outline of coverage - aetna · outline of coverage medicare supplement insurance underwritten by...
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Outline of CoverageMedicare Supplement Insurance
Underwritten by
Aetna Health and Life Insurance Company
Administrative Office800 Crescent Centre Dr.Suite 200Franklin, TN 37067800 264.4000aetnaseniorproducts.com
Aetna Health and Life Insurance Company
Rates Effective:
BENEFIT PLANS A, B, F, High Deductible F, G, N
Tennessee
AHLMS03614TN © 2018 Aetna Inc. 02/2018 A
AH
LMS0
3614
TN
1 02
/201
8 A
AETN
A H
EALT
H A
ND
LIF
E IN
SUR
ANC
E C
OM
PAN
Y O
UTL
INE
OF
MED
ICAR
E SU
PPLE
MEN
T C
OVE
RAG
E C
OVE
R P
AGE:
Pag
e 1
of 2
B
ENEF
IT P
LAN
S AV
AILA
BLE
: A, B
, F, H
IGH
DED
UC
TIB
LE F
, G, N
Th
ese
char
ts s
how
the
be
nefits
in
clu
de
d in e
ach
of
the s
tand
ard
Me
dic
are
su
pp
lem
ent
pla
ns. E
ve
ry c
om
pa
ny m
ust m
ake
ava
ilable
Pla
n “
A”
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.
H
ospi
ce: P
art A
coi
nsur
ance
A
B
C
D
F/
F*
G
K
L M
N
Ba
sic,
in
clud
ing
100%
Par
t B
coin
sura
nce
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
up to
$20
co
paym
ent f
or o
ffice
vi
sit,
and
up to
$50
co
paym
ent f
or E
R
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 th
e sa
me
bene
fits
as P
lan
F af
ter
one
has
paid
a c
alen
dar
year
$2
,240
ded
uctib
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 $
2,24
0.
Out
-of-p
ocke
t exp
ense
s fo
r th
is d
educ
tible
ar
e ex
pens
es th
at 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 f
or
Part
A a
nd P
art
B,
but
do n
ot
inclu
de t
he p
lan
’s
sepa
rate
fore
ign
trave
l em
erge
ncy
dedu
ctib
le.
AHLM
S036
14TN
2
02/2
018
A
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Sta
nd
ard
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 6
54
,36
6
4,7
37
5
,58
5
2,2
34
3
,94
3
3,5
41
Un
de
r 6
5n
/an
/an
/an
/an
/an
/a
6
51
,34
4
1,4
58
1
,72
0
68
8
1
,21
4
1,0
90
65
1,4
93
1
,62
0
1,9
11
7
64
1,3
50
1,2
11
6
61
,34
4
1,4
58
1
,72
0
68
8
1
,21
4
1,0
90
66
1,4
93
1
,62
0
1,9
11
7
64
1,3
50
1,2
11
6
71
,34
4
1,4
58
1
,72
0
68
8
1
,21
4
1,0
90
67
1,4
93
1
,62
0
1,9
11
7
64
1,3
50
1,2
11
6
81
,34
4
1,4
58
1
,72
0
68
8
1
,21
4
1,0
90
68
1,4
93
1
,62
0
1,9
11
7
64
1,3
50
1,2
11
6
91
,34
4
1,4
58
1
,72
0
68
8
1
,21
4
1,0
90
69
1,4
93
1
,62
0
1,9
11
7
64
1,3
50
1,2
11
7
01
,36
4
1,4
88
1
,75
4
70
1
1
,23
8
1,1
12
70
1,5
15
1
,65
3
1,9
49
7
79
1,3
75
1,2
36
7
11
,39
1
1,5
39
1
,81
5
72
7
1
,28
1
1,1
51
71
1,5
46
1
,71
0
2,0
17
8
07
1,4
23
1,2
79
7
21
,42
0
1,5
93
1
,87
8
75
2
1
,32
6
1,1
91
72
1,5
77
1
,77
0
2,0
87
8
36
1,4
74
1,3
23
7
31
,44
8
1,6
50
1
,94
5
77
8
1
,37
3
1,2
33
73
1,6
09
1
,83
3
2,1
61
8
64
1,5
26
1,3
69
7
41
,47
9
1,7
09
2
,01
6
80
6
1
,42
3
1,2
78
74
1,6
44
1
,89
9
2,2
40
8
96
1,5
81
1,4
20
7
51
,51
1
1,7
71
2
,08
8
83
6
1
,47
5
1,3
24
75
1,6
79
1
,96
8
2,3
21
9
28
1,6
38
1,4
71
7
61
,54
1
1,8
33
2
,16
2
86
5
1
,52
7
1,3
70
76
1,7
13
2
,03
7
2,4
02
9
62
1,6
96
1,5
23
7
71
,57
2
1,8
97
2
,23
8
89
5
1
,58
0
1,4
19
77
1,7
46
2
,10
8
2,4
86
9
94
1,7
56
1,5
76
7
81
,60
3
1,9
65
2
,31
6
92
6
1
,63
6
1,4
68
78
1,7
82
2
,18
3
2,5
74
1
,02
9
1,8
17
1,6
31
7
91
,63
8
2,0
36
2
,40
0
96
1
1
,69
5
1,5
21
79
1,8
20
2
,26
2
2,6
67
1
,06
8
1,8
83
1,6
91
8
01
,67
3
2,1
11
2
,48
9
99
5
1
,75
7
1,5
77
80
1,8
59
2
,34
5
2,7
65
1
,10
6
1,9
52
1,7
52
8
11
,70
8
2,1
66
2
,55
4
1,0
22
1
,80
3
1,6
19
81
1,8
98
2
,40
7
2,8
37
1
,13
5
2,0
03
1,7
99
8
21
,74
4
2,2
22
2
,62
0
1,0
48
1
,85
0
1,6
61
82
1,9
38
2
,46
9
2,9
11
1
,16
4
2,0
56
1,8
46
8
31
,78
0
2,2
79
2
,68
7
1,0
74
1
,89
7
1,7
03
83
1,9
77
2
,53
2
2,9
85
1
,19
4
2,1
07
1,8
92
8
41
,81
5
2,3
35
2
,75
3
1,1
01
1
,94
4
1,7
45
84
2,0
17
2
,59
5
3,0
59
1
,22
4
2,1
60
1,9
39
8
51
,85
7
2,4
02
2
,83
2
1,1
33
1
,99
9
1,7
96
85
2,0
64
2
,66
9
3,1
47
1
,25
9
2,2
21
1,9
95
8
61
,89
0
2,4
55
2
,89
5
1,1
58
2
,04
5
1,8
35
86
2,1
00
2
,72
8
3,2
16
1
,28
7
2,2
72
2,0
39
8
71
,92
2
2,5
08
2
,95
8
1,1
83
2
,08
9
1,8
75
87
2,1
35
2
,78
7
3,2
87
1
,31
5
2,3
21
2,0
83
8
81
,95
2
2,5
61
3
,02
0
1,2
09
2
,13
3
1,9
14
88
2,1
69
2
,84
6
3,3
56
1
,34
3
2,3
70
2,1
27
8
91
,98
2
2,6
15
3
,08
3
1,2
33
2
,17
6
1,9
54
89
2,2
03
2
,90
5
3,4
25
1
,36
9
2,4
18
2,1
71
90
2,0
13
2
,66
6
3,1
44
1
,25
8
2,2
20
1
,99
3
9
02
,23
7
2,9
62
3
,49
3
1,3
98
2
,46
7
2
,21
4
91
2,0
41
2
,71
8
3,2
05
1
,28
2
2,2
64
2
,03
2
9
12
,26
8
3,0
21
3
,56
1
1,4
25
2
,51
5
2
,25
8
92
2,0
70
2
,77
0
3,2
66
1
,30
6
2,3
06
2
,07
1
9
22
,30
0
3,0
78
3
,62
9
1,4
51
2
,56
2
2
,30
1
93
2,0
98
2
,82
0
3,3
25
1
,33
0
2,3
48
2
,10
8
9
32
,33
1
3,1
33
3
,69
5
1,4
78
2
,60
9
2
,34
3
94
2,1
24
2
,87
1
3,3
84
1
,35
3
2,3
89
2
,14
6
9
42
,36
0
3,1
90
3
,76
0
1,5
04
2
,65
5
2
,38
5
95
2,1
50
2
,92
0
3,4
43
1
,37
8
2,4
31
2
,18
3
9
52
,39
0
3,2
45
3
,82
5
1,5
31
2
,70
1
2
,42
6
96
2,1
76
2
,96
8
3,5
01
1
,40
0
2,4
71
2
,21
9
9
62
,41
7
3,2
98
3
,88
9
1,5
55
2
,74
6
2
,46
5
97
2,2
00
3
,01
7
3,5
56
1
,42
3
2,5
12
2
,25
4
9
72
,44
4
3,3
52
3
,95
1
1,5
81
2
,79
1
2
,50
5
98
2,2
23
3
,06
3
3,6
12
1
,44
5
2,5
50
2
,29
0
9
82
,47
0
3,4
03
4
,01
3
1,6
05
2
,83
3
2
,54
4
9
9+
2,2
45
3
,10
9
3,6
67
1
,46
7
2,5
89
2
,32
4
9
9+
2,4
95
3
,45
5
4,0
74
1
,63
0
2,8
76
2,5
82
Mo
da
l Fa
cto
rs:
Sem
i-A
nn
ua
l:0
.52
00
Qu
art
erl
y:0
.26
50
Mo
nth
ly:
0.0
83
3
Th
e a
bo
ve r
ate
s d
o n
ot
incl
ud
e t
he
$2
0 a
pp
lica
tio
n f
ee
.
To
ca
lcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ua
l pre
miu
m x
mo
da
l fa
cto
r =
mo
da
l pre
miu
m (
rou
nd
to
ne
are
st w
ho
le c
en
t)
M
od
al p
rem
ium
x .
93
= d
isco
un
ted
pre
miu
m
If a
pp
lyin
g d
uri
ng
Op
en
En
rollm
en
t o
r G
ua
ran
tee
d I
ssu
e P
eri
od
, use
Pre
ferr
ed
ra
tes.
Ra
tes
Eff
ect
ive
2/1
/20
18
Fo
r U
se i
n A
ll Z
IP C
od
es
Ae
tna
He
alt
h a
nd
Lif
e I
nsu
ran
ce C
om
pa
ny
An
nu
al
Pre
miu
ms
Fe
ma
le R
ate
s
AHLM
S036
14TN
3
02/2
018
A
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Sta
nd
ard
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 6
55
,02
1
5,4
47
6
,42
3
2,5
69
4
,53
5
4,0
72
Un
de
r 6
5n
/an
/an
/an
/an
/an
/a
6
51
,54
6
1,6
77
1
,97
8
79
1
1
,39
7
1,2
54
65
1,7
17
1
,86
3
2,1
98
8
79
1,5
52
1,3
92
6
61
,54
6
1,6
77
1
,97
8
79
1
1
,39
7
1,2
54
66
1,7
17
1
,86
3
2,1
98
8
79
1,5
52
1,3
92
6
71
,54
6
1,6
77
1
,97
8
79
1
1
,39
7
1,2
54
67
1,7
17
1
,86
3
2,1
98
8
79
1,5
52
1,3
92
6
81
,54
6
1,6
77
1
,97
8
79
1
1
,39
7
1,2
54
68
1,7
17
1
,86
3
2,1
98
8
79
1,5
52
1,3
92
6
91
,54
6
1,6
77
1
,97
8
79
1
1
,39
7
1,2
54
69
1,7
17
1
,86
3
2,1
98
8
79
1,5
52
1,3
92
7
01
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9
1,7
12
2
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7
80
6
1
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4
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79
70
1,7
42
1
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1
2,2
41
8
96
1,5
81
1,4
22
7
11
,60
0
1,7
70
2
,08
7
83
6
1
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3
1,3
23
71
1,7
78
1
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7
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19
9
28
1,6
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7
21
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3
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32
2
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0
86
4
1
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6
1,3
69
72
1,8
13
2
,03
6
2,4
00
9
61
1,6
95
1,5
21
7
31
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5
1,8
97
2
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7
89
5
1
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9
1,4
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73
1,8
50
2
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8
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9
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1,7
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1,5
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7
41
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1
1,9
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2
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8
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7
1
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74
1,8
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2
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4
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1
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0
1,8
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1,6
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8
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2
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1
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1
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6
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61
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2
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2
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6
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5
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3
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1
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2
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4
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1
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7
1,6
32
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2,0
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4
2,8
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1
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3
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1,8
12
7
81
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4
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2
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4
1,0
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1
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1
1,6
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78
2,0
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2
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1
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1
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3
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1,8
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4
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2
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0
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9
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2
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1
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1
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8
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5
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2
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8
22
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6
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1
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32
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6
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3
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0
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2
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83
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2
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2
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3
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8
42
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2,6
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3
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2
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5
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4
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6
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3
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2
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9
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3
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8
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4
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3
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0
1,3
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2
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1
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11
86
2,4
15
3
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3,6
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1
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1
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8
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0
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3
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2
1,3
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2
,40
2
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57
87
2,4
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3
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5
3,7
80
1
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2
2,6
69
2,3
96
8
82
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5
2,9
45
3
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2
1,3
90
2
,45
2
2,2
01
88
2,4
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3
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3
3,8
59
1
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5
2,7
25
2,4
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8
92
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0
3,0
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3
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5
1,4
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2
,50
2
2,2
47
89
2,5
34
3
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1
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39
1
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5
2,7
81
2,4
97
90
2,3
15
3
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6
3,6
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1
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7
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2
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2
9
02
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3
3,4
06
4
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7
1,6
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2
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7
2
,54
6
91
2,3
48
3
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6
3,6
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1
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4
2,6
03
2
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6
9
12
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8
3,4
74
4
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5
1,6
39
2
,89
2
2
,59
7
92
2,3
80
3
,18
6
3,7
56
1
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3
2,6
52
2
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1
9
22
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5
3,5
40
4
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3
1,6
68
2
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7
2
,64
6
93
2,4
13
3
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3
3,8
24
1
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0
2,7
01
2
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4
9
32
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1
3,6
04
4
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9
1,7
00
3
,00
0
2
,69
4
94
2,4
42
3
,30
1
3,8
91
1
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6
2,7
48
2
,46
9
9
42
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4
3,6
69
4
,32
4
1,7
29
3
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3
2
,74
3
95
2,4
73
3
,35
8
3,9
60
1
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4
2,7
96
2
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1
9
52
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8
3,7
32
4
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8
1,7
61
3
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6
2
,79
0
96
2,5
02
3
,41
4
4,0
26
1
,61
0
2,8
42
2
,55
2
9
62
,77
9
3,7
93
4
,47
3
1,7
88
3
,15
7
2
,83
5
97
2,5
29
3
,46
9
4,0
90
1
,63
6
2,8
89
2
,59
2
9
72
,81
1
3,8
55
4
,54
3
1,8
19
3
,20
9
2
,88
1
98
2,5
57
3
,52
3
4,1
54
1
,66
1
2,9
33
2
,63
3
9
82
,84
0
3,9
13
4
,61
5
1,8
46
3
,25
8
2
,92
5
9
9+
2,5
82
3
,57
5
4,2
17
1
,68
7
2,9
77
2
,67
2
9
9+
2,8
69
3
,97
3
4,6
85
1
,87
4
3,3
08
2,9
69
Mo
da
l Fa
cto
rs:
Sem
i-A
nn
ua
l:0
.52
00
Qu
art
erl
y:0
.26
50
Mo
nth
ly:
0.0
83
3
Th
e a
bo
ve r
ate
s d
o n
ot
incl
ud
e t
he
$2
0 a
pp
lica
tio
n f
ee
.
To
ca
lcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ua
l pre
miu
m x
mo
da
l fa
cto
r =
mo
da
l pre
miu
m (
rou
nd
to
ne
are
st w
ho
le c
en
t)
M
od
al p
rem
ium
x .
93
= d
isco
un
ted
pre
miu
m
If a
pp
lyin
g d
uri
ng
Op
en
En
rollm
en
t o
r G
ua
ran
tee
d I
ssu
e P
eri
od
, use
Pre
ferr
ed
ra
tes.
Ra
tes
Eff
ect
ive
2/1
/20
18
Ae
tna
He
alt
h a
nd
Lif
e I
nsu
ran
ce C
om
pa
ny
An
nu
al
Pre
miu
ms
For
Use
in
All
ZIP
Co
de
s
Ma
le R
ate
s
AHLM
S036
14TN
4
0
2/20
18 A
PREM
IUM
INFO
RM
ATI
ON
Aetn
a H
ealth
an
d Li
fe
Insu
ranc
e C
ompa
ny
can
only
ra
ise
your
pr
emiu
m if
we
rais
e th
e pr
emiu
m fo
r all
polic
ies
like
your
s in
this
sta
te.
Prem
ium
s fo
r thi
s po
licy
will
incr
ease
due
to th
e in
crea
se in
you
r age
. U
pon
atta
inm
ent
of a
n ag
e re
quiri
ng a
rat
e in
crea
se,
the
rene
wal
pr
emiu
m fo
r th
e po
licy
will
be th
e re
new
al p
rem
ium
then
in e
ffect
for
your
atta
ined
age
. O
ther
pol
icie
s m
ay b
e pr
ovid
ed w
ith I
ssue
Age
ra
ting
and
do n
ot in
crea
se w
ith a
ge. Y
ou s
houl
d co
mpa
re Is
sue
Age
with
Atta
ined
Age
pol
icie
s.
Prem
ium
s pa
yabl
e ot
her
than
ann
ually
will
be d
eter
min
ed a
ccor
ding
to
the
follo
win
g fa
ctor
s:
Sem
i-ann
ual:
0.52
00 Q
uarte
rly: 0
.265
0 M
onth
ly E
FT: 0
.083
3.
DIS
CLO
SUR
ES
Use
this
out
line
to c
ompa
re b
enef
its a
nd p
rem
ium
am
ong
polic
ies.
HO
USE
HO
LD D
ISC
OU
NT
In o
rder
to
be e
ligib
le f
or t
he H
ouse
hold
dis
coun
t un
der
an A
etna
H
ealth
and
Life
Ins
uran
ce C
ompa
ny M
edic
are
supp
lem
ent
plan
, yo
u m
ust
appl
y fo
r a
Med
icar
e su
pple
men
t pl
an a
t th
e sa
me
time
as
anot
her
Med
icar
e el
igib
le a
dult
or t
he o
ther
Med
icar
e el
igib
le a
dult
mus
t cu
rrent
ly b
e co
vere
d by
an
Aetn
a H
ealth
and
Life
Ins
uran
ce
Com
pany
Med
icar
e su
pple
men
t po
licy.
The
Med
icar
e el
igib
le a
dult
mus
t be
eith
er (a
) you
r spo
use;
(b) b
e so
meo
ne w
ith w
hom
you
are
in
a ci
vil u
nion
par
tner
ship
; an
d (c
) be
som
eone
with
who
m y
ou h
ave
cont
inuo
usly
res
ided
for t
he p
ast 1
2 m
onth
s. T
he h
ouse
hold
dis
coun
t w
ill on
ly b
e ap
plic
able
if
a po
licy
for
each
app
lican
t is
iss
ued.
The
di
scou
nted
rate
will
be 7
per
cent
low
er th
an th
e in
divi
dual
rate
s.
REA
D Y
OU
R P
OLI
CY
VER
Y C
AREF
ULL
Y
This
is
o
nly
a
n
outlin
e
describ
ing
yo
ur
polic
y’s
m
ost
imp
ort
ant
feat
ures
. Th
e po
licy
is y
our
insu
ranc
e co
ntra
ct.
You
mus
t re
ad t
he
polic
y its
elf t
o un
ders
tand
all
of th
e rig
hts
and
dutie
s of
bot
h yo
u an
d yo
ur in
sura
nce
com
pany
.
RIG
HT
TO R
ETU
RN
PO
LIC
Y
If yo
u fin
d th
at y
ou a
re n
ot s
atis
fied
with
you
r pol
icy,
you
may
retu
rn it
to
Aet
na H
ealth
and
Life
Ins
uran
ce C
ompa
ny,
P.O
. Bo
x 14
770,
Le
ton,
KY
4051
2-47
70. I
f you
sen
d th
e po
licy
back
to u
s w
ithin
30
days
afte
r you
rece
ive
it, w
e w
ill tre
at th
e po
licy
as if
it h
ad n
ever
bee
n is
sued
and
retu
rn a
ll yo
ur p
aym
ents
.
P
OLI
CY
REP
LAC
EMEN
T
If yo
u ar
e re
plac
ing
anot
her h
ealth
insu
ranc
e po
licy,
do
NO
T ca
ncel
it
until
you
hav
e ac
tual
ly r
ecei
ved
your
new
pol
icy
and
are
sure
you
w
ant t
o ke
ep it
.
NO
TIC
E
The
polic
y m
ay n
ot c
over
all
of y
our m
edic
al c
osts
.
Nei
ther
Aet
na H
ealth
and
Life
Insu
ranc
e C
ompa
ny n
or it
s ag
ents
are
co
nnec
ted
with
Med
icar
e.
This
out
line
of c
over
age
does
not
giv
e al
l th
e de
tails
of
Med
icar
e co
vera
ge.
Con
tact
yo
ur
loca
l So
cial
Se
curit
y O
ffice
or
co
nsul
t M
edic
are
& Y
ou fo
r mor
e de
tails
.
CO
MPL
ETE
ANSW
ERS
ARE
VER
Y IM
POR
TAN
T
Whe
n yo
u fil
l out
the
appl
icat
ion
for t
he n
ew p
olic
y, b
e su
re to
ans
wer
tru
thfu
lly a
nd c
ompl
etel
y an
y qu
estio
ns a
bout
you
r med
ical
and
hea
lth
hist
ory.
The
com
pany
may
can
cel y
our
polic
y an
d re
fuse
to
pay
any
clai
ms
if yo
u le
ave
out o
r fal
sify
impo
rtant
med
ical
info
rmat
ion.
Rev
iew
the
appl
icat
ion
care
fully
bef
ore
you
sign
it. B
e ce
rtain
that
all
info
rmat
ion
has
been
pro
perly
reco
rded
.
THE
FOLL
OW
ING
CH
ARTS
DES
CR
IBE
PLA
NS
A, B
, F,
HIG
H
DED
UC
TIB
LE F
, G
and
N O
FFER
ED B
Y AE
TNA
HEA
LTH
AN
D
LIFE
INSU
RAN
CE
CO
MPA
NY.
AHLMS03614TN 5 02/2018 A
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 All but $1,340 $0 $1,340 (Part A Deductible)
61st thru 90th day All but $335 a day $335 a day $0 91st day and after �While using 60 lifetime reserve days All but $670 a day $670 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 $167.50 a day $0 Up to $167.50 a
day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$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.
AHLMS03614TN 6 02/2018 A
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*
$0 $0 $183 (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 BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $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
AHLMS03614TN 7 02/2018 A
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 All but $1,340 $1,340 (Part A Deductible)
$0
61st thru 90th day All but $335 a day $335 a day $0 91st day and after �While using 60 lifetime reserve days All but $670 a day $670 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 $167.50 a day
$0 Up to $167.50 a day
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$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.
AHLMS03614TN 8 02/2018 A
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*
$0 $0 $183 (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 BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $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
AHLMS03614TN 9 02/2018 A
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 All but $1,340 $1,340 (Part A Deductible)
$0
61st thru 90th day All but $335 a day $335 a day $0 91st day and after �While using 60 lifetime reserve days All but $670 a day $670 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 $167.50 a day
Up to $167.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**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.
AHLMS03614TN 10 02/2018 A
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*
$0 $183 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*
$0 $183 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts 80% 20% $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 $183 (Part B Deductible)
$0
�Remainder of Medicare Approved amounts 80% 20% $0
AHLMS03614TN 11 02/2018 A
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 $0 $0 $250 Remainder of charges $0 80% to a lifetime
maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
AHLMS03614TN 12 02/2018 A
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 $2,240 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses are $2,240. 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
$2,240 DEDUCTIBLE***
PLAN PAYS
IN ADDITION TO $2,240
DEDUCTIBLE*** YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1,340 $1,340 (Part A Deductible)
$0
61st thru 90th day All but $335 a day $335 a day $0 91st day and after �While using 60 lifetime reserve days All but $670 a day $670 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 $167.50 a day
Up to $167.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0
AHLMS03614TN 13 02/2018 A
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.
AHLMS03614TN 14 02/2018 A
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 $2,240 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses are $2,240. 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
$2,240 DEDUCTIBLE***
PLAN PAYS
IN ADDITION TO $2,240
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*
$0 $183 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*
$0 $183 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
AHLMS03614TN 15 02/2018 A
HIGH DEDUCTIBLE PLAN F
PARTS A & B
SERVICES MEDICARE
PAYS AFTER YOU PAY
$2,240 DEDUCTIBLE***
PLAN PAYS
IN ADDITION TO $2,240
DEDUCTIBLE*** 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 $183 (Part B Deductible)
$0
�Remainder of Medicare Approved amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE
PAYS AFTER YOU PAY
$2,240 DEDUCTIBLE**
PLAN PAYS
IN ADDITION TO $2,240
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 $0 $0 $250 Remainder of charges $0 80% to a lifetime
maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
AHLMS03614TN 16 02/2018 A
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 All but $1,340 $1,340 (Part A Deductible)
$0
61st thru 90th day All but $335 a day $335 a day $0 91st day and after �While using 60 lifetime reserve days All but $670 a day $670 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 $167.50 a day
Up to $167.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness services
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**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.
AHLMS03614TN 17 02/2018 A
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*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $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
AHLMS03614TN 18 02/2018 A
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 $0 $0 $250 Remainder of charges $0 80% to a lifetime
maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
AHLMS03614TN 19 02/2018 A
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 All but $1,340 $1,340 (Part A Deductible)
$0
61st thru 90th day All but $335 a day $335 a day $0 91st day and after �While using 60 lifetime reserve days All but $670 a day $670 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 $167.50 a day
Up to $167.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness services
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare co-payment/ coinsurance
$0
**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.
AHLMS03614TN 20 02/2018 A
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*
$0 $0 $183 (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 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 $0 All costs $0 Next $183 of Medicare-Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
AHLMS03614TN 21 02/2018 A
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 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
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 $0 $0 $250
Remainder of charges $0 80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
