new medicare supplement insurance · 2019. 10. 24. · benefit plans available: a, b, f, hf, g & n...
TRANSCRIPT
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Outline of coverageMedicare Supplement Insurance
Benefit plans: A, B, F, H, G, N
Deleware
Underwritten by
Aetna Health and Life Insurance Company
aetnaseniorproducts.comAHLMS05035DE ©2019 Aetna Inc. Rates effective: 02/2019 B
http://aetnaseniorproducts.com
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AETNA HEALTH AND LIFE INSURANCE COMPANYOUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE:
BENEFIT PLANS AVAILABLE: A, B, F, HF, G & N
This chart shows the benefits included in each of the standard Medicare supplement plans. Every companymust make Plan "A" available. Some plans may not be available. Only applicants first eligible for Medicarebefore 2020 may purchase Plans C, F, and high deductible F.Note: A ✓ means 100% of the benefit is paid.
Benefits Plans Available to All Applicants
A B D G1 K L M N
Medicare first eligible before 2020 only C F1
Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Medicare Part B coinsurance or copayment ✓ ✓ ✓ ✓ 50% 75% ✓
✓
copays apply3
✓ ✓
Blood (first three pints) ✓ ✓ ✓ ✓ 50% 75% ✓ ✓ ✓ ✓Part A hospice care coinsurance or copayment ✓ ✓ ✓ ✓ 50% 75% ✓ ✓ ✓ ✓
Skilled nursing facility coinsurance ✓ ✓ 50% 75% ✓ ✓ ✓ ✓Medicare Part A deductible ✓ ✓ ✓ 50% 75% 50% ✓ ✓ ✓Medicare Part B deductible ✓ ✓Medicare Part B excess charges ✓ ✓Foreign travel emergency (up to plan limits) ✓ ✓ ✓ ✓ ✓ ✓
Out-of-pocket limit in 20192 $5,5602 $2,7802
1 Plans F and G also have a high deductible option, which require first paying a plan deductible of $2,300 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible. 2 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit. 3 Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission.
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Aetna Health and Life Insurance CompanyAnnual Attained A ge Premiums
For Use in ZIP Codes: Entire State
Female Rates
Rates Effective 2/1/2019
Attained
Age
Preferred
Plan A Plan B Plan F Plan HF Plan G Plan N
Under 65 (ESRD) 25,290 29,114 37,616 25,732 26,164 19,852
Under 65 (non-ESRD) 5,248 6,023 7,777 2,380 5,408 4,100
65 1,552 1,748 2,245 688 1,556 1,176
66 1,596 1,806 2,323 711 1,611 1,217
67 1,638 1,862 2,395 733 1,663 1,258
68 1,680 1,916 2,470 756 1,716 1,299
69 1,723 1,971 2,544 778 1,766 1,339
70 1,766 2,025 2,615 800 1,818 1,379
71 1,806 2,080 2,688 822 1,869 1,418
72 1,846 2,131 2,759 844 1,920 1,457
73 1,880 2,187 2,833 867 1,975 1,499
74 1,916 2,239 2,905 889 2,026 1,541
75 1,950 2,291 2,979 911 2,080 1,583
76 1,984 2,341 3,050 933 2,130 1,624
77 2,018 2,394 3,123 956 2,183 1,665
78 2,040 2,442 3,193 978 2,236 1,708
79 2,061 2,490 3,263 999 2,290 1,751
80 2,082 2,536 3,335 1,021 2,342 1,794
81 2,103 2,584 3,405 1,042 2,395 1,836
82 2,124 2,630 3,474 1,064 2,446 1,878
83 2,152 2,672 3,541 1,084 2,501 1,923
84 2,178 2,715 3,611 1,105 2,553 1,968
85 2,200 2,748 3,670 1,124 2,600 2,007
86 2,220 2,784 3,730 1,141 2,648 2,048
87 2,242 2,818 3,790 1,160 2,696 2,090
88 2,265 2,853 3,852 1,179 2,746 2,132
89 2,286 2,890 3,915 1,198 2,793 2,174
90 2,309 2,922 3,974 1,216 2,843 2,216
91 2,329 2,957 4,034 1,235 2,890 2,257
92 2,352 2,991 4,092 1,253 2,938 2,298
93 2,375 3,024 4,150 1,271 2,984 2,337
94 2,398 3,057 4,207 1,287 3,031 2,377
95 2,421 3,088 4,263 1,305 3,076 2,416
96 2,444 3,118 4,320 1,322 3,120 2,454
97 2,468 3,150 4,374 1,339 3,166 2,492
98 2,492 3,180 4,428 1,356 3,207 2,530
99+ 2,517 3,210 4,481 1,371 3,251 2,566
Attained
Age
Standard
Plan A Plan B Plan F Plan HF Plan G Plan N
Under 65 (ESRD) 28,099 32,350 41,796 28,592 29,072 22,058
Under 65 (non-ESRD) 5,832 6,694 8,643
2,645 6,009 4,556
65 1,724 1,943 2,495 764 1,729 1,307
66 1,772 2,007 2,579 790 1,789 1,352
67 1,820 2,069 2,663 815 1,847 1,398
68 1,867 2,129 2,745 840 1,907 1,443
69 1,914 2,191 2,825 864 1,964 1,488
70 1,962 2,250 2,906 889 2,020 1,532
71 2,007 2,311 2,987 914 2,076 1,576
72 2,050 2,369 3,065 938 2,133 1,619
73 2,091 2,429 3,147 964 2,193 1,666
74 2,129 2,486 3,229 988 2,252 1,712
75 2,167 2,545 3,309 1,012 2,310 1,759
76 2,204 2,602 3,390 1,037 2,368 1,804
77 2,242 2,661 3,468 1,062 2,426 1,850
78 2,267 2,712 3,549 1,086 2,485 1,898
79 2,291 2,766 3,625 1,110 2,544 1,946
80 2,313 2,818 3,706 1,134 2,603 1,993
81 2,337 2,870 3,784 1,157 2,659 2,040
82 2,361 2,922 3,859 1,182 2,718 2,087
83 2,391 2,969 3,935 1,204 2,778 2,137
84 2,420 3,017 4,011 1,227 2,836 2,187
85 2,444 3,053 4,078 1,248 2,888 2,230
86 2,468 3,092 4,144 1,268 2,941 2,276
87 2,492 3,132 4,211 1,289 2,995 2,322
88 2,517 3,170 4,280 1,310 3,050 2,369
89 2,540 3,210 4,348 1,331 3,104 2,416
90 2,565 3,247 4,417 1,351 3,158 2,462
91 2,590 3,285 4,481
1,372 3,212 2,508
92 2,615 3,322 4,546 1,392 3,264 2,553
93 2,640 3,360 4,611 1,411 3,317 2,597
94 2,665 3,395 4,675 1,430 3,367 2,641
95 2,691 3,431 4,738 1,450 3,418 2,684
96 2,716 3,466 4,800 1,469 3,467 2,727
97 2,742 3,500 4,860 1,488 3,516 2,769
98 2,769 3,534 4,921 1,506 3,564 2,811
99+ 2,796 3,566 4,979 1,524 3,612 2,851
Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833
The above rates do not include the $20 application fee.
To calculate a Household discount:
Annual premium x modal factor = modal premium (round to nearest whole cent)
Modal premium x .93 = discounted premium
If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates.
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Aetna Health and Life Insurance CompanyAnnual Attained A ge Premiums
For Use in ZIP Codes: Entire State
Male Rates
Rates Effective 2/1/2019
Attained
Age
Preferred
Plan A Plan B Plan F Plan HF Plan G Plan N
Under 65 (ESRD) 29,083 33,482 43,259 29,592 30,089 22,830
Under 65 (non-ESRD) 6,035 6,928 8,945 2,737 6,219 4,715
65 1,785 2,011 2,582 791 1,789 1,352
66 1,836 2,076 2,669 818 1,851 1,400
67 1,885 2,141 2,756 843 1,912 1,447
68 1,931 2,203 2,841 869 1,973 1,494
69 1,981 2,267 2,926 895 2,032 1,540
70 2,030 2,329 3,008 920 2,090 1,586
71 2,076 2,391 3,091 945 2,151 1,631
72 2,123 2,451 3,173 971 2,207 1,676
73 2,164 2,514 3,258 998 2,270 1,724
74 2,203 2,573 3,342
1,023 2,330 1,772
75 2,242 2,635 3,425 1,048 2,392 1,820
76 2,281 2,693 3,508 1,073 2,450 1,868
77 2,321 2,753 3,590 1,099 2,510 1,915
78 2,346 2,809 3,672 1,125 2,573 1,964
79 2,371 2,862 3,753 1,149 2,633 2,014
80 2,394 2,917 3,837 1,174 2,693 2,063
81 2,419 2,971 3,916 1,198 2,753 2,111
82 2,443 3,025 3,996 1,223 2,814 2,160
83 2,474 3,073 4,073 1,246 2,875 2,211
84 2,505 3,121 4,153 1,271 2,937 2,263
85 2,529 3,160 4,220 1,293 2,990 2,308
86 2,553 3,200 4,289 1,313 3,044 2,355
87 2,578 3,242 4,359 1,335 3,100 2,404
88 2,603 3,282 4,430 1,356 3,157 2,452
89 2,628 3,322 4,501 1,378 3,214 2,500
90 2,654 3,362 4,570 1,399 3,268 2,548
91 2,679 3,401 4,638 1,420 3,324 2,596
92 2,705 3,440 4,704 1,441 3,378 2,643
93 2,733 3,477 4,773 1,462 3,432 2,688
94 2,758 3,515 4,837 1,481 3,486 2,734
95 2,785 3,550 4,903 1,500 3,537 2,778
96 2,811 3,587 4,967 1,520 3,589 2,822
97 2,838 3,622 5,030 1,539 3,640 2,866
98 2,866 3,657 5,094 1,559 3,687 2,910
99+ 2,894 3,692 5,154 1,577 3,739 2,951
Attained
Age
Standard
Plan A Plan B Plan F Plan HF Plan G Plan N
Under 65 (ESRD) 32,314 37,202 48,066 32,881 33,432 25,367
Under 65 (non-ESRD) 6,706 7,699 9,940 3,042 6,909 5,239
65 1,982 2,236 2,870 879 1,988 1,503
66 2,038 2,309 2,967 908 2,057 1,555
67 2,094 2,378 3,062 937 2,124 1,608
68 2,148 2,448 3,157 966 2,192 1,659
69 2,201 2,519 3,249 993 2,259 1,711
70 2,255 2,589 3,343 1,023 2,325 1,762
71 2,309 2,657 3,434
1,051 2,389 1,812
72 2,360 2,724 3,524 1,078 2,452 1,862
73 2,403 2,794 3,619 1,109 2,522 1,916
74 2,448 2,860 3,711 1,136 2,588 1,969
75 2,493 2,927 3,805 1,164 2,657 2,023
76 2,535 2,993 3,898 1,193 2,723 2,075
77 2,578 3,060 3,988 1,221 2,789 2,128
78 2,608 3,118 4,081 1,248 2,858 2,183
79 2,635 3,182 4,169 1,277 2,926 2,238
80 2,661 3,242 4,261 1,304 2,993 2,292
81 2,688 3,301 4,352 1,330 3,060 2,346
82 2,715 3,362 4,438 1,360 3,124 2,400
83 2,750 3,415 4,526 1,385 3,194 2,458
84 2,784 3,469 4,612 1,411 3,262 2,515
85 2,811 3,512 4,689 1,435 3,321 2,565
86 2,838 3,557 4,767 1,458 3,384 2,617
87 2,866 3,601 4,843 1,483 3,444 2,670
88 2,894 3,645 4,922 1,507 3,507 2,724
89 2,920 3,692 5,001 1,531 3,571 2,778
90 2,948 3,734 5,079 1,554 3,632 2,831
91 2,978 3,777 5,154 1,578 3,694 2,884
92 3,007 3,819 5,229 1,601 3,754 2,936
93 3,036 3,864 5,303 1,623 3,814 2,987
94 3,064 3,905 5,376 1,644 3,873 3,037
95 3,095 3,946 5,449 1,667 3,930 3,087
96 3,124 3,986 5,520 1,689 3,987 3,136
97 3,153 4,025 5,590 1,712 4,044 3,184
98 3,184 4,064 5,659 1,731 4,098 3,233
99+ 3,216 4,102 5,727 1,752 4,154 3,279
Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833
The above rates do not include the $20 application fee.
To calculate a Household discount:
Annual premium x modal factor = modal premium (round to nearest whole cent)
Modal premium x .93 = discounted premium
If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates.
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PREMIUM INFORMATION
Aetna Health and Life Insurance Company can only raise your premium if we raise the premium for all policies like yours in this state. Premiums for this policy will increase due to the increase in your age. Upon attainment of an age requiring a rate increase, the renewal premium for the policy will be the renewal premium then in effect for your attained age. Other policies may be provided with Issue Age rating and do not increase with age. You should compare Issue Age with Attained Age policies.
Premiums payable other than annually will be determined according to the following factors:
Semi-annual: 0.5200 Quarterly: 0.2650 Monthly EFT: 0.0833.
HOUSEHOLD DISCOUNT
In order to be eligible for the Household discount under an Aetna Health and Life Insurance Company Medicare supplement plan, you must apply for a Medicare supplement plan at the same time as another Medicare eligible adult or the other Medicare eligible adult must currently be covered by a Aetna Health and Life Insurance Company Medicare supplement policy. The Medicare eligible adult must be either (a) your spouse; (b) be someone with whom you are in a civil union partnership; or (c) be a permanent resident in your home. The household discount will only be applicable if a policy for each applicant is issued. The discounted rate will be 7 percent lower than the individual rates and will apply as long as both policies remain in force.
DISCLOSURES
Use this outline to compare benefits and premium among policies.
READ YOUR POLICY VERY CAREFULLY
This is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.
RIGHT TO RETURN POLICY
If you find that you are not satisfied with your policy, you may return it to Aetna Health and Life Insurance Company, P.O. Box 14770, Lexington, KY 40512-4770. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all your payments.
POLICY REPLACEMENTIf you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
NOTICEThe policy may not cover all OF your medical costs.
Neither Aetna Health and Life Insurance Company nor its agents are connected with Medicare.
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare & You for more details.
COMPLETE ANSWERS ARE VERYIMPORTANT
When you fill out the application for the new policy, be sure to answer truthfully and completely any questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
THE FOLLOWING CHARTS DESCRIBE PLANS A, B, F, HIGH DEDUCTIBLE F, G and N OFFERED BY AETNA HEALTH AND LIFE INSURANCE COMPANY.
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PLAN AMEDICARE (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 $1364 $0 $1364
(Part A Deductible)
61st thru 90th day All but $341 a day $341 a day $0 91st day and after •While using 60 lifetime reserve days All but $682 a day $682 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 $170.50 a day $0 Up to $170.50 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.
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PLAN AMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $185 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 test, durable medical equipment First $185 of Medicare-Approved amounts*
$0 $0 $185 (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 $185 of Medicare-Approved amounts*
$0 $0 $185 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
PARTS A & B
SERVICES MEDICARE PAYS PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies
100% $0 $0
•Durable medical equipment •First $185 of Medicare Approved amounts*
$0 $0 $185 (Part B Deductible)
•Remainder of Medicare Approved amounts 80% 20% $0
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PLAN BMEDICARE (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 $1364 $1364
(Part A Deductible) $0
61st thru 90th day All but $341 a day $341 a day $0 91st day and after •While using 60 lifetime reserve days All but $682 a day $682 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 $170.50 a day
$0 Up to $170.50 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 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
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PLAN BMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
* Once you have been billed $185 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'sservices, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic test, durable medical equipment First $185 of Medicare-Approved amounts*
$0 $0 $185 (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 $185 of Medicare-Approved amounts*
$0 $0 $185 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
PARTS A & B
SERVICES MEDICARE PAYS PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled careservices and medical supplies
100% $0 $0
•Durable medical equipment •First $185 of Medicare Approved amounts*
$0 $0 $185 (Part B Deductible)
•Remainder of Medicare Approved amounts
80% 20% $0
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PLAN FMEDICARE (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 $1364 $1364
(Part A Deductible) $0
61st thru 90th day All but $341 a day $341 a day $0 91st day and after •While using 60 lifetime reserve days All but $682 a day $682 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 $170.50 a day
Up to $170.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
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 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
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PLAN FMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $185 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 test, durable medical equipment First $185 of Medicare-Approved amounts*
$0 $185 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $185 of Medicare-Approved amounts*
$0 $185 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
PARTS A & B
SERVICES MEDICARE PAYS PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies
100% $0 $0
•Durable medical equipment •First $185 of Medicare Approved amounts*
$0 $185 (Part B Deductible)
$0
•Remainder of Medicare Approved amounts 80% 20% $0
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PLAN FOTHER 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
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HIGH DEDUCTIBLE PLAN FMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. ***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2300 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2300. 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.
SERVICES MEDICARE PAYS
AFTER YOU PAY $2300
DEDUCTIBLE*** PLAN PAYS
IN ADDITION TO $2300
DEDUCTIBLE*** YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1364 $1364
(Part A Deductible) $0
61st thru 90th day All but $341 a day $341 a day $0 91st day and after •While using 60 lifetime reserve days All but $682 a day $682 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 $170.50 a day
Up to $170.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0
AHLMS05035DE 12 02/2019 B
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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 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.
AHLMS05035DE 13 02/2019 B
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HIGH DEDUCTIBLE PLAN FMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $185 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. ***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2300 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2300. 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’sseparate foreign travel emergency deductible.
SERVICES MEDICARE PAYS
AFTER YOU PAY $2300
DEDUCTIBLE*** PLAN PAYS
IN ADDITION TO $2300
DEDUCTIBLE*** 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 test, durable medical equipment First $185 of Medicare-Approved amounts*
$0 $185 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges(Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $185 of Medicare-Approved amounts*
$0 $185 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
AHLMS05035DE 14 02/2019 B
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HIGH DEDUCTIBLE PLAN F
PARTS A & B
SERVICES MEDICARE PAYS
AFTER YOU PAY $2300
DEDUCTIBLE*** PLAN PAYS
IN ADDITION TO $2300
DEDUCTIBLE*** YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies
100% $0 $0
•Durable medical equipment •First $185 of Medicare Approved amounts*
$0 $185 (Part B Deductible)
$0
•Remainder of Medicare Approved amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS
AFTER YOU PAY $2300
DEDUCTIBLE** PLAN PAYS
IN ADDITION TO $2300
DEDUCTIBLE** 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
AHLMS05035DE 15 02/2019 B
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PLAN GMEDICARE (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 $1364 $1364
(Part A Deductible) $0
61st thru 90th day All but $341 a day $341 a day $0 91st day and after •While using 60 lifetime reserve days All but $682 a day $682 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 $170.50 a day
Up to $170.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness services
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 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.
AHLMS05035DE 16 02/2019 B
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PLAN GMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $185 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 test, durable medical equipment First $185 of Medicare-Approved amounts*
$0 $0 $185 (Part B Deductible)
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges(Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $185 of Medicare-Approved amounts*
$0 $0 $185 (Part B Deductible)
Remainder of Medicare-Approvedamounts 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 $185 of Medicare Approved amounts*
$0 $0 $185 (Part B Deductible)
•Remainder of Medicare Approved amounts 80% 20% $0
AHLMS05035DE 17 02/2019 B
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PLAN G
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
AHLMS05035DE 18 02/2019 B
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PLAN NMEDICARE (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 $1364 $1364
(Part A Deductible) $0
61st thru 90th day All but $341 a day $341 a day $0 91st day and after •While using 60 lifetime reserve days All but $682 a day $682 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 $170.50 a day
Up to $170.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness services
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 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.
AHLMS05035DE 19 02/2019 B
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PLAN NMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $185 of Medicare-Approved amounts for covered services (which are notedwith 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 test, durable medical equipment First $185 of Medicare-Approved amounts*
$0 $0 $185 (Part B Deductible)
Remainder of Medicare-Approvedamounts
Generally 80% Balance, other thanup to $20 per office visit and up to $50 per emergency room visit. The co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
Part B Excess Charges(Above Medicare-Approved amounts) $0 0% All costs BLOOD First 3 pints $0 All costs $0Next $185 of Medicare-Approved amounts*
$0 $0 $185 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
AHLMS05035DE 20 02/2019 B
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PLAN N
PARTS A & B
SERVICES MEDICARE PAYS PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES • Medically necessary skilled careservices and medical supplies 100% $0 $0 •Durable medical equipment •First $185 of Medicare Approved amounts*
$0 $0 $185 (Part B Deductible)
•Remainder of Medicare Approved amounts 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 thefirst 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
AHLMS05035DE 02/2019 B
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Medicare Supplement InsuranceBENEFIT PLANS AVAILABLE: A, B, F, HF, G & NAnnual Attained Age Premiums For Use in ZIP Codes: Entire State Female RatesAnnual Attained Age Premiums For Use in ZIP Codes: Entire State Male RatesPREMIUM INFORMATIONHOUSEHOLD DISCOUNT DISCLOSURESREAD YOUR POLICY VERY CAREFULLY RIGHT TO RETURN POLICYPOLICY REPLACEMENTNOTICECOMPLETE ANSWERS ARE VERY IMPORTANTPLAN A MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIODPLAN A MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEARPARTS A & BPLAN B MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIODPLAN B MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEARPARTS A & BPLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIODPLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEARPARTS A & BOTHER BENEFITS – NOT COVERED BY MEDICAREHIGH DEDUCTIBLE PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIODHIGH DEDUCTIBLE PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEARPARTS A & BOTHER BENEFITS – NOT COVERED BY MEDICAREPLAN G MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIODPLAN G MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEARPARTS A & BOTHER BENEFITS – NOT COVERED BY MEDICARE PLAN N MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIODPLAN N MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEARPARTS A & BOTHER BENEFITS – NOT COVERED BY MEDICARE