Plan K

Plan Benefit Tables: Medicare Supplement Plan K

Medicare Part A: Hospital Services per Benefit Period

Notes

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.

NOTICE

When your Medicare Part A hospital benefits are exhausted, the issuer stands in 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.

You will pay half of the cost-sharing of some coveredservices until you reach the annual out-of-pocket limit of$5120 each calendar year. The amounts that counttoward your annual limit are noted with diamonds (♦) inthe chart above. Once you reach the annual limit, theplan pays 100% of the Medicare co-payment andcoinsurance for the rest of the calendar year. However,this limit does NOT include charges from your providerthat exceed Medicare-approved amounts (these arecalled “Excess Charges”) and you will be responsible forpaying this difference in the amount charged by yourprovider and the amount paid by Medicare for the item orservice.

Medicare Part B: Medical Services per Calendar Year

Parts A and B

Notes

This plan limits your annual out-of-pocket payments forMedicare-approved amounts to $5120 per calendar year.However, this limit does NOT include charges from yourprovider that exceed Medicare-approved amounts (theseare called “Excess Charges”) and you will be responsiblefor paying this difference in the amount charged by yourprovider and the amount paid by Medicare for the item orservice.

Once you have been billed $183 of Medicare-approvedamounts for covered services, your Part B deductible willhave been met for the calendar year.

Medicare benefits are subject to change.Please consult the latest Guide to HealthInsurance for People with Medicare.

NO COST, NO OBLIGATION

Answers To Your Medicare Questions