American Automobile Association (AAA) Medicare Supplement Insurance Office 800 Crescent Centre Dr. Suite 200 Franklin, TN 37067 855 663.2201 aetnaseniorproducts.com Outline of Coverage Medicare Supplement Insurance BENEFIT S: A, B, F, G, & N An Aetna Company AAA Medicare Supplement Plans Insured by Aetna Health and Life Insurance Company Virginia AHLAA02724VA 2016 Aetna Inc. Rates Effective:
AHLAA02724VA 1 AETNA HEALTH AND LIFE INSURANCE COMPANY OUTLINE OF SUPPLEMENT COVERAGE COVER PAGE: Page 1 of 2 BENEFIT S AVAILABLE: A, B, F, G, N These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan A and Plan B. Some plans may not be available in your state. See Outlines of Coverage section for details about ALL plans Basic Benefits: Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses: Part B coinsurance (generally 20% of Medicare-Approved expenses) or, co-payments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of coinsurance or copayments Blood: First three pints of blood each year. Hospice-Part A coinsurance A B C D F/F* G K L M N Basic, Basic, Basic, Basic, Basic, Basic, including including including including including including 100% Part B 100% Part B 100% Part B 100% Part B 100% Part B 100% Part B coinsurance coinsurance coinsurance coinsurance coinsurance coinsurance Basic, including 100% Part B coinsurance Part A Deductible Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Foreign Travel Emergency Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency 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 $4960; 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 $2480; paid at 100% after limit reached Skilled Nursing Facility Coinsurance 50% Part A Deductible Foreign Travel Emergency Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency *Plans 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 $2180 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan s separate foreign travel emergency deductible.
Aetna Health and Life Insurance Company Annual Attained Age Premiums For Use in ZIP Codes: 220-225 Female Rates Attained Non-Smoker Attained Smoker Age Plan A Plan B Plan F Plan G Plan N Age Plan A Plan B Plan F Plan G Plan N 65 1,293 1,464 1,745 1,576 1,209 65 1,421 1,610 1,920 1,734 1,330 66 1,330 1,514 1,808 1,634 1,254 66 1,463 1,665 1,989 1,798 1,379 67 1,368 1,563 1,869 1,690 1,299 67 1,504 1,719 2,056 1,859 1,429 68 1,405 1,611 1,929 1,745 1,343 68 1,545 1,773 2,121 1,920 1,476 69 1,441 1,660 1,989 1,801 1,386 69 1,585 1,826 2,188 1,981 1,525 70 1,478 1,708 2,046 1,855 1,430 70 1,625 1,879 2,251 2,040 1,573 71 1,514 1,755 2,106 1,909 1,473 71 1,665 1,930 2,318 2,100 1,620 72 1,549 1,800 2,164 1,963 1,515 72 1,704 1,980 2,380 2,159 1,666 73 1,581 1,850 2,228 2,023 1,563 73 1,740 2,035 2,450 2,225 1,719 74 1,614 1,899 2,290 2,080 1,610 74 1,775 2,089 2,519 2,288 1,771 75 1,644 1,945 2,349 2,136 1,655 75 1,809 2,140 2,584 2,350 1,820 76 1,675 1,993 2,409 2,194 1,701 76 1,843 2,191 2,650 2,414 1,871 77 1,705 2,039 2,470 2,251 1,748 77 1,875 2,243 2,718 2,476 1,923 78 1,720 2,075 2,521 2,300 1,789 78 1,893 2,283 2,774 2,530 1,968 79 1,733 2,111 2,570 2,349 1,830 79 1,906 2,323 2,828 2,584 2,013 80 1,743 2,141 2,614 2,391 1,865 80 1,916 2,355 2,875 2,630 2,051 81 1,755 2,176 2,663 2,439 1,906 81 1,930 2,394 2,929 2,683 2,098 82 1,769 2,211 2,710 2,486 1,946 82 1,946 2,433 2,981 2,735 2,141 83 1,783 2,273 2,805 2,583 2,031 83 1,961 2,500 3,085 2,841 2,235 84 1,795 2,333 2,899 2,678 2,115 84 1,975 2,566 3,189 2,945 2,326 85 1,810 2,378 2,974 2,756 2,185 85 1,991 2,615 3,271 3,033 2,404 86 1,824 2,424 3,050 2,838 2,259 86 2,006 2,666 3,355 3,121 2,485 87 1,836 2,469 3,129 2,921 2,336 87 2,020 2,716 3,441 3,214 2,570 88 1,851 2,516 3,210 3,005 2,414 88 2,036 2,768 3,531 3,305 2,655 89 1,865 2,565 3,293 3,094 2,495 89 2,051 2,821 3,621 3,404 2,745 90+ 1,879 2,613 3,378 3,185 2,579 90+ 2,066 2,874 3,715 3,504 2,836 Modal Factors: Semi-Annual: 0.5000 Quarterly: 0.2500 Monthly: 0.0833 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 Non-Smoker rates AHLAA02724VA 2
Aetna Health and Life Insurance Company Annual Attained Age Premiums For Use in ZIP Codes: 220-225 Male Rates Attained Non-Smoker Attained Smoker Age Plan A Plan B Plan F Plan G Plan N Age Plan A Plan B Plan F Plan G Plan N 65 1,399 1,584 1,885 1,688 1,276 65 1,539 1,743 2,074 1,856 1,404 66 1,439 1,638 1,951 1,749 1,325 66 1,583 1,801 2,146 1,924 1,458 67 1,479 1,690 2,019 1,809 1,374 67 1,626 1,859 2,221 1,990 1,511 68 1,520 1,744 2,083 1,869 1,419 68 1,673 1,919 2,291 2,056 1,561 69 1,559 1,795 2,148 1,929 1,465 69 1,715 1,975 2,363 2,121 1,611 70 1,598 1,848 2,210 1,985 1,511 70 1,758 2,033 2,431 2,184 1,663 71 1,638 1,898 2,275 2,044 1,556 71 1,801 2,088 2,503 2,249 1,713 72 1,676 1,949 2,336 2,101 1,601 72 1,844 2,144 2,570 2,311 1,761 73 1,710 2,001 2,405 2,165 1,651 73 1,881 2,201 2,645 2,381 1,816 74 1,745 2,054 2,473 2,228 1,701 74 1,920 2,259 2,720 2,450 1,871 75 1,778 2,105 2,536 2,288 1,750 75 1,955 2,315 2,790 2,516 1,925 76 1,813 2,155 2,601 2,349 1,798 76 1,994 2,370 2,861 2,584 1,978 77 1,845 2,206 2,668 2,410 1,846 77 2,030 2,428 2,934 2,651 2,031 78 1,860 2,246 2,723 2,463 1,890 78 2,046 2,471 2,995 2,709 2,079 79 1,875 2,284 2,776 2,515 1,934 79 2,063 2,513 3,054 2,766 2,128 80 1,885 2,316 2,823 2,560 1,973 80 2,074 2,548 3,105 2,816 2,170 81 1,899 2,354 2,875 2,610 2,014 81 2,089 2,589 3,163 2,871 2,215 82 1,914 2,393 2,928 2,663 2,056 82 2,105 2,631 3,220 2,929 2,263 83 1,929 2,459 3,029 2,765 2,146 83 2,121 2,705 3,331 3,041 2,361 84 1,943 2,524 3,131 2,868 2,234 84 2,136 2,776 3,445 3,154 2,458 85 1,958 2,573 3,211 2,951 2,310 85 2,154 2,830 3,533 3,246 2,541 86 1,973 2,623 3,294 3,038 2,388 86 2,170 2,885 3,624 3,341 2,626 87 1,986 2,671 3,380 3,128 2,469 87 2,185 2,939 3,718 3,440 2,716 88 2,003 2,721 3,466 3,218 2,551 88 2,203 2,994 3,813 3,539 2,806 89 2,018 2,775 3,556 3,314 2,636 89 2,219 3,053 3,913 3,645 2,900 90+ 2,033 2,826 3,648 3,410 2,726 90+ 2,236 3,109 4,013 3,751 2,999 Modal Factors: Semi-Annual: 0.5000 Quarterly: 0.2500 Monthly: 0.0833 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 Non-Smoker rates AHLAA02724VA 3
Aetna Health and Life Insurance Company Annual Attained Age Premiums For Use in ZIP Codes: 230-237 Female Rates Attained Non-Smoker Attained Smoker Age Plan A Plan B Plan F Plan G Plan N Age Plan A Plan B Plan F Plan G Plan N 65 1,168 1,323 1,577 1,425 1,093 65 1,285 1,455 1,736 1,567 1,202 66 1,202 1,368 1,634 1,477 1,133 66 1,322 1,505 1,798 1,625 1,246 67 1,236 1,413 1,689 1,528 1,174 67 1,359 1,554 1,859 1,680 1,292 68 1,270 1,457 1,744 1,577 1,214 68 1,397 1,602 1,918 1,736 1,335 69 1,303 1,501 1,798 1,628 1,253 69 1,433 1,651 1,978 1,791 1,379 70 1,336 1,544 1,850 1,677 1,293 70 1,469 1,698 2,035 1,844 1,422 71 1,368 1,587 1,904 1,726 1,331 71 1,505 1,745 2,095 1,898 1,464 72 1,400 1,627 1,956 1,774 1,370 72 1,540 1,790 2,152 1,952 1,506 73 1,429 1,672 2,014 1,828 1,413 73 1,573 1,840 2,215 2,011 1,554 74 1,459 1,716 2,070 1,880 1,455 74 1,605 1,888 2,277 2,068 1,601 75 1,486 1,758 2,123 1,931 1,496 75 1,635 1,935 2,336 2,124 1,645 76 1,514 1,801 2,178 1,983 1,538 76 1,666 1,981 2,396 2,182 1,692 77 1,541 1,843 2,233 2,035 1,580 77 1,695 2,027 2,457 2,239 1,738 78 1,555 1,876 2,279 2,079 1,617 78 1,711 2,063 2,507 2,287 1,779 79 1,566 1,909 2,323 2,123 1,654 79 1,723 2,100 2,556 2,336 1,819 80 1,575 1,936 2,363 2,162 1,686 80 1,732 2,129 2,599 2,378 1,854 81 1,587 1,967 2,407 2,205 1,723 81 1,745 2,164 2,648 2,425 1,896 82 1,599 1,999 2,450 2,248 1,759 82 1,759 2,199 2,695 2,472 1,936 83 1,611 2,054 2,536 2,335 1,836 83 1,773 2,260 2,789 2,568 2,020 84 1,623 2,109 2,620 2,420 1,912 84 1,785 2,320 2,883 2,662 2,103 85 1,636 2,149 2,688 2,492 1,975 85 1,800 2,364 2,957 2,741 2,173 86 1,649 2,191 2,757 2,565 2,042 86 1,814 2,410 3,033 2,822 2,246 87 1,660 2,232 2,828 2,641 2,112 87 1,826 2,455 3,111 2,905 2,323 88 1,674 2,275 2,902 2,717 2,182 88 1,841 2,502 3,192 2,988 2,400 89 1,686 2,319 2,976 2,797 2,255 89 1,854 2,550 3,274 3,077 2,481 90+ 1,698 2,362 3,053 2,879 2,331 90+ 1,868 2,598 3,358 3,167 2,564 Modal Factors: Semi-Annual: 0.5000 Quarterly: 0.2500 Monthly: 0.0833 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 Non-Smoker rates AHLAA02724VA 4
Aetna Health and Life Insurance Company Annual Attained Age Premiums For Use in ZIP Codes: 230-237 Male Rates Attained Non-Smoker Attained Smoker Age Plan A Plan B Plan F Plan G Plan N Age Plan A Plan B Plan F Plan G Plan N 65 1,264 1,432 1,704 1,526 1,154 65 1,391 1,575 1,875 1,678 1,269 66 1,301 1,480 1,764 1,581 1,198 66 1,431 1,628 1,940 1,739 1,318 67 1,337 1,528 1,825 1,635 1,242 67 1,470 1,680 2,008 1,799 1,366 68 1,374 1,576 1,883 1,689 1,283 68 1,512 1,735 2,071 1,859 1,411 69 1,409 1,623 1,941 1,744 1,324 69 1,550 1,785 2,136 1,918 1,457 70 1,444 1,670 1,998 1,794 1,366 70 1,589 1,837 2,198 1,974 1,503 71 1,480 1,715 2,057 1,848 1,407 71 1,628 1,887 2,262 2,033 1,548 72 1,515 1,762 2,112 1,900 1,448 72 1,667 1,938 2,323 2,089 1,592 73 1,546 1,809 2,174 1,957 1,493 73 1,701 1,990 2,391 2,153 1,642 74 1,577 1,857 2,235 2,014 1,538 74 1,736 2,042 2,459 2,215 1,692 75 1,607 1,903 2,293 2,068 1,582 75 1,767 2,093 2,522 2,275 1,740 76 1,639 1,948 2,352 2,123 1,625 76 1,802 2,142 2,587 2,336 1,788 77 1,668 1,994 2,411 2,179 1,669 77 1,835 2,194 2,652 2,397 1,836 78 1,681 2,031 2,461 2,226 1,709 78 1,850 2,234 2,707 2,449 1,879 79 1,695 2,065 2,510 2,274 1,748 79 1,865 2,271 2,761 2,501 1,923 80 1,704 2,094 2,552 2,314 1,783 80 1,875 2,303 2,807 2,546 1,962 81 1,716 2,128 2,599 2,359 1,820 81 1,888 2,340 2,859 2,596 2,002 82 1,730 2,163 2,646 2,407 1,859 82 1,903 2,379 2,911 2,648 2,045 83 1,744 2,223 2,738 2,500 1,940 83 1,918 2,445 3,011 2,749 2,135 84 1,756 2,281 2,831 2,592 2,019 84 1,931 2,510 3,114 2,851 2,222 85 1,770 2,326 2,903 2,668 2,088 85 1,947 2,558 3,193 2,935 2,297 86 1,783 2,371 2,978 2,746 2,158 86 1,962 2,608 3,276 3,020 2,374 87 1,796 2,415 3,056 2,827 2,232 87 1,975 2,657 3,361 3,110 2,455 88 1,810 2,460 3,133 2,909 2,306 88 1,991 2,706 3,447 3,199 2,537 89 1,824 2,509 3,215 2,996 2,383 89 2,006 2,759 3,537 3,295 2,622 90+ 1,837 2,555 3,297 3,083 2,465 90+ 2,022 2,810 3,627 3,391 2,711 Modal Factors: Semi-Annual: 0.5000 Quarterly: 0.2500 Monthly: 0.0833 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 Non-Smoker rates AHLAA02724VA 5
Aetna Health and Life Insurance Company Annual Attained Age Premiums For Use in ZIP Codes: Rest of State Female Rates Attained Non-Smoker Attained Smoker Age Plan A Plan B Plan F Plan G Plan N Age Plan A Plan B Plan F Plan G Plan N 65 1,034 1,171 1,396 1,261 967 65 1,137 1,288 1,536 1,387 1,064 66 1,064 1,211 1,446 1,307 1,003 66 1,170 1,332 1,591 1,438 1,103 67 1,094 1,250 1,495 1,352 1,039 67 1,203 1,375 1,645 1,487 1,143 68 1,124 1,289 1,543 1,396 1,074 68 1,236 1,418 1,697 1,536 1,181 69 1,153 1,328 1,591 1,441 1,109 69 1,268 1,461 1,750 1,585 1,220 70 1,182 1,366 1,637 1,484 1,144 70 1,300 1,503 1,801 1,632 1,258 71 1,211 1,404 1,685 1,527 1,178 71 1,332 1,544 1,854 1,680 1,296 72 1,239 1,440 1,731 1,570 1,212 72 1,363 1,584 1,904 1,727 1,333 73 1,265 1,480 1,782 1,618 1,250 73 1,392 1,628 1,960 1,780 1,375 74 1,291 1,519 1,832 1,664 1,288 74 1,420 1,671 2,015 1,830 1,417 75 1,315 1,556 1,879 1,709 1,324 75 1,447 1,712 2,067 1,880 1,456 76 1,340 1,594 1,927 1,755 1,361 76 1,474 1,753 2,120 1,931 1,497 77 1,364 1,631 1,976 1,801 1,398 77 1,500 1,794 2,174 1,981 1,538 78 1,376 1,660 2,017 1,840 1,431 78 1,514 1,826 2,219 2,024 1,574 79 1,386 1,689 2,056 1,879 1,464 79 1,525 1,858 2,262 2,067 1,610 80 1,394 1,713 2,091 1,913 1,492 80 1,533 1,884 2,300 2,104 1,641 81 1,404 1,741 2,130 1,951 1,525 81 1,544 1,915 2,343 2,146 1,678 82 1,415 1,769 2,168 1,989 1,557 82 1,557 1,946 2,385 2,188 1,713 83 1,426 1,818 2,244 2,066 1,625 83 1,569 2,000 2,468 2,273 1,788 84 1,436 1,866 2,319 2,142 1,692 84 1,580 2,053 2,551 2,356 1,861 85 1,448 1,902 2,379 2,205 1,748 85 1,593 2,092 2,617 2,426 1,923 86 1,459 1,939 2,440 2,270 1,807 86 1,605 2,133 2,684 2,497 1,988 87 1,469 1,975 2,503 2,337 1,869 87 1,616 2,173 2,753 2,571 2,056 88 1,481 2,013 2,568 2,404 1,931 88 1,629 2,214 2,825 2,644 2,124 89 1,492 2,052 2,634 2,475 1,996 89 1,641 2,257 2,897 2,723 2,196 90+ 1,503 2,090 2,702 2,548 2,063 90+ 1,653 2,299 2,972 2,803 2,269 Modal Factors: Semi-Annual: 0.5000 Quarterly: 0.2500 Monthly: 0.0833 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 Non-Smoker rates AHLAA02724VA 6
Aetna Health and Life Insurance Company Annual Attained Age Premiums For Use in ZIP Codes: Rest of State Male Rates Attained Non-Smoker Attained Smoker Age Plan A Plan B Plan F Plan G Plan N Age Plan A Plan B Plan F Plan G Plan N 65 1,119 1,267 1,508 1,350 1,021 65 1,231 1,394 1,659 1,485 1,123 66 1,151 1,310 1,561 1,399 1,060 66 1,266 1,441 1,717 1,539 1,166 67 1,183 1,352 1,615 1,447 1,099 67 1,301 1,487 1,777 1,592 1,209 68 1,216 1,395 1,666 1,495 1,135 68 1,338 1,535 1,833 1,645 1,249 69 1,247 1,436 1,718 1,543 1,172 69 1,372 1,580 1,890 1,697 1,289 70 1,278 1,478 1,768 1,588 1,209 70 1,406 1,626 1,945 1,747 1,330 71 1,310 1,518 1,820 1,635 1,245 71 1,441 1,670 2,002 1,799 1,370 72 1,341 1,559 1,869 1,681 1,281 72 1,475 1,715 2,056 1,849 1,409 73 1,368 1,601 1,924 1,732 1,321 73 1,505 1,761 2,116 1,905 1,453 74 1,396 1,643 1,978 1,782 1,361 74 1,536 1,807 2,176 1,960 1,497 75 1,422 1,684 2,029 1,830 1,400 75 1,564 1,852 2,232 2,013 1,540 76 1,450 1,724 2,081 1,879 1,438 76 1,595 1,896 2,289 2,067 1,582 77 1,476 1,765 2,134 1,928 1,477 77 1,624 1,942 2,347 2,121 1,625 78 1,488 1,797 2,178 1,970 1,512 78 1,637 1,977 2,396 2,167 1,663 79 1,500 1,827 2,221 2,012 1,547 79 1,650 2,010 2,443 2,213 1,702 80 1,508 1,853 2,258 2,048 1,578 80 1,659 2,038 2,484 2,253 1,736 81 1,519 1,883 2,300 2,088 1,611 81 1,671 2,071 2,530 2,297 1,772 82 1,531 1,914 2,342 2,130 1,645 82 1,684 2,105 2,576 2,343 1,810 83 1,543 1,967 2,423 2,212 1,717 83 1,697 2,164 2,665 2,433 1,889 84 1,554 2,019 2,505 2,294 1,787 84 1,709 2,221 2,756 2,523 1,966 85 1,566 2,058 2,569 2,361 1,848 85 1,723 2,264 2,826 2,597 2,033 86 1,578 2,098 2,635 2,430 1,910 86 1,736 2,308 2,899 2,673 2,101 87 1,589 2,137 2,704 2,502 1,975 87 1,748 2,351 2,974 2,752 2,173 88 1,602 2,177 2,773 2,574 2,041 88 1,762 2,395 3,050 2,831 2,245 89 1,614 2,220 2,845 2,651 2,109 89 1,775 2,442 3,130 2,916 2,320 90+ 1,626 2,261 2,918 2,728 2,181 90+ 1,789 2,487 3,210 3,001 2,399 Modal Factors: Semi-Annual: 0.5000 Quarterly: 0.2500 Monthly: 0.0833 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 Non-Smoker rates AHLAA02724VA 7
PREMIUM INFORMATION Premiums for this Aetna Health and Life Insurance Company certificate are attained age rated. Premiums for this certificate will increase each year as you get older. Premiums for other Medicare Supplement certificates that are issue age or community rated do not increase due to the change in your age. While the cost of this certificate at your present age may be lower than the cost of a Medicare supplement certificate that is based on issue age or community rated, it is important to compare the potential cost of these certificates over the life of the certificate. We guarantee to renew this Certificate during your lifetime as long as You pay Your renewal premiums on time, either in advance or during the grace period. Your certificate will end on the date any required premium is due and unpaid subject to the end of the thirty-one (31) day Grace Period. We may not cancel or non-renew this Certificate solely on the ground of Your health status. We also may not cancel or non-renew this Certificate for a reason other than nonpayment of premium or material misrepresentation. Your premium will change on the first renewal date that coincides with or follows each Anniversary of the Effective Date. The new premium will be based upon your age at that time. Additionally, We reserve the right to revise the table of premium rates. If We make such a change of premium, We will provide to You advance notice. Premiums payable other than annual will be determined according to the following factors: Semi-annual: 0.5000 Quarterly: 0.2500 Monthly EFT: 0.0833. HOUSEHOLD DISCOUNT In order to be eligible for the Household discount under an Aetna Health and Life 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 a member of American Grandparents Association and covered by an Aetna Health and Life Insurance Company Medicare supplement certificate. The Medicare eligible adult must be either (a) your spouse; (b) be a permanent resident in your home. The household discount will only be applicable if a certificate 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. DISCLOSURE Use this outline to compare benefits and premium among certificates. READ R CERTIFICATE VERY CAREFULLY This is only an outline describing your certificate s most important features. The certificate is your insurance contract. You must read the certificate itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN CERTIFICATE If you find that you are not satisfied with your certificate, you may return it to Aetna Health and Life Insurance Company, P.O. Box 2368, Brentwood, Tennessee 37024. If you send the certificate back to us within 30 days after you receive it, we will treat the certificate as if it had never been issued and return all your payments promptly. CERTIFICATE REPLACEMENT If you are replacing another health insurance certificate, do NOT cancel it until you have actually received your new certificate and are sure you want to keep it. NOTICE The certificate may not cover all of your medical costs. Neither Aetna Health and Life 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 enrollment form for the new certificate, be sure to answer truthfully and completely any questions about your medical and health history. The company may cancel your certificate and refuse to pay any claims if you leave out or falsify important medical information. Review the enrollment form carefully before you sign it. Be certain that all information has been properly recorded. THE FOLLOWING CHARTS DESCRIBE S A, B, F, G and N OFFERED BY AETNA HEALTH AND LIFE INSURANCE COMPANY. AHLAA02724VA 8
A (PART A) HOSPITAL PER CALENDAR YEAR *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 $1288 $0 $1288 (Part A Deductible) 61st thru 90th day All but $322 a day $322 a day $0 91st day and after While using 60 lifetime reserve days All but $644 a day $644 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses Beyond the Additional 365 days $0 $0 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 $0 $0 21st thru 100th day All but $161.00 a day $0 Up to $161.00 a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 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 certificate 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. $0** $0 AHLAA02724VA 9
A (PART B) MEDICAL PER CALENDAR YEAR *Once you have been billed $166 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 test, durable medical equipment First $166 of Medicare-Approved amounts* $0 $0 $166 Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $166 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% $0 $0 $0 $0 $166 HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies PARTS A & B 100% $0 $0 Durable medical equipment First $166of Medicare Approved amounts* $0 $0 $166 Remainder of Medicare Approved amounts 80% 20% $0 AHLAA02724VA 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 $1288 $1288 (Part A Deductible) 61st thru 90th day All but $322 a day $322 a day $0 91st day and after While using 60 lifetime reserve days All but $644 a day $644 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses Beyond the Additional 365 days $0 $0 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 $0 $0** All approved $0 $0 amounts 21st thru 100th day All but $161.00 a day $0 Up to $161.00 a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 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 365 days as provided in the certificate 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. $0 AHLAA02724VA 11
B (PART B) MEDICAL PER CALENDAR YEAR * Once you have been billed $166 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 test, durable medical equipment First $166 of Medicare-Approved amounts* $0 $0 $166 Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $166 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% $0 $0 $0 $0 $166 HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies PARTS A & B 100% $0 $0 Durable medical equipment First $166 of Medicare Approved amounts* $0 $0 $166 Remainder of Medicare Approved amounts 80% 20% $0 AHLAA02724VA 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 $1288 $1288 (Part A Deductible) 61st thru 90th day All but $322 a day $322 a day $0 91st day and after While using 60 lifetime reserve days All but $644 a day $644 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses Beyond the Additional 365 days $0 $0 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 $0 $0 amounts 21st thru 100th day All but $161.00 a Up to $161.00 a $0 day day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 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 $0 $0** **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 certificate 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. $0 AHLAA02724VA 13
F (PART B) MEDICAL PER CALENDAR YEAR *Once you have been billed $166 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 test, durable medical equipment First $166 of Medicare-Approved amounts* $0 $166 Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $166 of Medicare-Approved $0 $166 $0 amounts* Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% $0 $0 $0 HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies PARTS A & B 100% $0 $0 Durable medical equipment First $166 of Medicare Approved amounts* $0 $166 $0 Remainder of Medicare Approved amounts 80% 20% $0 AHLAA02724VA 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 $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum AHLAA02724VA 15
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 $1288 $1288 (Part A Deductible) 61st thru 90th day All but $322 a day $322 a day $0 91st day and after While using 60 lifetime reserve days All but $644 a day $644 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses Beyond the Additional 365 days $0 $0 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 $0 $0 amounts 21st thru 100th day All but $161.00 a Up to $161.00 a $0 day day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness services All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance $0 $0** **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 certificate 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. $0 AHLAA02724VA 16
G (PART B) MEDICAL PER CALENDAR YEAR *Once you have been billed $166 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 test, durable medical equipment First $166 of Medicare-Approved amounts* $0 $0 $166 Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $166 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% $0 $0 $0 $0 $166 PARTS A & B HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $166 of Medicare Approved amounts* $0 $0 $166 Remainder of Medicare Approved amounts 80% 20% $0 AHLAA02724VA 17
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 $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum AHLAA02724VA 18
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 $1288 $1288 (Part A Deductible) 61st thru 90th day All but $322 a day $322 a day $0 91st day and after While using 60 lifetime reserve days All but $644 a day $644 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses Beyond the Additional 365 days $0 $0 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 $0 $0 amounts 21st thru 100th day All but $161.00 a Up to $161.00 a $0 day day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness services All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare co-payment/ coinsurance $0 $0** **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 certificate 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. $0 AHLAA02724VA 19
N (PART B) MEDICAL PER CALENDAR YEAR *Once you have been billed $166 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 test, durable medical equipment First $166 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts $0 $0 $166 Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. Part B Excess Charges (Above Medicare-Approved amounts) $0 0% All costs BLOOD First 3 pints $0 All costs $0 Next $166 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% $0 $0 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. $0 $0 $166 AHLAA02724VA 20
N PARTS A & B HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $166 of Medicare Approved amounts* $0 $0 $166 Remainder of Medicare Approved amounts 80% 20% $0 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 $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum AHLAA02724VA 21