hospital for at least 3 days and en- tered a Medicare-approved facility within 30 days after leaving the hos- pital       First 20 days       21st thru 100th day       101st day and after	All approved amounts All but $99 a day $0	$0 Up to $99 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 cer- tifies you are terminally ill and you elect to receive these services	All but very limited co- insurance for out- patient drugs and inpa- tient 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 $1,580 deductible. Benefits from high deductible Plan J will not begin until out-of-pocket expenses are $1,580. 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 $1,580 DEDUCTIBLE,** PLAN PAYS	IN ADDITION TO $1,580 DEDUCTIBLE,** YOU PAY
MEDICAL EXPENSES--IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREAT- MENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physi- cal 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 SER- VICES--BLOOD TESTS FOR DI- AGNOSTIC 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	100%     $0   80%	$0     $100 (Part B deductible)   20%	$0     $0   $0
HOME HEALTH CARE (continued) 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 vis- its, not to exceed 7 each week $1,600	Balance

PLAN J or HIGH DEDUCTIBLE PLAN J (cont.)

PARTS A & B (continued)

OTHER BENEFITS--NOT COVERED BY MEDICARE
 

FOREIGN TRAVEL-- NOT COV- ERED 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 maxi- mum benefit of $50,000	$250 20% and amounts over the $50,000 lifetime maximum
EXTENDED OUTPATIENT PRE- SCRIPTION DRUGS--NOT COV- ERED 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 COV- ERED BY MEDICARE Some annual physical and preventive tests and services such as: digital rectal exam, hearing screening, dipstick urinalysis, diabetes screen- ing, thyroid function test, tetanus and diphtheria booster and educa- tion, 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.

§ 89.790.  Guaranteed issue for eligible persons.

   (a)  Guaranteed issue.

   (1)  Eligible persons are those individuals described in subsection (b) who, subject to subsection (b)(2)(vi) 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.

*      *      *      *      *

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

*      *      *      *      *

   (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, or the individual is 65 years of age or older and is enrolled with a Program of All-Inclusive Care for the Elderly (PACE) provider under section 1894 of the Social Security Act (42 U.S.C.A. § 1395eee), and there are circumstances similar to those described as follows that would permit discontinuance of the individual's enrollment with the provider if the individual were enrolled in a Medicare+Choice plan:

   (i)  The certification of the organization or plan under this part has been terminated, or the organization or plan has notified the individual of an impending termination of the certification.

   (ii)  The organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides, or has notified the individual of an impending termination or discontinuance of the plan.

   (iii)  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).

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

*      *      *      *      *

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

   (vi)  An individual described in paragraph (2) may elect to apply subsection (a) by substituting, for the date of termination of enrollment, the date on which the individual was notified by the Medicare+Choice organization of the impending termination or discontinuance of the Medicare+Choice plan it offers in the area in which the individual resides, but only if the individual disenrolls from the plan as a result of the notification.

   (vii)  In the case of an individual making the election in subparagraph (vi), the issuer involved shall accept the application of the individual submitted before the date of termination of enrollment, but the coverage under subsection A shall only become effective upon termination of coverage under the Medicare+Choice plan involved.

*      *      *      *      *

   (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) (42 U.S.C.A. § 1395mm), any similar organization operating under demonstration project authority, any PACE program under section 1894 of the Social Security Act, 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 and enrolled in Part B, if eligible, of Medicare, enrolls in a Medicare + Choice plan under Part C of Medicare, or in a PACE program under section 1894, and disenrolls from the plan or program within 12 months after the effective date of enrollment.

*      *      *      *      *

[Pa.B. Doc. No. 00-2260. Filed for public inspection December 29, 2000, 9:00 a.m.]

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