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Click on link for information on any standardized Medicare Supplement Policy:
Basic Information on Each Medicare Supplement Plan
| Plan Letter |
Basic
Benefits |
Part A
Deductible |
Skilled
Nursing
Coinsurance |
Part B
Deductible |
Part B
Excess< |
Foreign
Travel
Emergency |
At Home
Recovery |
Preventive
Care |
| A |
 |
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| B |
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| C |
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| D |
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| E |
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| F* |
|
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100% |
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| G |
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80% |
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| H |
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| I |
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100% |
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| J* |
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100% |
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Basic Benefits for Plans K and L include similar services as Plans A-J, but cost-sharing for the basic benefits is at different levels.
| Plan Letter |
Basic
Benefits |
Part A
Deductible |
Skilled
Nursing
Coinsurance |
Part B
Deductible |
Part B
Excess< |
Foreign
Travel
Emergency |
At Home
Recovery |
Preventive
Care |
| K** |
|
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| L** |
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| A-J |
K** |
L** |
| Basic Benefits |
100% of Part A Hospitalization Coinsurance plus coverage for 365 days after Medicare Benefits End |
100% of Part A Hospitalization Coinsurance plus coverage for 365 days after Medicare Benefits End |
| |
50% Hospice cost-sharing |
75% Hospice cost-sharing |
| |
50 % of Medicare-eligible expenses for the first three pints of blood |
75% of Medicare-eligible expenses for the first three pints of blood |
| |
50% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services |
75% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services |
| Skilled Nursing |
50% Skilled Nursing Facility Coinsurance |
75% Skilled Nursing Facility Coinsurance |
| Part A Deductible |
50% Part A Deductible |
75% Part A Deductible |
| Part B Deductible |
|
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| Part B Excess (100%) |
|
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| Foreign Travel Emergency |
|
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| At-Home Recover |
|
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| Preventive Care NOT covered by Medicare |
|
|
| |
$4440 Out of Pocket Annual Limit*** |
$2220 Out of Pocket Annual Limit*** |
Notes
- States may allow only some of the twelve standard benefit plans.
- States may approve innovative additional benefit plans under certain circumstances.
- These standard benefit plans do not apply to policies sold in MA, MN and WI.
- Availability of plans varies from company to company.
- Beneficiaries must keep good records of prescription drug expenses as they must file
the claims themselves.
*Plans F,J,K and L also have an option called a high deductible option. These high deductible plans pay the same benefits as Plans F and J after you pay a calendar year $1790 deductible. Benefits from high deductible Plans F and J will not begin until out-of-pocket expenses total $1790. Out-of-pocket expenses for this deductible
are expenses that would normally be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B. These expenses do not include the prescription drug deductible of $250 in Plan J. They also do not include the $250 foreign travel emergency deductible in Plan F and Plan J.
** Plans K and L provide for different cost-sharing for items and services than Plans A-J.
Once your reach the annual limit, the plans pays 100% of the Medicare co-payments,
coinsurance, and deductibles for the rest of the calendar year. The out-of-pocket annual
limit does NOT include charges from your provider that exceed Medicare-approved
amounts, called "Excess Charges". You will be responsible for paying excess charges.
*** The out-of-pocket annual limit will increase each year for inflation. |
