aetna life insurance company outline of medicare ...€¦ · benefit plans a, b, c , f, g and n are...
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Aetna Life Insurance Company
Outline of Medicare Supplement Coverage
Benefit Plans A, B, C , F, G and N are Offered�This chart shows the benefits included in each of the standard Medicare supplement plans. Every insurer must make available Plan "A." Some plans may not be
available in your state.
Basic Benefits:
Hospitalization - Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
Medical Expenses - Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L and N
require insured to pay a portion of Part B coinsurance or copayments.
Blood - First three pints of blood each year.
Hospice - Part A coinsurance.
A B C D F l F*
G K** L** M N
Basic
including
100% Part B
coinsurance
Basic
including
100% Part B
coinsurance
Basic
including
100% Part B
coinsurance
Basic including
100% Part B
coinsurance
Basic including
100% Part B
coinsurance *
Basic including
100% Part B
coinsurance
Hospitalization
and preventive
care paid at
100%; other
basic benefits
paid at 50%
Hospitalization
and
preventive
care paid at
100%; other
basic benefits
paid at 75%
Basic including
100% Part B
coinsurance
Basic including
100% Part B
coinsurance,
except up to
$20 copayment
for office visit,
and up to $50
copayment for
ER
Skilled
Nursing
Facility
Coinsurance
Skilled Nursing
Facility
Coinsurance
Skilled Nursing
Facility
Coinsurance
Skilled Nursing
Facility
Coinsurance
50% Skilled
Nursing Facility
Coinsurance
75% Skilled
Nursing
Facility
Coinsurance
Skilled Nursing
Facility
Coinsurance
Skilled Nursing
Facility
Coinsurance
Part A
Deductible
Part A
Deductible
Part A
Deductible
Part A
Deductible
Part A
Deductible
50% Part A
Deductible
75% Part A
Deductible
50% Part A
Deductible
Part A
Deductible
Part B
Deductible
Part B
Deductible
Part B Excess-
100%
Part B Excess-
100%
Foreign Travel
Emergency
Foreign Travel
Emergency
Foreign Travel
Emergency
Foreign Travel
Emergency
Foreign Travel
Emergency
Foreign Travel
Emergency
Out-of-pocket
limit $4,960;
paid at 100%
after limit
reached***
Out-of-pocket
limit $2,480;
paid at 100%
after limit
reached***
GR-11613-03-OOC –MI Effective 01-01-2016
18.02.312.1-MI K (12/15)
Aetna Life Insurance Company
Outline of Medicare Supplement Coverage
Benefit Plans A, B, C, F, G and N are Offered�
*Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180
deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. Out-of-pocket expenses for this deductible are
expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the Plan’s
separate foreign travel emergency deductible.
**Plans K and L provide for different cost-sharing for items and services than the other plans.
Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance, and deductibles for the rest of the calendar year. The out-of-
pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called “Excess Charges.” You will be responsible for
payment of excess charges.
***The out-of-pocket annual limit will increase each year for inflation.
GR-11613-03-OOC –MI Effective 01-01-2016
18.02.312.1-MI K (12/15)
PREMIUM INFORMATION Questions? We’re here to help.
Just call us at 1-800-345-6022
(TTY: 711)
We, Aetna Life Insurance Company, can only raise your premium if we raise the premium for all policies like yours in this state, when your age changes or to
coincide with changes in Medicare. Aetna will send a written notice at least 31 days before the change becomes effective.
The monthly premiums shown will apply when payment is made on a quarterly, semi-annual or annual basis or if you elect to have your payments
automatically deducted from your checking account (Electronic Funds Transfer program) or credit card account. To obtain quarterly premium, multiply the
monthly premium by 3. For semi-annual premium and annual premium, multiply the monthly premium by 6 or 12, respectively. If you elect to pay your
premium on a monthly basis by check or money order, add $2 to the monthly premium shown to calculate your monthly premium amount.
If you use tobacco and you enroll other than during the Medicare Supplement Open Enrollment and Guaranteed issue rights periods, a tobacco use premium
rate will apply. Please refer to the Guaranteed Issue Guidelines notice included in your enrollment materials for details on open enrollment and guaranteed
issue rights. Tobacco use premium rates are determined by multiplying the premium shown by a factor of 1.10.
GR-11613-03-OOC –MI Effective 01-01-2016
18.02.312.1-MI K (12/15)
MONTHLY PREMIUMS The rates in the table below apply to the following ZIP CODES: 48600 through 49299�
Attained Age
PLAN A
Male Female
PLAN B
Male Female
PLAN C
Male Female
PLAN F
Male Female
PLAN G
Male Female
PLAN N
Male Female
65 $140.91 $130.08 $156.83 $143.99 $181.41 $166.74 $182.16 $167.41 $160.49 $149.41 $125.49 $117.00
66 $146.16 $134.99 $162.66 $149.41 $188.16 $173.08 $188.99 $173.74 $168.16 $156.49 $131.58 $122.66
67 $151.49 $139.83 $168.49 $154.74 $194.91 $179.24 $195.74 $179.99 $175.91 $163.66 $137.74 $128.41
68 $157.58 $145.41 $176.41 $161.91 $204.16 $187.74 $204.99 $188.49 $183.58 $170.83 $143.91 $134.16
69 $163.66 $151.08 $184.16 $168.99 $213.41 $196.24 $214.24 $196.99 $191.24 $177.91 $149.99 $139.83
70 $169.74 $156.74 $191.91 $176.08 $222.49 $204.66 $223.41 $205.41 $198.83 $185.08 $156.16 $145.58
71 $175.83 $162.33 $199.58 $183.24 $231.66 $212.99 $232.57 $213.82 $206.49 $192.16 $162.24 $151.16
72 $181.83 $167.83 $207.24 $190.24 $240.74 $221.32 $241.66 $222.24 $214.07 $199.16 $168.33 $156.91
73 $185.99 $171.74 $213.66 $196.16 $248.66 $228.57 $249.57 $229.49 $222.57 $207.08 $175.16 $163.33
74 $190.08 $175.49 $220.07 $202.08 $256.41 $235.74 $257.41 $236.74 $230.91 $214.91 $182.08 $169.74
75 $194.16 $179.24 $226.57 $207.99 $264.16 $242.99 $265.24 $243.91 $239.32 $222.66 $188.91 $176.08
76 $198.24 $183.08 $232.99 $213.91 $271.99 $250.16 $273.07 $251.07 $247.66 $230.49 $195.74 $182.49
77 $202.33 $186.74 $239.32 $219.74 $279.74 $257.24 $280.91 $258.24 $256.07 $238.24 $202.58 $188.83
78 $205.33 $189.49 $243.74 $223.74 $285.49 $262.49 $286.49 $263.41 $263.07 $244.82 $208.57 $194.33
79 $208.24 $192.16 $247.99 $227.66 $290.99 $267.57 $292.15 $268.57 $270.07 $251.32 $214.49 $199.91
80 $210.99 $194.83 $252.24 $231.57 $296.40 $272.66 $297.57 $273.57 $276.99 $257.74 $220.32 $205.41
81 $213.66 $197.24 $256.41 $235.41 $301.90 $277.57 $302.99 $278.66 $283.99 $264.24 $226.32 $210.99
82 $216.24 $199.66 $260.66 $239.32 $307.40 $282.66 $308.49 $283.66 $290.91 $270.74 $232.24 $216.41
83 $217.99 $201.16 $265.74 $243.91 $314.74 $289.41 $315.82 $290.41 $304.65 $283.49 $244.49 $227.82
84 $219.57 $202.66 $270.66 $248.49 $321.99 $296.15 $323.15 $297.15 $318.49 $296.40 $256.57 $239.24
85 $221.07 $204.16 $275.91 $253.41 $329.74 $303.24 $330.82 $304.24 $330.49 $307.49 $267.41 $249.32
86 $222.57 $205.41 $280.16 $257.16 $336.40 $309.24 $337.49 $310.32 $342.90 $319.07 $278.74 $259.91
87 $223.91 $206.66 $284.32 $260.99 $341.32 $313.99 $342.57 $314.90 $355.90 $331.15 $290.49 $270.82
88 $225.41 $208.08 $288.49 $264.91 $346.49 $318.65 $347.74 $319.65 $369.24 $343.65 $302.82 $282.32
89 $226.82 $209.32 $292.90 $268.91 $351.74 $323.40 $352.90 $324.49 $383.15 $356.57 $315.65 $294.24
90+ $228.24 $210.66 $297.32 $272.91 $356.99 $328.32 $358.24 $329.32 $397.57 $369.99 $328.90 $306.65
Under 65 $389.98 $360.07 N/A N/A $516.23 $474.81 N/A N/A N/A N/A N/A N/A
GR-11613-03-OOC –MI Effective 01-01-2016
18.02.312.1-MI K (12/15)
MONTHLY PREMIUMS The rates in the table below apply to the following ZIP CODES: 49300 through 49999�
Attained Age
PLAN A
Male Female
PLAN B
Male Female
PLAN C
Male Female
PLAN F
Male Female
PLAN G
Male Female
PLAN N
Male Female
65 $133.87 $123.57 $148.99 $136.79 $172.34 $158.41 $173.05 $159.04 $152.47 $141.94 $119.22 $111.15
66 $138.85 $128.24 $154.53 $141.94 $178.75 $164.42 $179.54 $165.06 $159.75 $148.67 $125.00 $116.53
67 $143.92 $132.84 $160.07 $147.01 $185.16 $170.28 $185.96 $170.99 $167.11 $155.48 $130.86 $121.99
68 $149.70 $138.14 $167.59 $153.81 $193.95 $178.36 $194.74 $179.07 $174.40 $162.29 $136.72 $127.45
69 $155.48 $143.52 $174.95 $160.54 $202.74 $186.43 $203.53 $187.14 $181.68 $169.01 $142.49 $132.84
70 $161.26 $148.91 $182.31 $167.27 $211.37 $194.43 $212.24 $195.14 $188.88 $175.82 $148.35 $138.30
71 $167.03 $154.21 $189.60 $174.08 $220.07 $202.34 $220.95 $203.13 $196.17 $182.55 $154.13 $143.60
72 $172.73 $159.44 $196.88 $180.73 $228.70 $210.26 $229.57 $211.13 $203.37 $189.20 $159.91 $149.06
73 $176.69 $163.16 $202.98 $186.35 $236.22 $217.15 $237.09 $218.02 $211.45 $196.72 $166.40 $155.16
74 $180.57 $166.72 $209.07 $191.97 $243.59 $223.95 $244.54 $224.90 $219.36 $204.16 $172.97 $161.26
75 $184.45 $170.28 $215.25 $197.59 $250.95 $230.84 $251.98 $231.71 $227.36 $211.52 $179.46 $167.27
76 $188.33 $173.92 $221.34 $203.21 $258.39 $237.65 $259.42 $238.52 $235.27 $218.97 $185.96 $173.37
77 $192.21 $177.41 $227.36 $208.75 $265.75 $244.38 $266.86 $245.33 $243.27 $226.33 $192.45 $179.38
78 $195.06 $180.02 $231.55 $212.55 $271.21 $249.37 $272.16 $250.24 $249.92 $232.58 $198.15 $184.61
79 $197.83 $182.55 $235.59 $216.27 $276.44 $254.19 $277.55 $255.14 $256.57 $238.76 $203.77 $189.91
80 $200.44 $185.08 $239.63 $220.00 $281.58 $259.02 $282.69 $259.89 $263.14 $244.85 $209.31 $195.14
81 $202.98 $187.38 $243.59 $223.64 $286.81 $263.69 $287.84 $264.72 $269.79 $251.03 $215.01 $200.44
82 $205.43 $189.68 $247.62 $227.36 $292.03 $268.52 $293.06 $269.47 $276.36 $257.20 $220.63 $205.59
83 $207.09 $191.10 $252.45 $231.71 $299.00 $274.93 $300.03 $275.88 $289.42 $269.31 $232.27 $216.43
84 $208.60 $192.53 $257.12 $236.07 $305.89 $281.35 $307.00 $282.30 $302.56 $281.58 $243.74 $227.28
85 $210.02 $193.95 $262.11 $240.74 $313.25 $288.08 $314.28 $289.03 $313.96 $292.11 $254.04 $236.86
86 $211.45 $195.14 $266.15 $244.30 $319.58 $293.78 $320.61 $294.80 $325.76 $303.12 $264.80 $246.91
87 $212.71 $196.33 $270.11 $247.94 $324.25 $298.29 $325.44 $299.16 $338.11 $314.60 $275.96 $257.28
88 $214.14 $197.67 $274.06 $251.66 $329.16 $302.72 $330.35 $303.67 $350.77 $326.47 $287.68 $268.21
89 $215.48 $198.86 $278.26 $255.46 $334.15 $307.23 $335.26 $308.26 $363.99 $338.74 $299.87 $279.53
90+ $216.83 $200.13 $282.46 $259.26 $339.14 $311.90 $340.32 $312.85 $377.69 $351.49 $312.46 $291.32
Under 65 $370.49 $342.07 N/A N/A $490.42 $451.07 N/A N/A N/A N/A N/A N/A
GR-11613-03-OOC –MI Effective 01-01-2016
18.02.312.1-MI K (12/15)
MONTHLY PREMIUMS
The rates in the table below apply to the following ZIP CODES: 48000 through 48599�
Attained Age
PLAN A
Male Female
PLAN B
Male Female
PLAN C
Male Female
PLAN F
Male Female
PLAN G
Male Female
PLAN N
Male Female
65 $170.50 $157.39 $189.76 $174.23 $219.51 $201.76 $220.41 $202.57 $194.20 $180.79 $151.85 $141.56
66 $176.85 $163.34 $196.82 $180.79 $227.67 $209.42 $228.68 $210.23 $203.47 $189.36 $159.21 $148.42
67 $183.31 $169.19 $203.88 $187.24 $235.84 $216.88 $236.85 $217.79 $212.85 $198.03 $166.67 $155.38
68 $190.67 $175.95 $213.46 $195.91 $247.03 $227.17 $248.04 $228.08 $222.13 $206.70 $174.13 $162.34
69 $198.03 $182.80 $222.83 $204.48 $258.22 $237.45 $259.23 $238.36 $231.40 $215.27 $169.19
70 $205.39 $189.66 $232.21 $213.05 $269.21 $247.64 $270.32 $248.54 $240.58 $223.94 $188.95 $176.15
71 $212.75 $196.42 $241.49 $221.72 $280.31 $257.72 $281.41 $258.73 $249.86 $232.51 $196.31 $182.90
72 $220.01 $203.07 $250.76 $230.19 $291.30 $267.80 $292.40 $268.91 $259.03 $240.98 $203.68 $189.86
73 $225.05 $207.81 $258.53 $237.35 $300.87 $276.57 $301.98 $277.68 $269.32 $250.56 $211.94 $197.63
74 $229.99 $212.35 $266.29 $244.51 $310.25 $285.25 $311.46 $286.46 $279.40 $260.04 $220.31 $205.39
75 $234.93 $216.88 $274.15 $251.67 $319.63 $294.02 $320.94 $295.13 $289.58 $269.42 $228.58 $213.05
76 $239.87 $221.52 $281.92 $258.83 $329.11 $302.69 $330.42 $303.80 $299.66 $278.89 $236.85 $220.82
77 $244.81 $225.96 $289.58 $265.89 $338.48 $311.26 $339.90 $312.47 $309.85 $288.27 $245.12 $228.48
78 $248.44 $229.29 $294.93 $270.73 $345.44 $317.61 $346.65 $318.72 $318.32 $296.24 $252.38 $235.13
79 $251.97 $232.51 $300.07 $275.47 $352.10 $323.76 $353.51 $324.97 $326.79 $304.10 $259.53 $241.89
80 $255.30 $235.74 $305.21 $280.20 $358.65 $329.91 $360.06 $331.02 $335.16 $311.87 $266.59 $248.54
81 $258.53 $238.66 $310.25 $284.84 $365.30 $335.86 $366.62 $337.17 $343.63 $319.73 $273.85 $255.30
82 $261.65 $241.59 $315.39 $289.58 $371.96 $342.01 $373.27 $343.22 $352.00 $327.59 $281.01 $261.85
83 $263.77 $243.40 $321.54 $295.13 $380.83 $350.18 $382.14 $351.39 $368.63 $343.02 $295.83 $275.67
84 $265.69 $245.22 $327.49 $300.67 $389.60 $358.35 $391.02 $359.56 $385.37 $358.65 $310.45 $289.48
85 $267.50 $247.03 $333.85 $306.62 $398.98 $366.92 $400.29 $368.13 $399.89 $372.06 $323.56 $301.68
86 $269.32 $248.54 $338.99 $311.16 $407.05 $374.18 $408.36 $375.49 $414.91 $386.08 $337.27 $314.49
87 $270.93 $250.06 $344.03 $315.80 $413.00 $379.92 $414.51 $381.03 $430.64 $400.70 $351.49 $327.70
88 $272.74 $251.77 $349.07 $320.54 $419.25 $385.57 $420.76 $386.78 $446.77 $415.82 $366.41 $341.61
89 $274.46 $253.28 $354.41 $325.38 $425.60 $391.32 $427.01 $392.63 $463.61 $431.45 $381.94 $356.03
90+ $276.17 $254.90 $359.76 $330.22 $431.95 $397.27 $433.47 $398.48 $481.06 $447.68 $397.97 $371.05
Under 65 $471.88 $435.68 N/A N/A $624.64 $574.53 N/A N/A N/A N/A N/A N/A
GR-11613-03-OOC –MI Effective 01-01-2016
18.02.312.1-MI K (12/15)
DISCLOSURES Questions? We’re here to help.
Just call us at 1-800-345-6022
(TTY: 711)
Use this outline to compare benefits and premiums among policies.
READ YOUR POLICY VERY CAREFULLY This is only an outline describing your policy's most important features. The policy is your insurance
contract. You must read the policy itself to understand all of the rights and duties of both you and Aetna
Life Insurance Company.
RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to Aetna Life Insurance
Company, PO Box 14770, Lexington, KY 40512. If you send the policy back to us within 30 days after you
receive it, we will treat the policy as if it had never been issued and return all of your payments.
POLICY REPLACEMENT If you are replacing another health insurance policy, do NOT cancel it until you have actually received
your new policy and are sure you want to keep it.
NOTICE This policy may not fully cover all of your medical costs. Neither Aetna Life Insurance Company nor its
agents are connected with Medicare. This outline of coverage does not give all the details of Medicare
coverage. Contact your local Social Security Office or consult "Medicare & You" for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new policy, be sure to answer truthfully and completely all
questions about your medical and health history. The Company may cancel your policy and refuse to pay
any claims if you leave out or falsify important medical information.
Review the application carefully before you sign it. Be certain that all information has been properly recorded.�
GR-11613-03-OOC –MI Effective 01-01-2016
18.02.312.1-MI K (12/15)
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PLAN A
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan A
Plan Pays You Pay
HOSPITALIZATION*
Semi-private room and board, general nursing
and miscellaneous services and supplies
First 60 days All but $1,288 $0 $1,288
(Part A deductible)
61st thru 90th day All but $322 a day $322 a day $0
91st day and after:
While using 60 lifetime reserve days All but $644 a day $644 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 $161
a day
$0 Up to $161
a day
101st day and after $0 $0 All costs
*A Benefit Period begins on the first day you receive care 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.
** NOTICE – When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare
and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s
“Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference
between its billed charges and the amount Medicare would have paid.
GR-11613-03-OOC –MI Effective 01-01-2016
18.02.312.1-MI K (12/15)
PLAN A (continued)
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan A
Plan Pays You Pay
BLOOD
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s requirements,
including a doctor’s certification of terminal
illness
All but a very limited
copayment/
coinsurance for
outpatient drugs and
inpatient respite care
Medicare
copayment/
coinsurance
$0
PLAN A
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan A
Plan Pays You Pay
MEDICAL EXPENSES
IN OR OUT OF THE HOSPITAL AND
OUTPATIENT HOSPITAL TREATMENTS, such as
physician's services, inpatient and outpatient
medical and surgical services and supplies,
physical and speech therapy, diagnostic tests,
durable medical equipment
First $166 of Medicare-approved amounts* $0 $0 $166
(Part B deductible)
Remainder of Medicare-approved amounts Generally 80% Generally 20% $0
Part B excess charges (above Medicare-
approved amounts) $0 $0 All costs
*Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.
GR-11613-03-OOC –MI Effective 01-01-2016
18.02.312.1-MI K (12/15)
PLAN A (continued)
Medicare (Part B) – Medical Services – Per Calendar Year
•
•
Services Medicare Pays Plan A
Plan Pays You Pay
BLOOD
First 3 pints $0 All costs $0
Next $166 of Medicare-approved amounts* $0 $0 $166
(Part B deductible)
Remainder of Medicare-approved amounts 80% 20% $0
CLINICAL LABORATORY SERVICES
Tests for diagnostic services 100% $0 $0
PARTS A & B
Services Medicare Pays Plan A
Plan Pays You Pay
HOME HEALTH CARE
Medicare-Approved Services
Medically necessary skilled care services
and medical supplies 100% $0 $0
Durable medical equipment:
-
-
First $166 of Medicare-approved
amounts*
$0 $0 $166
(Part B deductible)
Remainder of Medicare-approved
amounts
80% 20% $0
*Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.
GR-11613-03-OOC –MI Effective 01-01-2016
18.02.312.1-MI K (12/15)
•
•
PLAN B
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan B
Plan Pays You Pay
HOSPITALIZATION*
Semi-private room and board, general nursing
and miscellaneous services and supplies
First 60 days All but $1,288 $1,288
(Part A deductible)
$0
61st thru 90th day All but $322 a day $322 a day $0
91st day and after:
While using 60 lifetime reserve days All but $644 a day $644 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 $161
a day
$0 Up to $161
a day
101st day and after $0 $0 All costs
*A Benefit Period begins on the first day you receive care 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.
** NOTICE – When your Medicare Part A Hospital benefits are exhausted, the insurer stands in the place of Medicare
and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s
“Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference
between its billed charges and the amount Medicare would have paid.
GR-11613-03-OOC –MI Effective 01-01-2016
18.02.312.1-MI K (12/15)
PLAN B (continued)
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan B
Plan Pays You Pay
BLOOD
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s requirements
including a doctor’s certification of terminal
illness
All but very limited
copayment/
coinsurance for
outpatient drugs and
inpatient respite care
Medicare copayment/
coinsurance
$0
PLAN B
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan B
Plan Pays You Pay
MEDICAL EXPENSES
IN OR OUT OF THE HOSPITAL AND
OUTPATIENT HOSPITAL TREATMENTS, such as
physician’s services, inpatient and outpatient
medical and surgical services and supplies,
physical and speech therapy, diagnostic tests,
durable medical equipment
First $166 of Medicare-approved amounts* $0 $0 $166
(Part B deductible)
Remainder of Medicare-approved amounts Generally 80% Generally 20% $0
Part B Excess Charges (above Medicare-
approved amounts) $0 $0 All costs
*Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.
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PLAN B (continued)
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan B
Plan Pays You Pay
BLOOD
First 3 pints $0 All costs $0
Next $166 of Medicare-approved amounts* $0 $0 $166
(Part B deductible)
Remainder of Medicare-approved amounts 80% 20% $0
CLINICAL LABORATORY SERVICES
Tests for diagnostic services 100% $0 $0
PARTS A & B
Services Medicare Pays Plan B
Plan Pays You Pay
HOME HEALTH CARE
Medicare-Approved Services
•
•
Medically necessary skilled care services
and medical supplies
100% $0 $0
Durable medical equipment:
-
-
First $166 of Medicare-approved
amounts*
$0 $0 $166
(Part B deductible)
Remainder of Medicare-approved
amounts
80% 20% $0
*Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.
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PLAN C
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan C
Plan Pays You Pay
HOSPITALIZATION*
Semi-private room and board, general nursing
and miscellaneous services and supplies
First 60 days All but $1,288 $1,288
(Part A deductible)
$0
61st thru 90th day All but $322 a day $322 a day $0
91st day and after:
While using 60 lifetime reserve days All but $644 a day $644 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 $161
a day
Up to $161
a day
$0
101st day and after $0 $0 All costs
*A Benefit Period begins on the first day you receive care 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.
** NOTICE – When your Medicare Part A Hospital benefits are exhausted, the insurer stands in the place of Medicare
and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s
“Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference
between its billed charges and the amount Medicare would have paid.
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PLAN C (continued)
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan C
Plan Pays You Pay
BLOOD
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s requirements
including a doctor’s certification of terminal
illness
All but very limited
copayment/
coinsurance for
outpatient drugs and
inpatient respite care
Medicare copayment/
coinsurance
$0
PLAN C
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan C
Plan Pays You Pay
MEDICAL EXPENSES
IN OR OUT OF THE HOSPITAL AND
OUTPATIENT HOSPITAL TREATMENTS, such as
physician’s services, inpatient and outpatient
medical and surgical services and supplies,
physical and speech therapy, diagnostic tests,
durable medical equipment
First $166 of Medicare-approved amounts* $0 $166
(Part B deductible)
$0
Remainder of Medicare-approved amounts Generally 80% Generally 20% $0
Part B Excess Charges (above Medicare-
approved amounts) $0 $0 All costs
*Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.
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PLAN C (continued)
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan C
Plan Pays You Pay
BLOOD
First 3 pints $0 All costs $0
Next $166 of Medicare-approved amounts* $0 $166
(Part B deductible)
$0
Remainder of Medicare-approved amounts 80% 20% $0
CLINICAL LABORATORY SERVICES
Tests for diagnostic services 100% $0 $0
PARTS A & B
Services Medicare Pays Plan C
Plan Pays You Pay
HOME HEALTH CARE
Medicare-Approved Services
•
•
Medically necessary skilled care services
and medical supplies
100% $0 $0
Durable medical equipment:
-
-
First $166 of Medicare-approved
amounts*
$0 $166
(Part B deductible)
$0
Remainder of Medicare-approved
amounts
80% 20% $0
*Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.
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PLAN C OTHER BENEFITS – Not Covered by Medicare
Services Medicare Pays Plan C
Plan 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 such charges $0 80% to a lifetime
maximum benefit of
$50,000
20% and amounts
over the $50,000
lifetime maximum
*Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.
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PLAN F
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan F
Plan Pays You Pay
HOSPITALIZATION*
Semi-private room and board, general nursing
and miscellaneous services and supplies
First 60 days All but $1,288 $1,288
(Part A deductible)
$0
61st thru 90th day All but $322 a day $322 a day $0
91st day and after:
While using 60 lifetime reserve days All but $644 a day $644 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 $161
a day
Up to $161
a day
$0
101st day and after $0 $0 All costs
*A Benefit Period begins on the first day you receive care 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.
** NOTICE – When your Medicare Part A Hospital benefits are exhausted, the insurer stands in the place of Medicare
and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s
“Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference
between its billed charges and the amount Medicare would have paid.
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PLAN F (continued)
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan F
Plan Pays You Pay
BLOOD
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s requirements,
including a doctor’s certification of terminal
illness
All but very limited
copayment/
coinsurance for
outpatient drugs and
inpatient respite care
Medicare
copayment/
coinsurance
$0
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan F
Plan Pays You Pay
MEDICAL EXPENSES
IN OR OF THE HOSPITAL AND OUTPATIENT
HOSPITAL TREATMENTS, such as physician's
services, inpatient and outpatient medical and
surgical services and supplies, physical and
speech therapy, diagnostic tests, durable
medical equipment
First $166 of Medicare-approved amounts* $0 $166
(Part B deductible)
$0
Remainder of Medicare-approved amounts Generally 80% Generally 20% $0
Part B Excess Charges (above Medicare-
approved amounts) $0 100% of all costs $0
BLOOD
First 3 pints $0 All costs $0
Next $166 of Medicare-approved amounts* $0 $166
(Part B deductible)
$0
Remainder of Medicare-approved amounts 80% 20% $0
*Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.
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PLAN F (continued)
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan F
Plan Pays You Pay
CLINICAL LABORATORY SERVICES
Tests for diagnostic services 100% $0 $0
PARTS A & B
Services Medicare Pays Plan F
Plan Pays You Pay
HOME HEALTH CARE
Medicare-Approved Services
Medically necessary skilled care services
and medical supplies
100% $0 $0
Durable medical equipment:
-
-
First $166 of Medicare-approved
amounts*
$0 $166
(Part B deductible)
$0
Remainder of Medicare-approved
amounts
80% 20% $0
OTHER BENEFITS – Not Covered by Medicare
Services Medicare Pays Plan F
Plan 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 such charges $0 80% to a lifetime
maximum benefit of
$50,000
20% and amounts
over the $50,000
lifetime maximum
*Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.
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PLAN G
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan G
Plan Pays You Pay
HOSPITALIZATION*
Semi-private room and board, general nursing
and miscellaneous services and supplies
First 60 days All but $1,288 $1,288
(Part A deductible)
$0
61st thru 90th day All but $322 a day $322 a day $0
91st day and after:
While using 60 lifetime reserve days All but $644 a day $644 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 $161 a day Up to $161 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
You must meet Medicare’s requirements,
including a doctor’s certification of terminal
illness
All but very limited
copayment/coinsurance
for outpatient drugs and
inpatient respite care
Medicare copayment/
coinsurance
$0
*A Benefit Period begins on the first day you receive care 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.
**NOTICE – When your Medicare Part A Hospital benefits are exhausted, the insurer stands in the place of Medicare
and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s
“Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference
between its billed charges and the amount Medicare would have paid.
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PLAN G
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan G
Plan Pays You Pay
MEDICAL EXPENSES
IN OR OUT OF THE HOSPITAL AND
OUTPATIENT HOSPITAL TREATMENTS, such
as physician’s services, inpatient and
outpatient medical and surgical services and
supplies, physical and speech therapy,
diagnostic tests, durable medical equipment
First $166 of Medicare-approved amounts* $0 $0 $166 (Part B
deductible)
Remainder of Medicare-approved amounts Generally 80% Generally 20% $0
Part B Excess Charges (above Medicare-
approved amounts) $0 100% of all costs $0
BLOOD
First 3 pints $0 All costs $0
Next $166 of Medicare-approved amounts* $0 $0 $166 (Part B
deductible)
Remainder of Medicare-approved amounts 80% 20% $0
CLINICAL LABORATORY SERVICES
Tests for diagnostic services 100% $0 $0
*Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B Deductible will have been met for the calendar year.
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PLAN G PARTS A & B
Services Medicare Pays Plan G
Plan Pays You Pay
HOME HEALTH CARE
Medicare-Approved Services
Medically necessary skilled care services
and medical supplies
100% $0 $0
Durable medical equipment:
-
-
First $166 of Medicare-approved
amounts*
$0 $0 $166 (Part B
deductible)
Remainder of Medicare-approved
amounts
80% 20% $0
OTHER BENEFITS – Not Covered by Medicare
Services Medicare Pays Plan G
Plan 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 such charges $0 80% to a lifetime
maximum benefit of
$50,000
20% and amounts
over the $50,000
lifetime maximum
*Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an asterisk),
your Part B Deductible will have been met for the calendar year.
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PLAN N
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan N
Plan Pays You Pay
HOSPITALIZATION*
Semi-private room and board, general nursing
and miscellaneous services and supplies
First 60 days All but $1,288 $1,288
(Part A deductible)
$0
61st thru 90th day All but $322 a day $322 a day $0
91st day and after:
While using 60 lifetime reserve days All but $644 a day $644 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 $161 a day Up to $161 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
You must meet Medicare’s requirements,
including a doctor’s certification of terminal
illness
All but very limited
copayment/coinsurance
for outpatient drugs and
inpatient respite care
Medicare copayment/
coinsurance
$0
*A Benefit Period begins on the first day you receive care 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.
**NOTICE – When your Medicare Part A Hospital benefits are exhausted, the insurer stands in the place of Medicare
and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s
“Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference
between its billed charges and the amount Medicare would have paid.
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PLAN N
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan N
Plan Pays You Pay
MEDICAL EXPENSES
IN OR OUT OF THE HOSPITAL AND
OUTPATIENT HOSPITAL TREATMENTS, such
as physician’s services, inpatient and
outpatient medical and surgical services and
supplies, physical and speech therapy,
diagnostic tests, durable medical equipment
First $166 of Medicare-approved amounts* $0 $0 $166 (Part B
deductible)
Remainder of Medicare-approved amounts Generally 80% Balance, other than up
to $20 per office visit
and up to $50 per
emergency room visit.
The co-payment of up
to $50 is waived if the
insured is admitted to
any hospital and the
emergency visit is
covered as a Medicare
Part A expense.
Up to $20 per office
visit and up to $50
per emergency
room visit. The co-
payment of up to
$50 is waived if the
insured is admitted
to any hospital and
the emergency visit
is covered as a
Medicare Part A
expense.
Part B Excess Charges (above Medicare-
approved amounts) $0 $0 All costs
BLOOD
First 3 pints $0 All costs $0
Next $166 of Medicare-approved amounts* $0 $0 $166 (Part B
deductible)
Remainder of Medicare-approved amounts 80% 20% $0
CLINICAL LABORATORY SERVICES
Tests for diagnostic services 100% $0 $0
*Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B Deductible will have been met for the calendar year.
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PLAN N PARTS A & B�
Services Medicare Pays Plan N
Plan Pays You Pay
HOME HEALTH CARE
Medicare-Approved Services
•
•
Medically necessary skilled care services
and medical supplies
100% $0 $0
Durable medical equipment:
-
-
First $166 of Medicare-approved
Amounts*
$0 $0 $166 (Part B
Deductible)
Remainder of Medicare-approved
amounts
80% 20% $0
OTHER BENEFITS – Not Covered by Medicare
Services Medicare Pays Plan N
Plan 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 such charges $0 80% to a lifetime
maximum benefit of
$50,000
20% and amounts
over the $50,000
lifetime maximum
*Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B Deductible will have been met for the calendar year.
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Guaranteed Issue Guidelines Questions? We’re here to help.
Just call us at 1-800-345-6022
(TTY: 711)
FOR INDIVIDUALS WHO ARE 65 YEARS OF AGE OR OLDER AT THE TIME OF ENROLLMENT:
In some situations, you are eligible for Guaranteed Issue of a Medicare Supplement Plan. If one of the following
conditions applies to you, you are eligible for an Aetna Individual Medicare Supplement PlanSM
on a guaranteed issue
basis (“Eligible Person”) and you will not be required to complete the Statement of Health Questions section of the
Application.
Open Enrollment - You are eligible for Guaranteed Issue if you are at least age 65 and apply for an Aetna Individual
Medicare Supplement Plan insurance policy prior to or during the six-month period beginning with the first day of the
month in which you are enrolled for benefits under Medicare Part B. You must submit evidence that you have Medicare
Parts A and B with your Application.
Other Situations - You are eligible for Guaranteed Issue for an Aetna Individual Medicare Supplement Plan insurance
policy if you apply for the policy in the guarantee issue time periods described below, you submit evidence of the date
of termination or disenrollment with the Application, and you meet one of the following conditions:
1. You are enrolled in an employee welfare benefit plan that provides health benefits that supplement the benefits
under Medicare, and the plan terminates or ceases to provide such supplemental health benefits to you;
2. You are enrolled with a Medicare Advantage organization under a Medicare Advantage Plan (the “Plan”) under
Medicare Part C or under a Program of All-Inclusive Care for the Elderly (PACE) and any of the following apply:
The certification of the organization or plan under this part has been terminated; or
The organization has terminated or otherwise discontinued providing the Plan in the area in which you
reside; or
You are no longer eligible to elect the Plan because:
(i) of a change in your place of residence or other change in circumstances specified by the Secretary of
the Department of Health and Human Services (the “Secretary”), excluding those circumstances
where you were disenrolled from the Plan for any of the reasons described in Section 1851 (g)(3)(B) of
the federal Social Security Act (e.g., where you have not paid premiums on a timely basis, or you have
engaged in disruptive behavior as specified in standards under Section 1856); or
(ii) the Plan is terminated for all enrollees residing within a particular residential service area; or
You demonstrate, in accordance with guidelines established by the Secretary, that:
(i) The organization offering the Plan substantially violated a material provision of the organization’s
contract with the Centers for Medicare and Medicaid Services in relation to you, including the failure
to provide you, on a timely basis, with medically necessary care for which benefits are available under
the Plan, or the failure to provide such covered care in accordance with applicable quality standards;
or
(ii) The organization or agent or other entity acting on the organization’s behalf, materially
misrepresented the Plan’s provisions in marketing the Plan to you; or
You meet such other exceptional conditions as the Secretary may provide.
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3. You are enrolled with:
An eligible organization under a contract under Section 1876 (Medicare cost); a similar organization
operating under demonstration project authority, effective for periods before April 1, 1999; an organization
under agreement under section 1833(a)(1 )(A) (health care prepayment plan); or an organization under a
Medicare SELECT policy; and
Your enrollment ceases under the same circumstances that would permit discontinuance of an individual’s
election of coverage under Section 2 above.
4. You are enrolled in a Medicare supplement policy and the enrollment ceases because:
Of the insolvency of the issuer or bankruptcy of the non-issuer organization; or
Of other involuntary termination of coverage or enrollment under the policy; or
The issuer of the policy substantially violated a material provision of the policy; or
The issuer or an agent or other entity acting on the issuer’s behalf, materially misrepresented the policy’s
provisions in marketing the policy to you.
5. You were enrolled under a Medicare supplement policy and you terminate enrollment and subsequently enroll, for
the first time, with; (1) any Medicare Advantage organization under a Medicare Advantage Plan under Medicare Part
C; (2) any eligible organization under a contract under Section 1876 (Medicare cost); (3) any similar organization
operating under demonstration project authority; (4) any PACE program under Section 1894 of the Social Security
Act; (5) any organization under an agreement under Section 1833(a)(1)(A) (health care prepayment plan); or (6) a
Medicare SELECT policy, and enrollment under this section is terminated by you during any period within the first 12
months of such subsequent enrollment (during which you are permitted to terminate such subsequent enrollment
under Section 1851(e) of the federal Social Security Act).
6. You, upon first becoming enrolled for benefits under Medicare Part A at age sixty-five or older, enroll in a Medicare
Advantage Plan under Medicare Part C, or in a PACE program under Section 1894 of the Social Security Act, and
disenroll from the plan by not later than 12 months after the effective date of enrollment.
7. You enroll in a Medicare Part D plan during the initial enrollment period and, at the time of enrollment in Part D,
were enrolled under a Medicare supplement policy that covers outpatient prescription drugs and you terminate
enrollment in the Medicare supplement policy and submit evidence of enrollment in Medicare Part D along with the
application for a policy.
Guaranteed Issue Time Periods
In the case of an individual described in situation #1, the guaranteed issue period begins on the later of: (i) the
date you receive a notice of termination or cessation of all supplemental health benefits (or, if a notice is not
received, notice that a claim has been denied because of such a termination or cessation); or (ii) the date that
the applicable coverage terminates or ceases; and ends sixty-three (63) days after the date of the applicable
notice;
In the case of an individual described in situations #2, #3, #5 or #6 whose enrollment terminated involuntarily,
the guaranteed issue period begins on the date that you receive a notice of termination and ends sixty-three
(63) days after the date the applicable coverage is terminated;
In the case of an individual described in situation #4 (insolvency of the issuer or bankruptcy of the non-issuer
organization), the guaranteed issue period begins on the earlier of: (i) the date that you receive a notice of
termination, a notice of the issuer’s bankruptcy or insolvency, or other such similar notice if any, and (ii) the
date that the applicable coverage is terminated, and ends on the date that is sixty-three (63) days after the date
the coverage is terminated;
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In the case of an individual described in situations #2, #4 (issuer or the policy substantially violated a material
provision of the policy), #4 (the issuer or an agent or other entity acting on the issuer’s behalf, materially
misrepresented the policy’s provisions in marketing the policy to you), #5 or #6, who disenrolls voluntarily, the
guaranteed issue period begins on the date that is sixty (60) days before the effective date of the disenrollment
and ends on the date that is sixty-three (63) days after the effective date;
In the case of an individual described in situation #7, the guaranteed issue period begins on the date you receive
notice from the Medicare supplement issuer during the sixty (60) day period immediately preceding the Part D
enrollment period and ends on the date that is sixty-three (63) days after the effective date of the individual’s
coverage under Medicare Part D; and
In the case of an individual described in this Guaranteed Issue Guide but not described in the preceding
situations, the guaranteed issue period begins on the effective date of disenrollment and ends on the date that
is sixty-three (63) days after the effective date.
Extended Medigap Access for Interrupted Trial Periods
In the case of an individual described in situation #5 whose enrollment with an organization or provider
described in item (1) is involuntarily terminated within the first twelve (12) months of enrollment, and who,
without an intervening enrollment, enrolls with another such organization or provider, the subsequent
enrollment shall be deemed to be an initial enrollment;
In the case of an individual described in situation #6, whose enrollment with a plan or in a program described in
situation #6 is involuntarily terminated within the first twelve (12) months of enrollment, and who, without an
intervening enrollment, enrolls in another such plan or program, the subsequent enrollment shall be deemed to
be an initial enrollment; and
For the purposes of situations #5 and #6, no enrollment of an individual with an organization or provider
described in #5 (1 through 6), or with a plan or in a program described in #6, may be deemed to be an initial
enrollment under this paragraph after the two-year period beginning on the date on which you first enrolled
with such an organization, provider, plan or program.
Products to which Eligible Persons are Entitled
The Aetna Individual Medicare Supplement Plan insurance policy to which Eligible Persons are entitled.
During Open Enrollment
An Eligible Person may enroll in Aetna Individual Medicare Supplement Plan insurance policy A, B, C, F, G or N.
During Other Situations
Under situations #1, #2, #3 and #4, an Eligible Person may enroll in a Medicare supplement policy which has a benefit
package classified as plan A, B, C, F or G.
Under situation #5, an Eligible Person may enroll in the same Medicare supplement policy in which you were most
recently previously enrolled, if available, or, if not so available, a policy described as plan A, B, C, F or G.
Under situation #6, an Eligible Person may enroll in any Medicare supplement policy offered by Aetna Life Insurance
Company.
Under situation #7, an Eligible Person may enroll in a Medicare supplement policy that has a benefit package classified
as Plan A, B, C or F and that is offered and is available for issuance to new enrollees by the same issuer that issued the
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individual's Medicare supplement policy with outpatient prescription drug coverage.
FOR INDIVIDUALS WHO ARE LESS THAN AGE 65 AT THE TIME OF ENROLLMENT:
You may be eligible for Guaranteed Issue of a Medicare Supplement Plan. If the following applies to you, you are eligible
for an Aetna Individual Medicare Supplement PlanSM
on a guaranteed issue basis (“Eligible Person”).
Enrollment for under age 65 individuals is permitted only for the policies referenced below:
Open Enrollment - You are eligible for Guaranteed Issue if you become eligible for Medicare by reason of disability and
you apply for an Aetna Individual Medicare Supplement Plan insurance policy prior to or during the six-month period
beginning with the first day of the month in which you are enrolled for benefits under Medicare Part B. You must
submit evidence that you have Medicare Parts A and B with your Application.
You are also eligible for Guaranteed Issue if you are already enrolled in Medicare by reason of disability. You must
submit evidence that you have Medicare Parts A and B with your Application.
An Eligible Person may enroll in Aetna Individual Medicare Supplement Plan insurance policy A or C.
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