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APPLICATION for MEDICARE SUPPLEMENT INSURANCE · 2020-02-10 · APPLICATION for MEDICARE SUPPLEMENT...
52
MAP550_IN 01/22/2020 3316 Farnam Street Omaha, Nebraska 68175 ________________________________________________________________________ INDIANA APPLICATION for MEDICARE SUPPLEMENT INSURANCE
Transcript of APPLICATION for MEDICARE SUPPLEMENT INSURANCE · 2020-02-10 · APPLICATION for MEDICARE SUPPLEMENT...
MAP550_IN 01/22/2020
3316 Farnam Street Omaha, Nebraska 68175
________________________________________________________________________
INDIANA
APPLICATION for MEDICARE SUPPLEMENT INSURANCE
IN U
W A
GY 00
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IN_U
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EDIC
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22
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9.16
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4.86
311.3
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8.86
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7.55
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rding
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seho
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emian
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emium
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ltiply
the ab
ove-
quote
d pre
mium
s by 1
2, 6,
and 3
, res
pecti
vely.
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W A
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23
IN_U
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1242
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HLY
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124.9
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60.87
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8.70
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9.36
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316.7
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82.81
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251.5
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6.73
254.0
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3.05
84.68
227.0
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6.60
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7.07
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6.59
95.46
210.8
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9.13
329.5
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1.61
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292.8
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2.35
97.61
261.7
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5.08
264.3
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8.67
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ly the
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e-qu
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316
0.26
42.01
111.3
639
.9391
.5265
142.4
118
1.09
47.47
125.8
445
.1210
3.42
126.0
316
0.26
42.01
111.3
639
.9391
.5266
142.4
118
1.09
47.47
125.8
445
.1210
3.42
126.0
316
0.26
42.01
111.3
639
.9391
.5267
142.4
118
1.09
47.47
125.8
445
.1210
3.42
130.5
716
6.03
43.52
115.3
741
.6994
.8168
147.5
418
7.61
49.18
130.3
747
.1110
7.14
135.1
017
1.79
45.03
119.3
943
.4498
.1169
152.6
719
4.13
50.89
134.9
149
.1011
0.87
139.6
417
7.56
46.55
123.3
945
.2110
1.40
7015
7.79
200.6
552
.6013
9.43
51.08
114.5
814
4.18
183.3
348
.0612
7.40
46.96
104.6
971
162.9
120
7.16
54.30
143.9
653
.0611
8.31
148.7
118
9.10
49.57
131.4
148
.7210
7.99
7216
8.04
213.6
956
.0114
8.49
55.05
122.0
315
3.48
195.1
651
.1613
5.75
50.28
111.5
673
173.4
222
0.53
57.81
153.3
956
.8212
6.05
158.2
320
1.21
52.74
140.0
851
.8411
5.11
7417
8.80
227.3
659
.6015
8.29
58.58
130.0
816
2.99
207.2
654
.3314
4.41
54.12
118.6
875
184.1
823
4.20
61.39
163.1
961
.1613
4.11
167.7
521
3.31
55.92
148.7
655
.7112
2.25
7618
9.56
241.0
463
.1816
8.09
62.95
138.1
417
2.50
219.3
657
.5015
3.09
57.29
125.8
177
194.9
324
7.87
64.98
172.9
964
.7414
2.16
176.9
922
5.07
59.00
158.3
058
.7913
0.09
7820
0.00
254.3
266
.6717
8.87
66.43
147.0
018
1.48
230.7
760
.4916
3.50
60.28
134.3
679
205.0
726
0.76
68.35
184.7
668
.1215
1.83
185.9
623
6.47
61.99
168.7
161
.7813
8.64
8021
0.14
267.2
170
.0519
0.63
69.81
156.6
619
0.45
242.1
763
.4817
3.91
63.27
142.9
281
215.2
027
3.65
71.74
196.5
271
.5016
1.49
194.9
324
7.87
64.98
179.1
264
.7714
7.19
8222
0.27
280.1
073
.4220
2.40
73.19
166.3
319
8.83
252.8
466
.2818
1.62
66.07
149.2
683
224.6
828
5.71
74.90
205.2
474
.6616
8.66
202.7
325
7.79
67.57
184.1
367
.3715
1.32
8422
9.08
291.3
076
.3620
8.07
76.12
170.9
920
6.63
262.7
568
.8818
6.65
68.67
153.3
885
233.4
929
6.90
77.83
210.9
077
.6017
3.32
210.5
326
7.70
70.18
189.1
569
.9715
5.44
8623
7.89
302.5
179
.3021
3.73
79.07
175.6
421
4.42
272.6
771
.4719
1.66
71.26
157.5
087
242.3
030
8.11
80.76
216.5
780
.5317
7.97
218.7
127
8.11
72.91
195.4
972
.7016
0.64
8824
7.15
314.2
782
.3922
0.90
82.15
181.5
422
3.09
283.6
874
.3619
9.40
74.15
163.8
789
252.0
932
0.56
84.03
225.3
283
.7918
5.16
227.5
528
9.36
75.85
203.3
975
.6416
7.14
9025
7.13
326.9
785
.7122
9.83
85.48
188.8
723
2.10
295.1
477
.3720
7.46
77.16
170.4
991
262.2
733
3.51
87.43
234.4
287
.1919
2.65
236.7
430
1.04
78.91
211.6
178
.7017
3.90
9226
7.52
340.1
889
.1723
9.11
88.94
196.4
924
1.48
307.0
680
.4921
5.84
80.28
177.3
793
272.8
734
6.98
90.96
243.8
990
.7220
0.43
246.3
131
3.21
82.10
220.1
581
.8918
0.92
9427
8.33
353.9
292
.7824
8.77
92.54
204.4
425
1.24
319.4
783
.7422
4.55
83.53
184.5
495
283.8
936
1.00
94.63
253.7
594
.4020
8.53
256.2
632
5.86
85.42
229.0
585
.2118
8.23
9628
9.57
368.2
296
.5225
8.82
96.29
212.7
026
1.38
332.3
887
.1323
3.63
86.92
191.9
997
295.3
637
5.58
98.46
264.0
098
.2221
6.95
266.6
133
9.02
88.87
238.3
088
.6619
5.83
9830
1.27
383.0
910
0.43
269.2
810
0.19
221.2
927
1.94
345.8
090
.6524
3.06
90.44
199.7
599
+30
7.29
390.7
610
2.43
274.6
610
2.19
225.7
1*S
ee P
REMI
UM IN
FORM
ATIO
N re
gard
ing R
isk C
lass a
nd H
ouse
hold
Prem
ium D
iscou
nt ra
ting.
To ob
tain a
nnua
l, sem
iannu
al, an
d qua
rterly
prem
iums,
multip
ly the
abov
e-qu
oted p
remi
ums b
y 12,
6, an
d 3, r
espe
ctive
ly.
IN U
W A
GY 00
25
IN_U
W_A
GY_0
1242
0
MONT
HLY
TOBA
CCO
PREM
IUMS
*ZI
P CO
DES:
463 -
464
FEMA
LEMA
LEPl
an A
WM2
0Pl
an F
WM2
4Pl
an H
igh
FW
M34
Plan
GW
M25
Plan
Hig
hG
WM3
6
Plan
NW
M35
Atta
ined
Age
Plan
AW
M20
Plan
FW
M24
Plan
Hig
hF
WM3
4
Plan
GW
M25
Plan
Hig
hG
WM3
6
Plan
NW
M35
144.8
618
4.21
48.29
128.0
045
.9010
5.19
6516
3.69
208.1
554
.5614
4.65
51.86
118.8
714
4.86
184.2
148
.2912
8.00
45.90
105.1
966
163.6
920
8.15
54.56
144.6
551
.8611
8.87
144.8
618
4.21
48.29
128.0
045
.9010
5.19
6716
3.69
208.1
554
.5614
4.65
51.86
118.8
715
0.08
190.8
450
.0213
2.61
47.92
108.9
868
169.5
821
5.64
56.53
149.8
554
.1512
3.14
155.2
919
7.46
51.76
137.2
249
.9411
2.77
6917
5.48
223.1
458
.5015
5.06
56.43
127.4
316
0.50
204.1
053
.5014
1.83
51.96
116.5
570
181.3
723
0.63
60.46
160.2
658
.7113
1.70
165.7
221
0.73
55.24
146.4
353
.9812
0.34
7118
7.26
238.1
262
.4216
5.47
60.99
135.9
817
0.94
217.3
656
.9815
1.05
56.00
124.1
372
193.1
524
5.62
64.38
170.6
863
.2814
0.26
176.4
122
4.32
58.80
156.0
357
.7912
8.22
7319
9.34
253.4
866
.4517
6.31
65.30
144.8
918
1.87
231.2
760
.6216
1.01
59.58
132.3
174
205.5
226
1.34
68.50
181.9
467
.3314
9.52
187.3
423
8.22
62.45
165.9
962
.2113
6.42
7521
1.70
269.1
970
.5718
7.58
70.30
154.1
419
2.82
245.1
864
.2717
0.98
64.03
140.5
176
217.8
827
7.06
72.62
193.2
172
.3615
8.78
198.2
825
2.14
66.10
175.9
765
.8614
4.61
7722
4.06
284.9
174
.6919
8.84
74.42
163.4
020
3.44
258.7
067
.8218
1.95
67.58
149.5
378
229.8
929
2.32
76.63
205.6
076
.3616
8.96
208.5
926
5.25
69.53
187.9
469
.2915
4.44
7923
5.71
299.7
378
.5721
2.37
78.30
174.5
221
3.75
271.8
171
.2519
3.92
71.01
159.3
680
241.5
430
7.14
80.51
219.1
280
.2418
0.07
218.9
027
8.35
72.97
199.9
072
.7316
4.27
8124
7.36
314.5
482
.4622
5.89
82.18
185.6
222
4.06
284.9
174
.6920
5.88
74.45
169.1
882
253.1
832
1.95
84.39
232.6
584
.1319
1.18
228.5
429
0.62
76.18
208.7
675
.9417
1.56
8325
8.26
328.4
086
.0923
5.90
85.82
193.8
623
3.02
296.3
177
.6721
1.65
77.43
173.9
384
263.3
133
4.83
87.77
239.1
687
.5019
6.54
237.5
030
2.02
79.17
214.5
478
.9317
6.30
8526
8.38
341.2
689
.4624
2.42
89.19
199.2
224
1.98
307.7
080
.6621
7.41
80.42
178.6
686
273.4
434
7.71
91.14
245.6
790
.8820
1.89
246.4
631
3.41
82.15
220.3
081
.9118
1.03
8727
8.50
354.1
492
.8324
8.93
92.56
204.5
725
1.39
319.6
783
.8022
4.70
83.56
184.6
588
284.0
836
1.23
94.70
253.9
194
.4220
8.66
256.4
232
6.06
85.47
229.2
085
.2318
8.35
8928
9.76
368.4
696
.5825
8.99
96.31
212.8
326
1.55
332.5
987
.1823
3.78
86.94
192.1
190
295.5
537
5.82
98.52
264.1
798
.2521
7.09
266.7
833
9.24
88.93
238.4
688
.6919
5.96
9130
1.46
383.3
410
0.49
269.4
510
0.22
221.4
327
2.11
346.0
290
.7024
3.22
90.46
199.8
892
307.5
039
1.02
102.5
027
4.84
102.2
222
5.86
277.5
635
2.94
92.52
248.0
992
.2820
3.87
9331
3.65
398.8
310
4.55
280.3
410
4.28
230.3
828
3.11
360.0
194
.3725
3.05
94.13
207.9
594
319.9
240
6.81
106.6
428
5.94
106.3
723
4.98
288.7
836
7.21
96.26
258.1
096
.0221
2.11
9532
6.31
414.9
410
8.77
291.6
610
8.50
239.6
929
4.55
374.5
598
.1826
3.27
97.94
216.3
596
332.8
442
3.24
110.9
429
7.50
110.6
824
4.48
300.4
438
2.04
100.1
426
8.54
99.90
220.6
897
339.5
043
1.70
113.1
730
3.45
112.9
024
9.37
306.4
538
9.68
102.1
527
3.90
101.9
122
5.09
9834
6.29
440.3
411
5.43
309.5
111
5.16
254.3
531
2.58
397.4
710
4.19
279.3
810
3.95
229.5
999
+35
3.21
449.1
411
7.74
315.7
011
7.46
259.4
4*S
ee P
REMI
UM IN
FORM
ATIO
N re
gard
ing R
isk C
lass a
nd H
ouse
hold
Prem
ium D
iscou
nt ra
ting.
To ob
tain a
nnua
l, sem
iannu
al, an
d qua
rterly
prem
iums,
multip
ly the
abov
e-qu
oted p
remi
ums b
y 12,
6, an
d 3, r
espe
ctive
ly.
IN U
W A
GY 00
26
IN_U
W_A
GY_0
1242
0
Disc
losu
res
Use t
his ou
tline t
o com
pare
bene
fits an
d pre
mium
s amo
ng po
licies
.
Prem
ium
Info
rmat
ion
The p
remi
um fo
r you
r poli
cy w
ill ch
ange
. Bec
ause
the p
remi
um ra
te is
base
d on y
our a
ttaine
d age
, the p
remi
um w
ill inc
reas
e eac
h yea
r as y
ouag
e. Th
is an
nual
prem
ium ch
ange
will
occu
r on t
he fir
st po
licy r
enew
alda
te wh
ich co
incide
s with
or fo
llows
the p
olicy
anniv
ersa
ry da
te.
A pr
emium
chan
ge fo
r any
othe
r rea
son c
an oc
cur o
n any
polic
y ren
ewal
date.
How
ever
, we c
anno
t mak
e suc
h a ch
ange
unles
s we m
ake t
hesa
me ch
ange
to al
l poli
cies u
sing t
his fo
rm is
sued
in th
e sam
e stat
e to
perso
ns of
the s
ame c
lassif
icatio
n.
Risk
Clas
s Rat
ing
If, ac
cord
ing to
our u
nder
writin
g stan
dard
s, yo
u are
over
weigh
t or
unde
rweig
ht for
your
heigh
t, you
will
be co
nside
red t
o be a
grea
terins
urab
le ris
k. In
such
a ca
se, y
our p
remi
um w
ill be
price
d eith
er as
Clas
s I –
10%
or C
lass I
I – 20
% hi
gher
than
the r
ates i
llustr
ated,
base
don
your
Bod
y Mas
s Ind
ex (B
MI) r
eadin
g. Ri
sk cl
ass r
ating
will
not b
eap
plica
ble w
hen y
ou ap
ply fo
r cov
erag
e dur
ing an
open
enro
llmen
t or
guar
antee
d iss
ue pe
riod.
Hous
ehol
d Pr
emiu
m D
iscou
ntYo
u are
eligi
ble fo
r a ho
useh
old pr
emium
disc
ount
if for
the p
ast y
ear y
ouha
ve re
sided
with
at le
ast o
ne, b
ut no
t mor
e tha
n thr
ee, o
ther M
edica
re-
eligib
le ad
ults w
ho ow
n or a
re is
sued
a Me
dicar
e sup
pleme
nt po
licy
unde
rwritt
en by
us or
our a
ffiliat
es. T
he re
siden
cy re
quire
ment
will b
ewa
ived i
f you
are m
arrie
d or in
a civ
il unio
n or d
omes
tic pa
rtner
ship
with
an in
dividu
al tha
t has
an ex
isting
Med
icare
supp
lemen
t plan
with
us or
our a
ffiliat
es. F
or th
e pur
pose
s of th
is dis
coun
t, a ci
vil un
ion pa
rtner
ordo
mesti
c par
tner w
ill be
cons
idere
d a le
gal s
pous
e whe
n suc
hpa
rtner
ships
are v
alid a
nd re
cogn
ized i
n you
r stat
e of r
eside
nce.
We m
ayre
ques
t add
itiona
l doc
umen
tation
to de
termi
ne el
igibil
ity. T
he di
scou
nted
prem
ium w
ill be
price
d 7%
lowe
r tha
n the
rates
illus
trated
.
Read
You
r Pol
icy V
ery C
aref
ully
This
is on
ly an
outlin
e des
cribin
g you
r poli
cy's
most
impo
rtant
featur
es.
The p
olicy
is yo
ur in
sura
nce c
ontra
ct. Y
ou m
ust r
ead t
he po
licy i
tself t
oun
derst
and a
ll of th
e righ
ts an
d duti
es of
both
you a
nd yo
ur in
sura
nce
comp
any.
Righ
t to
Retu
rn P
olicy
If you
find t
hat y
ou ar
e not
satis
fied w
ith yo
ur po
licy,
you m
ay re
turn i
t to33
00 M
utual
of Om
aha P
laza,
Omah
a, NE
6817
5. If y
ou se
nd th
e poli
cyba
ck to
us w
ithin
30 da
ys af
ter yo
u rec
eive i
t, we w
ill tre
at the
polic
y as i
fit h
ad ne
ver b
een i
ssue
d and
retur
n all o
f you
r pay
ments
.
Polic
y Rep
lacem
ent
If you
are r
eplac
ing an
other
healt
h ins
uran
ce po
licy,
do N
OT ca
ncel
itun
til yo
u hav
e actu
ally r
eceiv
ed yo
ur ne
w po
licy a
nd ar
e sur
e you
wan
t toke
ep it.
Notic
eTh
e poli
cy m
ay no
t fully
cove
r all o
f you
r med
ical c
osts.
Neit
her U
nited
Wor
ld Lif
e Ins
uran
ce C
ompa
ny no
r its a
gents
are c
onne
cted w
ithMe
dicar
e. Th
is ou
tline o
f cov
erag
e doe
s not
give a
ll the
detai
ls of
Medic
are C
over
age.
Conta
ct yo
ur lo
cal S
ocial
Sec
urity
offic
e or c
onsu
lt"M
edica
re &
You
" for
mor
e deta
ils.
Com
plet
e Ans
wers
Are
Ver
y Im
porta
ntW
hen y
ou fil
l out
the ap
plica
tion f
or th
e new
polic
y, be
sure
to an
swer
truthf
ully a
nd co
mplet
ely al
l que
stion
s abo
ut yo
ur m
edica
l and
healt
hhis
tory.
The c
ompa
ny m
ay ca
ncel
your
polic
y and
refus
e to p
ay an
ycla
ims i
f you
leav
e out
or fa
lsify
impo
rtant
medic
al inf
orma
tion.
Revie
wthe
appli
catio
n car
efully
befor
e you
sign
it. B
e cer
tain t
hat a
ll info
rmati
onha
s bee
n pro
perly
reco
rded
.
Exclu
sions
Exclu
sions
apply
to yo
ur co
vera
ge. P
lease
be su
re to
revie
w the
exclu
sions
in yo
ur po
licy.
This
polic
y doe
s not
cove
r Par
t A be
nefits
for
bene
fit pe
riods
that
begin
whil
e this
polic
y is n
ot in
force
, and
othe
rex
clusio
ns ap
ply.
IN U
W A
GY 00
27
IN_U
W_A
GY_0
1242
0
PLAN
AME
DICA
RE (P
ART
A) –
HOSP
ITAL
SER
VICE
S – P
ER B
ENEF
IT P
ERIO
D
*A be
nefit
perio
d be g
ins on
the f
irst d
ay yo
u rec
eive s
ervic
e as a
n inp
atien
t in a
hosp
ital a
nd en
ds af
ter yo
u hav
e bee
n out
of the
hosp
ital a
nd ha
ve no
t rec
eived
skille
d car
ein
any o
ther f
acilit
y for
60 da
ys in
a ro
w.SE
RVIC
ESME
DICA
RE P
AYS
PLAN
A P
AYS
YOU
PAY
HOSP
ITAL
IZAT
ION*
Semi
priva
te ro
om an
d boa
rd, g
ener
al nu
rsing
, and
misc
ellan
eous
servi
ces a
nd su
pplie
sFir
st 60
days
All b
ut $1
,408
$0$1
,408 (
Part
A de
ducti
ble)
61st t
hrou
gh 90
th day
All b
ut $3
52 a
day
$352
a da
y$0
91st d
ay an
d afte
r:W
hile u
sing 6
0 life
time r
eser
ve da
ysAl
l but
$704
a da
y$7
04 a
day
$0On
ce lif
etime
rese
rve da
ys ar
e use
d:Ad
dition
al 36
5 day
s$0
100%
of M
edica
re-e
ligibl
e exp
ense
s$0
**Be
yond
the a
dditio
nal 3
65 da
ys$0
$0Al
l cos
tsSK
ILLE
D NU
RSIN
G FA
CILI
TY C
ARE*
You m
ust m
eet M
edica
re’s
requ
ireme
nts, in
cludin
gha
ving b
een i
n a ho
spita
l for a
t leas
t 3 da
ys an
den
tered
a Me
dicar
e-ap
prov
ed fa
cilit y
with
in 30
days
after
leav
ing th
e hos
pital.
First
20 da
ysAl
l app
rove
d amo
unts
$0$0
21st t
hrou
gh 10
0th day
All b
ut $1
76 a
day
$0Up
to $1
76 a
day
101st d
ay an
d afte
r$0
$0Al
l cos
tsBL
OOD
First
3 pint
s$0
3 pint
s$0
Addit
ional
amou
nts10
0%$0
$0HO
SPIC
E CA
REYo
u mus
t mee
t Med
icare
’s re
quire
ments
, inclu
ding a
docto
r’s ce
rtifica
tion o
f term
inal il
lness
All b
ut ve
ry lim
ited
copa
ymen
t/coin
sura
nce f
or ou
tpatie
ntdr
ugs a
nd in
patie
nt re
spite
care
Medic
are c
opa y
ment/
coins
uran
ce$0
**NOT
ICE:
Whe
n you
r Med
icare
Par
t A ho
spita
l ben
efits
are e
xhau
sted,
we st
and i
n the
plac
e of M
edica
re an
d will
pay w
hatev
er am
ount
Medic
are w
ould
have
paid
up to
an ad
dition
al 36
5 da y
s as p
rovid
ed in
the p
olicy
’s/ce
rtifica
te’s “
Core
Ben
efits”
. Dur
ing th
is tim
e the
hosp
ital is
proh
ibited
from
billin
g you
for t
he ba
lance
base
d on a
nydif
feren
ce be
twee
n its
billed
char
ges a
nd th
e amo
unt M
edica
re w
ould
have
paid.
IN U
W A
GY 00
28
IN_U
W_A
GY_0
1242
0
PLAN
AME
DICA
RE (P
ART
B) –
MEDI
CAL
SERV
ICES
– PE
R CA
LEND
AR Y
EAR
*Onc
e you
have
been
bille
d $19
8 of M
edica
re-a
ppro
ved a
moun
ts for
cove
red s
ervic
es (w
hich a
re no
ted w
ith an
aster
isk),
your
Par
t B de
ducti
ble w
ill ha
ve be
en m
et for
the
calen
dar y
ear.
SERV
ICES
MEDI
CARE
PAY
SPL
AN A
PAY
SYO
U PA
YME
DICA
L EX
PENS
ES– I
N OR
OUT
OF
THE
HOSP
ITAL
AND
OUTP
ATIE
NT H
OSPI
TAL T
REAT
MENT
, suc
h as p
h ysic
ian’s
servi
ces,
inpati
ent a
nd ou
tpatie
nt me
dical
and s
urgic
al se
rvice
san
d sup
plies
, phy
sical
and s
peec
h the
rapy
, diag
nosti
c tes
ts,du
rable
med
ical e
quipm
ent
First
$198
of M
edica
re-a
ppro
ved a
moun
ts*$0
$0$1
98 (P
art B
dedu
ctible
)Re
maind
er of
Med
icare
-app
rove
d amo
unts
Gene
rally
80%
Gene
rally
20%
$0Pa
rt B
Exce
ss C
harg
es (a
bove
Med
icare
-app
rove
d amo
unts)
$0$0
All c
osts
BLOO
DFir
st 3 p
ints
$0Al
l cos
ts$0
Next
$198
of M
edica
re-a
ppro
ved a
moun
ts*$0
$0$1
98 (P
art B
dedu
ctible
)Re
maind
er of
Med
icare
-app
rove
d amo
unts
80%
20%
$0CL
INIC
AL L
ABOR
ATOR
Y SE
RVIC
ES –
TEST
S FO
RDI
AGNO
STIC
SER
VICE
S10
0%$0
$0
PART
S A
AND
BHO
ME H
EALT
H CA
RE –
MEDI
CARE
-APP
ROVE
D SE
RVIC
ESMe
dicall
y nec
essa
ry sk
illed c
are s
ervic
es an
d med
ical s
uppli
es10
0%$0
$0DU
RABL
E ME
DICA
L EQ
UIPM
ENT
First
$198
of M
edica
re-a
ppro
ved a
moun
ts*$0
$0$1
98 (P
art B
dedu
ctible
)Re
maind
er of
Med
icare
-app
rove
d amo
unts
80%
20%
$0
IN U
W A
GY 00
29
IN_U
W_A
GY_0
1242
0
PLAN
S F
AND
HIGH
DED
UCTI
BLE
FME
DICA
RE (P
ART
A) –
HOSP
ITAL
SER
VICE
S – P
ER B
ENEF
IT P
ERIO
D – M
edica
re fi
rst e
ligib
le be
fore
2020
onl
y*A
bene
fit pe
riod b
egins
on th
e firs
t day
you r
eceiv
e ser
vice a
s an i
npati
ent in
a ho
spita
l and
ends
after
you h
ave b
een o
ut of
the ho
spita
l and
have
not r
eceiv
ed sk
illed c
are
in an
y othe
r fac
ility f
or 60
days
in a
row.
SERV
ICES
MEDI
CARE
PAY
SPL
AN F
PAY
SYO
U PA
Y
HIGH
DED
UCTI
BLE
F(A
FTER
YOU
PAY
$2,34
0 DED
UCTI
BLE*
**)PL
AN P
AYS
HIGH
DED
UCTI
BLE
F(IN
ADD
ITIO
N TO
$2,34
0DE
DUCT
IBLE
***)
YOU
PAY
HOSP
ITAL
IZAT
ION*
Semi
priva
te ro
om an
d boa
rd, g
ener
al nu
rsing
and m
iscell
aneo
us se
rvice
s and
supp
lies
First
60 da
ysAl
l but
$1,40
8$1
,408 (
Part
Ade
ducti
ble)
$0$1
,408 (
Part
A de
ducti
ble)
$0
61st t
hrou
gh 90
th day
All b
ut $3
52 a
day
$352
a da
y$0
$352
a da
y$0
91st d
ay an
d afte
r:W
hile u
sing 6
0 life
time r
eser
ve da
ysAl
l but
$704
a da
y$7
04 a
day
$0$7
04 a
day
$0On
ce lif
etime
rese
rve da
ys ar
e use
d:Ad
dition
al 36
5 day
s$0
100%
of M
edica
re-
eligib
le ex
pens
es$0
**10
0% of
Med
icare
-elig
ible
expe
nses
$0**
Beyo
nd th
e add
itiona
l 365
days
$0$0
All c
osts
$0Al
l cos
tsSK
ILLE
D NU
RSIN
G FA
CILI
TY C
ARE*
You m
ust m
eet M
edica
re’s
requ
ireme
nts,
includ
in g ha
ving b
een i
n a ho
spita
l for a
t leas
t3 d
a ys a
nd en
tered
a Me
dicar
e-ap
prov
edfac
ility w
ithin
30 da
ys af
ter le
aving
the h
ospit
al.Fir
st 20
days
All a
ppro
ved a
moun
ts$0
$0$0
$021
st thr
ough
100th d
ayAl
l but
$176
a da
yUp
to $1
76 a
day
$0Up
to $1
76 a
day
$010
1st day
and a
fter
$0$0
All c
osts
$0Al
l cos
tsBL
OOD
First
3 pint
s$0
3 pint
s$0
3 pint
s$0
Addit
ional
amou
nts10
0%$0
$0$0
$0HO
SPIC
E CA
REYo
u mus
t mee
t Med
icare
’s re
quire
ments
,inc
ludin g
a do
ctor’s
certif
icatio
n of te
rmina
lilln
ess.
All b
ut ve
ry lim
ited
copa
ymen
t/coin
sura
nce
for ou
t patie
nt dr
ugs a
ndin p
atien
t res
pite c
are
Medic
are
copa
ymen
t/co
insur
ance
$0Me
dicar
e cop
ayme
nt/co
insur
ance
$0
**NOT
ICE:
Whe
n you
r Med
icare
Par
t A ho
spita
l ben
efits
are e
xhau
sted,
we st
and i
n the
plac
e of M
edica
re an
d will
pay w
hatev
er am
ount
Medic
are w
ould
have
paid
up to
an ad
dition
al 36
5 day
s as p
rovid
ed in
the p
olicy
’s/ce
rtifica
te’s “
Core
Ben
efits”
. Dur
ing th
is tim
e the
hosp
ital is
proh
ibited
from
billin
g you
for t
he ba
lance
base
d on a
nydif
feren
ce be
twee
n its
billed
char
ges a
nd th
e amo
unt M
edica
re w
ould
have
paid.
***H
igh D
educ
tible
Plan
F pa
ys th
e sam
e ben
efits
as P
lan F
after
one h
as pa
id a c
alend
arye
ar $2
,340 d
educ
tible.
Ben
efits
from
High
Ded
uctib
le Pl
an F
will
not b
egin
until
out-o
f-poc
ket e
xpen
ses e
xcee
d $2,3
40. O
ut-of-
pock
et ex
pens
es fo
r this
dedu
ctible
are
expe
nses
that
would
ordin
arily
be pa
id by
the p
olicy
/certif
icate.
The
se ex
pens
es in
clude
the M
edica
re de
ducti
bles f
or P
art A
and P
art B
, but
do no
t inclu
de th
e plan
’sse
para
te for
ei gn t
rave
l eme
rgen
cy de
ducti
ble.
IN U
W A
GY 00
210
IN_U
W_A
GY_0
1242
0
PLAN
S F
AND
HIGH
DED
UCTI
BLE
FME
DICA
RE (P
ART
B) –
MEDI
CAL
SERV
ICES
– PE
R CA
LEND
AR Y
EAR
– Med
icare
firs
t elig
ible
befo
re 20
20 o
nly
*Onc
e you
have
been
bille
d $19
8 of M
edica
re-a
ppro
ved a
moun
ts for
cove
red s
ervic
es (w
hich a
re no
ted w
ith an
aster
isk),
your
Par
t B de
ducti
ble w
ill ha
ve be
en m
et for
the
calen
dar y
ear.
SERV
ICES
MEDI
CARE
PAY
SPL
AN F
PAY
SYO
U PA
Y
HIGH
DED
UCTI
BLE
F(A
FTER
YOU
PAY
$2,34
0DE
DUCT
IBLE
***)
PLAN
PAY
S
HIGH
DED
UCTI
BLE
F(IN
ADD
ITIO
N TO
$2,34
0DE
DUCT
IBLE
***)
YOU
PAY
MEDI
CAL
EXPE
NSES
– IN
OR O
UT O
F TH
EHO
SPIT
AL A
ND O
UTPA
TIEN
T HO
SPIT
ALTR
EATM
ENT,
such
as ph
ysici
an’s
servi
ces,
inpati
ent a
nd ou
tpatie
nt me
dical
and s
urgic
alse
rvice
s and
supp
lies,
phys
ical a
nd sp
eech
thera
py, d
iagno
stic t
ests,
dura
ble m
edica
leq
uipme
ntFir
st $1
98 of
Med
icare
-app
rove
d amo
unts*
$0$1
98 (P
art B
dedu
ctible
)$0
$198
(Par
t B de
ducti
ble)
$0Re
maind
er of
Med
icare
-app
rove
d amo
unts
Gene
rally
80%
Gene
rally
20%
$0Ge
nera
lly 20
%$0
Part
B Ex
cess
Cha
rges
(abo
ve M
edica
re-
appr
oved
amou
nts)
$010
0%$0
100%
$0
BLOO
DFir
st 3 p
ints
$0Al
l cos
ts$0
All c
osts
$0Ne
xt $1
98 of
Med
icare
-app
rove
d amo
unts*
$0$1
98 (P
art B
dedu
ctible
)$0
$198
(Par
t B de
ducti
ble)
$0Re
maind
er of
Med
icare
-app
rove
d amo
unts
80%
20%
$020
%$0
CLIN
ICAL
LAB
ORAT
ORY
SERV
ICES
–TE
STS
FOR
DIAG
NOST
IC S
ERVI
CES
100%
$0$0
$0$0
PART
S A
AND
BHO
ME H
EALT
H CA
RE –
MEDI
CARE
-AP
PROV
ED S
ERVI
CES
Medic
ally n
eces
sary
skille
d car
e ser
vices
and
medic
al su
pplie
s10
0%$0
$0$0
$0
DURA
BLE
MEDI
CAL
EQUI
PMEN
TFir
st $1
98 of
Med
icare
-app
rove
d amo
unts*
$0$1
98 (P
art B
dedu
ctible
)$0
$198
(Par
t B de
ducti
ble)
$0
Rema
inder
of M
edica
re-a
ppro
ved a
moun
ts80
%20
%$0
20%
$0***
High
Ded
uctib
le Pl
an F
pays
the s
ame b
enefi
ts as
Plan
F af
ter on
e has
paid
a cale
ndar
year
$2,34
0 ded
uctib
le. B
enefi
ts fro
m Hi
gh D
educ
tible
Plan
F w
ill no
t beg
in un
tilou
t-of-p
ocke
t exp
ense
s exc
eed $
2,340
. Out-
of-po
cket
expe
nses
for t
his de
ducti
ble ar
e exp
ense
s tha
t wou
ld or
dinar
il y be
paid
by th
e poli
cy/ce
rtifica
te. T
hese
expe
nses
includ
e the
Med
icare
dedu
ctible
s for
Par
t A an
d Par
t B, b
ut do
not in
clude
the p
lan’s
sepa
rate
foreig
n tra
vel e
merg
ency
dedu
ctible
.
IN U
W A
GY 00
211
IN_U
W_A
GY_0
1242
0
PLAN
S F
AND
HIGH
DED
UCTI
BLE
FME
DICA
RE (P
ART
B) –
MEDI
CAL
SERV
ICES
– PE
R CA
LEND
AR Y
EAR
– Med
icare
firs
t elig
ible
befo
re 20
20 o
nly
OTHE
R BE
NEFI
TS –
NOT
COVE
RED
BY M
EDIC
ARE
SERV
ICES
MEDI
CARE
PAY
SPL
AN F
PAY
SYO
U PA
Y
HIGH
DED
UCTI
BLE
F(A
FTER
YOU
PAY
$2,34
0DE
DUCT
IBLE
***)
PLAN
PAY
S
HIGH
DED
UCTI
BLE
F(IN
ADD
ITIO
N TO
$2,34
0DE
DUCT
IBLE
***)
YOU
PAY
FORE
IGN
TRAV
EL– N
OT C
OVER
ED B
YME
DICA
REMe
dicall
y nec
essa
ry em
erge
ncy c
are s
ervic
esbe
ginnin
g dur
ing th
e firs
t 60 d
ays o
f eac
h trip
outsi
de th
e USA
First
$250
each
calen
dar y
ear
$0$0
$250
$0$2
50Re
maind
er of
char
ges
$080
% to
a life
time
maxim
um be
nefit
of $5
0,000
20%
and
amou
nts ov
er th
e$5
0,000
lifeti
mema
ximum
bene
fit
80%
to a
lifetim
ema
ximum
bene
fit of
$50,0
00
20%
and a
moun
tsov
er th
e $50
,000
lifetim
e max
imum
bene
fit***
High
Ded
uctib
le Pl
an F
pays
the s
ame b
enefi
ts as
Plan
F af
ter on
e has
paid
a cale
ndar
year
$2,34
0 ded
uctib
le. B
enefi
ts fro
m Hi
gh D
educ
tible
Plan
F w
ill no
t beg
in un
tilou
t-of-p
ocke
t exp
ense
s exc
eed $
2,340
. Out-
of-po
cket
expe
nses
for t
his de
ducti
ble ar
e exp
ense
s tha
t wou
ld or
dinar
ily be
paid
by th
e poli
cy/ce
rtifica
te. T
hese
expe
nses
includ
e the
Med
icare
dedu
ctible
s for
Par
t A an
d Par
t B, b
ut do
not in
clude
the p
lan’s
sepa
rate
foreig
n tra
vel e
merg
ency
dedu
ctible
.
IN U
W A
GY 00
212
IN_U
W_A
GY_0
1242
0
PLAN
G O
R HI
GH D
EDUC
TIBL
E PL
AN G
MEDI
CARE
(PAR
T A)
– HO
SPIT
AL S
ERVI
CES
– PER
BEN
EFIT
PER
IOD
*A be
nefit
perio
d beg
ins on
the f
irst d
ay yo
u rec
eive s
ervic
e as a
n inp
atien
t in a
hosp
ital a
nd en
ds af
ter yo
u hav
e bee
n out
of the
hosp
ital a
nd ha
ve no
t rec
eived
skille
dca
re in
any o
ther f
acilit
y for
60 da
ys in
a ro
w. **
*This
high
dedu
ctible
plan
pays
the s
ame b
enefi
ts as
Plan
G af
ter yo
u hav
e paid
a ca
lenda
r yea
r $2,3
40 de
ducti
ble. B
enefi
tsfro
m the
high
dedu
ctible
Plan
G w
ill no
t beg
in un
til ou
t-of-p
ocke
t exp
ense
s are
$2,34
0.Ou
t-of-p
ocke
t exp
ense
s for
this
dedu
ctible
inclu
de ex
pens
es fo
r the
Med
icare
Par
t Bde
ducti
ble, a
nd ex
pens
es th
at wo
uld or
dinar
il y be
paid
by th
e poli
cy. T
his do
es no
t inclu
de th
e plan
’s se
para
te for
eign t
rave
l eme
rgen
cy de
ducti
ble.
SERV
ICES
MEDI
CARE
PAY
SPL
AN G
PAY
SYO
U PA
Y
HIGH
DED
UCTI
BLE
G(A
FTER
YOU
PAY
$2,34
0DE
DUCT
IBLE
***)
PLAN
PAY
S
HIGH
DED
UCTI
BLE
G(IN
ADD
ITIO
N TO
$2,34
0DE
DUCT
IBLE
***)
YOU
PAY
HOSP
ITAL
IZAT
ION*
Semi
priva
te ro
om an
d boa
rd, g
ener
al nu
rsing
and
misc
ellan
eous
servi
ces a
nd su
pplie
sFir
st 60
days
All b
ut $1
,408
$1,40
8 (Pa
rt A
dedu
ctible
)$0
$1,40
8 (Pa
rt A
dedu
ctible
)$0
61st t
hrou
gh 90
th day
All b
ut $3
52 a
day
$352
a da
y$0
$352
a da
y$0
91st d
ay an
d afte
r:W
hile u
sing 6
0 life
time r
eser
ve da
ysAl
l but
$704
a da
y$7
04 a
day
$0$7
04 a
day
$0On
ce lif
etime
rese
rve da
ys ar
e use
d:Ad
dition
al 36
5 day
s$0
100%
of M
edica
re-
eligib
le ex
pens
es$0
**10
0% of
Med
icare
-eli
gible
expe
nses
$0**
Beyo
nd th
e add
itiona
l 365
days
$0$0
All c
osts
$0Al
l cos
tsSK
ILLE
D NU
RSIN
G FA
CILI
TY C
ARE*
You m
ust m
eet M
edica
re’s
requ
ireme
nts,
includ
in g ha
ving b
een i
n a ho
spita
l for a
t leas
t 3da
ys an
d ente
red a
Med
icare
-app
rove
d fac
ility
withi
n 30 d
ays a
fter le
aving
the h
ospit
alFir
st 20
days
All a
ppro
ved a
moun
ts$0
$0$0
$021
st thr
ough
100th d
ayAl
l but
$176
a da
yUp
to $1
76 a
day
$0Up
to $1
76 a
day
$010
1st day
and a
fter
$0$0
All c
osts
$0Al
l cos
tsBL
OOD
First
3 pint
s$0
3 pint
s$0
3 pint
s$0
Addit
ional
amou
nts10
0%$0
$0$0
$0HO
SPIC
E CA
REYo
u mus
t mee
t Med
icare
’s re
quire
ments
,inc
ludin g
a do
ctor’s
certif
icatio
n of te
rmina
l illne
ss.
All b
ut ve
ry lim
ited
copa
ymen
t/coin
sura
nce
for ou
tpatie
nt dr
u gs a
ndinp
atien
t res
pite c
are
Medic
are c
opay
ment/
coins
uran
ce$0
Medic
are c
opay
ment/
coins
uran
ce$0
**NOT
ICE:
Whe
n you
r Med
icare
Par
t A ho
spita
l ben
efits
are e
xhau
sted,
we st
and i
n the
plac
e of M
edica
re an
d will
pay w
hatev
er am
ount
Medic
are w
ould
have
paid
up to
an ad
dition
al 36
5 da y
s as p
rovid
ed in
the p
olicy
’s “C
ore B
enefi
ts.” D
uring
this
time t
he ho
spita
l is pr
ohibi
ted fr
om bi
lling y
ou fo
r the
balan
ce ba
sed o
n any
diffe
renc
ebe
twee
n its
billed
char
ges a
nd th
e amo
unt M
edica
re w
ould
have
paid.
IN U
W A
GY 00
213
IN_U
W_A
GY_0
1242
0
PLAN
G O
R HI
GH D
EDUC
TIBL
E PL
AN G
MEDI
CARE
(PAR
T B)
– ME
DICA
L SE
RVIC
ES –
PER
CALE
NDAR
YEA
R*O
nce y
ou ha
ve be
en bi
lled $
198 o
f Med
icare
-app
rove
d amo
unts
for co
vere
d ser
vices
(whic
h are
noted
with
an as
terisk
), yo
ur P
art B
dedu
ctible
will
have
been
met
for th
eca
lenda
r yea
r. ***
This
high d
educ
tible
plan p
ays t
he sa
me be
nefits
as P
lan G
after
you h
ave p
aid a
calen
dar y
ear $
2,340
dedu
ctible
. Ben
efits
from
the hi
gh de
ducti
ble P
lanG
will n
ot be
gin un
til ou
t-of-p
ocke
t exp
ense
s are
$2,34
0.Ou
t-of-p
ocke
t exp
ense
s for
this
dedu
ctible
inclu
de ex
pens
es fo
r the
Med
icare
Par
t B de
ducti
ble, a
nd ex
pens
estha
t wou
ld or
dinar
ily be
paid
by th
e poli
cy. T
his do
es no
t inclu
de th
e plan
’s se
para
te for
eign t
rave
l eme
rgen
cy de
ducti
ble.
SERV
ICES
MEDI
CARE
PAY
SPL
AN G
PAY
SYO
U PA
Y
HIGH
DED
UCTI
BLE
G(A
FTER
YOU
PAY
$2,34
0DE
DUCT
IBLE
***)
PLAN
PAY
S
HIGH
DED
UCTI
BLE
G(IN
ADD
ITIO
N TO
$2,34
0DE
DUCT
IBLE
***)
YOU
PAY
MEDI
CAL
EXPE
NSES
– IN
OR O
UT O
F TH
EHO
SPIT
AL A
ND O
UTPA
TIEN
T HO
SPIT
ALTR
EATM
ENT,
such
as ph
ysici
an’s
servi
ces,
inpati
ent a
nd ou
tpatie
nt me
dical
and s
urgic
alse
rvice
s and
supp
lies,
phys
ical a
nd sp
eech
ther
apy,
diagn
ostic
tests
, dur
able
medic
al eq
uipme
ntFir
st $1
98 of
Med
icare
-app
rove
d amo
unts*
$0$0
$198
(Par
t Bde
ducti
ble)
$0$1
98 (U
nless
Par
t Bde
ducti
ble ha
s bee
n met)
Rema
inder
of M
edica
re-a
ppro
ved a
moun
tsGe
nera
lly 80
%Ge
nera
lly 20
%$0
Gene
rally
20%
$0Pa
rt B
Exce
ss C
harg
es (a
bove
Med
icare
-app
rove
dam
ounts
)$0
100%
$010
0%$0
BLOO
DFir
st 3 p
ints
$0Al
l cos
ts$0
All c
osts
$0Ne
xt $1
98 of
Med
icare
-app
rove
d amo
unts*
$0$0
$198
(Par
t Bde
ducti
ble)
$0$1
98 (U
nless
Par
t Bde
ducti
ble ha
s bee
n met)
Rema
inder
of M
edica
re-a
ppro
ved a
moun
ts80
%20
%$0
20%
$0CL
INIC
AL L
ABOR
ATOR
Y SE
RVIC
ES –
TEST
SFO
R DI
AGNO
STIC
SER
VICE
S10
0%$0
$0$0
$0
PART
S A
AND
BHO
ME H
EALT
H CA
RE –
MEDI
CARE
-APP
ROVE
DSE
RVIC
ESMe
dicall
y nec
essa
ry sk
illed c
are s
ervic
es an
dme
dical
supp
lies
100%
$0$0
$0$0
DURA
BLE
MEDI
CAL
EQUI
PMEN
TFir
st $1
98 of
Med
icare
-app
rove
d amo
unts*
$0$0
$198
(Par
t Bde
ducti
ble)
$0$1
98 (U
nless
Par
t Bde
ducti
ble ha
s bee
nme
t)Re
maind
er of
Med
icare
-app
rove
d amo
unts
80%
20%
$020
%$0
IN U
W A
GY 00
214
IN_U
W_A
GY_0
1242
0
PLAN
G O
R HI
GH D
EDUC
TIBL
E PL
AN G
MEDI
CARE
(PAR
T B)
– ME
DICA
L SE
RVIC
ES –
PER
CALE
NDAR
YEA
R
OTHE
R BE
NEFI
TS –
NOT
COVE
RED
BY M
EDIC
ARE
***Th
is hig
h ded
uctib
le pla
n pay
s the
same
bene
fits as
Plan
G af
ter yo
u hav
e paid
a ca
lenda
r yea
r $2,3
40 de
ducti
ble. B
enefi
ts fro
m the
high
dedu
ctible
Plan
G w
ill no
tbe
gin un
til ou
t-of-p
ocke
t exp
ense
s are
$2,34
0.Ou
t-of-p
ocke
t exp
ense
s for
this
dedu
ctible
inclu
de ex
pens
es fo
r the
Med
icare
Par
t B de
ducti
ble, a
nd ex
pens
es th
at wo
uldor
dinar
il y be
paid
by th
e poli
cy. T
his do
es no
t inclu
de th
e plan
’s se
para
te for
eign t
rave
l eme
rgen
cy de
ducti
ble.
SERV
ICES
MEDI
CARE
PAY
SPL
AN G
PAY
SYO
U PA
Y
HIGH
DED
UCTI
BLE
G(A
FTER
YOU
PAY
$2,34
0DE
DUCT
IBLE
***)
PLAN
PAY
S
HIGH
DED
UCTI
BLE
G(IN
ADD
ITIO
N TO
$2,34
0DE
DUCT
IBLE
***)
YOU
PAY
FORE
IGN
TRAV
EL– N
OT C
OVER
ED B
YME
DICA
REMe
dicall
y nec
essa
ry em
erge
ncy c
are
servi
ces b
eginn
ing du
ring t
he fir
st 60
days
ofea
ch tr
ip ou
tside
the U
SAFir
st $2
50 ea
ch ca
lenda
r yea
r$0
$0$2
50$0
$250
Rema
inder
of ch
arge
s$0
80%
to a
lifetim
ema
ximum
bene
fit of
$50,0
00
20%
and
amou
nts ov
er th
e$5
0,000
lifeti
mema
ximum
bene
fit
80%
to a
lifetim
ema
ximum
bene
fit of
$50,0
00
20%
and a
moun
ts ov
erthe
$50,0
00 lif
etime
maxim
um be
nefit
IN U
W A
GY 00
215
IN_U
W_A
GY_0
1242
0
PLAN
NME
DICA
RE (P
ART
A) –
HOSP
ITAL
SER
VICE
S – P
ER B
ENEF
IT P
ERIO
D
*A be
nefit
perio
d be g
ins on
the f
irst d
ay yo
u rec
eive s
ervic
e as a
n inp
atien
t in a
hosp
ital a
nd en
ds af
ter yo
u hav
e bee
n out
of the
hosp
ital a
nd ha
ve no
t rec
eived
skille
d car
ein
any o
ther f
acilit
y for
60 da
ys in
a ro
w.SE
RVIC
ESME
DICA
RE P
AYS
PLAN
N P
AYS
YOU
PAY
HOSP
ITAL
IZAT
ION*
Semi
priva
te ro
om an
d boa
rd, g
ener
al nu
rsing
, and
misc
ellan
eous
servi
ces a
nd su
pplie
sFir
st 60
days
All b
ut $1
,408
$1,40
8 (Pa
rt A
dedu
ctible
)$0
61st t
hrou
gh 90
th day
All b
ut $3
52 a
day
$352
a da
y$0
91st d
ay an
d afte
r:W
hile u
sing 6
0 life
time r
eser
ve da
ysAl
l but
$704
a da
y$7
04 a
day
$0On
ce lif
etime
rese
rve da
ys ar
e use
d:Ad
dition
al 36
5 day
s$0
100%
of M
edica
re-e
ligibl
e exp
ense
s$0
**Be
yond
the a
dditio
nal 3
65 da
ys$0
$0Al
l cos
tsSK
ILLE
D NU
RSIN
G FA
CILI
TY C
ARE*
You m
ust m
eet M
edica
re’s
requ
ireme
nts, in
cludin
g hav
ingbe
en in
a ho
spita
l for a
t leas
t 3 da
ys an
d ente
red a
Medic
are-
appr
oved
facil
it y w
ithin
30 da
ys af
ter le
aving
the
hosp
ital.
First
20 da
ysAl
l app
rove
d amo
unts
$0$0
21st t
hrou
gh 10
0th day
All b
ut $1
76 a
day
Up to
$176
a da
y$0
101st d
ay an
d afte
r$0
$0Al
l cos
tsBL
OOD
First
3 pint
s$0
3 pint
s$0
Addit
ional
amou
nts10
0%$0
$0HO
SPIC
E CA
REYo
u mus
t mee
t Med
icare
’s re
quire
ments
, inclu
ding a
docto
r’s ce
rtifica
tion o
f term
inal il
lness
.
All b
ut ve
ry lim
ited
copa
ymen
t/coin
sura
nce f
orou
tpatie
nt dr
ugs a
nd in
patie
ntre
spite
care
Medic
are c
opay
ment/
coins
uran
ce$0
**NOT
ICE:
Whe
n you
r Med
icare
Par
t A ho
spita
l ben
efits
are e
xhau
sted,
we st
and i
n the
plac
e of M
edica
re an
d will
pay w
hatev
er am
ount
Medic
are w
ould
have
paid
up to
an ad
dition
al 36
5 da y
s as p
rovid
ed in
the p
olicy
’s “C
ore B
enefi
ts.” D
uring
this
time t
he ho
spita
l is pr
ohibi
ted fr
om bi
lling y
ou fo
r the
balan
ce ba
sed o
n any
diffe
renc
ebe
twee
n its
billed
char
ges a
nd th
e amo
unt M
edica
re w
ould
have
paid.
IN U
W A
GY 00
216
IN_U
W_A
GY_0
1242
0
PLAN
NME
DICA
RE (P
ART
B) –
MEDI
CAL
SERV
ICES
– PE
R CA
LEND
AR Y
EAR
*Onc
e you
have
been
bille
d $19
8 of M
edica
re-a
ppro
ved a
moun
ts for
cove
red s
ervic
es (w
hich a
re no
ted w
ith an
aster
isk),
your
Par
t B de
ducti
ble w
ill ha
ve be
en m
et for
the
calen
dar y
ear.
SERV
ICES
MEDI
CARE
PAY
SPL
AN N
PAY
SYO
U PA
YME
DICA
L EX
PENS
ES– I
N OR
OUT
OF
THE
HOSP
ITAL
AND
OUT
PATI
ENT
HOSP
ITAL
TREA
TMEN
T, su
ch as
phys
ician
’s se
rvice
s, inp
atien
tan
d outp
atien
t med
ical a
nd su
rgica
l ser
vices
and
supp
lies,
phys
ical a
nd sp
eech
ther
apy,
diagn
ostic
tests
,du
rable
med
ical e
quipm
ent
First
$198
of M
edica
re-a
ppro
ved a
moun
ts*$0
$0$1
98 (P
art B
dedu
ctible
)Re
maind
er of
Med
icare
-app
rove
d amo
unts
Gene
rally
80%
Balan
ce, o
ther t
han u
p to $
20 pe
roff
ice vi
sit an
d up t
o $50
per
emer
genc
y roo
m vis
it. Th
eco
paym
ent o
f up t
o $50
is w
aived
if the
insu
red i
s adm
itted t
o an y
hosp
ital a
nd th
e eme
rgen
cy vi
sitis
cove
red a
s a M
edica
re P
art A
expe
nse
Up to
$20 p
er of
fice v
isit a
nd up
to $5
0 per
emer
genc
y roo
mvis
it. Th
e cop
ayme
nt of
up to
$50 i
s waiv
ed if
the in
sure
d is
admi
tted t
o an y
hosp
ital a
nd th
eem
erge
ncy v
isit is
cove
red a
s aMe
dicar
e Par
t A ex
pens
e
Part
B Ex
cess
Cha
rges
(abo
ve M
edica
re-a
ppro
ved
amou
nts)
$0$0
All c
osts
BLOO
DFir
st 3 p
ints
$0Al
l cos
ts$0
Next
$198
of M
edica
re-a
ppro
ved a
moun
ts*$0
$0$1
98 (P
art B
dedu
ctible
)Re
maind
er of
Med
icare
-app
rove
d amo
unts
80%
20%
$0CL
INIC
AL L
ABOR
ATOR
Y SE
RVIC
ES –
TEST
S FO
RDI
AGNO
STIC
SER
VICE
S10
0%$0
$0
IN U
W A
GY 00
217
IN_U
W_A
GY_0
1242
0
PLAN
NME
DICA
RE (P
ART
B) –
MEDI
CAL
SERV
ICES
– PE
R CA
LEND
AR Y
EAR
PART
S A
AND
BSE
RVIC
ESME
DICA
RE P
AYS
PLAN
N P
AYS
YOU
PAY
HOME
HEA
LTH
CARE
– ME
DICA
RE-A
PPRO
VED
SERV
ICES
Medic
ally n
eces
sary
skille
d car
e ser
vices
and m
edica
lsu
pplie
s10
0%$0
$0
DURA
BLE
MEDI
CAL
EQUI
PMEN
TFir
st $1
98 of
Med
icare
-app
rove
d amo
unts*
$0$0
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Preferred Method of Communication (Select one) Phone Fax Email Contact info: __________________________________________________________________
Note: Producers must be under the same commission code to share or split commissions. Please update your contact information at http://www.mutualofomaha.com/.
Provide Applicant with the Guide to Health Insurance for People with Medicare Provide Applicant with the Outline of Coverage
• Calculate the premium based on age at application date
Complete the Calculate Your Premium form to determine rate Application (complete in full)
Sections A & B: Plan and Applicant Information• Select plan• Enter Requested Effective Date• Indicate where the policy is to be mailedSection C: Medicare Information• Include applicant’s Medicare number on the application. This number is required for electronic
claim processing. If this number is not available at time of application, the applicant/agent must provide this number by calling 1-877-617-5587 once it is received. If not already covered by Medicare, indicate “eligibility” and “enrollment” dates.
Section D: Household Premium Discount Information• Indicate if eligible for a Household Premium DiscountSection E: Previous or Existing Coverage Information• Please complete ALL questions in full
For Sections F and G – Refer to the Open Enrollment/Guaranteed Issue worksheet to help identify eligibility.
Section F: Please answer all of the following questions• If either Applicant A or B answered “YES” to BOTH questions 7(a) and 7(b) or question 8 and 9 in
Section F, they can skip to Section I Sections G & H: Health/Medication Information
• Do NOT answer if applicant is in an open enrollment or guaranteed issue periodSection I: Agreement and Authorization• Make sure applicant(s) sign and date the applicationSection K: To be Completed by Producer• Make sure producer(s) sign and date the application
Complete the Method of Payment form and return with the completed application• Use premium determined by the Calculate Your Premium form • The full modal premium is collected at the time of application
Complete Replacement Notice and leave a copy with the applicant (if applicable) Provide Applicant with Premium Receipt signed by agent (if applicable)
Note: An interviewer may call to verify/confirm the information provided on the application.This form is required if splitting commissions.
Indiana Producer Information – Please Complete
Application Submission Checklist – United World Medicare Supplement Coverage
W143406_IN_0120
W14
3406
_IN
_012
0
✍
Producer Name Agent Writing Number Commission Share Commission Code or Social Security Number Required only if you are not appointed or licensed or are changing brokerage firms
___________________________ %
___________________________ %
MUTUALLYWELL together with Tivity Health®
Mutual of Omaha is excited to introduce our new comprehensive wellness program called Mutually Well. Please visit www.mutuallywell.com for more information and to enroll.
If any of the following situations apply, applicant is in an open enrollment or guaranteed issue period: (Situations may vary by state and coverage may be limited. Please refer to the Underwriting Guide for more information.)ELIGIBILITY FOR OPEN ENROLLMENTApplicant is:
• at least 64 ½ years of age (in most states) and within six months before or after his/her effective date for Medicare Part B, or
• covered under Medicare Part B prior to age 65 (eligible for a six-month open enrollment period upon reaching age 65)
Note: Coverage cannot be effective until your Medicare coverage is effective.ELIGIBILITY FOR GUARANTEED ISSUE
Evidence of eligibility is required for the following situations.Applicant:
• is in the original Medicare plan, has an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays, and that coverage is ending
• is in the original Medicare plan, has a Medicare Select policy, and moves out of the Select plan’s service area• loses coverage due to their Medicare supplement insurance company’s insolvency or at no fault of the
applicant• the applicant leaves their Medicare supplement plan because the company has not followed rules, or has misled
the applicantIf Medicare Part A eligibility date is before 01/01/2020, applicant has the right to buy Medicare supplement Plan A, B, C, F, High Deductible F, K or L that is sold in the applicant’s state by any insurance company.If Medicare Part A eligibility date is on or after 01/01/2020, applicant has the right to buy Medicare supplement Plan A, B, D, G, High Deductible G, K or L that is sold in the applicant’s state by any insurance company.
Applicant was enrolled in a Medicare Advantage (MA) plan, and:• the plan is leaving the Medicare program or stops service in the applicant’s area, or the applicant moves out
of the plan’s service area (applicant must switch back to original Medicare)• the applicant leaves the plan because the company has not followed rules, or has misled the applicant
If Medicare Part A eligibility date is before 01/01/2020, applicant has the right to buy Medicare supplement Plan A, B, C, F, High Deductible F, K or L that is sold in the applicant’s state by any insurance company.If Medicare Part A eligibility date is on or after 01/01/2020, applicant has the right to buy Medicare supplement Plan A, B, D, G, High Deductible G, K or L that is sold in the applicant’s state by any insurance company.• the applicant decided to switch to original Medicare within the first year of joining a MA plan when first
eligible for Medicare Part A at age 65Applicant has the right to obtain their Medicare supplement policy back if that carrier still sells it or, if not available:
• If Medicare Part A eligibility date is before 01/01/2020, applicant has the right to buy Medicare supplement Plan A, B, C, F, High Deductible F, K or L that is sold in the applicant’s state by any insurance company.
• If Medicare Part A eligibility date is on or after 01/01/2020, applicant has the right to buy Medicare supplement Plan A, B, D, G, High Deductible G, K or L that is sold in the applicant’s state by any insurance company.
Applicant was enrolled in a Medicaid plan or state-specific variation of a Medicaid plan, and:• the applicant's state has Guaranteed Issue or Open Enrollment Rights for the loss of Medicaid or state-
specific variation of a Medicaid planReference the Underwriting Guidelines for states that have Guarantee Issue or Open Enrollment Rights for loss of Medicaid or state-specific variation of a Medicaid plan.
Acceptable Evidence of Eligibility (Can vary by situation, refer to Underwriting Guide):a. Copy of the applicant’s MA plan’s termination noticeb. Copy of the letter the applicant sent to his/her MA plan requesting disenrollmentc. Signed statement that the applicant has requested to be disenrolled from his/her MA pland. Certification of group coveragee. Copy of the termination letter from employer or group carrierf. Image of insurance ID card (ONLY allowed if your MA plan is being terminated)g. Copy of the termination letter that the applicant received regarding their state Medicaid plan or state-specific variation of a Medicaid plan
Open Enrollment and Guaranteed Issue Worksheet
M27788_0819
M27
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0819
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Medicare Supplement Insurance Plan Applicant A ______
Applicant B ______ Before you begin: Please go to the Height and Weight Chart on the next page to determine your eligibility for coverage, unless you are in an open enrollment or guaranteed issue period.
Steps ExampleRate displayed is used for calculation purposes only.
Applicant A Applicant B
#1 AgeWrite in your age at the time of signing the application.ZIP CodeIndicate your ZIP Code used to determine your rate.
65
51502
#2 PremiumWrite in your Med supp plan’s premium from the Outline of Coverage provided, based on your age and ZIP Code listed in Step #1.
$128.52
#3 Household Premium DiscountPlease refer to the application for state specific household discount premium rules.
If the rules apply, multiply the amount from Step #2 by .93. If the rules do not apply, enter the amount from Step #2.
$128.52 x .93 = $119.52
In this example, the person qualifies for the household premium discount.
#4 Rate AdjustmentIf you’re in your open enrollment or guaranteed issue period, skip to Step #5.
Locate your height, then weight on the next page. • If your weight is in the Standard column, enter the
amount from Step #3• If your weight is in the Class I or II column, multiply the
amount from Step #3 by: 1.10 if in Class I column 1.20 if in Class II column
$119.52 x 1.20 = $143.42
Person’s weight is in the Class II column.
#5 Payment OptionsYour monthly payment is your last premium entered (Step #3 or #4).
To determine other payment schedules, multiply your monthly premium by:
3 to pay 4 times a year (quarterly)6 to pay twice a year (semiannually)12 to pay once a year (annually)
$143.42 monthly payment
$430.26 quarterly payment$860.52 semiannual payment$1,721.04 annual payment
Calculate Your Premium PLEASE COMPLETE
3316 Farnam Street Omaha, Nebraska 68175
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EligibilityFind your height in the left-hand column and look across the row to find your weight. If your weight is in the Decline column, we’re sorry, you’re not eligible for coverage at this time.
Rate AdjustmentThe column heading above your weight will indicate your appropriate rate adjustment, if any (risk class).
Decline Class I (10%) Standard Class I (10%) Class II (20%) DeclineHeight Weight Weight Weight Weight Weight Weight4' 2'' < 54 54 – 60 61 – 110 111 – 128 129 – 145 146 + 4' 3'' < 56 56 – 62 63 – 114 115 – 133 134 – 151 152 + 4' 4'' < 58 58 – 65 66 – 119 120 – 138 139 – 157 158 + 4' 5'' < 60 60 – 67 68 – 123 124 – 143 144 – 163 164 + 4' 6'' < 63 63 – 70 71 – 128 129 – 149 150 – 170 171 + 4' 7'' < 65 65 – 73 74 – 133 134 – 154 155 – 176 177 + 4' 8'' < 67 67 – 75 76 – 138 139 – 160 161 – 182 183 + 4' 9'' < 70 70 – 78 79 – 143 144 – 166 167 – 189 190 + 4' 10'' < 72 72 – 81 82 – 148 149 – 172 173 – 196 197 + 4' 11'' < 75 75 – 84 85 – 153 154 – 178 179 – 202 203 + 5' 0'' < 77 77 – 87 88 – 158 159 – 184 185 – 209 210 + 5' 1'' < 80 80 – 89 90 – 164 165 – 190 191 – 216 217 + 5' 2'' < 83 83 – 92 93 – 169 170 – 196 197 – 224 225 + 5' 3'' < 85 85 – 95 96 – 175 176 – 203 204 – 231 232 + 5' 4'' < 88 88 – 99 100 – 180 181 – 209 210 – 238 239 + 5' 5'' < 91 91 – 102 103 – 186 187 – 216 217 – 246 247 + 5' 6'' < 93 93 – 105 106 – 192 193 – 223 224 – 254 255 + 5' 7'' < 96 96 – 108 109 – 197 198 – 229 230 – 261 262 + 5' 8'' < 99 99 – 111 112 – 203 204 – 236 237 – 269 270 + 5' 9'' < 102 102 – 115 116 – 209 210 – 243 244 – 277 278 + 5' 10'' < 105 105 – 118 119 – 216 217 – 250 251 – 285 286 + 5' 11'' < 108 108 – 121 122 – 222 223 – 258 259 – 293 294 + 6' 0'' < 111 111 – 125 126 – 228 229 – 265 266 – 302 303 + 6' 1'' < 114 114 – 128 129 – 234 235 – 272 273 – 310 311 + 6' 2'' < 117 117 – 132 133 – 241 242 – 280 281 – 319 320 + 6' 3'' < 121 121 – 136 137 – 248 249 – 288 289 – 328 329 + 6' 4'' < 124 124 – 139 140 – 254 255 – 295 296 – 336 337 + 6' 5'' < 127 127 – 143 144 – 261 262 – 303 304 – 345 346 + 6' 6'' < 130 130 – 147 148 – 268 269 – 311 312 – 354 355 + 6' 7'' < 134 134 – 150 151 – 275 276 – 319 320 – 363 364 + 6' 8'' < 137 137 – 154 155 – 282 283 – 327 328 – 373 374 + 6' 9'' < 140 140 – 158 159 – 289 290 – 335 336 – 382 383 + 6' 10'' < 144 144 – 162 163 – 296 297 – 344 345 – 392 393 + 6' 11'' < 147 147 – 166 167 – 303 304 – 352 353 – 401 402 + 7' 0'' < 151 151 – 170 171 – 311 312 – 361 362 – 411 412 + 7' 1'' < 155 155 – 174 175 – 318 319 – 369 370 – 421 422 + 7' 2'' < 158 158 – 178 179 – 326 327 – 378 379 – 431 432 + 7' 3'' < 162 162 – 183 184 – 333 334 – 387 388 – 441 442 + 7' 4'' < 166 166 – 187 188 – 341 342 – 396 397 – 451 452 +
Height and Weight Chart
WA5981-12 Rev United World Life Insurance Company • 3316 Mutual of Omaha Plaza• Omaha, Nebraska 68175 1
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A. Plan Information (to be completed by Producer)Applicant A Applicant B
DNIS ________________ Auth # _________________
Agent Writing # Group # (if applicable) ______________ Keyline _________________
United World Life Insurance CompanyA Mutual of Omaha Company
Application for Medicare Supplement Coverage
Plan (select one): Plan A Plan G
High Deductible Plan G Plan NOR
If your Medicare Part A eligibility date is before 01/01/2020, these additional plans are available options:
Plan F Plan F - High Deductible
Requested Effective Date
Deliver Policy to
Applicant A Producer
/ / / /
Plan (select one): Plan A Plan G
High Deductible Plan G Plan NOR
If your Medicare Part A eligibility date is before 01/01/2020, these additional plans are available options:
Plan F Plan F - High Deductible
Requested Effective Date
Deliver Policy to
Applicant B Producer
Applicant acknowledges and agrees that if there is more than one applicant on this application, all information provided may be viewed or shared with the other applicant.
Applicant A Applicant BB. Applicant Information
Name (First/Middle Initial/Last)
Residence Address
City
State ZIP
Mailing Address (if different from residence address)
City
State ZIP
Home Phone
(area code)E-mail Address
Current Age ________
Date of Birth mo day yr
Male Female
Name (First/Middle Initial/Last)
Residence Address (if different from Applicant A’s)
City
State ZIP
Mailing Address (if different from residence address)
City
State ZIP
Home Phone
(area code)E-mail Address
Current Age ________
Date of Birth mo day yr
Male Female
/ / / /
– – – –
How Did You Hear About Us?Please select all that apply. Thank you for providing this helpful information.
Agent/Broker/Producer
Direct Mail
Family Member/Friend
Internet Search
Physician Referral
Radio
Social Media
TV
WA5981-12 Rev United World Life Insurance Company • 3316 Mutual of Omaha Plaza• Omaha, Nebraska 68175 2
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Medicare Number
Medicare Part A Effective Date / / If you are not covered under Medicare Part A, what is your eligibility date
/ /
Medicare Part B Effective Date / / If you are not covered under Medicare Part B, indicate the date you plan to enroll
/ /
Medicare Number
Medicare Part A Effective Date / / If you are not covered under Medicare Part A, what is your eligibility date
/ /
Medicare Part B Effective Date / / If you are not covered under Medicare Part B, indicate the date you plan to enroll
/ /
Applicant A Applicant B
C. Medicare InformationPlease reference your Medicare card to complete this section.
D. Household Premium Discount Information You may be eligible for a policy with a lower premium rate based on your answers to the statements in this section. 1. Does a member of your household: (a) with whom you have continuously resided for the last 12 months; or (b) to whom you are either married or in a civil union partnership
either have an existing Medicare supplement plan with, or is applying for coverage with United World Life Insurance Company, United of Omaha Life Insurance Company, Omaha Insurance Company, or Mutual of Omaha Insurance Company?..................................................
2. If you answered “YES” to Question 1 above, please fill out the following information, except if both applicants are both applying for coverage on this application.
Name (First/Middle/Last)
Policy Number
Street Address
City/State/ZIP
Applicant A
Y N
Applicant B
Y N
Go paperless! To receive your Explanation of Benefits (EOBs) online, select “YES” below and provide your current e-mail address in Section B. If you subscribe, you will not receive paper EOBs, but instead, will receive an e-mail notification when new EOBs become available with a link to access each specific EOB. We will continue to mail EOBs if you are entitled to receive any monetary reimbursement from United of Omaha Life Insurance Company.
Receive statement online? ................................... Y N Receive statement online? ................................... Y N
B. Applicant Information (Continued)Applicant A Applicant B
Social Security #
Height Weight Ft In Lbs
Have you used any form of tobacco, an electronic cigarette (e-cig) or other nicotine product in the past 12 months?......................................................... ■ Y ■ N
Social Security #
Height Weight Ft In Lbs
Have you used any form of tobacco, an electronic cigarette (e-cig) or other nicotine product in the past 12 months?......................................................... ■ Y ■ N
– – – –
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If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplement insurance policy or certificate, or that you had certain rights to buy such a policy or certificate, you may be guaranteed acceptance in one or more of our Medicare supplement plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS. Please mark “YES” or “NO” with an “X” to the questions below.
Applicant B
Name of Company
Plan
Applicant A
Y N
Y N
Y N
Y N
Y N
Applicant B Y N
Y N
Y N
Y N
Y N
Applicant A
Y N
Applicant B
Y N
E. Previous or Existing Coverage Information
(b) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplement policy?................................................
(c) Planned date of termination/disenrollment?........................................... Applicant A / /
Applicant B / /
(d) Was this your first time in this type of Medicare plan?............................................... (e) Did you drop a Medicare supplement or Medicare Select policy/certificate to enroll in this Medicare plan?..................................................................................................
(f) Is your former Medicare supplement or Medicare Select policy certificate still available?
To the Best of Your Knowledge and Belief:3. Are you covered for medical assistance through the state Medicaid program?.................
(NOTE TO APPLICANT: If you are participating in a “Spend-Down Program” and have not met your “Share of Cost,” please answer “NO” to this question.) If “YES,” answer the following about this existing coverage:
(a) Will Medicaid pay your premiums for this Medicare supplement policy?................... (b) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?........................................................................................
4. Do you have another Medicare supplement or Medicare Select insurance policy or certificate in force?.......................................................................................................... If “YES,” answer the following about this existing coverage: (a) Do you intend to replace your current Medicare supplement policy/certificate with this policy?....................................................................................................................
(b) Indicate planned termination or disenrollment date............................... Applicant A / /
Applicant B / / (c) With what company, and what plan do you have?
5. Have you had coverage from any Medicare plan other than Medicare Part A or B within the past 63 days? (for example, a Medicare Advantage plan, or a Medicare HMO or PPO)...... If “YES,” answer the following about this previous or existing coverage:
(a) Fill in your start and end dates below. If you are still covered under this plan, leave “END” blank......................................................................... Applicant A START / /
END / /
Applicant B START / /
END / /
Please answer questions regarding another Medicare supplement or Select plan:
Y N Y N
Y N
Y N
Y N
Y N
Y N
Y N
Applicant A
Name of Company
Plan
Please answer questions regarding Medicare plan coverage (other than Medicare supplement):
WA5981-12 Rev United World Life Insurance Company • 3316 Mutual of Omaha Plaza• Omaha, Nebraska 68175 4
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Please answer questions regarding other health insurance:Applicant A
Y N
Applicant B
Y N 6. Have you had coverage under any other health insurance within the past 63 days?.......... (For example, an employer group health plan, union plan, or individual non-Medicare supplement plan.) If “YES,” answer the following about this previous or existing coverage: (a) What are your dates of coverage under the other policy/certificate? If you are still covered under this plan, leave “END” blank................ Applicant A START / /
END / /
Applicant B START / /
END / /
(b) Planned date of termination/disenrollment?............................................ Applicant A / /
Applicant B / /
(c) Have you disenrolled from your current coverage voluntarily?................................... (d) Please state the reason for your disenrollment:
________________________________________________________ Applicant A________________________________________________________
Applicant B (e) With what company and what kind of policy/certificate? (List below.)
Applicant B
Name of Company
Policy/Certificate type
Applicant A
Applicant B
(g) Please indicate reason for termination/disenrollment: ■ Your Medicare Advantage plan is leaving the Medicare program.................................■ Your Medicare Advantage organization stopped offering Medicare Advantage plans.......■ Your Medicare Advantage organization stopped offering coverage in the area in which you live............................................................................................................■ You moved out of the geographic service area of your Medicare Advantage plan..........■ You had a Medicare Advantage plan with Medicare Part D benefits and are enrolling in a stand-alone Medicare Part D plan...........................................................................
■ Other: ________________________________________________________ Applicant A
_________________________________________________________ Applicant B
Applicant A
Name of Company
Policy/Certificate type
Check box(s) below if applicable
Y N Y N
To the Best of Your Knowledge and Belief:
7. Are you applying during an open enrollment period? (a) Did you turn age 65 in the last six months?................................................................. (b) Did you enroll in Medicare Part B in the last six months?.............................................
If either question 7a or 7b is "YES", indicate your Medicare Part B effective date Applicant A / /
Applicant B / /
8. Are you applying during a guaranteed issue period?........................................................ (NOTE: Refer to the Guide to Health Insurance for People with Medicare to help identify if you are eligible. If the answer above is “YES,” attach proof of eligibility.)
IF YOU ANSWER “YES” TO BOTH QUESTIONS 7A AND 7B OR QUESTION 8 IN SECTION F, OR ARE OTHERWISEIN AN OPEN ENROLLMENT PERIOD, SKIP SECTIONS G & H AND GO TO SECTION I.
F. Please answer all of the following questions:Applicant A
Y N
Y N
Applicant B
Y N
Y N
Y N Y N
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G. Health Information For all plans, answer questions 9-19. Note: An interviewer may call to confirm and verify the information you have provided on this application. Part A: Medical Questions: (If “YES” is answered to any of the following questions 9-15, that person is not eligible for coverage.)
If you are applying during an open enrollment or guaranteed issue period: SKIP SECTIONS G & H and GO TO SECTION I. (Please see the enclosed material for explanation of the open enrollment and guaranteed issue periods.)
Applicant A Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Applicant B Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
To the Best of Your Knowledge and Belief: 9. Are you currently confined to a wheelchair or any motorized mobility device?..........................10. Are you currently hospitalized, confined to a bed, in a nursing home or assisted living
facility?....................................................................................................................................11. Within the past five years, have you been medically diagnosed with, treated for, or had surgery
for any of the following:A. Chronic kidney disease (Stages 3, 4, or 5), kidney failure, or kidney disease requiring dialysis? B. Emphysema, chronic obstructive pulmonary disease (COPD), any other chronic
pulmonary disorder or any cardio-pulmonary disorder requiring oxygen?..........................C. Alzheimer’s disease, dementia or any other cognitive disorder? .......................................D. Parkinson’s disease, multiple sclerosis or amyotrophic lateral sclerosis (Lou Gehrig’s
Disease), Huntington's disease, or cerebral palsy?...........................................................
E. Systemic lupus, scleroderma or myasthenia gravis? .........................................................
F. Chronic hepatitis or cirrhosis? ...........................................................................................
G. Human Immunodeficiency Virus (HIV)? .............................................................................
12. Have you had an organ or stem cell transplant or been advised to have an organ or stem cell transplant (excluding cornea implants)? ................................................................................
13. Do you have Osteoporosis, and as a result, experienced a fracture? .......................................14. Do you have diabetes with complications including retinopathy, neuropathy, peripheral artery
disease, peripheral venous thrombotic disease, stroke, transient ischemic attack (TIA), any heart disorder or any kidney disease?................................................................................................
15. Do you have an implanted cardiac defibrillator? .....................................................................
NOTE: Please verify the completeness and accuracy of the above statements as they may impact claim payment.
Part B: Medical Questions: (If “YES” is answered to any of the following questions 16-19 that person MAY not be eligible for coverage and is subject to an underwriting review.) If you would like consideration to be given to an application that contains a "Yes" answer to any question in Part B, attach an explanation stating how long the condition has existed and how it is being controlled.
To the Best of Your Knowledge and Belief:16. Within the past two years, have you been treated for, or been advised by a physician to have
treatment for: A. Coronary artery disease, angina, heart attack, cardiac angioplasty, bypass surgery or stent
placement?....................................................................................................................................... B. Cardiomyopathy, congestive heart failure, aortic or cardiac aneurysm, peripheral artery disease,
peripheral venous thrombotic disease, vascular angioplasty, endarterectomy, carotid artery disease, any heart or heart valve disorder, atrial fibrillation, other heart rhythm disorder, or implantation of a pacemaker?...........................................................................................................
C. Alcoholism or drug abuse? ............................................................................................................ D. Any mental or nervous disorder requiring treatment (including hospital confinement)? ................. E. Internal cancer, lymphoma or melanoma? ..................................................................................... F. A stroke or transient ischemic attack (TIA)? .................................................................................... G. Degenerative bone disease, spinal stenosis, rheumatoid arthritis, psoriatic arthritis, arthritis that
restricts mobility or have you been advised to have joint replacement? .........................................17. Do you have diabetes with high blood pressure and have you: A. Taken more than two medications for either condition (insulin dependent or oral medications)? ... B. Had any changes in your medications within the past two years? ..................................................18. Have you been hospital confined three or more times in the past two years for a same or similar
condition? .....................................................................................................................................19. Within the past five years, have you been advised by a medical professional to have treatment,
further diagnostic evaluation, diagnostic testing, follow up visits or any surgery that has not been performed? ....................................................................................................................................
Applicant A
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Applicant B
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
WA5981-12 Rev United World Life Insurance Company • 3316 Mutual of Omaha Plaza• Omaha, Nebraska 68175 6
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Applicant A
Applicant B
H. Medication Information If you are applying for ANY plan OUTSIDE of an open enrollment or guaranteed issue period, please answer the question. If "yes" list all over-the-counter or prescription medications you are currently taking or have been prescribed in the last 2 years.
Medication Name (copy off pharmacy label) Dosage Frequency
Have you taken this medication for more than 2 years?
Prescribed by Primary Physician?
Diagnosis/Condition
Y N Y N
Y N Y N
Y N Y N
Y N Y N
Y N Y N
Y N Y N
Y N Y N
Y N Y N
Medication Name (copy off pharmacy label) Dosage Frequency
Have you taken this medication for more than 2 years?
Prescribed by Primary Physician?
Diagnosis/Condition
Y N Y N
Y N Y N
Y N Y N
Y N Y N
Y N Y N
Y N Y N
Y N Y N
Y N Y N
To the Best of Your Knowledge and Belief:20. Are you currently taking, or have you been prescribed during the previous 2 years any
prescription drugs or over-the-counter medications? .....................................................................
Applicant A
Y N
Applicant B
Y N
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IMPORTANT STATEMENTS■ You do not need more than one Medicare supplement policy.■ If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple
coverages.■ If you are age 65 or older, you may be eligible for benefits under Medicaid and may not need a Medicare supplement policy.■ If, after purchasing the policy, you become eligible for Medicaid, the benefits and premiums under your Medicare
supplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing Medicaid eligibility. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.
■ If you are eligible for, and have enrolled in a Medicare supplement policy by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare supplement policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.
■ Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement insurance and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB).
I. Agreement and Authorization
AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION TO UNITED WORLD LIFE INSURANCE COMPANY■ I authorize any physician, medical or dental practitioners, hospitals, clinics, pharmacies, pharmacy benefit managers,
other medical care facilities, health maintenance organizations and all other providers of medical or dental services, the group of companies which presently includes Omaha Insurance Company, Mutual of Omaha Insurance Company, United of Omaha Life Insurance Company, Companion Life Insurance Company, and any additional companies which may become part of this group of companies and their successors, along with other persons and entities which act on behalf of those companies to provide services to them, employers, consumer reporting agencies, and other insurance companies to disclose Personal Information about me to United World Life Insurance Company. Unless revoked earlier, this authorization will remain in effect for 24 months from the date I sign this application. I understand that I may revoke this authorization at any time, by written notice to: ATTN: Individual Underwriting, United World Life Insurance Company,
P.O. Box 3608, Omaha, NE 68103-3608. I realize that my right to revoke this authorization is limited to the extent that United World Life Insurance Company has taken action in reliance on the authorization or the law allows United World Life Insurance Company to contest the issuance of the policy or a claim under the policy.
■ “Personal Information” means all health information, such as medical history, mental and physical condition, including the presence of HIV infection, AIDS or ARC, prescription drug records, drug and alcohol use and other information such as finances, occupation, general reputation and insurance claims information about me. Personal Information does not include Psychotherapy Notes, which are notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a counseling session, which notes are separated from the rest of the person’s medical record. Certain information, such as that relating to prescriptions, diagnosis and functional status, is not included in the term Psychotherapy Notes.
■ The Personal Information will be used to determine my eligibility for insurance and to resolve or contest any issues of incomplete, incorrect or misrepresented information on my application which may arise during the processing of my application or in connection with claims for insurance benefits. This authorization will not be used if the applicant is in an open enrollment or guaranteed issue period.
■ If the person or entity to whom Personal Information is disclosed is not a health care provider or health plan subject to federal privacy regulations, the Personal Information may then be subject to further disclosure by that person or entity without the protections of the federal privacy regulations.
■ I understand that I may refuse to sign this application. I realize that if I refuse to sign, the insurance for which I am applying will not be issued.
■ I understand that I will receive a copy of the signed application. A copy of this application is as effective as the original. I acknowledge and agree that if there is more than one applicant on this application, all information provided may be reviewed or shared with the other applicant. I understand that, upon acceptance of the completed application, each applicant will receive a separate policy and a completed and signed application will become part of each applicant’s policy.
I represent that my answers and statements on this application are true and complete to the best of my knowledge and belief. I understand that my policy benefits can start no earlier than my Medicare effective date, my first month’s premium has been received and/or processed and my application has been approved by United World Life Insurance Company.I acknowledge receipt of A Guide to Health Insurance for People with Medicare (not applicable for Direct-to-Consumer business) and an Outline of Coverage.
✍ Dated at _______________________, on / / __________________________________ City State Month Day Year Applicant A’s Signature
✍ Dated at _______________________, on / / __________________________________ City State Month Day Year Applicant B’s Signature (if applying)
WA5981-12 Rev United World Life Insurance Company • 3316 Mutual of Omaha Plaza• Omaha, Nebraska 68175 8
WA
5981
-12
Rev
21. Producers shall list any other health insurance policies/certificates they have sold to the applicant(s).(a) List policies/certificates sold to the applicant(s) which are still in force.
(b) List policies/certificates sold to the applicant(s) in the past five (5) years which are no longer in force.
I/We certify as follows:I/We have accurately recorded in the application the information supplied by the applicant(s)........................... Y N
I/We certify that we have interviewed the proposed applicant(s)........................................................................ Y N
If you answered “NO” to any of the above statements, please explain why. __________________________________________
_________________________________________________________________________________________________________
I acknowledge that if the applicant(s) is replacing coverage, I/We have provided a copy of the replacement notice.
✍ ________________________________________________ ✍ _____________________________________________ Signature of Licensed Producer Date Signature of Licensed Producer Date
________________________________________________________ ____________________________________________________ Printed Name Printed Name
Agent Writing Number Agent Writing Number
Applicant A
Applicant B
Applicant A
Applicant B
K. To be Completed by Producer
J. Producer Comments (please attach a separate sheet if needed)
Applicant A
$
1st through the 28th or the last day of every month
______________________ Week (1st, 2nd, 3rd, 4th, last) _______________________ Weekday (Mon, Tue, Wed, Thu, Fri) _________
every_____months Insert 3, 6, or 12
Applicant B
$
1st through the 28th or the last day of every month
______________________ Week (1st, 2nd, 3rd, 4th, last)
______________________ Weekday (Mon, Tue, Wed, Thu, Fri) ________
every_____months Insert 3, 6, or 12
1. Account Owner Name, if different than applicant's...................... 2. If premium is NOT paid by Proposed Insured/Insured (includes spouse or joint-married account), indicate the bank account owner's relationship to Proposed Insured/Insured by selecting one of the following. Employer (3 app minimum/applicant must be retired.
Refer to List-Bill guidelines. N/A for Direct-to-Consumer business) Living Trust
Power of Attorney or legal guardian (documentation required) Business owned by applicant or applicant’s spouse
Part I . Select Premium Payment Option
Part II. Payor Information
METHOD OF PAYMENT FORM REQUIRED FORM – PLEASE RETURN PAGES 1 & 2
Applicant A
Applicant B
______________________ _____________________
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. . Initial Premium Payment (Select option #1 or #2)
✍ Initial premium amount (based on age at application date)................ 1. Paper Check (submit signed check with application)..........................(California collect only one month's premium at time of application) 2. Automatic Bank Account Withdrawal....................................................Ongoing Premium Payments (Select option #1a, #1b, or #2) 1. I want my payments automatically withdrawn from my bank a. Choose the day payments will be deducted every month from your bank account......................................................................... OR b. Choose the week and weekday that payments will be deducted every month from your bank account............................. (For Example: 3rd Wednesday of every month)
2. I will mail my premium to the company every 3, 6, or 12 months. (Monthly billing is not allowed. Select frequency of billing).............
When choosing automatic bank account withdrawal, MONEY WILL BE WITHDRAWN FROM YOUR ACCOUNT IMMEDIATELY UPON POLICY APPROVAL AND ISSUE. The first withdrawal date may be different from the monthly date selected for ongoing premiums. Depending on the amount of time elapsed between the policy date and the date the policy is placed inforce, the amount of the first ongoing withdrawal may exceed one modal premium and may occur on a date other than the policy date. The Proposed Insured(s) will not receive premium billing notices while on this premium payment option. We CANNOT establish electronic payments from foreign banks.
Each month, payments will be automatically deducted from the account below on the day selected above. If no date is selected, premiums will be deducted on the policy date (which is determined at the time the policy is issued and can be found within the policy). Ongoing deductions will begin once the policy is issued. If the scheduled deduction date begins on a weekend or holiday, the payment will process on the following business day.
Page 1 W27785_1219
I authorize United World Life Insurance Company ("United World") to withdraw funds from my account for the initial and/or monthly renewal premiums and understand that the amounts may differ. This authorization shall apply to any future payments unless specifically revoked by me. Premium shortages may result from a variety of causes, including underwriting adjustments. I authorize my financial institution to pay from my account to United World any preauthorized bank account withdrawals. I agree that my financial institution shall be fully protected in honoring any such payment and that its rights and responsibilities regarding the payment shall be the same as if the payment were signed personally by me. I agree to notify the business in writing of any changes in my account information. This authorization will be effective until I give you at least three business days' notice to cancel. If notice is given verbally, United World may require written confirmation from me within 14 days after my verbal notice.
Page 2 W27785_1219
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Applicant A
✍_____________________________________________________Authorized Signature as Shown on Account________________________________________________________Date
Applicant B
✍______________________________________________ Authorized Signature as Shown on Account__________________________________________________Date
Part III. Account Information Complete the Following ONLY if Automated Bank Account Withdrawal is Chosen:This section is intended as authorization to debit your bank account. Complete bank account information below OR attach a copy of a voided check (Do NOT use a deposit slip)
Applicant A Account Type (check one): Checking Savings
__________________________________________________ Name of Financial Institution
Routing Number (9 digits on lower left side of check)
Account Number (Do NOT use Debit/Credit Card numbers)
__________________________________________________ Name as Shown on Account
Applicant B Same account as Applicant A Account Type (check one): Checking Savings
_________________________________________________ Name of Financial Institution
Routing Number (9 digits on lower left side of check)
Account Number (Do NOT use Debit/Credit Card numbers)
_________________________________________________ Name as Shown on Account
Can
att
ach
void
ed c
heck
her
e
• Payments cannot be postponed until a later date.• Payment from a third party, including any foundation, will not be accepted, except in certain pre-approved situations.• All refunds will be made to the applicant in the event of rejection, incomplete submission, overpayment, cancellation, etc.
Example: John Doe Check #1234 Street Address Town, City ZIP Code Date:___________ Pay to:__________________________________________ ________________________________________________Dollars Financial Institution Name & Address Memo____________ Signed By:____________________________
Account Holder Name
Account Number
Do NOT include the check # in the Routing or Account Number.
Routing/Transfer Number
|:123456789:| 12345678 ||■ 1234 ||■
United World Life Insurance CompanyA Mutual of Omaha Company
Save this notice! It may be important to you in the future.According to your application, you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by United World Life Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy.You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.
Statement to Applicant by Issuer, Agent, Broker or Other Representative:I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason(s) (check one):
Applicant A Applicant BAdditional benefits Additional benefits
No change in benefits, but lower premiums No change in benefits, but lower premiumsFewer benefits and lower premiums Fewer benefits and lower premiums
My plan has outpatient prescription drug coverage and I am enrolling in Part D
My plan has outpatient prescription drug coverage and I am enrolling in Part D
Disenrollment from a Medicare Advantage Plan (Please explain reason for disenrollment)
Disenrollment from a Medicare Advantage Plan (Please explain reason for disenrollment)
Other (please specify) Other (please specify)
If, you still wish to terminate your present policy or certificate and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the Company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded.Do not cancel your present policy or certificate until you have received your new policy and are sure that you want to keep it.
✍ ___________________________________________ _____________________Signature of Agent, Broker or Other Representative* DateUnited World Life Insurance Company, Mutual of Omaha Plaza, Omaha, NE 68175
Applicant A Applicant BSignature
✍Signature
✍Date Date
*Signature not required for direct response sales.
W24680_0605
NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE
W24
680_
0605
IMPORTANT DOCUMENTS
LEAVE THE FOLLOWING REMAINING PAGES WITH CLIENT(S)
As part of the application process, the applicant has signed multiple forms. Applicant copies of these forms and client notifications on the following pages are to be given to the applicant(s) if applicable.
Replacement Notice If replacing, both you and the applicant must sign the customer copy of the replacement notice.
Premium Receipt
United World Life Insurance CompanyA Mutual of Omaha Company
Save this notice! It may be important to you in the future.According to your application, you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by United World Life Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy.You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.
Statement to Applicant by Issuer, Agent, Broker or Other Representative:I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason(s) (check one):
Applicant A Applicant BAdditional benefits Additional benefits
No change in benefits, but lower premiums No change in benefits, but lower premiumsFewer benefits and lower premiums Fewer benefits and lower premiums
My plan has outpatient prescription drug coverage and I am enrolling in Part D
My plan has outpatient prescription drug coverage and I am enrolling in Part D
Disenrollment from a Medicare Advantage Plan (Please explain reason for disenrollment)
Disenrollment from a Medicare Advantage Plan (Please explain reason for disenrollment)
Other (please specify) Other (please specify)
If, you still wish to terminate your present policy or certificate and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the Company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded.Do not cancel your present policy or certificate until you have received your new policy and are sure that you want to keep it.
✍ ___________________________________________ _____________________Signature of Agent, Broker or Other Representative* DateUnited World Life Insurance Company, Mutual of Omaha Plaza, Omaha, NE 68175
Applicant A Applicant BSignature
✍Signature
✍Date Date
*Signature not required for direct response sales.
W24680_0605
NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE
W24
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0605
All premiums must be made payable to United World Life Insurance Company.Do not make check payable to the agent or leave the payee blank.
Applicant A Applicant B
Received from ___________________________________
this _____ day of _____________________ , __________
an application for Form_______________________Policy
and/or Riders ________________________________and
Check for ________________________________Dollars.
Received from ___________________________________
this _____ day of _____________________ , __________
an application for Form_______________________Policy
and/or Riders ________________________________and
Check for ________________________________Dollars.
✍ Agent ______________________________________ ✍ Agent ______________________________________
No insurance of any kind shall take effect until a policy is issued and delivered to the applicant, and the initial premium is paid, all during the life of the applicant. If no policy is issued, United World Life Insurance Company shall have no liability except to refund the initial premium to the applicant. This is a receipt of your application and initial premium.
Provide the completed premium receipt, if applicable.
Premium Receipt
W27790_0619
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3316 Farnam Street Omaha, Nebraska 68175
MAP642_IN01/16/2019
Mutual of Omaha Insurance Company3300 Mutual of Omaha Plaza, Omaha, NE 68175
APPLICATION for
INDIVIDUAL DENTAL INSURANCE WITH OPTIONAL VISION RIDER
INDIANA
For Producer Use only. Not for Use with the General Public.
Monthly Rates (Issue Age 19-99)
INDIANA
ZIPCodes MutualDentalPreferredDNT2
MutualDentalProtectionDNT5
VisionRider0PD1M
465-469,472-479 $46.12 $26.37 $8.28460-464,470,471 $50.04 $28.61 $8.28
Rates Subject to Change. As of 10/7/2017 The applicant will receive the following benefits under the Optional Vision Rider. The applicant must be enrolled in the Mutual of Omaha dental plan to apply. Up to $50 every calendar year for one eye exam (no waiting period) Up to $150 every two calendar years for eyeglasses or contact lenses (after a six-month waiting period)
MA6025 1
Mutual of Omaha Insurance Company3300 Mutual of Omaha Plaza, Omaha, NE 68175
Application for Individual Dental Insurance with Optional Vision Rider
A. Applicant InformationName (First, Middle Initial, Last) Phone Number
Home Cell
Residence Address (Street, City, State, ZIP) E-mail
Mailing Address (Street, City, State, ZIP) (if different from residence address) Deliver Policy to■ Applicant ■ Producer
Gender■ Male ■ Female
Date of Birth Social Security Number
B. Plan InformationSelect Dental Benefit Plan
■ Mutual Dental Preferred Annual Maximum $1,500
■ Mutual Dental Protection Annual Maximum $1,000
Requested Effective Date _______________________
Monthly Premium Rate for Dental $ ____________
■ Optional Vision Rider (only available with Dental) Monthly Premium Rate for Vision $ ____________
Total Monthly Premium $ ____________
C. Existing Coverage InformationAre you covered by any other dental or vision insurance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ■ Y ■ NIf Yes, answer the following about this existing coverage:Name of dental carrier(s) ________________________________________________________________________Name of vision carrier(s) ________________________________________________________________________Is the coverage you are applying for replacing existing dental insurance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ■ Y ■ NIs the coverage you are applying for replacing existing vision insurance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ■ Y ■ N
D. AgreementsI represent the information above is true and complete to the best of my knowledge and belief . Any incorrect or misleading answers may void this application and any issued policy . I understand that no insurance shall take effect until a policy is issued and the first premium is received by Mutual of Omaha during my lifetime .
✍ ____________________________________________________________________________ ______________________Applicant Signature Date Signed at City State
I/We acknowledge that if the applicant is replacing coverage, I/We have provided a copy of the replacement notice, if applicable .
✍ ____________________________________________________________________________________________________Signature of Licensed Insurance Producer Date
______________________________________________ ___________________ ______________%Printed Name Agent Writing Number Comm . % Share
✍ ____________________________________________________________________________________________________Signature of Licensed Insurance Producer Date
______________________________________________ ___________________ ______________%Printed Name Agent Writing Number Comm . % Share
Internal Tracking Code ________________ Group # (if applicable) ________________
This Page Left Blank Intentionally.
1. Account Owner Name, if different than applicant's.................................................................... ________________________ 2. If premium is NOT paid by Proposed Insured/Insured (includes spouse or joint-married account), indicate the bank account owner's relationship to Proposed Insured/Insured by selecting one of the following. Employer (3 app minimum/applicant must be retired. Refer to List-Bill guidelines. N/A for Direct-to-Consumer business)
Living Trust Power of Attorney or legal guardian (documentation required)
Business owned by applicant or applicant’s spouse
Part I . Select Premium Payment Option
Part II. Payor Information
METHOD OF PAYMENT FORM REQUIRED FORM – PLEASE RETURN PAGES 1 & 2
M44
903_
0119
Initial Premium Payment (Select option #1 or #2)
✍ Initial premium amount (based on age at application date)............................................................
1. Paper Check (submit signed check with application).................................................................
2. Automatic Bank Account Withdrawal.........................................................................................
Ongoing Premium Payments (Select option #1a, #1b, or #2) 1. I want my payments automatically withdrawn from my bank a. Choose the day payments will be deducted every month from your bank account..........................................................................................................
OR b. Choose the week and weekday that payments will be deducted every month from your bank account....................................................................... (For Example: 3rd Wednesday of every month)
2. I will mail my premium to the company every 3, 6, or 12 months. (Monthly billing is not allowed. Select frequency of billing).......................................................
When choosing automatic bank account withdrawal, MONEY WILL BE WITHDRAWN FROM YOUR ACCOUNT IMMEDIATELY UPON POLICY APPROVAL AND ISSUE. The first withdrawal date may be different from the monthly date selected for ongoing premiums. Depending on the amount of time elapsed between the policy date and the date the policy is placed inforce, the amount of the first ongoing withdrawal may exceed one modal premium and may occur on a date other than the policy date. The Proposed Insured(s) will not receive premium billing notices while on this premium payment option. We CANNOT establish electronic payments from foreign banks.
Each month, payments will be automatically deducted from the account below on the day selected above. If no date is selected, premiums will be deducted on the policy date (which is determined at the time the policy is issued and can be found within the policy). Ongoing deductions will begin once the policy is issued. If the scheduled deduction date begins on a weekend or holiday, the payment will process on the following business day.
Page 1 M44903_0119
$
1st through the 28th or the last day of every month
______________________
Week (1st, 2nd, 3rd, 4th, last) ______________________ Weekday (Mon, Tue, Wed, Thu, Fri) ________
every_____months
Insert 3, 6, or 12
.
I authorize Mutual of Omaha Insurance Company ("Mutual of Omaha") to withdraw funds from my account for the initial and/or monthlyrenewal premiums and understand that the amounts may differ. Premium shortages may result from a variety of causes, includingunderwriting adjustments. I authorize my financial institution to pay from my account to Mutual of Omaha any preauthorized bank accountwithdrawals. I agree that my financial institution shall be fully protected in honoring any such payment and that its rights and responsibilitiesregarding the payment shall be the same as if the payment were signed personally by me. I agree to notify the business in writing of anychanges in my account information. This authorization will be effective until I give you at least three business days' notice to cancel.If notice is given verbally, Mutual of Omaha may require written confirmation from me within 14 days after my verbal notice.
Page 2 M44903_0119 M44
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Applicant A
✍___________________________________________________________________________________________________________Authorized Signature as Shown on Account
_______________________________________________________________________________________________________________Date
Part III. Account Information Complete the Following ONLY if Automated Bank Account Withdrawal is Chosen:This section is intended as authorization to debit your bank account. Complete bank account information below OR attach a copy of a voided check (Do NOT use a deposit slip)
Applicant A Account Type (check one): Checking Savings
_______________________________________________________________________________________________________ Name of Financial Institution
Routing Number (9 digits on lower left side of check)
Account Number (Do NOT use Debit/Credit Card numbers)
________________________________________________________________________________________________________ Name as Shown on Account
Can
att
ach
void
ed c
heck
her
e
• Payments cannot be postponed until a later date.• Payment from a third party, including any foundation, will not be accepted, except in certain pre-approved situations.• All refunds will be made to the applicant in the event of rejection, incomplete submission, overpayment, cancellation, etc.
Example: John Doe Check #1234 Street Address Town, City ZIP Code Date:___________ Pay to:__________________________________________ ________________________________________________Dollars Financial Institution Name & Address Memo____________ Signed By:____________________________
Account Holder Name
Account Number
Do NOT include the check # in the Routing or Account Number.
Routing/Transfer Number
|:123456789:| 12345678 ||■ 1234 ||■
DNT2OC 1
MUTUAL OF OMAHA INSURANCE COMPANY 3300 MUTUAL OF OMAHA PLAZA
OMAHA, NEBRASKA 68175 (402) 342-7600
OUTLINE OF COVERAGE FOR POLICY SERIES DNT2
INDIVIDUAL DENTAL PREFERRED PROVIDER
ORGANIZATION (PPO) INSURANCE
THE POLICY PROVIDES LIMITED BENEFIT DENTAL COVERAGE ONLY. BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES.
Read Your Policy Carefully – This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!
Limited Benefit Dental-Only Insurance Coverage – This policy is designed to provide you ONLY with limited benefit dental insurance coverage. Coverage is NOT provided for any other diseases or accidents.
Benefits – This is a Preferred Provider Organization (PPO) dental insurance policy that pays benefits for covered dental services provided by in-network and out-of-network dentists. It pays benefits for Diagnostic and Preventive Services, Basic Services, and Major Services. If you incur expense for a covered dental service, we will pay the coinsurance percentage of the allowed amount after you have satisfied the deductible and any applicable waiting period. Benefits payable are limited to any annual maximum benefit and lifetime maximum benefit.
Shown below is a brief summary of the dental benefits we will pay under this policy. For a full list of covered dental services and procedures, please visit our website at www.mutualofomaha.com/dental-insurance.
DENTAL BENEFITS SUMMARY
DEDUCTIBLE AMOUNT
Class I -- Diagnostic & Preventive Services None Class II – Basic Services and Class III - Major Services Combined
$50.00
COINSURANCE PERCENTAGE PAYABLE Class I – Diagnostic & Preventive Services 100% Class II – Basic Services 80% Class III – Major Services 50%
WAITING PERIOD TIME FRAME Class I– Diagnostic & Preventive Services None Class II– Basic Services None Class III– Major Services 1 Year
MAXIMUM BENEFIT AMOUNT Annual Maximum Benefit per Calendar Year $1,500.00 Implant Lifetime Maximum Benefit $3,000.00
You may obtain dental care for covered dental services from any licensed dentist. No matter which dentist you choose, you will be eligible for some level of benefits for covered dental services. However, when you use an in-network dentist who participates in the PPO network, that dentist has agreed to provide dental care at negotiated fees. For in-network dentists, you will not be responsible for the difference between your dentist’s submitted amount and the scheduled fee amount that the dentist has contractually agreed to accept as payment in full. The PPO network used by this policy is DenteMax Plus.
If you select a dentist who does not participate in the PPO network, your out-of-pocket expenses may be greater. For out-of-network dentists, you will be responsible for the difference between your dentist’s submitted amount and our payment. The amount we use to calculate our payment will be the lesser of the dentist’s submitted amount or the 80th percentile amount for covered dental services as identified by the Dental Charges Database.
DNT2OC 2
Waiting Period – Class III covered dental services are subject to the waiting period shown in the above Dental Benefits Summary chart. You must satisfy the waiting period before benefits are paid for these services. The waiting period begins on the policy effective date and is applied once during the lifetime of your policy. Exclusions -- Your policy pays benefits only for covered dental services. We will not pay benefits for:
(a) first installation of a denture or fixed bridge, and any inlay and crown that serves as an abutment to replace congenitally missing teeth or to replace teeth all of which were lost while the person was not covered;
(b) services or treatment not prescribed by or under the direct supervision of a dentist; (c) services or treatment which is experimental or investigational; (d) services or treatment which is for any illness or bodily injury which occurs in the course of employment if a benefit or
compensation is available, in whole or in part, under the provision of any law or regulation or any government unit. This exclusion applies whether or not you claim the benefits or compensation;
(e) services or treatment received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, Veterans Administration hospital or similar person or group;
(f) services or treatment performed prior to the policy effective date; (g) services or treatment incurred after the termination date of your coverage unless otherwise indicated; (h) services or treatment which is not dentally necessary or which does not meet generally accepted standards of dental
practice; (i) services or treatment resulting from your failure to comply with professionally prescribed treatment; (j) telephone consultations; (k) any charges for failure to keep a scheduled appointment; (l) any services that are considered strictly cosmetic in nature including, but not limited to, charges for personalization or
characterization of prosthetic appliances; (m) fluoride treatments; (n) services or treatment provided as a result of intentionally self-inflicted injury or illness; (o) services or treatment provided as a result of injuries suffered while committing or attempting to commit a felony,
engaging in an illegal occupation, or participating in a riot, rebellion or insurrection; (p) office infection control charges; (q) charges for copies of your records, charts or x-rays, or any costs associated with forwarding/mailing copies of your
records, charts or x-rays; (r) state, federal, or territorial taxes on dental services performed; (s) those charges submitted by a dentist, which are for the same services performed on the same date by another dentist; (t) those dental services provided free of charge by any governmental unit, except where this exclusion is prohibited by law; (u) those dental services for which you would have no obligation to pay in the absence of this or any similar insurance; (v) those dental services which are for specialized procedures and techniques; (w) those dental services performed by a dentist who is compensated by a facility for similar covered services performed for
you on the same date; (x) duplicate, provisional and temporary devices, appliances, and services; (y) plaque control programs, oral hygiene instruction, and dietary instructions; (z) services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited
to: 1. equilibration; 2. periodontal splinting; 3. full mouth rehabilitation and; 4. restoration for misalignment of teeth;
(aa) gold foil restorations; (bb) services or treatment for injuries resulting from war or act of war, whether declared or undeclared, or from police or
military service for any country or organization; (cc) hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or
outpatient); (dd) charges by the provider for completing dental forms; (ee) adjustment of a denture or bridgework which is made within 6 months after installation by the same dentist who installed
it; (ff) use of material or home health aids to prevent decay, such as:
1. toothpaste; 2. fluoride gels; 3. dental floss and; 4. teeth whiteners;
(gg) sealants; (hh) precision attachments, personalization, precious metal bases and other specialized techniques;
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(ii) replacement of dentures that have been: 1. lost; 2. stolen or; 3. misplaced;
(jj) repair of damaged orthodontic appliances; (kk) replacement of lost or missing appliances; (ll) fabrication of athletic mouth guard; (mm) internal bleaching; (nn) nitrous oxide; (oo) oral sedation; (pp) topical medicament carrier; (qq) orthodontic services, treatment or supplies, including braces and retainers; (rr) bone grafts when done in connection with:
1. extractions; 2. apicoectomies or; 3. non-covered/non-eligible implants;
(ss) tooth whitening; (tt) occlusal guards; (uu) space maintainers; (vv) services or treatment provided by a member of your immediate family; (ww) services or treatment received outside of the United States, its possessions or territories, Canada, or Mexico; or (xx) services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMD, TMJD) and related
disorders.
Multiple Procedure Limitations – When two or more dental services are submitted and the dental services are considered part of the same service to one another, this policy will pay the most comprehensive service (the service that includes the other non-benefited service) as determined by us. When two or more dental services are submitted on the same day and the dental services are considered mutually exclusive (when one service contradicts the need for the other service), this policy will pay for the service that represents the final treatment as determined by us.
Guaranteed Renewable For Life – The policy is guaranteed renewable for life. We cannot cancel your policy as long as you pay the required premium before the end of each grace period.
Premiums Can Change – We will not increase your policy’s premium due to any change in your health. However, we can change premiums if we make the same change to all policies of this form issued to persons of the same class. We will give you the advance notice required by your state prior to any such premium change.
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MUTUAL OF OMAHA INSURANCE COMPANY 3300 MUTUAL OF OMAHA PLAZA
OMAHA, NEBRASKA 68175 (402) 342-7600
OUTLINE OF COVERAGE FOR POLICY SERIES DNT5
INDIVIDUAL DENTAL PREFERRED PROVIDER
ORGANIZATION (PPO) INSURANCE
THE POLICY PROVIDES LIMITED BENEFIT DENTAL COVERAGE ONLY. BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES.
Read Your Policy Carefully – This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!
Limited Benefit Dental-Only Insurance Coverage – This policy is designed to provide you ONLY with limited benefit dental insurance coverage. Coverage is NOT provided for any other diseases or accidents.
Benefits – This is a Preferred Provider Organization (PPO) dental insurance policy that pays benefits for covered dental services provided by in-network and out-of-network dentists. It pays benefits for Diagnostic and Preventive Services, Basic Services, and Major Services. If you incur expense for a covered dental service, we will pay the coinsurance percentage of the allowed amount after you have satisfied the deductible and any applicable waiting period. Benefits payable are limited to any annual maximum benefit and lifetime maximum benefit.
Shown below is a brief summary of the dental benefits we will pay under this policy. For a full list of covered dental services and procedures, please visit our website at www.mutualofomaha.com/dental-insurance.
DENTAL BENEFITS SUMMARY
DEDUCTIBLE AMOUNT
Class I -- Diagnostic & Preventive Services, Class II – Basic Services and Class III – Major Services Combined
$100.00
COINSURANCE PERCENTAGE PAYABLE Class I – Diagnostic & Preventive Services 100% Class II – Basic Services 50% Class III – Major Services 50%
WAITING PERIOD TIME FRAME Class I– Diagnostic & Preventive Services None Class II– Basic Services None Class III– Major Services 1 Year
MAXIMUM BENEFIT AMOUNT Annual Maximum Benefit per Calendar Year $1,000.00 Implant Lifetime Maximum Benefit $2,000.00
You may obtain dental care for covered dental services from any licensed dentist. No matter which dentist you choose, you will be eligible for some level of benefits for covered dental services. However, when you use an in-network dentist who participates in the PPO network, that dentist has agreed to provide dental care at negotiated fees. For in-network dentists, you will not be responsible for the difference between your dentist’s submitted amount and the scheduled fee amount that the dentist has contractually agreed to accept as payment in full. The PPO network used by this policy is DenteMax Plus.
If you select a dentist who does not participate in the PPO network, your out-of-pocket expenses may be greater. For out-of-network dentists, you will be responsible for the difference between your dentist’s submitted amount and our payment. The amount we use to calculate our payment will be the lesser of the dentist’s submitted amount or an amount equal to the lowest prevailing scheduled fee used for in-network dentists in the geographic area.
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Waiting Period – Class III covered dental services are subject to the waiting period shown in the above Dental Benefits Summary chart. You must satisfy the waiting period before benefits are paid for these services. The waiting period begins on the policy effective date and is applied once during the lifetime of your policy. Exclusions -- Your policy pays benefits only for covered dental services. We will not pay benefits for:
(a) first installation of a denture or fixed bridge, and any inlay and crown that serves as an abutment to replace congenitally missing teeth or to replace teeth all of which were lost while the person was not covered;
(b) services or treatment not prescribed by or under the direct supervision of a dentist; (c) services or treatment which is experimental or investigational; (d) services or treatment which is for any illness or bodily injury which occurs in the course of employment if a benefit or
compensation is available, in whole or in part, under the provision of any law or regulation or any government unit. This exclusion applies whether or not you claim the benefits or compensation;
(e) services or treatment received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, Veterans Administration hospital or similar person or group;
(f) services or treatment performed prior to the policy effective date; (g) services or treatment incurred after the termination date of your coverage unless otherwise indicated; (h) services or treatment which is not dentally necessary or which does not meet generally accepted standards of dental
practice; (i) services or treatment resulting from your failure to comply with professionally prescribed treatment; (j) telephone consultations; (k) any charges for failure to keep a scheduled appointment; (l) any services that are considered strictly cosmetic in nature including, but not limited to, charges for personalization or
characterization of prosthetic appliances; (m) fluoride treatments; (n) services or treatment provided as a result of intentionally self-inflicted injury or illness; (o) services or treatment provided as a result of injuries suffered while committing or attempting to commit a felony,
engaging in an illegal occupation, or participating in a riot, rebellion or insurrection; (p) office infection control charges; (q) charges for copies of your records, charts or x-rays, or any costs associated with forwarding/mailing copies of your
records, charts or x-rays; (r) state, federal, or territorial taxes on dental services performed; (s) those charges submitted by a dentist, which are for the same services performed on the same date by another dentist; (t) those dental services provided free of charge by any governmental unit, except where this exclusion is prohibited by law; (u) those dental services for which you would have no obligation to pay in the absence of this or any similar insurance; (v) those dental services which are for specialized procedures and techniques; (w) those dental services performed by a dentist who is compensated by a facility for similar covered services performed for
you on the same date; (x) duplicate, provisional and temporary devices, appliances, and services; (y) plaque control programs, oral hygiene instruction, and dietary instructions; (z) services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited
to: 1. equilibration; 2. periodontal splinting; 3. full mouth rehabilitation and; 4. restoration for misalignment of teeth;
(aa) gold foil restorations; (bb) services or treatment for injuries resulting from war or act of war, whether declared or undeclared, or from police or
military service for any country or organization; (cc) hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or
outpatient); (dd) charges by the provider for completing dental forms; (ee) adjustment of a denture or bridgework which is made within 6 months after installation by the same dentist who installed
it; (ff) use of material or home health aids to prevent decay, such as:
1. toothpaste; 2. fluoride gels; 3. dental floss and; 4. teeth whiteners;
(gg) sealants; (hh) precision attachments, personalization, precious metal bases and other specialized techniques;
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(ii) replacement of dentures that have been: 1. lost; 2. stolen or; 3. misplaced;
(jj) repair of damaged orthodontic appliances; (kk) replacement of lost or missing appliances; (ll) fabrication of athletic mouth guard; (mm) internal bleaching; (nn) nitrous oxide; (oo) oral sedation; (pp) topical medicament carrier; (qq) orthodontic services, treatment or supplies, including braces and retainers; (rr) bone grafts when done in connection with:
1. extractions; 2. apicoectomies or; 3. non-covered/non-eligible implants;
(ss) tooth whitening; (tt) occlusal guards; (uu) space maintainers; (vv) services or treatment provided by a member of your immediate family; (ww) services or treatment received outside of the United States, its possessions or territories, Canada, or Mexico; or (xx) services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMD, TMJD) and related
disorders.
Multiple Procedure Limitations – When two or more dental services are submitted and the dental services are considered part of the same service to one another, this policy will pay the most comprehensive service (the service that includes the other non-benefited service) as determined by us. When two or more dental services are submitted on the same day and the dental services are considered mutually exclusive (when one service contradicts the need for the other service), this policy will pay for the service that represents the final treatment as determined by us.
Guaranteed Renewable For Life – The policy is guaranteed renewable for life. We cannot cancel your policy as long as you pay the required premium before the end of each grace period.
Premiums Can Change – We will not increase your policy’s premium due to any change in your health. However, we can change premiums if we make the same change to all policies of this form issued to persons of the same class. We will give you the advance notice required by your state prior to any such premium change.
