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Medicare Supplement: Plan “G”

2009 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.

** $0 indicates your liability for covered charges. You are responsible for all other noncovered charges.

Services Medicare Pays Plan "G" Pays You Pay

Hospitalization*
Semiprivate room and board, general nursing, and miscellaneous services and supplies
• First 60 days
All but $1068 $1068 (Part A Deductible) $0**

• 61st thru 90th day
All but $267 a day $267 a day $0**

• 91st day and after:
- While using 60 lifetime reserve days
All but $534 a day $534 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 thru 100th day All but $133.50 a day Up to $133.50 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

2009 Medicare (Part B) -- 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.

** $0 indicates your liability for covered charges. You are responsible for all other noncovered charges.

Services Medicare Pays Plan "G" 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, and durable medical equipment
• First $135 of Medicare-approved amounts*
$0 $0 $135 (Part B Deductible)

• Remainder of Medicare-approved amounts, Generally 80% Generally 80% Generally 20% $0**

• Part B Excess Charges
(Above Medicare-approved amounts) $0 80% 20%

Blood
• First 3 pints $0 All Costs $0**

• Next $135 of Medicare-approved amounts* (Deductible) $0 $0 $135 (Part B Deductible)

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

Clinical Laboratory Services -- Tests for Diagnostic Services 100% $0 $0**

Medicare -- Parts A & B

Services Medicare Pays Plan "G" Pays You Pay

Home Health Care -- Medicare-approved services
• Medically necessary skilled care services and medical supplies

100% $0 $0**

• Durable medical equipment:
– First $135 of Medicare-approved amounts* $0 $0 $135 (Part B Deductible)

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

Home Health Care -- At-home recovery services -- not covered by Medicare
Home care certified by your doctor for personal care during recovery from an injury or sickness for which Medicare-approved a Home Care Treatment Plan
• Benefit for each visit $0 Actual Charges to $40 a visit Balance

• Number of visits covered (must be received within 8 weeks of last Medicare-approved visit) 0 Up to the number of Medicare-approved visits, not to exceed 7 each week -

• Calendar-year maximum
$0 $1,600 -

Other Benefits -- Not Covered by Medicare

Services Medicare Pays Plan "G" 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 each calendar year

$0 $0 $250

• Remainder of Charges $0 80% to a lifetime maximum of $50,000 20% and amounts over $50,000 lifetime maximum

For More Information

If you have questions or desire further information regarding Medicare Supplement Insurance Plans, including costs, benefits, exclusions, limitations, and renewal terms, please contact Golden Rule from our Consumer Information or Broker Information pages.

Plan availability varies by state. Golden Rule Insurance Company is authorized to do business in all states except New York. However, not every product Golden Rule offers is available in every state. Please contact Golden Rule for information about availability.

Benefits are subject to the exclusions and limitations in the policies. Please refer to the policies for complete details on exclusions and limitations.

Golden Rule Insurance Company’s Medicare Supplement Insurance Plans are not connected with, or endorsed by, the U.S. government or the federal Medicare program.

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UnitedHealthOne is a brand name used for products underwritten, administered, and/or provided by:
Golden Rule Insurance Company (Indiana domiciled, CA certificate of authority number 4407),
American Medical Security Life Insurance Company (Wisconsin domiciled, CA certificate of authority number 08079),
PacifiCare Life and Health Insurance Company(Indiana domiciled, CA certificate of authority number 5813),
PacifiCare Life Assurance Company (Colorado domiciled, CA certificate of authority number 5814),
Oxford Health Insurance, Inc.,
Oxford Health Plans (NJ), Inc., or
UnitedHealthcare Insurance Company.
UnitedHealthcare Services, Inc.,
Dental Benefit Providers, Inc.,
Spectera, Inc.

Health Insurance plans are medically underwritten and availability varies by state. Coverage may be provided by multiple policies/certificates

Additional Products are provided by:
Careington International Corporation,
EyeMed Vision Care, or
International Medical Group, Inc. (Indiana domiciled)

Medicare Supplement: Plan “G”

2009 Medicare (Part A) -- Hospital Services
-- Per Benefit Period

2009 Medicare (Part B) -- Hospital Services
-- Per Benefit Period

Medicare -- Parts A & B

Other Benefits -- Not Covered by Medicare

For More Information

2009 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. ** $0 indicates your liability for covered charges. You are responsible for all other noncovered charges.
Services	Medicare Pays	Plan "G" Pays	You Pay
Hospitalization* Semiprivate room and board, general nursing, and miscellaneous services and supplies • First 60 days	All but $1068	$1068 (Part A Deductible)	$0**
• 61st thru 90th day	All but $267 a day	$267 a day	$0**
• 91st day and after: - While using 60 lifetime reserve days	All but $534 a day	$534 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 thru 100th day	All but $133.50 a day	Up to $133.50 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

Medicare -- Parts A & B
Services	Medicare Pays	Plan "G" Pays	You Pay
Home Health Care -- Medicare-approved services • Medically necessary skilled care services and medical supplies	100%	$0	$0**
• Durable medical equipment: – First $135 of Medicare-approved amounts*	$0	$0	$135 (Part B Deductible)
– Remainder of Medicare-approved amounts	80%	20%	$0**
Home Health Care -- At-home recovery services -- not covered by Medicare Home care certified by your doctor for personal care during recovery from an injury or sickness for which Medicare-approved a Home Care Treatment Plan • Benefit for each visit	$0	Actual Charges to $40 a visit	Balance
• Number of visits covered (must be received within 8 weeks of last Medicare-approved visit)	0	Up to the number of Medicare-approved visits, not to exceed 7 each week	-
• Calendar-year maximum	$0	$1,600	-

Other Benefits -- Not Covered by Medicare
Services	Medicare Pays	Plan "G" 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 each calendar year	$0	$0	$250
• Remainder of Charges	$0	80% to a lifetime maximum of $50,000	20% and amounts over $50,000 lifetime maximum

Medicare Supplement: Plan “G”

2009 Medicare (Part A) -- Hospital Services -- Per Benefit Period

2009 Medicare (Part B) -- Hospital Services -- Per Benefit Period

Medicare -- Parts A & B

Other Benefits -- Not Covered by Medicare

For More Information

2009 Medicare (Part A) -- Hospital Services
-- Per Benefit Period

2009 Medicare (Part B) -- Hospital Services
-- Per Benefit Period