clims05022ri outline medsup ri 022021aaetnaseniorproducts.com. plans available to all applicants....

Outline of coverage Medicare Supplement Insurance

Benefit plans: A, B, F,High Deductible F, G, N

Rhode Island

Underwritten by

Continental Life Insurance Company of Brentwood, Tennessee

An Aetna Company

aetnaseniorproducts.com CLIMS05022RI ©2021 Aetna Inc. Rates effective: 02/2021 A

http://aetnaseniorproducts.com

CONTINENTAL LIFE INSURANCE COMPANY OFBRENTWOOD, TENNESSEEOUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE:

BENEFIT PLANS AVAILABLE: A, B, F, HF, G & N

This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan "A" available. Some plans may not be available. Only applicants first eligible for Medicare

before 2020 may purchase Plans C, F, and high deductible F. Note: A ✓means 100% of the benefit is paid.

Benefits Plans Available to All Applicants

A B D G1 K L M N

Medicare

first eligible before 2020 only

C F1

Medicare Part A coinsurance and hospital coverage (up to an

additional 365 days after Medicare benefits are used up)

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Medicare Part B coinsurance or copayment

✓ ✓ ✓ ✓ 50% 75% ✓✓copays

apply3

✓ ✓

Blood (first three pints) ✓ ✓ ✓ ✓ 50% 75% ✓ ✓ ✓ ✓Part A hospice care coinsurance or copayment

✓ ✓ ✓ ✓ 50% 75% ✓ ✓ ✓ ✓

Skilled nursing facility coinsurance ✓ ✓ 50% 75% ✓ ✓ ✓ ✓Medicare Part A deductible ✓ ✓ ✓ 50% 75% 50% ✓ ✓ ✓Medicare Part B deductible ✓ ✓Medicare Part B excess charges ✓ ✓Foreign travel emergency (up to plan limits)

✓ ✓ ✓ ✓ ✓ ✓

Out-of-pocket limit in 20212 $6,220 2 $3,110 2

1 Plans F and G also have a high deductible option, which require first paying a plan deductible of $2,370 before the plan begins to pay. Once the plan deductible is met, the plan pays 10 0% of covered services

for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible 2 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-ofpocket yearly limit.

3 Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission.

CLIMS05022RI 1 02/2021 A

Continental Life Insurance Company of Brentwood, Tennessee Annual Attained Age Premiums

For Use in ZIP Codes: Entire state Female Rates

Rates Effective 02/1/2021

Attained Age

Preferred Plan A Plan B Plan F Plan HF Plan G Plan N

65 1,536 1,937 2,176 732 1,811 1,258 66 1,536 1,937 2,176 732 1,811 1,258 67 1,536 1,937 2,176 732 1,811 1,258 68 1,601 2,016 2,267 763 1,889 1,311 69 1,671 2,108 2,355 793 1,972 1,370 70 1,740 2,192 2,441 823 2,051 1,424 71 1,806 2,275 2,526 849 2,129 1,478 72 1,869 2,353 2,605 877 2,203 1,531 73 1,926 2,428 2,675 901 2,273 1,579 74 1,983 2,499 2,744 923 2,337 1,623 75 2,033 2,560 2,806 944 2,398 1,667 76 2,080 2,620 2,863 964 2,453 1,704 77 2,124 2,672 2,911 979 2,505 1,742 78 2,163 2,728 2,956 995 2,554 1,775 79 2,202 2,775 2,998 1,009 2,598 1,804 80 2,240 2,819 3,036 1,023 2,641 1,834 81 2,270 2,858 3,073 1,035 2,676 1,860 82 2,300 2,897 3,114 1,048 2,713 1,885 83 2,331 2,936 3,152 1,061 2,749 1,910 84 2,359 2,970 3,189 1,073 2,783 1,934 85 2,387 3,007 3,222 1,085 2,816 1,955 86 2,413 3,042 3,257 1,096 2,847 1,978 87 2,439 3,073 3,289 1,107 2,876 1,998 88 2,464 3,105 3,320 1,118 2,905 2,019 89 2,487 3,134 3,347 1,126 2,934 2,038 90 2,508 3,161 3,376 1,136 2,959 2,056 91 2,531 3,188 3,402 1,145 2,984 2,072 92 2,550 3,213 3,423 1,152 3,004 2,088 93 2,564 3,236 3,445 1,161 3,027 2,103 94 2,584 3,256 3,463 1,165 3,047 2,116 95 2,598 3,273 3,482 1,171 3,065 2,129 96 2,616 3,293 3,501 1,179 3,083 2,142 97 2,628 3,313 3,519 1,184 3,102 2,153 98 2,644 3,331 3,536 1,191 3,119 2,165 99 2,662 3,352 3,551 1,196 3,137 2,179

Attained Age

Standard Plan A Plan B Plan F Plan HF Plan G Plan N

65 1,705 2,151 2,419 813 2,013 1,39966 1,705 2,151 2,419 813 2,013 1,39967 1,705 2,151 2,419 813 2,013 1,39968 1,779 2,241 2,517 847 2,099 1,45769 1,856 2,340 2,619 881 2,192 1,52370 1,930 2,434 2,712 913 2,280 1,58371 2,006 2,528 2,806 944 2,367 1,64272 2,075 2,617 2,894 975 2,450 1,700 73 2,139 2,696 2,975 1,001 2,525 1,75474 2,202 2,775 3,050 1,027 2,598 1,80575 2,258 2,846 3,121 1,049 2,665 1,85076 2,310 2,912 3,177 1,070 2,725 1,89277 2,360 2,972 3,235 1,089 2,783 1,934 78 2,406 3,029 3,284 1,106 2,838 1,97079 2,448 3,084 3,330 1,120 2,886 2,00380 2,487 3,134 3,372 1,135 2,934 2,038 81 2,521 3,178 3,415 1,149 2,975 2,06882 2,556 3,222 3,461 1,165 3,017 2,09483 2,589 3,262 3,502 1,179 3,054 2,12284 2,621 3,303 3,544 1,193 3,092 2,14885 2,650 3,342 3,584 1,205 3,128 2,17286 2,683 3,378 3,618 1,218 3,163 2,19787 2,710 3,414 3,655 1,230 3,196 2,22188 2,736 3,448 3,689 1,241 3,229 2,24189 2,763 3,481 3,719 1,253 3,259 2,264 90 2,787 3,512 3,749 1,261 3,289 2,285 91 2,810 3,542 3,778 1,272 3,314 2,301 92 2,832 3,569 3,805 1,282 3,342 2,322 93 2,851 3,593 3,828 1,289 3,365 2,336 94 2,871 3,617 3,850 1,295 3,387 2,353 95 2,888 3,638 3,868 1,303 3,405 2,367 96 2,902 3,660 3,888 1,308 3,426 2,379 97 2,922 3,682 3,908 1,315 3,445 2,392 98 2,938 3,702 3,929 1,323 3,465 2,40699 2,958 3,725 3,948 1,329 3,487 2,422

Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.08333

The above rates do not include the $20 application fee.

If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates.

CLIMS05022RI 2 02/2021 A

Male Rates

Rates Effective 02/1/2021

Attained Age

Preferred Plan A Plan B Plan F Plan HF Plan G Plan N

65 1,766 2,224 2,504 843 2,082 1,447 66 1,766 2,224 2,504 843 2,082 1,447 67 1,766 2,224 2,504 843 2,082 1,447 68 1,839 2,321 2,605 877 2,168 1,508 69 1,923 2,424 2,709 912 2,268 1,577 70 1,999 2,518 2,808 947 2,358 1,639 71 2,076 2,617 2,906 978 2,450 1,700 72 2,148 2,707 2,998 1,009 2,534 1,760 73 2,217 2,792 3,079 1,035 2,615 1,816 74 2,279 2,873 3,157 1,063 2,690 1,867 75 2,337 2,944 3,229 1,087 2,755 1,914 76 2,390 3,012 3,289 1,107 2,819 1,958 77 2,440 3,077 3,347 1,126 2,880 2,000 78 2,490 3,136 3,401 1,145 2,936 2,040 79 2,533 3,191 3,448 1,161 2,988 2,075 80 2,576 3,241 3,491 1,176 3,037 2,108 81 2,608 3,290 3,536 1,191 3,081 2,137 82 2,645 3,333 3,584 1,205 3,121 2,166 83 2,682 3,377 3,625 1,219 3,161 2,195 84 2,711 3,416 3,663 1,234 3,199 2,222 85 2,744 3,458 3,707 1,248 3,238 2,250 86 2,775 3,498 3,744 1,260 3,273 2,273 87 2,804 3,534 3,783 1,273 3,310 2,297 88 2,834 3,570 3,817 1,286 3,343 2,323 89 2,858 3,606 3,852 1,295 3,373 2,344 90 2,886 3,635 3,880 1,306 3,404 2,363 91 2,910 3,665 3,909 1,315 3,431 2,383 92 2,931 3,692 3,936 1,325 3,459 2,401 93 2,952 3,721 3,962 1,333 3,482 2,418 94 2,969 3,745 3,985 1,341 3,504 2,434 95 2,986 3,765 4,005 1,348 3,525 2,448 96 3,006 3,785 4,025 1,354 3,545 2,462 97 3,023 3,809 4,044 1,362 3,566 2,477 98 3,042 3,830 4,066 1,368 3,586 2,492 99 3,059 3,854 4,087 1,375 3,608 2,507

Attained Age

Standard Plan A Plan B Plan F Plan HF Plan G Plan N

65 1,962 2,471 2,781 936 2,314 1,60866 1,962 2,471 2,781 936 2,314 1,60867 1,962 2,471 2,781 936 2,314 1,60868 2,044 2,577 2,895 975 2,411 1,67569 2,135 2,691 3,011 1,012 2,520 1,75070 2,222 2,799 3,121 1,049 2,622 1,82171 2,308 2,906 3,229 1,087 2,722 1,89072 2,387 3,007 3,330 1,120 2,814 1,955 73 2,462 3,101 3,420 1,150 2,903 2,01774 2,533 3,191 3,507 1,181 2,988 2,07575 2,597 3,271 3,588 1,208 3,063 2,12876 2,655 3,346 3,656 1,231 3,134 2,17777 2,712 3,420 3,719 1,253 3,199 2,222 78 2,765 3,483 3,777 1,271 3,261 2,26779 2,813 3,546 3,831 1,289 3,317 2,30580 2,858 3,600 3,878 1,306 3,372 2,343 81 2,898 3,655 3,930 1,323 3,422 2,37682 2,939 3,703 3,978 1,340 3,467 2,40783 2,979 3,751 4,029 1,355 3,512 2,44084 3,014 3,797 4,073 1,371 3,555 2,47185 3,050 3,841 4,120 1,385 3,598 2,49786 3,084 3,887 4,162 1,400 3,637 2,52687 3,114 3,926 4,201 1,413 3,678 2,55288 3,149 3,965 4,240 1,427 3,713 2,58089 3,178 4,004 4,280 1,441 3,749 2,604 90 3,204 4,038 4,312 1,452 3,783 2,627 91 3,235 4,074 4,345 1,462 3,814 2,650 92 3,258 4,104 4,374 1,472 3,842 2,670 93 3,280 4,132 4,401 1,482 3,870 2,687 94 3,301 4,158 4,426 1,490 3,894 2,704 95 3,320 4,184 4,447 1,498 3,918 2,718 96 3,341 4,207 4,472 1,504 3,940 2,735 97 3,359 4,232 4,494 1,513 3,961 2,752 98 3,378 4,258 4,517 1,520 3,987 2,76999 3,397 4,282 4,539 1,529 4,010 2,785

Continental Life Insurance Company of Brentwood, Tennessee Annual Attained Age Premiums

For Use in ZIP Codes: Entire state

Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.08333

The above rates do not include the $20 application fee.

If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates.

CLIMS05022RI 3 02/2021 A

PREMIUM INFORMATION

Continental Life Insurance Company of Brentwood, Tennessee can only raise your premium if we raise the premium for all policies like yours in this state. Premiums for this policy will increase due to the increase in your age. Upon attainment of an age requiring a rate increase, the renewal premium for the policy will be the renewal premium then in effect for your attained age. Other policies may be provided with Issue Age rating and do not increase with age. You should compare Issue Age with Attained Age policies. Premiums payable other than annually will be determined according to the following factors: Semi-annual: 0.5200 Quarterly: 0.2650 Monthly EFT: 0.0833.

DISCLOSURES

Use this outline to compare benefits and premium 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 your insurance company.

RIGHT TO RETURN POLICY

If you find that you are not satisfied with your policy, you may return it to Continental Life Insurance Company of Brentwood, Tennessee, P.O. Box 14770, Lexington, KY 40512-4770. 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 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

The policy may not cover all of your medical costs.

Neither Continental Life Insurance Company of Brentwood, Tennessee 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 VERYIMPORTANT

When you fill out the application for the new policy, be sure to answer truthfully and completely any 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.

THEFOLLOWING CHARTSDESCRIBE PLANS A, B, F, HIGH DEDUCTIBLE F, G and N OFFERED BY CONTINENTAL LIFE INSURANCE COMPANY OF BRENTWOOD, TENNESSEE.

CLIMS05022RI 4 02/2021 A

PLAN A MEDICARE (PART A) – HOSPITAL SERVICES – PER CALENDAR YEAR

*A benefit period begins on the first day you receive service 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.

SERVICES MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,484 $0 $1,484

(Part A Deductible) 61st thru 90th day 91st day and after ●While using 60 lifetime reserve

All but $371 a day $371 a day $0

days ●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 $185.50 a day $0 Up to $185.50 a day 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

**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.

***Deductible amounts announced annually by CMS

CLIMS05022RI 5 02/2021 A

PLAN A

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR *Once you have been billed $203 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.


PLAN PAYS

YOU PAY

MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $203 of Medicare-Approved amounts*

$0 $0 $203 (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 BLOOD First 3 pints $0 All costs $0 Next $203 of Medicare-Approved amounts*


Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

PARTSA & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES ●Medically necessary skilled careservices and medical supplies

100% $0 $0

●Durable medical equipment ●First $203 of Medicare Approved amounts*


●Remainder of Medicare Approved amounts 80% 20% $0 ***Deductible amounts announced annually by CMS

CLIMS05022RI 6 02/2021 A

PLAN B MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

* A benefit period begins on the first day you receive service 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.


PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,484 $1,484

(Part A Deductible) $0

61st thru 90th day 91st day and after


●While using 60 lifetime reserve days All but $742 a day $742 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 $185.50 a day

$0 Up to $185.50 a day

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.



$0

**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 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. ***Deductible amounts announced annually by CMS

CLIMS05022RI 7 02/2021 A

PLAN B

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR * Once you have been billed $203 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.


PLAN PAYS

YOU PAY



Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges(Above Medicare-Approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $203 of Medicare-Approved amounts*



PARTSA & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES ●Medically necessary skilled care services and medical supplies

100% $0 $0



●Remainder of Medicare Approved amounts 80% 20% $0

CLIMS05022RI 8 02/2021 A

PLAN C MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY





●While using 60 lifetime reserve days ●Once lifetime reserve days are used:



$0**


amounts $0 $0


Up to $185.50 a day

$0




$0

**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 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. ***Deductible amounts announced annually by CMS

CLIMS05022RI 9 02/2021 A

PLAN C MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

*Once you have been billed $203 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.


PLAN PAYS

YOU PAY

MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $203 of Medicare-Approved amounts* Remainder of Medicare-Approved

$0 $203 (Part B Deductible)

$0

amounts Generally 80% Generally 20% $0 Part B Excess Charges(Above Medicare-Approved amounts) $0 $0 100% BLOOD First 3 pints $0 All costs $0 Next $203 of Medicare-Approved amounts* Remainder of Medicare-Approved


$0

amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

PARTSA & B


PLAN PAYS

YOU PAY


100% $0 $0



$0

●Remainder of Medicare Approved amounts 80% 20% $0 ***Deductible amounts announced annually by CMS

CLIMS05022RI 10 02/2021 A

PLAN C OTHER BENEFITS – NOT COVERED BY MEDICARE


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 charges $0 80% to a lifetime

maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum

CLIMS05022RI 11 02/2021 A

PLAN F

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY



61st thru 90th day 91st day and after ●While using 60 lifetime reserve


days ●Once lifetime reserve days are used:



$0**


amounts $0 $0


Up to $185.50 a day

$0




$0

**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 365 days as prov ided 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. ***Deductible amounts announced annually by CMS

CLIMS05022RI 12 02/2021 A

PLAN F



PLAN PAYS

YOU PAY



$0

Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges(Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $203 of Medicare-Approved amounts*


$0


PARTSA & B


PLAN PAYS

YOU PAY


100% $0 $0



$0



CLIMS05022RI 13 02/2021 A

PLAN F

OTHER BENEFITS – NOT COVERED BY MEDICARE


PLAN PAYS

YOU PAY





CLIMS05022RI 14 02/2021 A

HIGH DEDUCTIBLE PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service 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. **This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,370 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses are $2,370. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paidby the policy. These expenses include the Medicare deductibles for Part A and Part B, but do notinclude the plan’s separate foreign travel emergency deductible.


AFTER YOU PAY $2,370

DEDUCTIBLE** PLAN PAYS

IN ADDITION TO $2,370

DEDUCTIBLE** YOU PAY








$0**


amounts $0 $0


Up to $185.50 a day

$0

101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 ***Deductible amounts announced annually by CMS

CLIMS05022RI 15 02/2021 A

HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.



$0


CLIMS05022RI 16 02/2021 A

HIGH DEDUCTIBLE PLAN F

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR *Once you have been billed $203 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. **This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,370deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses are $2,370. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paidby the policy. These expenses include the Medicare deductibles for Part A and Part B, but do notinclude the plan’s separate foreign travel emergency deductible.


AFTER YOU PAY $2,370DEDUCTIBL

E** PLAN PAYS

IN ADDITION TO $2,370DEDUCTIBLE ** YOU PAY

MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $203 of Medicare-Approved amounts* Remainder of Medicare-Approved


$0

amounts Generally 80% Generally 20% $0 Part B Excess Charges(Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $203 of Medicare-Approved amounts*


$0



CLIMS05022RI 17 02/2021 A

HIGH DEDUCTIBLE PLAN F

PARTS A & B


AFTER YOU PAY $2,370DEDUCTIBL

E** PLAN PAYS

IN ADDITION TO $2,370DEDUCTIBL E** YOU PAY


100% $0 $0



$0




AFTER YOU PAY $2,370

DEDUCTIBLE** PLAN PAYS

IN ADDITION TO $2,370

DEDUCTIBLE** YOU PAY





CLIMS05022RI 18 02/2021 A

PLAN G MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY








$0**


amounts $0 $0


Up to $185.50 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 services



$0

**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 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited frombilling you for the balance based on any difference between its billed charges and the amount Medicare would have paid. ***Deductible amounts announced annually by CMS

CLIMS05022RI 19 02/2021 A

PLAN G



PLAN PAYS

YOU PAY

MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $203 of Medicare-Approved amounts*


Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges(Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $203 of Medicare-Approved amounts*



PARTSA & 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 $203 of Medicare Approved amounts*

$0 $0 $203

(Part B Deductible) ●Remainder of Medicare Approved amounts 80% 20% $0


CLIMS05022RI 20 02/2021 A

PLAN G


SERVICES MEDICARE PAYS PLAN PAYS YOU PAY





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PLAN N

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY








$0**


amounts $0 $0


Up to $185.50 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 services


Medicare co-payment/ coinsurance

$0


CLIMS05022RI 22 02/2021 A

PLAN N



PLAN PAYS

YOU PAY



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 copayment 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 $203 of Medicare-Approved amounts*


Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 *** Deductible amounts announced annually by CMS

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PLAN N

PARTSA & 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 $203 of Medicare Approved amounts*





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 charges $0 80% to a lifetime maximum benefit of $50,000


***Deductible amounts announced annually by CM

CLIMS05022RI 02/2021 A 24

clims05022ri outline medsup ri 022021aaetnaseniorproducts.com. plans available to all applicants....

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