Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium

800 Crescent Centre Dr. Suite 200

Franklin, TN 37067800 264.4000

aetnaseniorproducts.com

Outline of CoverageMedicare Supplement Insurance

Underwritten by

Continental Life Insurance Company of Brentwood, Tennessee

An Aetna Company

Rates Effective:

BENEFIT PLANS: A, B, F, HF, G, & N

SOUTH CAROLINA

CLIMS03706SC ©2017 Aetna Inc. 05/2017 A

CLI

MS0

3706

SC

1

05/2

017

A

CO

NTI

NEN

TAL

LIFE

INSU

RAN

CE

CO

MPA

NY

OF

BR

ENTW

OO

D, T

ENN

ESSE

E O

UTL

INE

OF

MED

ICAR

E SU

PPLE

MEN

T C

OVE

RAG

E C

OVE

R P

AGE:

Pag

e 1

of 1

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

bene

fits

incl

uded

in e

ach

of th

e st

anda

rd M

edic

are

sup

ple

me

nt

pla

ns.

Eve

ry c

om

pa

ny m

ust

ma

ke

ava

ilable

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-

Appr

oved

exp

ense

s) o

r, co

-pay

men

ts fo

r hos

pita

l out

patie

nt s

ervi

ces.

Pl

ans

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

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

cop

aym

ent

for o

ffice

vis

it, a

nd

up to

$50

cop

aym

ent

for 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

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

ns F

als

o ha

s an

opt

ion

calle

d a

high

ded

uctib

le p

lan

F. T

his

high

ded

uctib

le p

lan

pays

the

sam

e be

nefit

s as

Pla

n F

afte

r one

has

pai

d 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 no

t beg

in u

ntil

out-o

f-poc

ket e

xpen

ses

exce

ed $

2200

. O

ut-o

f-poc

ket e

xpen

ses

for t

his

dedu

ctib

le

are

expe

nses

that

wou

ld o

rdin

arily

be

paid

by

the

polic

y. T

hese

exp

ense

s in

clud

e th

e M

edic

are

dedu

ctib

les

for

Part

A an

d Pa

rt B,

but

do

not i

nclu

de th

e pla

n’s

separa

te f

ore

ign tra

vel em

erg

ency d

eductible

.

CLI

MS0

3706

SC

2

05/2

017

A

Att

ain

ed

Pre

ferr

ed

Att

ain

ed

Stan

dar

d

Age

Pla

n A

Pla

n B

Pla

n F

Pla

n H

FP

lan

GP

lan

NA

geP

lan

AP

lan

BP

lan

FP

lan

HF

Pla

n G

Pla

n N

65

1,03

7

1,

222

1,54

1

61

6

1,22

3

1,

034

651,

152

1,35

8

1,

711

685

1,

359

1,14

9

66

1,03

7

1,

222

1,54

1

61

6

1,22

3

1,

034

661,

152

1,35

8

1,

711

685

1,

359

1,14

9

67

1,03

7

1,

222

1,54

1

61

6

1,22

3

1,

034

671,

152

1,35

8

1,

711

685

1,

359

1,14

9

68

1,04

9

1,

237

1,55

9

62

4

1,23

8

1,

046

681,

165

1,37

5

1,

732

693

1,

376

1,16

2

69

1,07

2

1,

264

1,59

2

63

7

1,26

5

1,

068

691,

191

1,40

4

1,

770

708

1,

405

1,18

6

70

1,10

0

1,

298

1,63

5

65

4

1,29

9

1,

096

701,

223

1,44

2

1,

817

726

1,

443

1,21

8

71

1,13

3

1,

336

1,68

4

67

3

1,33

7

1,

129

711,

259

1,48

5

1,

871

748

1,

486

1,25

5

72

1,17

1

1,

380

1,73

9

69

5

1,38

1

1,

166

721,

301

1,53

3

1,

932

773

1,

534

1,29

5

73

1,21

1

1,

428

1,79

9

71

9

1,42

9

1,

207

731,

346

1,58

7

1,

999

799

1,

588

1,34

0

74

1,25

8

1,

484

1,86

9

74

8

1,48

5

1,

254

741,

398

1,64

9

2,

077

831

1,

650

1,39

3

75

1,31

1

1,

545

1,94

7

77

9

1,54

6

1,

305

751,

456

1,71

7

2,

164

865

1,

718

1,45

0

76

1,36

3

1,

606

2,02

5

81

0

1,60

9

1,

358

761,

514

1,78

5

2,

249

900

1,

787

1,50

9

77

1,41

4

1,

667

2,10

1

84

0

1,66

9

1,

409

771,

570

1,85

2

2,

335

933

1,

854

1,56

6

78

1,46

3

1,

726

2,17

5

86

9

1,72

7

1,

459

781,

625

1,91

7

2,

417

966

1,

918

1,62

1

79

1,51

3

1,

784

2,24

8

89

9

1,78

6

1,

508

791,

682

1,98

2

2,

498

999

1,

984

1,67

5

80

1,56

0

1,

840

2,31

9

92

7

1,84

2

1,

555

801,

733

2,04

4

2,

577

1,03

0

2,

047

1,72

8

81

1,61

0

1,

898

2,39

1

95

7

1,90

0

1,

604

811,

788

2,10

9

2,

658

1,06

3

2,

111

1,78

3

82

1,66

0

1,

957

2,46

7

98

7

1,95

9

1,

655

821,

844

2,17

5

2,

741

1,09

6

2,

177

1,83

9

83

1,71

1

2,

018

2,54

3

1,

017

2,01

9

1,

705

831,

902

2,24

3

2,

825

1,13

0

2,

244

1,89

4

84

1,76

4

2,

079

2,62

0

1,

048

2,08

2

1,

757

841,

960

2,31

0

2,

912

1,16

4

2,

313

1,95

2

85

1,82

5

2,

152

2,71

2

1,

085

2,15

4

1,

819

852,

028

2,39

0

3,

013

1,20

6

2,

394

2,02

1

86

1,87

7

2,

213

2,78

9

1,

116

2,21

5

1,

871

862,

085

2,45

9

3,

099

1,24

0

2,

462

2,07

9

87

1,93

0

2,

275

2,86

9

1,

148

2,27

9

1,

924

872,

145

2,52

8

3,

188

1,27

5

2,

532

2,13

7

88

1,98

4

2,

340

2,94

9

1,

179

2,34

2

1,

978

882,

204

2,60

0

3,

276

1,31

1

2,

603

2,19

8

89

2,04

0

2,

405

3,03

1

1,

212

2,40

8

2,

033

892,

267

2,67

2

3,

368

1,34

7

2,

675

2,25

9

902,

096

2,47

1

3,

114

1,24

6

2,

474

2,08

9

90

2,32

9

2,

746

3,46

0

1,

384

2,74

8

2,

321

912,

153

2,53

8

3,

198

1,28

0

2,

540

2,14

6

91

2,39

1

2,

821

3,55

4

1,

422

2,82

3

2,

385

922,

211

2,60

6

3,

285

1,31

4

2,

609

2,20

3

92

2,45

6

2,

895

3,65

0

1,

460

2,90

0

2,

448

932,

270

2,67

6

3,

373

1,34

9

2,

679

2,26

2

93

2,52

2

2,

974

3,74

7

1,

499

2,97

7

2,

514

942,

329

2,74

6

3,

461

1,38

5

2,

750

2,32

2

94

2,58

7

3,

052

3,84

6

1,

540

3,05

5

2,

581

952,

390

2,81

9

3,

552

1,42

1

2,

822

2,38

3

95

2,65

6

3,

132

3,94

6

1,

579

3,13

5

2,

648

962,

452

2,89

1

3,

644

1,45

7

2,

894

2,44

4

96

2,72

4

3,

212

4,04

9

1,

620

3,21

6

2,

716

972,

514

2,96

5

3,

737

1,49

5

2,

969

2,50

6

97

2,79

3

3,

295

4,15

2

1,

661

3,29

8

2,

785

982,

579

3,04

0

3,

831

1,53

3

3,

043

2,57

0

98

2,86

6

3,

377

4,25

7

1,

704

3,38

1

2,

856

99

2,64

2

3,

116

3,92

7

1,

571

3,12

0

2,

635

992,

936

3,46

2

4,

362

1,74

5

3,

467

2,92

7

Mo

dal

Fac

tors

:Se

mi-

An

nu

al:

0.52

00Q

uar

terl

y:0.

2650

Mo

nth

ly:

0.08

330

The

ab

ove

rat

es

do

no

t in

clu

de

th

e $

20 a

pp

lica

tio

n f

ee

.

To c

alcu

late

a H

ou

seh

old

dis

cou

nt:

A

nn

ual

pre

miu

m x

mo

dal

fac

tor

= m

od

al p

rem

ium

(ro

un

d t

o n

ear

est

wh

ole

ce

nt)

M

od

al p

rem

ium

x .9

3 =

dis

cou

nte

d p

rem

ium

If a

pp

lyin

g d

uri

ng

Op

en

En

roll

me

nt

or

Gu

aran

tee

d Is

sue

Pe

rio

d, u

se P

refe

rre

d r

ate

s.

Rat

es E

ffec

tive

05/

01/2

017

Fem

ale

Rat

es

Co

nti

ne

nta

l Lif

e In

sura

nce

Co

mp

any

of

Bre

ntw

oo

d, T

en

ne

sse

eA

nnua

l Att

aine

d A

ge P

rem

ium

s

For

Use

in Z

IP C

odes

: 29

4-29

5, 2

98-2

99

CLI

MS0

3706

SC

3

05/2

017

A

Att

ain

ed

Pre

ferr

ed

Att

ain

ed

Stan

dar

d

Age

Pla

n A

Pla

n B

Pla

n F

Pla

n H

FP

lan

GP

lan

NA

geP

lan

AP

lan

BP

lan

FP

lan

HF

Pla

n G

Pla

n N

65

1,19

2

1,

405

1,77

2

70

8

1,40

7

1,

189

651,

325

1,56

1

1,

968

788

1,

563

1,32

1

66

1,19

2

1,

405

1,77

2

70

8

1,40

7

1,

189

661,

325

1,56

1

1,

968

788

1,

563

1,32

1

67

1,19

2

1,

405

1,77

2

70

8

1,40

7

1,

189

671,

325

1,56

1

1,

968

788

1,

563

1,32

1

68

1,20

7

1,

424

1,79

4

71

8

1,42

5

1,

202

681,

340

1,58

1

1,

992

797

1,

583

1,33

6

69

1,23

3

1,

453

1,83

1

73

3

1,45

4

1,

227

691,

370

1,61

4

2,

035

815

1,

615

1,36

3

70

1,26

6

1,

492

1,88

0

75

2

1,49

4

1,

260

701,

407

1,65

9

2,

089

834

1,

660

1,40

1

71

1,30

3

1,

536

1,93

7

77

4

1,53

7

1,

299

711,

449

1,70

7

2,

152

860

1,

709

1,44

3

72

1,34

6

1,

587

1,99

9

79

9

1,58

8

1,

341

721,

496

1,76

3

2,

222

889

1,

764

1,48

9

73

1,39

3

1,

643

2,06

8

82

8

1,64

4

1,

387

731,

547

1,82

4

2,

300

920

1,

826

1,54

2

74

1,44

6

1,

706

2,14

9

86

0

1,70

7

1,

442

741,

609

1,89

7

2,

389

956

1,

898

1,60

2

75

1,50

8

1,

777

2,23

9

89

6

1,77

8

1,

501

751,

675

1,97

4

2,

488

995

1,

975

1,66

8

76

1,56

8

1,

847

2,32

8

93

2

1,84

9

1,

561

761,

741

2,05

3

2,

586

1,03

5

2,

055

1,73

6

77

1,62

6

1,

916

2,41

7

96

6

1,92

0

1,

621

771,

806

2,13

0

2,

685

1,07

3

2,

132

1,80

1

78

1,68

2

1,

984

2,50

1

1,

000

1,98

6

1,

678

781,

869

2,20

5

2,

779

1,11

0

2,

206

1,86

4

79

1,74

0

2,

051

2,58

5

1,

034

2,05

4

1,

734

791,

934

2,28

0

2,

872

1,14

9

2,

282

1,92

7

80

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CLIMS03706SC 6 05/2017 A

PREMIUM INFORMATION

Continental Life Insurance Company of Brentwood, Tennessee can only raise your premium if we raise the premium for all policies like yours in this state. Premiums for this policy will increase due to the increase in your age. Upon attainment of an age requiring a rate increase, the renewal premium for the policy will be the renewal premium then in effect for your attained age. Other policies may be provided with Issue Age rating and do not increase with age. You should compare Issue Age with Attained Age policies.

Premiums payable other than annually will be determined according to the following factors:

Semi-annual: 0.5200 Quarterly: 0.2650 Monthly EFT: 0.0833.

HOUSEHOLD DISCOUNT

In order to be eligible for the Household discount under an Continental Life Insurance Company of Brentwood, Tennessee Medicare supplement plan, you must apply for a Medicare supplement plan at the same time as another Medicare eligible adult or the other Medicare eligible adult must currently be covered by an Continental Life Insurance Company of Brentwood, Tennessee Medicare supplement policy. The Medicare eligible adult must be either (a) your spouse; (b) be someone with whom you are in a civil union partnership; or (c) someone with whom you have continuously resided for the past 12 months. The household discount will only be applicable if a policy for each applicant is issued. The discounted rate will be 7 percent lower than the individual rates and will apply as long as both policies remain in force.

DISCLOSURES

Use this outline to compare benefits and premium among policies.

READ YOUR POLICY VERY CAREFULLY

This is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.

RIGHT TO RETURN POLICY

If you find that you are not satisfied with your policy, you may return it to Continental Life Insurance Company of Brentwood, Tennessee P.O. Box 14770, Lexington, Kentucky 40512-4770. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all your payments.

POLICY REPLACEMENT

If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.

NOTICE

The policy may not cover all of your medical costs.

Neither Continental Life Insurance Company of Brentwood, Tennessee nor its agents are connected with Medicare.

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare & You for more details.

COMPLETE ANSWERS ARE VERY IMPORTANT

When you fill out the application for the new policy, be sure to answer truthfully and completely any questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

THE FOLLOWING CHARTS DESCRIBE PLANS A, B, F, HIGH DEDUCTIBLE F, G and N OFFERED BY CONTINENTAL LIFE INSURANCE COMPANY OF BRENTWOOD TENNESSEE.

CLIMS03706SC 7 05/2017 A

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 $329 a day $329 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.

CLIMS03706SC 05/2017 A 8

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.


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*


Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES

Medically necessary skilled care services and medical supplies

100% $0 $0

Durable medical equipment First $183 of Medicare Approved amounts*


Remainder of Medicare Approved amounts 80% 20% $0

CLIMS03706SC 05/2017 A 9

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.


PLAN PAYS

YOU PAY


First 60 days All but $1316 $1316 (Part A Deductible)

$0



$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.



$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.

CLIMS03706SC 05/2017 A 10

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.


PLAN PAYS

YOU PAY




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*


Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES –

TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

PARTS A & B


PLAN PAYS

YOU PAY



100% $0 $0




CLIMS03706SC 05/2017 A 11

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.


PLAN PAYS

YOU PAY



$0



$0**




$0 $0


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.



$0


CLIMS03706SC 05/2017 A 12

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.


PLAN PAYS

YOU PAY



$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


PARTS A & B


PLAN PAYS

YOU PAY



100% $0 $0



$0


CLIMS03706SC 05/2017 A 13

PLAN F

OTHER BENEFITS – NOT COVERED BY MEDICARE


PLAN PAYS

YOU PAY

FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime

maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum

CLIMS03706SC 05/2017 A 14

High Deductible 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



$0



$0**




$0 $0


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

CLIMS03706SC 05/2017 A 15

HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.



$0


CLIMS03706SC 05/2017 A 16

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







$0



$0


CLIMS03706SC 05/2017 A 17

HIGH DEDUCTIBLE PLAN F

PARTS A & B

SERVICES

MEDICARE

PAYS

AFTER YOU PAY $2200






100% $0 $0



$0



SERVICES

MEDICARE

PAYS

AFTER YOU PAY $2200

DEDUCTIBLE** PLAN PAYS


DEDUCTIBLE** YOU PAY





CLIMS03706SC 05/2017 A 18

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.


PLAN PAYS

YOU PAY



$0



$0**



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



$0


CLIMS03706SC 05/2017 A 19

PLAN G



PLAN PAYS

YOU PAY







PARTS A & B


PLAN PAYS

YOU PAY


Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $183 of Medicare Approved amounts*



CLIMS03706SC 05/2017 A 20

PLAN G



PLAN PAYS

YOU PAY





CLIMS03706SC 05/2017 A 21

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.


PLAN PAYS

YOU PAY



$0



$0**




$0 $0


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


Medicare co-payment/ coinsurance

$0


CLIMS03706SC 05/2017 A 22

PLAN N



PLAN PAYS

YOU PAY




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*



CLIMS03706SC 05/2017 A 23

PLAN N

PARTS A & B


PLAN PAYS

YOU PAY


Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $183 of Medicare Approved amounts*





PLAN PAYS

YOU PAY


First $250 each calendar year $0 $0 $250

Remainder of charges $0 80% to a lifetime maximum benefit of $50,000


Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium

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