Medicare Supplement State Disclosures

California

Medicare Supplement Policy Forms: Plan A: ARLIC-MS-AA-A-CA; Plan F: ARLIC-MS-AA-F-CA; Plan G: ARLIC-MS-AA-G-CA; Plan HDG: ARLIC-MS-AA-HDG-CA; Plan N: ARLIC-MS-AA-N-CA.

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medi-Cal); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Alabama, Kansas, Louisiana, Nevada and North Carolina

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Colorado

Medicare Supplement Policy Forms: Plan A: HIC-MS-AA-A.v2-CO; Plan F: HIC-MS-AA-F.v2-CO; Plan G: HIC-MS-AA-G.v2-CO; Plan HDG: HIC-MS-AA-HDG.v2-CO; Plan N: HIC-MS-AA-N.v2-CO

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Indiana

Medicare Supplement Policy Forms: Plan A: HIC-MS-AA-A.v2-IN; Plan F: HIC-MS-AA-F.v2-IN; Plan G: HIC-MS-AA-G.v2-IN; Plan HDG: HIC-MS-AA-HDG.v2-IN; Plan N: HIC-MS-AA-N.v2-IN

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Ohio

Medicare Supplement Policy Form Series: Plan A: HIC-MS-AA-A-OH; Plan F: HIC-MS-AA-F-OH; Plan G: HIC-MS-AA-G-OH; Plan HDG: HIC-MS-AA-HDG-OH; Plan N: HIC-MS-AA-N-OH

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Renewability: You may renew this policy for life by paying the premium when it becomes due. We may not cancel this policy before the expiration of the grace period. If the premium due is not paid during the grace period, the policy will terminate coverage at the end of the period for which premiums were paid.

Right to Adjust Future Premiums: The premium shown on the Policy Schedule Page will increase each year because of the increase in your attained age. The premium shown on the Policy Schedule Page may change on the premium due date following the date:

(1) We change the rates or discounts, which apply to all policies of this form issued by us and in force in the state where your policy was issued;

(2) Coverage under Medicare changes; or

(3) You move to a different zip code location.

We will send you a written notice at least thirty (30) days in advance when we change the premium rates or discounts, for all policies of this form issued by us and in force in the state where your policy was issued.

Grace Period: A grace period of thirty-one (31) days will be granted for the payment of each premium, falling due after the first premium. This policy will continue in force during the grace period. If the premium due is not paid during the grace period, the policy will terminate coverage at the end of the period for which premiums were paid.

Cancellation: You may cancel this policy at any time by written notice delivered or mailed to us, effective upon receipt or on such later date as may be specified in such notice. In the event of cancellation, we will return promptly the unearned portion of any premium paid. The earned premium shall be computed by the use of the short-rate table last filed with the state official having supervision of insurance in the state where the insured resided when this policy was issued. Cancellation will be without prejudice to any claim originating prior to the effective date of cancellation. We may not cancel this policy. This provision nullifies any other provision, contained in this policy or in any indorsement hereon or in any rider attached hereto, which provides for cancellation of this policy by you or by us.

Pennsylvania

Medicare Supplement Policy Forms: Plan A: HIC-MS-AA-A-PA, HIC-MS-AO-A-PA; Plan B: HIC-MS-AA-B-PA, HIC-MS-AO-B-PA; Plan F: HIC-MS-AA-F-PA, HIC-MS-AO-F-PA; Plan G: HIC-MS-AA-G-PA, HIC-MS-AO-G-PA; Plan HDG: HIC-MS-AA-HDG-PA, HIC-MS-AO-HDG-PA; Plan N: HIC-MS-AA-N-PA, HIC-MS-AO-N-PA

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Pre-existing Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Pre-existing Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Tennessee

Medicare Supplement Policy Forms: Plan A: HIC-MS-AA-A-TN; Plan F: HIC-MS-AA-F-TN; Plan G: HIC-MS-AA-G-TN; Plan HDG: HIC-MS-AA-HDG-TN; Plan N: HIC-MS-AA-N-TN.

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which you are not legally obligated to pay and no other services or organization has a legal obligation to provide or pay for;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare; or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) confinement that begins or expenses incurred while your policy is not in force.

Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Texas

Medicare Supplement Policy Forms: Plan A: HIC-MS-AA-A-TX; Plan F: HIC-MS-AA-F-TX; Plan G: HIC-MS-AA-G-TX; Plan HDG: HIC-MS-AA-HDG-TX; Plan N: HIC-MS-AA-N-TX

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied. Please see form entitled Medicare Supplement Supplementary Application to determine qualification for guaranteed issue status.

Arizona, Georgia, Kentucky, Maryland, Mississippi, South Dakota and Utah

Exclusions and Limitations

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(2) any services that are not medically necessary as determined by Medicare;

(3) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(4) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(5) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(6) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Arkansas

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-CR-A-AR; Plan F: HNHIC-MS-CR-F-AR; Plan G: HNHIC-MS-CR-G-AR; Plan HDG: HNHIC-MS-CR-HDG-AR; Plan N: HNHIC-MS-CR-N-AR

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Connecticut

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-CR-A-CT; Plan F: HNHIC-MS-CR-F-CT; Plan G: HNHIC-MS-CR-G-CT; Plan High Deductible G: HNHIC-MS-CR-HDG-CT; Plan N: HNHIC-MS-CR-N-CT

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Florida

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-IA-A-FL; Plan F: HNHIC-MS-IA-F-FL; Plan HDG: HNHIC-MS-IA-HDG-FL; Plan G: HNHIC-MS-IA-G-FL; Plan N: HNHIC-MS-IA-N-FL

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Renewal and Premium Payment Provisions: This policy may be kept in force during Your lifetime by paying the premiums on time. We cannot cancel or refuse to renew this policy for any reason other than nonpayment of premium or material misrepresentation in the application for insurance.

Renewal: All renewal premiums must be paid in consecutive terms. They shall be paid by modes currently offered by Us. Renewal premiums are payable to Us. Premiums must be paid on or before the date due or before the end of the grace period. If this policy should lapse, the payment of a premium will reinstate this policy only as provided in the reinstatement provision in this section.

Cancellation: You may cancel this policy at any time by notifying Us. Your cancellation will be effective upon receipt of Your notice or on such later date as may be specified in such notice. In the event of cancellation, We will return promptly the unearned portion of any premium paid by You. We will determine the amount of the refund, if any, by prorating the last modal premium paid from the date of the cancellation until the next modal premium due date. Cancellation will be without prejudice to any claim originating prior to the effective date of cancellation.

Illinois

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-AA-A-IL; Plan F: HNHIC-MS-AA-F-IL; Plan G: HNHIC-MS-AA-G-IL; Plan High Deductible G: HNHIC-MS-AA-HDG-IL; Plan N: HNHIC-MS-AA-N-IL

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Iowa

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-AA-A.v2-IA; Plan F: HNHIC-MS-AA-F.v2-IA; Plan G: HNHIC-MS-AA-G.v2-IA; Plan HDG: HNHIC-MS-AA-HDG.v2-IA; Plan N: HNHIC-MS-AA-N.v2-IA

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Michigan

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-AA-A-MI; Plan F: HNHIC-MS-AA-F-MI; Plan G: HNHIC-MS-AA-G-MI; Plan N: HNHIC-MS-AA-N-MI

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(2) any services that are not medically necessary as determined by Medicare;

(3) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

(4) any type of expense not a Medicare eligible expense except as provided previously in this policy;

(5) any deductible, coinsurance or co-payment not covered by Medicare, unless such coverage is listed as an additional benefit in this policy; or

(6) Pre-existing Conditions: We will not pay for any expenses incurred for care or treatment of a Pre-existing Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If You had less than six (6) months prior Creditable Coverage, the Pre-existing Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Missouri

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-IA-A.v2-MO; Plan F: HNHIC-MS-IA-F.v2-MO; Plan G: HNHIC-MS-IA-G.v2-MO; Plan N: HNHIC-MS-IA-N.v2-MO; Plan HDG: HNHIC-MS-IA-HDG.v2-MO

Exclusions and Limitations

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Montana

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-AA-A-MT; Plan F: HNHIC-MS-AA-F-MT; Plan G: HNHIC-MS-AA-G-MT; Plan HDG: HNHIC-MS-AA-HDG-MT; Plan N: HNHIC-MS-AA-N-MT.

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed 100% of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

New Hampshire

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-IA-A-NH; Plan F: HNHIC-MS-IA-F-NH; Plan G: HNHIC-MS-IA-G-NH; Plan N: HNHIC-MS-IA-N-NH

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible (not applicable in Plan F);

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

New Jersey

Medicare Supplement Policy Forms: HNHIC-MS-AA-A-NJ; Plan C: HNHIC-MS-AA-C-NJ; Plan D: HNHIC-MS-AA-D-NJ; Plan F: HNHIC-MS-AA-F-NJ; Plan High Deductible G (HDG): HNHIC-MS-AA-HDG-NJ; Plan G: HNHIC-MS-AA-G-NJ; Plan N: HNHIC-MS-AA-N-NJ.

Exclusions and Limitations

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least three (3) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a three (3) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than three (3) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

New Mexico

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-AA-A-NM; Plan F: HNHIC-MS-AA-F-NM; Plan G: HNHIC-MS-AA-G-NM; Plan HDG: HNHIC-MS-AA-HDG-NM; Plan N: HNHIC-MS-AA-N-NM

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible (not applicable in Plan F);

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

North Dakota

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-AA-A-ND, HNHIC-MS-AO-A-ND; Plan F: HNHIC-MS-AA-F-ND, HNHIC-MS-AO-F-ND; Plan G: HNHIC-MS-AA-G-ND, HNHIC-MS-AO-G-ND; Plan N: HNHIC-MS-AA-N-ND, HNHIC-MS-AO-N-ND

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible (not applicable in Plan F);

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Oklahoma

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-AA-A-OK; Plan F: HNHIC-MS-AA-F-OK; Plan G: HNHIC-MS-AA-G-OK; Plan High Deductible G: HNHIC-MS-AA-HDG-OK; Plan N: HNHIC-MS-AA-N-OK

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

1) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

2) any services that are not medically necessary as determined by Medicare;

3) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

4) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

5) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

6) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

South Carolina

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-AA-A-SC; Plan F: HNHIC-MS-AA-F-SC; Plan G: HNHIC-MS-AA-G-SC; Plan N: HNHIC-MS-AA-N-SC

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible (not applicable for Plan F);

(2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Pre-existing Conditions: We will not pay for any expenses incurred for care or treatment of a Pre-existing Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If You had less than six (6) months prior Creditable Coverage, the Pre-existing Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Virginia

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-AA-A-VA; Plan F: HNHIC-MS-AA-F-VA; Plan G: HNHIC-MS-AA-G-VA; Plan HDG: HNHIC-MS-AA-HDG-VA; Plan N: HNHIC-MS-AA-N-VA

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible (not applicable in Plan F);

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

West Virginia

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-AA-A-WV; Plan F: HNHIC-MS-AA-F-WV; Plan G: HNHIC-MS-AA-G-WV; Plan N: HNHIC-MS-AA-N-WV

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible (not applicable in Plans C and F);

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Wisconsin

Medicare Supplement Policy Form Series: HNHIC-MS-BASIC-WI, HNHIC-MS-AHC-WI, HNHIC-MS-FTV-WI, HNHIC-MS-PBCO-WI, HNHIC-MS-PBEX-WI, HNHIC-MS-PTAD-WI, HNHIC-MS-PTBD-WI

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) Skilled Nursing Facility Care costs beyond what is covered by Medicare and the Wisconsin mandated thirty (30) day skilled nursing benefit;

(2) Home Health Care visits beyond the number of visits covered by Medicare and the Wisconsin mandated forty (40) visits in a twelve (12) month period;

(3) Physician charges above Medicare's approved charge, unless the Optional Medicare Part B Excess Charges Rider is purchased;

(4) Outpatient prescription drugs;

(5) most care received outside the USA, unless the Optional Foreign Travel Emergency Rider is purchased;

(6) dental care (except anesthesia charges for dental care provided in a hospital or ambulatory surgery center), dentures, checkups, routine immunizations, cosmetic surgery, routine foot care, examinations for and the cost of eyeglasses or hearing aids, unless eligible by Medicare;

(7) any expense incurred in excess of the Usual and Customary Charge or not medically necessary as determined by Us for all required Wisconsin mandated benefits;

(8) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(9) any services that are not medically necessary as determined by Medicare;

(10) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(11) any type of expense not a Medicare Eligible Expense except as provided previously in this policy; and

(12) We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Wyoming

Medicare Supplement Policy Forms: Plan A: HNHIC-MS-AA-A-WY; Plan F: HNHIC-MS-AA-F-WY; Plan G: HNHIC-MS-AA-G-WY; Plan HDG: HNHIC-MS-AA-HDG-WY; Plan N: HNHIC-MS-AA-N-WY

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first ninety (90) days from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least ninety (90) days of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a ninety (90) day waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than ninety (90) days prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Alaska, District of Columbia and Hawaii

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare eligible expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible (not applicable in Plan F);

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare eligible expense except as provided previously in this policy;

(6) any deductible, coinsurance or co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy;

(7) confinement that begins or expenses incurred while your policy is not in force; or

(8) Pre-existing Conditions: These policies will not pay for any expenses incurred for care or treatment of a Pre-existing Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior creditable coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior creditable coverage, the pre-existing conditions limitation will be reduced by the aggregate amount of creditable coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied. A pre-existing condition is a condition for which medical advice was given or treatment was recommended by or received from a Physician within six (6) months prior to the policy effective date.

Idaho, Maine, Rhode Island and Vermont

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible (not applicable in Plans C and F);

(2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.