benefit plans a, b, f, hf, g, & n - asp | home · 800 crescent centre dr. suite 200 franklin,...
TRANSCRIPT
800 Crescent Centre Dr. Suite 200
Franklin, TN 37067800 264.4000
aetnaseniorproducts.com
Outline of CoverageMedicare Supplement Insurance
Underwritten by
Continental Life Insurance Company of Brentwood, Tennessee
An Aetna Company
Rates Effective:
BENEFIT PLANS A, B, F, HF, G, & N
Pennsylvania
CLIMS03889PA ©2018 Aetna Inc. 02/2018 A
CLI
MS0
3889
PA
02
/20
18
A
1
CONT
INEN
TAL
LIFE
INSU
RANC
E CO
MPA
NY O
F BR
ENTW
OO
D, T
ENNE
SSEE
O
UTLI
NE O
F M
EDIC
ARE
SUPP
LEM
ENT
COVE
RAG
E CO
VER
PAG
E
BENE
FIT
PLAN
S AV
AILA
BLE:
A, B
, F, H
IGH
DEDU
CTIB
LE F
, G, N
Th
ese
char
ts s
how
the
bene
fits
incl
uded
in e
ach
of th
e st
anda
rd M
edic
are
supp
lem
ent p
lans
. Eve
ry c
ompa
ny m
ust m
ake
avai
labl
e Pl
an “A
” and
“B
” and
“C” o
r “F”
. Som
e pl
ans
may
not
be
avai
labl
e in
you
r sta
te.
See
Out
lines
of C
over
age
sect
ions
for d
etai
ls a
bout
ALL
PLA
NS
Bas
ic B
enef
its:
Hos
pita
lizat
ion:
Par
t A c
oins
uran
ce p
lus
cove
rage
for 3
65 a
dditi
onal
day
s af
ter M
edic
are
bene
fits
end.
M
edic
al E
xpen
ses:
Par
t B c
oins
uran
ce (g
ener
ally
20%
of M
edic
are-
Appr
oved
exp
ense
s) o
r, co
-pay
men
ts fo
r hos
pita
l out
patie
nt s
ervi
ces.
Pla
ns
K, L
, and
N re
quire
insu
reds
to p
ay a
por
tion
of c
oins
uran
ce o
r cop
aym
ents
Bl
ood:
Firs
t thr
ee p
ints
of b
lood
eac
h ye
ar.
Hos
pice
: Par
t A c
oins
uran
ce
A
B
C
D
F/F*
G
K
L
M
N
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Hos
pita
lizat
ion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basi
c be
nefit
s pa
id a
t 50%
Hos
pita
lizat
ion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basi
c be
nefit
s pa
id a
t 75%
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c, in
clud
ing
100%
Par
t B
coin
sura
nce,
exc
ept u
p to
$20
cop
aym
ent f
or
offic
e vi
sit,
and
up to
$50
cop
aym
ent f
or
ER
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
50%
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
75%
Ski
lled
Nur
sing
Fac
ility
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Pa
rt A
Ded
uctib
le
Part
A D
educ
tible
Pa
rt A
Ded
uctib
le
Part
A D
educ
tible
Pa
rt A
Ded
uctib
le
50%
Par
t A
Ded
uctib
le
75%
Par
t A
Ded
uctib
le
50%
Par
t A
Ded
uctib
le
Part
A D
educ
tible
Part
B D
educ
tible
Part
B D
educ
tible
Part
B Ex
cess
(1
00%
)
Part
B Ex
cess
(1
00%
)
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Out
-of-p
ocke
t lim
it $5
240;
pa
id a
t 100
%
afte
r lim
it re
ache
d
Out
-of-p
ocke
t lim
it $2
620;
pa
id a
t 100
%
afte
r lim
it re
ache
d
*Pla
n F
also
has
an
optio
n ca
lled
a hi
gh d
educ
tible
pla
n F.
Thi
s hi
gh d
educ
tible
pla
n pa
ys t
he s
ame
bene
fits
as P
lan
F af
ter
one
has
paid
a c
alen
dar
year
$22
40
dedu
ctib
le. B
enef
its fr
om h
igh
dedu
ctib
le p
lan
F w
ill no
t beg
in u
ntil
out-o
f-poc
ket e
xpen
ses
exce
ed $
2240
. O
ut-o
f-poc
ket e
xpen
ses
for
this
ded
uctib
le a
re e
xpen
ses
that
w
ould
ord
inar
ily b
e pa
id b
y th
e po
licy.
The
se e
xpen
ses
incl
ude
the
Med
icar
e de
duct
ible
s fo
r Pa
rt A
and
Part
B, b
ut d
o no
t in
clud
e th
e pl
an’s
sep
arat
e fo
reig
n tra
vel
emer
genc
y de
duct
ible
.
CLI
MS0
3889
PA
02
/20
18
A
2
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n H
FP
lan
GP
lan
NA
geP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
Un
de
r 65
1,22
4
1,
319
1,70
2
68
0
1,46
0
1,
092
Un
de
r 65
1,35
9
1,
466
1,89
0
75
6
1,62
3
1,
214
65
1,22
4
1,
319
1,70
2
68
0
1,46
0
1,
092
651,
359
1,46
6
1,
890
756
1,
623
1,21
4
66
1,22
4
1,
319
1,70
2
68
0
1,46
0
1,
116
661,
359
1,46
6
1,
890
756
1,
623
1,24
1
67
1,22
4
1,
319
1,70
2
68
0
1,46
0
1,
142
671,
359
1,46
6
1,
890
756
1,
623
1,27
0
68
1,23
8
1,
335
1,72
2
68
9
1,47
8
1,
182
681,
376
1,48
3
1,
913
766
1,
642
1,31
4
69
1,26
6
1,
363
1,75
9
70
4
1,51
0
1,
235
691,
406
1,51
4
1,
955
782
1,
677
1,37
3
70
1,30
0
1,
399
1,80
6
72
2
1,54
9
1,
294
701,
444
1,55
5
2,
007
802
1,
721
1,43
8
71
1,33
8
1,
442
1,86
0
74
4
1,59
6
1,
333
711,
487
1,60
2
2,
067
826
1,
773
1,48
3
72
1,38
0
1,
486
1,91
8
76
7
1,64
5
1,
375
721,
533
1,65
1
2,
131
852
1,
828
1,52
9
73
1,42
5
1,
535
1,98
0
79
2
1,70
0
1,
420
731,
583
1,70
5
2,
200
880
1,
888
1,57
7
74
1,47
5
1,
589
2,05
0
82
0
1,75
9
1,
470
741,
639
1,76
5
2,
278
912
1,
955
1,63
3
75
1,52
9
1,
646
2,12
4
85
0
1,82
4
1,
522
751,
698
1,82
9
2,
361
945
2,
026
1,69
2
76
1,58
2
1,
704
2,19
9
87
9
1,88
7
1,
576
761,
758
1,89
4
2,
443
976
2,
097
1,75
2
77
1,63
5
1,
762
2,27
4
91
0
1,95
0
1,
629
771,
817
1,95
7
2,
527
1,01
0
2,
167
1,81
0
78
1,68
8
1,
819
2,34
7
93
9
2,01
5
1,
683
781,
876
2,02
2
2,
608
1,04
3
2,
239
1,86
9
79
1,74
4
1,
878
2,42
4
97
0
2,08
0
1,
738
791,
937
2,08
7
2,
693
1,07
7
2,
312
1,93
2
80
1,79
9
1,
938
2,50
1
1,
000
2,14
6
1,
792
801,
999
2,15
4
2,
779
1,11
1
2,
384
1,99
2
81
1,85
5
1,
999
2,57
9
1,
032
2,21
4
1,
849
812,
061
2,22
2
2,
866
1,14
6
2,
460
2,05
4
82
1,91
3
2,
061
2,65
9
1,
063
2,28
3
1,
906
822,
126
2,29
1
2,
954
1,18
2
2,
536
2,11
9
83
1,97
3
2,
124
2,74
1
1,
096
2,35
3
1,
965
832,
192
2,36
1
3,
046
1,21
8
2,
614
2,18
3
84
2,03
3
2,
190
2,82
5
1,
130
2,42
5
2,
025
842,
259
2,43
3
3,
139
1,25
5
2,
694
2,25
0
85
2,10
4
2,
266
2,92
3
1,
170
2,51
0
2,
095
852,
338
2,51
8
3,
248
1,30
0
2,
789
2,32
8
86
2,16
4
2,
331
3,00
7
1,
203
2,58
1
2,
156
862,
405
2,59
0
3,
341
1,33
7
2,
868
2,39
7
87
2,22
5
2,
397
3,09
3
1,
237
2,65
4
2,
217
872,
472
2,66
3
3,
436
1,37
5
2,
949
2,46
5
88
2,28
7
2,
463
3,18
0
1,
271
2,72
9
2,
280
882,
541
2,73
7
3,
534
1,41
3
3,
032
2,53
3
89
2,35
2
2,
532
3,26
8
1,
307
2,80
5
2,
342
892,
613
2,81
4
3,
631
1,45
3
3,
117
2,60
2
902,
416
2,60
2
3,
357
1,34
4
2,
882
2,40
7
90
2,68
5
2,
892
3,73
0
1,
493
3,20
1
2,
674
912,
481
2,67
2
3,
449
1,38
0
2,
959
2,47
2
91
2,75
7
2,
970
3,83
2
1,
533
3,28
8
2,
747
922,
548
2,74
5
3,
541
1,41
7
3,
040
2,53
9
92
2,83
2
3,
050
3,93
5
1,
574
3,37
8
2,
822
932,
616
2,81
8
3,
636
1,45
4
3,
121
2,60
7
93
2,90
6
3,
131
4,04
1
1,
616
3,46
8
2,
896
942,
686
2,89
3
3,
732
1,49
3
3,
204
2,67
5
94
2,98
4
3,
214
4,14
7
1,
659
3,56
0
2,
973
952,
756
2,96
9
3,
830
1,53
2
3,
287
2,74
6
95
3,06
2
3,
298
4,25
6
1,
703
3,65
2
3,
051
962,
827
3,04
4
3,
929
1,57
2
3,
372
2,81
7
96
3,14
1
3,
382
4,36
5
1,
747
3,74
7
3,
130
972,
900
3,12
2
4,
030
1,61
1
3,
458
2,88
8
97
3,22
2
3,
469
4,47
7
1,
790
3,84
2
3,
209
982,
972
3,20
1
4,
131
1,65
2
3,
545
2,96
1
98
3,30
2
3,
557
4,59
0
1,
835
3,93
9
3,
289
99
+3,
046
3,28
2
4,
234
1,69
4
3,
634
3,03
6
99
+3,
385
3,64
7
4,
704
1,88
3
4,
037
3,37
4
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.52
00Q
uar
terl
y:0.
2650
Mo
nth
ly:
0.08
33
The
ab
ove
rat
es
do
no
t in
clu
de
th
e $
20 o
ne
-tim
e p
oli
cy f
ee
.
To c
alcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ual
pre
miu
m x
mo
dal
fac
tor
= m
od
al p
rem
ium
(ro
un
d t
o n
ear
est
wh
ole
ce
nt)
M
od
al p
rem
ium
x .9
3 =
dis
cou
nte
d p
rem
ium
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d, u
se P
refe
rre
d r
ate
s.
Rat
es E
ffec
tive
2/1
/20
18
Fem
ale
Rat
es
Co
nti
ne
nta
l Lif
e In
sura
nce
Co
mp
any
of
Bre
ntw
oo
d, T
en
ne
sse
eA
nn
ual
Pre
miu
ms
For
Use
in
ZIP
Co
des
: 1
50
-15
4 a
nd
15
6
CLI
MS0
3889
PA
02
/20
18
A
3
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n H
FP
lan
GP
lan
NA
geP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
Un
de
r 65
1,40
7
1,
516
1,95
7
78
2
1,67
9
1,
255
Un
de
r 65
1,56
3
1,
686
2,17
4
86
9
1,86
6
1,
394
65
1,40
7
1,
516
1,95
7
78
2
1,67
9
1,
255
651,
563
1,68
6
2,
174
869
1,
866
1,39
4
66
1,40
7
1,
516
1,95
7
78
2
1,67
9
1,
285
661,
563
1,68
6
2,
174
869
1,
866
1,42
7
67
1,40
7
1,
516
1,95
7
78
2
1,67
9
1,
314
671,
563
1,68
6
2,
174
869
1,
866
1,46
1
68
1,42
4
1,
535
1,98
1
79
3
1,70
0
1,
361
681,
583
1,70
5
2,
200
881
1,
888
1,51
2
69
1,45
5
1,
567
2,02
4
80
9
1,73
6
1,
420
691,
617
1,74
1
2,
249
899
1,
929
1,57
9
70
1,49
5
1,
609
2,07
7
83
1
1,78
2
1,
488
701,
661
1,78
8
2,
307
923
1,
979
1,65
4
71
1,53
9
1,
658
2,13
9
85
5
1,83
5
1,
535
711,
710
1,84
3
2,
376
950
2,
039
1,70
5
72
1,58
7
1,
709
2,20
6
88
3
1,89
2
1,
581
721,
764
1,89
8
2,
451
980
2,
103
1,75
8
73
1,63
9
1,
765
2,27
7
91
1
1,95
5
1,
633
731,
820
1,96
1
2,
530
1,01
2
2,
172
1,81
4
74
1,69
6
1,
827
2,35
7
94
4
2,02
4
1,
689
741,
885
2,02
9
2,
619
1,04
9
2,
249
1,87
9
75
1,75
8
1,
894
2,44
3
97
7
2,09
7
1,
750
751,
953
2,10
4
2,
714
1,08
6
2,
330
1,94
6
76
1,81
9
1,
959
2,52
9
1,
011
2,17
1
1,
813
762,
022
2,17
8
2,
809
1,12
3
2,
411
2,01
5
77
1,88
0
2,
026
2,61
5
1,
046
2,24
3
1,
875
772,
089
2,25
1
2,
905
1,16
2
2,
493
2,08
3
78
1,94
1
2,
093
2,70
0
1,
080
2,31
7
1,
936
782,
157
2,32
4
2,
999
1,19
9
2,
574
2,14
9
79
2,00
5
2,
159
2,78
8
1,
115
2,39
2
1,
999
792,
227
2,40
0
3,
096
1,23
8
2,
659
2,22
2
80
2,06
9
2,
228
2,87
6
1,
150
2,46
8
2,
061
802,
298
2,47
7
3,
196
1,27
7
2,
743
2,29
1
81
2,13
3
2,
298
2,96
5
1,
187
2,54
6
2,
127
812,
371
2,55
5
3,
295
1,31
8
2,
830
2,36
2
82
2,20
0
2,
371
3,05
8
1,
223
2,62
5
2,
192
822,
444
2,63
4
3,
397
1,35
9
2,
917
2,43
6
83
2,26
9
2,
443
3,15
3
1,
261
2,70
5
2,
260
832,
521
2,71
4
3,
503
1,40
1
3,
006
2,51
1
84
2,33
8
2,
519
3,24
9
1,
300
2,78
9
2,
329
842,
598
2,79
8
3,
610
1,44
4
3,
098
2,58
8
85
2,41
9
2,
606
3,36
2
1,
345
2,88
6
2,
410
852,
688
2,89
5
3,
735
1,49
5
3,
207
2,67
7
86
2,48
8
2,
680
3,45
8
1,
384
2,96
9
2,
480
862,
765
2,97
9
3,
843
1,53
7
3,
298
2,75
6
87
2,55
8
2,
756
3,55
7
1,
423
3,05
2
2,
550
872,
843
3,06
3
3,
952
1,58
2
3,
392
2,83
4
88
2,63
1
2,
833
3,65
7
1,
462
3,13
8
2,
623
882,
922
3,14
7
4,
063
1,62
5
3,
486
2,91
4
89
2,70
4
2,
912
3,75
8
1,
504
3,22
5
2,
694
893,
005
3,23
6
4,
175
1,67
1
3,
584
2,99
3
902,
779
2,99
2
3,
861
1,54
5
3,
314
2,76
7
90
3,08
7
3,
326
4,28
9
1,
716
3,68
2
3,
075
912,
853
3,07
4
3,
966
1,58
7
3,
404
2,84
3
91
3,17
1
3,
415
4,40
7
1,
764
3,78
2
3,
158
922,
930
3,15
6
4,
073
1,62
9
3,
496
2,92
0
92
3,25
7
3,
508
4,52
5
1,
810
3,88
4
3,
244
933,
008
3,24
1
4,
182
1,67
2
3,
589
2,99
8
93
3,34
3
3,
601
4,64
7
1,
859
3,98
8
3,
331
943,
089
3,32
7
4,
292
1,71
6
3,
684
3,07
6
94
3,43
2
3,
696
4,77
0
1,
907
4,09
4
3,
418
953,
170
3,41
4
4,
404
1,76
2
3,
780
3,15
7
95
3,52
2
3,
793
4,89
4
1,
958
4,20
0
3,
509
963,
251
3,50
1
4,
519
1,80
8
3,
878
3,24
0
96
3,61
3
3,
889
5,01
9
2,
009
4,30
9
3,
599
973,
335
3,59
0
4,
634
1,85
3
3,
976
3,32
2
97
3,70
5
3,
990
5,14
8
2,
059
4,41
8
3,
691
983,
418
3,68
2
4,
751
1,90
0
4,
077
3,40
5
98
3,79
7
4,
091
5,27
8
2,
111
4,53
0
3,
783
99
+3,
503
3,77
4
4,
869
1,94
8
4,
179
3,49
2
99
+3,
893
4,19
3
5,
409
2,16
5
4,
643
3,87
9
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.52
00Q
uar
terl
y:0.
2650
Mo
nth
ly:
0.08
33
The
ab
ove
rat
es
do
no
t in
clu
de
th
e $
20 o
ne
-tim
e p
oli
cy f
ee
.
To c
alcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ual
pre
miu
m x
mo
dal
fac
tor
= m
od
al p
rem
ium
(ro
un
d t
o n
ear
est
wh
ole
ce
nt)
M
od
al p
rem
ium
x .9
3 =
dis
cou
nte
d p
rem
ium
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d, u
se P
refe
rre
d r
ate
s.
Rat
es E
ffec
tive
2/1
/20
18
Mal
e R
ates
Co
nti
ne
nta
l Lif
e In
sura
nce
Co
mp
any
of
Bre
ntw
oo
d, T
en
ne
sse
eA
nn
ual
Pre
miu
ms
For
Use
in
ZIP
Co
des
: 1
50
-15
4 a
nd
15
6
CLI
MS0
3889
PA
02
/20
18
A
4
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n H
FP
lan
GP
lan
NA
geP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
Un
de
r 65
1,36
5
1,
470
1,89
8
75
9
1,62
8
1,
217
Un
de
r 65
1,51
6
1,
634
2,10
8
84
3
1,80
9
1,
353
65
1,36
5
1,
470
1,89
8
75
9
1,62
8
1,
217
651,
516
1,63
4
2,
108
843
1,
809
1,35
3
66
1,36
5
1,
470
1,89
8
75
9
1,62
8
1,
245
661,
516
1,63
4
2,
108
843
1,
809
1,38
3
67
1,36
5
1,
470
1,89
8
75
9
1,62
8
1,
274
671,
516
1,63
4
2,
108
843
1,
809
1,41
6
68
1,38
1
1,
488
1,92
0
76
9
1,64
8
1,
318
681,
535
1,65
3
2,
133
854
1,
831
1,46
5
69
1,41
1
1,
520
1,96
2
78
5
1,68
3
1,
377
691,
567
1,68
8
2,
180
872
1,
870
1,53
1
70
1,44
9
1,
560
2,01
3
80
5
1,72
7
1,
443
701,
610
1,73
4
2,
238
895
1,
919
1,60
4
71
1,49
2
1,
608
2,07
4
82
9
1,77
9
1,
487
711,
658
1,78
7
2,
305
921
1,
977
1,65
3
72
1,53
8
1,
657
2,13
8
85
6
1,83
5
1,
533
721,
710
1,84
1
2,
376
950
2,
039
1,70
5
73
1,58
9
1,
711
2,20
8
88
3
1,89
5
1,
584
731,
765
1,90
1
2,
453
982
2,
105
1,75
9
74
1,64
4
1,
772
2,28
6
91
5
1,96
2
1,
639
741,
827
1,96
8
2,
540
1,01
7
2,
180
1,82
1
75
1,70
5
1,
836
2,36
9
94
8
2,03
4
1,
697
751,
894
2,04
0
2,
632
1,05
3
2,
259
1,88
6
76
1,76
4
1,
900
2,45
2
98
0
2,10
4
1,
758
761,
961
2,11
2
2,
724
1,08
9
2,
339
1,95
3
77
1,82
3
1,
964
2,53
5
1,
014
2,17
5
1,
817
772,
026
2,18
2
2,
817
1,12
6
2,
417
2,01
9
78
1,88
2
2,
029
2,61
7
1,
047
2,24
7
1,
876
782,
092
2,25
4
2,
908
1,16
3
2,
496
2,08
4
79
1,94
4
2,
094
2,70
3
1,
081
2,32
0
1,
938
792,
160
2,32
7
3,
003
1,20
1
2,
578
2,15
5
80
2,00
6
2,
161
2,78
8
1,
115
2,39
3
1,
998
802,
229
2,40
2
3,
098
1,23
9
2,
659
2,22
1
81
2,06
9
2,
229
2,87
5
1,
150
2,46
8
2,
061
812,
298
2,47
7
3,
195
1,27
8
2,
743
2,29
1
82
2,13
3
2,
298
2,96
5
1,
186
2,54
5
2,
126
822,
370
2,55
4
3,
294
1,31
8
2,
827
2,36
3
83
2,20
0
2,
369
3,05
7
1,
222
2,62
3
2,
191
832,
444
2,63
2
3,
397
1,35
8
2,
914
2,43
4
84
2,26
7
2,
442
3,15
0
1,
260
2,70
4
2,
258
842,
519
2,71
3
3,
500
1,40
0
3,
004
2,50
9
85
2,34
6
2,
526
3,26
0
1,
304
2,79
8
2,
336
852,
607
2,80
7
3,
621
1,44
9
3,
110
2,59
6
86
2,41
3
2,
599
3,35
3
1,
342
2,87
8
2,
404
862,
681
2,88
8
3,
726
1,49
1
3,
198
2,67
2
87
2,48
1
2,
672
3,44
9
1,
380
2,96
0
2,
472
872,
757
2,97
0
3,
832
1,53
3
3,
289
2,74
8
88
2,55
0
2,
747
3,54
6
1,
418
3,04
3
2,
543
882,
834
3,05
2
3,
940
1,57
5
3,
381
2,82
5
89
2,62
2
2,
824
3,64
4
1,
458
3,12
7
2,
612
892,
913
3,13
7
4,
048
1,62
0
3,
475
2,90
2
902,
694
2,90
2
3,
743
1,49
8
3,
213
2,68
4
90
2,99
4
3,
224
4,15
9
1,
664
3,57
0
2,
981
912,
767
2,98
0
3,
846
1,53
8
3,
300
2,75
7
91
3,07
4
3,
311
4,27
3
1,
710
3,66
7
3,
063
922,
841
3,06
1
3,
949
1,58
0
3,
389
2,83
1
92
3,15
8
3,
401
4,38
7
1,
755
3,76
6
3,
146
932,
917
3,14
2
4,
055
1,62
2
3,
480
2,90
7
93
3,24
1
3,
491
4,50
6
1,
802
3,86
7
3,
229
942,
995
3,22
6
4,
162
1,66
4
3,
572
2,98
2
94
3,32
8
3,
583
4,62
4
1,
850
3,96
9
3,
315
953,
073
3,31
0
4,
270
1,70
9
3,
665
3,06
2
95
3,41
5
3,
678
4,74
5
1,
899
4,07
2
3,
402
963,
153
3,39
4
4,
381
1,75
3
3,
760
3,14
1
96
3,50
3
3,
771
4,86
7
1,
948
4,17
8
3,
490
973,
233
3,48
1
4,
493
1,79
7
3,
856
3,22
1
97
3,59
2
3,
868
4,99
2
1,
996
4,28
4
3,
578
983,
314
3,57
0
4,
607
1,84
2
3,
953
3,30
1
98
3,68
2
3,
966
5,11
8
2,
046
4,39
2
3,
668
99
+3,
397
3,65
9
4,
721
1,88
9
4,
052
3,38
6
99
+3,
775
4,06
6
5,
245
2,09
9
4,
502
3,76
2
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.52
00Q
uar
terl
y:0.
2650
Mo
nth
ly:
0.08
33
The
ab
ove
rat
es
do
no
t in
clu
de
th
e $
20 o
ne
-tim
e p
oli
cy f
ee
.
To c
alcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ual
pre
miu
m x
mo
dal
fac
tor
= m
od
al p
rem
ium
(ro
un
d t
o n
ear
est
wh
ole
ce
nt)
M
od
al p
rem
ium
x .9
3 =
dis
cou
nte
d p
rem
ium
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d, u
se P
refe
rre
d r
ate
s.
Rat
es E
ffec
tive
2/1
/20
18
Fem
ale
Rat
es
Co
nti
ne
nta
l Lif
e In
sura
nce
Co
mp
any
of
Bre
ntw
oo
d, T
en
ne
sse
eA
nn
ual
Pre
miu
ms
For
Use
in
ZIP
Co
des
: 1
89
-19
4
CLI
MS0
3889
PA
02
/20
18
A
5
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n H
FP
lan
GP
lan
NA
geP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
Un
de
r 65
1,56
9
1,
691
2,18
2
87
2
1,87
2
1,
400
Un
de
r 65
1,74
3
1,
880
2,42
4
96
9
2,08
0
1,
555
65
1,56
9
1,
691
2,18
2
87
2
1,87
2
1,
400
651,
743
1,88
0
2,
424
969
2,
080
1,55
5
66
1,56
9
1,
691
2,18
2
87
2
1,87
2
1,
433
661,
743
1,88
0
2,
424
969
2,
080
1,59
1
67
1,56
9
1,
691
2,18
2
87
2
1,87
2
1,
465
671,
743
1,88
0
2,
424
969
2,
080
1,62
9
68
1,58
8
1,
711
2,20
9
88
5
1,89
5
1,
517
681,
765
1,90
1
2,
453
983
2,
105
1,68
6
69
1,62
3
1,
748
2,25
7
90
2
1,93
5
1,
584
691,
803
1,94
2
2,
507
1,00
3
2,
151
1,76
0
70
1,66
7
1,
794
2,31
6
92
6
1,98
7
1,
659
701,
852
1,99
3
2,
573
1,02
9
2,
206
1,84
5
71
1,71
6
1,
848
2,38
5
95
4
2,04
6
1,
711
711,
906
2,05
5
2,
650
1,06
0
2,
273
1,90
1
72
1,76
9
1,
905
2,46
0
98
4
2,10
9
1,
763
721,
967
2,11
7
2,
733
1,09
2
2,
345
1,96
1
73
1,82
7
1,
968
2,53
9
1,
016
2,18
0
1,
821
732,
030
2,18
6
2,
821
1,12
9
2,
422
2,02
2
74
1,89
1
2,
037
2,62
8
1,
052
2,25
7
1,
884
742,
102
2,26
3
2,
921
1,16
9
2,
507
2,09
5
75
1,96
1
2,
112
2,72
4
1,
090
2,33
9
1,
952
752,
177
2,34
6
3,
027
1,21
1
2,
598
2,17
0
76
2,02
9
2,
185
2,82
0
1,
128
2,42
0
2,
021
762,
254
2,42
8
3,
132
1,25
2
2,
689
2,24
7
77
2,09
7
2,
259
2,91
6
1,
167
2,50
1
2,
090
772,
330
2,51
0
3,
239
1,29
5
2,
780
2,32
2
78
2,16
5
2,
334
3,01
0
1,
205
2,58
3
2,
158
782,
405
2,59
2
3,
344
1,33
7
2,
870
2,39
7
79
2,23
5
2,
408
3,10
8
1,
244
2,66
7
2,
229
792,
483
2,67
6
3,
452
1,38
1
2,
965
2,47
7
80
2,30
7
2,
485
3,20
7
1,
283
2,75
2
2,
298
802,
563
2,76
2
3,
563
1,42
4
3,
058
2,55
4
81
2,37
9
2,
563
3,30
6
1,
323
2,83
9
2,
371
812,
643
2,84
9
3,
674
1,46
9
3,
155
2,63
3
82
2,45
3
2,
643
3,41
0
1,
363
2,92
7
2,
444
822,
725
2,93
7
3,
788
1,51
6
3,
252
2,71
7
83
2,53
0
2,
724
3,51
5
1,
406
3,01
6
2,
520
832,
811
3,02
7
3,
906
1,56
2
3,
352
2,80
0
84
2,60
7
2,
809
3,62
3
1,
449
3,11
0
2,
597
842,
897
3,12
0
4,
026
1,61
0
3,
455
2,88
5
85
2,69
8
2,
906
3,74
9
1,
499
3,21
8
2,
688
852,
998
3,22
8
4,
164
1,66
7
3,
576
2,98
5
86
2,77
5
2,
989
3,85
6
1,
544
3,31
0
2,
766
863,
083
3,32
1
4,
285
1,71
4
3,
678
3,07
3
87
2,85
3
3,
073
3,96
6
1,
586
3,40
3
2,
844
873,
170
3,41
6
4,
406
1,76
4
3,
783
3,16
0
88
2,93
3
3,
159
4,07
7
1,
630
3,49
9
2,
924
883,
258
3,50
9
4,
531
1,81
2
3,
887
3,25
0
89
3,01
5
3,
247
4,19
1
1,
677
3,59
6
3,
004
893,
350
3,60
9
4,
656
1,86
4
3,
997
3,33
8
903,
098
3,33
6
4,
305
1,72
2
3,
696
3,08
6
90
3,44
2
3,
708
4,78
3
1,
914
4,10
5
3,
428
913,
182
3,42
7
4,
423
1,76
9
3,
795
3,17
0
91
3,53
6
3,
808
4,91
4
1,
967
4,21
7
3,
522
923,
267
3,51
9
4,
541
1,81
7
3,
898
3,25
6
92
3,63
1
3,
911
5,04
5
2,
019
4,33
1
3,
617
933,
354
3,61
4
4,
663
1,86
5
4,
002
3,34
3
93
3,72
7
4,
016
5,18
1
2,
073
4,44
7
3,
714
943,
445
3,70
9
4,
785
1,91
4
4,
108
3,43
0
94
3,82
7
4,
121
5,31
8
2,
127
4,56
5
3,
812
953,
534
3,80
6
4,
910
1,96
4
4,
215
3,52
0
95
3,92
7
4,
230
5,45
7
2,
184
4,68
3
3,
912
963,
625
3,90
3
5,
039
2,01
6
4,
324
3,61
2
96
4,02
8
4,
337
5,59
7
2,
240
4,80
4
4,
013
973,
718
4,00
3
5,
167
2,06
6
4,
434
3,70
4
97
4,13
2
4,
449
5,74
1
2,
296
4,92
7
4,
115
983,
812
4,10
5
5,
297
2,11
8
4,
546
3,79
6
98
4,23
4
4,
561
5,88
5
2,
354
5,05
1
4,
218
99
+3,
906
4,20
8
5,
429
2,17
2
4,
659
3,89
3
99
+4,
341
4,67
6
6,
032
2,41
4
5,
177
4,32
6
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.52
00Q
uar
terl
y:0.
2650
Mo
nth
ly:
0.08
33
The
ab
ove
rat
es
do
no
t in
clu
de
th
e $
20 o
ne
-tim
e p
oli
cy f
ee
.
To c
alcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ual
pre
miu
m x
mo
dal
fac
tor
= m
od
al p
rem
ium
(ro
un
d t
o n
ear
est
wh
ole
ce
nt)
M
od
al p
rem
ium
x .9
3 =
dis
cou
nte
d p
rem
ium
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d, u
se P
refe
rre
d r
ate
s.
Rat
es E
ffec
tive
2/1
/201
8
Mal
e R
ates
Co
nti
ne
nta
l Lif
e In
sura
nce
Co
mp
any
of
Bre
ntw
oo
d, T
en
ne
sse
eA
nnua
l Pr
emiu
ms
For
Use
in Z
IP C
odes
: 18
9-19
4
CLI
MS0
3889
PA
02
/20
18
A
6
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n H
FP
lan
GP
lan
NA
geP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
Un
de
r 65
1,08
3
1,
167
1,50
6
60
2
1,29
2
96
6
Un
de
r 65
1,20
3
1,
297
1,67
3
66
9
1,43
6
1,
074
65
1,08
3
1,
167
1,50
6
60
2
1,29
2
96
6
651,
203
1,29
7
1,
673
669
1,
436
1,07
4
66
1,08
3
1,
167
1,50
6
60
2
1,29
2
98
8
661,
203
1,29
7
1,
673
669
1,
436
1,09
8
67
1,08
3
1,
167
1,50
6
60
2
1,29
2
1,
011
671,
203
1,29
7
1,
673
669
1,
436
1,12
4
68
1,09
6
1,
181
1,52
4
61
0
1,30
8
1,
046
681,
218
1,31
2
1,
693
678
1,
453
1,16
3
69
1,12
0
1,
206
1,55
7
62
3
1,33
6
1,
093
691,
244
1,34
0
1,
730
692
1,
484
1,21
5
70
1,15
0
1,
238
1,59
8
63
9
1,37
1
1,
145
701,
278
1,37
6
1,
776
710
1,
523
1,27
3
71
1,18
4
1,
276
1,64
6
65
8
1,41
2
1,
180
711,
316
1,41
8
1,
829
731
1,
569
1,31
2
72
1,22
1
1,
315
1,69
7
67
9
1,45
6
1,
217
721,
357
1,46
1
1,
886
754
1,
618
1,35
3
73
1,26
1
1,
358
1,75
2
70
1
1,50
4
1,
257
731,
401
1,50
9
1,
947
779
1,
671
1,39
6
74
1,30
5
1,
406
1,81
4
72
6
1,55
7
1,
301
741,
450
1,56
2
2,
016
807
1,
730
1,44
5
75
1,35
3
1,
457
1,88
0
75
2
1,61
4
1,
347
751,
503
1,61
9
2,
089
836
1,
793
1,49
7
76
1,40
0
1,
508
1,94
6
77
8
1,67
0
1,
395
761,
556
1,67
6
2,
162
864
1,
856
1,55
0
77
1,44
7
1,
559
2,01
2
80
5
1,72
6
1,
442
771,
608
1,73
2
2,
236
894
1,
918
1,60
2
78
1,49
4
1,
610
2,07
7
83
1
1,78
3
1,
489
781,
660
1,78
9
2,
308
923
1,
981
1,65
4
79
1,54
3
1,
662
2,14
5
85
8
1,84
1
1,
538
791,
714
1,84
7
2,
383
953
2,
046
1,71
0
80
1,59
2
1,
715
2,21
3
88
5
1,89
9
1,
586
801,
769
1,90
6
2,
459
983
2,
110
1,76
3
81
1,64
2
1,
769
2,28
2
91
3
1,95
9
1,
636
811,
824
1,96
6
2,
536
1,01
4
2,
177
1,81
8
82
1,69
3
1,
824
2,35
3
94
1
2,02
0
1,
687
821,
881
2,02
7
2,
614
1,04
6
2,
244
1,87
5
83
1,74
6
1,
880
2,42
6
97
0
2,08
2
1,
739
831,
940
2,08
9
2,
696
1,07
8
2,
313
1,93
2
84
1,79
9
1,
938
2,50
0
1,
000
2,14
6
1,
792
841,
999
2,15
3
2,
778
1,11
1
2,
384
1,99
1
85
1,86
2
2,
005
2,58
7
1,
035
2,22
1
1,
854
852,
069
2,22
8
2,
874
1,15
0
2,
468
2,06
0
86
1,91
5
2,
063
2,66
1
1,
065
2,28
4
1,
908
862,
128
2,29
2
2,
957
1,18
3
2,
538
2,12
1
87
1,96
9
2,
121
2,73
7
1,
095
2,34
9
1,
962
872,
188
2,35
7
3,
041
1,21
7
2,
610
2,18
1
88
2,02
4
2,
180
2,81
4
1,
125
2,41
5
2,
018
882,
249
2,42
2
3,
127
1,25
0
2,
683
2,24
2
89
2,08
1
2,
241
2,89
2
1,
157
2,48
2
2,
073
892,
312
2,49
0
3,
213
1,28
6
2,
758
2,30
3
902,
138
2,30
3
2,
971
1,18
9
2,
550
2,13
0
90
2,37
6
2,
559
3,30
1
1,
321
2,83
3
2,
366
912,
196
2,36
5
3,
052
1,22
1
2,
619
2,18
8
91
2,44
0
2,
628
3,39
1
1,
357
2,91
0
2,
431
922,
255
2,42
9
3,
134
1,25
4
2,
690
2,24
7
92
2,50
6
2,
699
3,48
2
1,
393
2,98
9
2,
497
932,
315
2,49
4
3,
218
1,28
7
2,
762
2,30
7
93
2,57
2
2,
771
3,57
6
1,
430
3,06
9
2,
563
942,
377
2,56
0
3,
303
1,32
1
2,
835
2,36
7
94
2,64
1
2,
844
3,67
0
1,
468
3,15
0
2,
631
952,
439
2,62
7
3,
389
1,35
6
2,
909
2,43
0
95
2,71
0
2,
919
3,76
6
1,
507
3,23
2
2,
700
962,
502
2,69
4
3,
477
1,39
1
2,
984
2,49
3
96
2,78
0
2,
993
3,86
3
1,
546
3,31
6
2,
770
972,
566
2,76
3
3,
566
1,42
6
3,
060
2,55
6
97
2,85
1
3,
070
3,96
2
1,
584
3,40
0
2,
840
982,
630
2,83
3
3,
656
1,46
2
3,
137
2,62
0
98
2,92
2
3,
148
4,06
2
1,
624
3,48
6
2,
911
99
+2,
696
2,90
4
3,
747
1,49
9
3,
216
2,68
7
99
+2,
996
3,22
7
4,
163
1,66
6
3,
573
2,98
6
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.52
00Q
uar
terl
y:0.
2650
Mo
nth
ly:
0.08
33
The
ab
ove
rat
es
do
no
t in
clu
de
th
e $
20 o
ne
-tim
e p
oli
cy f
ee
.
To c
alcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ual
pre
miu
m x
mo
dal
fac
tor
= m
od
al p
rem
ium
(ro
un
d t
o n
ear
est
wh
ole
ce
nt)
M
od
al p
rem
ium
x .9
3 =
dis
cou
nte
d p
rem
ium
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d, u
se P
refe
rre
d r
ate
s.
Rat
es E
ffec
tive
2/1
/20
18
Fem
ale
Rat
es
Co
nti
ne
nta
l Lif
e In
sura
nce
Co
mp
any
of
Bre
ntw
oo
d, T
en
ne
sse
eA
nn
ual
Pre
miu
ms
For
Use
in
: R
est
of
Stat
e
CLI
MS0
3889
PA
02
/20
18
A
7
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n H
FP
lan
GP
lan
NA
geP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
Un
de
r 65
1,24
5
1,
342
1,73
2
69
2
1,48
6
1,
111
Un
de
r 65
1,38
3
1,
492
1,92
4
76
9
1,65
1
1,
234
65
1,24
5
1,
342
1,73
2
69
2
1,48
6
1,
111
651,
383
1,49
2
1,
924
769
1,
651
1,23
4
66
1,24
5
1,
342
1,73
2
69
2
1,48
6
1,
137
661,
383
1,49
2
1,
924
769
1,
651
1,26
3
67
1,24
5
1,
342
1,73
2
69
2
1,48
6
1,
163
671,
383
1,49
2
1,
924
769
1,
651
1,29
3
68
1,26
0
1,
358
1,75
3
70
2
1,50
4
1,
204
681,
401
1,50
9
1,
947
780
1,
671
1,33
8
69
1,28
8
1,
387
1,79
1
71
6
1,53
6
1,
257
691,
431
1,54
1
1,
990
796
1,
707
1,39
7
70
1,32
3
1,
424
1,83
8
73
5
1,57
7
1,
317
701,
470
1,58
2
2,
042
817
1,
751
1,46
4
71
1,36
2
1,
467
1,89
3
75
7
1,62
4
1,
358
711,
513
1,63
1
2,
103
841
1,
804
1,50
9
72
1,40
4
1,
512
1,95
2
78
1
1,67
4
1,
399
721,
561
1,68
0
2,
169
867
1,
861
1,55
6
73
1,45
0
1,
562
2,01
5
80
6
1,73
0
1,
445
731,
611
1,73
5
2,
239
896
1,
922
1,60
5
74
1,50
1
1,
617
2,08
6
83
5
1,79
1
1,
495
741,
668
1,79
6
2,
318
928
1,
990
1,66
3
75
1,55
6
1,
676
2,16
2
86
5
1,85
6
1,
549
751,
728
1,86
2
2,
402
961
2,
062
1,72
2
76
1,61
0
1,
734
2,23
8
89
5
1,92
1
1,
604
761,
789
1,92
7
2,
486
994
2,
134
1,78
3
77
1,66
4
1,
793
2,31
4
92
6
1,98
5
1,
659
771,
849
1,99
2
2,
571
1,02
8
2,
206
1,84
3
78
1,71
8
1,
852
2,38
9
95
6
2,05
0
1,
713
781,
909
2,05
7
2,
654
1,06
1
2,
278
1,90
2
79
1,77
4
1,
911
2,46
7
98
7
2,11
7
1,
769
791,
971
2,12
4
2,
740
1,09
6
2,
353
1,96
6
80
1,83
1
1,
972
2,54
5
1,
018
2,18
4
1,
824
802,
034
2,19
2
2,
828
1,13
0
2,
427
2,02
7
81
1,88
8
2,
034
2,62
4
1,
050
2,25
3
1,
882
812,
098
2,26
1
2,
916
1,16
6
2,
504
2,09
0
82
1,94
7
2,
098
2,70
6
1,
082
2,32
3
1,
940
822,
163
2,33
1
3,
006
1,20
3
2,
581
2,15
6
83
2,00
8
2,
162
2,79
0
1,
116
2,39
4
2,
000
832,
231
2,40
2
3,
100
1,24
0
2,
660
2,22
2
84
2,06
9
2,
229
2,87
5
1,
150
2,46
8
2,
061
842,
299
2,47
6
3,
195
1,27
8
2,
742
2,29
0
85
2,14
1
2,
306
2,97
5
1,
190
2,55
4
2,
133
852,
379
2,56
2
3,
305
1,32
3
2,
838
2,36
9
86
2,20
2
2,
372
3,06
0
1,
225
2,62
7
2,
195
862,
447
2,63
6
3,
401
1,36
0
2,
919
2,43
9
87
2,26
4
2,
439
3,14
8
1,
259
2,70
1
2,
257
872,
516
2,71
1
3,
497
1,40
0
3,
002
2,50
8
88
2,32
8
2,
507
3,23
6
1,
294
2,77
7
2,
321
882,
586
2,78
5
3,
596
1,43
8
3,
085
2,57
9
89
2,39
3
2,
577
3,32
6
1,
331
2,85
4
2,
384
892,
659
2,86
4
3,
695
1,47
9
3,
172
2,64
9
902,
459
2,64
8
3,
417
1,36
7
2,
933
2,44
9
90
2,73
2
2,
943
3,79
6
1,
519
3,25
8
2,
721
912,
525
2,72
0
3,
510
1,40
4
3,
012
2,51
6
91
2,80
6
3,
022
3,90
0
1,
561
3,34
7
2,
795
922,
593
2,79
3
3,
604
1,44
2
3,
094
2,58
4
92
2,88
2
3,
104
4,00
4
1,
602
3,43
7
2,
871
932,
662
2,86
8
3,
701
1,48
0
3,
176
2,65
3
93
2,95
8
3,
187
4,11
2
1,
645
3,52
9
2,
948
942,
734
2,94
4
3,
798
1,51
9
3,
260
2,72
2
94
3,03
7
3,
271
4,22
1
1,
688
3,62
3
3,
025
952,
805
3,02
1
3,
897
1,55
9
3,
345
2,79
4
95
3,11
7
3,
357
4,33
1
1,
733
3,71
7
3,
105
962,
877
3,09
8
3,
999
1,60
0
3,
432
2,86
7
96
3,19
7
3,
442
4,44
2
1,
778
3,81
3
3,
185
972,
951
3,17
7
4,
101
1,64
0
3,
519
2,94
0
97
3,27
9
3,
531
4,55
6
1,
822
3,91
0
3,
266
983,
025
3,25
8
4,
204
1,68
1
3,
608
3,01
3
98
3,36
0
3,
620
4,67
1
1,
868
4,00
9
3,
348
99
+3,
100
3,34
0
4,
309
1,72
4
3,
698
3,09
0
99
+3,
445
3,71
1
4,
787
1,91
6
4,
109
3,43
3
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.52
00Q
uar
terl
y:0.
2650
Mo
nth
ly:
0.08
33
The
ab
ove
rat
es
do
no
t in
clu
de
th
e $
20 o
ne
-tim
e p
oli
cy f
ee
.
To c
alcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ual
pre
miu
m x
mo
dal
fac
tor
= m
od
al p
rem
ium
(ro
un
d t
o n
ear
est
wh
ole
ce
nt)
M
od
al p
rem
ium
x .9
3 =
dis
cou
nte
d p
rem
ium
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d, u
se P
refe
rre
d r
ate
s.
Rat
es E
ffec
tive
2/1
/20
18
Mal
e R
ates
Co
nti
ne
nta
l Lif
e In
sura
nce
Co
mp
any
of
Bre
ntw
oo
d, T
en
ne
sse
eA
nn
ual
Pre
miu
ms
For
Use
in
: R
est
of
Stat
e
CLIMS03889PA 02/2018 A
8
PREMIUM INFORMATION Continental Life Insurance Company of Brentwood, Tennessee can only raise your premium if we raise the premium for all policies like yours in this state. Premiums for this policy will increase annually due to the increase in your age. Upon attainment of an age requiring a rate increase, the renewal premium for the policy will be the renewal premium then in effect for your attained age. Other policies may be provided with Issue Age rating and do not increase with age. You should compare Issue Age with Attained Age policies.
Premiums payable other than annual will be determined according to the following factors:
Semi-annual: 0.5200 Quarterly: 0.2650 Monthly EFT: 0.0833.
HOUSEHOLD DISCOUNT
In order to be eligible for the Household discount under an Continental Life Insurance Company of Brentwood, Tennessee 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 covered by a Company Continental Life Insurance Company of Brentwood, Tennessee Medicare Supplement policy. The Medicare eligible adult must be either (a) your spouse; (b) be someone with whom you are in a civil union partnership; and (c) be someone with whom you have continuously resided for the past 12 months. The household discount will only be applicable if a policy for each applicant is issued. The discounted rate will be 7 percent lower than the individual rates and will apply as long as both policies remain in force.
DISCLOSURES Use this outline to compare benefits and premium 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 Continental Life Insurance Company of Brentwood, Tennessee P.O. Box 14770, Lexington, KY 40512-4770. 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 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
The policy may not cover all of your medical costs. Neither Continental Life Insurance Company of Brentwood, Tennessee 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 any 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.
THE FOLLOWING CHARTS DESCRIBE PLANS A, B, F, HIGH DEDUCTIBLE F, G and N OFFERED BY CONTINENTAL LIFE INSURANCE COMPANY OF BRENTWOOD, TENNESSEE.
CLIMS03889PA 02/2018 A
9
PLAN A
MEDICARE (PART A) – MEDICAL 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
61st thru 90th day 91st day and after •While using 60 lifetime reserve days •Once lifetime reserve days are used: •Additional 365 days
•Beyond the Additional 365 days
All but $1340
All but $335 a day
All but $670 a day
$0 $0
$0
$335 a day
$670 a day
100% of Medicare Eligible Expenses $0
$1340 (Part A Deductible) $0
$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 21st thru 100th day
101st day and after
All approved amounts All but $167.50 a day
$0
$0 $0
$0
$0 Up to $167.50 a day All costs
BLOOD First 3 pints Additional amounts
$0 100%
3 pints $0
$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
**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.
CLIMS03889PA 02/2018 A
10
PLAN A
MEDICARE (PART B) – MEDICAL SERVICES – 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.
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 $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts
$0
Generally 80%
$0
Generally 20%
$183 (Part B Deductible)
$0
Part B Excess Charges (Above Medicare-Approved amounts)
$0
$0
All costs BLOOD First 3 pints Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts
$0 $0
80%
All costs $0
20%
$0 $183 (Part B Deductible)
$0
CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES
100%
$0
$0
PARTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies
•Durable medical equipment
•First $183of Medicare Approved amounts*
•Remainder of Medicare Approved amounts
100%
$0
80%
$0
$0
20%
$0
$183 (Part B Deductible)
$0
CLIMS03889PA 02/2018 A
11
PLAN B
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
61st thru 90th day 91st day and after •While using 60 lifetime reserve days •Once lifetime reserve days are used: •Additional 365 days
•Beyond the Additional 365 days
All but $1340 All but $335 a day
All but $670 a day
$0 $0
$1340 (Part A Deductible) $335 a day
$670 a day
100% of Medicare Eligible Expenses $0
$0 $0
$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
21st thru 100th day
101st day and after
All approved amounts All but $167.50 a day $0
$0 $0
$0
$0 Up to $167.50 a day All costs
BLOOD First 3 pints Additional amounts
$0 100%
3 pints $0
$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
**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 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.
CLIMS03889PA 02/2018 A
12
PLAN B
MEDICARE (PART B) – MEDICAL SERVICES – 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.
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 $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts
$0
Generally 80%
$0
Generally 20%
$183 (Part B Deductible)
$0
Part B Excess Charges (Above Medicare-Approved amounts)
$0
$0
All costs BLOOD First 3 pints Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts
$0 $0
80%
All costs $0
20%
$0 $183 (Part B Deductible)
$0
CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES
100%
$0
$0
PARTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies
•Durable medical equipment •First $183 of Medicare Approved amounts*
•Remainder of Medicare Approved amounts
100%
$0
80%
$0
$0
20%
$0
$183 (Part B Deductible)
$0
CLIMS03889PA 02/2018 A
13
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
61st thru 90th day 91st day and after •While using 60 lifetime reserve days •Once lifetime reserve days are used: •Additional 365 days
•Beyond the Additional 365 days
All but $1340 All but $335 a day
All but $670 a day
$0 $0
$1340 (Part A Deductible) $335 a day
$670 a day
100% of Medicare Eligible Expenses $0
$0 $0
$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
21st thru 100th day
101st day and after
All approved amounts All but $167.50 a day $0
$0 Up to $167.50 a day $0
$0 $0
All costs
BLOOD First 3 pints Additional amounts
$0 100%
3 pints $0
$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
**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 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.
CLIMS03889PA 02/2018 A
14
PLAN F
MEDICARE (PART B) – MEDICAL SERVICES – 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.
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 $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts
$0
Generally 80%
$183 (Part B Deductible)
Generally 20%
$0
$0 Part B Excess Charges (Above Medicare-Approved amounts)
$0
100%
$0 BLOOD First 3 pints Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts
$0 $0
80%
All costs $183 (Part B Deductible)
20%
$0 $0
$0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES
100%
$0
$0
PARTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies
•Durable medical equipment •First $183 of Medicare Approved amounts*
•Remainder of Medicare Approved amounts
100%
$0
80%
$0
$183 (Part B Deductible)
20%
$0
$0
$0
CLIMS03889PA 02/2018 A
15
PLAN F
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS
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 Remainder of charges
$0 $0
$0 80% to a lifetime maximum benefit of $50,000
$250 20% and amounts over the $50,000 lifetime maximum
CLIMS03889PA 02/2018 A
16
HIGH DEDUCTIBLE 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.
***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2240 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2240. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.
SERVICES
MEDICARE PAYS
AFTER YOU PAY $2240
DEDUCTIBLE*** PLAN PAYS
IN ADDITION TO $2240
DEDUCTIBLE*** YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days
61st thru 90th day 91st day and after •While using 60 lifetime reserve days •Once lifetime reserve days are used: •Additional 365 days
•Beyond the Additional 365 days
All but $1340 All but $335 a day
All but $670 a day
$0 $0
$1340 (Part A Deductible) $335 a day
$670 a day
100% of Medicare Eligible Expenses $0
$0 $0
$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
21st thru 100th day
101st day and after
All approved amounts All but $167.50 a day $0
$0 Up to $167.50 a day $0
$0 $0
All costs
BLOOD First 3 pints Additional amounts
$0 100%
3 pints $0
$0 $0
CLIMS03889PA 02/2018 A
17
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
**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 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.
CLIMS03889PA 02/2018 A
18
HIGH DEDUCTIBLE PLAN F
MEDICARE (PART B) – MEDICAL SERVICES – 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.
***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2240 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2240. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.
SERVICES
MEDICARE PAYS
AFTER YOU PAY $2240
DEDUCTIBLE*** PLAN PAYS
IN ADDITION TO $2240
DEDUCTIBLE*** 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 $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts
$0
Generally 80%
$183 (Part B Deductible)
Generally 20%
$0
$0 Part B Excess Charges (Above Medicare-Approved amounts)
$0
100%
$0 BLOOD First 3 pints Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts
$0 $0
80%
All costs $183 (Part B Deductible)
20%
$0 $0
$0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES
100%
$0
$0
CLIMS03889PA 02/2018 A
19
HIGH DEDUCTIBLE PLAN F
PARTS A & B
SERVICES
MEDICARE PAYS
AFTER YOU PAY $2240
DEDUCTIBLE*** PLAN PAYS
IN ADDITION TO $2240
DEDUCTIBLE*** YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies
•Durable medical equipment •First $183 of Medicare Approved amounts*
•Remainder of Medicare Approved amounts
100%
$0
80%
$0
$183 (Part B Deductible)
20%
$0
$0
$0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES
MEDICARE PAYS
AFTER YOU PAY $2240
DEDUCTIBLE** PLAN PAYS
IN ADDITION TO $2240
DEDUCTIBLE** 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 Remainder of charges
$0 $0
$0 80% to a lifetime maximum benefit of $50,000
$250 20% and amounts over the $50,000 lifetime maximum
CLIMS03889PA 02/2018 A
20
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
61st thru 90th day 91st day and after •While using 60 lifetime reserve days •Once lifetime reserve days are used: •Additional 365 days
•Beyond the Additional 365 days
All but $1340 All but $335 a day
All but $670 a day
$0 $0
$1340 (Part A Deductible) $335 a day
$670 a day
100% of Medicare Eligible Expenses $0
$0 $0
$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
21st thru 100th day 101st day and after
All approved amounts All but $167.50 a day $0
$0 Up to $167.50 a day $0
$0 $0 All costs
BLOOD First 3 pints Additional amounts
$0 100%
3 pints $0
$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
**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 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.
CLIMS03889PA 02/2018 A
21
PLAN G
MEDICARE (PART B) – MEDICAL SERVICES – 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.
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 $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts
$0
Generally 80%
$0
Generally 20%
$183 (Part B Deductible)
$0
Part B Excess Charges (Above Medicare-Approved amounts)
$0
100%
$0 BLOOD First 3 pints Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts
$0 $0
80%
All costs $0
20%
$0 $183 (Part B Deductible)
$0
CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES
100%
$0
$0
PARTS A & B
SERVICES MEDICARE PAYS
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 $183 of Medicare Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
CLIMS03889PA 02/2018 A
22
PLAN G
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS
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 Remainder of charges
$0 $0
$0 80% to a lifetime maximum benefit of $50,000
$250 20% and amounts over the $50,000 lifetime maximum
CLIMS03889PA 02/2018 A
23
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
61st thru 90th day 91st day and after •While using 60 lifetime reserve days •Once lifetime reserve days are used: •Additional 365 days
•Beyond the Additional 365 days
All but $1340 All but $335 a day
All but $670 a day
$0 $0
$1340 (Part A Deductible) $335 a day
$670 a day
100% of Medicare Eligible Expenses $0
$0 $0
$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
21st thru 100th day
101st day and after
All approved amounts All but $167.50 a day $0
$0 Up to $167.50 a day $0
$0 $0
All costs
BLOOD First 3 pints Additional amounts
$0 100%
3 pints $0
$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
**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 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.
CLIMS03889PA 02/2018 A
24
PLAN N
MEDICARE (PART B) – MEDICAL SERVICES – 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.
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 $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts
$0
Generally 80%
$0
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.
$183 (Part B Deductible) 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)
$0
0%
All costs BLOOD First 3 pints Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts
$0 $0
80%
All costs $0
20%
$0 $183 (Part B Deductible)
$0
CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES
100%
$0
$0
CLIMS03889PA 02/2018 A
25
PLAN N
PARTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies •Durable medical equipment •First $183 of Medicare Approved amounts* •Remainder of Medicare Approved amounts
100% $0
80%
$0 $0
20%
$0
$183 (Part B Deductible)
$0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS
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
Remainder of charges
$0
$0
$0
80% to a lifetime maximum benefit of $50,000
$250
20% and amounts over the $50,000 lifetime maximum