(1) The following amounts, as published in the Federal Register, for services furnished in the current calendar year under Medicare's hospital insurance program (Medicare Part A), must apply to the charts for 1990 Plans A through L for policies issued prior to June 2010 in (2)(b) through (m). In each chart, the rule cited in brackets as ARM [6.6.511(1)(a)], [6.6.511(1)(b)], [6.6.511(1)(c)], [6.6.511(1)(d)], [6.6.511(1)(e)], [6.6.511(1)(f)], [6.6.511(1)(g)], [6.6.511(1)(h)], [6.6.511(1)(i)], or [6.6.511(1)(j)], represents the dollar amount specified in the cited rule subsection. The issuer must replace each bracket and rule cite with the correct dollar amount contained in the cited rule subsection when the issuer prints the charts:

(a) inpatient hospital deductible = $1068.00;

(b) benefit period = $267.00;

(c) daily coinsurance amount for the 61st through 90th days of hospitalization in a coinsurance amount for lifetime reserve days = $534.00;

(d) daily coinsurance amount for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period = $133.50;

(e) 50% of inpatient hospital deductible = $534.00;

(f) 75% of inpatient hospital deductible = $801.00;

(g) 25% of inpatient hospital deductible = $267.00;

(h) 50% of daily coinsurance amount for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period = $66.75;

(i) 75% of daily coinsurance amount for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period = $100.13; and

(j) 25% of daily coinsurance amount for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period = $33.38.

(2) The following are sample forms of the outline of coverage for Medicare supplement policies.

(3) The CSI adopts and incorporates by reference the National Association of Insurance Commissioners (NAIC) Model Regulation to Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act, page 651-56 through page 651-106, which sets forth the Medicare payment tables for insurers, and specifically in this rule are Plans A, B, C, D, E, F or High Deductible F, G, H, I, J or High Deductible J, K, L, Medicare Part A - Hospital Services - Per Benefit Period; Plans A, B, C, D, E, F or High Deductible F, G, H, I, J or High Deductible J, K, L, Medicare Part B - Medical Services - Per Calendar Year; Plans A, B, C, D, E, F or High Deductible F, G, H, I, J or High Deductible J, K, L, Medicare Parts A & B; Plans C, D, E, F or High Deductible F, G, H, I, J or High Deductible J, Other Benefits - Not Covered by Medicare; adopted 7/17/09. Copies of the NAIC Model rule containing Plans A - L are available for public inspection at the Office of the Commissioner of Securities and Insurance, Montana State Auditor, Legal Department, 840 Helena Avenue, Helena, Montana 59601, or on the department's web site. Persons obtaining a copy of these forms must pay the cost of providing such copies.