Part B. Coinsurance. 50% Skilled Nursing Facility. Nursing Facility. Coinsurance 75% Part A Deductible. Coinsurance 50% Part A.

Transcription

1 LOYAL AMERICAN LIFE INSURANCE COMPANY P. O. BOX AUSTIN, TX Outline of Medicare Supplement Coverage - Benefit Plans A, F, G and N This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan A available. Some plans may not be available in your state. See Outline of Coverage sections for details about ALL Plans. BASIC BENEFITS: Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses: Part B coinsurance (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 three pints of blood each year. Hospice: Part A coinsurance. A B C D F F* G K L M N Basic, Basic, Basic, Basic, Basic, Hospitalization Hospitalization Basic, Including Including Including Including 100% Including 100% and Preventive and Preventive Including 100% 100% 100% Part B Part B Care Paid at Care Paid at 100% Part B Part B Part B Coinsurance* Coinsurance 100%; Other 100%; Other Part B Coinsurance Coinsurance Coinsurance Basic Benefits Basic Benefits Coinsurance paid at 50% Paid at 75% Basic, Including 100% Part B Coinsurance Part A Deductible Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Foreign Travel Emergency Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency Skilled Nursing Facility Coinsurance Part A Deductible Part B Excess (100%) Foreign Travel Emergency 50% Skilled Nursing Facility Coinsurance 50% Part A Deductible Out-of-Pocket Limit $4,940; Paid at 100% After Reached 75% Skilled Nursing Facility Coinsurance 75% Part A Deductible Out-of-Pocket Limit $2,470; Paid At 100% After Reached Skilled Nursing Facility Coinsurance 50% Part A Deductible Foreign Travel Emergency Basic, Including 100% Part B Coinsurance, Except Up to $20 Copayment for Office Visit, and up to $50 Copayment for ER Visit Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency * Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. 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. LOYAL-OC-AA-VA PAGE 1 01/15

2 Loyal American Life Insurance Co. MEDICARE SUPPLEMENT VIRGINIA Attained Age Rates -- Effective 9/21/ Area I ( , , ) PREFERRED PLUS ANNUAL & MONTHLY BANK DRAFT RATES FEMALE RATES MALE RATES Plan A Plan F Plan G Plan N Attained Plan A Plan F Plan G Plan N Annual Monthly Annual Monthly Annual Monthly Annual Monthly Age Annual Monthly Annual Monthly Annual Monthly Annual Monthly 1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply the above-quoted annual premium by To obtain quarterly premiums, multiply the above quoted premium by Add one-time enrollment fee of.00 to the first premium. LOYAL-OC-AA-VA PAGE 2 01/15

3 Loyal American Life Insurance Co. MEDICARE SUPPLEMENT VIRGINIA Attained Age Rates -- Effective 9/21/ Area I ( , , ) PREFERRED ANNUAL & MONTHLY BANK DRAFT RATES FEMALE RATES MALE RATES Plan A Plan F Plan G Plan N Attained Plan A Plan F Plan G Plan N Annual Monthly Annual Monthly Annual Monthly Annual Monthly Age Annual Monthly Annual Monthly Annual Monthly Annual Monthly 1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply the above-quoted annual premium by To obtain quarterly premiums, multiply the above quoted premium by Add one-time enrollment fee of.00 to the first premium. LOYAL-OC-AA-VA PAGE 3 01/15

4 Loyal American Life Insurance Co. MEDICARE SUPPLEMENT VIRGINIA Attained Age Rates -- Effective 9/21/ Area I ( , , ) STANDARD ANNUAL & MONTHLY BANK DRAFT RATES FEMALE RATES MALE RATES Plan A Plan F Plan G Plan N Attained Plan A Plan F Plan G Plan N Annual Monthly Annual Monthly Annual Monthly Annual Monthly Age Annual Monthly Annual Monthly Annual Monthly Annual Monthly 0 1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply the above-quoted annual premium by To obtain quarterly premiums, multiply the above quoted premium by Add one-time enrollment fee of.00 to the first premium. LOYAL-OC-AA-VA PAGE 4 01/15

5 Loyal American Life Insurance Co. MEDICARE SUPPLEMENT VIRGINIA Attained Age Rates -- Effective 9/21/ Area II ( , , , 246) PREFERRED PLUS ANNUAL & MONTHLY BANK DRAFT RATES FEMALE RATES MALE RATES Plan A Plan F Plan G Plan N Attained Plan A Plan F Plan G Plan N Annual Monthly Annual Monthly Annual Monthly Annual Monthly Age Annual Monthly Annual Monthly Annual Monthly Annual Monthly 1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply the above-quoted annual premium by To obtain quarterly premiums, multiply the above quoted premium by Add one-time enrollment fee of.00 to the first premium. LOYAL-OC-AA-VA PAGE 5 01/15

6 Loyal American Life Insurance Co. MEDICARE SUPPLEMENT VIRGINIA Attained Age Rates -- Effective 9/21/ Area II ( , , , 246) PREFERRED ANNUAL & MONTHLY BANK DRAFT RATES FEMALE RATES MALE RATES Plan A Plan F Plan G Plan N Attained Plan A Plan F Plan G Plan N Annual Monthly Annual Monthly Annual Monthly Annual Monthly Age Annual Monthly Annual Monthly Annual Monthly Annual Monthly 1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply the above-quoted annual premium by To obtain quarterly premiums, multiply the above quoted premium by Add one-time enrollment fee of.00 to the first premium. LOYAL-OC-AA-VA PAGE 6 01/15

7 Loyal American Life Insurance Co. MEDICARE SUPPLEMENT VIRGINIA Attained Age Rates -- Effective 9/21/ Area II ( , , , 246) STANDARD ANNUAL & MONTHLY BANK DRAFT RATES FEMALE RATES MALE RATES Plan A Plan F Plan G Plan N Attained Plan A Plan F Plan G Plan N Annual Monthly Annual Monthly Annual Monthly Annual Monthly Age Annual Monthly Annual Monthly Annual Monthly Annual Monthly 0 1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply the above-quoted annual premium by To obtain quarterly premiums, multiply the above quoted premium by Add one-time enrollment fee of.00 to the first premium. LOYAL-OC-AA-VA PAGE 7 01/15

8 Loyal American Life Insurance Co. MEDICARE SUPPLEMENT VIRGINIA Attained Age Rates -- Effective 9/21/ Area III (201, ) PREFERRED PLUS ANNUAL & MONTHLY BANK DRAFT RATES FEMALE RATES MALE RATES Plan A Plan F Plan G Plan N Attained Plan A Plan F Plan G Plan N Annual Monthly Annual Monthly Annual Monthly Annual Monthly Age Annual Monthly Annual Monthly Annual Monthly Annual Monthly 1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply the above-quoted annual premium by To obtain quarterly premiums, multiply the above quoted premium by Add one-time enrollment fee of.00 to the first premium. LOYAL-OC-AA-VA PAGE 8 01/15

9 Loyal American Life Insurance Co. MEDICARE SUPPLEMENT VIRGINIA PREFERRED ANNUAL RATES -- Effective 9/21/ Area III (201, ) PREFERRED PLUS ANNUAL & MONTHLY BANK DRAFT RATES FEMALE RATES MALE RATES Plan A Plan F Plan G Plan N Attained Plan A Plan F Plan G Plan N Annual Monthly Annual Monthly Annual Monthly Annual Monthly Age Annual Monthly Annual Monthly Annual Monthly Annual Monthly 1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply the above-quoted annual premium by To obtain quarterly premiums, multiply the above quoted premium by Add one-time enrollment fee of.00 to the first premium. LOYAL-OC-AA-VA PAGE 9 01/15

10 Loyal American Life Insurance Co. MEDICARE SUPPLEMENT VIRGINIA Attained Age Rates -- Effective 9/21/ Area III (201, ) STANDARD ANNUAL & MONTHLY BANK DRAFT RATES FEMALE RATES MALE RATES Plan A Plan F Plan G Plan N Attained Plan A Plan F Plan G Plan N Annual Monthly Annual Monthly Annual Monthly Annual Monthly Age Annual Monthly Annual Monthly Annual Monthly Annual Monthly 0 2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply the above-quoted annual premium by To obtain quarterly premiums, multiply the above quoted premium by Add one-time enrollment fee of.00 to the first premium. LOYAL-OC-AA-VA PAGE 10 01/15