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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
Idaho
AHLMS03829ID © 2018 Aetna Inc. 01/2018 A
AHLM
S038
29ID
01
/201
8 A
1
AETN
A H
EALT
H A
ND
LIF
E IN
SUR
ANC
E C
OM
PAN
Y
OU
TLIN
E O
F M
EDIC
ARE
SUPP
LEM
ENT
CO
VER
AGE
CO
VER
PAG
E
BEN
EFIT
PLA
NS
AVAI
LAB
LE: A
, B, F
, HIG
H D
EDU
CTI
BLE
F, G
, N
Thes
e ch
arts
sho
w th
e be
nefit
s 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.
Basi
c Be
nefit
s:
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
paym
ents
for h
ospi
tal o
utpa
tient
ser
vice
s. P
lans
K,
L, a
nd N
requ
ire in
sure
ds to
pay
a p
ortio
n of
coi
nsur
ance
or c
opay
men
ts
Bloo
d: F
irst t
hree
pin
ts o
f blo
od e
ach
year
.
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
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 t
he s
ame
bene
fits
as P
lan
F af
ter
one
has
paid
a
cale
ndar
yea
r $2
,240
ded
uctib
le. B
enef
its fr
om h
igh
dedu
ctib
le p
lan
F w
ill n
ot b
egin
unt
il ou
t-of-p
ocke
t exp
ense
s ex
ceed
$2,
240.
Out
-of-p
ocke
t ex
pens
es fo
r thi
s de
duct
ible
are
exp
ense
s 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 fo
r Par
t A
and
Pa
rt B
, b
ut
do n
ot in
clu
de
th
e p
lan’s
se
para
te fo
reig
n tra
ve
l e
merg
ency d
ed
uctib
le
AHLM
S038
29ID
01
/201
8 A
2
Rat
es E
ffec
tive
1/1
/201
8
Issu
ePr
efer
red
Issu
eSt
anda
rd
Age
Plan
APl
an B
Plan
FPl
an H
FPl
an G
Plan
NA
gePl
an A
Plan
BPl
an F
Plan
HF
Plan
GPl
an N
Und
er 6
51,
833
2,14
6
2,
689
1,07
5
2,
241
1,82
4
U
nder
65
2,03
7
2,
386
2,98
6
1,
195
2,48
8
2,
028
65
1,22
2
1,
431
1,79
3
71
7
1,49
4
1,
216
651,
358
1,59
1
1,
991
797
1,
659
1,35
2
66
1,22
3
1,
432
1,79
3
71
8
1,49
4
1,
217
661,
359
1,59
1
1,
992
797
1,
661
1,35
2
67
1,22
5
1,
435
1,79
7
71
9
1,49
7
1,
219
671,
361
1,59
4
1,
997
799
1,
663
1,35
5
68
1,23
1
1,
442
1,80
5
72
2
1,50
4
1,
225
681,
367
1,60
2
2,
006
802
1,
671
1,36
1
69
1,23
8
1,
451
1,81
6
72
7
1,51
3
1,
232
691,
376
1,61
2
2,
018
807
1,
681
1,36
9
70
1,24
9
1,
464
1,83
2
73
3
1,52
7
1,
243
701,
388
1,62
6
2,
036
815
1,
697
1,38
2
71
1,26
3
1,
480
1,85
3
74
1
1,54
4
1,
257
711,
404
1,64
4
2,
058
824
1,
715
1,39
7
72
1,28
0
1,
498
1,87
6
75
1
1,56
3
1,
273
721,
422
1,66
4
2,
085
834
1,
737
1,41
4
73
1,29
4
1,
515
1,89
7
75
9
1,58
0
1,
287
731,
437
1,68
3
2,
107
843
1,
755
1,43
0
74
1,30
9
1,
533
1,92
0
76
8
1,59
9
1,
302
741,
454
1,70
3
2,
133
853
1,
777
1,44
6
75
1,32
4
1,
549
1,94
0
77
6
1,61
7
1,
316
751,
470
1,72
1
2,
155
863
1,
796
1,46
3
76
1,36
0
1,
592
1,99
3
79
7
1,66
1
1,
352
761,
511
1,76
9
2,
215
886
1,
846
1,50
3
77
1,39
7
1,
635
2,04
7
81
9
1,70
6
1,
389
771,
552
1,81
6
2,
274
909
1,
896
1,54
4
78
1,43
2
1,
676
2,09
9
84
0
1,74
9
1,
424
781,
591
1,86
2
2,
332
933
1,
943
1,58
3
79
1,46
7
1,
718
2,15
2
86
1
1,79
3
1,
460
791,
630
1,90
9
2,
391
956
1,
992
1,62
2
80
1,50
3
1,
761
2,20
4
88
2
1,83
7
1,
496
801,
670
1,95
7
2,
449
981
2,
041
1,66
1
81
1,53
0
1,
791
2,24
3
89
7
1,86
9
1,
522
811,
699
1,99
0
2,
493
996
2,
077
1,69
1
82
1,55
6
1,
822
2,28
2
91
3
1,90
1
1,
548
821,
729
2,02
5
2,
535
1,01
4
2,
113
1,72
0
83
1,58
2
1,
853
2,32
1
92
8
1,93
3
1,
575
831,
758
2,05
9
2,
578
1,03
2
2,
148
1,74
9
84
1,61
0
1,
885
2,36
0
94
4
1,96
7
1,
601
841,
788
2,09
4
2,
623
1,04
9
2,
185
1,77
8
85
1,63
7
1,
916
2,39
9
96
0
2,00
0
1,
628
851,
819
2,12
8
2,
666
1,06
7
2,
222
1,81
0
86
1,66
3
1,
948
2,43
9
97
6
2,03
3
1,
655
861,
849
2,16
5
2,
711
1,08
4
2,
259
1,83
9
87
1,69
1
1,
980
2,47
9
99
2
2,06
6
1,
682
871,
879
2,20
1
2,
755
1,10
2
2,
295
1,86
9
88
1,71
9
2,
012
2,51
9
1,
008
2,09
9
1,
709
881,
910
2,23
6
2,
799
1,12
0
2,
332
1,89
9
89
1,74
6
2,
045
2,56
0
1,
024
2,13
3
1,
736
891,
940
2,27
2
2,
845
1,13
8
2,
370
1,93
0
901,
774
2,07
6
2,
600
1,04
0
2,
166
1,76
4
90
1,97
0
2,
307
2,88
9
1,
156
2,40
7
1,
960
911,
801
2,10
8
2,
640
1,05
6
2,
200
1,79
1
91
2,00
1
2,
342
2,93
4
1,
173
2,44
4
1,
990
921,
827
2,14
0
2,
679
1,07
2
2,
233
1,81
8
92
2,03
0
2,
378
2,97
7
1,
190
2,48
0
2,
020
931,
854
2,17
1
2,
718
1,08
7
2,
265
1,84
5
93
2,06
0
2,
412
3,02
1
1,
208
2,51
6
2,
049
941,
880
2,20
2
2,
756
1,10
3
2,
297
1,87
0
94
2,08
8
2,
446
3,06
2
1,
226
2,55
3
2,
078
951,
904
2,23
0
2,
792
1,11
7
2,
326
1,89
4
95
2,11
6
2,
477
3,10
2
1,
241
2,58
5
2,
105
961,
927
2,25
6
2,
826
1,13
0
2,
355
1,91
7
96
2,14
1
2,
507
3,14
0
1,
256
2,61
6
2,
129
971,
947
2,28
0
2,
855
1,14
2
2,
378
1,93
6
97
2,16
4
2,
533
3,17
2
1,
268
2,64
2
2,
152
981,
962
2,29
7
2,
876
1,15
1
2,
397
1,95
2
98
2,18
0
2,
553
3,19
6
1,
278
2,66
3
2,
168
99
+1,
970
2,30
8
2,
890
1,15
5
2,
408
1,96
1
99
+2,
190
2,56
4
3,
211
1,28
4
2,
675
2,17
8
Mo
dal F
acto
rs:
Sem
i-A
nnua
l:0.
5200
Qua
rter
ly:
0.26
50M
ont
hly:
0.08
33
The
abo
ve r
ates
do
no
t in
clud
e th
e $2
0 o
ne-t
ime
polic
y fe
e.
If a
pply
ing
duri
ng O
pen
Enr
ollm
ent
or
Gua
rant
eed
Issu
e Pe
rio
d, u
se P
refe
rred
rat
es.
Un
isex
Rat
es
Ae
tna
He
alth
an
d L
ife
Insu
ran
ce C
om
pan
yA
nn
ual
Pre
miu
ms
For
Use
in E
nti
re S
tate
AHLMS03829ID 3 01/2018 A
PREMIUM INFORMATION
Aetna Health and Life Insurance Company can only raise your premium if we raise the premium for all policies like yours in this state.
Semi-annual: 0.5200 Quarterly: 0.2650 Monthly EFT: 0.0833.
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 Aetna Health and Life Insurance Company, 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 Aetna Health and Life Insurance Company nor its agents are connected with Medicare.
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare & You for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT
When you fill out the 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.
EXCLUSIONS
We will not pay for:
1. Loss incurred while your policy is not in force, except as provided in the Extension of Benefits section of your policy;
2. Hospital or Skilled Nursing Facility confinement incurred during a Medicare Part A Benefit Period that begins while this policy is not in force;
3. That portion of any Loss incurred which is paid for by Medicare;
4. Services for non-Medicare Eligible Expenses, including, but not limited to, routine exams, take-home drugs and eye refractions;
5. Services for which a charge is not normally made in the absence of insurance;
THE FOLLOWING CHARTS DESCRIBE THE FOLLOWING PLANS OFFERED BY AETNA HEALTH AND LIFE INSURANCE COMPANY: A (AHLMSP17A ID) B (AHLMSP17B ID) F (AHLMSP17F ID) HIGH DEDUCTIBLE F (AHLMSP17HF ID) G (AHLMSP17G ID) and N (AHLMSP17N ID)
AHLMS03829ID 4 01/2018 A
PLAN A 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 $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.
AHLMS03829ID 5 01/2018 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
AHLMS03829ID 6 01/2018 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.
AHLMS03829ID 7 01/2018 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
AHLMS03829ID 8 01/2018 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.
AHLMS03829ID 9 01/2018 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
AHLMS03829ID 10 01/2018 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
AHLMS03829ID 11 01/2018 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
AHLMS03829ID 12 01/2018 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.
AHLMS03829ID 13 01/2018 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
AHLMS03829ID 14 01/2018 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
AHLMS03829ID 15 01/2018 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.
AHLMS03829ID 16 01/2018 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
AHLMS03829ID 17 01/2018 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
AHLMS03829ID 18 01/2018 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 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.
AHLMS03829ID 19 01/2018 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 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.
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
AHLMS03829ID 20 01/2018 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