Shenandoah Life Insurance Company Administrative Office: P.O. Box 14558, Clearwater, FL 33766-4558 (855) 406-9085 Outline of Medicare Supplement Coverage Cover Page Benefit Plans A, F, G and N Benefit Chart of Medicare Supplement Plans Sold for Effective Dates 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. 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 copayment for hospital outpatient services. Plans K, L and N require insured to pay a portion of Part B 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, Basic, Basic, Basic, Basic, Hospitalization and Hospitalization and Basic, preventive care preventive care including including including including including Including 100% paid at 100%; other paid at 100%; other 100% Part B 100% Part B 100% Part B 100% Part B 100% Part B Part B basic benefits paid basic benefits paid at 50% at 75% Basic, including 100% Part B Part A Skilled Nursing Facility Part A Part B Foreign Travel Emergency Skilled Nursing Facility Part A Foreign Travel Emergency Skilled Nursing Facility Part A Part B Part B Excess (100%) Foreign Travel Emergency Skilled Nursing Facility Part A Part B Excess (100%) Foreign Travel Emergency 50% Skilled Nursing Facility 50% Part A Out-of-Pocket limit $5,560; paid at 100% after limit reached 75% Skilled Nursing Facility 75% Part A Out-of-Pocket limit $2,780; paid at 100% after limit reached Skilled Nursing Facility 50% Part A 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 Part A 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 $2,300 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,300. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include Medicare deductibles for Part A and Part B, but do not include the plan s separate foreign travel emergency deductible. SHENMS OOC 08/2014 TX Page 1 0119 TX
SHENANDOAH LIFE INSURANCE COMPANY - MONTHLY RATES* ZIP CODES: 733, 739, 754-760, 762-769, 771, 778-780, 781, 786-792, 795-799, 885 STANDARD PLANS NON-TOBACCO Female Male Attained Age 456.33 n/a n/a n/a Under 65 524.52 n/a n/a n/a 91.26 122.95 92.87 74.84 65 104.90 141.32 106.75 86.02 91.26 122.95 92.87 74.84 66 104.90 141.32 106.75 86.02 91.26 122.95 92.87 74.84 67 104.90 141.32 106.75 86.02 91.87 123.76 93.33 75.39 68 105.60 142.25 107.28 86.65 95.53 128.70 97.05 78.39 69 109.81 147.93 111.55 90.10 99.37 133.88 100.96 81.55 70 114.22 153.89 116.05 93.73 103.42 139.31 105.06 84.86 71 118.87 160.13 120.76 97.54 107.45 144.76 109.17 88.17 72 123.51 166.39 125.48 101.35 111.62 150.36 113.40 91.58 73 128.30 172.83 130.34 105.27 115.34 155.38 117.18 94.64 74 132.58 178.60 134.69 108.78 118.94 160.22 120.83 97.60 75 136.71 184.16 138.89 112.18 123.64 166.54 125.60 101.45 76 142.11 191.43 144.37 116.61 127.10 171.22 129.12 104.29 77 146.09 196.80 148.41 119.87 130.47 175.75 132.54 107.05 78 149.96 202.01 152.35 123.05 133.85 180.32 135.98 109.84 79 153.85 207.27 156.30 126.25 137.20 184.83 139.39 112.58 80 157.70 212.45 160.22 129.40 140.49 189.26 142.73 115.28 81 161.48 217.54 164.06 132.51 143.72 193.62 146.01 117.93 82 165.20 222.55 167.83 135.55 146.89 197.87 149.23 120.53 83 168.84 227.44 171.53 138.54 149.97 202.03 152.36 123.05 84 172.38 232.22 175.13 141.44 152.82 205.87 155.25 125.39 85 175.66 236.63 178.45 144.13 155.57 209.57 158.04 127.66 86 178.82 240.89 181.66 146.73 158.06 212.93 160.58 129.69 87 181.68 244.75 184.58 149.07 159.97 215.49 162.51 131.25 88 183.87 247.69 186.79 150.86 161.56 217.64 164.13 132.57 89 185.70 250.16 188.65 152.38 163.17 219.82 165.78 133.89 90 187.55 252.67 190.55 153.90 164.48 221.57 167.10 134.96 91 189.06 254.68 192.07 155.13 165.63 223.13 168.27 135.91 92 190.38 256.47 193.41 156.22 166.47 224.24 169.11 136.58 93 191.34 257.75 194.38 156.99 167.27 225.33 169.93 137.25 94 192.26 259.00 195.32 157.76 167.88 226.16 170.55 137.74 95 192.96 259.95 196.04 158.32 168.48 226.97 171.16 138.25 96 193.66 260.88 196.74 158.91 169.15 227.88 171.85 138.80 97 194.43 261.93 197.53 159.54 169.75 228.69 172.47 139.30 98 195.12 262.86 198.24 160.11 170.03 229.06 172.74 139.52 99 195.44 263.29 198.55 160.37 See PREMIUM INFORMATION regarding Household Premium Discount rating. To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, or 3, respectively. SHENMS OOC 08/2014 TX Page 2 0119 TX
SHENANDOAH LIFE INSURANCE COMPANY - MONTHLY RATES* ZIP CODES: 733, 739, 754-760, 762-769, 771, 778-780, 781, 786-792, 795-799, 885 STANDARD PLANS TOBACCO Female Male Attained Age 524.52 n/a n/a n/a Under 65 602.90 n/a n/a n/a 104.90 141.32 106.75 86.02 65 120.58 162.44 122.70 98.87 104.90 141.32 106.75 86.02 66 120.58 162.44 122.70 98.87 104.90 141.32 106.75 86.02 67 120.58 162.44 122.70 98.87 105.60 142.25 107.28 86.65 68 121.38 163.50 123.31 99.60 109.81 147.93 111.55 90.10 69 126.22 170.03 128.22 103.56 114.22 153.89 116.05 93.73 70 131.29 176.88 133.39 107.74 118.87 160.13 120.76 97.54 71 136.63 184.06 138.81 112.12 123.51 166.39 125.48 101.35 72 141.96 191.25 144.23 116.49 128.30 172.83 130.34 105.27 73 147.47 198.66 149.82 121.00 132.58 178.60 134.69 108.78 74 152.39 205.29 154.82 125.03 136.71 184.16 138.89 112.18 75 157.14 211.68 159.64 128.94 142.11 191.43 144.37 116.61 76 163.35 220.04 165.94 134.03 146.09 196.80 148.41 119.87 77 167.92 226.21 170.59 137.78 149.96 202.01 152.35 123.05 78 172.37 232.20 175.11 141.44 153.85 207.27 156.30 126.25 79 176.84 238.24 179.66 145.11 157.70 212.45 160.22 129.40 80 181.27 244.19 184.16 148.74 161.48 217.54 164.06 132.51 81 185.61 250.05 188.57 152.31 165.20 222.55 167.83 135.55 82 189.89 255.80 192.91 155.81 168.84 227.44 171.53 138.54 83 194.07 261.42 197.16 159.24 172.38 232.22 175.13 141.44 84 198.14 266.92 201.30 162.58 175.66 236.63 178.45 144.13 85 201.91 271.99 205.12 165.67 178.82 240.89 181.66 146.73 86 205.54 276.89 208.81 168.65 181.68 244.75 184.58 149.07 87 208.83 281.32 212.16 171.35 183.87 247.69 186.79 150.86 88 211.34 284.70 214.70 173.40 185.70 250.16 188.65 152.38 89 213.45 287.54 216.84 175.15 187.55 252.67 190.55 153.90 90 215.58 290.42 219.02 176.90 189.06 254.68 192.07 155.13 91 217.31 292.74 220.77 178.31 190.38 256.47 193.41 156.22 92 218.83 294.79 222.31 179.56 191.34 257.75 194.38 156.99 93 219.93 296.26 223.43 180.45 192.26 259.00 195.32 157.76 94 220.99 297.70 224.51 181.33 192.96 259.95 196.04 158.32 95 221.79 298.79 225.33 181.98 193.66 260.88 196.74 158.91 96 222.60 299.86 226.14 182.65 194.43 261.93 197.53 159.54 97 223.48 301.07 227.05 183.38 195.12 262.86 198.24 160.11 98 224.28 302.14 227.86 184.03 195.44 263.29 198.55 160.37 99 224.64 302.63 228.22 184.33 See PREMIUM INFORMATION regarding Household Premium Discount rating. To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, or 3, respectively. SHENMS OOC 08/2014 TX Page 3 0119 TX
SHENANDOAH LIFE INSURANCE COMPANY - MONTHLY RATES* ZIP CODES: 750-753, 761, 774, 776-777, 782-784, 793-794 STANDARD PLANS NON-TOBACCO Female Male Attained Age 511.10 n/a n/a n/a Under 65 587.47 n/a n/a n/a 102.22 137.70 104.02 83.82 65 117.49 158.28 119.56 96.34 102.22 137.70 104.02 83.82 66 117.49 158.28 119.56 96.34 102.22 137.70 104.02 83.82 67 117.49 158.28 119.56 96.34 102.90 138.60 104.54 84.43 68 118.28 159.31 120.16 97.05 107.00 144.13 108.70 87.79 69 122.99 165.67 124.94 100.91 111.29 149.95 113.08 91.33 70 127.92 172.36 129.98 104.98 115.83 156.03 117.68 95.05 71 133.14 179.35 135.26 109.25 120.35 162.12 122.27 98.75 72 138.33 186.35 140.54 113.51 125.02 168.41 127.01 102.57 73 143.70 193.58 145.99 117.90 129.19 174.03 131.25 105.99 74 148.49 200.03 150.86 121.83 133.21 179.45 135.34 109.31 75 153.12 206.26 155.56 125.64 138.48 186.53 140.67 113.62 76 159.17 214.40 161.69 130.60 142.35 191.77 144.61 116.80 77 163.62 220.42 166.22 134.25 146.12 196.84 148.44 119.90 78 167.95 226.25 170.62 137.82 149.91 201.96 152.30 123.01 79 172.31 232.14 175.06 141.39 153.67 207.01 156.12 126.09 80 176.63 237.94 179.45 144.93 157.35 211.98 159.85 129.12 81 180.86 243.65 183.74 148.41 160.98 216.86 163.53 132.08 82 185.03 249.26 187.97 151.82 164.52 221.62 167.14 134.99 83 189.10 254.73 192.11 155.16 167.97 226.28 170.65 137.83 84 193.07 260.09 196.15 158.42 171.16 230.58 173.89 140.44 85 196.74 265.03 199.87 161.43 174.23 234.73 177.02 142.97 86 200.27 269.80 203.47 164.33 177.03 238.48 179.86 145.26 87 203.48 274.12 206.73 166.96 179.16 241.35 182.00 147.00 88 205.93 277.41 209.20 168.96 180.94 243.75 183.82 148.48 89 207.98 280.17 211.29 170.67 182.75 246.19 185.67 149.96 90 210.06 282.98 213.41 172.37 184.22 248.17 187.15 151.16 91 211.75 285.25 215.12 173.75 185.51 249.90 188.46 152.22 92 213.23 287.24 216.62 174.97 186.44 251.14 189.41 152.97 93 214.30 288.67 217.71 175.83 187.34 252.37 190.32 153.72 94 215.33 290.08 218.76 176.69 188.02 253.29 191.02 154.27 95 216.11 291.14 219.56 177.32 188.70 254.20 191.70 154.84 96 216.90 292.18 220.35 177.98 189.45 255.22 192.48 155.46 97 217.76 293.36 221.24 178.69 190.13 256.14 193.16 156.01 98 218.54 294.41 222.02 179.32 190.43 256.55 193.47 156.26 99 218.89 294.89 222.38 179.61 See PREMIUM INFORMATION regarding Household Premium Discount rating. To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, or 3, respectively. SHENMS OOC 08/2014 TX Page 4 0119 TX
SHENANDOAH LIFE INSURANCE COMPANY - MONTHLY RATES* ZIP CODES: 750-753, 761, 774, 776-777, 782-784, 793-794 STANDARD PLANS TOBACCO Female Male Attained Age 587.47 n/a n/a n/a Under 65 675.25 n/a n/a n/a 117.49 158.28 119.56 96.34 65 135.05 181.93 137.42 110.73 117.49 158.28 119.56 96.34 66 135.05 181.93 137.42 110.73 117.49 158.28 119.56 96.34 67 135.05 181.93 137.42 110.73 118.28 159.31 120.16 97.05 68 135.95 183.12 138.11 111.55 122.99 165.67 124.94 100.91 69 141.37 190.43 143.61 115.99 127.92 172.36 129.98 104.98 70 147.04 198.11 149.40 120.67 133.14 179.35 135.26 109.25 71 153.03 206.15 155.47 125.57 138.33 186.35 140.54 113.51 72 159.00 214.20 161.54 130.47 143.70 193.58 145.99 117.90 73 165.17 222.50 167.80 135.52 148.49 200.03 150.86 121.83 74 170.68 229.92 173.40 140.03 153.12 206.26 155.56 125.64 75 176.00 237.08 178.80 144.41 159.17 214.40 161.69 130.60 76 182.95 246.44 185.85 150.11 163.62 220.42 166.22 134.25 77 188.07 253.36 191.06 154.31 167.95 226.25 170.62 137.82 78 193.05 260.06 196.12 158.41 172.31 232.14 175.06 141.39 79 198.06 266.83 201.22 162.52 176.63 237.94 179.45 144.93 80 203.02 273.49 206.26 166.59 180.86 243.65 183.74 148.41 81 207.88 280.06 211.20 170.59 185.03 249.26 187.97 151.82 82 212.68 286.50 216.06 174.51 189.10 254.73 192.11 155.16 83 217.36 292.79 220.82 178.35 193.07 260.09 196.15 158.42 84 221.92 298.95 225.46 182.09 196.74 265.03 199.87 161.43 85 226.14 304.63 229.73 185.55 200.27 269.80 203.47 164.33 86 230.20 310.12 233.87 188.89 203.48 274.12 206.73 166.96 87 233.89 315.08 237.62 191.91 205.93 277.41 209.20 168.96 88 236.70 318.86 240.46 194.21 207.98 280.17 211.29 170.67 89 239.06 322.04 242.86 196.17 210.06 282.98 213.41 172.37 90 241.45 325.27 245.30 198.13 211.75 285.25 215.12 173.75 91 243.39 327.87 247.26 199.71 213.23 287.24 216.62 174.97 92 245.09 330.16 248.99 201.11 214.30 288.67 217.71 175.83 93 246.32 331.81 250.24 202.10 215.33 290.08 218.76 176.69 94 247.51 333.42 251.45 203.09 216.11 291.14 219.56 177.32 95 248.40 334.64 252.37 203.82 216.90 292.18 220.35 177.98 96 249.31 335.84 253.28 204.57 217.76 293.36 221.24 178.69 97 250.30 337.20 254.30 205.39 218.54 294.41 222.02 179.32 98 251.19 338.40 255.20 206.11 218.89 294.89 222.38 179.61 99 251.60 338.95 255.61 206.45 See PREMIUM INFORMATION regarding Household Premium Discount rating. To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, or 3, respectively. SHENMS OOC 08/2014 TX Page 5 0119 TX
SHENANDOAH LIFE INSURANCE COMPANY - MONTHLY RATES* ZIP CODES: 770, 772-773, 775, 785 STANDARD PLANS NON-TOBACCO Female Male Attained Age 584.11 n/a n/a n/a Under 65 671.39 n/a n/a n/a 116.82 157.37 118.88 95.79 65 134.28 180.89 136.64 110.10 116.82 157.37 118.88 95.79 66 134.28 180.89 136.64 110.10 116.82 157.37 118.88 95.79 67 134.28 180.89 136.64 110.10 117.60 158.40 119.47 96.50 68 135.17 182.07 137.32 110.92 122.29 164.73 124.22 100.34 69 140.56 189.35 142.78 115.33 127.19 171.37 129.23 104.38 70 146.20 196.98 148.54 119.98 132.37 178.32 134.48 108.62 71 152.15 204.97 154.58 124.85 137.54 185.29 139.73 112.87 72 158.09 212.98 160.61 129.73 142.87 192.46 145.15 117.23 73 164.22 221.22 166.84 134.75 147.64 198.89 150.00 121.13 74 169.70 228.61 172.41 139.23 152.24 205.09 154.67 124.91 75 174.99 235.73 177.78 143.58 158.26 213.18 160.77 129.86 76 181.91 245.04 184.79 149.26 162.69 219.16 165.27 133.48 77 187.00 251.91 189.97 153.43 167.00 224.96 169.65 137.03 78 191.95 258.58 195.00 157.50 171.33 230.82 174.06 140.58 79 196.93 265.31 200.07 161.59 175.63 236.58 178.42 144.11 80 201.87 271.93 205.08 165.64 179.82 242.25 182.69 147.57 81 206.69 278.45 209.99 169.62 183.97 247.83 186.89 150.95 82 211.46 284.86 214.82 173.51 188.02 253.27 191.01 154.28 83 216.12 291.12 219.55 177.33 191.97 258.60 195.02 157.51 84 220.65 297.24 224.16 181.05 195.61 263.51 198.73 160.51 85 224.84 302.89 228.42 184.49 199.13 268.26 202.30 163.39 86 228.89 308.35 232.53 187.81 202.32 272.55 205.55 166.01 87 232.55 313.28 236.26 190.82 204.75 275.83 208.01 168.00 88 235.35 317.05 239.09 193.10 206.80 278.57 210.09 169.69 89 237.70 320.20 241.48 195.05 208.86 281.37 212.19 171.38 90 240.07 323.41 243.90 196.99 210.54 283.62 213.89 172.76 91 242.00 326.00 245.85 198.57 212.01 285.60 215.39 173.97 92 243.69 328.28 247.57 199.96 213.07 287.02 216.46 174.83 93 244.91 329.91 248.81 200.95 214.11 288.42 217.51 175.68 94 246.10 331.52 250.01 201.93 214.87 289.48 218.31 176.31 95 246.98 332.73 250.93 202.65 215.66 290.51 219.09 176.96 96 247.89 333.92 251.83 203.40 216.51 291.68 219.97 177.67 97 248.86 335.27 252.84 204.22 217.29 292.72 220.75 178.30 98 249.76 336.46 253.74 204.94 217.64 293.20 221.10 178.58 99 250.16 337.01 254.14 205.27 See PREMIUM INFORMATION regarding Household Premium Discount rating. To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, or 3, respectively. SHENMS OOC 08/2014 TX Page 6 0119 TX
SHENANDOAH LIFE INSURANCE COMPANY - MONTHLY RATES* ZIP CODES: 770, 772-773, 775, 785 STANDARD PLANS TOBACCO Female Male Attained Age 671.39 n/a n/a n/a Under 65 771.71 n/a n/a n/a 134.28 180.89 136.64 110.10 65 154.34 207.92 157.06 126.55 134.28 180.89 136.64 110.10 66 154.34 207.92 157.06 126.55 134.28 180.89 136.64 110.10 67 154.34 207.92 157.06 126.55 135.17 182.07 137.32 110.92 68 155.37 209.28 157.84 127.49 140.56 189.35 142.78 115.33 69 161.56 217.64 164.12 132.56 146.20 196.98 148.54 119.98 70 168.05 226.41 170.74 137.91 152.15 204.97 154.58 124.85 71 174.89 235.60 177.68 143.51 158.09 212.98 160.61 129.73 72 181.71 244.80 184.61 149.11 164.22 221.22 166.84 134.75 73 188.76 254.28 191.77 154.88 169.70 228.61 172.41 139.23 74 195.06 262.77 198.17 160.04 174.99 235.73 177.78 143.58 75 201.14 270.95 204.34 165.04 181.91 245.04 184.79 149.26 76 209.09 281.65 212.40 171.56 187.00 251.91 189.97 153.43 77 214.94 289.55 218.36 176.36 191.95 258.58 195.00 157.50 78 220.63 297.22 224.14 181.04 196.93 265.31 200.07 161.59 79 226.36 304.95 229.96 185.74 201.87 271.93 205.08 165.64 80 232.03 312.56 235.72 190.39 206.69 278.45 209.99 169.62 81 237.58 320.06 241.37 194.96 211.46 284.86 214.82 173.51 82 243.06 327.42 246.92 199.44 216.12 291.12 219.55 177.33 83 248.41 334.62 252.36 203.83 220.65 297.24 224.16 181.05 84 253.62 341.66 257.66 208.10 224.84 302.89 228.42 184.49 85 258.44 348.15 262.55 212.06 228.89 308.35 232.53 187.81 86 263.09 354.42 267.28 215.87 232.55 313.28 236.26 190.82 87 267.30 360.09 271.56 219.33 235.35 317.05 239.09 193.10 88 270.52 364.42 274.82 221.95 237.70 320.20 241.48 195.05 89 273.22 368.05 277.56 224.19 240.07 323.41 243.90 196.99 90 275.94 371.74 280.35 226.43 242.00 326.00 245.85 198.57 91 278.16 374.71 282.59 228.24 243.69 328.28 247.57 199.96 92 280.10 377.33 284.56 229.84 244.91 329.91 248.81 200.95 93 281.51 379.21 285.99 230.98 246.10 331.52 250.01 201.93 94 282.87 381.06 287.37 232.10 246.98 332.73 250.93 202.65 95 283.89 382.45 288.42 232.93 247.89 333.92 251.83 203.40 96 284.93 383.82 289.46 233.79 248.86 335.27 252.84 204.22 97 286.05 385.37 290.62 234.73 249.76 336.46 253.74 204.94 98 287.08 386.74 291.66 235.56 250.16 337.01 254.14 205.27 99 287.54 387.37 292.12 235.94 See PREMIUM INFORMATION regarding Household Premium Discount rating. To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, or 3, respectively. SHENMS OOC 08/2014 TX Page 7 0119 TX
PREMIUM INFORMATION Your premium will increase each year because of the increase in Your attained age. We, Shenandoah Life Insurance Company, ca n also raise Your premium if (a) We change the premium rates which apply to all policies of this form issued by Us and in-force in Your state; (b) coverage under Medicare changes; or (c) You move to a different ZIP code location. We will send You the advance written notice required by your state when We change the premium rates for a ll policies of this form issued by Us and inforce in Your state. There will be a one-time policy fee of $25.00 added to the first premium. HOUSEHOLD PREMIUM DISCOUNT You are eligible for a household premium discount if for the past year you have resided with at least one, but no more than three, other adults who are age 50 or older or if you live with another adult who is your legal spouse, including validly recognized domestic partners. We may request additional documentation to determine eligibility. The discount will be priced 7% lower than the rates illustrated. 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 Your insurance company. 30-DAY RIGHT TO RETURN POLICY If You find that You are not satisfied with your policy, You may return it to Shenandoah Life Insurance Company, P.O. Box 14558, Clearwater, FL 33766-4558. 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 premiums. 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 Shenandoah Life Insurance Company nor its producers 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. LIMITATIONS AND EXCLUSIONS Your Medicare Supplement policy will not contain limitations and exclusions that are more restrictive than the limitations and exclusions contained in Medicare. The limitations and exclusions include: (a) an expense incurred while the policy is not in force, except as provided in the Extension of Benefits section of the policy; (b) Hospital or Skilled Nursing Facility confinement charges incurred prior to the effective date of coverage; (c) services for non-medicare Eligible Expenses, including, but not limited to, routine exams, take-home drugs and eye refractions; or (e) services for which a charge is not normally made in the absence of insurance. REFUND OF PREMIUM The policy contains a provision providing for a refund or partial refund of premium upon Your death or the surrender of the policy. SHENMS OOC 08/2014 TX Page 8 0119 TX
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. RENEWABILITY This Policy is guaranteed renewable for life. SHENMS OOC 08/2014 TX Page 9 0119 TX
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 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: While using 60 lifetime reserve days Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days 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 21 st thru 100 th day 101 st day and after BLOOD First 3 pints Additional amounts HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but $1,364 All but $341 a day All but $682 a day All approved amounts All but $170.50 a day 100% All but very limited copayment/ for outpatient drugs and inpatient respite care $341 a day $682 a day 100% of Medicare Eligible Expenses 3 pints Medicare copayment/ $1,364 (Part A ) ** Up to $170.50 a day **NOTICE: When Your Medicare Part A hospital benefits are exhausted, the insurer stands in 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. SHENMS OOC 08/2014 Page 10 0119 TX
PLAN A MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once You have been billed $185 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B will have been met for the calendar year. 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 $185 of Medicare-approved amounts* Generally 80% Generally 20% Part B Excess Charges (Above Medicare-approved amounts) All costs BLOOD First 3 pints Next $185 of Medicare-approved amounts* 80% 20% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% PARTS A & B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $185 of Medicare-approved amounts* 100% 80% 20% SHENMS OOC 08/2014 Page 11 0119 TX
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 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: While using 60 lifetime reserve days Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days 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 21 st thru 100 th day 101 st day and after BLOOD First 3 pints Additional amounts HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but $1,364 All but $341 a day All but $682 a day All approved amounts All but $170.50 a day 100% All but very limited copayment/ for outpatient drugs and inpatient respite care $1,364 (Part A ) $341 a day $682 a day 100% of Medicare Eligible Expenses Up to $170.50 a day 3 pints Medicare copayment/ ** **NOTICE: When Your Medicare Part A hospital benefits are exhausted, the insurer stands in 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. SHENMS OOC 08/2014 Page 12 0119 TX
PLAN F MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once You have been billed $185 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B will have been met for the calendar year. 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 $185 of Medicare-approved amounts* Generally 80% Generally 20% Part B Excess Charges (Above Medicare-approved amounts) 100% BLOOD First 3 pints Next $185 of Medicare-approved amounts* 80% 20% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $185 of Medicare-approved amounts* 100% 80% PARTS A & B 20% OTHER BENEFITS NOT COVERED BY MEDICARE FOREIGN TRAVEL NOT 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 Remainder of charges 80% to a lifetime maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum SHENMS OOC 08/2014 Page 13 0119 TX
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 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: While using 60 lifetime reserve days Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days 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 21 st thru 100 th day 101 st day and after BLOOD First 3 pints Additional amounts HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but $1,364 All but $341 a day All but $682 a day All approved amounts All but $170.50 a day 100% All but very limited copayment/ for outpatient drugs and inpatient respite care $1,364 (Part A ) $341 a day $682 a day 100% of Medicare Eligible Expenses Up to $170.50 a day 3 pints Medicare copayment/ ** **NOTICE: When Your Medicare Part A hospital benefits are exhausted, the insurer stands in 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. SHENMS OOC 08/2014 Page 14 0119 TX
PLAN G MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once You have been billed $185 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B will have been met for the calendar year. 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 $185 of Medicare-approved amounts* (the Part B ) Generally 80% Generally 20% Part B Excess Charges (Above Medicare-approved amounts) 100% BLOOD First 3 pints Next $185 of Medicare-approved amounts* 80% 20% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $185 of Medicare-approved amounts* 100% 80% PARTS A & B 20% OTHER BENEFITS NOT COVERED BY MEDICARE FOREIGN TRAVEL NOT 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 Remainder of charges 80% to a lifetime maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum SHENMS OOC 08/2014 Page 15 0119 TX
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 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: While using 60 lifetime reserve days Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days 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 21 st thru 100 th day 101 st day and after BLOOD First 3 pints Additional amounts HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but $1,364 All but $341 a day All but $682 a day All approved amounts All but $170.50 a day 100% All but very limited copayment/ for outpatient drugs and inpatient respite care $1,364 (Part A ) $341 a day $682 a day 100% of Medicare Eligible Expenses Up to $170.50 a day 3 pints Medicare copayment/ ** **NOTICE: When Your Medicare Part A hospital benefits are exhausted, the insurer stands in 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. SHENMS OOC 08/2014 Page 16 0119 TX
PLAN N MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once You have been billed $185 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B will have been met for the calendar year. 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 $185 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) BLOOD First 3 pints Next $185 of Medicare-approved amounts* 80% 20% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% 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. SHENMS OOC 08/2014 Page 17 0119 TX
PLAN N PARTS A & B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $185 of Medicare-approved amounts* 100% 80% 20% OTHER BENEFITS NOT COVERED BY MEDICARE FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges 80% to a lifetime maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum SHENMS OOC 08/2014 Page 18 0119 TX