aetna life insurance company outline of medicare supplement … · 2016. 7. 13. · aetna life...

Aetna Life Insurance Company

Outline of Medicare Supplement Coverage

Benefit Plans A, B, F, G and N are Offered�Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010

This chart show the benefits included in each of the standard Medicare supplement plans with an effective date for coverage on or after June 1, 2010. Every company must make Plan "A"

available. Some plans may not be available in your state.

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 copayments for hospital outpatient services. Plans K, L and N require insured to pay a

portion of Part B coinsurance or copayments.

Blood - First three pints of blood each year.

Hospice - Part A coinsurance.

A B C D F l F* G K L M N

Basic

including

100% Part B

coinsurance

Basic

including

100% Part B

coinsurance

Basic

including

100% Part B

coinsurance

Basic including

100% Part B

coinsurance

Basic including

100% Part B

coinsurance *

Basic including

100% Part B

coinsurance

Hospitalization

and preventive

care paid at

100%; other

basic benefits

paid at 50%

Hospitalization

and preventive

care paid at

100%; other basic

benefits paid at

75%

Basic including

100% Part B

coinsurance

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

Skilled Nursing

Facility

Coinsurance

Skilled Nursing

Facility

Coinsurance

Skilled Nursing

Facility

Coinsurance

50% Skilled

Nursing Facility

Coinsurance

75% Skilled

Nursing Facility

Coinsurance

Skilled Nursing

Facility

Coinsurance

Skilled

Nursing

Facility

Coinsurance

Part A

Deductible

Part A

Deductible

Part A

Deductible

Part A

Deductible

Part A

Deductible

50% Part A

Deductible

75% Part A

Deductible

50% Part A

Deductible

Part A

Deductible

Part B

Deductible

Part B

Deductible

Part B Excess-

100%

Part B Excess-

100%

Foreign

Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Out-of-pocket

limit $4,960;

paid at 100%

after limit

reached

Out-of-pocket

limit $2,480; paid

at 100% after

limit reached

Effective 01-01-2016

GR-11613-03-OOC -OH 18.02.312.1-OH L (12/15)

•

•

•

•

Aetna Life Insurance Company Outline of Medicare Supplement Coverage

Benefit Plans A, B, F, G and N are Offered

*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 $ 2,180

deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. Out-of-pocket expenses for this deductible are

expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B but does not include the Plan’s

separate foreign travel emergency deductible.


GR-11613-03-OOC -OH 18.02.312.1-OH L (12/15)

PREMIUM INFORMATION Questions? We’re here to help.

Just call us at 1-800-345-6022

(TTY: 711)

We, Aetna Life Insurance Company, can only raise your premium if we raise the premium for all policies like yours in this state when your age

changes or to coincide with changes in Medicare.

The monthly premiums shown will apply when payment is made on a quarterly, semi-annual or annual basis or if you elect to have your

payments automatically deducted from your checking account (Electronic Funds Transfer program) or credit card account. To obtain

quarterly premium, multiply the monthly premium by 3. For semi-annual premium and annual premium, multiply the monthly premium by 6

or 12, respectively. If you elect to pay your premium on a monthly basis by check or money order, add $2 to the monthly premium shown to

calculate your monthly premium amount.

If you smoke and you enroll other than during the Medicare Supplement Open Enrollment and Guaranteed issue rights periods, a smoker

premium rate will apply. Please refer to the Guaranteed Issue Guidelines notice included in your enrollment materials for details on open

enrollment and guaranteed issue rights. Smoker premium rates are determined by multiplying the premium shown by a factor of 1.10.


GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

MONTHLY PREMIUMS

Attained

Age

PLAN A

MALE FEMALE

PLAN B

MALE FEMALE

PLAN F

MALE FEMALE

PLAN G

MALE FEMALE

PLAN N

MALE FEMALE

65 $138.99 $128.33 $154.66 $141.99 $174.66 $160.58 $158.66 $147.74 $124.16 $115.75

66 $144.16 $133.16 $160.41 $147.24 $181.16 $166.58 $166.33 $154.74 $130.41 $121.50

67 $149.33 $137.91 $166.24 $152.66 $187.74 $172.58 $173.99 $161.91 $136.41 $127.16

68 $155.41 $143.49 $173.99 $159.74 $196.66 $180.74 $181.49 $168.91 $142.49 $132.83

69 $161.41 $149.08 $181.58 $166.66 $205.49 $188.91 $189.08 $175.99 $148.58 $138.49

70 $167.49 $154.58 $189.16 $173.74 $214.24 $196.99 $196.66 $182.99 $154.66 $144.16

71 $173.41 $160.08 $196.83 $180.66 $223.07 $205.08 $204.16 $189.99 $160.66 $149.74

72 $179.33 $165.58 $204.33 $187.66 $231.74 $213.07 $211.66 $196.99 $166.66 $155.41

73 $183.41 $169.33 $210.82 $193.58 $239.41 $220.07 $220.07 $204.83 $173.58 $161.83

74 $187.49 $173.16 $217.07 $199.33 $246.82 $226.91 $228.32 $212.49 $180.33 $168.16

75 $191.49 $176.83 $223.41 $205.16 $254.32 $233.91 $236.66 $220.24 $187.08 $174.41

76 $195.49 $180.58 $229.74 $210.99 $261.91 $240.74 $244.99 $227.91 $193.91 $180.74

77 $199.58 $184.24 $236.07 $216.74 $269.32 $247.66 $253.07 $235.57 $200.58 $186.99

78 $202.49 $186.91 $240.32 $220.66 $274.74 $252.57 $260.16 $242.07 $206.49 $192.49

79 $205.33 $189.58 $244.66 $224.66 $280.07 $257.49 $267.07 $248.57 $212.41 $197.99

80 $208.08 $192.08 $248.74 $228.41 $285.32 $262.32 $273.91 $254.91 $218.24 $203.49

81 $210.74 $194.58 $252.91 $232.24 $290.57 $267.16 $280.82 $261.32 $224.16 $208.91

82 $213.32 $196.91 $257.07 $236.07 $295.74 $271.99 $287.74 $267.74 $229.99 $214.41

83 $214.91 $198.41 $262.07 $240.57 $302.82 $278.41 $301.24 $280.41 $242.07 $225.66

84 $216.57 $199.91 $266.91 $245.16 $309.82 $284.91 $314.90 $292.99 $254.16 $236.91

85 $218.07 $201.33 $272.16 $249.82 $317.24 $291.66 $326.74 $304.07 $264.91 $246.91

86 $219.49 $202.66 $276.32 $253.66 $323.57 $297.49 $339.15 $315.57 $276.16 $257.41

87 $220.82 $203.91 $280.41 $257.41 $328.40 $301.99 $351.90 $327.40 $287.82 $268.24

88 $222.24 $205.24 $284.57 $261.24 $333.40 $306.49 $365.15 $339.82 $299.90 $279.57

89 $223.66 $206.49 $288.82 $265.24 $338.32 $311.15 $378.90 $352.57 $312.57 $291.41

90+ $225.07 $207.91 $293.15 $269.16 $343.40 $315.74 $393.15 $365.90 $325.82 $303.74


GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

DISCLOSURES Questions? We’re here to help.

Just call us at 1-800-345-6022

(TTY: 711)

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.

RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to Aetna Life Insurance

Company, PO Box 14770, Lexington, KY 40512. If you send the policy back to us within 30 days after you

receive it, we will treat the policy as if it had never been issued and return all of your payments.

POLICY REPLACEMENT If you are replacing another health insurance policy, do NOT cancel it until you have actually received

your new policy and are sure you want to keep it.

NOTICE This policy may not fully cover all of your medical costs. Neither Aetna 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 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.�


GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)


GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

PLAN A

Medicare (Part A) – Hospital Services – Per Benefit Period

Services Medicare Pays Plan A

Plan Pays You Pay

HOSPITALIZATION*

Semi-private room and board, general nursing

and miscellaneous services and supplies

First 60 days All but $1,288 $0 $1,288

(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

$0**

- 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

a day

$0 Up to $161

a day

101st day and after $0 $0 All costs

*A Benefit Period begins on the first day you receive care 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.

** NOTICE – When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and

will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core

Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference between

its billed charges and the amount Medicare would have paid.

PLAN A (continued)



Plan Pays You Pay

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 a very limited

copayment/

coinsurance for

outpatient drugs and

inpatient respite care

Medicare copayment/

coinsurance

$0

PLAN A

Medicare (Part B) – Medical Services – Per Calendar Year


Plan Pays You Pay

MEDICAL EXPENSES

IN OR OUT OF THE HOSPITAL AND

OUTPATIENT HOSPITAL TREATMENTS, such

as physician's services, inpatient and

outpatient medical and surgical services and

supplies, physical and speech therapy,

diagnostic tests, durable medical equipment

First $166 of Medicare-approved amounts* $0 $0 $166

(Part B deductible)

Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B excess charges (above Medicare-

approved amounts) $0 $0 All costs

*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.


GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

PLAN A (continued)



Plan Pays You Pay

•

•

BLOOD

First 3 pints $0 All costs $0

Next $166 of Medicare-approved amounts* $0 $0 $166

(Part B deductible)

Remainder of Medicare-approved amounts 80% 20% $0

CLINICAL LABORATORY SERVICES

Tests for diagnostic services 100% $0 $0

PARTS A & B


Plan Pays You Pay

HOME HEALTH CARE

Medicare-Approved Services

Medically necessary skilled care services

and medical supplies

100% $0 $0

Durable medical equipment:

First $166 of Medicare-approved

amounts*

$0 $0 $166

(Part B deductible)

Remainder of Medicare-approved

amounts

80% 20% $0




-

-

GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

PLAN B


Services Medicare Pays Plan B

Plan Pays You Pay

HOSPITALIZATION*

Semi-private room and board, general

nursing and miscellaneous services and

supplies

First 60 days All but $1,288 $1,288

(Part A deductible)

$0


91st day and after:

• While using 60 lifetime reserve days

•




eligible expenses

$0**







hospital



a day

$0 Up to $161

a day




**NOTICE – When your Medicare Part A Hospital benefits are exhausted, the insurer stands in the place of Medicare and





GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

PLAN B (continued)



Plan Pays You Pay

BLOOD



HOSPICE CARE

You must meet Medicare’s requirements


illness

All but very limited

copayment/

coinsurance for



Medicare copayment/

coinsurance

$0

PLAN B



Plan Pays You Pay

MEDICAL EXPENSES



as physician’s services, inpatient and




First $166 of Medicare-approved amounts* $0 $0 $166

(Part B deductible)


Part B Excess Charges (above Medicare-





GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

PLAN B (continued)



Plan Pays You Pay

BLOOD


Next $166 of Medicare-approved amounts* $0 $0 $166

(Part B deductible)




PARTS A & B


Plan Pays You Pay

HOME HEALTH CARE


• Medically necessary skilled care services


100% $0 $0

• Durable medical equipment:

- First $166 of Medicare-approved

amounts*

$0 $0 $166

(Part B deductible)

- Remainder of Medicare-approved

amounts

80% 20% $0




GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

PLAN F


Services Medicare Pays Plan F

Plan Pays You Pay

HOSPITALIZATION*

Semi-private room and board, general

nursing and miscellaneous services and

supplies


(Part A deductible)

$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:


eligible expenses

$0**







hospital



a day

Up to $161

a day

$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 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.


GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

PLAN F (continued)



Plan Pays You Pay

BLOOD



HOSPICE CARE



illness


copayment/

coinsurance for



Medicare copayment/

coinsurance

$0

PLAN F



Plan Pays You Pay

MEDICAL EXPENSES

IN OR OF THE HOSPITAL AND OUTPATIENT

HOSPITAL TREATMENTS, such as physician's

services, inpatient and outpatient medical

and surgical services and supplies, physical

and speech therapy, diagnostic tests, durable

medical equipment

First $166 of Medicare-approved amounts* $0 $166

(Part B deductible)

$0



approved amounts) $0 100% of all costs $0

BLOOD


Next $166 of Medicare-approved amounts* $0 $166

(Part B deductible)

$0





GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

PLAN F (continued)



Plan Pays You Pay



PARTS A & B


Plan Pays You Pay

HOME HEALTH CARE




100% $0 $0



amounts*

$0 $166

(Part B deductible)

$0


amounts

80% 20% $0

OTHER BENEFITS – Not Covered by Medicare


Plan Pays You Pay

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 $0 $0 $250

Remainder of such charges $0 80% to a lifetime

maximum benefit of

$50,000

20% and amounts

over the $50,000

lifetime maximum




GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

PLAN G


Services Medicare Pays Plan G

Plan Pays You Pay

HOSPITALIZATION*




(Part A deductible)

$0


91st day and after:


•



-Additional 365 days $0 100% of Medicare

eligible expenses

$0**

-Beyond the additional 365 days $0 $0 All costs






hospital


21st thru 100th day All but $161 a day Up to $161 a day $0


BLOOD



HOSPICE CARE



illness


copayment/coinsurance

for outpatient drugs and


Medicare copayment/

coinsurance

$0








GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

PLAN G



Plan Pays You Pay

MEDICAL EXPENSES







First $166 of Medicare-approved amounts* $0 $0 $166 (Part B

deductible)



approved amounts) $0 100% of all costs $0

BLOOD


Next $166 of Medicare-approved amounts* $0 $0 $166 (Part B

deductible)

Remainder of Medicare-approved amounts 80%

20% $0




asterisk), your Part B Deductible will have been met for the calendar year.


GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

PLAN G (continued) PARTS A & B


Plan Pays You Pay

•

HOME HEALTH CARE


Medically necessary skilled care services


100% $0 $0

•

-

Durable medical equipment:

First $166 of Medicare-approved

amounts*

$0 $0 $166 (Part B

deductible)


amounts

80% 20% $0



Plan Pays You Pay

FOREIGN TRAVEL




outside the USA



maximum benefit of

$50,000

20% and amounts

over the $50,000

lifetime maximum

*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.


GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

PLAN N


Services Medicare Pays Plan N

Plan Pays You Pay

HOSPITALIZATION*




(Part A deductible)

$0


91st day and after:


•



-Additional 365 days $0 100% of Medicare

eligible expenses

$0**

-Beyond the additional 365 days $0 $0 All costs






hospital


21st thru 100th day All but $161 a day Up to $161 a day $0


BLOOD



HOSPICE CARE



illness


copayment/coinsurance

for outpatient drugs and


Medicare copayment/

coinsurance

$0





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.


GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

PLAN N



Plan Pays You Pay

MEDICAL EXPENSES







First $166 of Medicare-approved amounts* $0 $0 $166 (Part B

Deductible)

Remainder of Medicare-approved amounts 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.

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.



BLOOD


Next $166 of Medicare-approved amounts* $0 $0 $166 (Part B

deductible)







GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

PLAN N (continued)

PARTS A & B�


Plan Pays You Pay

HOME HEALTH CARE




100% $0 $0



amounts*

$0 $0 $166 (Part B

Deductible)


amounts

80% 20% $0



Plan Pays You Pay

FOREIGN TRAVEL




outside the USA



maximum benefit of

$50,000

20% and amounts

over the $50,000

lifetime maximum




GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

aetna life insurance company outline of medicare supplement … · 2016. 7. 13. · aetna life...

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