Medicare Supplement Chart

This chart shows the benefits included in each of the Standard Medicare Supplement plans. Every company must make available Plan “A.” Some Plans may not be available in every State.

Basic Benefits:
» Hospitalization: Part A coinsurance plus coverage for 365 days after Medicare benefits end.
» Medical Expenses: Part B coinsurance (generally 20% of Medicare Approved Expenses) or, copayments for hospital outpatient services and Office Visits (Plan N). Plans K, L and N require insureds to pay a portion of coinsurance or copayments.
» Blood: First three pints of blood each year.
» Hospice: Part A Coinsurance.

PLAN A PLAN B PLAN C PLAN D PLAN F/F*
Basic, Including 100% Part B Coinsurance Basic, Including 100% Part B Coinsurance Basic, Including 100% Part B Coinsurance Basic, Including 100% Part B Coinsurance Basic, Including 100% Part B Coinsurance
Skilled Nursing Facility
Coinsurance
Skilled Nursing Facility
Coinsurance
Skilled Nursing Facility
Coinsurance
Part A Deductible ($1,316.00) Part A Deductible ($1,316.00)
Part B Deductible ($183.00)
Part A Deductible

($1,316.00)

Part A Deductible ($1,316.00)
Part B Deductible ($183.00)
Part B Excess at 100%
Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency
PLAN G PLAN K PLAN L PLAN M PLAN N
Basic, Including 100% Part B Coinsurance Hospitalization and preventative care paid at 100%; other basic benefits paid at 50% Hospitalization and preventative care paid at 100%; other basic benefits paid at 75% Basic, Including 100% Part B Coinsurance Basic, including 100% Part B Coinsurance except up to $20 copayment for office visit and up to $50 copayment for ER
Skilled Nursing Facility Coinsurance 50% Skilled Nursing Facility Coinsurance 75% Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance
Part A Deductible

($1,316.00)

50% Part A Deductible

($658.00)

75% Part A Deductible

($987.00)

50% Part A Deductible

($658.00)

Part A Deductible ($1,316.00)
Part B Excess (100%)
Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency
Out of Pocket Limit ($5,120); paid at 100% after limit is reached Out of Pocket Limit ($2,560); paid at 100% after limit reached

*Plan F also has an option called a High Deductible Plan. This High Deductible Plan pays the same benefits as Plan F after you have paid a calendar year $2,200 deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses exceed $2,200. Out-of-pocket expenses for this deductible are for expenses that would ordinarily be paid by the policy. These expenses include the Medicare Deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible, currently $250.