§2008.APPENDIX A. Policy Checklist

Applicant's Name
Policy Number
Name of Existing Insurer
Expiration Date of Existing Insurance
SERVICE	BENEFIT					MEDICARE PAYS	EXISTING COVERAGE		SUPPLEMENT PAYS	YOU PAY
Hospital Inpatient	First 60 Days					All But ($        )
	61st to 90th Day					All But ($        ) a Day
	91st to 150th Day (Lifetime Reserve)					($        ) a Day
	Beyond 150 Days					Nothing
Skilled Nursing Home Care	First 20 Days Additional 80 Days					100% of Cost All But ($        ) A Day
	Beyond 100 Days					Nothing
Medical Expense	Physician's Services in hospital, office or home, inpatient and out-patient medical services and supplies at a hospital, physical and speech therapy and ambulance					80% of Medicare Determined allowable charges after ($              ) Deductible
Prescription Drugs						Inpatient Prescription Drugs.  80% of allowable charges for immunosuppressive drugs during the first year following a covered transplant.

 

This policy does/does not comply with the minimum standards set forth in Section 363 of the Illinois Insurance Code.

 

DATE		SIGNATURE OF APPLICANT
		SIGNATURE OF INSURANCE PRODUCER

 

(Source:  Amended at 16 Ill. Reg. 2766, effective February 11, 1992; corrected at 16 Ill. Reg. 3590)