BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement...

22
Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent Centre Dr. Suite 200 Franklin, TN 37067 800 264.4000 aetnaseniorproducts.com An Aetna Company BENEFIT PLANS A, B, F, G, N PENNSYLVANIA FHLMS02089PA ©2016 Aetna Inc. 01012016

Transcript of BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement...

Page 1: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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

Page 2: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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

.

Page 3: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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

Page 4: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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

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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

Page 5: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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

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18

9-1

94

Page 6: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

FH

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s:

18

9-1

94

Page 7: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

FH

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Page 8: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

FH

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2089

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Page 9: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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Page 10: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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.

Page 11: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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

Page 12: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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.

Page 13: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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

Page 14: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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.

Page 15: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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

Page 16: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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

Page 17: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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.

Page 18: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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

Page 19: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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

Page 20: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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.

Page 21: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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

Page 22: BENEFIT PLANS A, B, F, G, N - documents.oneexchange.com · Outline of Coverage Medicare Supplement Insurance Underwritten by First Health Life & Health Insurance Company 800 Crescent

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