American Continental Application Packet

Transcription

1 American Continental Application Packet Thank you for your interest in applying for the American Continental/Aetna Medicare Supplement plan! This application packet provides you with access to a printable copy of the Enrollment Form and the Outline of Coverage in addition to a link to the Choosing a Medigap Policy Guide. Should you decide to apply by secure upload/mail/fax/ , the printable application needs to be reviewed and signed by an Agent before it can be submitted to Aetna. You may upload, , fax or mail it in to CDA Insurance: Fax: cs@cda-insurance.com Secure File Upload: Click here Mail: CDA Insurance LLC PO Box Eugene, Oregon Other Important Information Download Medicare s Choosing a Medigap Policy Guide (.pdf) Download Policy Outline (.pdf) Download Application (.pdf) Our website: If you should have any questions on the application, please call us at or

2 1 AMERICAN CONTINENTAL INSURANCE COMPANY OUTLINE OF SUPPLEMENT COVERAGE COVER PAGE: Page 1 of 2 BENEFIT S AVAILABLE: A, B, F, HIGH DEDUCTIBLE F, G, N 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. Basic Benefits: Hospitalization: Part A plus coverage for 365 additional days after Medicare benefits end. Medical Expenses: Part B (generally 20% of Medicare-Approved expenses) or, copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of or copayments Blood: First three pints of blood each year. Hospice: Part A A B C D F/F* G K L M N Basic, including 100% Part B Basic, including 100% Part B Part A Deductible Basic, including 100% Part B Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Coinsurance Part A Deductible Part B Excess (100%) Foreign Travel Emergency Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility Coinsurance 50% Part A Deductible Out-of-pocket limit $5,120; paid at 100% after limit reached Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% 75% Skilled Nursing Facility Coinsurance 75% Part A Deductible Out-of-pocket limit $2,560; paid at 100% after limit reached Basic, including 100% Part B Skilled Nursing Facility Coinsurance 50% Part A Deductible Foreign Travel Emergency Basic, including 100% Part B, except up to $20 copayment for office visit, and up to $50 copayment for ER 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 $2,200 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2,200. 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.

3 American Continental Insurance Company Annual Attained Age Premiums For Use in ZIP Codes: 889, 891 Female Rates Rates Effective 6/1/2017 Attained Preferred Attained Standard Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N 65 1,691 2,132 2, ,672 1, ,879 2,369 2,826 1,080 1,855 1, ,691 2,132 2, ,672 1, ,879 2,369 2,826 1,080 1,855 1, ,691 2,132 2, ,672 1, ,879 2,369 2,826 1,080 1,855 1, ,763 2,219 2,651 1,013 1,740 1, ,958 2,466 2,942 1,124 1,933 1, ,841 2,321 2,750 1,054 1,818 1, ,045 2,578 3,060 1,172 2,020 1, ,914 2,412 2,854 1,091 1,890 1, ,126 2,680 3,172 1,213 2,102 1, ,990 2,503 2,951 1,129 1,963 1, ,208 2,783 3,281 1,256 2,183 1, ,053 2,590 3,044 1,164 2,033 1, ,285 2,880 3,383 1,295 2,258 1, ,119 2,672 3,128 1,198 2,095 1, ,354 2,969 3,474 1,330 2,328 2, ,184 2,750 3,208 1,228 2,154 1, ,425 3,054 3,564 1,366 2,396 2, ,237 2,819 3,281 1,256 2,209 1, ,485 3,134 3,646 1,396 2,456 2, ,291 2,885 3,346 1,282 2,262 1, ,544 3,204 3,713 1,422 2,512 2, ,338 2,942 3,402 1,302 2,310 1, ,599 3,272 3,780 1,446 2,567 2, ,381 3,001 3,455 1,324 2,354 2, ,647 3,336 3,838 1,470 2,617 2, ,425 3,054 3,503 1,340 2,396 2, ,695 3,395 3,889 1,489 2,662 2, ,464 3,103 3,547 1,358 2,434 2, ,737 3,450 3,940 1,508 2,704 2, ,498 3,148 3,593 1,375 2,470 2, ,778 3,498 3,992 1,526 2,743 2, ,531 3,191 3,641 1,394 2,502 2, ,813 3,546 4,042 1,548 2,782 2, ,567 3,232 3,682 1,410 2,534 2, ,850 3,593 4,091 1,565 2,818 2, ,598 3,270 3,726 1,426 2,566 2, ,887 3,636 4,140 1,583 2,851 2, ,628 3,310 3,767 1,441 2,597 2, ,918 3,678 4,186 1,601 2,885 2, ,657 3,348 3,805 1,457 2,626 2, ,952 3,720 4,228 1,620 2,917 2, ,684 3,384 3,846 1,471 2,653 2, ,986 3,757 4,271 1,633 2,948 2, ,712 3,418 3,881 1,486 2,680 2, ,013 3,796 4,308 1,648 2,977 2, ,737 3,450 3,912 1,495 2,704 2, ,042 3,830 4,346 1,664 3,005 2, ,761 3,478 3,946 1,511 2,729 2, ,070 3,868 4,382 1,676 3,032 2, ,784 3,510 3,976 1,522 2,752 2, ,094 3,898 4,414 1,691 3,058 2, ,806 3,536 4,000 1,530 2,772 2, ,116 3,928 4,447 1,702 3,079 2, ,822 3,560 4,027 1,543 2,791 2, ,139 3,956 4,475 1,712 3,102 2, ,846 3,583 4,045 1,548 2,810 2, ,158 3,980 4,499 1,723 3,122 2, ,861 3,602 4,069 1,558 2,826 2, ,180 4,007 4,519 1,730 3,139 2, ,879 3,625 4,088 1,565 2,842 2, ,194 4,028 4,544 1,739 3,157 2, ,894 3,646 4,114 1,574 2,861 2, ,217 4,052 4,566 1,747 3,176 2, ,908 3,667 4,132 1,582 2,876 2, ,234 4,075 4,594 1,758 3,194 2, ,930 3,690 4,151 1,589 2,894 2, ,254 4,103 4,614 1,766 3,215 2,761 Modal Factors: Semi-Annual: Quarterly: Monthly: The above rates do not include the $20 application fee. To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x.95 = discounted premium If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates. 2

4 American Continental Insurance Company Annual Attained Age Premiums For Use in ZIP Codes: 889, 891 Male Rates Rates Effective 6/1/2017 Attained Preferred Attained Standard Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N 65 1,944 2,449 2,927 1,120 1,921 1, ,160 2,720 3,250 1,243 2,132 1, ,944 2,449 2,927 1,120 1,921 1, ,160 2,720 3,250 1,243 2,132 1, ,944 2,449 2,927 1,120 1,921 1, ,160 2,720 3,250 1,243 2,132 1, ,026 2,554 3,044 1,164 2,002 1, ,251 2,837 3,384 1,295 2,224 1, ,117 2,668 3,166 1,212 2,092 1, ,350 2,963 3,516 1,344 2,324 1, ,200 2,772 3,282 1,258 2,176 1, ,446 3,083 3,646 1,396 2,418 2, ,286 2,880 3,396 1,301 2,258 1, ,540 3,198 3,773 1,442 2,509 2, ,365 2,980 3,503 1,340 2,334 2, ,628 3,310 3,889 1,489 2,594 2, ,438 3,072 3,595 1,375 2,410 2, ,711 3,415 3,995 1,528 2,677 2, ,509 3,163 3,691 1,412 2,479 2, ,786 3,512 4,098 1,571 2,754 2, ,573 3,240 3,773 1,442 2,543 2, ,858 3,601 4,192 1,606 2,825 2, ,632 3,316 3,846 1,471 2,600 2, ,923 3,683 4,272 1,634 2,890 2, ,686 3,388 3,912 1,495 2,657 2, ,988 3,767 4,346 1,664 2,951 2, ,741 3,454 3,974 1,522 2,707 2, ,043 3,834 4,412 1,690 3,008 2, ,786 3,512 4,030 1,543 2,754 2, ,098 3,904 4,477 1,712 3,060 2, ,834 3,569 4,081 1,561 2,798 2, ,148 3,965 4,534 1,734 3,110 2, ,872 3,622 4,132 1,582 2,840 2, ,192 4,024 4,595 1,758 3,155 2, ,912 3,670 4,186 1,601 2,876 2, ,235 4,076 4,649 1,781 3,197 2, ,951 3,719 4,236 1,621 2,914 2, ,277 4,128 4,708 1,800 3,240 2, ,987 3,760 4,283 1,640 2,951 2, ,317 4,180 4,760 1,823 3,280 2, ,019 3,806 4,332 1,660 2,986 2, ,359 4,229 4,813 1,842 3,318 2, ,054 3,850 4,376 1,675 3,019 2, ,395 4,278 4,864 1,862 3,355 2, ,086 3,890 4,422 1,692 3,052 2, ,427 4,324 4,909 1,879 3,390 2, ,118 3,929 4,459 1,709 3,080 2, ,466 4,366 4,956 1,896 3,425 2, ,148 3,968 4,500 1,723 3,112 2, ,498 4,408 5,000 1,914 3,455 2, ,176 4,003 4,536 1,734 3,138 2, ,526 4,445 5,039 1,928 3,487 2, ,203 4,036 4,568 1,747 3,166 2, ,558 4,483 5,077 1,942 3,517 3, ,224 4,066 4,600 1,762 3,188 2, ,586 4,518 5,111 1,956 3,541 3, ,251 4,094 4,631 1,774 3,211 2, ,610 4,548 5,142 1,968 3,566 3, ,269 4,122 4,656 1,782 3,230 2, ,634 4,577 5,173 1,980 3,590 3, ,289 4,144 4,678 1,790 3,250 2, ,655 4,606 5,197 1,991 3,612 3, ,308 4,166 4,702 1,799 3,269 2, ,677 4,632 5,226 1,998 3,634 3, ,328 4,192 4,724 1,811 3,289 2, ,697 4,661 5,249 2,009 3,654 3, ,348 4,217 4,751 1,818 3,306 2, ,720 4,686 5,279 2,022 3,676 3, ,367 4,242 4,775 1,826 3,326 2, ,743 4,715 5,304 2,030 3,698 3,175 Modal Factors: Semi-Annual: Quarterly: Monthly: The above rates do not include the $20 application fee. To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x.95 = discounted premium If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates. 3

5 American Continental Insurance Company Annual Attained Age Premiums For Use in ZIP Codes: Rest of State Female Rates Rates Effective 6/1/2017 Attained Preferred Attained Standard Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N 65 1,409 1,777 2, ,393 1, ,566 1,974 2, ,546 1, ,409 1,777 2, ,393 1, ,566 1,974 2, ,546 1, ,409 1,777 2, ,393 1, ,566 1,974 2, ,546 1, ,469 1,849 2, ,450 1, ,632 2,055 2, ,611 1, ,534 1,934 2, ,515 1, ,704 2,148 2, ,683 1, ,595 2,010 2, ,575 1, ,772 2,233 2,643 1,011 1,752 1, ,658 2,086 2, ,636 1, ,840 2,319 2,734 1,047 1,819 1, ,711 2,158 2, ,694 1, ,904 2,400 2,819 1,079 1,882 1, ,766 2,227 2, ,746 1, ,962 2,474 2,895 1,108 1,940 1, ,820 2,292 2,673 1,023 1,795 1, ,021 2,545 2,970 1,138 1,997 1, ,864 2,349 2,734 1,047 1,841 1, ,071 2,612 3,038 1,163 2,047 1, ,909 2,404 2,788 1,068 1,885 1, ,120 2,670 3,094 1,185 2,093 1, ,948 2,452 2,835 1,085 1,925 1, ,166 2,727 3,150 1,205 2,139 1, ,984 2,501 2,879 1,103 1,962 1, ,206 2,780 3,198 1,225 2,181 1, ,021 2,545 2,919 1,117 1,997 1, ,246 2,829 3,241 1,241 2,218 1, ,053 2,586 2,956 1,132 2,028 1, ,281 2,875 3,283 1,257 2,253 1, ,082 2,623 2,994 1,146 2,058 1, ,315 2,915 3,327 1,272 2,286 1, ,109 2,659 3,034 1,162 2,085 1, ,344 2,955 3,368 1,290 2,318 1, ,139 2,693 3,068 1,175 2,112 1, ,375 2,994 3,409 1,304 2,348 2, ,165 2,725 3,105 1,188 2,138 1, ,406 3,030 3,450 1,319 2,376 2, ,190 2,758 3,139 1,201 2,164 1, ,432 3,065 3,488 1,334 2,404 2, ,214 2,790 3,171 1,214 2,188 1, ,460 3,100 3,523 1,350 2,431 2, ,237 2,820 3,205 1,226 2,211 1, ,488 3,131 3,559 1,361 2,457 2, ,260 2,848 3,234 1,238 2,233 1, ,511 3,163 3,590 1,373 2,481 2, ,281 2,875 3,260 1,246 2,253 1, ,535 3,192 3,622 1,387 2,504 2, ,301 2,898 3,288 1,259 2,274 1, ,558 3,223 3,652 1,397 2,527 2, ,320 2,925 3,313 1,268 2,293 1, ,578 3,248 3,678 1,409 2,548 2, ,338 2,947 3,333 1,275 2,310 1, ,597 3,273 3,706 1,418 2,566 2, ,352 2,967 3,356 1,286 2,326 1, ,616 3,297 3,729 1,427 2,585 2, ,372 2,986 3,371 1,290 2,342 2, ,632 3,317 3,749 1,436 2,602 2, ,384 3,002 3,391 1,298 2,355 2, ,650 3,339 3,766 1,442 2,616 2, ,399 3,021 3,407 1,304 2,368 2, ,662 3,357 3,787 1,449 2,631 2, ,412 3,038 3,428 1,312 2,384 2, ,681 3,377 3,805 1,456 2,647 2, ,423 3,056 3,443 1,318 2,397 2, ,695 3,396 3,828 1,465 2,662 2, ,442 3,075 3,459 1,324 2,412 2, ,712 3,419 3,845 1,472 2,679 2,301 Modal Factors: Semi-Annual: Quarterly: Monthly: The above rates do not include the $20 application fee. To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x.95 = discounted premium If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates. 4

6 American Continental Insurance Company Annual Attained Age Premiums For Use in ZIP Codes: Rest of State Male Rates Rates Effective 6/1/2017 Attained Preferred Attained Standard Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N 65 1,620 2,041 2, ,601 1, ,800 2,267 2,708 1,036 1,777 1, ,620 2,041 2, ,601 1, ,800 2,267 2,708 1,036 1,777 1, ,620 2,041 2, ,601 1, ,800 2,267 2,708 1,036 1,777 1, ,688 2,128 2, ,668 1, ,876 2,364 2,820 1,079 1,853 1, ,764 2,223 2,638 1,010 1,743 1, ,958 2,469 2,930 1,120 1,937 1, ,833 2,310 2,735 1,048 1,813 1, ,038 2,569 3,038 1,163 2,015 1, ,905 2,400 2,830 1,084 1,882 1, ,117 2,665 3,144 1,202 2,091 1, ,971 2,483 2,919 1,117 1,945 1, ,190 2,758 3,241 1,241 2,162 1, ,032 2,560 2,996 1,146 2,008 1, ,259 2,846 3,329 1,273 2,231 1, ,091 2,636 3,076 1,177 2,066 1, ,322 2,927 3,415 1,309 2,295 1, ,144 2,700 3,144 1,202 2,119 1, ,382 3,001 3,493 1,338 2,354 2, ,193 2,763 3,205 1,226 2,167 1, ,436 3,069 3,560 1,362 2,408 2, ,238 2,823 3,260 1,246 2,214 1, ,490 3,139 3,622 1,387 2,459 2, ,284 2,878 3,312 1,268 2,256 1, ,536 3,195 3,677 1,408 2,507 2, ,322 2,927 3,358 1,286 2,295 1, ,582 3,253 3,731 1,427 2,550 2, ,362 2,974 3,401 1,301 2,332 2, ,623 3,304 3,778 1,445 2,592 2, ,393 3,018 3,443 1,318 2,367 2, ,660 3,353 3,829 1,465 2,629 2, ,427 3,058 3,488 1,334 2,397 2, ,696 3,397 3,874 1,484 2,664 2, ,459 3,099 3,530 1,351 2,428 2, ,731 3,440 3,923 1,500 2,700 2, ,489 3,133 3,569 1,367 2,459 2, ,764 3,483 3,967 1,519 2,733 2, ,516 3,172 3,610 1,383 2,488 2, ,799 3,524 4,011 1,535 2,765 2, ,545 3,208 3,647 1,396 2,516 2, ,829 3,565 4,053 1,552 2,796 2, ,572 3,242 3,685 1,410 2,543 2, ,856 3,603 4,091 1,566 2,825 2, ,598 3,274 3,716 1,424 2,567 2, ,888 3,638 4,130 1,580 2,854 2, ,623 3,307 3,750 1,436 2,593 2, ,915 3,673 4,167 1,595 2,879 2, ,647 3,336 3,780 1,445 2,615 2, ,938 3,704 4,199 1,607 2,906 2, ,669 3,363 3,807 1,456 2,638 2, ,965 3,736 4,231 1,618 2,931 2, ,687 3,388 3,833 1,468 2,657 2, ,988 3,765 4,259 1,630 2,951 2, ,709 3,412 3,859 1,478 2,676 2, ,008 3,790 4,285 1,640 2,972 2, ,724 3,435 3,880 1,485 2,692 2, ,028 3,814 4,311 1,650 2,992 2, ,741 3,453 3,898 1,492 2,708 2, ,046 3,838 4,331 1,659 3,010 2, ,757 3,472 3,918 1,499 2,724 2, ,064 3,860 4,355 1,665 3,028 2, ,773 3,493 3,937 1,509 2,741 2, ,081 3,884 4,374 1,674 3,045 2, ,790 3,514 3,959 1,515 2,755 2, ,100 3,905 4,399 1,685 3,063 2, ,806 3,535 3,979 1,522 2,772 2, ,119 3,929 4,420 1,692 3,082 2,646 Modal Factors: Semi-Annual: Quarterly: Monthly: The above rates do not include the $20 application fee. To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x.95 = discounted premium If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates. 5

7 PREMIUM INFORMATION American Continental Insurance Company can only raise your premium if we raise the premium for all policies like yours in this state. Premiums for this policy will increase due to the increase in your age. Upon attainment of an age requiring a rate increase, the renewal premium for the policy will be the renewal premium then in effect for your attained age. Other policies may be provided with Issue Age rating and do not increase with age. You should compare Issue Age with Attained Age policies. Premiums payable other than annually will be determined according to the following factors: Semi-annual: Quarterly: Monthly EFT: HOUSEHOLD DISCOUNT In order to be eligible for the Household discount under an American Continental Insurance Company Medicare supplement plan, you must apply for a Medicare supplement plan at the same time as another Medicare eligible adult or the other Medicare eligible adult must currently be covered by an American Continental Insurance Company Medicare supplement policy. The Medicare eligible adult must be either (a) your spouse; (b) be someone with whom you are in a civil union partnership; or (c) be a permanent resident in your home. The household discount will only be applicable if a policy for each applicant is issued. The discounted rate will be 5 percent lower than the individual rates and will apply as long as both policies remain in force. DISCLOSURES Use this outline to compare benefits and premium among policies. READ R POLICY VERY CAREFULLY This is only an outline describing your policy s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to American Continental Insurance Company, P.O. Box 14770, Lexington, KY If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all your payments. POLICY REPLACEMENT If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. NOTICE The policy may not cover all of your medical costs. Neither American Continental Insurance Company nor its agents are connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare & You for more details. COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new policy, be sure to answer truthfully and completely any questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded. THE FOLLOWING CHARTS DESCRIBE S A, B, F, HIGH DEDUCTIBLE F, G and N OFFERED BY AMERICAN CONTINENTAL INSURANCE COMPANY. 6

8 A (PART A) HOSPITAL PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A Deductible) 61st thru 90th day All but $329 a day $329 a day 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible Expenses Beyond the Additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- Approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $ a day Up to $ a day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy s Core Benefits. During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. ** 7

9 A (PART B) MEDICAL PER CALENDAR YEAR *Once you have been billed $183 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. MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests durable medical equipment First $183 of Medicare-Approved amounts* $183 Remainder of Medicare-Approved amounts Generally 80% Generally 20% Part B Excess Charges (Above Medicare-Approved amounts) All costs BLOOD First 3 pints All costs Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts 80% 20% CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% $183 HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies PARTS A & B 100% Durable medical equipment First $183 of Medicare Approved amounts* $183 Remainder of Medicare Approved amounts 80% 20% 8

10 B (PART A) HOSPITAL PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A Deductible) 61st thru 90th day All but $329 a day $329 a day 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible Expenses Beyond the Additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- Approved facility within 30 days after leaving the hospital First 20 days ** All approved amounts 21st thru 100th day All but $ a day Up to $ a day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy s Core Benefits. During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. 9

11 B (PART B) MEDICAL PER CALENDAR YEAR * Once you have been billed $183 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. MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare-Approved amounts* $183 Remainder of Medicare-Approved amounts Generally 80% Generally 20% Part B Excess Charges (Above Medicare-Approved amounts) All costs BLOOD First 3 pints All costs Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts 80% 20% CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% $183 HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies PARTS A & B 100% Durable medical equipment First $183 of Medicare Approved amounts* $183 Remainder of Medicare Approved amounts 80% 20% 10

12 F (PART A) HOSPITAL PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A Deductible) 61st thru 90th day All but $329 a day $329 a day 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible Expenses Beyond the Additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- Approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $ a Up to $ a day day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ ** **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy s Core Benefits. During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. 11

13 F (PART B) MEDICAL PER CALENDAR YEAR *Once you have been billed $183 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. MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare-Approved amounts* $183 Remainder of Medicare-Approved amounts Generally 80% Generally 20% Part B Excess Charges (Above Medicare-Approved amounts) 100% BLOOD First 3 pints All costs Next $183 of Medicare-Approved $183 amounts* Remainder of Medicare-Approved amounts 80% 20% CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies PARTS A & B 100% Durable medical equipment First $183 of Medicare Approved amounts* $183 Remainder of Medicare Approved amounts 80% 20% 12

14 F OTHER BENEFITS NOT COVERED BY FOREIGN TRAVEL NOT COVERED BY Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 13

15 HIGH DEDUCTIBLE F (PART A) HOSPITAL PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. ***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,200 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses are $2,200. 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. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,316 $1,316 AFTER $2,200 DEDUCTIBLE*** (Part A Deductible) 61st thru 90th day All but $329 a day $329 a day 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible Expenses Beyond the Additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- Approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $ a Up to $ a day day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% IN ADDITION TO $2,200 DEDUCTIBLE*** ** 14

16 HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy s Core Benefits. During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. 15

17 HIGH DEDUCTIBLE F (PART B) MEDICAL PER CALENDAR YEAR *Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. ***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,200 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses are $2,200. 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. MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare-Approved amounts* AFTER $2,200 DEDUCTIBLE*** $183 Remainder of Medicare-Approved amounts Generally 80% Generally 20% Part B Excess Charges (Above Medicare-Approved amounts) 100% BLOOD First 3 pints All costs Next $183 of Medicare-Approved $183 amounts* Remainder of Medicare-Approved amounts 80% 20% CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% IN ADDITION TO $2,200 DEDUCTIBLE*** 16

18 HIGH DEDUCTIBLE F HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies PARTS A & B AFTER $2,200 DEDUCTIBLE*** 100% IN ADDITION TO $2,200 DEDUCTIBLE*** Durable medical equipment First $183 of Medicare Approved amounts* $183 Remainder of Medicare Approved amounts 80% 20% OTHER BENEFITS NOT COVERED BY AFTER $2,200 DEDUCTIBLE** FOREIGN TRAVEL NOT COVERED BY Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 IN ADDITION TO $2,200 DEDUCTIBLE** 20% and amounts over the $50,000 lifetime maximum 17

19 G (PART A) HOSPITAL PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A Deductible) 61st thru 90th day All but $329 a day $329 a day 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible Expenses Beyond the Additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- Approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $ a Up to $ a day day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness services All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ ** **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy s Core Benefits. During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. 18

20 G (PART B) MEDICAL PER CALENDAR YEAR *Once you have been billed $183 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. MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare-Approved amounts* $183 Remainder of Medicare-Approved amounts Generally 80% Generally 20% Part B Excess Charges (Above Medicare-Approved amounts) 100% BLOOD First 3 pints All costs Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts 80% 20% CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% $183 PARTS A & B HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies 100% Durable medical equipment First $183 of Medicare Approved amounts* $183 Remainder of Medicare Approved amounts 80% 20% 19

21 G OTHER BENEFITS NOT COVERED BY FOREIGN TRAVEL NOT COVERED BY Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 20

22 N (PART A) HOSPITAL PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A Deductible) 61st thru 90th day All but $329 a day $329 a day 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible Expenses Beyond the Additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- Approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $ a Up to $ a day day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness services All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ ** **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy s Core Benefits. During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. 21

23 N (PART B) MEDICAL PER CALENDAR YEAR *Once you have been billed $183 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. MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts $183 Generally 80% Balance, other than Up to $20 per office up to $20 per office visit and up to $50 visit and up to $50 per emergency per emergency room visit. The room visit. The copayment of up to co-payment of up to $50 is waived if the $50 is waived if the insured is admitted insured is admitted to any hospital and to any hospital and the emergency visit the emergency visit is covered as a is covered as a Medicare Part A Medicare Part A expense. expense. Part B Excess Charges (Above Medicare-Approved amounts) 0% All costs BLOOD First 3 pints All costs Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts 80% 20% CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% $183 22

24 N PARTS A & B HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies 100% Durable medical equipment First $183 of Medicare Approved amounts* $183 Remainder of Medicare Approved amounts 80% 20% OTHER BENEFITS NOT COVERED BY FOREIGN TRAVEL NOT COVERED BY Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 23