western united life application packet

Western United Life Application Packet

Thank you for your interest in the Western United Life Medicare Supplement plan!

Attached is a copy of the policy Outline of Coverage and we have supplied you with a link to a printable copy of the Enrollment.

Should you decide to apply by upload/mail/fax/email, the printable application needs to be reviewed and signed by an Agent before it can be submitted to Western United. You may upload, email, fax or mail it in to CDA Insurance:

• Fax: 1.541.284.2994

• Email: [email protected]

• Secure File Upload: Click here

• Mail: CDA Insurance LLC PO Box 26540 Eugene, Oregon 97402

Other Important Information Download Medicare’s Choosing a Medigap Policy Guide (.pdf) Download Policy Outline (.pdf) Download Application (.pdf)

Our website: http://www.medicare-texas.net

If you should have any questions on the application, please call us at 1.800.884.2343 or 1.541.434.9613.

mailto:[email protected]

mailto:[email protected]

https://cda-insurance.citrixdata.com/r/r7a05451975a43c2b

https://cda-insurance.citrixdata.com/r/r7a05451975a43c2b

https://www.medicare.gov/Pubs/pdf/02110-Medicare-Medigap.guide.pdf

https://www.medicare.gov/Pubs/pdf/02110-Medicare-Medigap.guide.pdf

https://medicare-texas.net/shared/docs/medigap/TX/wul/2020/ooc.2020.pdf

https://medicare-texas.net/shared/docs/medigap/TX/wul/2020/ooc.2020.pdf

https://medicare-texas.net/shared/docs/medigap/TX/wul/2020/app.2020.pdf

https://medicare-texas.net/shared/docs/medigap/TX/wul/2020/app.2020.pdf

http://www.medicare-texas.net/medigap/western-united-life/

http://www.medicare-texas.net/medigap/western-united-life/

WMSOCTX20 Effective 09-01-2019 Page 1

WESTERN UNITED LIFE ASSURANCE COMPANY Outline of Medicare Supplement Coverage-Cover Page

Benefit Plans A, C, F, G, AND N

Benefit Chart of Medicare Supplement Plans Sold on or after January 1, 2020.

This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan “A” available. Some plans may not be available. Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F. Western United Life Assurance Company offers five of the twelve plans available.

Note: A ✓ means 100% of the benefit is paid.

Benefits Plans Available to All Applicants Medicare first eligible before 2020 only

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)

A B D G G1 K L M N C F F1

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

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 20202 $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.


WESTERN UNITED LIFE ASSURANCE COMPANY ANNUAL PREFERRED ATTAINED AGE PREMIUMS

FOR USE IN TEXAS ZIP CODES 770-773, 775

Attained Female Male Age Plan A Plan C Plan F Plan G Plan N Plan A Plan C Plan F Plan G Plan N

0-64 6,131 N/A N/A N/A N/A 7,050 N/A N/A N/A N/A 65 1,461 1,913 1,897 1,408 1,212 1,680 2,200 2,182 1,618 1,393 66 1,461 1,913 1,897 1,408 1,212 1,680 2,200 2,182 1,618 1,393 67 1,461 1,913 1,897 1,408 1,212 1,680 2,200 2,182 1,618 1,393 68 1,512 1,974 1,957 1,460 1,256 1,739 2,269 2,250 1,679 1,444 69 1,562 2,036 2,019 1,513 1,299 1,796 2,340 2,322 1,740 1,494 70 1,614 2,097 2,080 1,566 1,344 1,855 2,412 2,392 1,801 1,546 71 1,655 2,157 2,138 1,615 1,387 1,904 2,480 2,459 1,857 1,595 72 1,700 2,220 2,201 1,668 1,433 1,955 2,553 2,532 1,918 1,649 73 1,744 2,282 2,263 1,721 1,479 2,007 2,624 2,602 1,980 1,701 74 1,794 2,352 2,331 1,780 1,530 2,063 2,705 2,682 2,046 1,760 75 1,852 2,431 2,410 1,845 1,587 2,128 2,795 2,772 2,121 1,825 76 1,898 2,508 2,487 1,908 1,643 2,183 2,885 2,860 2,195 1,890 77 1,946 2,587 2,566 1,972 1,701 2,238 2,977 2,952 2,268 1,956 78 1,995 2,669 2,647 2,037 1,761 2,293 3,069 3,044 2,343 2,024 79 2,049 2,757 2,733 2,108 1,824 2,355 3,170 3,144 2,424 2,098 80 2,103 2,848 2,823 2,181 1,889 2,418 3,274 3,247 2,508 2,174 81 2,155 2,945 2,920 2,259 1,962 2,479 3,386 3,357 2,598 2,256 82 2,209 3,044 3,018 2,338 2,037 2,540 3,501 3,470 2,690 2,343 83 2,265 3,150 3,123 2,423 2,116 2,605 3,623 3,591 2,787 2,433 84 2,323 3,257 3,229 2,511 2,197 2,671 3,746 3,713 2,886 2,525 85 2,384 3,372 3,342 2,601 2,282 2,743 3,878 3,843 2,991 2,623 86 2,440 3,477 3,446 2,685 2,358 2,806 3,998 3,963 3,088 2,712 87 2,496 3,585 3,552 2,771 2,439 2,871 4,122 4,087 3,187 2,805 88 2,555 3,696 3,662 2,859 2,521 2,938 4,249 4,212 3,288 2,900 89 2,615 3,809 3,775 2,949 2,606 3,005 4,380 4,341 3,393 2,997 90 2,674 3,926 3,890 3,043 2,691 3,075 4,515 4,474 3,499 3,095 91 2,725 4,032 3,996 3,127 2,772 3,133 4,638 4,595 3,596 3,188 92 2,774 4,137 4,099 3,211 2,852 3,190 4,759 4,715 3,692 3,278 93 2,825 4,245 4,206 3,297 2,933 3,248 4,883 4,836 3,791 3,373 94 2,875 4,356 4,316 3,383 3,015 3,306 5,009 4,962 3,890 3,468 95 2,926 4,468 4,427 3,473 3,100 3,366 5,139 5,090 3,994 3,566 96 2,977 4,543 4,501 3,532 3,153 3,423 5,226 5,178 4,061 3,626 97 3,027 4,621 4,578 3,592 3,207 3,482 5,315 5,265 4,131 3,688 98 3,079 4,701 4,656 3,654 3,261 3,540 5,405 5,355 4,202 3,750 99 3,131 4,780 4,734 3,716 3,317 3,600 5,497 5,445 4,274 3,815

Premium payable other than annual will be determined according to the following factors:

Semi Annual Quarterly Monthly 1/2 1/4 1/12

There is a one-time $25.00 policy fee.

A discount factor of .93 is applied for household discount applicants


WESTERN UNITED LIFE ASSURANCE COMPANY ANNUAL STANDARD ATTAINED AGE PREMIUMS

FOR USE IN TEXAS ZIP CODES 770-773, 775








WESTERN UNITED LIFE ASSURANCE COMPANY

ANNUAL PREFERRED ATTAINED AGE PREMIUMS FOR USE IN TEXAS ZIP CODES

750-753, 760, 761, 774, 776, 777, 782, 784, 793, 794 Attained Female Male

Age Plan A Plan C Plan F Plan G Plan N Plan A Plan C Plan F Plan G Plan N








FOR USE IN TEXAS ZIP CODES 750-753, 760, 761, 774, 776, 777, 782, 784, 793, 794








WESTERN UNITED LIFE ASSURANCE COMPANY

ANNUAL PREFERRED ATTAINED AGE PREMIUMS FOR USE IN TEXAS ZIP CODES ALL EXCEPT 750-753, 760, 761, 770-777, 782, 784, 793, 794

Attained Age

Female Male

Plan A Plan C Plan F Plan G Plan N Plan A Plan C Plan F Plan G Plan N








FOR USE IN TEXAS ZIP CODES ALL EXCEPT 750-753, 760, 761, 770-777, 782, 784, 793, 794





There is a onetime $25.00 policy fee.



PREMIUM INFORMATION Western United Life Assurance Company may change your premium if a new table of rates is applicable to the policy. The change in the table of rates will apply to all covered persons in the same class on the date of change. Class is defined as attained age, underwriting class, and state of residence. Western United Life Assurance Company will not change premium rates for a Medicare supplement policy, unless the rates, rating schedule, and supporting documentation have been approved by the Commissioner of the Texas Department Insurance.

Premiums are based on your attained age, and household discount for qualified household discount applicants, and will change on Your Policy Anniversary Date.

DISCOSURES

Use this outline to compare benefits 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 Western United Life Assurance Company.

RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to our Medicare Supplement Administrative Office at P. O. Box 924408, Houston, Texas 77292-4408. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.

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

NOTICE This policy may not fully cover all of your medical costs. Neither Western United Life Assurance 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 and You for more details.

LIMITATIONS AND EXCLUSIONS We will not pay benefits for:

(a) expense incurred while this Policy is not in force, except as provided in the Extension of Benefits section;

(b) We will not pay benefits for hospital or skilled nursing facility charges incurred while this policy is not in force.

(c) that portion of any expense incurred which is paid for by Medicare; (d) services for non-Medicare Eligible Expenses, including, but not limited to, routine

exams, take home drugs and eye refractions; (e) services for which a charge is not normally made in the absence of insurance; or (f) loss or expense that is payable under any other Medicare Supplement Insurance

Policy or certificate.

REFUND OF PREMIUMS The Policy does contain a Pro-Rata Refund provision which provides for the refund of that part of any premium You have paid which covers the period after the death occurs.

The Policy does contain a Cancellation By Insured provision which provides for a pro-rata refund of any premium paid beyond the date of cancellation of the Policy.

COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded.


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 $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 co-payment/coinsurance for outpatient drugs and inpatient respite care

Medicare co-payment/ 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.


PLAN A

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.

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 $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


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


PLAN C





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:


$0**




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


HOSPICE CARE


All but very limited co-payment/coinsurance for outpatient drugs and inpatient respite care.




PLAN C 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.



First $185 of Medicare Approved Amounts* $0 $185 (Part B deductible) $0 Remainder of Medicare Approved Amounts Generally 80% Generally 20% $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


PARTS A & B

HOME HEALTH CARE



— 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

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






reserve days All but $682 a day $682 a day $0 — Once lifetime reserve

days are used:


$0***





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.



***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.


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.



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


PARTS A & B


HOME HEALTH CARE MEDICARE APPROVED SERVICES


— Durable medical equipment First $185 of Medicare Approved Amounts* $0 $185 (Part B deductible) $0 Remainder of Medicare Approved Amounts 80% 20% $0

OTHER SERVICES – NOT COVERED BY MEDICARE


FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA


maximum benefit of $50,000

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


PLAN G







are used:


$0**





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.





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




First $185 of Medicare Approved Amounts* $0 $0

$185 (Unless Part B deductible has been met)

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


Remainder of Medicare Approved Amounts 80% 20% $0


PARTS A & B


HOME HEALTH CARE



— Durable medical equipment First $185 of Medicare Approved Amounts* $0 $0


Remainder of Medicare Approved Amounts 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

Remainder of Charges $0 80% to a lifetime maximum benefit of $50,000.

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


PLAN N




HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies:



are used:


$0**





BLOOD


HOSPICE CARE






PLAN N

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




First $185 of Medicare Approved Amounts* $0 $0 $185 (Part B deductible) Remainder of Medicare Approved Amounts

Generally 80%

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

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


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


PLAN N

PARTS A & B


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



FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA


maximum benefit of $50,000.

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

western united life application packet

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