BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement...
Transcript of BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement...
Outline of CoverageMedicare Supplement Insurance
Underwritten by
First Health Life & Health Insurance Company
800 Crescent Centre Dr. Suite 200
Franklin, TN 37067800 264.4000
aetnaseniorproducts.com
An Aetna Company
BENEFIT PLANS A, B, F, G, N
PENNSYLVANIA
FHLMS02089PA ©2016 Aetna Inc. 01012016
FHLM
S020
89PA
1
01
0120
16
FIR
ST H
EALT
H L
IFE
& H
EALT
H IN
SUR
ANC
E C
OM
PAN
Y O
UTL
INE
OF
MED
ICAR
E SU
PPLE
MEN
T C
OVE
RAG
E C
OVE
R P
AGE:
Pag
e 1
of 2
B
ENEF
IT P
LAN
S AV
AILA
BLE
: A, B
, F, G
, N
Thes
e ch
arts
sho
w th
e be
nefit
s in
clud
ed in
eac
h of
the
stan
dard
Med
icar
e su
pple
men
t pla
ns. E
very
com
pany
mus
t m
ake
ava
ilable
Pla
n “
A”
and
“B”
and
“C
” o
r “F
”. S
ome
plan
s m
ay n
ot b
e av
aila
ble
in y
our s
tate
.
See
Out
lines
of C
over
age
sect
ions
for d
etai
ls a
bout
ALL
PLA
NS
Bas
ic B
enef
its:
Hos
pita
lizat
ion:
Par
t A c
oins
uran
ce p
lus
cove
rage
for 3
65 a
dditi
onal
day
s af
ter M
edic
are
bene
fits
end.
M
edic
al E
xpen
ses:
Par
t B c
oins
uran
ce (g
ener
ally
20%
of M
edic
are-
Appr
oved
exp
ense
s) o
r, co
-pay
men
ts fo
r hos
pita
l out
patie
nt s
ervi
ces.
Pla
ns
K, L
, and
N re
quire
insu
reds
to p
ay a
por
tion
of c
oins
uran
ce o
r cop
aym
ents
Bl
ood:
Firs
t thr
ee p
ints
of b
lood
eac
h ye
ar.
H
ospi
ce-P
art A
coi
nsur
ance
A
B
C
D
F/F*
G
K
L
M
N
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Hos
pita
lizat
ion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basi
c be
nefit
s pa
id a
t 50%
Hos
pita
lizat
ion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basi
c be
nefit
s pa
id a
t 75%
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c, in
clud
ing
100%
Par
t B
coin
sura
nce,
exc
ept
up to
$20
cop
aym
ent
for o
ffice
vis
it, a
nd
up to
$50
cop
aym
ent
for E
R
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
50%
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
75%
Ski
lled
Nur
sing
Fac
ility
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Pa
rt A
Ded
uctib
le
Part
A D
educ
tible
Pa
rt A
Ded
uctib
le
Part
A D
educ
tible
Pa
rt A
Ded
uctib
le
50%
Par
t A
Ded
uctib
le
75%
Par
t A
Ded
uctib
le
50%
Par
t A
Ded
uctib
le
Part
A D
educ
tible
Part
B D
educ
tible
Part
B D
educ
tible
Part
B Ex
cess
(1
00%
)
Part
B Ex
cess
(1
00%
)
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Out
-of-p
ocke
t lim
it $4
,960
; pa
id a
t 100
%
afte
r lim
it re
ache
d
Out
-of-p
ocke
t lim
it $2
,480
; pa
id a
t 100
%
afte
r lim
it re
ache
d
*Pla
ns F
als
o ha
s an
opt
ion
calle
d a
high
ded
uctib
le p
lan
F. T
his
high
ded
uctib
le p
lan
pays
the
sam
e be
nefit
s as
Pla
n F
afte
r on
e ha
s pa
id a
cal
enda
r ye
ar
$2,1
80 d
educ
tible
. Ben
efits
from
hig
h de
duct
ible
pla
n F
will
not b
egin
unt
il ou
t-of-p
ocke
t exp
ense
s ex
ceed
$2,
180.
O
ut-o
f-poc
ket e
xpen
ses
for
this
ded
uctib
le
are
expe
nses
that
wou
ld o
rdin
arily
be
paid
by
the
polic
y. T
hese
exp
ense
s in
clud
e th
e M
edic
are
dedu
ctib
les
for
Part
A an
d Pa
rt B
, but
do n
ot
inclu
de t
he p
lan’s
se
para
te fo
reig
n tra
vel e
mer
genc
y de
duct
ible
.
FHLM
S020
89PA
01
0120
16
2
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n G
Pla
n N
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n G
Pla
n N
U
nd
er
651,
407
1,61
21,
891
1,73
51,
341
Un
de
r 65
1,54
91,
772
2,08
01,
909
1,47
5
65
1,40
71,
612
1,89
11,
735
1,34
165
1,54
91,
772
2,08
01,
909
1,47
5
66
1,44
91,
667
1,95
81,
799
1,39
266
1,59
31,
833
2,15
41,
978
1,53
0
67
1,48
91,
722
2,02
41,
861
1,44
167
1,63
81,
893
2,22
82,
047
1,58
6
68
1,53
01,
774
2,09
11,
923
1,49
168
1,68
31,
951
2,29
92,
115
1,63
9
69
1,57
01,
827
2,15
51,
983
1,53
869
1,72
72,
010
2,37
12,
181
1,69
2
70
1,60
91,
880
2,21
92,
043
1,58
670
1,77
02,
067
2,44
12,
247
1,74
5
71
1,64
91,
932
2,28
12,
102
1,63
271
1,81
32,
125
2,51
02,
312
1,79
5
72
1,68
71,
983
2,34
52,
162
1,68
072
1,85
72,
181
2,58
02,
377
1,84
8
73
1,72
32,
037
2,41
32,
228
1,73
373
1,89
52,
241
2,65
52,
450
1,90
6
74
1,75
72,
091
2,48
22,
292
1,78
674
1,93
32,
299
2,72
92,
522
1,96
5
75
1,79
02,
142
2,54
52,
353
1,83
575
1,96
92,
356
2,80
02,
588
2,01
9
76
1,82
42,
195
2,61
12,
416
1,88
776
2,00
52,
413
2,87
32,
658
2,07
6
77
1,85
82,
246
2,67
72,
479
1,93
877
2,04
32,
471
2,94
62,
727
2,13
2
78
1,87
22,
286
2,73
22,
533
1,98
378
2,06
02,
514
3,00
52,
786
2,18
1
79
1,88
82,
325
2,78
52,
587
2,03
079
2,07
72,
558
3,06
52,
846
2,23
3
80
1,89
82,
357
2,83
32,
635
2,07
080
2,08
72,
593
3,11
52,
897
2,27
7
81
1,91
12,
396
2,88
62,
686
2,11
481
2,10
22,
637
3,17
52,
955
2,32
5
82
1,92
62,
434
2,93
82,
739
2,15
982
2,11
92,
679
3,23
23,
013
2,37
5
83
1,94
02,
468
2,99
02,
792
2,20
783
2,13
42,
716
3,28
83,
070
2,42
7
84
1,95
62,
503
3,03
92,
844
2,25
384
2,15
22,
753
3,34
43,
128
2,47
8
85
1,97
02,
537
3,09
22,
899
2,30
085
2,16
82,
791
3,40
13,
189
2,53
0
86
1,98
62,
571
3,14
52,
954
2,35
086
2,18
42,
829
3,46
03,
248
2,58
5
87
2,00
12,
606
3,19
93,
009
2,39
887
2,20
12,
868
3,51
83,
309
2,63
9
88
2,01
62,
641
3,25
33,
066
2,45
088
2,21
82,
906
3,57
83,
373
2,69
5
89
2,03
22,
677
3,30
93,
124
2,50
189
2,23
42,
946
3,64
03,
436
2,75
2
90
+2,
046
2,71
43,
365
3,18
22,
553
90+
2,25
22,
985
3,70
33,
500
2,80
9
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.50
00Q
uar
terl
y:0.
2500
Mo
nth
ly:
0.08
33
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d u
se P
refe
rre
d r
ate
s.
Fem
ale
Ra
tes
Firs
t H
eal
th L
ife
& H
eal
th In
sura
nce
Co
mp
any
An
nu
al
Att
ain
ed
Ag
e P
rem
ium
s
For
Use
in
ZIP
Co
de
s:
15
0-1
54
, 1
56
FH
LMS0
2089
PA
01
0120
16
3
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n G
Pla
n N
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n G
Pla
n N
U
nd
er
651,
536
1,75
32,
047
1,87
41,
441
Un
de
r 65
1,69
01,
928
2,25
32,
063
1,58
6
65
1,53
61,
753
2,04
71,
874
1,44
165
1,69
01,
928
2,25
32,
063
1,58
6
66
1,58
11,
813
2,12
01,
943
1,49
666
1,74
01,
995
2,33
22,
137
1,64
6
67
1,62
61,
871
2,19
22,
010
1,54
967
1,78
82,
059
2,41
12,
211
1,70
4
68
1,67
01,
929
2,26
32,
077
1,60
168
1,83
72,
123
2,48
92,
285
1,76
1
69
1,71
31,
988
2,33
32,
142
1,65
369
1,88
42,
188
2,56
62,
356
1,81
9
70
1,75
62,
045
2,40
22,
207
1,70
570
1,93
22,
250
2,64
22,
427
1,87
4
71
1,80
02,
101
2,47
12,
272
1,75
671
1,97
92,
311
2,71
82,
499
1,93
2
72
1,84
12,
157
2,53
92,
334
1,80
672
2,02
52,
373
2,79
32,
567
1,98
7
73
1,88
02,
215
2,61
32,
406
1,86
373
2,06
72,
437
2,87
42,
646
2,04
9
74
1,91
82,
275
2,68
62,
475
1,92
074
2,11
12,
503
2,95
52,
723
2,11
2
75
1,95
42,
330
2,75
72,
542
1,97
375
2,14
92,
563
3,03
22,
796
2,17
0
76
1,99
02,
386
2,82
82,
609
2,02
876
2,19
02,
625
3,11
12,
871
2,23
2
77
2,02
72,
443
2,89
92,
677
2,08
377
2,23
12,
687
3,18
92,
946
2,29
2
78
2,04
42,
486
2,95
72,
737
2,13
378
2,24
82,
735
3,25
33,
011
2,34
6
79
2,06
02,
529
3,01
62,
794
2,18
179
2,26
72,
782
3,31
93,
073
2,39
9
80
2,07
02,
564
3,06
72,
845
2,22
480
2,27
72,
820
3,37
43,
130
2,44
8
81
2,08
62,
606
3,12
42,
901
2,27
381
2,29
52,
868
3,43
63,
191
2,50
0
82
2,10
22,
648
3,18
12,
958
2,32
182
2,31
22,
913
3,49
93,
254
2,55
3
83
2,11
82,
685
3,23
73,
015
2,37
283
2,33
02,
954
3,56
13,
318
2,60
8
84
2,13
42,
721
3,29
13,
072
2,42
284
2,34
72,
993
3,62
03,
380
2,66
4
85
2,15
12,
759
3,34
73,
130
2,47
385
2,36
53,
035
3,68
23,
442
2,72
0
86
2,16
62,
796
3,40
53,
189
2,52
686
2,38
43,
076
3,74
63,
509
2,77
9
87
2,18
22,
835
3,46
33,
249
2,57
887
2,40
13,
117
3,80
93,
575
2,83
6
88
2,20
02,
873
3,52
23,
310
2,63
288
2,42
13,
160
3,87
43,
641
2,89
6
89
2,21
72,
912
3,58
23,
374
2,68
889
2,43
83,
203
3,94
03,
710
2,95
8
90
+2,
233
2,95
13,
642
3,43
82,
746
90+
2,45
63,
246
4,00
63,
782
3,02
1
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.50
00Q
uar
terl
y:0.
2500
Mo
nth
ly:
0.08
33
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d u
se P
refe
rre
d r
ate
s.
Ma
le R
ate
s
Firs
t H
eal
th L
ife
& H
eal
th In
sura
nce
Co
mp
any
An
nu
al
Att
ain
ed
Ag
e P
rem
ium
s
For
Use
in
ZIP
Co
de
s:
15
0-1
54
, 1
56
FH
LMS0
2089
PA
01
0120
16
4
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n G
Pla
n N
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n G
Pla
n N
U
nd
er
651,
535
1,75
82,
063
1,89
21,
463
Un
de
r 65
1,69
01,
933
2,26
92,
082
1,60
9
65
1,53
51,
758
2,06
31,
892
1,46
365
1,69
01,
933
2,26
92,
082
1,60
9
66
1,58
01,
818
2,13
61,
962
1,51
866
1,73
81,
999
2,35
02,
158
1,66
9
67
1,62
51,
878
2,20
82,
030
1,57
267
1,78
72,
065
2,43
02,
233
1,73
0
68
1,66
91,
936
2,28
12,
098
1,62
668
1,83
62,
129
2,50
82,
308
1,78
8
69
1,71
21,
993
2,35
12,
164
1,67
869
1,88
42,
192
2,58
62,
380
1,84
6
70
1,75
62,
051
2,42
02,
228
1,73
070
1,93
12,
255
2,66
32,
452
1,90
3
71
1,79
92,
107
2,48
92,
293
1,78
171
1,97
82,
318
2,73
82,
522
1,95
8
72
1,84
12,
164
2,55
82,
358
1,83
272
2,02
62,
380
2,81
42,
593
2,01
6
73
1,87
92,
222
2,63
32,
430
1,89
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2,89
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74
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22,
336
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81
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2,30
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3,20
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2,35
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83
2,11
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3,26
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2,40
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2,32
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3,58
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3,83
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2,72
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Use
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18
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FH
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01
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045
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104
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250
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1,63
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177
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02,
246
2,63
02,
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9
68
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83
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If a
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aran
tee
d Is
sue
Pe
rio
d u
se P
refe
rre
d r
ate
s.
Firs
t H
eal
th L
ife
& H
eal
th In
sura
nce
Co
mp
any
An
nu
al
Att
ain
ed
Ag
e P
rem
ium
s
For
Use
in
ZIP
Co
de
s:
Re
st o
f St
ate
Ma
le R
ate
s
FHLM
S020
89PA
8
0
1012
016
PREM
IUM
INFO
RM
ATIO
N
Firs
t H
ealth
Life
& H
ealth
Ins
uran
ce C
ompa
ny c
an o
nly
rais
e yo
ur p
rem
ium
if w
e ra
ise
the
prem
ium
for
all p
olic
ies
like
your
s in
this
sta
te. P
rem
ium
s fo
r thi
s po
licy
will
incr
ease
ann
ually
due
to
the
incr
ease
in y
our a
ge. U
pon
atta
inm
ent o
f an
age
requ
iring
a
rate
incr
ease
, th
e re
new
al p
rem
ium
for
the
polic
y w
ill be
the
re
new
al p
rem
ium
the
n in
effe
ct f
or y
our
atta
ined
age
. O
ther
po
licie
s m
ay b
e pr
ovid
ed w
ith I
ssue
Age
rat
ing
and
do n
ot
incr
ease
with
age
. You
sho
uld
com
pare
Issu
e A
ge w
ith A
ttain
ed
Age
pol
icie
s.
Pre
miu
ms
paya
ble
othe
r th
an
annu
ally
w
ill be
de
term
ined
ac
cord
ing
to th
e fo
llow
ing
fact
ors:
S
emi-a
nnua
l: 0.
5000
Qua
rterly
: 0.2
500
Mon
thly
EFT
: 0.0
833.
DIS
CLO
SUR
ES
Use
thi
s ou
tline
to
com
pare
ben
efits
and
pre
miu
m a
mon
g po
licie
s.
REA
D Y
OU
R P
OLI
CY
VER
Y C
AREF
ULL
Y
Th
is i
s o
nly
an
ou
tlin
e d
escrib
ing y
ou
r p
olic
y’s
mo
st
imp
ort
an
t fe
atur
es.
The
polic
y is
you
r in
sura
nce
cont
ract
. You
mus
t rea
d th
e po
licy
itsel
f to
unde
rsta
nd a
ll of
the
right
s an
d du
ties
of b
oth
you
and
your
insu
ranc
e co
mpa
ny.
RIG
HT
TO R
ETU
RN
PO
LIC
Y
If yo
u fin
d th
at y
ou a
re n
ot s
atis
fied
with
you
r po
licy,
you
may
re
turn
it to
Firs
t Hea
lth L
ife &
Hea
lth In
sura
nce
Com
pany
, P.O
. B
ox 1
188,
Bre
ntw
ood,
Ten
ness
ee 3
7024
. If y
ou s
end
the
polic
y ba
ck t
o us
with
in 3
0 da
ys a
fter
you
rece
ive
it, w
e w
ill tre
at th
e po
licy
as
if it
had
neve
r be
en i
ssue
d an
d re
turn
all
your
pa
ymen
ts.
PO
LIC
Y R
EPLA
CEM
ENT
If yo
u ar
e re
plac
ing
anot
her
heal
th i
nsur
ance
pol
icy,
do
NO
T ca
ncel
it u
ntil
you
have
act
ually
rec
eive
d yo
ur n
ew p
olic
y an
d ar
e su
re y
ou w
ant t
o ke
ep it
. NO
TIC
E
The
polic
y m
ay n
ot c
over
all
of y
our m
edic
al c
osts
.
Nei
ther
Firs
t H
ealth
Life
& H
ealth
Ins
uran
ce C
ompa
ny n
or i
ts
agen
ts a
re c
onne
cted
with
Med
icar
e.
This
ou
tline
of
co
vera
ge
does
no
t gi
ve
all
the
deta
ils
of
Med
icar
e co
vera
ge. C
onta
ct y
our l
ocal
Soc
ial S
ecur
ity O
ffice
or
cons
ult M
ed
icare
& Y
ou
for m
ore
deta
ils.
CO
MPL
ETE
ANSW
ERS
ARE
VER
Y IM
POR
TAN
T
Whe
n yo
u fil
l out
the
appl
icat
ion
for
the
new
pol
icy,
be
sure
to
answ
er
truth
fully
an
d co
mpl
etel
y an
y qu
estio
ns a
bout
you
r m
edic
al a
nd h
ealth
his
tory
. Th
e co
mpa
ny m
ay c
ance
l yo
ur
polic
y an
d re
fuse
to
pay
any
clai
ms
if yo
u le
ave
out
or f
alsi
fy
impo
rtant
med
ical
info
rmat
ion.
Rev
iew
the
app
licat
ion
care
fully
bef
ore
you
sign
it.
Be
certa
in
that
all
info
rmat
ion
has
been
pro
perly
reco
rded
.
THE
FOLL
OW
ING
CH
ARTS
DES
CR
IBE
PLAN
S A,
B,
F, G
an
d N
O
FFER
ED
BY
FIR
ST
HEA
LTH
LI
FE
&
HEA
LTH
IN
SUR
ANC
E C
OM
PAN
Y.
FHLMS02089PA 9 01012016
PLAN A MEDICARE (PART A) – HOSPITAL SERVICES – PER CALENDAR YEAR
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1,288 $0 $1,288 (Part A Deductible)
61st thru 90th day All but $322 a day $322 a day $0 91st day and after While using 60 lifetime reserve days All but $644 a day $644 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts $0 $0 21st thru 100th day All but $161 a day $0 Up to $161 a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
FHLMS02089PA 01012016 10
PLAN A MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $166 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $166 of Medicare-Approved amounts*
$0 $0 $166 (Part B Deductible)
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $166 of Medicare-Approved amounts*
$0 $0 $166 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
PARTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment
First $166 of Medicare Approved amounts*
$0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
FHLMS02089PA 01012016 11
PLAN B MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1,288 $1,288 (Part A Deductible)
$0
61st thru 90th day All but $322 a day $322 a day $0 91st day and after While using 60 lifetime reserve days All but $644 a day $644 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $161 a day $0 Up to $161 a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
FHLMS02089PA 01012016 12
PLAN B MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
* Once you have been billed $166 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $166 of Medicare-Approved amounts*
$0 $0 $166 (Part B Deductible)
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $166 of Medicare-Approved amounts*
$0 $0 $166 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES –
TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
PARTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment First $166 of Medicare Approved amounts*
$0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
FHLMS02089PA 01012016 13
PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1,288 $1,288 (Part A Deductible)
$0
61st thru 90th day All but $322 a day $322 a day $0 91st day and after While using 60 lifetime reserve days All but $644 a day $644 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $161 a day Up to $161 a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
FHLMS02089PA 01012016 14
PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $166 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $166 of Medicare-Approved amounts*
$0 $166 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $166 of Medicare-Approved amounts*
$0 $166 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
PARTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment First $166 of Medicare Approved amounts*
$0 $166 (Part B Deductible)
$0
Remainder of Medicare Approved amounts 80% 20% $0
FHLMS02089PA 01012016 15
PLAN F
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime
maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
FHLMS02089PA 01012016 16
PLAN G
MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1,288 $1,288 (Part A Deductible)
$0
61st thru 90th day All but $322 a day $322 a day $0 91st day and after While using 60 lifetime reserve days All but $644 a day $644 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $161 a day Up to $161 a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness services
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
FHLMS02089PA 01012016 17
PLAN G
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR *Once you have been billed $166 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $166 of Medicare-Approved amounts*
$0 $0 $166 (Part B Deductible)
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $166 of Medicare-Approved amounts*
$0 $0 $166 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
PARTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $166 of Medicare Approved amounts*
$0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
FHLMS02089PA 01012016 18
PLAN G
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime
maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
FHLMS02089PA 01012016 19
PLAN N MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1,288 $1,288 (Part A Deductible)
$0
61st thru 90th day All but $322 a day $322 a day $0 91st day and after While using 60 lifetime reserve days All but $644 a day $644 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $161 a day Up to $161 a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness services
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare co-payment/ coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
FHLMS02089PA 01012016 20
PLAN N
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR *Once you have been billed $166 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $166 of Medicare-Approved amounts*
$0 $0 $166 (Part B Deductible)
Remainder of Medicare-Approved amounts
Generally 80%
Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
Part B Excess Charges (Above Medicare-Approved amounts) $0 0% All costs BLOOD First 3 pints $0 All costs $0 Next $166 of Medicare-Approved amounts*
$0 $0 $166 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
FHLMS02089PA 01012016 21
PLAN N
PARTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $166 of Medicare Approved amounts*
$0 $0 $166 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum