Plan L

Plan Benefit Tables: Medicare Supplement Plan L

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 one-fourth of the cost-sharing of somecovered services until you reach the annual out-of-pocketlimit of $2560 each calendar year. The amountsthat count toward your annual limit are noted withdiamonds (♦) in the chart above. Once you reach theannual limit, the plan pays 100% of the Medicare copaymentand coinsurance for the rest of the calendaryear. However, this limit does NOT include charges fromyour provider that exceed Medicare-approved amounts(these are called “Excess Charges”) and you will beresponsible for paying this difference in the amountcharged by your provider and the amount paid byMedicare for the item or service.

Medicare Part B: Medical Services per Calendar Year

Parts A and B

Notes

This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2560 per calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

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

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

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