Medicare Supplement Outline of Coverage. Plans A, F, G & N. Amerigroup Insurance Company Arizona 2018

Transcription

1 Medicare Supplement Outline of Coverage Plans A, F, G & N Amerigroup Insurance Company Arizona 2018 This booklet includes premium rates, Medicare deductibles, copays and maximum out-of-pocket costs. Call toll-free with questions. Administrative Office: P.O. Box , San Antonio, TX AG_OOC01(18)-AZ

2 Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010 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. Plans shown in gray are available for purchase. Basic Benefits n Hospitalization Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. n Medical Expenses Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or copayments. n Blood First three pints of blood each year. n Hospice Part A coinsurance. Benefits A t B C D F F* G K L M N Basic Coverage, Including 100% Part B Coinsurance Hospitalization & Preventative Care /Other Basic Benefits P P P P P * P P P s 100% /50% 100% /75% Skilled Nursing Facility Coinsurance P P P P 50% 75% P P Part A Deductible P P P P P 50% 75% 50% P Part B Deductible P P Part B Excess (100%) P P Foreign Travel Emergency P P P P P P Out-of-pocket Limit; Paid at 100% after Limit is Reached $5,240 $2,620 * 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 $2,240 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,240. 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. Amerigroup does not offer a high deductible Plan F option. s Basic benefits, EXCEPT up to $20 copayment for office visit, and up to $50 copayment for emergency room visit Outline of Medicare Supplement Coverage 1

3 Finding Premium Your Information Monthly Premium Plans A, F, G & N Effective June 1, 2018 We, Amerigroup Insurance Company, can only raise your premium if we raise the premium for all plans like yours in this State. Should this occur, you will receive a 30-day notice. Find Your Premium Premiums (and future changes to premiums) are determined by several factors, the county where you live, tobacco use, age, gender, plan, and the costs of medical services and supplies. Here s how to find your premium, step-by-step: SteP 1: Determine Your Rating Area SteP 2: Determine Which Premium Table Applies to You n Tobacco / Non-Tobacco n Male / Female P Find Your Premium NOW You Are Ready to Compare Plan Premiums enrollment Premium Discount Program If eligible for our Enrollment Premium Discount, the amount of the discount is dependent on your age as of your policy effective date and will reduce by 3% every year through age 74 when the discount expires. When you are Medicare eligible at age 65 to 65½, you are automatically eligible for the Enrollment Premium Discount Program at a 30% discount. If you are past age 65½, you may still qualify for the discounted rate. The change in discount occurs in the next month s bill after your policy anniversary. When your discount no longer applies, you will be charged the standard rate, less any discounts that you are still eligible for; such as, our $2 EFT discount, our $48 annual pay discount or our 5% Household discount.* As an example, if you delay enrollment into Medicare Part B and enroll at age 67 your Enrollment Premium Discount will be 24% off the standard monthly premium and will continue to reduce by 3% through age 74. *See our Application or Brochure for more details on these discounts Outline of Medicare Supplement Coverage 2

4 Finding Your Monthly Premium Plans A, F, G & N Effective June 1, 2018 Step 1: Determine Your Rating Area County Area Guide Find the county you live in from the list below. 3 Got Your Rating Area? Now you are ready to go to Step #2. County Area County Area Apache 1 Cochise 1 Coconino 1 Gila 1 Graham 1 Greenlee 1 La Paz 1 Maricopa 2 Mohave 1 Navajo 1 Pima 1 Pinal 2 Santa Cruz 1 Yavapai 1 Yuma Outline of Medicare Supplement Coverage 3

5 Finding Your Monthly Premium Plans A, F, G & N Effective June 1, 2018 Premium is based upon your tobacco usage, age, area, gender and plan. Step 2: Find Your Premium Table 1 Area 1: Non-tobacco If you have not used tobacco products in the past 12 months, use this table. Male: Enrollment Premium Discount Rate* Male: Standard Rates Plan A Plan F Plan G Plan N Plan A Plan F Plan G Plan N 65 $ $ $ $96.60 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Age** * To be eligible for the discounted rate, the applicant must be in either their Open Enrollment period, based on their Part B effective date, OR a qualifying Guarantee Issue (GI) situation. GI situations vary by plan. All other applicants will be subject to an underwriting review to determine appropriate rate. ** Age as of the date the plan is issued Outline of Medicare Supplement Coverage (see next page for female rates) 4

6 Finding Your Monthly Premium Plans A, F, G & N Effective June 1, 2018 Premium is based upon your tobacco usage, age, area, gender and plan. Step 2: Find Your Premium Table 1 Area 1: Non-tobacco If you have not used tobacco products in the past 12 months, use this table. Age** Female: Enrollment Premium Discount Rate* Plan A $93.10 $ $ $ $ $ $ $ $ $ $ $ $ Plan F $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Plan G $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Plan N $89.60 $97.82 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Plan A $ $ $ $ $ $ $ $ $ $ $ $ $ Female: Standard Rates Plan F Plan G Plan N $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ * To be eligible for the discounted rate, the applicant must be in either their Open Enrollment period, based on their Part B effective date, OR a qualifying Guarantee Issue (GI) situation. GI situations vary by plan. All other applicants will be subject to an underwriting review to determine appropriate rate. ** Age as of the date the plan is issued Outline of Medicare Supplement Coverage (see next page for more areas) 5

7 Finding Your Monthly Premium Plans A, F, G & N Effective June 1, 2018 Premium is based upon your tobacco usage, age, area, gender and plan. Step 2: Find Your Premium Table 1 Area 2: Non-tobacco If you have not used tobacco products in the past 12 months, use this table. Male: Enrollment Premium Discount Rate* Male: Standard Rates Plan A Plan F Plan G Plan N Plan A Plan F Plan G Plan N 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Age** * To be eligible for the discounted rate, the applicant must be in either their Open Enrollment period, based on their Part B effective date, OR a qualifying Guarantee Issue (GI) situation. GI situations vary by plan. All other applicants will be subject to an underwriting review to determine appropriate rate. ** Age as of the date the plan is issued Outline of Medicare Supplement Coverage (see next page for female rates) 6

8 Finding Your Monthly Premium Plans A, F, G & N Effective June 1, 2018 Premium is based upon your tobacco usage, age, area, gender and plan. Step 2: Find Your Premium Table 1 Area 2: Non-tobacco If you have not used tobacco products in the past 12 months, use this table. Age** Female: Enrollment Premium Discount Rate* Plan A $ $ $ $ $ $ $ $ $ $ $ $ $ Plan F $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Plan G $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Plan N $98.70 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Plan A $ $ $ $ $ $ $ $ $ $ $ $ $ Female: Standard Rates Plan F Plan G Plan N $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ * To be eligible for the discounted rate, the applicant must be in either their Open Enrollment period, based on their Part B effective date, OR a qualifying Guarantee Issue (GI) situation. GI situations vary by plan. All other applicants will be subject to an underwriting review to determine appropriate rate. ** Age as of the date the plan is issued Outline of Medicare Supplement Coverage (see next page for tobacco rates) 7

9 Finding Your Monthly Premium Plans A, F, G & N Effective June 1, 2018 Step 2: Find Your Premium Table 2 Area 1: Tobacco If you have used tobacco products in the past 12 months, use this table. Male: Enrollment Premium Discount Rate* Male: Standard Rates Plan A Plan F Plan G Plan N Plan A Plan F Plan G Plan N 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Age** * To be eligible for the discounted rate, the applicant must be in either their Open Enrollment period, based on their Part B effective date, OR a qualifying Guarantee Issue (GI) situation. GI situations vary by plan. All other applicants will be subject to an underwriting review to determine appropriate rate. ** Age as of the date the plan is issued Outline of Medicare Supplement Coverage (see next page for female rates) 8

10 Finding Your Monthly Premium Plans A, F, G & N Effective June 1, 2018 Step 2: Find Your Premium Table 2 Area 1: Tobacco If you have used tobacco products in the past 12 months, use this table. Age** Female: Enrollment Premium Discount Rate* Plan A $ $ $ $ $ $ $ $ $ $ $ $ Plan F $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Plan G $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Plan N $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Plan A $ $ $ $ $ $ $ $ $ $ $ $ Female: Standard Rates Plan F Plan G Plan N $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ * To be eligible for the discounted rate, the applicant must be in either their Open Enrollment period, based on their Part B effective date, OR a qualifying Guarantee Issue (GI) situation. GI situations vary by plan. All other applicants will be subject to an underwriting review to determine appropriate rate. ** Age as of the date the plan is issued Outline of Medicare Supplement Coverage (see next page for more areas) 9

11 Finding Your Monthly Premium Plans A, F, G & N Effective June 1, 2018 Step 2: Find Your Premium Table 2 Area 2: Tobacco If you have used tobacco products in the past 12 months, use this table. Male: Enrollment Premium Discount Rate* Male: Standard Rates Plan A Plan F Plan G Plan N Plan A Plan F Plan G Plan N 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Age** * To be eligible for the discounted rate, the applicant must be in either their Open Enrollment period, based on their Part B effective date, OR a qualifying Guarantee Issue (GI) situation. GI situations vary by plan. All other applicants will be subject to an underwriting review to determine appropriate rate. ** Age as of the date the plan is issued Outline of Medicare Supplement Coverage (see next page for female rates) 10

12 Finding Your Monthly Premium Plans A, F, G & N Effective June 1, 2018 Step 2: Find Your Premium Table 2 Area 2: Tobacco If you have used tobacco products in the past 12 months, use this table. Age** Female: Enrollment Premium Discount Rate* Plan A $ $ $ $ $ $ $ $ $ $ $ $ $ Plan F $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Plan G $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Plan N $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Plan A $ $ $ $ $ $ $ $ $ $ $ $ $ Female: Standard Rates Plan F Plan G Plan N $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ * To be eligible for the discounted rate, the applicant must be in either their Open Enrollment period, based on their Part B effective date, OR a qualifying Guarantee Issue (GI) situation. GI situations vary by plan. All other applicants will be subject to an underwriting review to determine appropriate rate. ** Age as of the date the plan is issued Outline of Medicare Supplement Coverage 11

13 Important Plan Disclosures Plans A, F, G & N Retain this outline for your records. DISCLOSURES Use this outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY This is only an outline describing your policy s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and Amerigroup Insurance Company. RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to us at our Administrative Office: Amerigroup Insurance Company, P.O. Box , San Antonio, TX If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments. POLICY REPLACEMENT If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. NOTICE This policy may not fully cover all of your medical costs. Neither Amerigroup 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 and 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 all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded Outline of Medicare Supplement Coverage 12

14 PLAN A MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY W HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61 st thru 90 th day 91 st day and after: QWhile using 60 lifetime reserve days QOnce lifetime reserve days are used: QAdditional 365 days QBeyond the additional 365 days All but $1,340 All but $335 a day All but $670 a day $335 a day $670 a day 100% of Medicare eligible expenses $1,340 (Part A deductible) ** All costs W 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 21 st thru 100 th day All but $ a day Up to $ a day 101 st day and after All costs W BLOOD First 3 pints 3 pints Additional amounts 100% W HOSPICE CARE You 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 ** 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 Outline of Medicare Supplement Coverage 13

15 PLAN A MEDICARE (PART B) MEDICAL SERVICES 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. W SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare Approved Amounts* $183 (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% W PART B EXCESS CHARGES Above Medicare Approved Amounts All costs W BLOOD First 3 pints Next $183 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts All costs 80% 20% $183 (Part B deductible) W CLINICAL LABORATORY SERVICES Tests for Diagnostic Services 100% PARTS A & B SERVICES SERVICES MEDICARE PAYS PLAN PAYS YOU PAY W,KD,>d,ZͷMEDICARE APPROVED SERVICES QMedically necessary skilled care services 100% and medical supplies QDurable medical equipment: QFirst $183 of Medicare approved amounts* QRemainder of Medicare approved amounts 80% 20% $183 (Part B deductible) 2018 Outline of Medicare Supplement Coverage 14

16 PLAN F MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY W HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61 st thru 90 th day 91 st day and after: QWhile using 60 lifetime reserve days QOnce lifetime reserve days are used: QAdditional 365 days QBeyond the additional 365 days All but $1,340 All but $335 a day All but $670 a day $1,340 (Part A deductible) $335 a day $670 a day 100% of Medicare eligible expenses ** All costs W 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 21 st thru 100 th day All but $ a day Up to $ a day 101 st day and after All costs W BLOOD First 3 pints 3 pints Additional amounts 100% W HOSPICE CARE You 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 ** 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 Outline of Medicare Supplement Coverage 15

17 PLAN F MEDICARE (PART B) MEDICAL SERVICES 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. W SERVICES MEDICARE PAYS PLAN PAYS YOU PAY D/>yWE^^ͷ 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 (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% W PART B EXCESS CHARGES Above Medicare Approved Amounts 100% W BLOOD First 3 pints Next $183 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 80% All costs $183 (Part B deductible) 20% W CLINICAL LABORATORY SERVICES Tests for Diagnostic Services 100% PARTS A & B SERVICES SERVICES MEDICARE PAYS PLAN PAYS YOU PAY W,KD,>d,ZͷMEDICARE APPROVED SERVICES QMedically necessary skilled care services and medical 100% supplies QDurable medical equipment: QFirst $183 of Medicare Approved Amounts* QRemainder of Medicare approved amounts $183 (Part B deductible) 80% 20% 2018 Outline of Medicare Supplement Coverage 16

18 PLAN F OTHER BENEFITS NOT COVERED BY MEDICARE W SERVICES MEDICARE PAYS PLAN PAYS YOU PAY &KZ/'EdZs>ͷNOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 80% to a lifetime 20% and amounts Remainder of Charges maximum benefit of $50,000 over the $50,000 lifetime maximum 2018 Outline of Medicare Supplement Coverage 17

19 PLAN G MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY W HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61 st thru 90 th day 91 st day and after: QWhile using 60 lifetime reserve days QOnce lifetime reserve days are used: QAdditional 365 days QBeyond the additional 365 days All but $1,340 All but $335 a day All but $670 a day $1,340 (Part A deductible) $335 a day $670 a day 100% of Medicare eligible expenses ** All costs W 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 21 st thru 100 th day All but $ a day Up to $ a day 101 st day and after All costs W BLOOD First 3 pints 3 pints Additional amounts 100% W HOSPICE CARE You 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 ** 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 Outline of Medicare Supplement Coverage 18

20 PLAN G MEDICARE (PART B) MEDICAL SERVICES 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. W SERVICES MEDICARE PAYS PLAN PAYS YOU PAY D/>yWE^^ͷ 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 (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% W PART B EXCESS CHARGES Above Medicare Approved Amounts 100% W BLOOD First 3 pints Next $183 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts All costs 80% 20% $183 (Part B deductible) W CLINICAL LABORATORY SERVICES Tests for Diagnostic Services 100% PARTS A & B SERVICES SERVICES MEDICARE PAYS PLAN PAYS YOU PAY W,KD,>d,ZͷMEDICARE APPROVED SERVICES QMedically necessary skilled care services and medical 100% supplies QDurable medical equipment: QFirst $183 of Medicare Approved Amounts* QRemainder of Medicare approved amounts 80% 20% $183 (Part B deductible) 2018 Outline of Medicare Supplement Coverage 19

21 PLAN G OTHER BENEFITS NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY W &KZ/'EdZs>ͷNOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 80% to a lifetime 20% and amounts Remainder of Charges maximum benefit of $50,000 over the $50,000 lifetime maximum 2018 Outline of Medicare Supplement Coverage 20

22 PLAN N MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY W HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61 st thru 90 th day 91 st day and after: QWhile using 60 lifetime reserve days QOnce lifetime reserve days are used: QAdditional 365 days QBeyond the additional 365 days All but $1,340 All but $335 a day All but $670 a day $1,340 (Part A deductible) $335 a day $670 a day 100% of Medicare eligible expenses ** All costs W 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 21 st thru 100 th day All but $ a day Up to $ a day 101 st day and after All costs W BLOOD First 3 pints 3 pints Additional amounts 100% W HOSPICE CARE You 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 ** 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 Outline of Medicare Supplement Coverage 21

23 PLAN N MEDICARE (PART B) MEDICAL SERVICES 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. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY W D/>yWE^^ͷ 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 Generally 80% Approved Amounts W PART B EXCESS CHARGES 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. $183 (Part B deductible) 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. Above Medicare Approved Amounts All costs W BLOOD First 3 pints Next $183 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts All costs 80% 20% $183 (Part B deductible) W CLINICAL LABORATORY SERVICES Tests for Diagnostic Services 100% 2018 Outline of Medicare Supplement Coverage 22

24 PLAN N PARTS A & B SERVICES * 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. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY W,KD,>d,ZͷMEDICARE APPROVED SERVICES QMedically necessary skilled care services and medical 100% supplies QDurable medical equipment: QFirst $183 of Medicare approved amounts* QRemainder of Medicare approved amounts 80% 20% $183 (Part B deductible) OTHER BENEFITS NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY W &KZ/'EdZs>ͷNOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 80% to a lifetime 20% and amounts Remainder of Charges maximum benefit over the $50,000 of $50,000 lifetime maximum 2018 Outline of Medicare Supplement Coverage 23

25 P.O. Box San Antonio, TX Coverage is provided by Amerigroup Insurance Company. 2018_OOC-AZ (Rev. 03_2018)