Extended Basic Plan

1. Hospital Stays
This Plan will pay 80% of the Usual and Customary Charge if you are confined for inpatient care in a Hospital and the stay is not covered by Medicare. This Plan will pay for Hospital room and board, and other services and supplies furnished by the Hospital for medical care.

This benefit has these added requirements

Benefits will be paid up to the maximum charge amount allowed by law.

This Plan will not pay benefits for a private room if the charge is more than the Hospital's charge for its most common semi-private room, unless a private room is prescribed as Medically Necessary by your Physician.

2. Medical Care
This Plan will pay 80% of the Usual and Customary Charge for the following Covered Expenses when the charges are not paid by Medicare or otherwise covered under this Plan.

This benefit has these added requirements

Benefits will be paid up to the maximum charge amount allowed by law.

Payment of benefits will not duplicate benefits payable under Medicare or any other coverage provided by this Plan.

These Covered Expenses include the following:

A. Physician Services – Physician services for the diagnosis and treatment of Sickness or Injury. This includes a second opinion from a Physician on any surgical procedure expected to cost at least $500 in Physician, laboratory and Hospital fees.

B. Nursing Home Services – Nursing Home services for the following:

1. Nursing Home room and board for regular daily services and supplies furnished by the Nursing Home. This Plan will not pay benefits for a private room if the charge is more than the Nursing Home's charge for its most common semi-private room, unless a private room is prescribed as Medically Necessary by your Physician. If the Nursing Home does not have semi-private rooms, its most common semi-private room charge will be 90% of its lowest private room charge.
2. All other services and supplies furnished by the Nursing Home for medical care. Benefits will not be paid for more than 120 days in a calendar year. Your Nursing Horne stay must start with in 30 days after you are Hospital confined for at least three days in a row for the same or related Sickness or Injury. You must need nursing care 24 hours a day to treat your Sickness or Injury.

C. Therapy – Treatment by a physical therapist or occupational therapist at the direction of your Physician.

D. Oral Surgery – Oral surgery for partially or completely unerupted impacted teeth, a tooth root without extraction of the entire tooth, or the gums and tissue of your mouth. Benefits will not be paid for oral surgery performed in connection with the extraction or repair of teeth. Benefits will not be paid for root canal, gingivitis or periodontal disease.

E. Ambulance – Ambulance transportation provided by a licensed ambulance service to the nearest facility qualified to treat your Sickness or Injury. This includes a reasonable mileage rate for transportation to a kidney dialysis center for treatment.

F. Other Services and Supplies – The following other services and supplies:

• Use of radium or other radioactive materials
• Oxygen
• Anesthetics and their administration
• Artificial limbs, eyes, larynx, and other prosthetic devices (other than dental, but including scalp hair prosthesis worn for hair loss suffered as a result of alopecia areata; see the "Additional State Mandated Benefits" section for scalp hair prosthesis benefit limitations)
• Rental or purchase, as appropriate, of durable medical equipment, other than eyeglasses and hearing aids
• Diagnostic x-ray exam and laboratory tests

G. Home Health Agency – Home Health Agency services for the following:

1. Part-time or intermittent home nursing care by or under the supervision of a Registered Nurse.
2. Part-time or intermittent home health aide services, primarily for your care.

You must receive services in your home by a member of a Home Health Agency. Services must be for the care and treatment of your Sickness or Injury. If you could not receive these services in your home, confinement in a Hospital or nursing facility would be needed for you to receive the required care. Each visit by a member of a Home Health Agency shall be considered as one visit. Benefits will not be paid for prescription drugs included in the home care plan of treatment. For care received outside the United States, you must receive home health services outside a hospital or nursing home facility.

H. Emergency Services – Emergency services 24 hours a day and seven days a week for the treatment of an Emergency Medical Condition.

3. Care received outside the United States
Medicare usually does not cover care you receive outside the United States. In most cases, you are responsible for the full cost of care you receive out side the United States.

This Plan covers certain care while you are on a Trip outside the United States.

This Plan will pay 80% of the Usual and Customary Charge for the services described above as Hospital Stays and Medical Care under the "Description of Benefits for Expenses Not Covered by Medicare." This Plan will pay these benefits if the services you received while in a foreign country would have qualified as Medicare Eligible Expenses if they had been received in the United States.

This benefit has these added requirements

Benefits will be paid for a stay or care only if these three things are true:

1. The service is not covered by Medicare, but would have been covered by Medicare if it had been received in the United States.
2. The service is received on or after your Effective Date while you are in a foreign country.
3. The person providing medical care cannot be you or your spouse; your or your spouse's child, brother, sister or parent.

The following exclusions apply to this benefit:

1. Benefits are not payable for charges in excess of any charge limitation established by Medicare or Minnesota law.
2. If you establish residency outside the United States, we will not pay benefits for any service or supply rendered in the foreign country. You must provide us with an itemized bill for your care. You must also provide us with any necessary and relevant medical records that we request. We will pay these benefits in United States currency. We will calculate the amount of our payment using the bank transfer exchange rate in effect on the day we process your claim for payment.

Payment of benefits will not duplicate benefits payable under Medicare or any other coverage provided by this Plan.

4. Preventive Medical Care

This Plan will pay benefits for the actual charges up to 100% of the Medicare-approved amount for the following preventive health services:

1. An annual clinical preventive medical history and physical examination. This examination may include tests and services from paragraph b. below and patient education to address preventive health care measures.
2. Preventive screening tests and preventive services. The selection and frequency of these tests and services must be medically appropriate as determined by your Physician.

This Plan will pay benefits for these preventive health services, as if Medicare were to cover the service as identified in American Medical Association Current Procedural Terminology (AMA CPT) codes. The preventive health service must be received on or after the Effective Date. This benefit has a limit of $120 each calendar year for all preventive health services combined.

This benefit will not be paid for any preventive health service that is:

• covered by Medicare.
• performed for the treatment of a Sickness or Injury.
• used to diagnose or treat a condition that has already manifested itself.

5. Additional State-Mandated Benefits

This Plan will pay benefits for the following care and services only if these two things are true:

1. The procedure must be deemed appropriate by your Physician.
2. The procedure must be received on or after your Effective Date.

Payment of benefits will not duplicate benefits payable under Medicare or any other coverage provided by this Plan.

A. Alcoholism, Chemical Dependency, Drug Addiction
This Plan will pay 80% of the Usual and Customary Charge for the treatment of alcoholism and chemical dependency on the same basis as coverage for any other condition when treatment is provided for: (1) outpatient chemical dependency and alcoholism services that must not place a greater financial burden on the Insured or be more restrictive than those requirements and limitations for outpatient medical services; (2) inpatient hospital and residential chemical dependency and alcoholism services that must not place a greater financial burden on the Insured or be more restrictive than those requirements and limitations for inpatient hospital medical services.

B. Ambulatory Surgical Center Services
This Plan will pay 80% of the Usual and Customary Charge for care provided in an Ambulatory Surgical Center.

C. Court-ordered Mental Health Services
This Plan will pay 80% of the Usual and Customary Charge, when ordered by a court of competent jurisdiction, for mental health services issued on the basis of a behavioral care evaluation performed by a licensed psychiatrist which includes the diagnosis and an individual treatment plan for care in the most appropriate, least restrictive environment. Coverage is contingent on the evaluation and court-ordered treatment plan being performed by a participating provider or another provider as required by law.

D. Diabetes Equipment and Supplies; Diabetes Outpatient Self-Management Training and Education
This Plan will pay 80% for all Physician-prescribed, Medically Necessary diabetic equipment and supplies (includes oral and injectable insulin) for diabetes self-management training and self-education classes, medical nutrition therapy, and treatment of diabetes not otherwise covered under Part D of the Medicare program. The Plan coverage for diabetes outpatient self-management training and education, including medical nutrition therapy, is covered when provided by a certified, registered, or licensed health care professional working in a program consistent with the national standards of diabetes self-management education as established by the American Diabetes Association. Coverage includes persons with gestational, Type I, or Type II diabetes, subject to the Medicare Part B Deductible.

E. Immunizations
This Plan will pay 100% of the cost of routine immunizations that are not covered under Medicare. Immunizations include any medically recognized vaccine intended to produce immunity against a specified disease or condition.

F. Lyme Disease Benefit
This Plan will pay for treatment of Lyme Disease to the same extent that we pay for treatment of any other Sickness.

G. Mental Health Services Benefit
This Plan will pay 80% of the Usual and Customary Charge for outpatient mental health covered services that are intended to treat or ameliorate an emotional, behavioral, or psychiatric condition if they are Medically Necessary.

H. Phenylketonuria Treatment
This Plan will pay 80% of Covered Expenses for special dietary treatment for phenylketonuria when recommended by a Physician.

I. Reconstructive Surgery
This Plan will pay 80% of the Usual and Customary Charge for the following types of care:

• Reconstructive surgery. The surgery must be incidental to or following surgery for Injury, Sickness, or other diseases of the involved part.
• Reconstructive breast surgery following mastectomies if mastectomy is Medically Necessary. This includes all stages of reconstruction of the breast on which the mastectomy has been performed, surgery, and reconstruction of the other breast to produce a symmetrical appearance, and prosthesis and physical complications at all stages of a mastectomy, including lymphedemas.

J. Routine Cancer Screening
This Plan will pay 100% of the cost of routine cancer screening procedures that are not covered under Medicare. Cancer screening procedures include:

• Mammograms. Coverage for preventive mammogram screening that includes digital breast tomosynthesis (3D) for women who are at risk for breast cancer.
• Surveillance tests for ovarian cancer for women who are at risk for ovarian cancer (annual screening using CA-125 serum tumor marker testing, transvaginal ultrasound, pelvic examination, or other proven ovarian cancer screening tests currently being evaluated by the federal Food and Drug Administration or by the National Cancer Institute).
  1. "At risk for ovarian cancer" means (1) having a family history with one or more first or second degree relatives with ovarian cancer, of clusters of women relatives with breast cancer, or of nonpolyposis colorectal cancer, or (2) testing positive for BRCA1 or BRCA2 mutations.
• Papanicolaou tests (pap smears)
• Colorectal screening tests
• Prostate cancer screening consisting of a prostate-specific antigen blood test and a digital rectal examination

K. Scalp Hair Prosthesis
This Plan will pay 80% of the Usual and Customary Charge for a scalp hair prosthesis needed because of hair loss suffered as a result of alopecia areata, This Plan has a limit of one (1) scalp hair pros thesis per calendar year.

L. Temporomandibular Joint Disorder and Craniomandibular Disorder
This Plan will pay 80% of the Usual and Customary Charge for the surgical and nonsurgical treatment of temporomandibular joint disorder and craniomandibular disorder on the same basis as that for treatment to any other joint in the body. Such treatment must be administered or prescribed by a Physician or dentist.

M. Ventilator Dependent Benefit
This Plan will pay 80% of the Usual and Customary Charge for services by a private-duty nurse or personal care assistant to a ventilator-dependent person in the person's home. The Plan pay the Usual and Customary Charge for services provided by a private-duty nurse or personal care assistant to the ventilator-dependent person during the time the ventilator-dependent person is in a licensed hospital, not to exceed 120 hours. The personal care assistant or private-duty nurse shall perform only the services of communicator or interpreter for the ventilator-dependent patient during a transition period of up to 120 hours to assure adequate training of the hospital staff to communicate with the patient and to understand the unique comfort, safety, and personal care needs of the ventilator-dependent patient.

6. Out-of-pocket expenses – After total out-of-pocket Covered Expenses of $1,000 are paid in any calendar year by you, all benefits not subject to an annual limit will be paid at 100% of the Usual and Customary Charge for the rest of the calendar year.