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 Arizona 2016 Aetna Inc. Rates Effective:
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 Some plans may not be available in your state. 1 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, co-payments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of or copayments Blood: First three pints of blood each year. Hospice-Part A A B C D F/F* G K L M N Basic, including 100% Part B Basic, including 100% Part B Part A Deductible Basic, including 100% Part B Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Coinsurance Part A Deductible Part B Excess (100%) Foreign Travel Emergency Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility Coinsurance 50% Part A Deductible Out-of-pocket limit $5,120; paid at 100% after limit reached Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% 75% Skilled Nursing Facility Coinsurance 75% Part A Deductible Out-of-pocket limit $2,560; paid at 100% after limit reached Basic, including 100% Part B Skilled Nursing Facility Coinsurance 50% Part A Deductible Foreign Travel Emergency Basic, including 100% Part B, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,200 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2,200. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the 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.
2 Aetna Health and Life Insurance Company Annual Issue Age Premiums For Use in ZIP Code: 850 Female Rates Rates Effective 06/01/2016 Issue Preferred Issue Standard Age Plan A Plan B Plan F Plan G Plan N Age Plan A Plan B Plan F Plan G Plan N 65 1,546 1,851 2,202 1,481 1,434 65 1,701 2,036 2,422 1,630 1,577 66 1,576 1,897 2,262 1,521 1,476 66 1,734 2,086 2,488 1,674 1,624 67 1,607 1,943 2,320 1,562 1,518 67 1,768 2,139 2,553 1,719 1,669 68 1,637 1,989 2,378 1,602 1,558 68 1,802 2,189 2,616 1,763 1,714 69 1,665 2,034 2,435 1,642 1,599 69 1,832 2,236 2,678 1,807 1,759 70 1,693 2,079 2,494 1,682 1,642 70 1,864 2,288 2,744 1,851 1,807 71 1,720 2,123 2,551 1,725 1,684 71 1,893 2,335 2,807 1,897 1,852 72 1,746 2,168 2,611 1,767 1,728 72 1,922 2,385 2,871 1,943 1,901 73 1,768 2,208 2,666 1,806 1,768 73 1,943 2,429 2,933 1,986 1,945 74 1,789 2,248 2,719 1,845 1,808 74 1,968 2,473 2,993 2,029 1,989 75 1,809 2,290 2,774 1,882 1,851 75 1,989 2,518 3,052 2,072 2,036 76 1,825 2,327 2,829 1,923 1,892 76 2,008 2,560 3,112 2,115 2,081 77 1,841 2,366 2,883 1,962 1,934 77 2,025 2,602 3,172 2,158 2,128 78 1,852 2,400 2,933 2,000 1,974 78 2,037 2,640 3,226 2,200 2,172 79 1,862 2,435 2,985 2,040 2,017 79 2,048 2,678 3,285 2,244 2,218 80 1,873 2,472 3,040 2,079 2,063 80 2,059 2,718 3,345 2,288 2,269 81 1,885 2,513 3,102 2,126 2,114 81 2,073 2,765 3,412 2,338 2,325 82 1,896 2,556 3,168 2,176 2,170 82 2,085 2,811 3,486 2,394 2,388 83 1,908 2,601 3,243 2,234 2,234 83 2,098 2,861 3,567 2,457 2,457 84 1,920 2,644 3,312 2,286 2,295 84 2,112 2,908 3,643 2,516 2,524 85 1,930 2,682 3,375 2,335 2,351 85 2,124 2,950 3,712 2,569 2,586 86 1,941 2,717 3,434 2,384 2,406 86 2,135 2,989 3,778 2,622 2,646 87 1,951 2,750 3,492 2,428 2,456 87 2,146 3,024 3,841 2,671 2,701 88 1,958 2,779 3,540 2,466 2,501 88 2,155 3,056 3,894 2,713 2,751 89 1,965 2,800 3,577 2,496 2,536 89 2,162 3,081 3,936 2,745 2,790 90+ 1,968 2,813 3,600 2,513 2,556 90+ 2,164 3,095 3,961 2,763 2,812 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 cent) Modal premium x.95 = discounted premium If applying during Open Enrollment or Guaranteed Issue Period use Preferred rates
3 Aetna Health and Life Insurance Company Annual Issue Age Premiums For Use in ZIP Code: 850 Male Rates Rates Effective 06/01/2016 Issue Preferred Issue Standard Age Plan A Plan B Plan F Plan G Plan N Age Plan A Plan B Plan F Plan G Plan N 65 1,712 2,025 2,375 1,590 1,513 65 1,882 2,228 2,613 1,748 1,664 66 1,746 2,076 2,439 1,635 1,557 66 1,922 2,283 2,684 1,797 1,713 67 1,781 2,128 2,505 1,679 1,601 67 1,958 2,340 2,756 1,847 1,760 68 1,813 2,178 2,566 1,721 1,643 68 1,995 2,395 2,823 1,893 1,808 69 1,845 2,227 2,628 1,765 1,686 69 2,029 2,450 2,891 1,942 1,854 70 1,875 2,275 2,690 1,809 1,730 70 2,063 2,502 2,959 1,990 1,903 71 1,904 2,324 2,754 1,853 1,775 71 2,096 2,557 3,028 2,039 1,953 72 1,931 2,373 2,817 1,898 1,820 72 2,125 2,611 3,099 2,089 2,002 73 1,957 2,418 2,877 1,940 1,864 73 2,153 2,660 3,163 2,134 2,051 74 1,980 2,461 2,935 1,981 1,907 74 2,178 2,706 3,229 2,179 2,097 75 2,002 2,506 2,994 2,024 1,950 75 2,203 2,757 3,293 2,227 2,145 76 2,022 2,547 3,052 2,067 1,995 76 2,223 2,802 3,359 2,273 2,195 77 2,039 2,590 3,110 2,109 2,040 77 2,244 2,850 3,421 2,320 2,244 78 2,051 2,628 3,165 2,148 2,081 78 2,256 2,891 3,482 2,363 2,290 79 2,063 2,666 3,221 2,191 2,126 79 2,268 2,933 3,543 2,410 2,339 80 2,075 2,706 3,281 2,235 2,175 80 2,281 2,978 3,610 2,458 2,392 81 2,086 2,750 3,348 2,284 2,229 81 2,295 3,024 3,683 2,513 2,452 82 2,098 2,796 3,420 2,340 2,289 82 2,308 3,076 3,762 2,573 2,518 83 2,112 2,846 3,499 2,400 2,356 83 2,323 3,132 3,849 2,641 2,591 84 2,125 2,894 3,573 2,458 2,420 84 2,338 3,183 3,932 2,704 2,662 85 2,137 2,935 3,642 2,510 2,479 85 2,351 3,229 4,006 2,761 2,727 86 2,148 2,976 3,708 2,562 2,538 86 2,363 3,273 4,078 2,818 2,791 87 2,159 3,011 3,767 2,610 2,591 87 2,375 3,312 4,144 2,871 2,850 88 2,169 3,041 3,820 2,650 2,638 88 2,386 3,346 4,202 2,915 2,901 89 2,175 3,066 3,861 2,684 2,674 89 2,392 3,373 4,247 2,952 2,941 90+ 2,180 3,081 3,884 2,701 2,696 90+ 2,399 3,389 4,274 2,972 2,966 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 cent) Modal premium x.95 = discounted premium If applying during Open Enrollment or Guaranteed Issue Period use Preferred rates
Aetna Health and Life Insurance Company Annual Issue Age Premiums For Use in ZIP Codes: Rest of State Female Rates Rates Effective 06/01/2016 Issue Preferred Issue Standard Age Plan A Plan B Plan F Plan G Plan N Age Plan A Plan B Plan F Plan G Plan N 65 1,267 1,517 1,805 1,214 1,175 65 1,394 1,669 1,985 1,336 1,293 66 1,292 1,555 1,854 1,247 1,210 66 1,421 1,710 2,039 1,372 1,331 67 1,317 1,593 1,902 1,280 1,244 67 1,449 1,753 2,093 1,409 1,368 68 1,342 1,630 1,949 1,313 1,277 68 1,477 1,794 2,144 1,445 1,405 69 1,365 1,667 1,996 1,346 1,311 69 1,502 1,833 2,195 1,481 1,442 70 1,388 1,704 2,044 1,379 1,346 70 1,528 1,875 2,249 1,517 1,481 71 1,410 1,740 2,091 1,414 1,380 71 1,552 1,914 2,301 1,555 1,518 72 1,431 1,777 2,140 1,448 1,416 72 1,575 1,955 2,353 1,593 1,558 73 1,449 1,810 2,185 1,480 1,449 73 1,593 1,991 2,404 1,628 1,594 74 1,466 1,843 2,229 1,512 1,482 74 1,613 2,027 2,453 1,663 1,630 75 1,483 1,877 2,274 1,543 1,517 75 1,630 2,064 2,502 1,698 1,669 76 1,496 1,907 2,319 1,576 1,551 76 1,646 2,098 2,551 1,734 1,706 77 1,509 1,939 2,363 1,608 1,585 77 1,660 2,133 2,600 1,769 1,744 78 1,518 1,967 2,404 1,639 1,618 78 1,670 2,164 2,644 1,803 1,780 79 1,526 1,996 2,447 1,672 1,653 79 1,679 2,195 2,693 1,839 1,818 80 1,535 2,026 2,492 1,704 1,691 80 1,688 2,228 2,742 1,875 1,860 81 1,545 2,060 2,543 1,743 1,733 81 1,699 2,266 2,797 1,916 1,906 82 1,554 2,095 2,597 1,784 1,779 82 1,709 2,304 2,857 1,962 1,957 83 1,564 2,132 2,658 1,831 1,831 83 1,720 2,345 2,924 2,014 2,014 84 1,574 2,167 2,715 1,874 1,881 84 1,731 2,384 2,986 2,062 2,069 85 1,582 2,198 2,766 1,914 1,927 85 1,741 2,418 3,043 2,106 2,120 86 1,591 2,227 2,815 1,954 1,972 86 1,750 2,450 3,097 2,149 2,169 87 1,599 2,254 2,862 1,990 2,013 87 1,759 2,479 3,148 2,189 2,214 88 1,605 2,278 2,902 2,021 2,050 88 1,766 2,505 3,192 2,224 2,255 89 1,611 2,295 2,932 2,046 2,079 89 1,772 2,525 3,226 2,250 2,287 90+ 1,613 2,306 2,951 2,060 2,095 90+ 1,774 2,537 3,247 2,265 2,305 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 cent) Modal premium x.95 = discounted premium If applying during Open Enrollment or Guaranteed Issue Period use Preferred rates 4
Aetna Health and Life Insurance Company Annual Issue Age Premiums For Use in ZIP Codes: Rest of State Male Rates Rates Effective 06/01/2016 Issue Preferred Issue Standard Age Plan A Plan B Plan F Plan G Plan N Age Plan A Plan B Plan F Plan G Plan N 65 1,403 1,660 1,947 1,303 1,240 65 1,543 1,826 2,142 1,433 1,364 66 1,431 1,702 1,999 1,340 1,276 66 1,575 1,871 2,200 1,473 1,404 67 1,460 1,744 2,053 1,376 1,312 67 1,605 1,918 2,259 1,514 1,443 68 1,486 1,785 2,103 1,411 1,347 68 1,635 1,963 2,314 1,552 1,482 69 1,512 1,825 2,154 1,447 1,382 69 1,663 2,008 2,370 1,592 1,520 70 1,537 1,865 2,205 1,483 1,418 70 1,691 2,051 2,425 1,631 1,560 71 1,561 1,905 2,257 1,519 1,455 71 1,718 2,096 2,482 1,671 1,601 72 1,583 1,945 2,309 1,556 1,492 72 1,742 2,140 2,540 1,712 1,641 73 1,604 1,982 2,358 1,590 1,528 73 1,765 2,180 2,593 1,749 1,681 74 1,623 2,017 2,406 1,624 1,563 74 1,785 2,218 2,647 1,786 1,719 75 1,641 2,054 2,454 1,659 1,598 75 1,806 2,260 2,699 1,825 1,758 76 1,657 2,088 2,502 1,694 1,635 76 1,822 2,297 2,753 1,863 1,799 77 1,671 2,123 2,549 1,729 1,672 77 1,839 2,336 2,804 1,902 1,839 78 1,681 2,154 2,594 1,761 1,706 78 1,849 2,370 2,854 1,937 1,877 79 1,691 2,185 2,640 1,796 1,743 79 1,859 2,404 2,904 1,975 1,917 80 1,701 2,218 2,689 1,832 1,783 80 1,870 2,441 2,959 2,015 1,961 81 1,710 2,254 2,744 1,872 1,827 81 1,881 2,479 3,019 2,060 2,010 82 1,720 2,292 2,803 1,918 1,876 82 1,892 2,521 3,084 2,109 2,064 83 1,731 2,333 2,868 1,967 1,931 83 1,904 2,567 3,155 2,165 2,124 84 1,742 2,372 2,929 2,015 1,984 84 1,916 2,609 3,223 2,216 2,182 85 1,752 2,406 2,985 2,057 2,032 85 1,927 2,647 3,284 2,263 2,235 86 1,761 2,439 3,039 2,100 2,080 86 1,937 2,683 3,343 2,310 2,288 87 1,770 2,468 3,088 2,139 2,124 87 1,947 2,715 3,397 2,353 2,336 88 1,778 2,493 3,131 2,172 2,162 88 1,956 2,743 3,444 2,389 2,378 89 1,783 2,513 3,165 2,200 2,192 89 1,961 2,765 3,481 2,420 2,411 90+ 1,787 2,525 3,184 2,214 2,210 90+ 1,966 2,778 3,503 2,436 2,431 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 cent) Modal premium x.95 = discounted premium If applying during Open Enrollment or Guaranteed Issue Period use Preferred rates 5
PREMIUM INFORMATION Aetna Health and Life Insurance Company can only raise your premium if we raise the premium for all certificates like yours in this state. Premiums may be changed for this certificate on any premium due date, provided premiums for all certificates issued on this form number in your state are also changed. Premiums payable other than annually 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 AAA 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 someone with whom you are in a civil union partnership; or (c) be a permanent resident in your home. The household discount will only be applicable if a 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 certificates remain in force. DISCLOSURES 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. certificate, you may return it to Aetna Health and Life Insurance Company, P.O. Box 14770, Lexington, KY 40512-4770. 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. 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 forms 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 forms 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. RIGHT TO RETURN CERTIFICATE If you find that you are not satisfied with your 6
A (PART A) HOSPITAL PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A Deductible) 61st thru 90th day All but $329 a day $329 a day 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible Expenses Beyond the Additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- Approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $164.50 a day Up to $164.50 a day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the 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. ** 7
A (PART B) MEDICAL PER CALENDAR YEAR *Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare-Approved amounts* $183 Remainder of Medicare-Approved amounts Generally 80% Generally 20% Part B Excess Charges (Above Medicare-Approved amounts) All costs BLOOD First 3 pints All costs Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts 80% 20% CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% $183 HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies PARTS A & B 100% Durable medical equipment First $183 of Medicare Approved amounts* $183 Remainder of Medicare Approved amounts 80% 20% 8
B (PART A) HOSPITAL PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A Deductible) 61st thru 90th day All but $329 a day $329 a day 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible Expenses Beyond the Additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- Approved facility within 30 days after leaving the hospital First 20 days ** All approved amounts 21st thru 100th day All but $164.50 a day Up to $164.50 a day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the 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. 9
B (PART B) MEDICAL PER CALENDAR YEAR * Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare-Approved amounts* $183 Remainder of Medicare-Approved amounts Generally 80% Generally 20% Part B Excess Charges (Above Medicare-Approved amounts) All costs BLOOD First 3 pints All costs Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts 80% 20% CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% $183 HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies PARTS A & B 100% Durable medical equipment First $183 of Medicare Approved amounts* $183 Remainder of Medicare Approved amounts 80% 20% 10
F (PART A) HOSPITAL PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A Deductible) 61st thru 90th day All but $329 a day $329 a day 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible Expenses Beyond the Additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- Approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $164.50 a Up to $164.50 a day day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ ** **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the 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. 11
F (PART B) MEDICAL PER CALENDAR YEAR *Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare-Approved amounts* $183 Remainder of Medicare-Approved amounts Generally 80% Generally 20% Part B Excess Charges (Above Medicare-Approved amounts) 100% BLOOD First 3 pints All costs Next $183 of Medicare-Approved $183 amounts* Remainder of Medicare-Approved amounts 80% 20% CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies PARTS A & B 100% Durable medical equipment First $183 of Medicare Approved amounts* $183 Remainder of Medicare Approved amounts 80% 20% 12
F OTHER BENEFITS NOT COVERED BY FOREIGN TRAVEL NOT COVERED BY Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 13
G (PART A) HOSPITAL PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A Deductible) 61st thru 90th day All but $329 a day $329 a day 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible Expenses Beyond the Additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- Approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $164.50 a Up to $164.50 a day day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness services All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ ** **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the 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. 14
G (PART B) MEDICAL PER CALENDAR YEAR *Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare-Approved amounts* $183 Remainder of Medicare-Approved amounts Generally 80% Generally 20% Part B Excess Charges (Above Medicare-Approved amounts) 100% BLOOD First 3 pints All costs Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts 80% 20% CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% $183 PARTS A & B HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies 100% Durable medical equipment First $183 of Medicare Approved amounts* $183 Remainder of Medicare Approved amounts 80% 20% 15
G OTHER BENEFITS NOT COVERED BY FOREIGN TRAVEL NOT COVERED BY Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 16
N (PART A) HOSPITAL PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A Deductible) 61st thru 90th day All but $329 a day $329 a day 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible Expenses Beyond the Additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- Approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $164.50 a Up to $164.50 a day day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness services All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare co-payment/ ** **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. 17
N (PART B) MEDICAL PER CALENDAR YEAR *Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts $183 Generally 80% Balance, other than Up to $20 per office up to $20 per office visit and up to $50 visit and up to $50 per emergency per emergency room visit. The room visit. The copayment of up to co-payment of up to $50 is waived if the $50 is waived if the insured is admitted insured is admitted to any hospital and to any hospital and the emergency visit the emergency visit is covered as a is covered as a Medicare Part A Medicare Part A expense. expense. Part B Excess Charges (Above Medicare-Approved amounts) 0% All costs BLOOD First 3 pints All costs Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts 80% 20% CLINICAL LABORATORY TESTS FOR DIAGNOSTIC 100% $183 18
N PARTS A & B HOME HEALTH CARE APPROVED Medically necessary skilled care services and medical supplies 100% Durable medical equipment First $183 of Medicare Approved amounts* $183 Remainder of Medicare Approved amounts 80% 20% OTHER BENEFITS NOT COVERED BY FOREIGN TRAVEL NOT COVERED BY Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 19