Medicare Supplement Insurance

Transcription

1 Medicare Supplement Insurance Iowa Outline of Coverage AveraHealthPlans.com Effective: July 2018

2 Benefit Chart of Medicare Supplement Insurance Plans Standard Medicare Supplement Plans A, B, C, F, G and N Medicare Select Supplement Plans A, B, C, F, G and N are available. These charts show 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. The plans in bold type listed below (A, B, C, F, G and N) are also available as Medicare Select Plans. Medicare Select plans contain restrictions on your use of specific hospitals and, in some cases, specific doctors or other healthcare providers to get full coverage. See Outline of Coverage sections for details about ALL plans. Basic Benefits for Plans A N: o Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. o Medical Expenses: (generally 20% of Medicare-approved expenses) or co-payments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of or copayments. o Blood: First three pints of blood each year. o Hospice: Part A coinsurance This table describes: A B C D F F 1 G * Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part B Deductible Part B Deductible Part B Excess (100%) Part B Excess (100%) 1 Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plans F after the policyholder 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. 1 P a g e

3 Benefit Chart of Medicare Supplement Insurance Plans Basic Benefits for Plans K and L include similar services as Plans A G, but cost-sharing for the basic benefits is at different levels. K 2 L 2 M N Hospitalization and preventative care Part B paid at 100%; other basic benefits coinsurance paid at 75% Hospitalization and preventative care paid at 100%; other basic benefits paid at 50% 50% Facility Coinsurance 75% Facility Coinsurance Facility Coinsurance Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER 50% Part A deductible 75% Part A Deductible 50% Part A Deductible Part A Deductible Out-of-pocket annual limit $5,240 benefits paid at 100% after limit reached Out-of -pocket annual limit $2,620; benefits paid at 100% after limit reached Service Area Standard Plan Service Area: All counties in Iowa are included in the service area for the Standard Plan. Select Plan Service Area: Dickinson, Emmet, Lyon, O Brien, Osceola, Plymouth, Sioux and Woodbury Counties. (updated 11/27/2013) Premium Information Avera Health Plans can only raise your premium if we raise the premium for all policies like yours in this state. Your premiums are based on your attained age on the annual effective date of your policy. 2 Plans K and L provide for different cost-sharing for items and services than Plans A-G. After you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance, and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called Excess Charges. You will be responsible for paying excess charges. The out-of-pocket annual limit will increase each year for inflation. 2 P a g e

4 Monthly Premium ATTAINED AGE Standard Plan A Select Plan A Standard Plan B Select Plan B Standard Plan C Select Plan C Male Female Male Female Male Female Male Female Male Female Male Female Under 65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A P a g e

5 Monthly Premium ATTAINED AGE Standard Plan F Select Plan F Standard Plan G Select Plan G Standard Plan N Select Plan N Male Female Male Female Male Female Male Female Male Female Male Female Under 65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A P a g e

6 Discrimination is Against the Law Avera Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Avera Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Avera Health Plans: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as: Qualified interpreters and information written in other languages. If you need these services, contact the Avera Health Plans Service Center at , 8 a.m. to 5 p.m. CST, Monday through Friday. If you believe that Avera Health Plans has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: Complaint and Appeals Coordinator, Avera Health Plans 3816 S. Elmwood, Suite 100, Sioux Falls, SD (phone), TTY 711, (fax) ComplaintAppeals@AveraHealthPlans.com You can file a grievance in person or by mail, fax, or . You may also contact the Complaint and Appeals Coordinator if you need assistance with filing a complaint. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: US Department of Health and Human Services, 200 Independence Avenue SW Room 509F, HHH Building, Washington, D.C or (TDD). Complaint forms are available at For language assistance in your language call ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj.hu rau (TTY: ). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: ). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: (TTY: ). ملحوظت: إذا كنج حخحدد اذكر اللغت فإن خدماث المساعدة اللغويت حخوافر لك بالمجان. احصل برقم )رقم هاحف الصم والبكم: (. Getting Help in other Languages ໂປດຊາບ: າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລ ການຊ ວຍເຫ ດ ານພາສາ, ໂດຍບ ເສ ຽ າ, ແມ ນມ ພ ມໃຫ ທ ານ. ໂທຣ (TTY: ). ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (TTY: ). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (መስማት ለተሳናቸው: TTY: ) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: ) ប រយ ត ន បរ ស នជ អ នកន យ យ ភ ស ខ ម រ, បសវ ជ ន យខ នកភ ស ប យម នគ ត ឈ ន ល គ អ ចម នស រ រ រ បរ អ នក ច រ ទ រស ព ទ (TTY: )

7 Main Office Address: 3816 S. Elmwood Ave. Suite 100 Sioux Falls, SD For other office locations, visit AveraHealthPlans.com Toll-Free: Iowa Outline of Coverage (07/18) Form C [OOC-IA ]