Assured Life Association

Transcription

1 Assured Life Association A Fraternal Benefit Society P.O. Box 2397 Omaha, ebraska T01_310_OH 09/14/2011

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3 2011 Medicare Supplement Insurance Plans on your team ou can rely on an Assured Life Association Medicare supplement plan to help you protect your savings from ever-rising health care expenses. Each plan can help pay your Medicare Parts A and B charges Medicare doesn t cover. What s more, you have: Seven plans from which to select the coverage that best meets your needs for your personalized care facility Put an Assured Life Association plan on your team, today. T01_206_OH_0111 Ohio Certificate Forms MTA20-Plan A, MTA21-Plan B, MTA22-Plan C, MTA23-Plan D, MTA24-Plan F, MTA25-Plan G, MTA31-Plan

4 SUPPLEMET our Medicare Coverage our Assured Life Association Medicare supplement insurance certificate helps pay some eligible expenses not paid for by Medicare Part A and Medicare Part B. There may be charges above what Medicare and your certificate pay. Medicare Part A Hospital Coverage Deductible Plans B, C, D, F, G and pay the $1,132 inpatient hospital deductible for each benefit period. First 60 Days After the Medicare Part A deductible, Medicare pays all eligible expenses for services from your first through 60th day of hospital confinement. Services include semiprivate room and board, general nursing, and miscellaneous hospital services and supplies. Coinsurance Plans A, B, C, D, F, G and pay $283 a day when you are hospitalized from the 61st through the 90th day. And, when you are in the hospital from the 91st day through the 150th day, you receive $566 a day for each Lifetime Reserve day used. Extended Hospital Coverage When you are in the hospital longer than 150 days during a benefit period, and you have exhausted your 60 days of Medicare Lifetime Reserve, Plans A, B, C, D, F, G and 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 Medicare has one calendar-year deductible for blood that is the cost of the first three pints needed. Plans A, B, C, D, F, G and pay this deductible. Skilled ursing Facility Care First 20 Days Medicare pays all eligible expenses. Coinsurance Plans C, D, F, G and pay up to $ a day from the 21st through the 100th day during which you receive skilled nursing care. ou must enter a Medicare-certified skilled nursing facility within 30 days of being hospitalized for at least three days. Hospice Care Benefit Outpatient Prescription Drugs Plans A, B, C, D, F, G and pay $5 per prescription for outpatient prescription drugs for pain and symptom management. Inpatient Respite Care Plans A, B, C, D, F, G and 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 Physician s Services & Supplies Deductible Plans C and F pay the $162 calendar-year deductible. Coinsurance After the Medicare Part B deductible, Plans A, B, C, D, F, G and pay generally 20% of eligible expenses for physician s services and supplies, physical and speech therapy, and ambulance service. With Plan, you pay up to a $20 copayment for an office visit and up to a $50 copayment for an emergency room visit. For hospital outpatient services, the copayment amount will be paid under a prospective payment system. If this system is not used, then generally 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. Ohio health care providers are prohibited from balance billing Medicare beneficiaries so this benefit applies when you receive services outside of Ohio or services from Ohio providers that are allowed to balance bill. Benefit for Blood Medicare has one calendar-year deductible for blood that is the cost of the first three pints needed. Plans A, B, C, D, F, G and pay this deductible.

5 Additional Benefit Emergency Care Received Outside the U.S. After you pay a $250 calendar-year deductible, Plans C, D, F, G and pay you generally 80% of eligible expenses for care beginning during the first 60 days of each trip up to a lifetime maximum of $50,000. Benefits are payable for health care you need because of a covered injury or illness. Plan Highlights our certificate is guaranteed renewable. It cannot be canceled. It will be renewed as long as the premiums are paid on time and the information on your application is correct. our Medicare supplement 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 or to your hospital or doctor. ou have 31 days from your renewal date to pay your premium. our certificate will stay in force during this 31-day grace period. ou cannot be singled out for a rate increase, no matter how many times you receive benefits. our premium changes: (a) each year on the renewal date coinciding with or following the anniversary of your Certificate Date until you reach age 99; and (b) when the same premium change is made on all in-force Medicare supplement certificates of the same form issued to persons of your classification in the same geographic area of your state. our coverage begins immediately. There is no waiting period for preexisting conditions. Benefits will be paid from the time your certificate is in force. Definitions Medicare Part A eligible expenses for hospital/skilled nursing facility care include expenses for semiprivate room and board, general nursing and miscellaneous services and supplies. Medicare Part B eligible expenses for medical services include expenses for physicians services, hospital outpatient services and supplies, physical and speech therapy and ambulance service. Medicare eligible expenses are expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare. A benefit period begins the first full day you are hospitalized and ends when you have not been in a hospital or skilled nursing facility for 60 days in a row. Coinsurance is the portion of the eligible expense not paid by Medicare and paid by Assured Life Association. A preexisting condition is a condition for which medical advice or treatment was recommended by or received from a health care services provider within six months before the insured s coverage effective date. Exclusions and Limitations our Medicare supplement insurance certificate will not pay for: any expense incurred before your Certificate Date hospital or skilled nursing facility confinement incurred during a Medicare Part A benefit period that begins while this certificate 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

6 M our Plan Choices Whether you need a little or a lot of coverage, we have a Medicare supplement that meets your needs and budget. Please refer to the previous pages and your outline of coverage for details. Every plan includes these basic benefits: benefits end Plan A Plan B Plan C Plan D Plan requires up to a $20 copayment for an office visit and up to a $50 copayment for an emergency room visit. This is a brief description of your coverage. The outline of coverage must accompany this brochure. For complete information on benefits, exceptions, reductions and limitations, please read your outline of coverage and your certificate. This is a solicitation of insurance and an agent will contact you by telephone. Plan F Plan G Basic Benefits Skilled ursing Coinsurance Medicare Part A Deductible Medicare Part B Deductible either Assured Life Association nor its Medicare supplement insurance certificates are connected with or endorsed by the U.S. government or the federal Medicare program. Plan Assured Life Association is a fraternal benefit society that exists solely for the well being of its members and their beneficiaries. The certificateholders are the company. Our Fraternal Program is built on a foundation of community service and volunteerism that offers all members opportunities to make friends, become involved in their community and make connections that will truly last a lifetime. To learn more about what we re doing to make lives better and how you can be involved, please visit us on the Web. Medicare supplement insurance is underwritten by: A Fraternal Benefit Society Insuring Life, Ensuring Quality of Life T01_206_OH_0111_BW

7 ASSURED LIFE ASSOCIATIO A Legal Reserve Fraternal Benefit Society OUTLIE OF MEDICARE SUPPLEMET COVERAGE COVER PAGE BEEFIT PLAS A, B, C, D, F, G, AD These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan A. Some plans may not be available in your state. See Outlines 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 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. A B C D F F* G K L M Basic, including 100% Part B co-insurance 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 $4,640; 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 $2,320; 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 $2,000 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,000. 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 plans' separate foreign travel emergency deductible. CP24 1 T01_156_OH_1011

8 MOTHL O-TOBACCO RATES ZIP CODES: , , FEMALE MALE Attained Age Plan A Plan B Plan C Plan D Plan F Plan G Plan Plan A Plan B Plan C Plan D Plan F Plan G Plan MTA20 MTA21 MTA22 MTA23 MTA24 MTA25 MTA31 MTA20 MTA21 MTA22 MTA23 MTA24 MTA25 MTA To obtain annual, semiannual and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. RP24.1.T01 2 T01_156_OH_1011

9 MOTHL TOBACCO RATES ZIP CODES: , , FEMALE MALE Attained Age Plan A Plan B Plan C Plan D Plan F Plan G Plan Plan A Plan B Plan C Plan D Plan F Plan G Plan MTA20 MTA21 MTA22 MTA23 MTA24 MTA25 MTA31 MTA20 MTA21 MTA22 MTA23 MTA24 MTA25 MTA To obtain annual, semiannual and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. RP24.1.T01 3 T01_156_OH_1011

10 MOTHL O-TOBACCO RATES ZIP CODES: 436, 440, FEMALE MALE Plan A Plan B Plan C Plan D Plan F Plan G Plan Attained Plan A Plan B Plan C Plan D Plan F Plan G Plan MTA20 MTA21 MTA22 MTA23 MTA24 MTA25 MTA31 Age MTA20 MTA21 MTA22 MTA23 MTA24 MTA25 MTA To obtain annual, semiannual and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. RP24.1.T01 4 T01_156_OH_1011

11 MOTHL TOBACCO RATES ZIP CODES: 436, 440, FEMALE MALE Plan A Plan B Plan C Plan D Plan F Plan G Plan Plan A Plan B Plan C Plan D Plan F Plan G Plan Attained Age MTA20 MTA21 MTA22 MTA23 MTA24 MTA25 MTA31 MTA20 MTA21 MTA22 MTA23 MTA24 MTA25 MTA To obtain annual, semiannual and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. RP24.1.T01 5 T01_156_OH_1011

12 MOTHL O-TOBACCO RATES ZIP CODES: 439, 441, FEMALE MALE Plan A Plan B Plan C Plan D Plan F Plan G Plan Attained Plan A Plan B Plan C Plan D Plan F Plan G Plan MTA20 MTA21 MTA22 MTA23 MTA24 MTA25 MTA31 Age MTA20 MTA21 MTA22 MTA23 MTA24 MTA25 MTA To obtain annual, semiannual and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. RP24.1.T01 6 T01_156_OH_1011

13 MOTHL TOBACCO RATES ZIP CODES: 439, 441, FEMALE MALE Plan A Plan B Plan C Plan D Plan F Plan G Plan Attained Plan A Plan B Plan C Plan D Plan F Plan G Plan MTA20 MTA21 MTA22 MTA23 MTA24 MTA25 MTA31 Age MTA20 MTA21 MTA22 MTA23 MTA24 MTA25 MTA To obtain annual, semiannual and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. RP24.1.T01 7 T01_156_OH_1011

14 Disclosures Use this outline to compare benefits and premiums among certificates or policies. Premium Information We, Assured Life Association, can only raise your premium if we raise the premium for all the certificates like yours in the same geographic area of the state where you live. Until you are age 99, your premium may change each year. This change will only be made on the first renewal date that coincides with or follows each anniversary of the certificate date. Schedules of rates may vary depending upon your certificate date. There will be a one-time enrollment fee of $25.00 added to the first premium. Premiums do not include dues. Read our Certificate Very Carefully This is only an outline describing your certificate's most important features. The certificate is your insurance contract. ou must read the certificate itself to understand all of the rights and duties of both you and your insurance company. DP1.T01 Right to Return Certificate If you find that you are not satisfied with your certificate, you may return it to Assured Life Association at our administrative office, 3316 Farnam Street, Omaha, E If you send the certificate back to us within 30 days after you receive it, we will treat the certificate as if it had never been issued and return all of your payments. Certificate Replacement If you are replacing another health insurance certificate, do OT cancel it until you have actually received your new certificate and are sure you want to keep it. otice The certificate may not fully cover all of your medical costs. either Assured Life Association 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 & ou" for more details. Complete Answers Are Very Important When you fill out the application for the new certificate, be sure to answer truthfully and completely all questions about your medical and health history. The Company may cancel your certificate 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. 8 T01_156_OH_1011

15 PLAS A AD B 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 Plan B Pays ou Pay HOSPITALIZATIO* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,132 $0 $1,132 (Part A $1,132 (Part A 61 st through 90 th day All but $283 a day $283 a day $0 $283 a day $0 91 st day and after: While using 60 lifetime reserve days All but $566 a day $566 a day $0 $566 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses $0** 100% of Medicare Eligible 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 $ a day $0 Up to $ a BLOOD day 101 st day and after $0 $0 All costs $0 All costs $0 $0** $0 Up to $ a day 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/coinsuran ce for outpatient drugs and inpatient respite care **OTICE: 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/certificate's "Core Benefits." Medicare copayment/ coinsurance $0 Medicare copayment/ coinsurance 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 BC24 9 T01_156_OH_1011

16 PLAS A AD B MEDICARE (PART B) - MEDICAL SERVICES - PER CALEDAR EAR *Once you have been billed $162 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 Plan B 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 $162 of Medicare Approved Amounts* $0 $0 $162 (Part B $0 $162 (Part B Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 Generally 20% $0 Part B Excess Charges (above Medicare Approved Amounts) $0 $0 All costs $0 All costs BLOOD First 3 pints $0 All costs $0 All costs $0 ext $162 of Medicare Approved Amounts* $0 $0 $162 (Part B $0 $162 (Part B 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 $162 of Medicare Approved Amounts* $0 $0 $162 (Part B $0 $162 (Part B Remainder of Medicare Approved Amounts 80% 20% $0 20% $0 BC24 10 T01_156_OH_1011

17 PLAS C AD D 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 C Pays ou Pay Plan D Pays ou Pay HOSPITALIZATIO* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,132 $1,132 (Part A $0 $1,132 (Part A 61 st through 90 th day All but $283 a day $283 a day $0 $283 a day $0 91 st day and after: While using 60 lifetime reserve days All but $566 a day $566 a day $0 $566 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses $0** 100% of Medicare Eligible 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 $ a day Up to $ a day $0 Up to $ 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/coinsuran ce for outpatient drugs and inpatient respite care **OTICE: 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/certificate's "Core Benefits." Medicare copayment/ coinsurance $0 Medicare copayment/ coinsurance $0 $0** 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 BC24 11 T01_156_OH_1011

18 PLAS C AD D MEDICARE (PART B) - MEDICAL SERVICES - PER CALEDAR EAR *Once you have been billed $162 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 C Pays ou Pay Plan D 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 $162 of Medicare Approved Amounts* $0 $162 (Part B $0 $0 $162 (Part B Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 Generally 20% $0 Part B Excess Charges (above Medicare Approved Amounts) $0 $0 All costs $0 All costs BLOOD First 3 pints $0 All costs $0 All costs $0 ext $162 of Medicare Approved Amounts* $0 $162 (Part B $0 $0 $162 (Part B 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 $162 of Medicare Approved Amounts* $0 $162 (Part B $0 $0 $162 (Part B Remainder of Medicare Approved Amounts 80% 20% $0 20% $0 BC24 12 T01_156_OH_1011

19 PLAS C AD D MEDICARE (PART B) - MEDICAL SERVICES - PER CALEDAR EAR OTHER BEEFITS OT COVERED B MEDICARE Services Medicare Pays Plan C Pays ou Pay Plan D 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 BC24 13 T01_156_OH_1011

20 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 $1,132 $1,132 (Part A $0 $1,132 (Part A 61 st through 90 th day All but $283 a day $283 a day $0 $283 a day $0 91 st day and after: While using 60 lifetime reserve days All but $566 a day $566 a day $0 $566 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses $0** 100% of Medicare Eligible 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 $ a day Up to $ a day $0 Up to $ 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/coinsuran ce for outpatient drugs and inpatient respite care **OTICE: 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/certificate's "Core Benefits." Medicare copayment/ coinsurance $0 Medicare copayment/ coinsurance $0 $0** 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 BC24 14 T01_156_OH_1011

21 PLAS F AD G MEDICARE (PART B) - MEDICAL SERVICES - PER CALEDAR EAR *Once you have been billed $162 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 $162 of Medicare Approved Amounts* $0 $162 (Part B $0 $0 $162 (Part B 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 $162 of Medicare Approved Amounts* $0 $162 (Part B $0 $0 $162 (Part B 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 $162 of Medicare Approved Amounts* $0 $162 (Part B $0 $0 $162 (Part B Remainder of Medicare Approved Amounts 80% 20% $0 20% $0 BC24 15 T01_156_OH_1011

22 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 BC24 16 T01_156_OH_1011

23 PLA 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 Pays ou Pay HOSPITALIZATIO* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,132 $1,132 (Part A 61 st through 90 th day All but $283 a day $283 a day $0 91 st day and after: While using 60 lifetime reserve days All but $566 a day $566 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare $0** Eligible 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 $ a day Up to $ a day $0 101 st day and after $0 $0 All costs BLOOD 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. **OTICE: 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/certificate's "Core Benefits." All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/coinsurance 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 BC24 17 T01_156_OH_1011

24 PLA MEDICARE (PART B) - MEDICAL SERVICES - PER CALEDAR EAR *Once you have been billed $162 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 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 $162 of Medicare Approved Amounts* $0 $0 $162 (Part B 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 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 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. First 3 pints $0 All costs $0 ext $162 of Medicare Approved Amounts* $0 $0 $162 (Part B 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 $162 of Medicare Approved Amounts* $0 $0 $162 (Part B Remainder of Medicare Approved Amounts 80% 20% $0 BC24 18 T01_156_OH_1011

25 PLA MEDICARE (PART B) - MEDICAL SERVICES - PER CALEDAR EAR OTHER BEEFITS OT COVERED B MEDICARE Services Medicare Pays Plan 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 Remainder of charges $0 80% to a lifetime Maximum 20% and amounts over the Benefit of $50,000 $50,000 lifetime Maximum Benefit BC24 19 T01_156_OH_1011

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27 Ohio Producer Information Please Complete Producer ame Agent Writing umber Commission Share Commission Code- Required only if or Social Security umber you are not appointed or licensed or are changing brokerage firms % % ote: Producers must be under the same commission code to share or split commissions. Application Submission Checklist Assured Life Association Medicare Supplement/ Select 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 Guarantee Issue situations. Complete the Calculate our Premium form (T01_360) to determine rate Application (complete in full) Sections A & B: Plan and Applicant Information Select plan Enter Requested Effective Date Indicate where the certificate 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: Previous or Existing Coverage Information Please complete ALL questions in full For Sections E and F Refer to the Open Enrollment/Guaranteed Issue worksheet (T00_631) to help identify eligibility. Section E: Please answer all of the following questions If either Applicant A or B answered ES to question 5 OR BOTH questions 6 and 7 in Section E, they can skip to Section H Sections F & G: Health/Medication Information Do OT answer if applicant is in an open enrollment or guaranteed issue period Section H: Agreement and Authorization Make sure applicant(s) sign and date the application Section J: To be Completed by Producer Make sure producer(s) sign and date the application Complete the Method of Payment form (T01_629) and return with the completed application Use premium determined by the Calculate our Premium form (T01_360) The full modal premium is collected at the time of application Complete Replacement otice (T01_49_OH) and leave a copy with the applicant (if applicable) Provide Applicant with Premium Receipt signed by agent (if applicable), and provide Applicant with otice of Information Practices (T01_628) Complete Medicare Select Certificate Disclosure Agreement (T01_31) (if applicable) Complete the Solicitation and Sale Disclosure (T01_613_OH) and leave with Applicant ote: An interviewer may call to verify/confirm the information provided on the application. This form is required if splitting commissions. T01_354_OH_0611 T01_354_OH_0611

28 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/certificate, 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/certificate 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/certificate 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) T00_631 T00_631

29 Assured Life Association A Fraternal Benefit Society Calculate our Premium PLEASE COMPLETE Medicare Supplement Insurance Plan Applicant A Applicant B 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. Applicant A Applicant B #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 Fraternal Membership Dues There will be $1.00 per month added to your initial and renewal premiums as membership dues. $ $1.00 = $ monthly payment #4 Payment Options To determine other payment schedules, multiply your monthly premium (including the $1.00 monthly Fraternal Membership Dues) 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 #5 Enrollment/Policy Fee There is a one-time application fee of $ This will be collected with your initial payment and will OT affect your renewal premiums amount. $ $25.00 = $ Example shows initial payment (monthly schedule). T01_360 T01_360

30 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. Decline Standard Decline Height 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 Assured Life Association Administrative Office P.O. Box 2397 Omaha, ebraska T01_360 T01_360

31 Agent Writing # FAV Key Assured Life Association A Fraternal Benefit Society 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) Applicant A Applicant B Plan (select one) Plan A Plan B Plan C Plan D Plan F Plan G Plan Select Plan B Select Plan C Select Plan D Select Plan F Select Plan G Plan (select one) Plan A Plan B Plan C Plan D Plan F Plan G Plan Select Plan B Select Plan C Select Plan D Select Plan F Select Plan G Requested Effective Date / / Requested Effective Date / / Deliver Certificate to Deliver Certificate to Applicant B Producer B. Applicant Information Applicant A Applicant B Producer Applicant B ame (First/Middle/Last) ame (First/Middle/Last) Residence Address Residence Address City 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 Home Phone (area code) Address Current Age Current Age T Date of Birth Male / / mo day yr Female Social Security # Date of Birth Male / / mo day yr Female Social Security # T Assured Life Association Administrative Office P.O. Box 2397 Omaha, ebraska

32 B. Applicant Information (continued) Applicant A Height Weight Ft In Lbs Have you used tobacco in any form in the past 12 months?... Applicant B Height Weight Ft In Lbs Have you used tobacco in any form in the past 12 months?... C. Medicare Information Please reference your Medicare card to complete this section. Applicant A 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 Applicant B 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 / / T T Assured Life Association Administrative Office P.O. Box 2397 Omaha, ebraska