enrollment materialssmsteam.net/wp-content/uploads/products/med-supp/... · a plan that lets you...

BC10015TX

AARP® MEDICARE SUPPLEMENT

INSURANCE PLANS Insured by UnitedHealthcare

Insurance Company

These types of plans help with some of the out-of-pocket costs not paid by Medicare.

2017EnrollmentMaterials

UWAARP Medicare Supplement Insurance Plans

Texas

Enrollment materials for plan effectivedates from July 1, 2017 – June 1, 2018.

Discover the healthcare coverage that goes the distance with you:A Medicare Supplement Insurance Plan

Questions? Contact your licensed insurance agent or call toll-free: 1-866-387-7550Mon.-Fri. 7 a.m. to 11 p.m. and Sat. 9 a.m. to 5 p.m., Eastern Time.* From a report prepared for UnitedHealthcare Insurance Company by GFK Custom Research NA, “Medicare Supplement

Plan Satisfaction Posted Questionnaire,” 6/17/2013, www.uhcmedsupstats.com or call 1-800-523-5800 to request a copy of the full report.

AARP endorses the AARP Medicare Supplement Insurance Plans, insured by UnitedHealthcare Insurance Company. UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers.

LA26295TX Important disclosures on back

Hello...

With an AARP® Medicare Supplement Insurance Plan, insured by UnitedHealthcare Insurance Company (UnitedHealthcare), you get supplemental coverage that can serve your needs with:

• Competitive group rates. These rates are available exclusively to AARP members.

• High customer satisfaction. 9 out of 10 plan holders surveyed would recommend their AARP Medicare Supplement Plan to a friend or family member.*

• A plan that lets you choose. 95% of plan holders surveyed were satisfied with the ability to choose their own doctor who accepts Medicare patients.*

As with all standardized Medicare supplement plans, you get important supplemental coverage that helps to pay some of the costs Medicare doesn’t pay.

In the following pages you will find rates as well as detailed descriptions of the benefits included in each plan. Please see the enclosed Outline of Coverage for important disclosures. Your Representative, who is a licensed insurance agent contracted with UnitedHealthcare to offer AARP Medicare Supplement Plans, can review the information with you and answer any questions you may have. Once you’ve chosen the plan that’s best for your needs and budget, your Representative can help you complete and submit the Application Form, along with the first month’s premium.

All of us at UnitedHealthcare look forward to serving your health insurance needs now and for many years to come | GO LONG®

Sincerely,

Marie A. Pero Licensed Insurance AgentUnitedHealthcare Insurance Company

P.S. If you’re not currently an AARP member, you must join to be eligible to enroll for these plans. You can join AARP online, by phone or by including the form and separate check for the annual membership dues with your application.

AARP does not employ or endorse agents, brokers or producers.

Insured by UnitedHealthcare Insurance Company, Horsham, PA (UnitedHealthcare Insurance Company of New York, Islandia, NY for New York residents). Policy form No. GRP 79171 GPS-1 (G-36000-4). In some states plans may be available to persons under age 65 who are eligible for Medicare by reason of disability or End Stage Renal Disease.

Not connected with or endorsed by the U.S. Government or the federal Medicare program.

This is a solicitation of insurance. A licensed insurance agent/producer may contact you.

See the following materials for complete information including benefits, costs, eligibility requirements, exclusions and limitations.

IMPORTANT INFORMATION

The enclosed application can only be used for a plan start date of 7/1/17 or later.

If you are requesting a plan start date of 6/1/17 or earlier, your Agent should provide you with the updated application.

SA25483ST (01-17) AGT

YOU MAY SAVE up to 36% with the Enrollment Discount* See the Enrollment Discount page in this booklet to determine your eligibility and discount.

TAKE $24 OFF with Electronic Funds Transfer Save $2 per month ($24 per year) on your total household premium when you sign up for Electronic Funds Transfer (EFT). Simply complete the EFT form located in this booklet.

SAVE 5% with the Multi-Insured Discount You can each take 5% off your monthly premiums

if two members are enrolled under the same AARP membership number and each is insured under an AARP-branded supplemental insurance policy with UnitedHealthcare Insurance Company.

SAVE $24 per year with the Annual Payer Discount Take $24 off your total household premium when you pay your entire calendar year premium in January. Note: Electronic Funds Transfer (EFT) discount and Annual Payer discount cannot be combined

When you choose an AARP® Medicare Supplement Insurance Plan, insured by UnitedHealthcare Insurance Company, you may be able to take advantage of the discounts shown below.

*The discount will be reduced by 3% each year until the discount decreases to 0%.You must be an AARP member to enroll in an AARP Medicare Supplement Insurance Plan. If you are not a member, you can join AARP when you enroll for just $16.00 a year.AARP endorses the AARP Medicare Supplement Insurance Plans, insured by UnitedHealthcare Insurance Company. UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers.AARP does not employ or endorse agents, brokers or producers.Insured by UnitedHealthcare Insurance Company, Horsham, PA. Policy Form No. GRP 79171 GPS-1 (G-36000-4). In some states, plans may be available to persons under age 65 who are eligible for Medicare by reason of disability or End-Stage Renal Disease.Not connected with or endorsed by the U.S. government or the federal Medicare program.This is a solicitation of insurance. A licensed insurance agent/producer may contact you.See the enclosed materials for complete information, including benefits, costs, eligibility requirements, exclusions, and limitations.Review the accompanying Outline of Coverage for benefit and important disclosure information.SA25549TX

Questions? Contact your licensed insurance agent/producer.

Bright Ways To

Save

Outline of Coverage | UnitedHealthcare Insurance Company Overview of Available Plans Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010 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 in your state. Medicare Supplement Plans A, B, C, F, K, L, N and Medicare Select Plans C and F are currently being offered by UnitedHealthcare Insurance Company. Basic Benefits: • Hospitalization: Part A co-insurance plus coverage for 365 additional days after Medicare benefits end. • Medical Expenses: Part B co-insurance (generally 20% of Medicare-approved expenses) or co-payments for

hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments.

• Blood: First 3 pints of blood each year. • Hospice: Part A coinsurance +Medicare Select Plans C and F contain the same benefits as standardized Medicare Supplement Plans C and F, except for restrictions on your use of hospitals.

*Plan F also has an option called a high deductible Plan F. This option is not currently offered by UnitedHealthcare Insurance Company. This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $2200 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2200. 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. POV4 1/17

Plan A

Plan B

Plan C+

Plan D

Plan F*+

Plan G

Plan K

Plan L

Plan M

Plan N

Basic, including

100% Part B coinsurance

Basic, including


Basic, including


Basic, including


Basic, including


Basic, including


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 co-payment

for office visit, and up to $50 copayment

for ER Skilled

nursing facility coinsurance

Skilled nursing

facility coinsurance

Skilled nursing


Skilled nursing


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 $5120; paid

at 100% after limit reached

Out-of- pocket limit $2560; paid

at 100% after limit reached

Grou

p 1

Appli

es to

indiv

iduals

who

se pl

an ef

fectiv

e date

will

be w

ithin

ten ye

ars f

ollow

ing th

eir 65

th bir

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or M

edica

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art B

effec

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ate, if

later

.

Age1

Plan

APl

an B

Plan

CSe

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2Pl

an F

Selec

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Plan

KPl

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Plan

NSt

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with

Enr

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for i

ndivi

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ages

65-7

6 who

se ac

cept

ance

is g

uara

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d or

who

do n

ot h

ave a

ny o

f the

med

ical

cond

ition

s on

the a

pplic

atio

n4 .65

$162.88

$132.64

$162.24

$144.00

$162.88

$144.64

$49.76

$93.60

$116.32

66$170.51

$138.85

$169.84

$150.75

$170.51

$151.42

$52.09

$97.98

$121.77

67$178.15

$145.07

$177.45

$157.50

$178.15

$158.20

$54.42

$102.37

$127.22

68$185.78

$151.29

$185.05

$164.25

$185.78

$164.98

$56.75

$106.76

$132.67

69$193.42

$157.51

$192.66

$171.00

$193.42

$171.76

$59.09

$111.15

$138.13

70$201.05

$163.72

$200.26

$177.75

$201.05

$178.54

$61.42

$115.53

$143.58

71$208.69

$169.94

$207.87

$184.50

$208.69

$185.32

$63.75

$119.92

$149.03

72$216.32

$176.16

$215.47

$191.25

$216.32

$192.10

$66.08

$124.31

$154.48

73$223.96

$182.38

$223.08

$198.00

$223.96

$198.88

$68.42

$128.70

$159.94

74$231.59

$188.59

$230.68

$204.75

$231.59

$205.66

$70.75

$133.08

$165.39

75$239.23

$194.81

$238.29

$211.50

$239.23

$212.44

$73.08

$137.47

$170.84

76$246.86

$201.03

$245.89

$218.25

$246.86

$219.22

$75.41

$141.86

$176.29

Stan

dard

Rat

es fo

r age

s 77 a

nd o

lder

who

se ac

cept

ance

is g

uara

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d or

who

do n

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ave a

ny o

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med

ical c

ondi

tions

on

the a

pplic

atio

n4 .77

+$254.50

$207.25

$253.50

$225.00

$254.50

$226.00

$77.75

$146.25

$181.75

Leve

l 2 R

ates

for i

ndivi

duals

ages

65 an

d ol

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acce

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and

who

have

one

or m

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n4 .65

+$381.75

$310.87

$380.25

$337.50

$381.75

$339.00

$116.62

$219.37

$272.62

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+$279.95

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$278.85

$247.50

$279.95

$248.60

$85.52

$160.87

$199.92

Leve

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+$381.75

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$380.25

$337.50

$381.75

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$219.37

$272.62

The

rate

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n4 .65

$179.16

$145.90

$178.46

$158.40

$179.16

$159.10

$54.73

$102.95

$127.94

66$187.56

$152.73

$186.82

$165.82

$187.56

$166.56

$57.29

$107.78

$133.94

67$195.96

$159.57

$195.19

$173.25

$195.96

$174.02

$59.86

$112.60

$139.94

68$204.36

$166.41

$203.56

$180.67

$204.36

$181.47

$62.42

$117.43

$145.94

69$212.76

$173.25

$211.92

$188.10

$212.76

$188.93

$64.99

$122.26

$151.93

70$221.16

$180.09

$220.29

$195.52

$221.16

$196.39

$67.56

$127.08

$157.93

71$229.55

$186.93

$228.65

$202.95

$229.55

$203.85

$70.12

$131.91

$163.93

72$237.95

$193.77

$237.02

$210.37

$237.95

$211.31

$72.69

$136.73

$169.93

73$246.35

$200.61

$245.38

$217.80

$246.35

$218.76

$75.25

$141.56

$175.92

74$254.75

$207.45

$253.75

$225.22

$254.75

$226.22

$77.82

$146.39

$181.92

75$263.15

$214.29

$262.11

$232.65

$263.15

$233.68

$80.38

$151.21

$187.92

76$271.55

$221.13

$270.48

$240.07

$271.55

$241.14

$82.95

$156.04

$193.92

Stan

dard

Rat

es fo

r age

s 77 a

nd o

lder

who

se ac

cept

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is g

uara

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d or

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do n

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ave a

ny o

f the

med

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ondi

tions

on

the a

pplic

atio

n4 .77

+$279.95

$227.97

$278.85

$247.50

$279.95

$248.60

$85.52

$160.87

$199.92

Leve

l 2 R

ates

for i

ndivi

duals

ages

65 an

d ol

der w

hose

acce

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and

who

have

one

or m

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med

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ondi

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on

the

appl

icatio

n4 .65

+$419.92

$341.95

$418.27

$371.25

$419.92

$372.90

$128.28

$241.30

$299.88

Grou

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Appli

es to

indiv

iduals

who

se pl

an ef

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will

be te

n or m

ore y

ears

follow

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eir 65

th bir

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edica

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effec

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later

.

Age1

Plan

APl

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Plan

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Selec

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Plan

KPl

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Plan

NLe

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ividu

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n4 .75

+$307.94

$250.76

$306.73

$272.25

$307.94

$273.46

$94.07

$176.95

$219.91

Leve

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for i

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n4 .75

+$419.92

$341.95

$418.27

$371.25

$419.92

$372.90

$128.28

$241.30

$299.88

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TEXAS Area 1 ZIP CodesThe ZIP Codes Below Apply to Rates Included on the Page Headed “Cover Page – Rates”

SA5074 TXA (09-16) Page 1 of 1

759347593975960770017700277003770047700577006770077700877009770107701177012770137701477015770167701777018770197702077021770227702377024770257702677027770287702977030770317703277033770347703577036770377703877039

770407704177042770437704477045770467704777048770497705077051770527705477055770567705777058770597706077061770627706377064770657706677067770687706977070770717707277073770747707577076770777707877079770807708177082

770837708477085770867708777088770897709077091770927709377094770957709677098770997720177202772037720477205772067720777208772097721077212772137721577216772177721877219772207722177222772237722477225772267722777228

772297723077231772337723477235772367723777238772407724177242772437724477245772487724977251772527725377254772557725677257772587725977261772627726377265772667726777268772697727077271772727727377274772757727777279

772807728277284772877728877289772907729177292772937729777299773017730277303773047730577306773157731677318773207732577326773277732877331773327733377334773357733677337773387733977340773417734277343773447734577346

773477734877349773507735177353773547735577356773577735877359773607736277364773657736777368773697737177372773737737577377773787737977380773817738277383773847738577386773877738877389773917739377396773997740177402

774107741177413774227742977430774317743377447774497745077463774807748477486774917749277493775017750277503775047750577506775077750877510775117751277514775157751677517775187752077521775227752377530775317753277533

775347753577536775387753977541775427754677547775497755077551775527755377554775557756077561775627756377564775657756677568775717757277573775747757577577775787758077581775827758377584775867758777588775907759177592

77597775987761777623776507766177665

Grou

p 1

Appli

es to

indiv

iduals

who

se pl

an ef

fectiv

e date

will

be w

ithin

ten ye

ars f

ollow

ing th

eir 65

th bir

thday

or M

edica

re P

art B

effec

tive d

ate, if

later

.

Age1

Plan

APl

an B

Plan

CSe

lect C

2Pl

an F

Selec

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Plan

KPl

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Plan

NSt

anda

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ates

with

Enr

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iscou

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for i

ndivi

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ages

65-7

6 who

se ac

cept

ance

is g

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d or

who

do n

ot h

ave a

ny o

f the

med

ical

cond

ition

s on

the a

pplic

atio

n4 .65

$158.24

$128.80

$157.60

$139.84

$158.24

$140.48

$48.32

$90.88

$112.96

66$165.65

$134.83

$164.98

$146.39

$165.65

$147.06

$50.58

$95.14

$118.25

67$173.07

$140.87

$172.37

$152.95

$173.07

$153.65

$52.85

$99.40

$123.55

68$180.49

$146.91

$179.76

$159.50

$180.49

$160.23

$55.11

$103.66

$128.84

69$187.91

$152.95

$187.15

$166.06

$187.91

$166.82

$57.38

$107.92

$134.14

70$195.32

$158.98

$194.53

$172.61

$195.32

$173.40

$59.64

$112.18

$139.43

71$202.74

$165.02

$201.92

$179.17

$202.74

$179.99

$61.91

$116.44

$144.73

72$210.16

$171.06

$209.31

$185.72

$210.16

$186.57

$64.17

$120.70

$150.02

73$217.58

$177.10

$216.70

$192.28

$217.58

$193.16

$66.44

$124.96

$155.32

74$224.99

$183.13

$224.08

$198.83

$224.99

$199.74

$68.70

$129.22

$160.61

75$232.41

$189.17

$231.47

$205.39

$232.41

$206.33

$70.97

$133.48

$165.91

76$239.83

$195.21

$238.86

$211.94

$239.83

$212.91

$73.23

$137.74

$171.20

Stan

dard

Rat

es fo

r age

s 77 a

nd o

lder

who

se ac

cept

ance

is g

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who

do n

ot h

ave a

ny o

f the

med

ical c

ondi

tions

on

the a

pplic

atio

n4 .77

+$247.25

$201.25

$246.25

$218.50

$247.25

$219.50

$75.50

$142.00

$176.50

Leve

l 2 R

ates

for i

ndivi

duals

ages

65 an

d ol

der w

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acce

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and

who

have

one

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on

the

appl

icatio

n4 .65

+$370.87

$301.87

$369.37

$327.75

$370.87

$329.25

$113.25

$213.00

$264.75

Cov

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Com

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Grou

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Appli

es to

indiv

iduals

who

se pl

an ef

fectiv

e date

will

be te

n or m

ore y

ears

follow

ing th

eir 65

th bir

thday

or M

edica

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art B

effec

tive d

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.

Age1

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APl

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2Pl

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Plan

KPl

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Rat

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ividu

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ondi

tions

on

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appl

icatio

n4 .75

+$271.97

$221.37

$270.87

$240.35

$271.97

$241.45

$83.05

$156.20

$194.15

Leve

l 2 R

ates

for i

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ages

75 an

d ol

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n4 .75

+$370.87

$301.87

$369.37

$327.75

$370.87

$329.25

$113.25

$213.00

$264.75

The

rate

s ab

ove

are

for p

lan

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tes

from

Jul

y 20

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17

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The

rate

s ab

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P008

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17

Grou

p 1

Appli

es to

indiv

iduals

who

se pl

an ef

fectiv

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will

be w

ithin

ten ye

ars f

ollow

ing th

eir 65

th bir

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or M

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Age1

Plan

APl

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CSe

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2Pl

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Plan

KPl

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Plan

NSt

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ates

with

Enr

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65-7

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who

do n

ot h

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ny o

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med

ical

cond

ition

s on

the a

pplic

atio

n4 .65

$174.06

$141.67

$173.35

$153.82

$174.06

$154.52

$53.15

$99.96

$124.25

66$182.21

$148.31

$181.48

$161.03

$182.21

$161.77

$55.64

$104.65

$130.08

67$190.37

$154.95

$189.60

$168.24

$190.37

$169.01

$58.13

$109.34

$135.90

68$198.53

$161.60

$197.73

$175.45

$198.53

$176.25

$60.62

$114.02

$141.72

69$206.69

$168.24

$205.86

$182.66

$206.69

$183.50

$63.11

$118.71

$147.55

70$214.85

$174.88

$213.98

$189.87

$214.85

$190.74

$65.60

$123.39

$153.37

71$223.01

$181.52

$222.11

$197.08

$223.01

$197.98

$68.10

$128.08

$159.20

72$231.17

$188.16

$230.23

$204.29

$231.17

$205.23

$70.59

$132.77

$165.02

73$239.33

$194.80

$238.36

$211.50

$239.33

$212.47

$73.08

$137.45

$170.85

74$247.49

$201.44

$246.49

$218.71

$247.49

$219.71

$75.57

$142.14

$176.67

75$255.65

$208.08

$254.61

$225.92

$255.65

$226.96

$78.06

$146.82

$182.50

76$263.81

$214.72

$262.74

$233.13

$263.81

$234.20

$80.55

$151.51

$188.32

Stan

dard

Rat

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s 77 a

nd o

lder

who

se ac

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ny o

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med

ical c

ondi

tions

on

the a

pplic

atio

n4 .77

+$271.97

$221.37

$270.87

$240.35

$271.97

$241.45

$83.05

$156.20

$194.15

Leve

l 2 R

ates

for i

ndivi

duals

ages

65 an

d ol

der w

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one

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the

appl

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n4 .65

+$407.95

$332.05

$406.30

$360.52

$407.95

$362.17

$124.57

$234.30

$291.22

Grou

p 2

Appli

es to

indiv

iduals

who

se pl

an ef

fectiv

e date

will

be te

n or m

ore y

ears

follow

ing th

eir 65

th bir

thday

or M

edica

re P

art B

effec

tive d

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.

Age1

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APl

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CSe

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Rat

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appl

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n4 .75

+$299.16

$243.50

$297.95

$264.38

$299.16

$265.59

$91.35

$171.82

$213.56

Leve

l 2 R

ates

for i

ndivi

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ages

75 an

d ol

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on

the

appl

icatio

n4 .75

+$407.95

$332.05

$406.30

$360.52

$407.95

$362.17

$124.57

$234.30

$291.22

1 You

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the c

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u rec

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n you

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disc

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Appli

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Toba

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Rate

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$489.50

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SA5074 TXB (09-16) Page 1 of 2 u

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750567505775058750607506175062750637506575067750687506975070750717507475075750767507775078750807508175082750837508575086750877508875089750907509175092750937509475097750987509975101751027510375104751057510675109751107511475115

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TEXAS Area 2 ZIP Codes CONTINUED

Page 2 of 2

77703777047770577706777077770877710777137772077725777267893178933789347893578943789447895078951789627903179064790827931279313793147931679322793237932479326793297933079331793367933879339793427934379344793457934679347

79350793517935379355793567935779358793597936079363793647936679367793697937179372793737937679377793787937979380793817938279383794017940279403794047940679407794087940979410794117941279413794147941579416794237942479430

7945279453794577946479490794917949379499

Grou

p 1

Appli

es to

indiv

iduals

who

se pl

an ef

fectiv

e date

will

be w

ithin

ten ye

ars f

ollow

ing th

eir 65

th bir

thday

or M

edica

re P

art B

effec

tive d

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later

.

Age1

Plan

APl

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Plan

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2Pl

an F

Selec

t F2

Plan

KPl

an L

Plan

NSt

anda

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ates

with

Enr

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iscou

nt3

for i

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ages

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6 who

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ance

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who

do n

ot h

ave a

ny o

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med

ical

cond

ition

s on

the a

pplic

atio

n4 .65

$148.00

$120.48

$147.52

$130.88

$148.00

$131.52

$45.28

$85.12

$105.76

66$154.93

$126.12

$154.43

$137.01

$154.93

$137.68

$47.40

$89.11

$110.71

67$161.87

$131.77

$161.35

$143.15

$161.87

$143.85

$49.52

$93.10

$115.67

68$168.81

$137.42

$168.26

$149.28

$168.81

$150.01

$51.64

$97.09

$120.63

69$175.75

$143.07

$175.18

$155.42

$175.75

$156.18

$53.77

$101.08

$125.59

70$182.68

$148.71

$182.09

$161.55

$182.68

$162.34

$55.89

$105.07

$130.54

71$189.62

$154.36

$189.01

$167.69

$189.62

$168.51

$58.01

$109.06

$135.50

72$196.56

$160.01

$195.92

$173.82

$196.56

$174.67

$60.13

$113.05

$140.46

73$203.50

$165.66

$202.84

$179.96

$203.50

$180.84

$62.26

$117.04

$145.42

74$210.43

$171.30

$209.75

$186.09

$210.43

$187.00

$64.38

$121.03

$150.37

75$217.37

$176.95

$216.67

$192.23

$217.37

$193.17

$66.50

$125.02

$155.33

76$224.31

$182.60

$223.58

$198.36

$224.31

$199.33

$68.62

$129.01

$160.29

Stan

dard

Rat

es fo

r age

s 77 a

nd o

lder

who

se ac

cept

ance

is g

uara

ntee

d or

who

do n

ot h

ave a

ny o

f the

med

ical c

ondi

tions

on

the a

pplic

atio

n4 .77

+$231.25

$188.25

$230.50

$204.50

$231.25

$205.50

$70.75

$133.00

$165.25

Leve

l 2 R

ates

for i

ndivi

duals

ages

65 an

d ol

der w

hose

acce

ptan

ce is

not

gua

rant

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+$346.87

$282.37

$345.75

$306.75

$346.87

$308.25

$106.12

$199.50

$247.87

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+$254.37

$207.07

$253.55

$224.95

$254.37

$226.05

$77.82

$146.30

$181.77

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75 an

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+$346.87

$282.37

$345.75

$306.75

$346.87

$308.25

$106.12

$199.50

$247.87

The

rate

s ab

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The

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$162.79

$132.52

$162.27

$143.96

$162.79

$144.67

$49.80

$93.63

$116.33

66$170.42

$138.73

$169.87

$150.71

$170.42

$151.45

$52.13

$98.02

$121.78

67$178.05

$144.94

$177.48

$157.46

$178.05

$158.23

$54.47

$102.41

$127.23

68$185.69

$151.16

$185.09

$164.21

$185.69

$165.01

$56.80

$106.79

$132.69

69$193.32

$157.37

$192.69

$170.96

$193.32

$171.79

$59.14

$111.18

$138.14

70$200.95

$163.58

$200.30

$177.71

$200.95

$178.57

$61.47

$115.57

$143.59

71$208.58

$169.79

$207.91

$184.45

$208.58

$185.36

$63.81

$119.96

$149.05

72$216.21

$176.00

$215.51

$191.20

$216.21

$192.14

$66.14

$124.35

$154.50

73$223.84

$182.22

$223.12

$197.95

$223.84

$198.92

$68.48

$128.74

$159.95

74$231.47

$188.43

$230.73

$204.70

$231.47

$205.70

$70.81

$133.13

$165.41

75$239.10

$194.64

$238.33

$211.45

$239.10

$212.48

$73.15

$137.52

$170.86

76$246.73

$200.85

$245.94

$218.20

$246.73

$219.26

$75.48

$141.91

$176.31

Stan

dard

Rat

es fo

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s 77 a

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on

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pplic

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n4 .77

+$254.37

$207.07

$253.55

$224.95

$254.37

$226.05

$77.82

$146.30

$181.77

Leve

l 2 R

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for i

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+$381.55

$310.60

$380.32

$337.42

$381.55

$339.07

$116.73

$219.45

$272.65

Grou

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iduals

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n or m

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ears

follow

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th bir

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+$279.80

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$247.44

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$160.93

$199.94

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SA5074 TXC (09-16) Page 1 of 3 u

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The following ZIP codes are no longer recognized by the U.S. Post Office: 76505, 78049

Outline of Coverage | UnitedHealthcare Insurance Company

Premium information We, UnitedHealthcare Insurance Company, can only raise your premium for all certificates like yours in the state. Any change will apply to all members of the same class insured under your plan who reside in your state. Your premium can only be changed with the approval of AARP and your state insurance department.

Limitations and exclusions • Care or services provided by a non-network hospital, except in the event of a medical emergency, or services are not available from any network hospital in the service area.

• Benefits provided under Medicare. • Benefits provided under a Medicare Advantage Plan. • Care not meeting Medicare’s standards.

• Care for which you have no obligation to pay. Disclosures Use this outline to compare benefits and premiums among plans. This outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums. Plans E, H, I and J are no longer available for sale.

Read your certificate very carefully This is only an outline describing your certificate’s most important features. The certificate is your insurance contract. You must read the certificate itself to understand all of the rights and duties of both you and your insurance company.

Right to return the certificate If you find that you are not satisfied with your coverage, you may return the certificate to:

UnitedHealthcare PO BOX 30607 Salt Lake City, UT 84130-0607

If you send the certificate back to us within 30 days after you receive it, we will treat the certificate as if it had never been issued and return all of your premium payments.

• Care you receive in a government hospital. • Injury or sickness for which you are entitled to worker’s compensation benefits.

• Benefits provided under another policy. • Charges in excess of Medicare eligible expenses. •Expenses you incur during the first 3 months after your effective date if due to a pre-existing condition. A pre-existing condition is a condition for which one of these things happened within 3 months before your effective date: 1) a physician gave you medical advice for the

condition. 2) a physician recommended or gave you treatment

for the condition, which includes a physician recommending or prescribing a prescription drug for the condition.

(If you are an Eligible Person or had Creditable Coverage within the last 63 days, this limitation will not apply to you.)

• Other exclusions may apply. However, your plan will not have limitations or exclusions for Medicare eligible benefits that are more restrictive than those of Medicare.

Refund of Premium The certificate provides a refund of any unearned monthly premium upon the death of an insured or the surrender of the Certificate.

Policy replacement If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new certificate and are sure you want to keep it.

Notice The certificate may not fully cover all of your medical costs. Neither UnitedHealthcare 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.

RD35 5/15

Grievance Procedure Complaint and Grievance Procedure - We have a formal process to receive and respond to complaints or grievances. Our goal is to provide a fair way to evaluate, consider and settle all complaints and grievances. If we find that any action we have taken is not proper, we will correct it. Here is what you need to do to file a complaint or a grievance. Complaints - If you have a complaint, call our toll-free number at 1-800-523-5800. You can also write to us at UnitedHealthcare, PO BOX 740807, Atlanta, GA 30374-0807. We will let you know that we received your complaint within 15 days. We will respond to it within a reasonable period of time. Grievances - If you are not satisfied with how a complaint was handled, a claim denial, or for any other reason, you may submit a formal grievance. Grievances must be in writing and must state “This is a grievance” so the purpose of your communication is understood. You must clearly state the nature of your grievance. Mail it to us at PO BOX 740807, Atlanta, GA 30374-0807. You must send us your grievance within 60 days from the date of your claim denial or other reason for your grievance. We will let you know that we received your grievance within 15 days. We will respond to it within a reasonable period of time. If you are not satisfied with how we handled your complaint or grievance, or for any other reason, you may file a written complaint with the Department of Insurance in your state. Grievances While Staying at a Network Hospital If you are staying at a Network Hospital and you have a Grievance regarding hospital services being provided, you may contact our Customer Service Division by phone at 1-800-523-5800 to express the Grievance. We will relay the Grievance to the Network Hospital’s Administration immediately for prompt resolution. We will communicate all Complaint and Grievances resolutions to you promptly.

Complete answers are very important When you fill out the application for the new certificate, be sure to answer truthfully all questions about your medical and health history. The company may cancel your certificate 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.

Plan A 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.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1,316 $0 $1,316 (Part A Deductible)

61st thru 90th day All but $329 a day $329 a day $0 91st day and after: – While using 60 lifetime reserve days

All but $658 a day $658 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 $164.50 a day $0 Up to $164.50 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. BT70 1/17

Plan A MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

* Once you have been billed $183 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.

SERVICES MEDICARE PAYS 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 $183 of Medicare Approved

Amounts*

$0

$0

$183 (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 $183 of Medicare Approved Amounts*

$0 $0 $183 (Part B Deductible)


80% 20% $0

CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B SERVICES MEDICARE PAYS 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 $183 of Medicare Approved Amounts*

$0

$0 $183 (Part B Deductible)


80% 20% $0

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.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

All but $1,316

$1,316 (Part A Deductible)

$0

61st thru 90th day All but $329 a day $329 a day $0 91st day and after:

– While using 60 lifetime reserve days




$0


$0**


$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


$0

$0

21st thru 100th day All but $164.50 a day $0 Up to $164.50 a day

101st day and after $0 $0 All costs BLOOD First 3 pints

$0

3 pints

$0


All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care


$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. BT71 1/17

Plan B MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

* Once you have been billed $183 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.


Amounts*

$0

$0




PART B EXCESS CHARGES (Above Medicare Approved amounts)

$0

$0

All costs

BLOOD First 3 pints

$0

All costs

$0




80% 20% $0


100%

$0

$0



100%

$0

$0


$0



80% 20% $0

Plan C

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.


First 60 days

All but $1,316


$0





$0


$0**


$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


$0

$0

21st thru 100th day All but $164.50 a day Up to $164.50 a day $0 101st day and after $0 $0 All costs

BLOOD First 3 pints

$0

3 pints

$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 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.

BT72 1/17

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



Amounts*

$0


$0




$0

$0

All costs

BLOOD First 3 pints

$0

All costs

$0



$0


80% 20% $0

CLINICAL LABORATORY SERVICES– TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0



100%

$0

$0


$0


$0


80% 20% $0

OTHER BENEFITS – NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS 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

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.


First 60 days

All but $1,316


$0




Additional 365 days

$0


$0***

Beyond the additional 365 days

$0 $0 All costs


First 20 days


$0

$0


BLOOD First 3 pints

$0

3 pints

$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 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.

BT73 1/17

Plan F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR


SERVICES MEDICARE PAYS 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 $183 of Medicare Approved

Amounts*

$0


$0




$0

100%

$0

BLOOD First 3 pints

$0

All costs

$0



$0


80% 20% $0


100%

$0

$0



100%

$0

$0

Durable medical equipment First $183 of Medicare Approved Amounts*

$0


$0


80% 20% $0




$0

$0

$250



Plan K * You will pay half of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $5120 each calendar year. The amounts that count toward your annual limit are noted with diamonds (♦) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

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.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

All but $1,316

$658 (50% of Part A Deductible)

$658 (50% of Part A Deductible)♦





$0


$0***


$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


$0

$0

21st thru 100th day All but $164.50 a day Up to $82.25 a day $82.25 a day♦ 101st day and after $0 $0 All costs

BLOOD First 3 Pints

$0

50%

50%♦



50% of copayment/ coinsurance

50% of Medicare copayment/ coinsurance♦

*** 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. BT74 1/17

Plan K MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

SERVICES MEDICARE PAYS 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 $183 of Medicare

Approved Amounts****

$0

$0

$183 (Part B Deductible)****♦

Preventive Benefits for Medicare covered services

Generally 80% or more of Medicare Approved Amounts


All costs above Medicare Approved Amounts


Generally 80% Generally 10% Generally 10%♦


Amounts)

$0

$0

All costs (and they do not count toward annual out-of-pocket limit of $5120)*

BLOOD First 3 Pints $0 50% 50%♦ Next $183 of Medicare

Approved Amounts**** $0 $0 $183 (Part B

Deductible)****♦ Remainder of Medicare

Approved Amounts Generally 80% Generally 10% Generally 10%♦


100%

$0

$0

* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $5120 per year. However, this limit does NOT include charges from your provider that exceed Medicare- approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. PARTS A & B

SERVICES MEDICARE PAYS 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 $183 of Medicare Approved Amounts*****

$0

$0 $183 (Part B Deductible)♦


80% 10% 10%♦

***** Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

**** Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with asterisks), your Part B Deductible will have been met for the calendar year.

Plan L * You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2560 each calendar year. The amounts that count toward your annual limit are noted with diamonds (♦) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

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.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

All but $1,316

$987 (75% of Part A Deductible)

$329 (25% of Part A Deductible)♦





$0


$0***


$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


$0

$0

21st thru 100th day All but $164.50 a day Up to $123.38 a day $41.12 a day♦ 101st day and after $0 $0 All costs

BLOOD First 3 Pints

$0

75%

25%♦



75% of copayment/ coinsurance

25% of Medicare copayment/ coinsurance♦

*** 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. BT75 1/17

Plan L MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

SERVICES MEDICARE PAYS 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 $183 of Medicare

Approved Amounts****

$0

$0

$183 (Part B Deductible)****♦

Preventive Benefits for Medicare covered services

Generally 80% or more of Medicare Approved Amounts


All costs above Medicare Approved Amounts


Generally 80% Generally 15% Generally 5%♦


Amounts)

$0

$0

All costs (and they do not count toward annual out-of-pocket limit of $2560)*

BLOOD First 3 Pints $0 75% 25%♦ Next $183 of Medicare

Approved Amounts**** $0 $0 $183 (Part B

Deductible)♦ Remainder of Medicare

Approved Amounts Generally 80% Generally 15% Generally 5%♦


100%

$0

$0

* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2560 per year. However, this limit does NOT include charges from your provider that exceed Medicare- approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

PARTS A & B SERVICES MEDICARE PAYS 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 $183 of Medicare Approved Amounts*****

$0

$0 $183 (Part B Deductible)♦


80% 15% 5%♦

***** Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

**** Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with asterisks), your Part B Deductible will have been met for the calendar year.

Plan N

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.


First 60 days

All but $1,316


$0





$0


$0**


$0 $0 All costs


First 20 days


$0

$0


BLOOD First 3 pints

$0

3 pints

$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 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. BT76 1/17

Plan N

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR * Once you have been billed $183 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. SERVICES MEDICARE PAYS 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 $183 of Medicare Approved

Amounts*

$0

$0



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.


amounts)

$0

$0

All Costs

BLOOD First 3 pints

$0

All costs

$0




80% 20% $0


100%

$0

$0



100%

$0

$0


$0



80% 20% $0




$0

$0

$250



Medicare Select - Plan C


have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. *** You must use a Network Hospital.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* in a Network Hospital*** Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

All but $1,316


$0





$0


$0**


$0 $0 All costs


First 20 days


$0

$0


BLOOD First 3 pints

$0

3 pints

$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 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.

BT59 1/17

Medicare Select - Plan C MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR


*** You must use a Network Hospital. SERVICES MEDICARE PAYS 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 $183 of Medicare Approved

Amounts*

$0


$0



PART B EXCESS CHARGES (Above Medicare Approved Amounts)

$0

$0

All costs

BLOOD First 3 pints

$0

All costs

$0



$0


80% 20% $0


100%

$0

$0



100%

$0

$0


$0


$0


80% 20% $0


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



Medicare Select - Plan F


have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. **** You must use a Network Hospital.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* in a Network Hospital**** Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

All but $1,316


$0




Additional 365 days

$0


$0***

Beyond the additional 365 days

$0 $0 All costs


First 20 days


$0

$0


BLOOD First 3 pints

$0

3 pints

$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 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. BT60 1/17

Medicare Select - Plan F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

* Once you have been billed $183 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. **** You must use a Network Hospital.

SERVICES MEDICARE PAYS 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 $183 of Medicare

Approved Amounts*

$0


$0




Amounts)

$0

100%

$0

BLOOD First 3 pints

$0

All costs

$0


$0 $183 (Part B Deductible) $0


80% 20% $0


100%

$0

$0



100%

$0

$0

– Durable medical equipment

First $183 of Medicare Approved Amounts*

$0

$183 (Part B Deductible) $0


80% 20% $0


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



This Guide contains detailed information about the AARP Medicare Select and AARP Medicare Supplement Insurance Plans and accompanies the Outlines of Coverage.

AARP Medicare Select and Medicare Supplement Insurance Portfolio of Plans, insured by UnitedHealthcare InsuranceCompany, provides a choice of benefits to AARP members, so you can choose the plan that best fits your individualsupplemental health insurance needs.

To help you choose the AARP Medicare Select Plan or AARP MedicareSupplement Plan to meet your needs and budget:� Look at the Cover Page, which shows the benefits of each Medicare Select and Medicare supplement plan and any

specific provisions that may apply in your state. Also be sure to review the Monthly Premium information. Benefitsand cost vary depending upon the plan selected.

� For more information on a specific plan, look at the chart(s) which outline(s) the benefits of that plan. Thedetailed chart(s) show(s) the expenses Medicare pays, the benefits the plan pays and the specific costs youwould have to pay yourself.

Eligibility to ApplyTo be eligible to apply, you must be an AARP member or spouse of a member, age 50 or over, enrolled in both Part Aand Part B of Medicare, and not duplicating any Medicare supplement coverage. (If you are not yet age 65, you mustenroll within 6 months after enrolling in Medicare Part B, unless you are an “Eligible Person” entitled to GuaranteedAcceptance as shown under the following “Guaranteed Acceptance” section. Regardless of when you enroll, youmay only enroll in Plan A.)

Guaranteed Acceptance� During your open enrollment period, you cannot be denied any Medicare supplement or Medicare select

insurance policy sold by any Medicare supplement insurer if your application is submitted during the six-monthperiod beginning on the first day of the month in which you enroll in Medicare Part B. If you are on Medicareunder age 65, you will also have a six-month open enrollment period beginning the month you turn age 65.

� If you lose health insurance coverage, you may be considered an “Eligible Person” entitled to guaranteedacceptance and you may have a guaranteed right to enroll in certain Medicare supplement plans under specificcircumstances. You are required to:

1. Apply within the required time period following the termination of your prior health insurance plan.

2. Provide a copy of the termination notice you received from your prior insurer with your application. Thisnotice must verify the circumstances of your prior plan’s termination and describe your right to guaranteedissue of Medicare supplement insurance.

Please see the “Supplement to Application” for additional information on guaranteed right to insurance. If you haveany further questions on your guaranteed right to insurance, you may wish to contact the administrator of yourprior health insurance plan or your local state department on aging.

The Health Information Counseling & Advocacy Program (HICAP) assists older Texans and Texans with disabilitiesby providing free information about health insurance and public benefits. To speak to a benefits counselor in yourarea, please call 1-800-252-9240.

Continued…GU25003TX (07-12)

Your GuideTo AARP Medicare Select and Medicare Supplement Insurance Plans

AARP endorses the AARP Medicare Supplement Insurance Plans, insured by UnitedHealthcare InsuranceCompany. UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectualproperty. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers.

This package describes the AARP Medicare Select and AARP Medicare Supplement Plans available in your state, butis not a contract, policy, or insurance certificate. Please read your Certificate of Insurance, upon receipt, for planbenefits, definitions, exclusions, and limitations. AARP Medicare Select and AARP Medicare Supplement Plans havebeen developed in line with federal standards.


The Group Policy Form No. GRP79171 GPS-1 (G-36000-4) is issued in the District of Columbia to the Trustees of the AARP Insurance Plan – Certificates of Insurance numbered MDA0802 / MAA0809 (Plan A), MDB0803 / MAB0810(Plan B), MDC0804 / MAC0811 (Plan C), MDF0805 / MAF0812 (Plan F), MDK0806 / MAK0813 (Plan K), MDL0807 /MAL0814 (Plan L), MDN0808 / MAN0815 (Plan N), MDSC0816 / MASC0818 (Select Plan C), MDSF0817 / MASF0819(Select Plan F). By enrolling, you are agreeing to the release of Medicare claim information to UnitedHealthcareInsurance Company so your AARP Medicare Supplement Plan claims can be processed automatically.

If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicaresupplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longerentitled to Medicaid, your suspended Medicare supplement policy (or, if that is no longer available, a substantiallyequivalent policy) will be reinstituted if requested within 90 days of losing Medicaid eligibility. If the Medicaresupplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D whileyour policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but willotherwise be substantially equivalent to your coverage before the date of the suspension.

If you are eligible for, and have enrolled in a Medicare supplement policy by reason of disability and you laterbecome covered by an employer or union-based group health plan, the benefits and premiums under yourMedicare supplement policy can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare supplement policy under these circumstances, and laterlose your employer or union-based group health plan, your suspended Medicare supplement policy (or, if that is nolonger available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing youremployer or union-based group health plan. If the Medicare supplement policy provided coverage for outpatientprescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy willnot have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coveragebefore the date of the suspension.


This is a solicitation of insurance. An agent may contact you.

Continued…

Questions? Call Toll Free:1-800-523-5800

Weekdays, 7 a.m. to 11 p.m., Saturday 9 a.m. to 5 p.m., Eastern Time.

Hablamos Español — Llame 1-800-822-0246

de lunes a viernes de las 8 a.m. a las 5 p.m., y sábado de las 9 a.m. a las 5 p.m., hora del este.

TTY — for members with speech or hearing impairments —711

Weekdays, 9 a.m. to 5 p.m., Eastern Time.

General Information

Glossary of Terms� Medicare Eligible Expenses are the health care expenses of the kinds covered under Medicare Parts A and B that

Medicare recognizes as reasonable and medically necessary. Physicians under Medicare can agree to acceptMedicare’s eligible expenses as their fee amount. Your physician or surgeon may charge you more; however, thecharge cannot exceed any charge limitation established by the Medicare program or state law.

� Hospital or Skilled Nursing Facility – A hospital is an institution that provides care for which Medicare payshospital benefits. A skilled nursing facility is a facility that provides skilled nursing care and is approved forpayment by Medicare. The skilled nursing facility stay must begin within 30 days after a hospital stay of 3 ormore days in a row or a prior covered skilled nursing facility stay.

� Excess Charge is the difference between the actual Medicare Part B charge as billed, not to exceed any chargelimitation established by the Medicare program or state law, and the Medicare-approved Part B charge.

� Network Hospital is a hospital that has entered into a written agreement to provide services under aUnitedHealthcare Insurance Company Medicare Select Plan.

� Medical Emergency is the sudden and unexpected onset of symptoms, illness, injury, or condition; that if careor services are withheld, would be deemed, under appropriate medical standards, to carry substantial risk ofserious medical complication or permanent damage to you.

� Service Area is the geographic area within which an issuer is authorized to offer Medicare Select coverage.

� Lifetime Reserve Days are limited by Medicare to 60 days during your lifetime. Once these are used, Medicareprovides no hospital coverage after 90 days of a benefit period.

� Hospice Caremeans care for those who are terminally ill. Hospice Care focuses on comfort (controllingsymptoms and pain) rather than seeking a cure.

Exclusions� Benefits provided under Medicare.

� Care not meeting Medicare’s standards.

� Care or supplies received before your plan’s effective date.

� Any period of hospital or skilled nursing facility stay that occurs prior to the effective date.

� Injury or sickness payable by Workers’ Compensation or similar laws.

� Stays or treatment provided by a government-owned or -operated hospital or facility unless payment of chargesis required by law.

� Stays, care, or visits for which no charge would be made to you in the absence of insurance.

� Care or services provided by a non-participating hospital, except in the event of a medical emergency, or if theservices are not available from any participating hospital in the service area.

� Expenses you incur during the first 3 months after your effective date will not be considered if due to a pre-existing condition. A pre-existing condition is a condition for which medical advice was given or treatmentwas recommended by or received from a physician within 3 months prior to your plan’s effective date.

The following individuals are entitled to a waiver of this pre-existing condition exclusion:

1. Individuals 65 years of age or older who are replacing prior creditable coverage within 63 days after termination,OR

2. Individuals whose application form is received prior to or during the 6-month period beginning with the firstday of the month in which the individual is age 65 or older and enrolled in Medicare Part B, OR

3. Individuals who are “Eligible Persons” entitled to Guaranteed Acceptance, OR

4. Individuals who are replacing a Medicare supplement or Medicare select plan.

Other exclusions may apply; however, in no event will your plan contain coverage limitations or exclusions for theMedicare Eligible Expenses that are more restrictive than those of Medicare. Benefits and exclusions paid by yourplan will automatically change when Medicare’s requirements change.

Continued…

MEDICARE SELECT DISCLOSURE STATEMENT

Please read this form carefully. The following information is provided in order to make a full and fair disclosure to youof the provisions, restrictions, and limitations of the AARP Medicare Select Plan. Please use the Cover Page, Outlines ofCoverage and Rate Information which allows you to compare the benefits and rate of AARP Medicare Select and AARPMedicare Supplement Plans with other Medicare supplement plans.

Medicare Select Provider Restrictions In order for benefits to be payable under this insurance plan, you must use one of the network hospitals locatedthroughout the United States, unless:

(1) there is a Medical Emergency;(2) covered services are not available from any network hospital in the Service Area; or (3) covered services are received from a Medicare-approved non-network hospital more than 100 miles from your

Primary Residence.

In the case of (1) and (2) above, the following benefits may be payable subject to the terms and conditions of this plan:- 100% of the Part A Medicare Inpatient Hospital Deductible amount per Benefit Period;- 100% of the Part A Medicare Eligible Expenses not paid by Medicare; and- 100% of the Part B Medicare Eligible Expenses for outpatient hospital services not paid by Medicare.

In the case of (3) above, the following benefits may be payable subject to the terms and conditions of this plan:- 75% of the Part A Medicare Inpatient Hospital Deductible amount per Benefit Period;- 75% of the Part A Medicare Eligible Expenses not paid by Medicare; and- 75% of the Part B Medicare Eligible Expenses for outpatient hospital services not paid by Medicare.

Only certain hospitals are network providers under this policy. Check with your physician to determine if he or she has admitting privileges at the Network Hospital. If he or she does not, you may be required to use anotherphysician at the time of hospitalization or you will be required to pay for all expenses.

Right to Replace Your Medicare Select PlanYou have the right to replace your AARP Medicare Select Plan with any other AARP Medicare Supplement Planinsured by UnitedHealthcare Insurance Company that has the same or lesser benefits as your current insurance and which does not require the use of participating providers, without providing evidence of insurability.

Quality AssuranceParticipating providers are required to maintain a quality assurance program conforming with nationallyrecognized quality of care standards.

FORYOUR PROTECTION, PLEASE BE AWARE OF THE FOLLOWING:

You Cannot Be Singled Out for CancellationYour coverage can never be canceled because of your age, your health, or the number of claims you make. YourMedicare supplement plan may be canceled due to nonpayment of premium or material misrepresentation. Youmay keep your plan in force by paying the required premium when due. The required payment for your plan issubject to change. Any change will apply to all members of the same class insured under your plan who reside in your state. Your premium can only be changed with the approval of AARP. If your group policy terminates and is notreplaced by another group policy providing the same type of coverage, you may convert your AARP Medicare SelectPlan or AARP Medicare Supplement Plan to an individual Medicare supplement policy issued by UnitedHealthcareInsurance Company. Of course, you may cancel your AARP Medicare Select Plan or AARP Medicare Supplement Planany time you wish. All transactions go into effect on the first of the month following receipt of the request.

Continued…

The AARP Insurance TrustAARP established the AARP Insurance Plan, a trust, to hold the master group insurance policies. The AARP MedicareSupplement Insurance Plan is insured by UnitedHealthcare Insurance Company, not by AARP or its affiliates. Pleasecontact UnitedHealthcare Insurance Company if you have questions about your policy, including any limitationsand exclusions.

Premiums are collected from you by the Trust. These premiums are paid to the insurance company for yourinsurance coverage, a percentage is used to pay expenses, benefitting the insureds, and incurred by the Trust inconnection with the insurance programs. At the direction of UnitedHealthcare Insurance Company, a portion of thepremium is paid as a royalty to AARP and used for the general purposes of AARP. Income earned from theinvestment of premiums while on deposit with the Trust is paid to AARP and used for the general purposes of AARP.

Participants are issued certificates of insurance by UnitedHealthcare Insurance Company under the master groupinsurance policy. The benefits of participating in an insurance program carrying the AARP name are solely the right toreceive the insurance coverage and ancillary services provided by the program.

AARP Medicare Select and AARP Medicare Supplement Plans Insured by UnitedHealthcare Insurance Company

1-800-523-5800For more information about

the family of health products and services

Visit www.aarphealthcare.com

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Anderson CountyPalestine Regional Medical Center 2900 South Loop 256Palestine, TX 75801(903) 731-1000

Angelina CountyMemorial Medical Center – Lufkin1201 West Frank AvenueLufkin, TX 75904(936) 634-8111

Woodland Heights Medical Center505 South John Redditt DriveLufkin, TX 75904(936) 634-8311

Austin CountyBellville St. Joseph Health Center44 North Cummings StreetBellville, TX 77418(979) 413-7400

Bailey CountyMuleshoe Area Medical Center708 South First StreetMuleshoe, TX 79347(806) 272-4524

Baylor CountySeymour Hospital200 Stadium DriveSeymour, TX 76380(940) 889-5572

Bee CountyChristus Spohn Hospital Beeville1500 East Houston StreetBeeville, TX 78102(361) 354-2000

Bexar CountyChristus Santa Rosa Medical Center Hospital2827 Babcock RoadSan Antonio, TX 78229(210) 705-6300

Christus Santa Rosa Westover Hills11212 State Highway 151San Antonio, TX 78251(210) 703-8000

HealthSouth Rehabilitation Hospital of San Antonio9119 Cinnamon HillSan Antonio, TX 78240(210) 691-0737

LifeCare Hospital of San Antonio8902 Floyd Curl Drive San Antonio, TX 78240(210) 690-7000

Nix Medical Center414 Navarro StreetSan Antonio, TX 78205(210) 271-1800

Southwest General Hospital7400 Barlite BoulevardSan Antonio, TX 78224(210) 921-2000

Bexar County (Continued)Warm Springs Rehabilitation Hospital – San Antonio5101 Medical DriveSan Antonio, TX 78229(210) 616-0100

Warm Springs Rehabilitation Hospital – Thousand Oaks14747 Jones Maltsberger RoadSan Antonio, TX 78247(210) 581-5300

Warm Springs Rehabilitation Hospital – Westover Hills10323 State Highway 151San Antonio, TX 78251(210) 581-5306

Warm Springs Specialty Hospital of San Antonio7400 Barlite Boulevard, 3rd floor San Antonio, TX 78224 (210) 921-3550

Bowie CountyChristus St. Michael Health System2600 St. Michael DriveTexarkana, TX 75503(903) 614-1000

Christus St. Michael Rehabilitation Hospital2400 St. Michael DriveTexarkana, TX 75503(903) 614-1000

Texas

SA5177TXT

Participating Hospitals - Effective January 2017For AARP® Medicare Select Plans C and F Only

Texas Resident Directory

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Bowie County (Continued)HealthSouth Rehabilitation Hospital of Texarkana515 West 12th StreetTexarkana, TX 75501(903) 793-0088

Wadley Regional Medical Center1000 Pine StreetTexarkana, TX 75501(903) 798-8000

Brazos CountyCollege Station Medical Center1604 Rock Prairie RoadCollege Station, TX 77845(979) 764-5100

Burleson CountyBurleson St. Joseph Health Center1101 Woodson DriveCaldwell, TX 77836(979) 567-3245

Caldwell CountyWarm Springs Specialty Hospital of Luling200 Memorial DriveLuling, TX 78648(830) 875-8400

Cameron CountyValley Baptist Medical Center – Brownsville1040 West JeffersonBrownsville, TX 78520(956) 698-5400

Valley Baptist Medical Center – Harlingen2101 Pease StreetHarlingen, TX 78550(956) 389-1100

Cass CountyChristus St. Michael Hospital – Atlanta1007 South William StreetAtlanta, TX 75551(903) 799-3000

Chambers CountyWinnie Community Hospital538 BroadwayWinnie, TX 77665(409) 296-6000

Cherokee CountyMother Frances Hospital – Jacksonville2026 South JacksonJacksonville, TX 75766(903) 541-4500

Clay CountyClay County Memorial Hospital310 West South StreetHenrietta, TX 76365(940) 538-5621

Cochran CountyCochran Memorial Hospital201 East Grant StreetMorton, TX 79346(806) 266-5565

Collin CountyCentennial Medical Center12505 Lebanon RoadFrisco, TX 75035(972) 963-3333

HealthSouth Rehabilitation Hospital of Plano2800 West 15th StreetPlano, TX 75075

Collin County (Continued)LifeCare Hospital of Plano6800 Preston RoadPlano, TX 75024(214) 473-8822

Warm Springs Rehabilitation Hospital of Allen1001 Raintree Circle Allen, TX 75013 (972) 908-2000

Colorado CountyColumbus Community Hospital110 Shult Drive Columbus, TX 78934(979) 732-2371

Rice Medical Center600 South Austin RoadEagle Lake, TX 77434(979) 234-5571

Comal CountyChristus Santa Rosa New Braunfels600 North Union AvenueNew Braunfels, TX 78130(830) 606-9111

Warm Springs Specialty Hospital of New Braunfels1445 Hanz DriveNew Braunfels, TX 78130(830) 627-7600

Comanche CountyComanche County Medical Center10201 Highway 16 NorthComanche, Texas 76442(254) 879-4900

Texas (Continued)

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Crane CountyCrane Memorial Hospital1310 South Alford StreetCrane, TX 79731(432) 558-3555

Crosby CountyCrosbyton Clinic Hospital710 West Main StreetCrosbyton, TX 79322(806) 675-2382

Culberson CountyCulberson HospitalEisenhower Road & FM 2185Van Horn, TX 79855(432) 283-2760

Dallam CountyCoon Memorial Hospital1411 Denver AvenueDalhart, TX 79022(806) 244-4571

Dallas CountyDallas Medical Center Seven Medical ParkwayDallas, TX 75234(972) 888-7000

Doctors Hospital at White Rock Lake 9440 Poppy Drive Dallas, TX 75218(214) 324-6100

Lake Pointe Medical Center 6800 Scenic Drive Rowlett, TX 75088(972) 412-2273

LifeCare Hospital of Dallas 1950 Record Crossing Road Dallas, TX 75235(214) 640-9600

Dallas County (Continued)Select Specialty Hospital – Dallas Downtown3500 Gaston Avenue, Floors 3-4 Dallas, TX 75246(469) 801-4650

Select Specialty Hospital - Garland2300 Marie Curie Drive Floors 3 & 4 JonssonGarland, TX 75042(469) 440-5800

Deaf Smith CountyHereford Regional Medical Center801 East Third StreetHereford, TX 79045(806) 364-2141

Denton CountyAtrium Medical Center of Corinth3305 Corinth ParkwayCorinth, TX 76208(940) 270-4100

El Paso CountyHighlands Regional Rehabilitation Hospital1395 George Dieter DriveEl Paso, TX 79936(915) 298-7222

University Medical Center of El Paso4815 Alameda AvenueEl Paso, TX 79905(915) 544-1200

Ellis CountyEnnis Regional Medical Center2201 West Lampasas StreetEnnis, TX 75119(972) 875-0900

Falls CountyFalls Community Hospital & Clinic322 Coleman StreetMarlin, TX 76661(254) 803-3561

Fisher CountyFisher County Hospital District774 State Hwy 70 NRotan, TX 79546(325) 735-2256

Floyd CountyW. J. Mangold Memorial Hospital320 North Main StreetLockney, TX 79241(806) 652-3373

Fort Bend CountyHealthSouth Sugar Land Rehabilitation Hospital1325 Highway 6Sugar Land, TX 77478(281) 276-7574

Frio CountyFrio Regional Hospital200 IH 35 SouthPearsall, TX 78061(830) 334-3617

Nix Community General Hospital230 West Miller StreetDilley, TX 78017(830) 965-2003

Gaines CountyMemorial Hospital – Seminole 209 NW Eighth Street Seminole, TX 79360(432) 758-5811

Texas (Continued)

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Grayson CountyWilson N. Jones Regional Medical Center500 N. Highland AvenueSherman, TX 75092(903) 870-4611

Gregg CountyAllegiance Specialty Hospital of Kilgore1612 Henderson BoulevardKilgore, TX 75662(903) 984-3505

Good Shepherd Medical Center 700 East Marshall Avenue Longview, TX 75601(903) 315-2000

Longview Regional Medical Center2901 North Fourth StreetLongview, TX 75605(903) 758-1818

Hamilton CountyHamilton General Hospital400 North Brown StreetHamilton, TX 76531(254) 386-3151

Harris CountyBen Taub General Hospital1504 Taub LoopHouston, TX 77030(713) 873-2000

Houston Methodist St. Catherine Hospital 701 S. Fry RoadKaty, TX 77450(281) 599-5700

Harris County (Continued)Houston Methodist St. John Hospital18300 St. John Drive Houston, TX 77058(281) 523-2000

Doctors Hospital of Tidwell510 West Tidwell RoadHouston, TX 77091(281) 618-8500

HealthSouth Rehabilitation Hospital of Cypress13031 Wortham Center DriveHouston, TX 77065(832) 280-2500

HealthSouth Rehabilitation Hospital of Humble19002 McKay DriveHumble, TX 77338(281) 319-9541

Hopebridge Community Hospital5556 Gasmer DriveHouston, TX 77035(713) 422-2625

Houston Hospital for Specialized Surgery5445 La BranchHouston, TX 77004(713) 528-6800

Lyndon B. Johnson General Hospital5656 Kelley StreetHouston, TX 77026(713) 566-5100

Quentin Mease Community Hospital3601 North MacGregor WayHouston, TX 77004(713) 873-3700

Harris County (Continued)Tomball Regional Hospital605 Holderrieth BoulevardTomball, TX 77375(281) 401-7500

University General Hospital7501 Fannin StreetHouston, TX 77054(713) 375-7000

Haskell CountyHaskell Memorial Hospital1 North Avenue NHaskell, TX 79521(940) 864-2621

Stamford Memorial Hospital1601 Columbia StreetStamford, TX 79553(325) 773-2725

Hemphill CountyHemphill County Hospital District1020 South Fourth StreetCanadian, TX 79014(806) 323-6422

Henderson CountyEast Texas Medical Center – Athens2000 South Palestine StreetAthens, TX 75751(903) 676-1000

Hidalgo CountyDoctors Hospital at Renaissance5501 South McColl RoadEdinburg, TX 78539(956) 362-8677

LifeCare Hospital of South Texas – McAllen Campus North5101 North JacksonMcAllen, TX 78504(956) 926-7000

Texas (Continued)

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Hidalgo County (Continued)LifeCare Hospital of South Texas – McAllen Campus South2001 South M StreetMcAllen, TX 78503(956) 688-4300

Jackson CountyJackson Healthcare Center1013 South Wells StreetEdna, TX 77957(361) 782-7800

Jasper CountyChristus Jasper Memorial Hospital1275 Marvin Hancock DriveJasper, TX 75951(409) 384-5461

Jefferson CountyBaptist Hospitals of Southeast Texas Beaumont3080 College StreetBeaumont, TX 77701(409) 212-5000

Christus Hospital – St. Elizabeth2830 Calder StreetBeaumont, TX 77702(409) 892-7171

Christus Hospital – St. Mary3600 Gates BoulevardPort Arthur, TX 77642(409) 985-7431

HealthSouth Rehabilitation Hospital of Beaumont3340 Plaza 10 BoulevardBeaumont, TX 77707(409) 839-3333

Jim Wells CountyChristus Spohn Hospital Alice2500 East Main StreetAlice, TX 78332(361) 661-8000

Jones CountyAnson General Hospital101 Avenue JAnson, TX 79501(325) 823-3231

Kimble CountyKimble Hospital2101 Main StreetJunction, TX 76849(325) 446-3321

Kleberg CountyChristus Spohn Hospital Kleberg1311 General Cavazos BoulevardKingsville, TX 78363(361) 595-1661

Knox CountyKnox County Hospital701 South Fifth StreetKnox City, TX 79529(940) 657-3535

Lamb CountyLamb Healthcare Center1500 South SunsetLittlefield, TX 79339(806) 385-6411

Lavaca CountyYoakum Community Hospital1200 Carl Ramert DriveYoakum, TX 77995(361) 293-2321

Liberty CountyLiberty Dayton Regional Medical Center1353 North Travis StreetLiberty, TX 77575(936) 336-7316

Limestone CountyLimestone Medical Center701 McClintic DriveGroesbeck, TX 76642(254) 729-3281

Lubbock CountyGrace Medical Center2412 50th StreetLubbock, TX 79412(806) 788-4000

Martin CountyMartin County Hospital District600 Interstate 20 EastStanton, TX 79782(432) 756-3345

McCulloch CountyHeart of Texas Memorial Hospital2008 Nine RoadBrady, TX 76825(325) 597-2901

McLennan CountyProvidence Health Center6901 Medical ParkwayWaco, TX 76712(254) 751-4000

Midland CountyHealthSouth Rehabilitation Hospital of Midland1800 Heritage BoulevardMidland, TX 79707(432) 520-1600

Texas (Continued)

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Milam CountyLittle River Healthcare – Cameron Hospital806 North Crockett AvenueCameron, TX 76520 (254) 605-1300

Little River Healthcare – Rockdale Hospital1700 Brazos AvenueRockdale, TX 76567(512) 446-4500

Mitchell CountyMitchell County Hospital997 West Interstate 20Colorado City, TX 79512(325) 728-3431

Montgomery CountyHealthSouth Rehabilitation Hospital of North Houston18550 I 45 SouthConroe, TX 77384(281) 364-2000

Nacogdoches CountyNacogdoches Medical Center4920 Northeast Stallings DriveNacogdoches, TX 75965(936) 569-9481

Nacogdoches Memorial Hospital1204 Mound StreetNacogdoches, TX 75961(936) 564-4611

Nueces CountyChristus Spohn Hospital Corpus Christi Memorial2606 Hospital Boulevard Corpus Christi, TX 78405(361) 902-4000

Nueces County (Continued)Christus Spohn Hospital Corpus Christi Shoreline600 Elizabeth Street Corpus Christi, TX 78404(361) 881-3000

Christus Spohn Hospital Corpus Christi South5950 Saratoga Boulevard Corpus Christi, TX 78414(361) 985-5000

Post Acute Specialty Hospital of Corpus Christi 6226 Saratoga Boulevard Corpus Christi, TX 78414(361) 986-1600

Orange CountyBaptist Hospitals of Southeast Texas Orange608 Strickland AvenueOrange, TX 77630(409) 883-9361

Parker CountyWeatherford Regional Medical Center713 East Anderson StreetWeatherford, TX 76086(682) 582-1000

Parmer CountyParmer Medical Center1307 Cleveland StreetFriona, TX 79035(806) 250-2754

Pecos CountyIraan General Hospital600 Highway 349 NorthIraan, TX 79744(432) 639-2575

Pecos County (Continued)Pecos County Memorial Hospital387 West IH-10Fort Stockton, TX 79735(432) 336-2004

Polk CountyMemorial Medical Center – Livingston1717 Highway 59 BypassLivingston, TX 77351(936) 329-8700

Potter CountyBaptist St. Anthony’s Hospital1600 Wallace BoulevardAmarillo, TX 79106(806) 212-2000

Panhandle Surgical Hospital7100 West 9th AvenueAmarillo, TX 79106(806) 212-0247

Quail Creek Surgical Hospital6819 Plum Creek DriveAmarillo, TX 79106(806) 354-6100

Reeves CountyReeves County Hospital2323 Texas StreetPecos, TX 79772(432) 447-3551

Runnels CountyNorth Runnels Hospital7821 State Highway 153 EastWinters, TX 79567(915) 754-4553

Texas (Continued)

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San Augustine CountyMemorial Medical Center – San Augustine511 East Hospital StreetSan Augustine, TX 75972(936) 275-3446

Scurry CountyCogdell Memorial Hospital1700 Cogdell BoulevardSnyder, TX 79549(325) 573-6374

Smith CountyMother Frances Hospital – Tyler800 East DawsonTyler, TX 75701(903) 593-8441

Trinity Mother Frances Rehabilitation Hospital3131 Troup Highway Tyler, TX 75701(903) 510-7000

University of Texas Health Center at Tyler 11937 Highway 271Tyler, TX 75708(903) 877-3451

Somervell CountyGlen Rose Medical Center1021 Holden StreetGlen Rose, TX 76043(254) 897-2215

Stonewall CountyStonewall Memorial Hospital821 North BroadwayAspermont, TX 79502(940) 989-3551

Tarrant CountyHealthSouth City View Rehabilitation Hospital6701 Oakmont BoulevardFort Worth, TX 76132(817) 370-4700

HealthSouth Rehabilitation Hospital of Arlington3200 Matlock RoadArlington, TX 76015(817) 468-4000

HealthSouth Rehabilitation Hospital of Fort Worth1212 West Lancaster AvenueFort Worth, TX 76102(817) 870-2336

John Peter Smith Hospital1500 South Main StreetFort Worth, TX 76104(817) 921-3431

LifeCare Hospital of Fort Worth6201 Overton Ridge BoulevardFort Worth, TX 76132(817) 370-6078

Texas Rehabilitation Hospital of Ft. Worth425 Alabama AvenueFort Worth, TX 76104(817) 820-3400

Taylor CountyAbilene Regional Medical Center6250 Highway 83/84Abilene, TX 79606(325) 428-1000

Hendrick Medical Center1900 Pine StreetAbilene, TX 79601(325) 670-2000

Terry CountyBrownfield Regional Medical Center705 East FeltBrownfield, TX 79316(806) 637-3551

Throckmorton CountyThrockmorton County Memorial Hospital802 North Minter StreetThrockmorton, TX 76483(940) 849-2151

Titus CountyTitus Regional Medical Center2001 North Jefferson AvenueMount Pleasant, TX 75455(903) 577-6000

Tom Green CountySan Angelo Community Medical Center3501 Knickerbocker RoadSan Angelo, TX 76904(325) 949-9511

Shannon Medical Center120 East Harris AvenueSan Angelo, TX 76903(325) 653-6741

Shannon Medical Center St. John’s Campus2018 Pulliam StreetSan Angelo, TX 76905(325) 659-7100

Shannon Women’s and Children’s Hospital201 East Harris AvenueSan Angelo, TX 76903(325) 653-6741

Texas (Continued)

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Little River CountyLittle River Memorial Hospital451 West Locke StreetAshdown, AR 71822(870) 898-5011

Arkansas

Travis CountyHealthSouth Rehabilitation Hospital of Austin1215 Red River StreetAustin, TX 78701(512) 474-5700

Northwest Hill Surgical Hospital6818 Austin Center BoulevardAustin, TX 78731(512) 346-1994

Upton CountyMcCamey County Hospital DistrictHighway 305 SouthMcCamey, TX 79752(432) 652-8626

Rankin County Hospital District1105 Elizabeth StreetRankin, TX 79778(432) 693-2443

Victoria CountyCitizens Medical Center2701 Hospital DriveVictoria, TX 77901(361) 573-9181

Detar Hospital Navarro506 East San Antonio StreetVictoria, TX 77901(361) 575-7441

Detar Hospital North101 Medical DriveVictoria, TX 77901(361) 573-6100

Victoria County (Continued)Post Acute Specialty Hospital of Victoria506 East San Antonio Street 3rd floor Victoria, TX 77901(361) 485-7300

Warm Springs Specialty Hospital of Victoria102 Medical DriveVictoria, TX 77904(361) 576-6200

Walker CountyHuntsville Memorial Hospital110 Memorial Hospital DriveHunstville, TX 77340(936) 291-3411

Ward CountyWard Memorial Hospital406 South Gary StreetMonahans, TX 79756(432) 943-2511

Wharton CountyGulf Coast Medical Center10141 US 59 RoadWharton, TX 77488(979) 532-2500

Wheeler CountyShamrock General Hospital1000 South Main StreetShamrock, TX 79079(806) 256-2114

Wichita CountyHealthSouth Rehabilitation Hospital of Wichita Falls3901 Armory RoadWichita Falls, TX 76302(940) 720-5713

Winkler CountyWinkler County Memorial Hospital821 Jeffee DriveKermit, TX 79745(432) 586-8299

Wood CountyMother Frances Hospital – Winnsboro719 West Coke RoadWinnsboro, TX 75494(903) 342-5227

Yoakum CountyYoakum County Hospital412 Mustang AvenueDenver City, TX 79323(806) 592-2121

Young CountyGraham Regional Medical Center1301 Montgomery RoadGraham, TX 76450(940) 549-3400

Texas (Continued)

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Participating Hospitals listed in this directory are subject to change. For health systems with multiple hospitals, all locations may not participate. Check with your doctor to make sure he or she has admitting privileges at a network hospital. Prior to scheduling any inpatient or outpatient hospital service it is recommended you contact Customer Service at 1-800-523-5800 (any weekday between 7 a.m. and 11 p.m., and on Saturdays between 9 a.m. and 5 p.m., Eastern Time) for a current listing of participating hospitals in your area. You may also call this number to obtain a directory of participating hospitals for other areas when you will be traveling.

All participating hospitals are open 24 hours a day, 7 days a week.

Your Medicare Select policy will only pay full supplemental benefits if covered services are obtained through specified participating hospitals. Medicare Select policies deny payment or pay less than the full benefit if you use a non-participating hospital for non-emergency services.

Caddo CountyChristus Highland Medical Center1453 East Bert Kouns Industrial LoopShreveport, LA 71105(318) 681-4500

Christus Schumpert Medical Center One St. Mary PlaceShreveport, LA 71101(318) 681-4500

University Health Shreveport1541 Kings HighwayShreveport, LA 71103(318) 675-5000

Calcasieu CountyDeQuincy Memorial Hospital110 West Fourth StreetDeQuincy, LA 70633(337) 786-1200

West Calcasieu Cameron Hospital701 Cypress StreetSulphur, LA 70663(337) 527-7034

Beauregard CountyBeauregard Memorial Hospital600 South Pine StreetDeridder, LA 70634(337) 462-7100

Sabine CountySabine Medical Center240 Highland DriveMany, LA 71449(318) 256-5691

Vernon CountyByrd Regional Hospital1020 West Fertitta BoulevardLeesville, LA 71446(337) 239-9041

Louisiana

Cimarron CountyCimarron Memorial Hospital100 South Ellis StreetBoise City, OK 73933(580) 544-2501

Pushmataha CountyPushmataha Hospital510 East Main StreetAntlers, OK 74523(580) 298-3341

Oklahoma

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CONTINUED ON REVERSE

For AARP® Medicare Select Plans OnlyTexas - Effective January 2017

Medicare Select C and Select F are available to individuals in the following zip code areas:

(1 of 7)SA25194TX (01-17)

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Live healthier with free access to fitness centers and classes.Use 13,000+ participating fitness locations,withaccess to exercise equipment, group fitness classes,social activities and more. Take signature group exercise classes designedjust for you and led by certified instructors.

SilverSneakers FLEX™ Community Classes offeradditional options such as Latin dance, tai chi andyoga. Self-directed physical activity programs areoffered for members who want to work out at homeor for those who can't get to a fitness location.Visit silversneakers.com to find a fitness centerlocation near you or to get more information.

HEALTHWAYS SILVERSNEAKERS® FITNESS PROGRAM

Your Exclusive Member Services.Get answers. Savemoney. Live healthy.

Save on every eyewear purchase and on routine eye exams.Save 30% on eyewear, including bifocals, lenses, and frames.* Contact lens wearers save 10% ondisposables and 20% on all other contact lenses.Plus, receive a 90-day guarantee on every eyewear purchase. Only at LensCrafters, take anadditional $50 off your AARP Vision Discount orbest in-store offer on no-line multifocal lenses with frame purchase.

Pay only $50 for routine eye exams** including an Eye Health Exam Report that details your results,and receive $10 off contact lens exams. Simply show your AARP® Medicare Supplementcard when you visit any participating LensCrafters®,Pearle Vision®, Sears Optical®, Target Optical®, andJCPenney Optical® location, or one of many privatepractice locations.**

AARP® VISION DISCOUNTS provided by EyeMed Vision Care

SA25517ST MISC

Get your health issues assessed, then get the helpyou need to make the right choices.Speak directly with registered nurses, toll-free, 24 hours a day, 365 days a year. Make informed decisions on how to get proper care.Nurses will review your symptoms, recommend

treatment options, and refer you to providers that meet high standards of quality and efficiency.Identify local resources such as transportationservices or community centers.Spanish is available, as well as translationassistance in 140+ languages.

NURSE HEALTHLINE

These are additional insured member services apart from the AARP Medicare Supplement Insurance Plan benefits, are not insurance programs, are subject to geographical availability, and may be discontinued at any time.

*30% discount only available when a complete pair of glasses (frames, lenses, and lens options) is purchased in thesame transaction. Items purchased separately will be discounted at 15% off the retail price.**Eye exams available by Independent Doctors of Optometry at or next to LensCrafters, Pearle Vision, Sears Opticaland Target Optical in most states. Doctors in some states are employed by the location. In California, optometrists arenot employed by LensCrafters, Sears Optical and Target Optical, which do not provide eye exams. For LensCrafters,eye exams are available from optometrists employed by EYEXAM of California, a licensed vision health care serviceplan. For Sears Optical and Target Optical, eye exams are available from self-employed doctors who lease spaceinside the store. Eye exam discount applies only to comprehensive eye exams and does not include contact lensexams or fitting. Contact lens purchase requires valid contact lens prescription. At LensCrafters locations, contactlenses are available by participating Independent Doctors of Optometry or at LensCrafters locations.The services provided by the SilverSneakers program are made available as a courtesy to AARP membersinsured by UnitedHealthcare Insurance Company (UnitedHealthcare) and are not part of insurance coverage and may be discontinued at any time. AARP and UnitedHealthcare do not endorse and are not responsible for theservices or information provided by this program. Consult a health care professional with questions about yourhealth care needs. EyeMed Vision Care LLC (EyeMed) is the network administrator of AARP Vision Discounts.These are not insurance programs and may be discontinued at any time. These discounts cannot be combinedwith any other discounts, promotions, coupons, or vision care plans. All decisions about medications and vision careare between you and your health care provider. Products or services that are reimbursable by federal programsincluding Medicare and Medicaid are not available on a discounted or complimentary basis. EyeMed pays a royaltyfee to AARP for use of the AARP intellectual property. Amounts paid are used for the general purposes of AARPand its members. Cannot be combined with any other offer, previous purchases, or vision and insurance plans.Some restrictions apply. Some brands excluded. See store for details. Void where prohibited. Valid at participatinglocations. Not all providers honor all discounts – employed LensCrafters, Sears Optical, Pearle Vision and TargetOptical locations honor the discount and some independent doctors may also honor the discount. Valid atparticipating Pearle Vision locations. The Sears trademark is registered and used under license from Sears BrandsLLC. Target Optical® is a registered mark of Target Brands, Inc. used under license. The Nurse HealthLine servicesare administered by OptumHealth Care Solutions, Inc. This service should not be used for emergency or urgentcare needs. In an emergency, call 911 or go to the nearest emergency room. The information provided throughthis service is for informational purposes only. The nurses cannot diagnose problems or recommend treatment andare not a substitute for your doctor's care. Your health information is kept confidential in accordance with the law.The service is not an insurance program and may be discontinued at any time.AARP endorses the AARP Medicare Supplement Insurance Plans, insured by UnitedHealthcare InsuranceCompany. UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property.These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers.Insured by UnitedHealthcare Insurance Company, Horsham, PA, Policy Form No. GRP 79171 GPS-1 (G-36000-4).In some states, plans may be available to persons under age 65 who are eligible for Medicare by reason ofdisability or End-Stage Renal Disease.Not connected with or endorsed by the U.S. Government or the federal Medicare program.This is a solicitation of insurance. A licensed insurance agent/producer may contact you. See enclosed materials for complete information including benefits, costs, eligibility requirements, exclusions and limitations.

SA25525TX

Enrollment Forms

You must be an AARP member to enroll in an AARP Medicare Supplement Insurance Plan.

AARP endorses the AARP Medicare Supplement Insurance Plans, insured by UnitedHealthcare Insurance Company. UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers.AARP does not employ or endorse agents, brokers or producers.Insured by UnitedHealthcare Insurance Company, Horsham, PA. Policy Form No. GRP 79171 GPS-1 (G-36000-4). In some states plans may be available to persons under age 65 who are eligible for Medicare by reason of disability or End Stage Renal Disease.Not connected with or endorsed by the U.S. Government or the federal Medicare program.This is a solicitation of insurance. A licensed insurance agent/producer may contact you.See enclosed materials for complete information including benefits, costs, eligibility requirements, exclusions and limitations.

AARP Medicare Supplement Insurance Plans

Enrollment Checklist

In the following section, you will find the forms you need to complete when applying for coverage. Please be sure to complete and submit all the necessary forms to ensure your enrollment is processed quickly and accurately.

Here is an overview of the different forms and some helpful tips:

Application Form • Be sure to review and complete each applicable section.

• Please only write comments where indicated on the application.

• Be sure to sign and date the application in all the places indicated.

AARP Membership FormAARP membership is required to enroll in an AARP Medicare Supplement Insurance Plan, insured by UnitedHealthcare Insurance Company. If you are not currently an AARP mem-ber or are unsure, you may enroll, renew or verify in one of three ways:

• Log on to AGNTU.aarpenrollment.com;

• Call toll-free 1-866-331-1964; or

• Complete the membership form and submit it with the plan application, along with a separate check for $16.00 payable to AARP. Note: One membership covers both the member and another individual living in the same household. Therefore, only one membership application is required if two individuals of a household are applying for AARP membership.

Electronic Funds Transfer (EFT) Authorization FormAutomatic payments are available by submitting the completed form (signed and dated). If requesting automatic payments, you may deduct $2 from the first month’s household premium check.

Notice to Applicants Regarding Replacement of CoverageIf you are replacing or losing current coverage as indicated on the form, complete both copies of the form, submit one copy with the enrollment application, and keep the other copy for your records. The licensed insurance agent must also sign and date both copies of the form.

If Reply Envelope Is MissingPlease mail completed application to: UnitedHealthcare Insurance Company P.O. Box 105331 Atlanta, GA 30348-5331

4

4

4

4

4

SA25510TX (Over Please)

AARP endorses the AARP Medicare Supplement Insurance Plans, insured by UnitedHealthcare Insurance Company. UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers.

AARP® Medicare Supplement Insurance Plans

You must be an AARP member in order to enroll in an AARP Medicare Supplement Insurance Plan.


Insured by UnitedHealthcare Insurance Company, Horsham, PA. Policy form No. GRP 79171 GPS-1 (G-36000-4). In some states plans may be available to persons under age 65 who are eligible for Medicare by reason of disability or End-Stage Renal Disease.



See the following materials for complete information including benefits, costs, eligibility requirements, exclusions and limitations.

S15S43AGMMTX01 01D Page 1 of 7

Application FormAARP® Medicare Supplement Insurance PlansInsured by UnitedHealthcare Insurance Company, Horsham, PA 19044

Plans and rates described in this package are good only for residents of Texas.

AARP Membership Number (If you are already a member) ___________________________________________If you are not already an AARP Member, please include your AARP Membership Application and a check or money orderfor your annual Membership dues and mail with this application.

_____________________________________ ____ __________________________________________Applicant First Name MI Last Name

___________________________________________ __________________ ____________ __________Permanent Home Address City State Zip

___________________________________________ __________________ ____________ __________Mailing Address (if different from above) City State Zip

1 Tell us about yourself

Fill in the information exactly as it is shown on your Medicare card.

1F. Will your Medicare Part A and Part B be active on your AARP Medicare Supplement Plan start date? Yes No

1G. Birthdate________________________ Month Day Year

1H. Phone Number____________________

1I. Email address (optional) ____________________________________________________________________By providing your email address, you are agreeing to receive important account information and product offers.Be sure to write all necessary periods (.) and symbols (@).

/ /

( ) -

2460720307

NAME OF BENEFICIARY1A. MEDICARE CLAIM NUMBER (Include all numbers and letters.)1B. 1C. Sex M FIS ENTITLED TO EFFECTIVE DATE HOSPITAL (PART A): 1D. /01/ MEDICAL (PART B): 1E. /01/

MEDICARE HEALTH INSURANCE

Instructions1. Fill in all requested information on this form and sign in the 2 places where a signature is needed.2. Print clearly. Use CAPITAL letters.3. Mark your answers with black or blue ink – not pencil. Example: X Yes No Not Sure4. Initial any changes or corrections you make while completing this application.

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2 Choose your plan and start date

3 Is your acceptance guaranteed?

Plan Choice2A. Choose only 1 plan from the right-hand column.

Plan A Plan B Plan C Plan F Plan K Plan L Plan N Medicare Select Plan C Medicare Select Plan F

Plan Start Date2B. Your plan will start on the first day of the month following receipt and approval of this application and receipt of your first month’s payment. If you would like your plan to start on a later date (the first day of a future month), please indicate the date:

____________________ Month Day Year

/01/

First Name Last Name

3A. Will your AARP Medicare Supplement Plan start date be within 6 months after you turn age 65 or enroll in Medicare Part B?

Yes No

• If YES, your acceptance is guaranteed. Go directly to Section 7. (You do not have to answer the questions in Sections 4, 5 and 6.)• If NO, you must answer Question 3B.

3B. Do you have guaranteed issue rights, as listed in the Guaranteed Acceptance section of “Your Guide” enclosed with this application? If so, include a copy of the termination notice from your prior insurer or employer.

Yes No

• If YES, go directly to Section 7. (You do not have to answer the questions in Sections 4, 5 and 6.)• If you answered NO to both questions in Section 3 and you are: - age 65 or over, continue to Section 4. - age 50-64, you are NOT eligible to apply for these plans.

4 Answer these health questions only if your acceptance is not guaranteed as defined in Section 3.

4A. Within the past 2 years, did a medical professional provide treatment or advice to you for any problems with your kidneys?

Yes No Not Sure

4B. Within the past 2 years, did a medical professional tell you that you may need any of the following? • hospital admittance as an inpatient • joint replacement • organ transplant • surgery for cancer • back or spine surgery • heart or vascular surgery

Yes No Not Sure

If you answered YES or NOT SURE to any question in Section 4, we will contact you for further information.


7 Tell us about your tobacco usage

7A. At any time within the past 12 months, have you smoked tobacco cigarettes or used any other tobacco product? Yes No

If you answered YES to Question 7A, your rate will be the tobacco rate. See the enclosed “Cover Page - Rates.”

6 Answer these health questions to determine your rate only if your acceptance is not guaranteed as defi ned in Section 3.

6A. Within the past 2 years, were you diagnosed as having, treated, given medical advice or prescribed medications/refi lls by a medical professional for any of the following conditions? • Artery or Vein Blockage • Peripheral Vascular Disease (PVD) • Cardiomyopathy • Congestive Heart Failure (CHF) • Coronary Artery Disease (CAD) • Chronic Obstructive Pulmonary Disease (COPD) or Emphysema • Chronic Kidney Disease • Diabetes, but only if you have circulation problems or Retinopathy • Cancer including Melanoma (but not other skin cancers), Leukemia and Lymphoma • Cirrhosis of the Liver

Yes No Not Sure Yes No Not Sure Yes No Not Sure Yes No Not Sure Yes No Not Sure Yes No Not Sure Yes No Not Sure Yes No Not Sure Yes No Not Sure Yes No Not Sure

6B. Within the past 2 years, did you have (as determined by a medical professional) aHeart Attack, Stroke, Transient Ischemic Attack (TIA) or Mini-Stroke? Yes No Not Sure

If you answered YES to any question in Section 6, your rate will be the Level 2 rate.See the enclosed “Cover Page – Rates.” If you answered NOT SURE to any question, we may need to contact you foradditional information.


5A. Within the past 90 days, were you hospitalized as an inpatient (not including overnight outpatient observation)? Yes No Not Sure

5B. Are you currently being treated or living in any type of nursing facility other than an assisted living facility? Yes No Not Sure

5C. Has a medical professional told you that you have End-Stage Renal (Kidney) Disease or that you require dialysis? Yes No Not Sure

Answering YES to any question in Section 5 will result in a denial of coverage.If your health status changes in the future, allowing you to answer NO to all of the questions in this section, please submit a new application at that time.If you answered NOT SURE to any question in Section 5, we will contact youfor further information.

5 Answer these eligibility health questions only if your acceptance is not guaranteed as defi ned in Section 3.


8 Tell us about your past and current coverage

PLEASE ANSWER ALL QUESTIONS.To the best of your knowledge,8A. Did you turn age 65 in the last 6 months? Yes No

8B. Did you enroll in Medicare Part B in the last 6 months? Yes No

8C. If YES, what is the effective date? ____________________ Month Day Year

Answer these questions about Medicaid 8D. Are you covered for medical assistance through the state Medicaid program?(Medicaid is a state-run health care program that helps with medical costs for people with low or limited income. It is not the federal Medicare program.) Note to applicant: If you are participating in a “Spend-down Program” and have not met your “Share of Cost”, answer NO to this question. If YES, you must answer Questions 8E and 8F.

Yes No

8E. Will Medicaid pay your premiums for this Medicare supplement policy? Yes No

8F. Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?

Yes No

Answer these questions about Medicare Advantage plans (sometimes called Medicare Part C)8G. Have you had coverage from any Medicare plan other than original Medicare within the past 63 days (for example, a Medicare Advantage plan, a Medicare HMO, or PPO)?If YES, you must answer Questions 8H through 8K.

Yes No

Review the statements below, then answer all questions to the best of your knowledge.• You do not need more than one Medicare supplement policy.• If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need more than one type of coverage in addition to your Medicare benefits.• You may be eligible for benefits under Medicaid and may not need a Medicare supplement policy.• If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing Medicaid eligibility. • If you are eligible for, and have enrolled in a Medicare supplement policy by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare supplement policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or union-based group health plan.• Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement insurance and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB).

If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplement insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplement plans. Please include a copy of the notice from your prior insurer with your application.

/01/



8 Tell us about your past and current coverage (continued)


7 ______________________________________________________________ __________________ Your Signature – 1 (required) Today’s Date (required) Month Day Year

/ /

8H. Fill in the start and end dates of your Medicare plan. If you are still covered under this plan, leave the end date blank.

Start Date____________________ Month Day Year

End Date____________________ Month Day Year

8I. If you are still covered under the Medicare plan, do you intend to replace yourcurrent coverage with this new Medicare supplement policy?(When you receive confirmation that this Medicare Supplement plan has been issued, you will need to cancel your Medicare Advantage Plan. Please contact your Medicare Advantage insurer for instructions on how to cancel, using the customer service number on the back of your ID card.)If YES, please enclose a copy of the Replacement Notice.

Yes No

8J. Was this your first time in this type of Medicare plan? Yes No

8K. Did you drop a Medicare supplement policy to enroll in the Medicare plan? Yes No

Answer these questions about Medicare supplement plans8L. Do you have another Medicare supplement policy in force?If so, what company and what plan do you have?Company: ________________________________________________________Policy: ___________________________________________________________If YES, you must answer Question 8M.

Yes No

8M. Do you intend to replace your current Medicare supplement policy with this policy?If YES, please enclose a copy of the Replacement Notice.

Yes No

Answer these questions about any other type of health insurance coverage8N. Have you had coverage under any other health insurance within the past 63 days (for example, an employer, union, or individual plan)?If YES, you must answer Questions 8O through 8Q.

Yes No

8O. If so, with what company and what kind of policy?Company:_______________________________________________________

Policy: HMO/PPO Major Medical Employer Plan Union Plan Other_______________

8P. What are your dates of coverage under the other policy? Leave the end date blank if you are still covered under the policy.

Start Date____________________ Month Day Year

End Date____________________ Month Day Year

8Q. Are you replacing this health insurance? Yes No

/ /

/ /

/01/

/ /


9 Authorization and Verification of Application Information

Read carefully, and sign and date in the signature box below. • My signature indicates I have read and understand the contents of this application form.• I declare the answers on this application form are complete and true to the best of my knowledge and belief and are the basis for issuing coverage. I understand that this application form becomes a part of the insurance contract and that if the answers are incomplete, incorrect or untrue, UnitedHealthcare Insurance Company may have the right to rescind my coverage, adjust my premium, or reduce my benefits.• Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act when determined by a court of competent jurisdiction, and as such may be subject to criminal and civil penalties.• I understand the agent or broker cannot grant approval. This application and payment of the initial premium does not guarantee coverage will be provided. I understand coverage, if provided, will not take effect until issued by UnitedHealthcare Insurance Company, and actual rates are not determined until coverage is issued.• I understand the agent or broker may not change or waive any terms or requirements related to this application and its contents, underwriting, premium, or coverage.• I understand the person discussing plan options with me is either employed by or contracted with UnitedHealthcare Insurance Company. This person may be compensated based on my enrollment in a plan.• If you are enrolling in a Medicare Select Plan: I acknowledge that I have received an Outline of Coverage, Grievance Procedure, Provider Directory and a Medicare Select Disclosure Statement covering Provider Restrictions, Right to Replace Your Medicare Supplement Plan and Quality Assurance Program. I affirm that I understand the benefits, restrictions, limitations and other provisions of the Medicare Select Plan for which I am applying.• I acknowledge receipt of the Guide to Health Insurance for People with Medicare and the Outline of Coverage.• I understand, for the Medicare Select Plan, I must determine whether any physician has admitting privileges to a network hospital.

Authorization for the Release of Medical InformationI authorize any health care provider, licensed physician, medical practitioner, hospital, pharmacy, clinic or other medical facility, health care clearinghouse, pharmacy benefit manager, insurance company, or other organization, institution, or person to give UnitedHealthcare Insurance Company and its affiliates (“The Company”) any data or records about me or my mental or physical health. I understand the purpose of this disclosure and use of my information is to allow The Company to determine my eligibility for coverage and rate. I understand this authorization is voluntary and I may refuse to sign the authorization. My refusal may, however, affect my eligibility to enroll in the health plan or to receive benefits, if permitted by law. I understand the information I authorize The Company to obtain and use may be re-disclosed to a third party only as permitted under applicable law, and once re-disclosed, the information may no longer be protected by Federal privacy laws. I understand I may end this authorization if I notify The Company, in writing, prior to the issuance of coverage. After coverage is issued, this authorization is not revocable. If not revoked, this authorization is valid for 24 months from the date of my signature.Please see “Your Guide” to determine if the following pre-existing condition waiting period applies to you.I understand the plan will not pay for expenses incurred during the first 3 months of coverage if they are due to conditions for which medical advice was given or treatment recommended by or received from a physician within 3 months prior to the insurance effective date.


I have read all information and have answered all questions to the best of my ability.

7 ______________________________________________________________ __________________ Your Signature – 2 (required) Today’s Date (required) Month Day YearNote: If you are signing as the legal representative for the applicant, please enclose a copy of the appropriate legal documentation.

/ /



Agent must complete the following information and include the notice of replacement coverage, if appropriate,with this application. All information must be complete or the application will be returned.1. List any other health insurance policies issued to the applicant: _____________________________________________________________________________________ _____________________________________________________________________________________2. List policies issued which are still in force: _____________________________________________________________________________________ _____________________________________________________________________________________3. List policies issued in the past 5 years which are no longer in force: _____________________________________________________________________________________ _____________________________________________________________________________________

/ /

Agent Name (PLEASE PRINT) _______________________ ___ _____________________________________ First Name MI Last Name

7 ______________________________________ ________________________ ___________________ Agent Signature (required) Agent ID (required) Today’s Date (required) Month Day Year

___________________________________________________ _______________________________ Agent Email Address Agent Phone Number

10 For Agent Use Only

BA25012TX

Supplement to Application

AARP® Medicare Supplement Insurance Plans Insured by UnitedHealthcare Insurance Company Horsham, PA 19044

Guaranteed issue for eligible persons

(a) Guaranteed issue

(1) Eligible persons are those individuals described in subsection (b) of this section who seek to enroll under the Medicare supplement policy during the period specified in subsection (d) of this section, and who submit evidence of the date of termination, disenrollment, or Medicare Part D enrollment with the application for a Medicare supplement policy.

(2) With respect to eligible persons, an issuer shall not deny or condition the issuance or effectiveness of a Medicare supplement policy described in subsection (c) of this section that is offered and is available for issuance to newly enrolled individuals by the issuer, and shall not discriminate in the pricing of such a Medicare supplement policy because of health status, claims experience, receipt of health care, or medical condition, and shall not impose an exclusion of benefits based on a preexisting condition under such a Medicare supplement policy.

(b) Eligible Persons

An eligible person is an individual described in any of the following paragraphs:

(1) The individual is enrolled under an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare, and the plan terminates, or the plan ceases to provide all such supplemental health benefits to the individual; or the individual is enrolled under an employee welfare benefit plan that is primary to Medicare and the plan terminates or the plan ceases to provide all health benefits to the individual because the individual leaves the plan.

(2) The individual is enrolled with a Medicare Advantage organization under a Medicare Advantage plan under Part C of Medicare, and any of the following circumstances apply, or the individual is 65 years of age or older and is enrolled with a Program of All-Inclusive Care for the Elderly (PACE) provider under section 1894 of the Social Security Act, and there are circumstances similar to the following that would permit discontinuance of the individual's enrollment with such provider if such individual were enrolled in a Medicare Advantage plan:

(A) The certification of the organization or plan has been terminated; or

(B) The organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides;

(C) The individual is no longer eligible to elect the plan because of a change in the individual's place of residence or other change in circumstances specified by the Secretary, but not including termination of the individual's enrollment on the basis described in section 1851(g)(3)(B) of the Social Security Act (where the individual has not paid premiums on a timely basis or has engaged

BA25012TX

in disruptive behavior as specified in standards under section 1856), or the plan is terminated for all individuals within a residence area;

(D) The individual demonstrates, 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 under U.S.C. Title 42, Chapter 7, Subchapter XVIII, Part D in relation to the individual, including the failure to provide an individual on a timely basis 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 the individual; or

(E) The individual meets such other exceptional conditions as the Secretary may provide.

(3) The individual is enrolled with an entity listed in subparagraphs (A) – (D) of this paragraph and enrollment ceases under the same circumstances that would permit discontinuance of an individual's election of coverage under paragraph (2) of this subsection:

(A) An eligible organization under a contract under section 1876 of the Social Security Act (Medicare cost);

(B) A similar organization operating under demonstration project authority, effective for periods before April 1, 1999;

(C) An organization under an agreement under section 1833(a)(1)(A) of the Social Security Act (health care prepayment plan); or

(D) An organization under a Medicare Select policy; and

(4) The individual is enrolled under a Medicare supplement policy and the enrollment ceases because:

(A) Of the insolvency of the issuer or bankruptcy of the nonissuer organization; or of other involuntary termination of coverage or enrollment under the policy;

(B) The issuer of the policy substantially violated a material provision of the policy; or

(C) 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 the individual;

(5) The individual was enrolled under a Medicare supplement policy and terminates enrollment and subsequently enrolls, for the first time, with any Medicare Advantage organization under a Medicare Advantage plan under part C of Medicare, any eligible organization under a contract under section 1876 of the Social Security Act (Medicare cost), any similar organization operating under demonstration project authority, any PACE provider under section 1894 of the Social Security Act, or a

BA25012TX

Medicare Select policy; and the subsequent enrollment is terminated by the individual during any period within the first 12 months of such subsequent enrollment (during which the individual is permitted to terminate such subsequent enrollment under section 1851(e) of the Social Security Act); or

(6) The individual, upon first becoming enrolled in Medicare part B for benefits at age 65 or older, enrolls in a Medicare Advantage plan under part C of Medicare, or with a PACE provider under section 1894 of the Social Security Act, and disenrolls from the plan or program no later than 12 months after the effective date of enrollment.

(7) The individual enrolls in a Medicare Part D plan during the initial enrollment period and, at the time of enrollment in Part D, was enrolled under a Medicare supplement policy that covers outpatient prescription drugs and the individual terminates enrollment in the Medicare supplement policy and submits evidence of enrollment in Medicare Part D along with the application for a policy described in subsection (c)(4) of this section.

(8) The individual loses eligibility for health benefits under Title XIX of the Social Security Act (Medicaid).

(c) Products to Which Eligible Persons are Entitled

The Medicare supplement policy to which eligible persons are entitled under:

(1) Subsection (b)(1), (2), (3), (4), and (8) of this section is a Medicare supplement policy which has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K, or L offered by any issuer, except that for persons under 65 years of age, it is a policy which has a benefit package classified as Plan A.

(2) Subsection (b)(5) of this section is the same Medicare supplement policy in which the individual was most recently previously enrolled, if available from the same issuer, or, if not so available, a policy described in paragraph (1) of this subsection. After December 31, 2005, if the individual was most recently enrolled in a Medicare supplement policy with an outpatient prescription drug benefit, the Medicare supplement policy described in this paragraph is the policy available from the same issuer but modified to remove outpatient prescription drug coverage, or at the election of the policyholder, a policy described in paragraph (1) of this subsection.

(3) Subsection (b)(6) of this section shall include any Medicare supplement policy offered by any issuer.

(4) Subsection (b)(7) of this section is a Medicare supplement policy that has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K, or L, and that is offered and is available for issuance to new enrollees by the same issuer that issued the individual's Medicare supplement policy with outpatient prescription drug coverage.

(d) Guaranteed Issue Time Period(s)

(1) In the case of an individual described in subsection (b)(1) of this section:

BA25012TX

(A) for a plan that supplements the benefits under Medicare, the guaranteed issue period begins on the later of:

(i) the date the individual receives a notice of termination or cessation of all supplemental health benefits (or if a notice is not received, the date the individual receives notice that a claim has been denied because of such termination or cessation); or

(ii) the date the applicable coverage terminates or ceases; and ends sixty-three (63) days thereafter; or

(B) for a plan that is primary to the benefits under Medicare, the guaranteed issue period begins on the later of:

(i) the date the individual receives a notice of termination or cessation of all health benefits (or if a notice is not received, the date the individual receives notice that a claim has been denied because of such termination or cessation); or

(ii) the date the applicable coverage terminates or ceases; and ends sixty-three (63) days thereafter.

(2) In the case of an individual described in subsection (b)(2), (3), (5), or (6) of this section whose enrollment is terminated involuntarily, the guaranteed issue period begins on the date that the individual receives a notice of termination and ends 63 days after the date the applicable coverage is terminated;

(3) In the case of an individual described in subsection (b)(4)(A) of this section, the guaranteed issue period begins on the earlier of the date that the individual receives a notice of termination, a notice of the issuer's bankruptcy or insolvency, or other such similar notice if any, and the date that the applicable coverage is terminated, and ends on the date that is 63 days after the date the coverage is terminated;

(4) In the case of an individual described in subsection (b)(2), (4)(B) and (C), (5), or (6) of this section, who disenrolls voluntarily, the guaranteed issue period begins on the date that is 60 days before the effective date of the disenrollment and ends on the date that is 63 days after the effective date of disenrollment;

(5) In the case of an individual described in subsection (b)(7) of this section, the guaranteed issue period begins on the date the individual receives notice pursuant to Section 1882(v)(2)(B) of the Social Security Act from the Medicare supplement issuer during the sixty-day period immediately preceding the initial Part D enrollment period and ends on the date that is 63 days after the effective date of the individual's coverage under Medicare Part D; and

(6) In the case of an individual described in subsection (b) of this section, but not described in paragraphs (1) - (5) of this subsection, the guaranteed issue period begins on the effective date of disenrollment and ends on the date that is 63 days after the effective date of disenrollment.

What each Member receives: Price

Membership - For individual member (12 months) $16

Membership - For member's spouse or partner (at any age) Included

Discounts (nationwide) - Vision: exams, frames, lenses Included- Pharmacy: prescriptions and over-the-counter items- Plus, look to AARPdiscounts.com for easy access to savings

on trusted brands, all in one place. Enjoy one-stop deals from shopping and dining to rental cars, hotels and cruises – and so much more!

Trusted Information - AARP The Magazine: the largest magazine circulation in the world Included- AARP Bulletin Newspaper (10 issues per year)

Access to Health Products - AARP-endorsed supplemental insurance Included- AARP-endorsed dental insurance

Advocacy - Representation of your interests in Washington and your state Included- Confronting age discrimination by employers- Strengthening Social Security- Protecting pension and retirement benefits- Fighting predatory home loan lending

Access to financial Programs - AARP-endorsed auto, homeowners, life, mobile home and Includedmotorcycle insurance

- Earn rewards with a no-annual-fee AARP-endorsed credit card

Local Opportunities - Safe driving courses (also available online) Included- Over 2,200 local AARP chapters- Social activities, volunteer opportunities, classes and workshops

AArP membershipoffers so much for so little.

Yes, I'd like to join AArP today! It's simple ... just follow these instructions. If you're already a member, give this to someoneyou know or complete it to renew your membership.

I agree to pay for the term I select:1 year/$16 3 years/$43 5 years/$63

___________________________________________________________My Name (please print: Mr./Mrs./Ms./Dr./First, Middle Initial, Last)

___________________________________________________________Address Apt.

___________________________________________________________City State Zip

_______ /________ /__________ Date of Birth: Month / Day / Year

___________________________________________________________Spouse’s/Partner’s Name (for free membership – at any age)

Check or money order enclosed, payableto AARP. Do not send cash.

Please keep in touch by e-mail about AARPactivities, events and member benefits:

__________________________________________E-mail Address V7FYUHG

BA25233 (07-14)

AA25001 (07-14) AGT

Choose from 3 easy ways to join:1.) Logonto www.AGNTU.aarpenrollment.com2.) Call toll-free: 1-866-331-19643.) Send completed form in the envelope

provided

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Please allow up to six weeks for delivery of your Membership Kit. Dues are not deductible for income tax purposes. One membership includes spouse/partner or 2ndhousehold member. Annual dues include $4.03 for a subscription to AARP The Magazine and $3.09 for the AARP Bulletin. We may steward your resources by convertingyour check into an electronic deposit. When you join or rejoin, AARP shares your membership information with the companies we have selected to provide AARPmember benefits, companies that support AARP operations, and select non-profit organizations. If you do not want us to share your information with providers of AARPmember benefits or non-profit organizations, please let us know by calling 1-800-516-1993 or e-mailing us at [email protected]. AARP member benefits areprovided by third parties, not by AARP or its affiliates. Providers pay a royalty fee to AARP for the use of its intellectual property. These fees are used for the general purposesof AARP. Some provider offers are subject to change and may have restrictions. Please contact the provider directly for details.

BeNefITS & SerVICeS

Travel DiscountsUsing AARP’s exclusive travel savings just once couldpay for your membership several times over!

• Savings on hotels, motels and resorts worldwide• Discounted rates on airfares, cruises and auto

rentals• Special pricing on vacation packages

Health-related BenefitsWith today’s high health care costs, AARP membershipis more valuable than ever.

• Supplemental health plans and dental insurancefor AARP members

• Vision, hearing and prescription discounts nationwide

Local OpportunitiesAARP offers many ways to getactive in your community.

• Over 2,200 local AARPchapters

• Social activities• Volunteer opportunities• Safe driving courses• Classes and workshops

Protection of Your rightsYour job. Your health. Your future. AARP will stand upfor you by ...

• Representing your interests in Washington andyour state

• Confronting age discrimination by employers• Strengthening Social Security• Protecting pension and retirement benefits• Fighting predatory home loan lending

Dependablefinancial ProgramsDesigned specifically forAARP members. Withthe high level of serviceyou expect.

• Earn rewards with a no-annual-feecredit card

• Auto, homeowners and life insurance

Valuable InformationAccurate and authoritative, direct from your reliable source – AARP.

• AARP The Magazine• AARP Bulletin• FREE financial and health guides• Our web site, www.aarp.org

Specially Priced Products & ServicesAARP helps you save in ways and places you neverimagined.

• Discounts on groceries, home security, restaurantsand more!

• Reduced-fee legal services*• Roadside assistance and emergency towing

NOTe: The benefits listed are only a partial list. YourMembership Kit will supply you with a full list of approvedservice providers that offer exclusive services and discounts to AARP members only.

Members often tell us their AARP membership paid for itself with the firstservice they used. They’re surprised at how many ways and places theirmembership proves valuable. And it’s an even better value because yourspouse/partner is included free (at any age)!

Value our members appreciate.

* Legal Services Network reduced-fee benefits are notavailable in HI, NV and OH.

explore the possibilities of AArP membership with:

Save $24 a year with the Electronic Funds Transfer (EFT) service

The Easiest Way to PayMore than 2.5 million AARP® members nationwide enjoy the convenience of the EFT option. With EFT,your monthly payment will automatically be deducted from your checking or savings account. Also,you’ll save $2.00 off the total monthly premium for your household.

In addition to saving up to $24 a year:• You’ll save on the cost of checks and rising postal rates.• You don’t have to take time to write a check each month.• You don’t have to worry about mailing a payment if you travel or become ill, because your payment is always deducted on or about the fifth day of each month.

Signing Up is Easy Complete the Automatic Payment Authorization Form on the reverse side. Return it with the application and be sure to keep a copy for your records. Please be sure the information is clear, as it is required for processing your request for EFT. You do not need to include a voided check.

Your EFT Effective DateIf you are submitting this EFT form with your enrollment application, your automatic payment start date will be the same as your plan effective date. A letter will be sent to confirm this and will include theamount of your withdrawal. Please note that if your coverage is effective in the future or your account is paid in advance, EFT withdrawals will begin for the next payment due. If your account is effective in the pastor is past due, a letter will be sent that explains how to make the payment that is due.

Complete Form on Reverse

This side for your information only, return not required.

�

BA25300ST Nov 13

IMPORTANTPlease refer to the diagram below to obtain your bank routing information.

We look forward to continuing to serve you.

VOID

AUTOMATIC PAYMENT AUTHORIZATION FORM

I allow UnitedHealthcare Insurance Company (UnitedHealthcare Insurance Company of NewYork for New York residents), hereafter named UnitedHealthcare, to take monthly withdrawals

for the then-current monthly rate from the account named on this form. I also allow the named banking facility (BANK) to charge such withdrawals to this account.

Monthly withdrawal amounts will be for the total household payment due each month. This will includepremiums for a spouse or other member(s) of the household on the same membership account. Thisauthority is active until UnitedHealthcare and the BANK receive notice from me to end withdrawals inenough time to give UnitedHealthcare and the BANK a reasonable opportunity to act on it. I have theright to stop payment of a withdrawal by giving notice to the BANK in such time as to give the BANK areasonable opportunity to act upon it. I understand such action may make the health care insurancecoverage past due and subject to cancellation.

Member Name ________________________________ AARP Member Number___________________

Member Address _____________________________________________________________________Street Addresss

Member Address _____________________________________________________________________City State Zip Code

Bank Name _____________________________

Bank Routing No. ________________________

(9 digit number)

Bank Account No. ________________________

Bank Account Holder’s Name if other than Member ________________________________________________

Bank Account Holder’s Signature _______________________________________________________________

Account Type: Checking Savings (statement savings only)

Save $24 a year with the Electronic Funds Transfer (EFT) service

The Easiest Way to PayMore than 2.5 million AARP® members nationwide enjoy the convenience of the EFT option. With EFT,your monthly payment will automatically be deducted from your checking or savings account. Also,you’ll save $2.00 off the total monthly premium for your household.

In addition to saving up to $24 a year:• You’ll save on the cost of checks and rising postal rates.• You don’t have to take time to write a check each month.• You don’t have to worry about mailing a payment if you travel or become ill, because your payment is always deducted on or about the fifth day of each month.

Signing Up is Easy Complete the Automatic Payment Authorization Form on the reverse side. Return it with the application and be sure to keep a copy for your records. Please be sure the information is clear, as it is required for processing your request for EFT. You do not need to include a voided check.

Your EFT Effective DateIf you are submitting this EFT form with your enrollment application, your automatic payment start date will be the same as your plan effective date. A letter will be sent to confirm this and will include theamount of your withdrawal. Please note that if your coverage is effective in the future or your account is paid in advance, EFT withdrawals will begin for the next payment due. If your account is effective in the pastor is past due, a letter will be sent that explains how to make the payment that is due.

Complete Form on Reverse

This side for your information only, return not required.

�

BA25300ST Nov 13

IMPORTANTPlease refer to the diagram below to obtain your bank routing information.

We look forward to continuing to serve you.

VOID

AUTOMATIC PAYMENT AUTHORIZATION FORM

I allow UnitedHealthcare Insurance Company (UnitedHealthcare Insurance Company of NewYork for New York residents), hereafter named UnitedHealthcare, to take monthly withdrawals

for the then-current monthly rate from the account named on this form. I also allow the named banking facility (BANK) to charge such withdrawals to this account.

Monthly withdrawal amounts will be for the total household payment due each month. This will includepremiums for a spouse or other member(s) of the household on the same membership account. Thisauthority is active until UnitedHealthcare and the BANK receive notice from me to end withdrawals inenough time to give UnitedHealthcare and the BANK a reasonable opportunity to act on it. I have theright to stop payment of a withdrawal by giving notice to the BANK in such time as to give the BANK areasonable opportunity to act upon it. I understand such action may make the health care insurancecoverage past due and subject to cancellation.

Member Name ________________________________ AARP Member Number___________________

Member Address _____________________________________________________________________Street Addresss

Member Address _____________________________________________________________________City State Zip Code

Bank Name _____________________________

Bank Routing No. ________________________

(9 digit number)

Bank Account No. ________________________

Bank Account Holder’s Name if other than Member ________________________________________________

Bank Account Holder’s Signature _______________________________________________________________

Account Type: Checking Savings (statement savings only)

NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE

UNITEDHEALTHCARE INSURANCE COMPANYHorsham, Pennsylvania

Save this notice! It may be important to you in the futureAccording to the information you furnished, you intend to terminate existing Medicare supplement or Medicare Advantage coverage and replace it with a policy to be issued by UnitedHealthcare Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep thepolicy. For your own information and protection, you should be aware of and seriously consider certain factors, whichmay affect the insurance protection available to you under the new policy.You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. Terminate your present policy or Medicare Advantage coverage only if, after due consideration and acceptance by thereplacing issuer, you find that purchase of this Medicare Supplement coverage is a wise decision.

You should evaluate the need for other accident and sickness coverage you have that may duplicate the benefits provided under this policy.Statement To Applicant By Issuer, Agent, Broker Or Other Representative:I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coveragebecause you intend to terminate your existing Medicare supplement policy or leave your Medicare Advantage plan. The replacement policy is being purchased for one of the following reasons:

Additional benefits.Same benefits, but lower premiums.Fewer benefits and lower premiumsMy plan has outpatient prescription drug coverage and I am enrolling in Part D.

Disenrollment from a Medicare Advantage plan. Please explain reason for Disenrollment.Other (Please Specify)

1. Health conditions which you may presently have (Pre-existing conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.

2. State law provides that your replacement policy or certificate may not contain new pre-existing conditions, waiting periods, elimination periods, or probationary periods. The insurer will waive any time periods applicable to pre-existing conditions, waiting periods, elimination periods, or probationary periods in the new policy (or coverage) to the extent such time was spent (depleted) under the original policy.

3. If you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the issuer to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certainthat all information has been properly recorded.

Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.

(Signature of Agent, Broker or Other Representative) (Date)

(Applicant’s Signature)

Typed Name and Address of Issuer or Agent

I call your attention to the following items for your consideration:

(Date)

Applicant’s Printed Name and AddressRN035 3/10

Once Your Application Is Approved, You Will Receive:

What’s Next

• Your insured member identification card

• A Welcome Kit, including your certificate of insurance and coverage details

• Ongoing educational materials about how to make the most of your health plan benefits

• Help and answers to any questions you may have from courteous Customer Service Representatives

• A friendly customer service call to review the items listed above

A continuing relationship with your agent/producer

SA25235ST Nov 15

Thank You for Applying for an AARP® Medicare Supplement Insurance Plan. For your records:

• You selected Plan __________

• The effective date you requested is (1st day of a future month): _____ / _____

• Based on the information you provided, your monthly premium for the plan you selected is $ __________

• You will be notified when review of your application has been completed

Please Note: Your final monthly premium will be determined once your application is approved.

Month Year

SA25553ST

UnitedHealthcare Insurance Company (UnitedHealthcare Insurance Company of New York for New York residents) does not treat members differently because of sex, age, race, color, disability, or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability, or national origin, you can send a complaint to the Civil Rights Coordinator. Online: [email protected] Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608, Salt Lake City, UT 84130

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call 1-800-523-5800, TTY 711, Monday through Friday, 7 a.m. to 11 p.m., and Saturday, 9 a.m. to 5 p.m. EST.

You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue, SW Room 509F HHH Building, Washington, DC 20201

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call 1-800-523-5800, TTY 711, Monday through Friday, 7 a.m. to 11 p.m., and Saturday, 9 a.m. to 5 p.m. EST.

IMPORTANT 2017 MEDICARE BENEFIT INFORMATION

Beginning January 1, 2017, the Medicare Part A inpatient Hospital Deductible will be $1,316.

The chart below lists Medicare’s updated benefits.

SERVICE BENEFIT MEDICARE PAYS❖❖

HOSPITALIZATION Semi-

private room & board, general nursing and miscellaneous hospital services and supplies per

benefit period.(1)

First 60 days

61st - 90th day

91st - 150th day❖

Beyond 150 days

All but $1,316

All but $329 a day

All but $658 a day

Nothing

SERVICE BENEFIT MEDICARE PAYS❖❖

POST HOSPITAL SKILLED NURSING FACILITY CARE

You must have been in a hospital for at least 3 days and enter a

Medicare-approved facility generally within 30 days after

hospital discharge.(2)

First 20 days

Additional 80 days

Beyond 100 days

100% of approved amount

All but $164.50 a day

Nothing

For 2017, the Medicare Part B Deductible will be $183.

2017 Out of Pocket Limits for Medigap Plans K & L - The 2017 out of pocket limits for Medigap Plans K & L are $5,120 and $2,560, respectively. 2017 Deductible Amount for Medigap High Deductible Options F & J - The 2017 annual deductible amount for these two plans is $2,200.

❖ 60 Reserve Days may be used only once; days used are not renewable. ❖❖ These figures are for 2017 and are subject to change each year. (1) 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 or skilled nursing facility for 60 days in a row. (2) Medicare and private insurance will not pay for most nursing home care.

SA2943Z

Choosing a Medigap Policy:A Guide to Health Insurance for People with Medicare

C E N T E R S F O R M E D I C A R E & M E D I C A I D S E R V I C E S

This official government guide has important information about:

• Medicare Supplement Insurance (Medigap) policies

• What Medigap policies cover

• Your rights to buy a Medigap policy

• How to buy a Medigap policy

This guide can help if you’re thinking about buying

a Medigap policy or already have one.

Developed jointly by the Centers for Medicare & Medicaid Services (CMS) and the National Association of Insurance Commissioners (NAIC)

Who should read this guide? This guide helps people with Medicare understand Medicare Supplement Insurance policies (also called Medigap policies). A Medigap policy is a type of private insurance that helps you pay for some of the costs that Original Medicare doesn’t cover.

Important information about this guideThe information in this booklet describes the Medicare program at the time this booklet was printed. Changes may occur after printing. Visit Medicare.gov, or call 1‑800‑MEDICARE (1‑800‑633‑4227) to get the most current information. TTY users should call 1‑877‑486‑2048.The “2016 Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare” isn’t a legal document. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.

3Table of Contents

Medicare Basics 5

A brief look at Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5What's Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6The different parts of Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Your Medicare coverage choices at a glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Medicare and the Health Insurance Marketplace . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Medigap Basics 9

What's a Medigap policy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9What Medigap policies cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10What Medigap policies don’t cover. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Types of coverage that are NOT Medigap policies . . . . . . . . . . . . . . . . . . . . . . . . . 12What types of Medigap policies can insurance companies sell? . . . . . . . . . . . . . . 12What do I need to know if I want to buy a Medigap policy?. . . . . . . . . . . . . . . . . 13When's the best time to buy a Medigap policy? . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Why is it important to buy a Medigap policy when I'm first eligible? . . . . . . . . . 16How do insurance companies set prices for Medigap policies? . . . . . . . . . . . . . . 17What this pricing may mean for you . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Comparing Medigap costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19What's Medicare SELECT? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20How does Medigap help pay my Medicare Part B bills? . . . . . . . . . . . . . . . . . . . . 20

Your Right to Buy a Medigap Policy 21

What are guaranteed issue rights? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21When do I have guaranteed issue rights?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Can I buy a Medigap policy if I lose my health care coverage? . . . . . . . . . . . . . . 24

Steps to Buying a Medigap Policy 25

Step‑by‑step guide to buying a Medigap policy . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

If You Already Have a Medigap Policy 31

Switching Medigap policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Losing Medigap coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Medigap policies and Medicare prescription drug coverage . . . . . . . . . . . . . . . . 36

Section 1:

Section 2:

Section 3:

Section 4:

Section 5:

4 Table of Contents

Medigap Policies for People with a Disability or ESRD 39

Information for people under 65 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Medigap Coverage in Massachusetts, Minnesota, and Wisconsin 41

Massachusetts benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Minnesota benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Wisconsin benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

For More Information 45

Where to get more information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45How to get help with Medicare and Medigap questions . . . . . . . . . . . . . . . . . . . . 46State Health Insurance Assistance Program and State Insurance Department. . 47

Definitions 49

Where words in BLUE are defined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Section 6:

Section 7:

Section 8:

Section 9:

1SECTION

5

Medicare Basics

A brief look at MedicareA Medicare Supplement Insurance (Medigap) Policy is a health insurance sold by private insurance companies which can help pay some of the health care costs that Original Medicare doesn't cover, like coinsurance, copayments, or deductibles. Some Medigap policies also cover certain benefits Original Medicare doesn’t cover like emergency foreign travel expenses. Medigap policies don’t cover your share of the costs under other types of health coverage, including Medicare Advantage Plans (like HMOs or PPOs), stand‑alone Medicare Prescription Drug Plans, employer/union group health coverage, Medicaid, or TRICARE. Insurance companies generally can’t sell you a Medigap policy if you have coverage through Medicaid or a Medicare Advantage Plan.

Before you learn more about Medigap policies, the next few pages provide a brief look at Medicare. If you already know the basics about Medicare and only want to learn about Medigap, skip to page 9.

Words in blue are defined on pages 49–50.

6 Section 1: Medicare Basics

What's Medicare? Medicare is health insurance for:

• People 65 or older• People under 65 with certain disabilities • People of any age with End‑Stage Renal Disease (ESRD) (permanent kidney failure

requiring dialysis or a kidney transplant)

The different parts of Medicare The different parts of Medicare help cover specific services:

Medicare Part A (Hospital Insurance) helps cover

• Inpatient care in hospitals • Skilled nursing facility, hospice, and home health care

Medicare Part B (Medical Insurance) helps cover

• Services from doctors and other health care providers, hospital outpatient care, durable medical equipment, and home health care

• Preventive services to help maintain your health and to keep certain illnesses from getting worse

Medicare Part C (Medicare Advantage)

• Includes all benefits and services covered under Part A and Part B• Run by Medicare‑approved private insurance companies • Usually includes Medicare prescription drug coverage (Part D) as part of the plan • May include extra benefits and services for an extra cost

Medicare Part D (Medicare Prescription Drug Coverage)

• Helps cover the cost of outpatient prescription drugs • Run by Medicare‑approved private insurance companies• May help lower your prescription drug costs and help protect against higher costs in

the future

7Section 1: Medicare Basics

Your Medicare coverage choices at a glance There are 2 main ways to get your Medicare coverage — Original Medicare or a Medicare Advantage Plan. Use these steps to help you decide which way to get your coverage. See page 35 for information about Medicare Advantage Plans and Medigap policies.

Part AHospital Insurance

Part BMedical Insurance

Medicare Supplement Insurance (Medigap) policy

Part D Prescription Drug Coverage

Part CCombines Part A, Part B, and usually Part D

OrIgInAl MeDICAre MeDICAre ADvAnTAge PlAnPart C (like an HMO or PPO)

STeP 3: Decide if you need to add supplemental coverage.

enD

enD

STeP 1: Decide how you want to get your coverage.

Part D Prescription Drug Coverage (Most Medicare Advantage Plans cover prescription drugs. You may be able to add drug coverage in some plan types if not already included.)

or

STArT

If you join a Medicare Advantage Plan, you can’t use and can’t be sold a Medigap policy. See page 35.

STeP 2: Decide if you need to add drug coverage.

STeP 2: Decide if you need to add drug coverage.

8 Section 1: Medicare Basics

Medicare and the Health Insurance MarketplaceThe Health Insurance Marketplace is a way for qualified individuals, families, and employees of small businesses to get health coverage. Medicare isn’t part of the Marketplace.

Is Medicare coverage "minimum essential coverage?"Minimum essential coverage is coverage that you need to have to meet the individual responsibility requirement under the Affordable Care Act.As long as you have Medicare Part A (Hospital Insurance) coverage or are enrolled in a Medicare Advantage Plan, you have minimum essential coverage and you don't have to get any additional coverage.If you only have Medicare Part B (Medical Insurance), you aren't considered to have minimum essential coverage. This means you may have to pay a fee for not having minimum essential coverage. You'd pay this fee when you file your federal income tax return.

Can I get a Marketplace plan instead of Medicare, or can I get a Marketplace plan in addition to Medicare?Generally, no. In most cases, it’s against the law for someone who knows you have Medicare to sell you a Marketplace plan, because that would duplicate your coverage. However, if you’re employed and your employer offers employer‑based coverage through the Marketplace, you may be eligible to get that type of coverage.Note: The Marketplace doesn’t offer Medicare Supplement Insurance (Medigap) policies, Medicare Advantage Plans, or Medicare drug plans (Part D).

For more information Remember, this guide is about Medigap policies. To learn more about Medicare, visit Medicare.gov, look at your “Medicare & You” handbook, or call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048.

2SECTION

9

Medigap Basics

What's a Medigap policy? A Medigap policy is private health insurance that helps supplement Original Medicare. This means it helps pay some of the health care costs that Original Medicare doesn’t cover (like copayments, coinsurance, and deductibles). These are “gaps” in Medicare coverage. If you have Original Medicare and a Medigap policy, Medicare will pay its share of the Medicare‑approved amounts for covered health care costs. Then your Medigap policy pays its share. A Medigap policy is different from a Medicare Advantage Plan (like an HMO or PPO) because those plans are ways to get Medicare benefits, while a Medigap policy only supplements the costs of your Original Medicare benefits. Note: Medicare doesn’t pay any of your costs for a Medigap policy.All Medigap policies must follow federal and state laws designed to protect you, and policies must be clearly identified as “Medicare Supplement Insurance.” Medigap insurance companies in most states can only sell you a “standardized” Medigap policy identified by letters A through N. Each standardized Medigap policy must offer the same basic benefits, no matter which insurance company sells it. Cost is usually the only difference between Medigap policies with the same letter sold by different insurance companies.

In Massachusetts, Minnesota, and Wisconsin, Medigap policies are standardized in a different way. See pages 42–44. In some states, you may be able to buy another type of Medigap policy called Medicare SELECT. Medicare SELECT plans are standardized plans that may require you to see certain providers and may cost less than other plans. See page 20.

10 Section 2: Medigap Basics

What Medigap policies cover

The chart on page 11 gives you a quick look at the standardized Medigap Plans available. You'll need more details than this chart provides to compare and choose a policy. Call your State Health Insurance Assistance Program (SHIP) for help. See pages 47–48 for your state’s phone number.

Notes: • Insurance companies selling Medigap policies are required to make Plan A

available. If they offer any other Medigap policy, they must also offer either Plan C or Plan F. Not all types of Medigap policies may be available in your state. See pages 42– 44 if you live in Massachusetts, Minnesota, or Wisconsin.

• Plans D and G effective on or after June 1, 2010, have different benefits than Plans D or G bought before June 1, 2010.

• Plans E, H, I, and J are no longer sold, but, if you already have one, you can generally keep it.

11Section 2: Medigap Basics

Medicare Supplement Insurance (Medigap) Plans

Benefits A B C D F* G K L M NMedicare Part A coinsurance and hospital costs (up to an additional 365 days after Medicare benefits are used)

100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Medicare Part B coinsurance or copayment

100% 100% 100% 100% 100% 100% 50% 75% 100% 100% ***

Blood (first 3 pints) 100% 100% 100% 100% 100% 100% 50% 75% 100% 100%Part A hospice care coinsurance or copayment

100% 100% 100% 100% 100% 100% 50% 75% 100% 100%

Skilled nursing facility care coinsurance

100% 100% 100% 100% 50% 75% 100% 100%

Part A deductible 100% 100% 100% 100% 100% 50% 75% 50% 100%Part B deductible 100% 100%Part B excess charges 100% 100%Foreign travel emergency (up to plan limits)

80% 80% 80% 80% 80% 80%

Out‑of‑pocket limit

in 2016**$4,960 $2,480

* Plan F is also offered as a high‑deductible plan by some insurance companies in some states. If you choose this option, this means you must pay for Medicare‑covered costs (coinsurance, copayments, deductibles) up to the deductible amount of $2,180 in 2016 before your policy pays anything. **For Plans K and L, after you meet your out‑of‑pocket yearly limit and your yearly Part B deductible ($166 in 2016), the Medigap plan pays 100% of covered services for the rest of the calendar year.*** 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 don’t result in an inpatient admission.

This chart shows basic information about the different benefits that Medigap policies cover. If a percentage appears, the Medigap plan covers that percentage of the benefit, and you must pay the rest.


What Medigap policies don’t coverGenerally, Medigap policies don’t cover long‑term care (like care in a nursing home), vision or dental care, hearing aids, eyeglasses, or private‑duty nursing.

Types of coverage that are nOT Medigap policies• Medicare Advantage Plans (Part C), like an HMO, PPO, or

Private Fee‑for‑Service Plan• Medicare Prescription Drug Plans (Part D)• Medicaid• Employer or union plans, including the Federal Employees Health

Benefits Program (FEHBP)• TRICARE • Veterans’ benefits • Long‑term care insurance policies • Indian Health Service, Tribal, and Urban Indian Health plans• Qualified Health Plans sold in the Health Insurance Marketplace

What types of Medigap policies can insurance companies sell?In most cases, Medigap insurance companies can sell you only a “standardized” Medigap policy. All Medigap policies must have specific benefits, so you can compare them easily. If you live in Massachusetts, Minnesota, or Wisconsin, see pages 42– 44.Insurance companies that sell Medigap policies don’t have to offer every Medigap plan. However, they must offer Plan A if they offer any Medigap policy. If they offer any plan in addition to Plan A, they must also offer Plan C or Plan F. Each insurance company decides which Medigap plan it wants to sell, although state laws might affect which ones they offer.In some cases, an insurance company must sell you a Medigap policy, even if you have health problems. Here are certain times that you’re guaranteed the right to buy a Medigap policy: • When you’re in your Medigap Open Enrollment Period. See pages 14 –15.• If you have a guaranteed issue right. See pages 21–23.

You may be able to buy a Medigap policy at other times, but the insurance company can deny you a Medigap policy based on your health. Also, in some cases it may be illegal for the insurance company to sell you a Medigap policy (like if you already have Medicaid or a Medicare Advantage Plan).



What do I need to know if I want to buy a Medigap policy?• You must have Medicare Part A (Hospital Insurance) and Medicare Part B

(Medical Insurance) to buy a Medigap policy.

• If you have a Medicare Advantage Plan (like an HMO or PPO) but are planning to return to Original Medicare, you can apply for a Medigap policy before your coverage ends. The Medigap insurer can sell it to you as long as you’re leaving the Plan. Ask that the new Medigap policy start when your Medicare Advantage Plan enrollment ends, so you'll have continuous coverage.

• You pay the private insurance company a premium for your Medigap policy in addition to the monthly Part B premium you pay to Medicare.

• A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you each will have to buy separate Medigap policies.

• When you have your Medigap Open Enrollment Period, you can buy a Medigap policy from any insurance company that’s licensed in your state.

• If you want to buy a Medigap policy, see page 11 for an overview of the basic benefits covered by different Medigap policies to review the benefit choices. Then, follow the “Steps to Buying a Medigap Policy” on pages 25 –30.

• If you want to drop your Medigap policy, write your insurance company to cancel the policy and confirm it’s cancelled. Your agent can’t cancel the policy for you.

• Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can’t cancel your Medigap policy as long as you pay the premium.

• Different insurance companies may charge different premiums for the same exact policy. As you shop for a policy, be sure you’re comparing the same policy (for example, compare Plan A from one company with Plan A from another company).

• Some states may have laws that may give you additional protections.


What do I need to know if I want to buy a Medigap policy? (continued)• Although some Medigap policies sold in the past covered prescription

drugs, Medigap policies sold after January 1, 2006, aren’t allowed to include prescription drug coverage.

• If you want prescription drug coverage, you can join a Medicare Prescription Drug Plan (Part D) offered by private companies approved by Medicare. See pages 6–7.

To learn about Medicare prescription drug coverage, visit Medicare.gov, or call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048.

When's the best time to buy a Medigap policy? The best time to buy a Medigap policy is during your Medigap Open Enrollment Period. This period lasts for 6 months and begins on the first day of the month in which you’re both 65 or older and enrolled in Medicare Part B. Some states have additional Open Enrollment Periods including those for people under 65. During this period, an insurance company can’t use medical underwriting. This means the insurance company can’t do any of these because of your health problems:• Refuse to sell you any Medigap policy it offers • Charge you more for a Medigap policy than they charge someone with no

health problems• Make you wait for coverage to start (except as explained below) While the insurance company can’t make you wait for your coverage to start, it may be able to make you wait for coverage related to a pre‑existing condition. A pre‑existing condition is a health problem you have before the date a new insurance policy starts. In some cases, the Medigap insurance company can refuse to cover your out‑of‑pocket costs for these pre‑existing health problems for up to 6 months. This is called a “pre‑existing condition waiting period.” After 6 months, the Medigap policy will cover the pre‑existing condition.



When's the best time to buy a Medigap policy? (continued) Coverage for a pre‑existing condition can only be excluded if the condition was treated or diagnosed within 6 months before the coverage starts under the Medigap policy. This is called the “look‑back period.” After the 6‑month pre‑existing condition waiting period, the Medigap policy will cover the condition that was excluded. Remember, for Medicare‑covered services, Original Medicare will still cover the condition, even if the Medigap policy won’t, but you’re responsible for the Medicare coinsurance or copayment.

Creditable coverageIf you have a pre‑existing condition, you buy a Medigap policy during your Medigap Open Enrollment Period, and you’re replacing certain kinds of health coverage that count as “creditable coverage,” it’s possible to avoid or shorten waiting periods for pre‑existing conditions. Prior creditable coverage is generally any other health coverage you recently had before applying for a Medigap policy. If you have had at least 6 months of continuous prior creditable coverage, the Medigap insurance company can’t make you wait before it covers your pre‑existing conditions.There are many types of health care coverage that may count as creditable coverage for Medigap policies, but they'll only count if you didn’t have a break in coverage for more than 63 days.Your Medigap insurance company can tell you if your previous coverage will count as creditable coverage for this purpose. You can also call your State Health Insurance Assistance Program. See pages 47– 48.If you buy a Medigap policy when you have a guaranteed issue right (also called “Medigap protection”), the insurance company can’t use a pre‑existing condition waiting period. See pages 21–23 for more information about guaranteed issue rights.Note: If you’re under 65 and have Medicare because of a disability or End‑Stage Renal Disease (ESRD), you might not be able to buy the Medigap policy you want, or any Medigap policy, until you turn 65. Federal law doesn’t require insurance companies to sell Medigap policies to people under 65. However, some states require Medigap insurance companies to sell you a Medigap policy, even if you’re under 65. See page 39 for more information.


Why is it important to buy a Medigap policy when I'm first eligible? When you're first eligible, you have the right to buy any Medigap policy offered in your state. In addition, you generally will get better prices and more choices among policies. It’s very important to understand your Medigap Open Enrollment Period. Medigap insurance companies are generally allowed to use medical underwriting to decide whether to accept your application and how much to charge you for the Medigap policy. However, if you apply during your Medigap Open Enrollment Period, you can buy any Medigap policy the company sells, even if you have health problems, for the same price as people with good health. If you apply for Medigap coverage after your Open Enrollment Period, there’s no guarantee that an insurance company will sell you a Medigap policy if you don’t meet the medical underwriting requirements, unless you’re eligible because of one of the limited situations listed on pages 22–23.It’s also important to understand that your Medigap rights may depend on when you choose to enroll in Medicare Part B. If you’re 65 or older, your Medigap Open Enrollment Period begins when you enroll in Part B and it can’t be changed or repeated. In most cases, it makes sense to enroll in Part B and purchase a Medigap policy when you’re first eligible for Medicare, because you might otherwise have to pay a Part B late enrollment penalty and you might miss your Medigap Open Enrollment Period. However, there are exceptions if you have employer coverage.

Employer coverageIf you have group health coverage through an employer or union, because either you or your spouse is currently working, you may want to wait to enroll in Part B. This is because benefits based on current employment often provide coverage similar to Part B, so you would be paying for Part B before you need it, and your Medigap Open Enrollment Period might expire before a Medigap policy would be useful. When the employer coverage ends, you’ll get a chance to enroll in Part B without a late enrollment penalty which means your Medigap Open Enrollment Period will start when you’re ready to take advantage of it. If you enrolled in Part B while you still had employer coverage, your Medigap Open Enrollment Period would start, and unless you bought a Medigap policy before you needed it, you would miss your Medigap Open Enrollment Period entirely. If you or your spouse is still working and you have coverage through an employer, contact your employer or union benefits administrator to find out how your insurance works with Medicare. See page 24 for more information.



How do insurance companies set prices for Medigap policies? Each insurance company decides how it’ll set the price, or premium, for its Medigap policies. It’s important to ask how an insurance company prices its policies. The way they set the price affects how much you pay now and in the future. Medigap policies can be priced or “rated” in 3 ways: 1. Community‑rated (also called “no‑age‑rated”)

2. Issue‑age‑rated (also called “entry‑age‑rated”)

3. Attained‑age‑rated

Each of these ways of pricing Medigap policies is described in the chart on the next page. The examples show how your age affects your premiums, and why it’s important to look at how much the Medigap policy will cost you now and in the future. The amounts in the examples aren’t actual costs. Other factors like where you live, medical underwriting, and discounts can also affect the amount of your premium.


How do insurance companies set prices for Medigap policies? (continued)

Type of pricing

Community-rated (also called “no-age-rated”)

How it’s priced

What this pricing may mean for you

examples

Generally the same premium is charged to everyone who has the Medigap policy, regardless of age or gender.

The premium is based on the age you are when you buy (are “issued”) the Medigap policy.

The premium is based on your current age (the age you've “attained”), so your premium goes up as you get older.

Your premium isn’t based on your age. Premiums may go up because of inflation and other factors but not because of your age.

Premiums are lower for people who buy at a younger age and won’t change as you get older. Premiums may go up because of inflation and other factors but not because of your age.

Premiums are low for younger buyers but go up as you get older. They may be the least expensive at first, but they can eventually become the most expensive. Premiums may also go up because of inflation and other factors.

Mr. Smith is 65. He buys a Medigap policy and pays a $165 monthly premium.

Mrs. Perez is 72. She buys the same Medigap policy as Mr. Smith. She also pays a $165 monthly premium because, with this type of Medigap pricing, everyone pays the same price regardless of age.

Mr. Han is 65. He buys a Medigap policy and pays a $145 monthly premium.

Mrs. Wright is 72. She buys the same Medigap policy as Mr. Han. Since she is older when she buys it, her monthly premium is $175.

Mrs. Anderson is 65. She buys a Medigap policy and pays a $120 monthly premium. Her premium will go up each year: • At 66, her premium goes up to $126. • At 67, her premium goes up to $132. • At 72, her premium goes up to $165.

Mr. Dodd is 72. He buys the same Medigap policy as Mrs. Anderson. He pays a $165 monthly premium. His premium is higher than Mrs. Anderson’s because it’s based on his current age. Mr. Dodd’s premium will go up each year:• At 73, his premium goes up to $171. • At 74, his premium goes up to $177.

Issue-age-rated (also called “entry age-rated”)

Attained-age-rated


Comparing Medigap costs As discussed on the previous pages, the cost of Medigap policies can vary widely. There can be big differences in the premiums that different insurance companies charge for exactly the same coverage. As you shop for a Medigap policy, be sure to compare the same type of Medigap policy, and consider the type of pricing used. See pages 17–18. For example, compare a Plan C from one insurance company with a Plan C from another insurance company. Although this guide can’t give actual costs of Medigap policies, you can get this information by calling insurance companies or your State Health Insurance Assistance Program. See pages 47– 48.You can also find out which insurance companies sell Medigap policies in your area by visiting Medicare.gov.The cost of your Medigap policy may also depend on whether the insurance company:

• Offers discounts (like discounts for women, non‑smokers, or people who are married; discounts for paying yearly; discounts for paying your premiums using electronic funds transfer; or discounts for multiple policies).

• Uses medical underwriting, or applies a different premium when you don’t have a guaranteed issue right or aren’t in a Medigap Open Enrollment Period.

• Sells Medicare SELECT policies that may require you to use certain providers. If you buy this type of Medigap policy, your premium may be less. See page 20.

• Offers a “high‑deductible option” for Plan F. If you buy Plan F with a high‑deductible option, you must pay the first $2,180 of deductibles, copayments, and coinsurance (in 2016) not paid by Medicare before the Medigap policy pays anything. You must also pay a separate deductible ($250 per year) for foreign travel emergency services.

If you bought your Medigap Plan J before January 1, 2006, and it still covers prescription drugs, you would also pay a separate deductible ($250 per year) for prescription drugs covered by the Medigap policy. And, if you have a Plan J with a high deductible option, you must also pay a $2,180 deductible (in 2016) before the policy pays anything for medical benefits.


What's Medicare SeleCT? Medicare SELECT is a type of Medigap policy sold in some states that requires you to use hospitals and, in some cases, doctors within its network to be eligible for full insurance benefits (except in an emergency). Medicare SELECT can be any of the standardized Medigap plans (see page 11). These policies generally cost less than other Medigap policies. However, if you don’t use a Medicare SELECT hospital or doctor for non‑emergency services, you’ll have to pay some or all of what Medicare doesn’t pay. Medicare will pay its share of approved charges no matter which hospital or doctor you choose.

How does Medigap help pay my Medicare Part B bills? In most Medigap policies, when you sign the Medigap insurance contract you agree to have the Medigap insurance company get your Medicare Part B claim information directly from Medicare, and then they pay the doctor directly whatever amount is owed under your policy. Some Medigap insurance companies also provide this service for Medicare Part A claims.If your Medigap insurance company doesn’t provide this service, ask your doctors if they participate in Medicare. Participating providers have signed an arrangement to accept assignment for all Medicare‑covered services. If your doctor participates, the Medigap insurance company is required to pay the doctor directly if you request. If your doctor doesn't participate but still accepts Medicare, you may be asked to pay the coinsurance amount at the time of service. In these cases, your Medigap insurance company will pay you directly according to policy limits.If you have any questions about Medigap claim filing, call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048.

3SECTION

21

Your right to Buy a Medigap Policy

What are guaranteed issue rights? As explained on pages 14–16, the best time to buy a Medigap policy is during your Medigap Open Enrollment Period, when you have the right to buy any Medigap policy offered in your state. However, even if you aren’t in your Medigap Open Enrollment Period, there are several situations in which you may still have a guaranteed right to buy a Medigap policy. Guaranteed issue rights are rights you have in certain situations when insurance companies must offer you certain Medigap policies. In these situations, an insurance company must: • Sell you a Medigap policy • Cover all your pre‑existing health conditions • Can’t charge you more for a Medigap policy regardless of past or present

health problems If you live in Massachusetts, Minnesota, or Wisconsin, you have guaranteed issue rights to buy a Medigap policy, but the Medigap policies are different. See pages 42– 44 for your Medigap policy choices.

When do I have guaranteed issue rights? In most cases, you have a guaranteed issue right when you have certain types of other health care coverage that changes in some way, like when you lose the other health care coverage. In other cases, you have a “trial right” to try a Medicare Advantage Plan and still buy a Medigap policy if you change your mind. For information on trial rights, see page 23.

22 Section 3: Your Right to Buy a Medigap Policy

This chart describes the situations, under federal law, that give you a right to buy a policy, the kind of policy you can buy, and when you can or must apply for it. States may provide additional Medigap guaranteed issue rights.

You have a guaranteed issue right if...

You’re in a Medicare Advantage Plan (like an HMO or PPO), and your plan is leaving Medicare or stops giving care in your area, or you move out of the plan’s service area.

You have Original Medicare and an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays and that plan is ending.

Note: In this situation, you may have additional rights under state law.

You have Original Medicare and a Medicare SELECT policy. You move out of the Medicare SELECT policy’s service area.

Call the Medicare SELECT insurer for more information about your options.

You have the right to buy...

Medigap Plan A, B, C, F, K, or L that’s sold in your state by any insurance company.

You only have this right if you switch to Original Medicare rather than join another Medicare Advantage Plan.


If you have COBRA coverage, you can either buy a Medigap policy right away or wait until the COBRA coverage ends.

Medigap Plan A, B, C, F, K, or L that’s sold by any insurance company in your state or the state you’re moving to.

You can/must apply for a Medigap policy...

As early as 60 calendar days before the date your health care coverage will end, but no later than 63 calendar days after your health care coverage ends. Medigap coverage can’t start until your Medicare Advantage Plan coverage ends.

No later than 63 calendar days after the latest of these 3 dates:

1. Date the coverage ends

2. Date on the notice you get telling you that coverage is ending (if you get one)

3. Date on a claim denial, if this is the only way you know that your coverage ended

As early as 60 calendar days before the date your Medicare SELECT coverage will end, but no later than 63 calendar days after your Medicare SELECT coverage ends.

23Section 3: Your Right to Buy a Medigap Policy

You have a guaranteed issue right if...

(Trial right) You joined a Medicare Advantage Plan (like an HMO or PPO) or Programs of All‑inclusive Care for the Elderly (PACE) when you were first eligible for Medicare Part A at 65, and within the first year of joining, you decide you want to switch to Original Medicare.

(Trial right) You dropped a Medigap policy to join a Medicare Advantage Plan (or to switch to a Medicare SELECT policy) for the first time, you’ve been in the plan less than a year, and you want to switch back.

Your Medigap insurance company goes bankrupt and you lose your coverage, or your Medigap policy coverage otherwise ends through no fault of your own.

You leave a Medicare Advantage Plan or drop a Medigap policy because the company hasn’t followed the rules, or it misled you.

You have the right to buy...

Any Medigap policy that’s sold in your state by any insurance company.

The Medigap policy you had before you joined the Medicare Advantage Plan or Medicare SELECT policy, if the same insurance company you had before still sells it. If your former Medigap policy isn’t available, you can buy Medigap Plan A, B, C, F, K, or L that’s sold in your state by any insurance company.



You can/must apply for a Medigap policy...

As early as 60 calendar days before the date your coverage will end, but no later than 63 calendar days after your coverage ends.

Note: Your rights may last for an extra 12 months under certain circumstances.

As early as 60 calendar days before the date your coverage will end, but no later than 63 calendar days after your coverage ends. Note: Your rights may last for an extra 12 months under certain circumstances.

No later than 63 calendar days from the date your coverage ends.

No later than 63 calendar days from the date your coverage ends.

This chart describes the situations, under federal law, that give you a right to buy a policy, the kind of policy you can buy, and when you can or must apply for it. States may provide additional Medigap guaranteed issue rights. (continued)

24

Can I buy a Medigap policy if I lose my health care coverage? Yes, you may be able to buy a Medigap policy. Because you may have a guaranteed issue right to buy a Medigap policy, make sure you keep these: • A copy of any letters, notices, emails, and/or claim denials that have your name on

them as proof of your coverage being terminated.

• The postmarked envelope these papers come in as proof of when it was mailed. You may need to send a copy of some or all of these papers with your Medigap application to prove you have a guaranteed issue right. If you have a Medicare Advantage Plan (like an HMO or PPO) but you’re planning to return to Original Medicare, you can apply for a Medigap policy before your coverage ends. The Medigap insurer can sell it to you as long as you’re leaving the plan. Ask that the new policy take effect when your Medicare Advantage enrollment ends, so you’ll have continuous coverage.

For more information If you have any questions or want to learn about any additional Medigap rights in your state, you can: • Call your State Health Insurance Assistance Program to make sure that you qualify

for these guaranteed issue rights. See pages 47– 48. • Call your State Insurance Department if you’re denied Medigap coverage in any of

these situations. See pages 47– 48.

Important: The guaranteed issue rights in this section are from federal law. These rights are for both Medigap and Medicare SELECT policies. Many states provide additional Medigap rights.

There may be times when more than one of the situations in the chart on pages 22–23 applies to you. When this happens, you can choose the guaranteed issue right that gives you the best choice. Some of the situations listed include loss of coverage under Programs of All‑inclusive Care for the Elderly (PACE). PACE combines medical, social, and long‑term care services, and prescription drug coverage for frail people. To be eligible for PACE, you must meet certain conditions. PACE may be available in states that have chosen it as an optional Medicaid benefit. If you have Medicaid, an insurance company can sell you a Medigap policy only in certain situations. For more information about PACE, visit Medicare.gov, or call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048.

Section 3: Your Right to Buy a Medigap Policy

4SECTION

25

Steps to Buying a Medigap Policy

Step-by-step guide to buying a Medigap policyBuying a Medigap policy is an important decision. Only you can decide if a Medigap policy is the way for you to supplement Original Medicare coverage and which Medigap policy to choose. Shop carefully. Compare available Medigap policies to see which one meets your needs. As you shop for a Medigap policy, keep in mind that different insurance companies may charge different amounts for exactly the same Medigap policy, and not all insurance companies offer all of the Medigap policies. Below is a step‑by‑step guide to help you buy a Medigap policy. If you live in Massachusetts, Minnesota, or Wisconsin, see pages 42– 44.

STeP 1: Decide which benefits you want, then decide which of the standardized Medigap policies meet your needs.

STeP 2: Find out which insurance companies sell Medigap policies in your state.

STeP 3: Call the insurance companies that sell the Medigap policies you’re interested in and compare costs.

STeP 4: Buy the Medigap policy.

26

STeP 1: Decide which benefits you want, then decide which of the Medigap policy meets your needs.

You should think about your current and future health care needs when deciding which benefits you want because you might not be able to switch Medigap policies later. Decide which benefits you need, and select the Medigap policy that will work best for you. The chart on page 11 provides an overview of Medigap benefits.

STeP 2: Find out which insurance companies sell Medigap policies in your state.

To find out which insurance companies sell Medigap policies in your state: • Call your State Health Insurance Assistance Program. See pages 47– 48.

Ask if they have a “Medigap rate comparison shopping guide” for your state. This guide usually lists companies that sell Medigap policies in your state and their costs.

• Call your State Insurance Department. See pages 47– 48. • Visit Medicare.gov/find‑a‑plan:

This website will help you find information on all your health plan options, including the Medigap policies in your area. You can also get information on: 4 How to contact the insurance companies that sell Medigap policies in your state.4 What each Medigap policy covers.4 How insurance companies decide what to charge you for a Medigap policy premium.

If you don’t have a computer, your local library or senior center may be able to help you look at this information. You can also call 1‑800‑MEDICARE (1‑800‑633‑4227). A customer service representative will help you get information on all your health plan options including the Medigap policies in your area. TTY users should call 1‑877‑486‑2048.

Section 4: Steps to Buying a Medigap Policy


27Section 4: Steps to Buying a Medigap Policy

STEP 2: (continued)

Since costs can vary between companies, you should plan to call more than one insurance company that sells Medigap policies in your state. Before you call, check the companies to be sure they’re honest and reliable by using one of these resources: • Call your State Insurance Department. Ask if they keep a record of

complaints against insurance companies that can be shared with you. When deciding which Medigap policy is right for you, consider these complaints, if any.

• Call your State Health Insurance Assistance Program. These programs can give you help with choosing a Medigap policy at no cost to you.

• Go to your local public library for help with: – Getting information on an insurance company’s financial strength

from independent rating services like weissratings.com, A.M. Best, and Standard & Poor’s.

– Looking at information about the insurance company online. • Talk to someone you trust, like a family member, your insurance agent,

or a friend who has a Medigap policy from the same Medigap insurance company.

28 Section 4: Steps to Buying a Medigap Policy

Before you call any insurance companies, figure out if you’re in your Medigap Open Enrollment Period or if you have a guaranteed issue right. Read pages 14 –15 and 22–23 carefully. If you have questions, call your State Health Insurance Assistance Program. See pages 47– 48. This chart can help you keep track of the information you get.

STeP 3: Call the insurance companies that sell the Medigap policies you’re interested in and compare costs.

Community Issue‑age Attained‑age

Community Issue‑age Attained‑age

Ask each insurance company…

“Are you licensed in ___?” (Say the name of your state.) Note: If the answer is NO, STOP here, and try another company. “Do you sell Medigap Plan ___?” (Say the letter of the Medigap Plan you’re interested in.) Note: Insurance companies usually offer some, but not all, Medigap policies. Make sure the company sells the plan you want. Also, if you’re interested in a Medicare SELECT or high‑deductible Medigap policy, tell them.

“Do you use medical underwriting for this Medigap policy?” Note: If the answer is NO, go to step 4 on page 30. If the answer is YES, but you know you’re in your Medigap Open Enrollment Period or have a guaranteed issue right to buy that Medigap policy, go to step 4. Otherwise, you can ask, “Can you tell me whether I'm likely to qualify for the Medigap policy?”

“Do you have a waiting period for pre‑existing conditions?” Note: If the answer is YES, ask how long the waiting period is and write it in the box.

“Do you price this Medigap policy by using community‑rating, issue‑age‑rating, or attained‑age‑rating?” See page 18. Note: Circle the one that applies for that insurance company.

“I'm ___ years old. What would my premium be under this Medigap policy?” Note: If it’s attained‑age, ask, “How frequently does the premium increase due to my age?”

“Has the premium for this Medigap policy increased in the last 3 years due to inflation or other reasons?” Note: If the answer is YES, ask how much it has increased, and write it in the box.

“Do you offer any discounts or additional benefits?” See page 19.

Company 2 Company 1

29Section 4: Steps to Buying a Medigap Policy

STEP 3: (continued)

Watch out for illegal practices. It’s illegal for anyone to:

• Pressure you into buying a Medigap policy, or lie to or mislead you to switch from one company or policy to another.

• Sell you a second Medigap policy when they know that you already have one, unless you tell the insurance company in writing that you plan to cancel your existing Medigap policy.

• Sell you a Medigap policy if they know you have Medicaid, except in certain situations.

• Sell you a Medigap policy if they know you’re in a Medicare Advantage Plan (like an HMO or PPO) unless your coverage under the Medicare Advantage Plan will end before the effective date of the Medigap policy.

• Claim that a Medigap policy is a part of Medicare or any other federal program. Medigap is private health insurance.

• Claim that a Medicare Advantage Plan is a Medigap policy. • Sell you a Medigap policy that can’t legally be sold in your state. Check with

your State Insurance Department (see pages 47– 48) to make sure that the Medigap policy you’re interested in can be sold in your state.

• Misuse the names, letters, or symbols of the U.S. Department of Health & Human Services (HHS), Social Security Administration (SSA), Centers for Medicare & Medicaid Services (CMS), or any of their various programs like Medicare. (For example, they can’t suggest the Medigap policy has been approved or recommended by the federal government.)

• Claim to be a Medicare representative if they work for a Medigap insurance company.

• Sell you a Medicare Advantage Plan when you say you want to stay in Original Medicare and buy a Medigap policy. A Medicare Advantage Plan isn’t the same as Original Medicare. See page 5. If you enroll in a Medicare Advantage Plan, you can’t use a Medigap policy.

If you believe that a federal law has been broken, call the Inspector General’s hotline at 1‑800‑HHS‑TIPS (1‑800‑447‑8477). TTY users should call 1‑800‑377‑4950. Your State Insurance Department can help you with other insurance‑related problems.

30

STeP 4: Buy the Medigap policy.

Once you decide on the insurance company and the Medigap policy you want, you should apply. The insurance company must give you a clearly worded summary of your Medigap policy. Read it carefully. If you don’t understand it, ask questions. Remember these when you buy your Medigap policy: • Filling out your application. Fill out the application carefully and completely,

including medical questions. The answers you give will determine your eligibility for an Open Enrollment Period or guaranteed issue rights. If the insurance agent fills out the application, make sure it’s correct. If you buy a Medigap policy during your Medigap Open Enrollment Period or provide evidence that you’re entitled to a guaranteed issue right, the insurance company can’t use any medical answers you give to deny you a Medigap policy or change the price. The insurance company can’t ask you any questions about your family history or require you to take a genetic test.

• Paying for your Medigap policy. You can pay for your Medigap policy by check, money order, or bank draft. Make it payable to the insurance company, not the agent. If buying from an agent, get a receipt with the insurance company’s name, address, and phone number for your records. Some companies may offer electronic funds transfer.

• Starting your Medigap policy. Ask for your Medigap policy to become effective when you want coverage to start. Generally, Medigap policies begin the first of the month after you apply. If, for any reason, the insurance company won’t give you the effective date for the month you want, call your State Insurance Department. See pages 47– 48. Note: If you already have a Medigap policy, ask for your new Medigap policy to become effective when your old Medigap policy coverage ends.

• Getting your Medigap policy. If you don’t get your Medigap policy in 30 days, call your insurance company. If you don’t get your Medigap policy in 60 days, call your State Insurance Department.

If you already have a Medigap policy, it’s illegal for an insurance company to sell you a second policy unless you tell them in writing that you’ll cancel the first Medigap policy. However, don’t cancel your old Medigap policy until the new one is in place, and you decide to keep it. See pages 29 and 32.

Section 4: Steps to Buying a Medigap Policy

5SECTION

31

If You Already Have a Medigap Policy

You should read this section if any of these situations apply to you:

• You’re thinking about switching to a different Medigap policy. See pages 32–35.

• You’re losing your Medigap coverage. See page 36.

• You have a Medigap policy with Medicare prescription drug coverage. See pages 36–38.

If you just want a refresher about Medigap insurance, turn to page 11.

32

Switching Medigap policies If you’re satisfied with your current Medigap policy’s cost, coverage, and customer service, you don’t need to do anything. If you’re thinking about switching to a new Medigap policy, see below and pages 33–35 to answer some common questions about switching Medigap policies.

Can I switch to a different Medigap policy?

In most cases, you won’t have a right under federal law to switch Medigap policies, unless you’re within your 6‑month Medigap Open Enrollment Period or are eligible under a specific circumstance for guaranteed issue rights. But, if your state has more generous requirements, or the insurance company is willing to sell you a Medigap policy, make sure you compare benefits and premiums before switching. If you bought your Medigap policy before 2010, it may offer coverage that isn’t available in a newer Medigap policy. On the other hand, Medigap policies bought before 1992 might not be guaranteed renewable and might have bigger premium increases than newer, standardized Medigap policies currently being sold.If you decide to switch, don’t cancel your first Medigap policy until you’ve decided to keep the second Medigap policy. On the application for the new Medigap policy, you’ll have to promise that you’ll cancel your first Medigap policy. You have 30 days to decide if you want to keep the new Medigap policy. This is called your “free look period.” The 30‑day free look period starts when you get your new Medigap policy. You’ll need to pay both premiums for one month.

Section 5: If You Already Have a Medigap Policy


33Section 5: If You Already Have a Medigap Policy

Switching Medigap policies (continued)

Do I have to switch Medigap policies if I have a Medigap policy that's no longer sold?

No. But you can’t have more than one Medigap policy, so if you buy a new Medigap policy, you have to give up your old policy (except for your 30‑day “free look period,” described on page 32). Once you cancel the policy, you can’t get it back.

Do I have to wait a certain length of time after I buy my first Medigap policy before I can switch to a different Medigap policy?

No. If you’ve had your old Medigap policy for less than 6 months, the Medigap insurance company may be able to make you wait up to 6 months for coverage of a pre‑existing condition. However, if your old Medigap policy had the same benefits, and you had it for 6 months or more, the new insurance company can’t exclude your pre‑existing condition. If you’ve had your Medigap policy less than 6 months, the number of months you’ve had your current Medigap policy must be subtracted from the time you must wait before your new Medigap policy covers your pre‑existing condition.If the new Medigap policy has a benefit that isn’t in your current Medigap policy, you may still have to wait up to 6 months before that benefit will be covered, regardless of how long you’ve had your current Medigap policy.If you’ve had your current Medigap policy longer than 6 months and want to replace it with a new one with the same benefits and the insurance company agrees to issue the new policy, they can’t write pre‑existing conditions, waiting periods, elimination periods, or probationary periods into the replacement policy.

34

Switching Medigap policies (continued)Why would I want to switch to a different Medigap policy?

Some reasons for switching may include: • You’re paying for benefits you don’t need. • You need more benefits than you needed before. • Your current Medigap policy has the right benefits, but you want to

change your insurance company. • Your current Medigap policy has the right benefits, but you want to find a

policy that’s less expensive.

It’s important to compare the benefits in your current Medigap policy to the benefits listed on page 11. If you live in Massachusetts, Minnesota, or Wisconsin, see pages 42– 44. To help you compare benefits and decide which Medigap policy you want, follow the “Steps to Buying a Medigap Policy” in Section 4. If you decide to change insurance companies, you can call the new insurance company and arrange to apply for your new Medigap policy. If your application is accepted, call your current insurance company, and ask to have your coverage end. The insurance company can tell you how to submit a request to end your coverage.As discussed on page 32, you should have your old Medigap policy coverage end after you have the new Medigap policy for 30 days. Remember, this is your 30‑day free look period. You’ll need to pay both premiums for one month.



Switching Medigap policies (continued)

Can I keep my current Medigap policy (or Medicare SELECT policy) or switch to a different Medigap policy if I move out-of-state?

In general, you can keep your current Medigap policy regardless of where you live as long as you still have Original Medicare. If you want to switch to a different Medigap policy, you’ll have to check with your current or the new insurance company to see if they’ll offer you a different Medigap policy.You may have to pay more for your new Medigap policy and answer some medical questions if you’re buying a Medigap policy outside of your Medigap Open Enrollment Period. See pages 14–16.If you have a Medicare SELECT policy and you move out of the policy’s area, you can:• Buy a standardized Medigap policy from your current Medigap policy

insurance company that offers the same or fewer benefits than your current Medicare SELECT policy. If you’ve had your Medicare SELECT policy for more than 6 months, you won’t have to answer any medical questions.

• Use your guaranteed issue right to buy any Plan A, B, C, F, K, or L that’s sold in most states by any insurance company.

Your state may provide additional Medigap rights. Call your State Health Insurance Assistance Program or State Department of Insurance for more information. See pages 47–78 for their phone numbers.

What happens to my Medigap policy if I join a Medicare Advantage Plan?

Medigap policies can’t work with Medicare Advantage Plans. If you decide to keep your Medigap policy, you’ll have to pay your Medigap policy premium, but the Medigap policy can’t pay any deductibles, copayments, coinsurance, or premiums under a Medicare Advantage Plan. So, if you join a Medicare Advantage Plan, you may want to drop your Medigap policy. Contact your Medigap insurance company to find out how to disenroll. However, if you leave the Medicare Advantage Plan you might not be able to get the same Medigap policy back, or in some cases, any Medigap policy unless you have a “trial right.” See page 23. Your rights to buy a Medigap policy may vary by state. You always have a legal right to keep the Medigap policy after you join a Medicare Advantage Plan. However, because you have a Medicare Advantage Plan, the Medigap policy would no longer provide benefits that supplement Medicare.


36

losing Medigap coverage Can my Medigap insurance company drop me?

If you bought your Medigap policy after 1992, in most cases the Medigap insurance company can’t drop you because the Medigap policy is guaranteed renewable. This means your insurance company can’t drop you unless one of these happens: • You stop paying your premium. • You weren’t truthful on the Medigap policy application. • The insurance company becomes bankrupt or insolvent.

If you bought your Medigap policy before 1992, it might not be guaranteed renewable. This means the Medigap insurance company can refuse to renew the Medigap policy, as long as it gets the state’s approval to cancel your Medigap policy. However, if this does happen, you have the right to buy another Medigap policy. See the guaranteed issue right on page 23.

Medigap policies and Medicare prescription drug coverage

If you bought a Medigap policy before January 1, 2006, and it has coverage for prescription drugs, see below and page 37.

Medicare offers prescription drug coverage (Part D) for everyone with Medicare. If you have a Medigap policy with prescription drug coverage, that means you chose not to join a Medicare Prescription Drug Plan when you were first eligible. However, you can still join a Medicare drug plan. Your situation may have changed in ways that make a Medicare drug plan fit your needs better than the prescription drug coverage in your Medigap policy. It’s a good idea to review your coverage each fall, because you can join a Medicare drug plan between October 15–December 7. Your new coverage will begin on January 1.



Medigap policies and Medicare prescription drug coverage (continued)

Why would I change my mind and join a Medicare drug plan?

In a Medicare Prescription Drug Plan, you may have to pay a monthly premium, but Medicare pays a large part of the cost. There’s no maximum yearly amount as with Medigap prescription drug benefits in old Plans H, I, and J (these plans are no longer sold). However, a Medicare drug plan might only cover certain prescription drugs (on its “formulary” or “drug list”). It’s important that you check whether your current prescription drugs are on the Medicare drug plan’s list of covered prescription drugs before you join. If your Medigap premium or your prescription drug needs were very low when you had your first chance to join a Medicare drug plan, your Medigap prescription drug coverage may have met your needs. However, if your Medigap premium or the amount of prescription drugs you use has increased recently, a Medicare drug plan might now be a better choice for you.

Will I have to pay a late enrollment penalty if I join a Medicare drug plan now?

If you qualify for Extra Help, you won’t pay a late enrollment penalty. If you don’t qualify for Extra Help, it will depend on whether your Medigap policy includes “creditable prescription drug coverage.” This means that the Medigap policy’s drug coverage pays, on average, at least as much as Medicare’s standard prescription drug coverage. If your Medigap policy's drug coverage isn’t creditable coverage, and you join a Medicare drug plan now, you’ll probably pay a higher premium (a penalty added to your monthly premium) than if you had joined when you were first eligible. Each month that you wait to join a Medicare drug plan will make your late enrollment penalty higher. Your Medigap carrier must send you a notice each year telling you if the prescription drug coverage in your Medigap policy is creditable. You should keep these notices in case you decide later to join a Medicare drug plan. You should also consider that your prescription drug needs could increase as you get older.

38

Will I have to pay a late enrollment penalty if I join a Medicare drug plan now? (continued)

If your Medigap policy includes creditable prescription drug coverage and you decide to join a Medicare Prescription Drug Plan, you won’t have to pay a late enrollment penalty as long as you don’t go 63 or more days in a row without creditable prescription drug coverage. So, don’t drop your Medigap policy before you join the Medicare drug plan and the coverage starts. You can only join a Medicare drug plan between October 15 –December 7 unless you lose your Medigap policy (for example, if it isn’t guaranteed renewable, and your company cancels it). In that case, you may be able to join a Medicare drug plan at the time you lose your Medigap policy.

Can I join a Medicare drug plan and have a Medigap policy with prescription drug coverage?

No. If your Medigap policy covers prescription drugs, you must tell your Medigap insurance company if you join a Medicare drug plan so it can remove the prescription drug coverage from your Medigap policy and adjust your premium. Once the drug coverage is removed, you can’t get that coverage back even though you didn’t change Medigap policies.

What if I decide to drop my entire Medigap policy (not just the Medigap prescription drug coverage) and join a Medicare Advantage Plan that offers prescription drug coverage?

You need to be careful about the timing because in general, you can only join a Medicare Prescription Drug Plan or Medicare Advantage Plan (like an HMO or PPO) during the Open Enrollment Period between October 15 –December 7. If you join during an Open Enrollment Period, your coverage will begin on January 1 as long as the plan gets your enrollment request by December 7.


6SECTION

39

Medigap Policies for People with a Disability or eSrD

Information for people under 65Medigap policies for people under 65 and eligible for Medicare because of a disability or End-Stage Renal Disease (ESRD)

You may have Medicare before turning 65 due to a disability or ESRD (permanent kidney failure requiring dialysis or a kidney transplant).If you’re a person with Medicare under 65 and have a disability or ESRD, you might not be able to buy the Medigap policy you want, or any Medigap policy, until you turn 65. Federal law generally doesn’t require insurance companies to sell Medigap policies to people under 65. However, some states require Medigap insurance companies to sell you a Medigap policy, even if you’re under 65. These states are listed on the next page.

Important: This section provides information on the minimum federal standards. For your state requirements, call your State Health Insurance Assistance Program. See pages 47– 48.

40

Medigap policies for people under 65 and eligible for Medicare because of a disability or End-Stage Renal Disease (ESRD) (continued)

At the time of printing this guide, these states required insurance companies to offer at least one kind of Medigap policy to people with Medicare under 65:

Section 6: Medigap Policies for People with a Disability or ESRD

•California•Colorado•Connecticut•Delaware•Florida•Georgia•Hawaii•Illinois•Kansas•Kentucky•Louisiana

•Maine•Maryland•Massachusetts•Michigan•Minnesota•Mississippi•Missouri•Montana•NewHampshire•NewJersey•NewYork

•NorthCarolina•Oklahoma•Oregon•Pennsylvania•SouthDakota•Tennessee•Texas•Vermont•Wisconsin

Note: Some states provide these rights to all people with Medicare under 65, while others only extend them to people eligible for Medicare because of disability or only to people with ESRD. Check with your State Insurance Department about what rights you might have under state law.

Even if your state isn’t on the list above, some insurance companies may voluntarily sell Medigap policies to people under 65, although they’ll probably cost you more than Medigap policies sold to people over 65, and they can probably use medical underwriting. Also, some of the federal guarantee rights are available to people with Medicare under 65, see pages 21‑24. Check with your State Insurance Department about what additional rights you might have under state law.Remember, if you’re already enrolled in Medicare Part B, you’ll get a Medigap Open Enrollment Period when you turn 65. You'll probably have a wider choice of Medigap policies and be able to get a lower premium at that time. During the Medigap Open Enrollment Period, insurance companies can’t refuse to sell you any Medigap policy due to a disability or other health problem, or charge you a higher premium (based on health status) than they charge other people who are 65.Because Medicare (Part A and/or Part B) is creditable coverage, if you had Medicare for more than 6 months before you turned 65, you may not have a pre‑existing condition waiting period. For more information about the Medigap Open Enrollment Period and pre‑existing conditions, see pages 16 –17. If you have questions, call your State Health Insurance Assistance Program. See pages 47–48.


7SECTION

41

Medigap Coverage in Massachusetts, Minnesota,

and Wisconsin

Massachusetts benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Minnesota benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Wisconsin benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

42 Section 7: Medigap Coverage Charts

Massachusetts benefits • Inpatient hospital care: covers the Medicare Part A coinsurance plus coverage for 365

additional days after Medicare coverage ends • Medical costs: covers the Medicare Part B coinsurance (generally 20% of the

Medicare‑approved amount) • Blood: covers the first 3 pints of blood each year• Part A hospice coinsurance or copaymentThe check marks in this chart mean the benefit is covered.

Massachusetts—Chart of standardized Medigap policies

Basic benefits

Part A: inpatient hospital deductible

Part A: skilled nursing facility (SNF) coinsurance

Part B: deductible

Foreign travel emergency

Inpatient days in mental health hospitals

State‑mandated benefits (annual Pap tests and mammograms. Check your plan for other state‑mandated benefits.)

60 days per calendar year

120 days per benefit year

3 3

3 3

3

3

3

3

Medigap benefits

Supplement 1 Plan Core plan

For more information on these Medigap policies, visit Medicare.gov/find‑a‑plan, or call your State Insurance Department. See pages 47– 48.

43Section 7: Medigap Coverage Charts

Minnesota benefits • Inpatient hospital care: covers the Part A coinsurance • Medical costs: covers the Part B coinsurance (generally 20% of the Medicare‑approved amount)• Blood: covers the first 3 pints of blood each year• Part A hospice and respite cost sharing• Parts A and B home health services and supplies cost sharingThe check marks in this chart mean the benefit is covered.

Minnesota—Chart of standardized Medigap policies

Basic benefits

Part A: inpatient hospital deductible


Part B: deductible

Foreign travel emergency

Outpatient mental health

Usual and customary fees

Medicare‑covered preventive care

Physical therapy

Coverage while in a foreign country

State‑mandated benefits (diabetic equipment and supplies, routine cancer screening, reconstructive surgery, and immunizations)

Medigap benefits Basic plan Extended

20% 20%

3 3

3 3

80%*

3

3(Provides 120 days of

SNF care)

3

3(Provides 100 days of

SNF care)

80%

80%*

20% 20%

80%*

basic plan

3 3

Mandatory riders

Insurance companies can offer 4 additional riders that can be added to a basic plan. You may choose any one or all of these riders to design a Medigap policy that meets your needs:

1. Part A: inpatient hospital deductible

2. Part B: deductible 3. Usual and

customary fees 4. Non‑medicare

preventive care

* Pays 100% after you spend $1,000 in out-of-pocket costs for a calendar year. Minnesota versions of Medigap Plans K, L, M, N, and high-deductible F are available.

Important: The basic and extended basic benefits are available when you enroll in Part B, regardless of age or health problems. If you are under 65, return to work and drop Part B to elect your employer’s health plan, you’ll get a 6‑month Medigap Open Enrollment Period after you retire from that employer when you can elect Part B again.

44 Section 7: Medigap Coverage Charts

Basic benefits


Inpatient mental health coverage

Home health care

State‑mandated benefits

Wisconsin benefits

• Inpatient hospital care: covers the Part A coinsurance • Medical costs: covers the Part B coinsurance (generally 20% of the

Medicare‑approved amount) • Blood: covers the first 3 pints of blood each year• Part A hospice coinsurance or copayment

The check marks in this chart mean the benefit is covered.

For more information on these Medigap policies, visit Medicare.gov/find‑a‑plan or call your State Insurance Department. See pages 47– 48.

Plans known as “50% and 25% cost‑sharing plans” are available. These plans are similar to standardized Plans K (50%) and L (25%). A high‑deductible plan ($2,180 deductible for 2016) is also available.

175 days per lifetime in addition to Medicare’s benefit

3

3

3

40 visits per year in addition to those paid by Medicare

Wisconsin — Chart of standardized Medigap policies

Medigap benefits Basic plan Optional riders

Insurance companies are allowed to offer these 7 additional riders to a Medigap policy:1. Part A deductible 2. Additional home health

care (365 visits including those paid by Medicare)

3. Part B deductible 4. Part B excess charges5. Foreign travel emergency6. 50% Part A deductible7. Part B copayment or coinsurance

8SECTION

45

For More Information

Where to get more information On pages 47– 48, you’ll find phone numbers for your State Health Insurance Assistance Program (SHIP) and State Insurance Department.

• Call your SHIP for help with:

– Buying a Medigap policy or long‑term care insurance.

– Dealing with payment denials or appeals.

– Medicare rights and protections.

– Choosing a Medicare plan.

– Deciding whether to suspend your Medigap policy.

– Questions about Medicare bills.

• Call your State Insurance Department if you have questions about the Medigap policies sold in your area or any insurance‑related problems.

46

How to get help with Medicare and Medigap questions If you have questions about Medicare, Medigap, or need updated phone numbers for the contacts listed on pages 47– 48:

Visit Medicare.gov: • For Medigap policies in your area, visit Medicare.gov/find‑a‑plan.• For updated phone numbers, visit Medicare.gov/contacts.

Call 1-800-MEDICARE (1-800-633-4227): Customer service representatives are available 24 hours a day, 7 days a week. TTY users should call 1‑877‑486‑2048. If you need help in a language other than English or Spanish, let the customer service representative know the language.

Section 8: For More Information

47Section 8: For More Information

State Insurance Department

State State Health Insurance Assistance Program

Alabama 1‑800‑243‑5463 1‑800‑433‑3966 Alaska 1‑800‑478‑6065 1‑800‑467‑8725 American Samoa Not available 1‑684‑633‑4116 Arizona 1‑800‑432‑4040 1‑800‑325‑2548 Arkansas 1‑800‑224‑6330 1‑800‑224‑6330 California 1‑800‑434‑0222 1‑800‑927‑4357 Colorado 1‑888‑696‑7213 1‑800‑930‑3745 Connecticut 1‑800‑994‑9422 1‑800‑203‑3447 Delaware 1‑800‑336‑9500 1‑800‑282‑8611 Florida 1‑800‑963‑5337 1‑877‑693‑5236 Georgia 1‑866‑552‑4464 1‑800‑656‑2298 Guam 1‑671‑735‑7421 1‑671‑635‑1835 Hawaii 1‑888‑875‑9229 1‑808‑586‑2790 Idaho 1‑800‑247‑4422 1‑800‑721‑4422 Illinois 1‑217‑524‑6911 1‑888‑473‑4858 Indiana 1‑800‑452‑4800 1‑800‑622‑4461 Iowa 1‑800‑351‑4664 1‑877‑955‑1212 Kansas 1‑800‑860‑5260 1‑800‑432‑2484 Kentucky 1‑877‑293‑7447 1‑800‑595‑6053 Louisiana 1‑800‑259‑5300 1‑800‑259‑5301 Maine 1‑877‑353‑3771 1‑800‑300‑5000 Maryland 1‑800‑243‑3425 1‑800‑492‑6116 Massachusetts 1‑800‑243‑4636 1‑877‑563‑4467 Michigan 1‑800‑803‑7174 1‑877‑999‑6442 Minnesota 1‑800‑333‑2433 1‑800‑657‑3602 Mississippi 1‑800‑948‑3090 1‑800‑562‑2957 Missouri 1‑800‑390‑3330 1‑800‑726‑7390 Montana 1‑800‑551‑3191 1‑800‑332‑6148 Nebraska 1‑800‑234‑7119 1‑800‑234‑7119

State Health Insurance Assistance Program and State Insurance Department

48 Section 8: For More Information

Nevada 1‑800‑307‑4444 1‑800‑992‑0900 New Hampshire 1‑866‑634‑9412 1‑800‑852‑3416 New Jersey 1‑800‑792‑8820 1‑800‑446‑7467 New Mexico 1‑800‑432‑2080 1‑888‑727‑5772 New York 1‑800‑701‑0501 1‑800‑342‑3736 North Carolina 1‑800‑443‑9354 1‑800‑546‑5664 North Dakota 1‑800‑247‑0560 1‑800‑247‑0560 Northern Mariana Not available 1‑670‑664‑3064 Islands Ohio 1‑800‑686‑1578 1‑800‑686‑1526 Oklahoma 1‑800‑763‑2828 1‑800‑522‑0071 Oregon 1‑800‑722‑4134 1‑888‑877‑4894 Pennsylvania 1‑800‑783‑7067 1‑877‑881‑6388 Puerto Rico 1‑877‑725‑4300 1‑888‑722‑8686 Rhode Island 1‑401‑462‑0510 1‑401‑462‑9500 South Carolina 1‑800‑868‑9095 1‑803‑737‑6160 South Dakota 1‑800‑536‑8197 1‑605‑773‑3563 Tennessee 1‑877‑801‑0044 1‑800‑342‑4029 Texas 1‑800‑252‑9240 1‑800‑252‑3439 Utah 1‑800‑541‑7735 1‑800‑439‑3805 Vermont 1‑800‑642‑5119 1‑800‑964‑1784 Virgin Islands 1‑340‑772‑7368 1‑340‑774‑7166 1‑340‑714‑4354 (St. Thomas) Virginia 1‑800‑552‑3402 1‑877‑310‑6560 Washington 1‑800‑562‑6900 1‑800‑562‑6900 Washington D.C. 1‑202‑994‑6272 1‑202‑727‑8000 West Virginia 1‑877‑987‑4463 1‑888‑879‑9842 Wisconsin 1‑800‑242‑1060 1‑800‑236‑8517 Wyoming 1‑800‑856‑4398 1‑800‑438‑5768

State Insurance Department

State State Health Insurance Assistance Program

9SECTION

49

Definitions

Assignment—An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.

Coinsurance—An amount you may be required to pay as your share of the costs for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).

Copayment—An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription.

Deductible—The amount you must pay for health care or prescriptions, before Original Medicare, your prescription drug plan, or your other insurance begins to pay.

Excess charge—If you have Original Medicare, and the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicare‑approved amount, the difference is called the excess charge.

Guaranteed issue rights —Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can’t deny you a Medigap policy, or place conditions on a Medigap policy, such as exclusions for pre‑existing conditions, and can’t charge you more for a Medigap policy because of a past or present health problem.

Where words in BlUe are defined

50 Section 9: Definitions

Guaranteed renewable policy—An insurance policy that can’t be terminated by the insurance company unless you make untrue statements to the insurance company, commit fraud, or don’t pay your premiums. All Medigap policies issued since 1992 are guaranteed renewable.

Medicaid—A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Medical underwriting—The process that an insurance company uses to decide, based on your medical history, whether or not to take your application for insurance, whether or not to add a waiting period for pre‑existing conditions (if your state law allows it), and how much to charge you for that insurance.

Medicare Advantage Plan (Part C)—A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee‑for‑Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

Medicare-approved amount—In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you're responsible for the difference.

Medicare prescription drug plan (Part D)— Part D adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private‑Fee‑for‑Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.

Medicare SELECT—A type of Medigap policy that may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.

Open Enrollment Period (Medigap)—A one‑time‑only, 6‑month period when federal law allows you to buy any Medigap policy you want that’s sold in your state. It starts in the first month that you’re covered under Medicare Part B, and you’re 65 or older. During this period, you can’t be denied a Medigap policy or charged more due to past or present health problems. Some states may have additional Open Enrollment rights under state law.

Premium—The periodic payment to Medicare, an insurance company, or a health care plan for health care or prescription drug coverage.

State Health Insurance Assistance Program (SHIP)—A state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare.

State Insurance Department—A state agency that regulates insurance and can provide information about Medigap policies and other private health insurance.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244‑1850

Official Business Penalty for Private Use, $300

CMS Product No. 02110 Revised April 2016

To get this publication on CD, in Braille, Spanish, or large print (English), visit Medicare.gov, or call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048.

¿Necesita una copia en español? Visite Medicare.gov en el sitio Web. Para saber si esta publicación esta impresa y disponible (en español), llame GRATIS al 1‑800‑MEDICARE (1‑800‑633‑4227). Los usuarios de TTY deben llamar al 1‑877‑486‑2048.

BA9917ST (04-16)

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AARP endorses the AARP Medicare Supplement Insurance Plans, insured by UnitedHealthcare Insurance Company. UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers.AARP does not employ or endorse agents, brokers or producers.

Insured by UnitedHealthcare Insurance Company, Horsham, PA. Policy form No. GRP 79171 GPS-1 (G-36000-4). In some states plans may be available to persons under age 65 who are eligible for Medicare by reason of disability or end-stage renal disease.



See enclosed materials for complete information including benefits, costs, eligibility requirements, exclusions and limitations.

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