BENEFITS This Plan And Medicare • Most of this plan's benefits are based on Medicare-eligible services, supplies and expenses (see Definitions). For these benefits to be provided, the services you receive must be provided by facilities and practitioners who are Medicare-eligible as defined in the Medicare program. Medicare may, from time to time, change its deductible and coinsurance amounts. When this happens, this plan will automatically cover the changed Medicare deductible and coinsurance amounts applicable to this plan. We will notify you 30 days in advance of any changes Medicare makes that affect your coverage under this plan. • Only the benefits shown in Benefits For Expenses Not Covered By Medicare are available for services or supplies which are not eligible expenses under Medicare Parts A and B. Otherwise, if Medicare doesn’t cover a service or supply, neither will this plan. • Medicare has requirements that must be met for some benefits, such as hospice and skilled nursing facility care. If you don’t meet Medicare’s requirements and as a result Medicare doesn’t cover a service or supply, neither will this plan. • Medicare has maximums for certain types of services. When you reach Medicare's benefit maximum for a particular type of service, coverage under this plan will also end for that type of service, except where specifically stated otherwise in this booklet. • If your enrollment in Part A and/or B of Medicare ends, this plan will continue to pay only the benefits listed below. This plan will not start paying the portion of Medicare-eligible expenses normally paid by Medicare. Benefits will only be provided for services and supplies which would have been Medicare-eligible had you been enrolled in Medicare Parts A and B. It is your responsibility to cancel your coverage if it no longer meets your needs in this event. Benefits For Expenses Covered By Medicare A Medicare benefit period starts This Medicare supplement plan will cover the following: on the first day of your inpatient • Medicare Part A Deductible This plan hospital stay after your Part A hospital coverage begins. The covers all of the Medicare Part A inpatient period ends after you have been hospital deductible amount per Medicare benefit period. out of the hospital or other facility primarily providing skilled nursing • Inpatient Hospital Coinsurance - or rehabilitative care for 60 days in a row (counting the day of Medicare Part A Coverage of Part A discharge). Medicare-eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period 2 Group Plan G/Age