Medicare Supplement Plan H

Plan A Plan B Plan C Plan D Plan E Plan F Plan G Plan H Plan I Plan J

Plan H - Medicare Part A - Hospital Services - Per Benefit Period

Services / Part A	In 2004 Medicare Pays	Plan H Pays	You Pay
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies -First 60 Days	All but $876.00	$876.00 (Part A Deductible)	$0
-61st through 90th day	All but $219.00 a day	$219.00 a day	$0
-91st day and after -While using 60 lifetime reserve days	All but $438.00 a day	$438.00 a day	$0
-Once lifetime reserve days are used: -Additional 365 days	$0	100% of Medicare Eligible Expenses	$0
-Beyond the additional 365 days	$0	$0	All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital -First 20 days	All approved amounts	$0	$0
-21st through 100th day	All but $109.50 a day	$109.50 a day	$0$
-101st day and after	$0	$0	All costs
Blood -First 3 Pints	$0	3 Pints	$0
-Additional amounts	100%	$0	$0
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for outpatient drugs and inpatient respite care	$0	Balance

Plan H - Medicare Part B - Medical Services - Per Calendar Year

Services / Part B	In 2004 Medicare Pays	Plan H Pays	You Pay
MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT: such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment -First $100.00 of Medicare Approved Amounts**	$0	$0	$100.00 (Part B Deductible)
-Remainder of Medicare Approved Amounts (after the Part B Deductible)	Generally 80%	Generally 20%	$0
-Part B Excess Charges (above Medicare Approved Amounts)	$0	$0	All costs
BLOOD -First 3 pints	$0	All costs	$0
-Next $100.00 of Medicare Approved Amounts**	$0	$0	$100.00 (Part B Deductible)
-Remainder of Medicare Approved Amounts	Generally 80%	Generally 20%	$0
CLINICAL LABORATORY SERVICES--BLOOD TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

Parts A & B	In 2004 Medicare Pays	Plan H Pays	You Pay
HOME HEALTH CARE - MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies	100% while approved	$0	$0
Durable medical equipment -First $100.00 of Medicare Approved Amounts**	$0	$0	$100.00 (Part B Deductible
-Remainder of Medicare Approved Amounts	80%	20%	$0

OTHER BENEFITS-NOT COVERED BY MEDICARE Part B
(Covered under Plan H)

Services / Part B	Medicare Pays	Plan H Pays	You Pay
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 of each calendar year	$0	$0	$250.00
-Remainder of Charges	$0	80% to a lifetime benefit maximum benefit of $50,000	20% and amounts over the $50,000 lifetime maximum
BASIC OUTPATIENT PRESCRIPTION DRUGS-NOT COVERED BY MEDICARE -First $250 each calendar year	$0	$0	$250
-Next $2,500 each calendar year	$0	50%-$1,250 calendar year max benefit	50%
-Over $2,500 each calendar year	$0	$0	All costs

Plan A Plan B Plan C Plan D Plan E Plan F Plan G Plan H Plan I Plan J

* 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.

**Once you have been billed $100.00 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.

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Security or any other Government Agency.

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   definition of terms, benefits, exceptions and exclusions as well as any waiting
   periods, you must see the policy itself.

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