MISSOURI MAP551_MO 06/18/2014

Transcription

1 MISSOURI MAP551_MO 06/18/2014

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3 Mutual of Omaha Insurance Company 2014 Medicare Supplement Insurance Plans Spontaneous. FU! Fearless. Whether you re six or sixty something, playing keeps you young-at-heart. The difference now, of course, is that you have adult responsibilities, including making sound financial decisions. ou ll probably enjoy playing, however you define it, even more when you feel you ve got your bases covered. A Medicare supplement insurance policy from Mutual of Omaha Insurance Company can help you attain that secure feeling. With a Medicare supplement insurance policy, you Keep your doctors and health care providers See specialists without referrals Receive benefits with no waiting period* Enjoy guaranteed coverage for life* Don t pay a policy fee with our plan Add our helpful midwestern customer service staff and affordable premiums and you have the financial value and security you seek. *see details on back cover Underwritten by Mutual of Omaha Insurance Company Mutual of Omaha Plaza Omaha, E mutualofomaha.com Mutual of Omaha Insurance Company is licensed nationwide. We ve got you covered. GO PLA! MC35022_MO Missouri Policy Forms MM20 - Plan A, MM24 - Plan F, MM25 - Plan G

4 Select the Medicare Supplement Insurance Plan that s Right for ou Medicare Pays Plan A Pays Plan F Pays Plan G Pays Medicare Part A Hospital Insurance* Deductible othing $1,216 $1,216 First 60 days 100% Coinsurance days Coinsurance days Extended Hospital Coverage (up to an additional 365 days in your lifetime) Benefit for Blood All but $304 a day All but $608 a day othing All but three pints Skilled ursing Facility Care First 20 days 100% Coinsurance days Hospice Care Outpatient Prescription Drugs Inpatient Respite Care All but $152 a day All but $5 All but 5% $304 a day $608 a day Eligible Expenses $304 a day $608 a day Eligible Expenses $304 a day $608 a day Eligible Expenses Three pints Three pints Three pints Up to $152 a day Up to $152 a day $5 $5 $5 5% of Medicare s approved amount 5% of Medicare s approved amount 5% of Medicare s approved amount Medicare Part B Medical Insurance* Deductible othing $147 Coinsurance 80% 20% 20% 20% Excess Benefits 100% up to Medicare s limit Benefit for Blood All but three pints Additional Benefit* Emergency Care Received Outside the U.S. * Refer to the next page and your outline of coverage for more information. othing 100% up to Medicare s limit Three pints Three pints Three pints 80% to lifetime max of $50,000 80% to lifetime max of $50,000 our Premium our Premium our Premium $ $ $

5 Medicare Part A Hospital Coverage Medicare Part A hospital/skilled nursing facility care eligible expenses include charges for semiprivate room and board, general nursing and miscellaneous services and supplies. Deductible Plans F and G pay the $1,216 inpatient hospital deductible for each benefit period, which begins the first full day you re hospitalized and ends when you haven t been in a hospital or skilled nursing facility for 60 days in a row. Coinsurance All plans pay $304 a day when you re hospitalized from the 61st through the 90th day. And, when you re in the hospital from the 91st day through the 150th day, you receive $608 a day for each Lifetime Reserve day used. Extended Hospital Coverage When you re in the hospital longer than 150 days during a benefit period, and you ve exhausted your 60 days of Medicare Lifetime Reserve, all plans pay the Medicare Part A eligible expenses for hospitalization, paid at the rate Medicare would have paid, subject to a lifetime maximum benefit of an additional 365 days. Benefit for Blood All plans pay Medicare s one calendar-year deductible for blood that is the cost of the first three pints needed. Skilled ursing Facility Care Benefit Coinsurance Plans F and G pay up to $152 a day from the 21st through the 100th day during which you receive skilled nursing care. ou must enter a Medicarecertified skilled nursing facility within 30 days of being hospitalized for at least three days. Hospice Care Benefit Outpatient Prescription Drugs All plans pay $5 per prescription for outpatient prescription drugs for pain and symptom management. Inpatient Respite Care All plans pay 5% of the Medicare-approved amount for inpatient respite care (short-term care given by another caregiver, so the usual caregiver can rest). Medicare Part B Medical Coverage Medicare Part B eligible expenses include charges for physicians services, hospital outpatient services and supplies, physical and speech therapy and ambulance service. Deductible Plan F pays the $147 calendar-year deductible. Coinsurance After the Medicare Part B deductible, all plans pay 20% of eligible expenses. For hospital outpatient services, the copayment amount will be paid under a prospective payment system. If this system is not used, then 20% of eligible expenses will be paid. Excess Benefits our bill for Medicare Part B services and supplies may exceed the Medicare eligible expense. When that occurs, Plans F and G pay 100% of the difference, up to the charge limitation established by Medicare. Benefit for Blood All plans pay Medicare s one calendar-year deductible for blood that is the cost of the first three pints needed. Additional Benefit Emergency Care Received Outside the U.S. After you pay a $250 calendar-year deductible, Plans F and G pay you 80% of eligible expenses for health care you need because of a covered injury or illness beginning during the first 60 days of each trip up to a lifetime maximum of $50,000.

6 Plan Overview our Mutual of Omaha Medicare supplement insurance policy helps pay some eligible expenses not paid for by Medicare Part A and Medicare Part B. There may be charges above what Medicare and Mutual of Omaha pay. If you receive Medicare benefits because of a disability, you may apply for a Mutual of Omaha Medicare supplement insurance policy regardless of your age. our Medicare supplement insurance does not pay for: any expense incurred before your policy date hospital or skilled nursing facility confinement incurred during a Medicare Part A benefit period that begins while this policy is not in force expense paid for by Medicare services for non-medicare eligible expenses services for which no charge is made when there is no insurance loss or expense that is payable under any other Medicare supplement insurance policy or certificate Medicare eligible expenses means charges of the kinds covered by Medicare Parts A and B, to the extent Medicare recognizes them as reasonable and medically necessary. Coinsurance is the portion of the eligible expense not paid by Medicare and paid by Mutual of Omaha. Features Give ou More Peace of Mind ou re covered immediately. There is no waiting period for preexisting conditions and benefits will be paid from the time your policy is in force. our policy cannot be canceled. It will be renewed as long as the premiums are paid on time and the information is correct on your application. our Medicare supplement insurance benefits will automatically increase as Medicare deductibles and coinsurance increase. Benefits are not paid for any expense paid by Medicare. Benefits are paid to you, your hospital or doctor. ou have 31 days from your renewal date to pay your premium. our policy will stay in force during this 31-day grace period. ou can t be singled out for a rate increase, no matter how many times you receive benefits. our premium changes when the same premium change is made on all in-force Medicare supplement insurance policies of the same form issued to persons of your classification in the same geographic area of your state. our policy s two-person household premium discount ends if the person you live with terminates his or her policy or moves to a different residence. ou can be confident that your Medicare supplement insurance benefits will be paid as promised because Mutual of Omaha Insurance Company has been serving people like you since Medicare began more than 40 years ago. And, we re committed to continue providing Medicare supplement insurance benefits amid an ever-changing political and economic environment. This is a brief description of your coverage. The outline of coverage must accompany this brochure. For complete information on benefits, exceptions, limitations and reductions, please read your outline of coverage and your policy. This is a solicitation of insurance and an insurance agent will contact you by telephone. either Mutual of Omaha Insurance Company nor its Medicare supplement insurance policies are connected with or endorsed by the U.S. government or the federal Medicare program. MC35022_MO_BW

7 MUTUAL OF OMAHA ISURACE COMPA OUTLIE OF MEDICARE SUPPLEMET COVERAGE COVER PAGE BEEFIT PLAS A, F, AD G 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. 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 copayments for hospital outpatient services. Plans K, L, and require insureds to pay a portion of Part B coinsurance or copayments. Blood: First 3 pints of blood each year. Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan F F* Plan G Plan K Plan L Plan M Plan Basic, including 100% Part B Coinsurance Basic, including 100% Part B Coinsurance Part A Deductible Basic, including 100% Part B Coinsurance Skilled ursing Facility Coinsurance Part A Deductible Part B Deductible Foreign Travel Emergency Basic, including 100% Part B Coinsurance Skilled ursing Facility Coinsurance Part A Deductible Basic, including 100% Part B Coinsurance * Skilled ursing Facility Coinsurance Part A Deductible Part B Deductible Part B Excess Basic, including 100% Part B Coinsurance Skilled ursing Facility Coinsurance Part A Deductible Foreign Travel Emergency (100%) Foreign Travel Emergency Part B Excess (100%) Foreign Travel Emergency Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% 50% Skilled ursing Facility Coinsurance 50% Part A Deductible Out-of-pocket limit $4,940; paid at 100% after limit reached Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% 75% Skilled ursing Facility Coinsurance 75% Part A Deductible Out-of-pocket limit $2,470; paid at 100% after limit reached Basic, including 100% Part B Coinsurance Skilled ursing 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 Skilled ursing 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 $2,140 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,140. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy/certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible. CO12.A-MO 1 M27009_MO_0714

8 Plan A MM20 MOTHL O-TOBACCO PREMIUMS* ZIP CODES: , FEMALE MALE Plan F MM24 Plan G MM25 Issue Age Plan A MM20 Plan F MM24 Plan G MM Thru *See PREMIUM IFORMATIO regarding Risk Class and Household Premium Discount rating. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. CO12.A-MO 2 M27009_MO_0714

9 Plan A MM20 MOTHL TOBACCO PREMIUMS* ZIP CODES: , FEMALE MALE Plan F MM24 Plan G MM25 Issue Age Plan A MM20 Plan F MM24 Plan G MM Thru *See PREMIUM IFORMATIO regarding Risk Class and Household Premium Discount rating. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. CO12.A-MO 3 M27009_MO_0714

10 Plan A MM20 MOTHL O-TOBACCO PREMIUMS* ZIP CODES: , 633, FEMALE MALE Plan F MM24 Plan G MM25 Issue Age Plan A MM20 Plan F MM24 Plan G MM Thru *See PREMIUM IFORMATIO regarding Risk Class and Household Premium Discount rating. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. CO12.A-MO 4 M27009_MO_0714

11 Plan A MM20 MOTHL TOBACCO PREMIUMS* ZIP CODES: , 633, FEMALE MALE Plan F MM24 Plan G MM25 Issue Age Plan A MM20 Plan F MM24 Plan G MM Thru *See PREMIUM IFORMATIO regarding Risk Class and Household Premium Discount rating. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. CO12.A-MO 5 M27009_MO_0714

12 Disclosures Use this outline to compare benefits and premiums among policies. Premium Information We, Mutual of Omaha, can only raise your premium if we raise the premium for all policies like yours in the same geographic area of the state where you live. Risk Class Rating If, according to our underwriting standards, you are overweight or underweight for your height, you will be considered to be a greater insurable risk. In such a case, your premium will be priced either as Class I - 10% or Class II - 20% higher than the rates illustrated, based on your Body Mass Index (BMI) reading. Risk class rating will not be applicable when you apply for coverage during an open-enrollment or guaranteed-issue period. Household Premium Discount If you reside with your spouse or domestic partner at the time of application, you may be eligible for the household premium discount. The discounted premium will be priced 12% lower than the rates illustrated. Read our Policy Very Carefully This is only an outline describing your policy's most important features. The policy is your insurance contract. ou must read the policy itself to understand all of the rights and duties of both you and us. CO12.A-MO Right to Return Policy If you find that you are not satisfied with your policy, you may return it to us at Mutual of Omaha Plaza, Omaha, E 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 OT cancel it until you have actually received your new policy and are sure you want to keep it. otice The policy may not fully cover all of your medical costs. either we nor our agents are connected with Medicare. This outline does not give all the details of Medicare coverage. Contact your local Social Security office or consult "Medicare & ou" 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 all questions about your medical and health history. We 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. Renewability of Policy We will renew this policy each time you pay the premium. It must be paid by the date it is due or during the 31 days that follow. onrenewal will not affect an existing claim. 6 M27009_MO_0714

13 PLA A MEDICARE (PART A) - HOSPITAL SERVICES - PER BEEFIT 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 A Pays ou Pay HOSPITALIZATIO* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,216 $0 $1,216 (Part A deductible) 61 st through 90 th day All but $304 a day $304 a day $0 91 st day and after: While using 60 lifetime reserve days All but $608 a day $608 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicareeligible expenses Beyond the additional 365 days $0 $0 All costs SKILLED URSIG FACILIT CARE* ou 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 21 st through 100 th day All but $152 a day $0 Up to $152 a day $0** BLOOD 101 st day and after $0 $0 All costs First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE ou 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 **OTICE: When your Medicare Part A hospital benefits are exhausted, we stand in the place of Medicare and will pay whatever amount Medicare would have paid up to an additional 365 days as provided in the policy's/certificate'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. $0 CO12.A-MO 7 M27009_MO_0714

14 PLA A MEDICARE (PART B) - MEDICAL SERVICES - PER CALEDAR EAR *Once you have been billed $147 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 A Pays ou Pay MEDICAL EXPESES I OR OUT OF THE HOSPITAL AD OUTPATIET HOSPITAL TREATMET, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $147 of Medicare-approved amounts* $0 $0 $147 (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 ext $147 of Medicare-approved amounts* $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 CLIICAL LABORATOR SERVICES TESTS FOR DIAGOSTIC SERVICES 100% $0 $0 PARTS A AD B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $147 of Medicare-approved amounts* $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 CO12.A-MO 8 M27009_MO_0714

15 PLAS F AD G MEDICARE (PART A) - HOSPITAL SERVICES - PER BEEFIT 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 F Pays ou Pay Plan G Pays ou Pay HOSPITALIZATIO* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,216 $1,216 (Part A deductible) $0 $1,216 (Part A deductible) 61 st through 90 th day All but $304 a day $304 a day $0 $304 a day $0 91 st day and after: While using 60 lifetime reserve days All but $608 a day $608 a day $0 $608 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicareeligible expenses $0** 100% of Medicareeligible expenses Beyond the additional 365 days $0 $0 All costs $0 All costs SKILLED URSIG FACILIT CARE* ou 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 $0 $0 21 st through 100 th day All but $152 a day Up to $152 a day $0 Up to $152 a day $0 101 st day and after $0 $0 All costs $0 All costs BLOOD First 3 pints $0 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 $0 $0 HOSPICE CARE ou 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 Medicare copayment/coinsurance **OTICE: When your Medicare Part A hospital benefits are exhausted, we stand in the place of Medicare and will pay whatever amount Medicare would have paid up to an additional 365 days as provided in the policy's/certificate'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. $0 $0** $0 CO12.A-MO 9 M27009_MO_0714

16 PLAS F AD G MEDICARE (PART B) - MEDICAL SERVICES - PER CALEDAR EAR *Once you have been billed $147 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 F Pays ou Pay Plan G Pays ou Pay MEDICAL EXPESES I OR OUT OF THE HOSPITAL AD OUTPATIET HOSPITAL TREATMET, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $147 of Medicare-approved amounts* $0 $147 (Part B deductible) $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Generally 20% $0 Part B Excess Charges (above Medicare-approved amounts) $0 100% $0 100% $0 BLOOD First 3 pints $0 All costs $0 All costs $0 ext $147 of Medicare-approved amounts* $0 $147 (Part B $0 $0 $147 (Part B deductible) deductible) Remainder of Medicare-approved amounts 80% 20% $0 20% $0 CLIICAL LABORATOR SERVICES TESTS FOR DIAGOSTIC SERVICES 100% $0 $0 $0 $0 PARTS A AD B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 $0 $0 Durable medical equipment First $147 of Medicare-approved amounts* $0 $147 (Part B $0 $0 $147 (Part B deductible) deductible) Remainder of Medicare-approved amounts 80% 20% $0 20% $0 CO12.A-MO 10 M27009_MO_0714

17 PLAS F AD G MEDICARE (PART B) - MEDICAL SERVICES - PER CALEDAR EAR OTHER BEEFITS OT COVERED B MEDICARE Services Medicare Pays Plan F Pays ou Pay Plan G Pays ou Pay FOREIG TRAVEL OT COVERED B 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 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum benefit 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum benefit CO12.A-MO 11 M27009_MO_0714

18 Missouri _ Producer Information Please Complete Producer ame _Agent Writing umber Commission Share Commission Code or Social Security umber Required only if you are not appointed or licensed or are changing brokerage firms % % Preferred Method of Communication (Select one) Phone Fax Contact info: ote: Producers must be under the same commission code to share or split commissions. Please update your contact information at Application Submission Checklist Mutual of Omaha Medicare Supplement Coverage Provide Applicant with the Guide to Health Insurance for People with Medicare Provide Applicant with the Outline of Coverage Calculate the premium based on age at application date Tobacco rates do not apply during open enrollment or guaranteed issue situations Complete the Calculate our Premium form (M28043_MO) to determine rate Application (complete in full) Sections A & B: Plan and Applicant Information Select plan Enter Requested Effective Date Indicate where the policy is to be mailed Section C: Medicare Information Include applicant s Medicare claim number on the application. This number is required for electronic claim processing. If this number is not available at time of application, the applicant/agent must provide this number by calling once it is received. If not already covered by Medicare, indicate eligibility and enrollment dates. Section D: Household Premium Discount Information Indicate if eligible for a Household Premium Discount Section E: Previous or Existing Coverage Information Please complete ALL questions in full For Sections F and G Refer to the Open Enrollment/Guaranteed Issue worksheet (M27788) to help identify eligibility. Section F: Please answer all of the following questions If either or B answered ES to question 6 OR BOTH questions 7 and 8 in Section F, they can skip to Section I Sections G & H: Health/Medication Information Do OT answer if applicant is in an open enrollment or guaranteed issue period Section I: Agreement and Authorization Make sure applicant(s) sign and date the application Section K: To be Completed by Producer Make sure producer(s) sign and date the application Complete the Method of Payment form (M27784_0314) and return with the completed application Use premium determined by the Calculate our Premium form (M28043_MO) The full modal premium is collected at the time of application Complete Replacement otice (M18362_0605) and leave a copy with the applicant (if applicable) Provide Applicant with Premium Receipt signed by agent (if applicable) (M27789) ote: An interviewer may call to verify/confirm the information provided on the application. This form is required if splitting commissions. MAP563_MO_0314 MAP563_MO_0314

19 Open Enrollment and Guaranteed Issue Worksheet If any of the following situations apply, applicant is in an open enrollment or guaranteed issue period: (Situations may vary by state and coverage may be limited. Please refer to the Underwriting Guide for more information.) ELIGIBILIT FOR OPE EROLLMET Applicant is: at least 64 ½ years of age (in most states) and within six months before or after his/her effective date for Medicare Part B, or covered under Medicare Part B prior to age 65 (eligible for a six-month open enrollment period upon reaching age 65) ote: Coverage cannot be effective until your Medicare coverage is effective. ELIGIBILIT FOR GUARATEED ISSUE Evidence of eligibility is required for the following situations. Applicant: is in the original Medicare plan, has an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays, and that coverage is ending is in the original Medicare plan, has a Medicare Select policy, and moves out of the Select plan s service area loses coverage due to their Medicare supplement insurance company s insolvency or at no fault of the applicant the applicant leaves their Medicare supplement plan because the company has not followed rules, or has misled the applicant Applicant has the right to buy Medicare supplement Plan A, B, C, F, K or L that is sold in the applicant s state by any insurance company. Applicant was enrolled in a Medicare Advantage (MA) plan, and: the plan is leaving the Medicare program or stops service in the applicant s area, or the applicant moves out of the plan s service area (applicant must switch back to original Medicare) the applicant leaves the plan because the company has not followed rules, or has misled the applicant Applicant has the right to buy Medicare supplement Plan A, B, C, F, K or L that is sold in the applicant s state by any insurance company. the applicant decided to switch to original Medicare within the first year of joining a MA plan when first eligible for Medicare Part A at age 65 Applicant has the right to buy any Medicare supplement plan that is sold in the applicant s state by any insurance company. after dropping their Medicare supplement policy to join a MA plan for the first time, has been on the MA plan less than one year and wants to switch back Applicant has the right to obtain their Medicare supplement policy back if that carrier still sells it or, if not available, buy any Medicare supplement Plan A, B, C, F, K or L that is sold in the applicant s state by any insurance company. Acceptable Evidence of Eligibility: a. Copy of the applicant s MA plan s termination notice b. Copy of the letter the applicant sent to his/her MA plan requesting disenrollment c. Signed statement that the applicant has requested to be disenrolled from his/her MA plan d. Certification of group coverage e. Copy of the termination letter from employer or group carrier f. Image of insurance ID card (OL allowed if your MA plan is being terminated) M27788 M27788

20 Mutual of Omaha Insurance Company Calculate our Premium PLEASE COMPLETE Medicare Supplement Insurance Plan Before you begin: Please go to the Height and Weight Chart on the next page to determine your eligibility for coverage, unless you are in an open enrollment or guaranteed issue period. Steps Example Rate displayed is used for calculation purposes only. #1 Age Write in your age at the time of signing the application. ZIP Code Indicate your ZIP Code used to determine your rate #2 Premium Write in your Med supp plan s premium from the Outline of Coverage provided, based on your age and ZIP Code listed in Step #1. $ #3 Household Premium Discount Do you currently reside with your spouse or domestic partner? $ x.88 = $ If yes, multiply the amount from Step #2 by.88. If no, enter the amount from Step #2. In this example, the person qualifies for the household premium discount. #4 Rate Adjustment If you re in your open enrollment or guaranteed issue period, skip to Step #5. $ x 1.20 = $ Locate your height, then weight on the next page. If your weight is in the Standard column, enter the amount from Step #3 If your weight is in the Class I or II column, multiply the amount from Step #3 by: 1.10 if in Class I column 1.20 if in Class II column Person s weight is in the Class II column. #5 Payment Options our monthly payment is your last premium entered (Step #3 or #4). To determine other payment schedules, multiply your monthly premium by: 3 to pay 4 times a year (quarterly) 6 to pay twice a year (semiannually) 12 to pay once a year (annually) $ monthly payment $ quarterly payment $ semiannual payment $1, annual payment M28043_MO M28043_MO

21 Height and Weight Chart Eligibility Find your height in the left-hand column and look across the row to find your weight. If your weight is in the Decline column, we re sorry, you re not eligible for coverage at this time. Rate Adjustment The column heading above your weight will indicate your appropriate rate adjustment, if any (risk class). Decline Class I (10%) Standard Class I (10%) Class II (20%) Decline Height Weight Weight Weight Weight Weight Weight 4' 2'' < ' 3'' < ' 4'' < ' 5'' < ' 6'' < ' 7'' < ' 8'' < ' 9'' < ' 10'' < ' 11'' < ' 0'' < ' 1'' < ' 2'' < ' 3'' < ' 4'' < ' 5'' < ' 6'' < ' 7'' < ' 8'' < ' 9'' < ' 10'' < ' 11'' < ' 0'' < ' 1'' < ' 2'' < ' 3'' < ' 4'' < ' 5'' < ' 6'' < ' 7'' < ' 8'' < ' 9'' < ' 10'' < ' 11'' < ' 0'' < ' 1'' < ' 2'' < ' 3'' < ' 4'' < Medicare supplement insurance is underwritten by Mutual of Omaha Insurance Company Mutual of Omaha Plaza Omaha, ebraska mutualofomaha.com M28043_MO M28043_MO

22 FAV Key Auth # Agent Writing # Group # (if applicable) Keyline Mutual of Omaha Insurance Company Application for Medicare Supplement Coverage Applicant acknowledges and agrees that if there is more than one applicant on this application, all information provided may be viewed or shared with the other applicant. A. Plan Information (to be completed by Producer) Plan (select one) Plan A Plan F Plan G Plan (select one) Plan A Plan F Plan G Requested Effective Date / / Requested Effective Date / / Deliver Policy to Producer B. Applicant Information ame (First/Middle/Last) Residence Address City Deliver Policy to Producer ame (First/Middle/Last) Residence Address (if different from s) City State ZIP State ZIP Mailing Address (if different from residence address) City Mailing Address (if different from residence address) City State ZIP State ZIP Home Phone (area code) Address Current Age Home Phone (area code) Address Current Age Date of Birth / / Date of Birth / / mo day yr mo day yr MA Male Social Security # Height Female Weight Ft In Lbs Male Female Social Security # Height Weight Ft In Lbs MA Mutual of Omaha Insurance Company P.O. Box 3608 Omaha, ebraska

23 B. Applicant Information (continued) Have you used tobacco in any form in the past 12 months?... Have you used tobacco in any form in the past 12 months?... Go paperless! To receive your Explanation of Benefits (EOBs) online, select ES below and provide your current address in Section B. If you subscribe, you will not receive paper EOBs, but instead, will receive an notification when new EOBs become available with a link to access each specific EOB. We will continue to mail EOBs if you are entitled to receive any monetary reimbursement from Mutual of Omaha. Receive statement online?... Receive statement online?... C. Medicare Information Please reference your Medicare card to complete this section. Medicare Claim umber Medicare Part A Effective Date / / If you are not covered under Medicare Part A, what is your eligibility date / / Medicare Claim umber Medicare Part A Effective Date / / If you are not covered under Medicare Part A, what is your eligibility date / / Medicare Part B Effective Date / / If you are not covered under Medicare Part B, indicate the date you plan to enroll / / Medicare Part B Effective Date / / If you are not covered under Medicare Part B, indicate the date you plan to enroll / / D. Household Premium Discount Information ou may be eligible for a policy with a lower premium rate based on your answers to the statements in this section. 1. Do you currently reside with your spouse or domestic partner?... MA MA Mutual of Omaha Insurance Company P.O. Box 3608 Omaha, ebraska

24 E. Previous or Existing Coverage Information If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplement insurance policy or certificate, or that you had certain rights to buy such a policy or certificate, you may be guaranteed acceptance in one or more of our Medicare supplement plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ASWER ALL QUESTIOS. Please mark ES or O with an X to the questions below. To the Best of our Knowledge and Belief: 2. Are you covered for medical assistance through the state Medicaid program?... (OTE TO APPLICAT: If you are participating in a Spend-Down Program and have not met your Share of Cost, please answer O to this question.) If ES, answer the following about this existing coverage: (a) Will Medicaid pay your premiums for this Medicare supplement policy?... (b) Do you receive any benefits from Medicaid OTHER THA payments toward your Medicare Part B premium?... Please answer questions regarding another Medicare supplement or Select plan: 3. Do you have another Medicare supplement or Medicare Select insurance policy or certificate in force?... If ES, answer the following about this existing coverage: (a) Do you intend to replace your current Medicare supplement policy/certificate with this policy?... (b) Indicate planned termination or disenrollment date... / / (c) With what company, and what plan do you have? / / ame of Company ame of Company Plan Plan Effective Date Effective Date Please answer questions regarding Medicare plan coverage (other than Medicare supplement): 4. Have you had coverage from any Medicare plan other than Medicare Part A or B within the past 63 days? (for example, a Medicare Advantage plan, or a Medicare HMO or PPO)... If ES, answer the following about this previous or existing coverage: (a) Fill in your start and end dates below. If you are still covered under this plan, leave ED blank... START / / ED / / START / / ED / / (b) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplement policy?... (c) Planned date of termination/disenrollment?... / / / / MA (d) Was this your first time in this type of Medicare plan?... (e) Did you drop a Medicare supplement or Medicare Select policy/certificate to enroll in this Medicare plan?... (f) Is your former Medicare Supplement or Medicare Select policy/certificate still available? MA Mutual of Omaha Insurance Company P.O. Box 3608 Omaha, ebraska

25 (g) Please indicate reason for termination/disenrollment: our Medicare Advantage plan is leaving the Medicare program... our Medicare Advantage organization stopped offering Medicare Advantage plans... our Medicare Advantage organization stopped offering coverage in the area in which you live... ou moved out of the geographic service area of your Medicare Advantage plan... ou had a Medicare Advantage plan with Medicare Part D benefits and are enrolling in a stand-alone Medicare Part D plan... Other: Please answer questions regarding other health insurance: Check box(s) below if applicable 5. Have you had coverage under any other health insurance within the past 63 days?... (For example, an employer group health plan, union plan, or individual non-medicare supplement plan.) If ES, answer the following about this previous or existing coverage: (a) What are your dates of coverage under the other policy/certificate? If you are still covered under this plan, leave ED blank... START / / ED / / START / / ED / / (b) Planned date of termination/disenrollment?... / / / / (c) Have you disenrolled from your current coverage voluntarily?... (d) Please state the reason for your disenrollment: (e) With what company and what kind of policy/certificate? (List below.) ame of Company Policy/Certificate type ame of Company Policy/Certificate type F. Please answer all of the following questions: To the Best of our Knowledge and Belief: 6. Are you applying during a guaranteed issue period?... (OTE: Refer to the guaranteed issue worksheet to help identify if you are eligible. If the answer above is ES, attach proof of eligibility.) 7. Did you turn age 65 in the last six months? Did you enroll in Medicare Part B in the last six months?... MA If ES, indicate your effective date... / / _ / / IF EITHER OU OR APPLICAT B ASWERED ES TO QUESTIO 6, 7 OR 8 I SECTIO F, SKIP SECTIOS G & H AD GO TO SECTIO I. MA Mutual of Omaha Insurance Company P.O. Box 3608 Omaha, ebraska

26 MA If you are applying during an open enrollment or guaranteed issue period: SKIP SECTIOS G & H and GO TO SECTIO I. G. Health Information For all plans, answer questions (If ES is answered to any of the following questions 9-18, that person is not eligible for coverage.) To the Best of our Knowledge and Belief: 9. Are you currently confined to a wheelchair or any motorized mobility device? Are you currently hospitalized, confined to a bed, in a nursing home or assisted living facility? Are you currently receiving any occupational or physical therapy? Have you been advised by a medical professional to have treatment, further diagnostic evaluation, diagnostic testing or any surgery that has not been performed? At any time have you been medically diagnosed with, treated for, or had surgery for any of the following: A. Chronic kidney disease, kidney failure, or kidney disease requiring dialysis?... B. Emphysema, Chronic Obstructive Pulmonary Disease (COPD), any other chronic pulmonary disorder or any cardio-pulmonary disorder requiring oxygen?... C. Alzheimer s Disease, dementia or any other cognitive disorder?... D. Parkinson s Disease, Multiple Sclerosis or Amyotrophic Lateral Sclerosis (Lou Gehrig s Disease)?... E. Systemic Lupus or Myasthenia Gravis?... F. Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?... G. An organ transplant or been advised to have an organ transplant (excluding cornea transplants)?... H. Chronic hepatitis or cirrhosis?... I. Osteoporosis with fractures? Do you have diabetes with complications including retinopathy, neuropathy, peripheral vascular disease, any related heart disorder (Including hypertension/high blood pressure) or kidney disease? Do you have an implanted cardiac defibrillator? Within the past two years, have you been treated for, or been advised by a physician to have treatment for: A. Coronary artery disease, angina, heart attack, cardiac angioplasty, bypass surgery or stent placement?... B. Cardiomyopathy, Congestive Heart Failure, aortic or cardiac aneurysm, peripheral vascular disease, vascular angioplasty, endarterectomy, carotid artery disease, heart or heart valve disorder, atrial fibrillation, other heart rhythm disorder, or implantation of a pacemaker?... C. Alcoholism or drug abuse?... D. Any mental or nervous disorder requiring treatment (including hospital confinement) by a psychiatrist, psychologist, counselor or therapist?... E. Internal cancer, lymphoma or melanoma?... F. A stroke or transient ischemic attack (TIA)?... G. Degenerative bone disease, spinal stenosis, rheumatoid arthritis, psoriatic arthritis, arthritis that restricts mobility or have you been advised to have a joint replacement? Have you been advised by a medical professional that surgery may be required within the next 12 months for cataracts? Have you been hospital confined three or more times in the past two years for a same or similar condition? Have you taken any prescription drugs in the past 24 months?... (If ES, please complete the Medication Information sheet on the next page) MA Mutual of Omaha Insurance Company P.O. Box 3608 Omaha, ebraska