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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, HF, G, & N
Maryland
AHLMS03845MD ©2017 Aetna Inc. 12/2017 A
AH
LMS
0384
5MD
12
/201
7 A
1
AET
NA
HEA
LTH
AN
D L
IFE
INSU
RA
NC
E C
OM
PAN
Y O
UTL
INE
OF
MED
ICA
RE
SUPP
LEM
ENT
CO
VER
AG
E C
OVE
R P
AG
E B
ENEF
IT P
LAN
S A
VAIL
AB
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
clud
ed in
eac
h of
the
stan
dard
Med
icar
e su
pple
men
t pla
ns. E
very
com
pany
mus
t m
ake
availa
ble
Pla
n “
A”.
Som
e pl
ans
may
not
be
avai
labl
e in
you
r sta
te.
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-
App
rove
d ex
pens
es) 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
Blo
od: 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
B
asic
, in
clud
ing
100%
Par
t B
coin
sura
nce
Bas
ic,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Bas
ic,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Bas
ic,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Bas
ic,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Bas
ic,
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%
Bas
ic,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Bas
ic, i
nclu
ding
10
0% P
art B
co
insu
ranc
e, e
xcep
t up
to $
20
copa
ymen
t for
offi
ce
visi
t, an
d up
to $
50
copa
ymen
t for
ER
S
kille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
50%
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
75%
Ski
lled
Nur
sing
Fac
ility
Coi
nsur
ance
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
P
art A
D
educ
tible
P
art A
D
educ
tible
P
art A
D
educ
tible
P
art A
D
educ
tible
P
art A
D
educ
tible
50
% P
art A
D
educ
tible
75
% P
art A
D
educ
tible
50
% P
art A
D
educ
tible
P
art A
Ded
uctib
le
Par
t B
Ded
uctib
le
P
art B
D
educ
tible
Par
t B
Exc
ess
(100
%)
Par
t B
Exc
ess
(100
%)
Fore
ign
Trav
el
Em
erge
ncy
Fore
ign
Trav
el
Em
erge
ncy
Fore
ign
Trav
el
Em
erge
ncy
Fore
ign
Trav
el
Em
erge
ncy
Fore
ign
Trav
el
Em
erge
ncy
Fore
ign
Trav
el
Em
erge
ncy
Out
-of-p
ocke
t lim
it $5
120;
pa
id a
t 100
%
afte
r lim
it re
ache
d
Out
-of-p
ocke
t lim
it $2
560;
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
200
dedu
ctib
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
$22
00.
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
an
d P
art
B, b
ut d
o n
ot in
clu
de t
he p
lan’s
separa
te fore
ign tra
vel e
merg
ency d
edu
ctib
le.
AH
LMS
0384
5MD
12
/201
7 A
2
Atta
ine
dP
re
fe
rre
dA
tta
ine
dS
ta
nd
ard
Ag
eP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
Ag
eP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
Un
de
r 6
52
,96
3
---
---
---
---
---
Un
de
r 6
5---
---
---
---
---
---
6
51
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4
1,5
56
1
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8
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7
1,6
23
1
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2
65
2,0
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1
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9
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87
8
74
1,8
03
1,4
58
6
61
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4
1,5
56
1
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8
78
7
1,6
23
1
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2
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1
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1,8
03
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3
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8
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1
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2
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20
7
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3
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3,7
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2
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2,6
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Mo
da
l F
acto
rs:
Se
mi-
An
nu
al:
0.5
20
0Q
ua
rte
rly
:0
.26
50
Mo
nth
ly:
0.0
83
3
Th
e a
bo
ve
ra
te
s d
o n
ot i
nclu
de
th
e $
20
ap
pli
ca
tio
n f
ee
.
To
ca
lcu
late
a H
ou
se
ho
ld d
isco
un
t:
A
nn
ua
l p
re
miu
m x
mo
da
l fa
cto
r =
mo
da
l p
re
miu
m (
ro
un
d t
o n
ea
re
st w
ho
le c
en
t)
M
od
al
pre
miu
m x
.9
3 =
dis
co
un
te
d p
re
miu
m
If a
pp
lyin
g d
urin
g O
pe
n E
nro
llm
en
t o
r G
ua
ra
nte
ed
Issu
e P
erio
d,
use
Pre
fe
rre
d r
ate
s.
Ra
tes E
ffe
cti
ve
12
/1
/2
01
7
Fo
r U
se
in
En
tire
Sta
te
Ae
tn
a H
ea
lth
an
d L
ife
In
su
ra
nce
Co
mp
an
yA
nn
ua
l P
rem
ium
s
Fe
ma
le R
ate
s
AH
LMS
0384
5MD
12
/201
7 A
3
Atta
ine
dP
re
fe
rre
dA
tta
ine
dS
ta
nd
ard
Ag
eP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
Ag
eP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
Un
de
r 6
53
,40
8
---
---
---
---
---
Un
de
r 6
5---
---
---
---
---
---
6
52
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9
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3
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5
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3
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88
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89
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01
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6
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92
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98
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Mo
da
l F
acto
rs:
Se
mi-
An
nu
al:
0.5
20
0Q
ua
rte
rly
:0
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Mo
nth
ly:
0.0
83
3
Th
e a
bo
ve
ra
te
s d
o n
ot i
nclu
de
th
e $
20
ap
pli
ca
tio
n f
ee
.
To
ca
lcu
late
a H
ou
se
ho
ld d
isco
un
t:
A
nn
ua
l p
re
miu
m x
mo
da
l fa
cto
r =
mo
da
l p
re
miu
m (
ro
un
d t
o n
ea
re
st w
ho
le c
en
t)
M
od
al
pre
miu
m x
.9
3 =
dis
co
un
te
d p
re
miu
m
If a
pp
lyin
g d
urin
g O
pe
n E
nro
llm
en
t o
r G
ua
ra
nte
ed
Issu
e P
erio
d,
use
Pre
fe
rre
d r
ate
s.
Ra
tes E
ffe
cti
ve
12
/1
/2
01
7
Ae
tn
a H
ea
lth
an
d L
ife
In
su
ra
nce
Co
mp
an
yA
nn
ua
l P
rem
ium
s
Fo
r U
se
in
En
tire
Sta
te
Ma
le R
ate
s
AH
LMS
0384
5MD
12
/201
7 A
4
PREM
IUM
INFO
RM
ATI
ON
Aet
na H
ealth
and
Life
Insu
ranc
e C
ompa
ny c
an o
nly
rais
e yo
ur
prem
ium
if w
e ra
ise
the
prem
ium
for a
ll po
licie
s lik
e yo
urs
in th
is
stat
e. P
rem
ium
s fo
r th
is p
olic
y w
ill in
crea
se d
ue to
the
incr
ease
in
yo
ur
age.
U
pon
atta
inm
ent
of
an
age
requ
iring
a
rate
in
crea
se, t
he re
new
al p
rem
ium
for t
he p
olic
y w
ill be
the
rene
wal
pr
emiu
m th
en in
effe
ct fo
r you
r atta
ined
age
. Oth
er p
olic
ies
may
be
pro
vide
d w
ith Is
sue
Age
ratin
g an
d do
not
incr
ease
with
age
. Y
ou s
houl
d co
mpa
re Is
sue
Age
with
Atta
ined
Age
pol
icie
s.
Pre
miu
ms
paya
ble
othe
r th
an
annu
ally
w
ill be
de
term
ined
ac
cord
ing
to th
e fo
llow
ing
fact
ors:
S
emi -a
nnua
l: 0.
5200
Qua
rterly
: 0.2
650
Mon
thly
EFT
: 0.0
833.
HO
USE
HO
LD D
ISC
OU
NT
In o
rder
to b
e el
igib
le fo
r the
Hou
seho
ld d
isco
unt u
nder
a A
etna
H
ealth
and
Life
Insu
ranc
e C
ompa
ny M
edic
are
supp
lem
ent p
lan,
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 a
noth
er M
edic
are
elig
ible
adu
lt or
the
oth
er M
edic
are
elig
ible
adu
lt m
ust c
urre
ntly
be
cove
red
by a
Aet
na H
ealth
and
Li
fe
Insu
ranc
e C
ompa
ny
Med
icar
e su
pple
men
t po
licy.
Th
e M
edic
are
elig
ible
adu
lt m
ust
be e
ither
(a)
you
r sp
ouse
; (b
) be
so
meo
ne w
ith w
hom
you
are
in
a ci
vil
unio
n pa
rtner
ship
; an
d
(c)
be a
per
man
ent
resi
dent
in
your
hom
e. T
he h
ouse
hold
di
scou
nt w
ill o
nly
be a
pplic
able
if a
pol
icy
for
each
app
lican
t is
is
sued
. Th
e di
scou
nted
rat
e w
ill be
7 p
erce
nt l
ower
tha
n th
e in
divi
dual
rate
s.
DIS
CLO
SUR
ES
Use
th
is
outli
ne
to
com
pare
be
nefit
s an
d pr
emiu
m
amon
g po
licie
s.
REA
D Y
OU
R P
OLI
CY
VER
Y C
AR
EFU
LLY
Th
is i
s o
nly
an o
utlin
e d
escribin
g y
our
polic
y’s
most
import
ant
feat
ures
. Th
e po
licy
is y
our
insu
ranc
e co
ntra
ct.
You
mus
t re
ad
the
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 po
licy,
you
may
re
turn
it to
Aet
na H
ealth
and
Life
Insu
ranc
e C
ompa
ny, P
.O. B
ox
1477
0, L
exin
gton
, KY
405
12-4
770.
If y
ou s
end
the
polic
y ba
ck
to u
s w
ithin
30
days
afte
r yo
u re
ceiv
e it,
we
will
treat
the
polic
y as
if it
had
nev
er b
een
issu
ed a
nd re
turn
all
your
pay
men
ts.
PO
LIC
Y R
EPLA
CEM
ENT
If yo
u ar
e re
plac
ing
anot
her
heal
th i
nsur
ance
pol
icy,
do
NO
T ca
ncel
it u
ntil
you
have
act
ually
rec
eive
d yo
ur n
ew p
olic
y an
d ar
e su
re y
ou w
ant t
o ke
ep it
. NO
TIC
E Th
e po
licy
may
not
cov
er a
ll of
you
r med
ical
cos
ts.
Nei
ther
A
etna
H
ealth
an
d Li
fe
Insu
ranc
e C
ompa
ny
nor
its
agen
ts a
re c
onne
cted
with
Med
icar
e.
This
out
line
of c
over
age
does
not
giv
e al
l the
det
ails
of M
edic
are
cove
rage
. C
onta
ct y
our
loca
l S
ocia
l S
ecur
ity O
ffice
or
cons
ult
Medic
are
& Y
ou fo
r mor
e de
tails
.
CO
MPL
ETE
AN
SWER
S A
RE
VER
Y IM
POR
TAN
T W
hen
you
fill o
ut t
he a
pplic
atio
n fo
r th
e ne
w p
olic
y, b
e su
re t
o an
swer
tru
thfu
lly
and
com
plet
ely
any
ques
tions
ab
out
your
m
edic
al a
nd h
ealth
his
tory
. Th
e co
mpa
ny m
ay c
ance
l yo
ur
polic
y an
d re
fuse
to
pay
any
clai
ms
if yo
u le
ave
out
or f
alsi
fy
impo
rtant
med
ical
info
rmat
ion.
R
evie
w t
he a
pplic
atio
n ca
refu
lly b
efor
e yo
u si
gn i
t. B
e ce
rtain
th
at a
ll in
form
atio
n ha
s be
en p
rope
rly re
cord
ed.
THE
FOLL
OW
ING
CH
AR
TS D
ESC
RIB
E PL
AN
S A
, B, F
, HIG
H
DED
UC
TIB
LE F
, G
and
N O
FFER
ED B
Y A
ETN
A H
EALT
H
AN
D L
IFE
INSU
RA
NC
E C
OM
PAN
Y.
AHLMS03845MD 12/2017 A 5
PLAN A MEDICARE (PART A) – HOSPITAL SERVICES – PER CALENDAR YEAR
*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 $1316 $0 $1316 (Part A Deductible)
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 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 $164.50 a day $0 Up to $164.50 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.
AHLMS03845MD 12/2017 A 6
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
AHLMS03845MD 12/2017 A 7
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 $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 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 $164.50 a day
$0 Up to $164.50 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.
AHLMS03845MD 12/2017 A 8
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
AHLMS03845MD 12/2017 A 9
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 $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 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 $164.50 a day
Up to $164.50 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 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.
AHLMS03845MD 12/2017 A 10
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
AHLMS03845MD 12/2017 A 11
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
AHLMS03845MD 12/2017 A 12
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 $2200 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2200. 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 $2200
DEDUCTIBLE** PLAN PAYS
IN ADDITION TO $2200
DEDUCTIBLE** YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 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 $164.50 a day
Up to $164.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0
AHLMS03845MD 12/2017 A 13
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.
AHLMS03845MD 12/2017 A 14
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 $2200 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2200. 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 $2200
DEDUCTIBLE** PLAN PAYS
IN ADDITION TO $2200
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
AHLMS03845MD 12/2017 A 15
HIGH DEDUCTIBLE PLAN F
PARTS A & B
SERVICES
MEDICARE PAYS
AFTER YOU PAY $2200
DEDUCTIBLE** PLAN PAYS
IN ADDITION TO $2200
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 $2200
DEDUCTIBLE** PLAN PAYS
IN ADDITION TO $2200
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
AHLMS03845MD 12/2017 A 16
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 $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 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 $164.50 a day
Up to $164.50 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 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.
AHLMS03845MD 12/2017 A 17
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
AHLMS03845MD 12/2017 A 18
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
AHLMS03845MD 12/2017 A 19
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 $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 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 $164.50 a day
Up to $164.50 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 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.
AHLMS03845MD 12/2017 A 20
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
AHLMS03845MD 12/2017 A 21
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
