outline of coverage - aetna · 2019-02-01 · page 1 of 2 benefit plans available: a, b, f, high...

800 Crescent Centre Dr. Suite 200

Franklin, TN 37067 800 264.4000

aetnaseniorproducts.com

Outline of Coverage Medicare Supplement Insurance BENEFIT PLANS A, B, F, HIGH DEDUCTIBLE F, G, N

Underwritten by

An Aetna Company Continental Life Insurance Company of Brentwood, Tennessee

Arizona

CLIMS03989AZ ©2016 Aetna Inc. Rates Effective: 03/2019 A

http://aetnaseniorproducts.com

CONTINEN

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R PAGE: Page 1 of 2

BEN

EFIT PLA

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IGH DED

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. C

LIM

S039

89AZ

03/

2019

A

Continental Life Insurance Company of Brentwood, Tennessee Annual Premiums

For Use in ZIP Codes: 850-853, 857 Female Rates

Rates Effective 3/1/2019

Issue

Age

Preferred

Plan A Plan B Plan F High F Plan G Plan N

65 1,365 1,509 1,923 768 1,440 1,074

66 1,373 1,518 1,934 774 1,448 1,098

67 1,391 1,537 1,959 784 1,466 1,128

68 1,414 1,562 1,990 796 1,490 1,165

69 1,440 1,591 2,028 812 1,518 1,204

70 1,470 1,624 2,070 827 1,549 1,248

71 1,500 1,659 2,112 845 1,581 1,274

72 1,531 1,693 2,156 862 1,614 1,299

73 1,562 1,728 2,201 880 1,647 1,327

74 1,597 1,765 2,249 900 1,683 1,356

75 1,633 1,804 2,298 919 1,720 1,385

76 1,664 1,840 2,345 937 1,755 1,414

77 1,697 1,876 2,389 956 1,789 1,440

78 1,727 1,909 2,432 972 1,820 1,466

79 1,759 1,946 2,478 992 1,855 1,494

80 1,793 1,983 2,524 1,010 1,890 1,523

81 1,826 2,019 2,572 1,029 1,926 1,551

82 1,861 2,058 2,620 1,049 1,962 1,579

83 1,896 2,095 2,668 1,068 1,998 1,609

84 1,930 2,133 2,718 1,087 2,035 1,638

85 1,974 2,182 2,780 1,112 2,081 1,675

86 2,007 2,218 2,826 1,130 2,116 1,704

87 2,039 2,255 2,872 1,149 2,149 1,731

88 2,072 2,291 2,919 1,167 2,184 1,759

89 2,106 2,328 2,966 1,186 2,219 1,788

90 2,139 2,364 3,012 1,206 2,254 1,815

91 2,172 2,401 3,059 1,223 2,289 1,843

92 2,204 2,437 3,104 1,242 2,324 1,872

93 2,237 2,472 3,149 1,259 2,358 1,898

94 2,267 2,506 3,194 1,277 2,390 1,925

95 2,297 2,540 3,235 1,294 2,421 1,950

96 2,324 2,570 3,272 1,309 2,450 1,973

97 2,348 2,596 3,307 1,323 2,475 1,994

98 2,365 2,616 3,333 1,333 2,494 2,009

99+ 2,377 2,628 3,347 1,339 2,506 2,019

Issue

Age

Standard


65 1,517 1,676 2,135 853 1,600 1,192

66 1,527 1,687 2,149 860 1,609 1,219

67 1,546 1,708 2,177 871 1,628 1,254

68 1,571 1,735 2,212 884 1,656 1,295

69 1,599 1,768 2,254 903 1,687 1,339

70 1,634 1,805 2,300 919 1,721 1,386

71 1,667 1,843 2,347 938 1,756 1,416

72 1,701 1,880 2,396 959 1,794 1,443

73 1,735 1,919 2,445 977 1,830 1,474

74 1,776 1,961 2,498 1,000 1,870 1,505

75 1,814 2,005 2,553 1,021 1,911 1,540

76 1,849 2,044 2,605 1,042 1,950 1,571

77 1,886 2,085 2,655 1,062 1,987 1,601

78 1,918 2,121 2,701 1,080 2,023 1,628

79 1,954 2,161 2,753 1,102 2,061 1,660

80 1,993 2,203 2,805 1,123 2,100 1,691

81 2,030 2,243 2,858 1,143 2,140 1,723

82 2,067 2,287 2,912 1,165 2,180 1,754

83 2,106 2,327 2,966 1,187 2,220 1,789

84 2,145 2,371 3,020 1,209 2,261 1,820

85 2,192 2,425 3,088 1,236 2,312 1,862

86 2,230 2,464 3,140 1,256 2,351 1,893

87 2,266 2,505 3,193 1,276 2,388 1,924

88 2,302 2,546 3,243 1,297 2,427 1,955

89 2,340 2,587 3,295 1,317 2,466 1,986

90 2,377 2,628 3,346 1,339 2,505 2,018

91 2,413 2,667 3,399 1,359 2,543 2,048

92 2,448 2,709 3,449 1,380 2,582 2,080

93 2,485 2,747 3,499 1,398 2,619 2,109

94 2,519 2,785 3,548 1,419 2,656 2,140

95 2,552 2,822 3,595 1,438 2,690 2,166

96 2,582 2,856 3,636 1,454 2,723 2,192

97 2,608 2,884 3,674 1,470 2,750 2,215

98 2,629 2,907 3,704 1,481 2,771 2,232

99+ 2,641 2,920 3,719 1,487 2,784 2,243

Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833

The above rates do not include the $20 one-time policy fee.

To calculate a Household discount:

Annual premium x modal factor = modal premium (round to nearest whole cent)

Modal premium x .93 = discounted premium

CLIMS03989AZ 2 03/2019 A


For Use in ZIP Codes: 850-853, 857

Male Rates


Issue

Age

Preferred


65 1,570 1,735 2,211 884 1,656 1,235

66 1,581 1,746 2,224 889 1,664 1,262

67 1,599 1,767 2,252 901 1,686 1,297

68 1,625 1,796 2,289 915 1,713 1,340

69 1,656 1,831 2,332 933 1,746 1,385

70 1,692 1,868 2,381 953 1,781 1,436

71 1,724 1,906 2,429 971 1,818 1,465

72 1,761 1,947 2,479 992 1,856 1,494

73 1,796 1,987 2,530 1,012 1,894 1,525

74 1,837 2,031 2,587 1,036 1,936 1,559

75 1,877 2,074 2,642 1,057 1,978 1,594

76 1,914 2,116 2,696 1,078 2,019 1,626

77 1,952 2,157 2,748 1,099 2,057 1,657

78 1,985 2,195 2,797 1,118 2,094 1,686

79 2,023 2,237 2,850 1,140 2,133 1,718

80 2,062 2,279 2,903 1,162 2,173 1,751

81 2,100 2,322 2,957 1,184 2,215 1,784

82 2,139 2,365 3,014 1,207 2,256 1,816

83 2,180 2,409 3,068 1,227 2,298 1,851

84 2,219 2,454 3,126 1,250 2,340 1,884

85 2,269 2,510 3,197 1,279 2,393 1,927

86 2,308 2,552 3,250 1,300 2,433 1,959

87 2,346 2,592 3,304 1,321 2,472 1,991

88 2,383 2,635 3,356 1,343 2,512 2,023

89 2,422 2,677 3,410 1,364 2,552 2,056

90 2,460 2,720 3,464 1,385 2,592 2,087

91 2,497 2,761 3,517 1,407 2,632 2,120

92 2,534 2,803 3,570 1,427 2,673 2,152

93 2,572 2,843 3,622 1,449 2,711 2,183

94 2,607 2,883 3,673 1,469 2,749 2,214

95 2,641 2,920 3,720 1,487 2,784 2,242

96 2,673 2,955 3,764 1,505 2,818 2,268

97 2,700 2,986 3,803 1,522 2,847 2,292

98 2,721 3,008 3,832 1,533 2,868 2,310

99+ 2,734 3,023 3,850 1,539 2,882 2,321

Issue

Age

Standard


65 1,745 1,928 2,457 982 1,840 1,371

66 1,756 1,939 2,471 990 1,850 1,402

67 1,777 1,964 2,503 1,001 1,873 1,442

68 1,807 1,996 2,544 1,017 1,904 1,488

69 1,840 2,034 2,591 1,038 1,940 1,539

70 1,878 2,075 2,644 1,057 1,979 1,595

71 1,917 2,120 2,699 1,079 2,020 1,627

72 1,957 2,163 2,754 1,103 2,063 1,660

73 1,996 2,207 2,812 1,124 2,105 1,694

74 2,042 2,256 2,873 1,150 2,151 1,731

75 2,086 2,304 2,936 1,174 2,197 1,771

76 2,127 2,350 2,996 1,198 2,242 1,807

77 2,167 2,398 3,053 1,222 2,285 1,841

78 2,206 2,439 3,107 1,243 2,326 1,874

79 2,248 2,486 3,166 1,268 2,371 1,909

80 2,292 2,532 3,225 1,292 2,415 1,945

81 2,334 2,580 3,286 1,315 2,460 1,982

82 2,376 2,630 3,348 1,340 2,507 2,018

83 2,422 2,676 3,410 1,365 2,554 2,057

84 2,467 2,726 3,474 1,390 2,600 2,094

85 2,521 2,788 3,551 1,421 2,659 2,142

86 2,564 2,834 3,611 1,444 2,704 2,177

87 2,606 2,882 3,671 1,468 2,747 2,213

88 2,648 2,928 3,730 1,492 2,791 2,248

89 2,691 2,975 3,790 1,514 2,835 2,285

90 2,734 3,023 3,849 1,539 2,881 2,320

91 2,775 3,067 3,909 1,563 2,924 2,355

92 2,815 3,114 3,965 1,587 2,969 2,391

93 2,858 3,158 4,024 1,609 3,012 2,426

94 2,896 3,204 4,081 1,633 3,055 2,460

95 2,935 3,244 4,134 1,652 3,093 2,492

96 2,970 3,284 4,182 1,672 3,132 2,521

97 3,000 3,317 4,225 1,692 3,162 2,547

98 3,024 3,343 4,259 1,704 3,186 2,567

99+ 3,038 3,357 4,277 1,710 3,201 2,579






CLIMS03989AZ 3 03/2019 A


For Use in : Rest of State

Female Rates


Issue

Age

Preferred


65 1,252 1,384 1,764 705 1,321 985

66 1,260 1,393 1,774 710 1,328 1,007

67 1,276 1,410 1,797 719 1,345 1,035

68 1,297 1,433 1,826 730 1,367 1,069

69 1,321 1,460 1,861 745 1,393 1,105

70 1,349 1,490 1,899 759 1,421 1,145

71 1,376 1,522 1,938 775 1,450 1,169

72 1,405 1,553 1,978 791 1,481 1,192

73 1,433 1,585 2,019 807 1,511 1,217

74 1,465 1,619 2,063 826 1,544 1,244

75 1,498 1,655 2,108 843 1,578 1,271

76 1,527 1,688 2,151 860 1,610 1,297

77 1,557 1,721 2,192 877 1,641 1,321

78 1,584 1,751 2,231 892 1,670 1,345

79 1,614 1,785 2,273 910 1,702 1,371

80 1,645 1,819 2,316 927 1,734 1,397

81 1,675 1,852 2,360 944 1,767 1,423

82 1,707 1,888 2,404 962 1,800 1,449

83 1,739 1,922 2,448 980 1,833 1,476

84 1,771 1,957 2,494 997 1,867 1,503

85 1,811 2,002 2,550 1,020 1,909 1,537

86 1,841 2,035 2,593 1,037 1,941 1,563

87 1,871 2,069 2,635 1,054 1,972 1,588

88 1,901 2,102 2,678 1,071 2,004 1,614

89 1,932 2,136 2,721 1,088 2,036 1,640

90 1,962 2,169 2,763 1,106 2,068 1,665

91 1,993 2,203 2,806 1,122 2,100 1,691

92 2,022 2,236 2,848 1,139 2,132 1,717

93 2,052 2,268 2,889 1,155 2,163 1,741

94 2,080 2,299 2,930 1,172 2,193 1,766

95 2,107 2,330 2,968 1,187 2,221 1,789

96 2,132 2,358 3,002 1,201 2,248 1,810

97 2,154 2,382 3,034 1,214 2,271 1,829

98 2,170 2,400 3,058 1,223 2,288 1,843

99+ 2,181 2,411 3,071 1,228 2,299 1,852

Issue

Age

Standard


65 1,392 1,538 1,959 783 1,468 1,094

66 1,401 1,548 1,972 789 1,476 1,118

67 1,418 1,567 1,997 799 1,494 1,150

68 1,441 1,592 2,029 811 1,519 1,188

69 1,467 1,622 2,068 828 1,548 1,228

70 1,499 1,656 2,110 843 1,579 1,272

71 1,529 1,691 2,153 861 1,611 1,299

72 1,561 1,725 2,198 880 1,646 1,324

73 1,592 1,761 2,243 896 1,679 1,352

74 1,629 1,799 2,292 917 1,716 1,381

75 1,664 1,839 2,342 937 1,753 1,413

76 1,696 1,875 2,390 956 1,789 1,441

77 1,730 1,913 2,436 974 1,823 1,469

78 1,760 1,946 2,478 991 1,856 1,494

79 1,793 1,983 2,526 1,011 1,891 1,523

80 1,828 2,021 2,573 1,030 1,927 1,551

81 1,862 2,058 2,622 1,049 1,963 1,581

82 1,896 2,098 2,672 1,069 2,000 1,609

83 1,932 2,135 2,721 1,089 2,037 1,641

84 1,968 2,175 2,771 1,109 2,074 1,670

85 2,011 2,225 2,833 1,134 2,121 1,708

86 2,046 2,261 2,881 1,152 2,157 1,737

87 2,079 2,298 2,929 1,171 2,191 1,765

88 2,112 2,336 2,975 1,190 2,227 1,794

89 2,147 2,373 3,023 1,208 2,262 1,822

90 2,181 2,411 3,070 1,228 2,298 1,851

91 2,214 2,447 3,118 1,247 2,333 1,879

92 2,246 2,485 3,164 1,266 2,369 1,908

93 2,280 2,520 3,210 1,283 2,403 1,935

94 2,311 2,555 3,255 1,302 2,437 1,963

95 2,341 2,589 3,298 1,319 2,468 1,987

96 2,369 2,620 3,336 1,334 2,498 2,011

97 2,393 2,646 3,371 1,349 2,523 2,032

98 2,412 2,667 3,398 1,359 2,542 2,048

99+ 2,423 2,679 3,412 1,364 2,554 2,058






CLIMS03989AZ 4 03/2019 A


For Use in : Rest of State Male Rates


Issue

Age

Preferred


65 1,440 1,592 2,028 811 1,519 1,133

66 1,450 1,602 2,040 816 1,527 1,158

67 1,467 1,621 2,066 827 1,547 1,190

68 1,491 1,648 2,100 839 1,572 1,229

69 1,519 1,680 2,139 856 1,602 1,271

70 1,552 1,714 2,184 874 1,634 1,317

71 1,582 1,749 2,228 891 1,668 1,344

72 1,616 1,786 2,274 910 1,703 1,371

73 1,648 1,823 2,321 928 1,738 1,399

74 1,685 1,863 2,373 950 1,776 1,430

75 1,722 1,903 2,424 970 1,815 1,462

76 1,756 1,941 2,473 989 1,852 1,492

77 1,791 1,979 2,521 1,008 1,887 1,520

78 1,821 2,014 2,566 1,026 1,921 1,547

79 1,856 2,052 2,615 1,046 1,957 1,576

80 1,892 2,091 2,663 1,066 1,994 1,606

81 1,927 2,130 2,713 1,086 2,032 1,637

82 1,962 2,170 2,765 1,107 2,070 1,666

83 2,000 2,210 2,815 1,126 2,108 1,698

84 2,036 2,251 2,868 1,147 2,147 1,728

85 2,082 2,303 2,933 1,173 2,195 1,768

86 2,117 2,341 2,982 1,193 2,232 1,797

87 2,152 2,378 3,031 1,212 2,268 1,827

88 2,186 2,417 3,079 1,232 2,305 1,856

89 2,222 2,456 3,128 1,251 2,341 1,886

90 2,257 2,495 3,178 1,271 2,378 1,915

91 2,291 2,533 3,227 1,291 2,415 1,945

92 2,325 2,572 3,275 1,309 2,452 1,974

93 2,360 2,608 3,323 1,329 2,487 2,003

94 2,392 2,645 3,370 1,348 2,522 2,031

95 2,423 2,679 3,413 1,364 2,554 2,057

96 2,452 2,711 3,453 1,381 2,585 2,081

97 2,477 2,739 3,489 1,396 2,612 2,103

98 2,496 2,760 3,516 1,406 2,631 2,119

99+ 2,508 2,773 3,532 1,412 2,644 2,129

Issue

Age

Standard


65 1,601 1,769 2,254 901 1,688 1,258

66 1,611 1,779 2,267 908 1,697 1,286

67 1,630 1,802 2,296 918 1,718 1,323

68 1,658 1,831 2,334 933 1,747 1,365

69 1,688 1,866 2,377 952 1,780 1,412

70 1,723 1,904 2,426 970 1,816 1,463

71 1,759 1,945 2,476 990 1,853 1,493

72 1,795 1,984 2,527 1,012 1,893 1,523

73 1,831 2,025 2,580 1,031 1,931 1,554

74 1,873 2,070 2,636 1,055 1,973 1,588

75 1,914 2,114 2,694 1,077 2,016 1,625

76 1,951 2,156 2,749 1,099 2,057 1,658

77 1,988 2,200 2,801 1,121 2,096 1,689

78 2,024 2,238 2,850 1,140 2,134 1,719

79 2,062 2,281 2,905 1,163 2,175 1,751

80 2,103 2,323 2,959 1,185 2,216 1,784

81 2,141 2,367 3,015 1,206 2,257 1,818

82 2,180 2,413 3,072 1,229 2,300 1,851

83 2,222 2,455 3,128 1,252 2,343 1,887

84 2,263 2,501 3,187 1,275 2,385 1,921

85 2,313 2,558 3,258 1,304 2,439 1,965

86 2,352 2,600 3,313 1,325 2,481 1,997

87 2,391 2,644 3,368 1,347 2,520 2,030

88 2,429 2,686 3,422 1,369 2,561 2,062

89 2,469 2,729 3,477 1,389 2,601 2,096

90 2,508 2,773 3,531 1,412 2,643 2,128

91 2,546 2,814 3,586 1,434 2,683 2,161

92 2,583 2,857 3,638 1,456 2,724 2,194

93 2,622 2,897 3,692 1,476 2,763 2,226

94 2,657 2,939 3,744 1,498 2,803 2,257

95 2,693 2,976 3,793 1,516 2,838 2,286

96 2,725 3,013 3,837 1,534 2,873 2,313

97 2,752 3,043 3,876 1,552 2,901 2,337

98 2,774 3,067 3,907 1,563 2,923 2,355

99+ 2,787 3,080 3,924 1,569 2,937 2,366






CLIMS03989AZ 5 03/2019 A

PREMIUM INFORMATION

Continental Life Insurance Company of Brentwood, Tennessee can only raise your premium if we raise the premium for all policies like yours in this state. Premiums 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 a Continental Life Insurance Company of Brentwood, Tennessee 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 an Aetna Company Medicare supplement policy. The Medicare eligible adult must be either: (a) your spouse; or (b) someone with whom you are in a civil union partnership; and (c) someone with whom you have continuously resided for the past 12 months. 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 Continental Life Insurance Company of Brentwood, Tennessee, P.O. Box 14770, Lexington, KY 40512-4770. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all your payments.

POLICY REPLACEMENT

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

NOTICE

The policy may not cover all of your medical costs.

Neither Continental Life Insurance Company of Brentwood, Tennessee nor its agents are connected with Medicare.

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare & You for more details.

COMPLETE ANSWERS ARE VERY IMPORTANT

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 CONTINENTAL LIFE INSURANCE COMPANY OF BRENTWOOD, TENNESSEE.

CLIMS03989AZ 6 03/2019 A

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.

CLIMS03989AZ 7 03/2019 A

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.


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 $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*


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

PARTS A & B


PLAN PAYS

YOU PAY

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

100% $0 $0

Durable medical equipment First $185 of Medicare

Approved amounts* $0 $0 $185

(Part B Deductible)

Remainder of Medicare Approved amounts 80% 20% $0

CLIMS03989AZ 8 03/2019 A

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.


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



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.



$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. CLIMS03989AZ 9 03/2019 A

PLAN B MEDICARE (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.


PLAN PAYS

YOU PAY



Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $185 of Medicare-Approved amounts*


Remainder of Medicare-Approvedamounts 80% 20% $0

CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

PARTS A & B


PLAN PAYS

YOU PAY


100% $0 $0



(Part B Deductible)


CLIMS03989AZ 10 03/2019 A

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



PLAN PAYS

YOU PAY






amounts $0 $0


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.



$0


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



PLAN PAYS

YOU PAY


$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


PARTS A & B


PLAN PAYS

YOU PAY


100% $0 $0


Approved amounts* $0 $185

(Part B Deductible) $0


CLIMS03989AZ 12 03/2019 A

PLAN F OTHER BENEFITS – NOT COVERED BY MEDICARE


PLAN PAYS

YOU PAY

FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime

maximum benefit of $50,000

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

CLIMS03989AZ 13 03/2019 A

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

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. ***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $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.


AFTER YOU PAY $2300

DEDUCTIBLE*** PLAN PAYS

IN ADDITION TO $2300

DEDUCTIBLE*** YOU PAY






amounts $0 $0


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

CLIMS03989AZ 14 03/2019 A

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



$0

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

CLIMS03989AZ 15 03/2019 A

HIGH DEDUCTIBLE PLAN F MEDICARE (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’s separate foreign travel emergency deductible.


AFTER YOU PAY $2300






$0



$0


CLIMS03989AZ 16 03/2019 A

HIGH DEDUCTIBLE PLAN F

PARTS A & B


AFTER YOU PAY $2300




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

100% $0 $0


Approved amounts* $0 $185

(Part B Deductible) $0


OTHER BENEFITS – NOT COVERED BY MEDICARE


AFTER YOU PAY $2300

DEDUCTIBLE** PLAN PAYS


DEDUCTIBLE** YOU PAY




CLIMS03989AZ 17 03/2019 A

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



PLAN PAYS

YOU PAY






amounts $0 $0


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



$0


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



PLAN PAYS

YOU PAY






PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES Medically necessary skilled careservices and medical supplies 100% $0 $0 Durable medical equipment First $185 of Medicare Approved amounts*


Remainder of Medicare

Approved amounts 80% 20% $0

CLIMS03989AZ 19 03/2019 A

PLAN G


SERVICES MEDICARE PAYS PLAN PAYS YOU PAY




CLIMS03989AZ 20 03/2019 A

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



PLAN PAYS

YOU PAY






amounts $0 $0


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



$0


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



PLAN PAYS

YOU PAY



Remainder of Medicare-Approved amounts

Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Part B Excess Charges (Above Medicare-Approved amounts) $0 0% All costs BLOOD First 3 pints $0 All costs $0 Next $185 of Medicare-Approved amounts*



CLIMS03989AZ 22 03/2019 A

PLAN N

PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES Medically necessary skilled careservices and medical supplies 100% $0 $0 Durable medical equipment First $185 of Medicare


(Part B Deductible) Remainder of Medicare

Approved amounts 80% 20% $0



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


CLIMS03989AZ 23 03/2019 A

outline of coverage - aetna · 2019-02-01 · page 1 of 2 benefit plans available: a, b, f, high...

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