2019 Outline of Medicare Supplement Coverage · 2019 Outline of Medicare Supplement Coverage New...

Form No. 0002_2_Medigap

2019 Outline of Medicare Supplement CoverageNew Hampshire

Benefit Chart of Medicare Supplement PlansSold for Effective Dates on or After June 1, 2010

This chart shows the benefits included in each of thestandard Medicare supplement plans. Every companyshall make Plan “A” available. Some plans may not beavailable in your State.

Basic Benefits:• Hospitalization – Part A Coinsurance plus coverage for 365 additional

days after Medicare benefits end.• Medical Expenses – Part B Coinsurance (generally 20% of Medicare

approved expenses) or copayments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B Coinsurance or copayments.

• Blood – First three pints of blood each year• Hospice – Part A Coinsurance

Plan A Plan B Plan C Plan D Plan FHigh

DeductiblePlan F*

Plan G Plan K Plan L Plan M Plan N

Basic,including100%Part BCoinsurance







Hospitalizationand preventivecare paid at100%; otherbasic benefitspaid at 50%

Hospitalizationand preventivecare paid at100%; otherbasic benefitspaid at 75%

Basic,including100% Part BCoinsurance

Basic,including100% Part BCoinsurance,except up to$20 copaymentfor office visit,and up to $50copaymentfor ER

Note: The Plans shaded in grey are currently available for sale

* Plan F also has an option called a high Deductible plan F. This high Deductible plan pays the same benefits as Plan F after one has paid a calendaryear $2,300 Deductible. Benefits for high Deductible Plan F will not begin until out-of-pocket expenses exceed $2,300. Out-of-pocket expensesfor this Deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare Deductible for Part A and Part Bbut do not include the plan’s separate foreign travel emergency deductible.

(continued next page)


2019 Outline of Medicare Supplement Coverage(Page 2 of 2)

Plan A Plan B Plan C Plan D Plan FHigh

DeductiblePlan F*

Plan G Plan K Plan L Plan M Plan N

SkilledNursingFacilityCoinsurance





50% SkilledNursingFacilityCoinsurance

75% SkilledNursingFacilityCoinsurance



Part ADeductible

Part ADeductible

Part ADeductible

Part ADeductible

Part ADeductible

Part ADeductible

50% Part ADeductible



Part ADeductible

Part BDeductible

Part BDeductible

Part BExcess(100%)

Part BExcess(100%)

Part BExcess(100%)

ForeignTravelEmergency







Out-of-pocketlimit $5,560paid at 100%after limit isreached

Out-of-pocketlimit $2,780paid at 100%after limit isreached

Note: The Plans shaded in grey are currently available for sale* Plan F also has an option called a high Deductible plan F. This high Deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,300 Deductible. Benefits for high Deductible Plan F will not begin until out-of-pocket expenses exceed $2,300. Out-of-pocket expenses for this Deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare Deductible for Part A and Part B but do not include the plan’s separate foreign travel emergency deductible.


Issue Age Plan A Plan F Plan G Plan M Plan N

< 65 $289.00 $433.00 $317.00 $314.00 $306.00

65 $171.00 $212.00 $145.00 $175.00 $149.00

66 $174.00 $215.00 $161.00 $177.00 $152.00

67 $178.00 $223.00 $168.00 $180.00 $156.00

68 $181.00 $226.00 $174.00 $186.00 $162.00

69 $185.00 $233.00 $181.00 $192.00 $166.00

70 $190.00 $244.00 $189.00 $198.00 $170.00

71 $198.00 $248.00 $196.00 $203.00 $177.00

72 $204.00 $254.00 $204.00 $208.00 $184.00

73 $207.00 $261.00 $212.00 $211.00 $188.00

74 $209.00 $266.00 $221.00 $217.00 $191.00

75 $214.00 $272.00 $229.00 $221.00 $196.00

76 $217.00 $277.00 $239.00 $225.00 $199.00

77 $224.00 $284.00 $248.00 $227.00 $205.00

78 $226.00 $289.00 $258.00 $232.00 $210.00

79 $231.00 $294.00 $268.00 $235.00 $212.00

80+ $289.00 $433.00 $317.00 $314.00 $306.00

Premium InformationWe, HPHC Insurance Company, Inc. can only raise your premium if we raise the premium for all Policies like yours in this State.


DisclosuresUse this outline to compare benefits and premiums among

Policies.

This outline shows benefits and premiums of policies sold for

effective dates on or after June 1, 2010.

Read Your Policy Very CarefullyThis is only an outline describing your Policy’s most important

features. The Policy is your insurance contract. You must read

the Policy itself to understand all of the rights and duties of

both you and HPHC Insurance Company, Inc.

Right to Return PolicyIf you find that you are not satisfied with your Policy, you may

return it to HPHC Insurance Company, Inc.

1600 Crown Colony Drive

ATTN: Enrollment/Billing Quincy, MA 02169.

If you send the Policy back to us within 30 days after you

receive it, we will treat the Policy as if it had never been issued

and return all of your payments.

Policy ReplacementIf you are replacing another health insurance Policy, do NOT

cancel it until you have actually received your new Policy and

are sure you want to keep it.

NoticeThis Policy may not fully cover all of your medical costs. HPHC

Insurance Company, Inc. is not connected with Medicare. This

outline of coverage does not give all the details of Medicare

coverage. Contact your local Social Security Office or consult

“Medicare & You” for more details.

Complete Answers Are Very ImportantWhen you fill out the application for the new policy, be sure

to answer truthfully and completely all questions about your

medical and health history. The company may cancel your policy

and refuse to pay any claims if you leave out or falsify important

medical information. Review the application carefully before

you sign it. Be certain that all information has been properly

recorded.


Plan AMedicare (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 andhave 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 of a Benefit Period All but $1,364 $0 $1,364 (Part A Deductible)

61st through 90th day of a Benefit Period All but $341 a day $341 a day $0

91st day and after of a Benefit Period- While using 60 lifetime reserve days All but $682 a day $682 a day $0

Once lifetime reserve days are used:

- Additional 365 days

- Beyond the additional 365 days

$0

$0

100% of Medicare eligible expenses

$0

$0**

All Costs

** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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.


Plan A (Continued)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.


Skilled Nursing Facility Care*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare approved facilitywithin 30 days after leaving the hospital

First 20 days of a Benefit Period All approved amounts $0 $0

21st through 100th day of a Benefit Period All but $170.50 a day $0 Up to $170.50 a day

101st day and after of a Benefit Period $0 $0 All Costs

Blood

First three pints $0 Three pints $0

Additional amounts 100% $0 $0

Hospice CareYou must meet Medicare’s requirements,including a doctor’s certification ofterminal illness

All but very limitedCopayment/Coinsurance foroutpatient drugs and inpatientrespite care

Medicare Copayment/Coinsurance

$0



Medical expenses in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medicaland surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment

First $185 of Medicare approved amounts* $0 $0 $185(Part B Deductible)

Remainder of Medicare approved amounts Generally 80% Generally 20% $0

Part B Excess Charges(Above Medicare approved amounts) $0 $0 All Costs

Blood

First three pints $0 All Costs $0

Next $185 of Medicare approved amounts* $0 $0$185(Part B Deductible)

Remainder of Medicare approved amounts 80% 20% $0

Clinical Laboratory Services – Tests forDiagnostic Services

100% $0 $0*

Plan A (Continued)Medicare (Part B) – Medical Services – Per Calendar Year

* Once you have been billed $185 of Medicare approved amounts for covered services (which are noted with an asterisk), your Part B Deductiblewill have been met for the calendar year.



Home Health Care – Medicare Approved Services

Medically necessary skilled care services andmedical supplies

100% $0 $0

Durable medical equipment

- First $185 of Medicare approved amounts* $0 $0$185(Part B Deductible)

- Remainder of Medicare approved amounts 80% 20% $0

Plan A (Continued)Medicare (Parts A & B)




HOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days of a Benefit Period All but $1,364 $1,364 (Part A Deductible) $0


91st day and after of a Benefit Period

- While using 60 lifetime reserve days All but $682 a day $682 a day $0


- Additional 365 days $0 100% of Medicare eligible expenses $0***

- Beyond the additional 365 days $0 $0 All Costs

*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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.

Plan FMedicare (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 havenot received skilled care in any other facility for 60 days in a row.


Plan F (Continued)Medicare (Part A) – Hospital Services – Per Benefit Period





21st through 100th day of a Benefit Period All but $170.50 a day Up to $170.50 a day $0


Blood






$0




First $185 of Medicare approved amounts* $0 $185(Part B Deductible)

$0


Part B Excess Charges(Above Medicare approved amounts) $0 100% $0

Blood


Next $185 of Medicare approved amounts* $0$185(Part B Deductible)

$0



100% $0 $0

Plan F (Continued)Medicare (Part B) – Medical Services – Per Calendar Year





Medically necessary skilled care services and medical supplies

100% $0 $0


- First $185 of Medicare approved amounts* $0$185(Part B Deductible)

$0


Plan F (Continued)Medicare (Parts A & B)


Plan F (Continued)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 $0 $0 $250

- Remainder of charges $080% to a lifetime maximumbenefit of $50,000

20% and amounts over the$50,000 lifetime maximum




First 60 days of a Benefit Period All but $1,364 $1,364 (Part A Deductible) $0





- Additional 365 days $0100% of Medicare eligibleexpenses

$0**



Plan GMedicare (Part A) – Hospital Services – Per Benefit Period



Plan G (Continued)Medicare (Part A) – Hospital Services – Per Benefit Period







Blood






$0






Part B Excess Charges(Above Medicare approved amounts) $0 100% $0

Blood





100% $0 $0*

Plan G (Continued)Medicare (Part B) – Medical Services – Per Calendar Year






100% $0 $0




Plan G (Continued)Medicare (Parts A & B)


Plan G (Continued)Other Benefits – Not Covered By Medicare





- Remainder of charges $0 80% to a lifetime maximumbenefit of $50,000





First 60 days of a Benefit Period All but $1,364$682(50% of Part A Deductible)

$682(50% of Part A Deductible)






$0**



Plan MMedicare (Part A) – Hospital Services – Per Benefit Period



Plan M (Continued)Medicare (Part A) – Hospital Services – Per Benefit Period







Blood






$0






Part B Excess Charges(Above Medicare approved amounts) $0 $0 All Costs

Blood





100% $0 $0*

Plan M (Continued)Medicare (Part B) – Medical Services – Per Calendar Year






100% $0 $0


- First $185 of Medicare approved amounts* $0 $0 $185(Part B Deductible)


Plan M (Continued)Medicare (Parts A & B)

Plan M (Continued)Other Benefits – Not Covered By Medicare





- Remainder of charges $0 80% to a lifetime maximumbenefit of $50,000





First 60 days of a Benefit Period All but $1,364$1,364(Part A Deductible)

$0






$0**



Plan NMedicare (Part A) – Hospital Services – Per Benefit Period



Plan N (Continued)Medicare (Part A) – Hospital Services – Per Benefit Period







Blood






$0





Remainder of Medicare approved amounts Generally 80% Balance, other than up to $20per office visit and up to $50per emergency room visit.The copayment of up to $50 iswaived if the insured isadmitted to any hospital andthe emergency visit is coveredas a Medicare Part A expense.

Up to $20 per office visit andup to $50 per emergency roomvisit. The copayment of up to$50 is waived if the insured isadmitted to any hospital and theemergency visit is covered as aMedicare Part A expense.

Part B Excess Charges(Above Medicare approved amounts)

$0 $0 All Costs

Plan N (Continued)Medicare (Part B) – Medical Services – Per Calendar Year




Blood





$100 $0 $0*

Plan N (Continued)Medicare (Parts A & B)


Medicare (Parts A & B)



Medically necessary skilled care services andmedical supplies 100% $0 $0




* Once you have been billed $185 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.




Medically necessary emergency care services beginningduring the first 60 days of each trip outside the USA


- Remainder of charges $080% to a lifetime maximumbenefit of $50,000


Plan N (Continued)Other Benefits – Not Covered By Medicare


NOTES

2019 Outline of Medicare Supplement Coverage · 2019 Outline of Medicare Supplement Coverage New...

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