Medicare Supplement InsuranceOutline of coverage Medicare Supplement Insurance...

Outline of coverageMedicare Supplement Insurance

aetnaseniorproducts.com

Rates effective:

Underwritten by

American Continental Insurance Company

An Aetna Company

Benefit plans A, B, F, High Deductible F, G and N

New Mexico

ACIMS05030NM ©2019 Aetna Inc. 10/2019 A

ACIMS05030NM 10/2019 A 1

AMERICAN CONTINENTAL INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE: BENEFIT PLANS AVAILABLE: A, B, F, High Deductible F, G and N

This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan "A" available. Some plans may not be available. Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F. Note: A means 100% of the benefit is paid.

Benefits Plans Available to All Applicants

Medicare first eligible before 2020 only

A B D G1 K L M N C F1

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)

Medicare Part B coinsurance or copayment 50% 75%

copays apply3

Blood (first three pints) 50% 75% Part A hospice care coinsurance or copayment 50% 75%

Skilled nursing facility coinsurance 50% 75% Medicare Part A deductible 50% 75% 50% Medicare Part B deductible Medicare Part B excess charges Foreign travel emergency (up to plan limits)

Out-of-pocket limit in 20192 $5,5602 $2,7802

1 Plans F and G also have a high deductible option, which require first paying a plan deductible of$2,300 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible. 2 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet theout-of-pocket yearly limit. 3 Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some officevisits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission.

ACIMS05030NM 10/2019 A 2

Attained Preferred Attained Standard

Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N65 1,507 1,899 2,247 867 1,322 1,036 65 1,676 2,112 2,497 964 1,469 1,151

66 1,507 1,899 2,247 867 1,322 1,036 66 1,676 2,112 2,497 964 1,469 1,151 67 1,507 1,899 2,247 867 1,322 1,036 67 1,676 2,112 2,497 964 1,469 1,151 68 1,572 1,979 2,340 903 1,378 1,079 68 1,744 2,198 2,598 1,004 1,530 1,201 69 1,641 2,068 2,430 940 1,438 1,128 69 1,823 2,297 2,704 1,044 1,600 1,254 70 1,705 2,153 2,520 975 1,495 1,173 70 1,895 2,388 2,800 1,080 1,663 1,303 71 1,772 2,231 2,608 1,006 1,552 1,217 71 1,967 2,481 2,898 1,118 1,726 1,352 72 1,834 2,310 2,689 1,039 1,606 1,261 72 2,037 2,567 2,989 1,153 1,786 1,400 73 1,891 2,384 2,762 1,068 1,658 1,300 73 2,099 2,647 3,069 1,187 1,842 1,444 74 1,948 2,451 2,833 1,094 1,704 1,337 74 2,162 2,724 3,149 1,218 1,896 1,487 75 1,994 2,513 2,898 1,118 1,748 1,372 75 2,216 2,794 3,221 1,244 1,943 1,524 76 2,042 2,571 2,955 1,143 1,789 1,403 76 2,266 2,858 3,281 1,267 1,988 1,559 77 2,084 2,624 3,007 1,162 1,828 1,435 77 2,316 2,918 3,338 1,291 2,030 1,593 78 2,123 2,676 3,051 1,181 1,864 1,462 78 2,360 2,974 3,392 1,310 2,071 1,623 79 2,162 2,724 3,095 1,196 1,896 1,486 79 2,404 3,028 3,437 1,327 2,105 1,650 80 2,196 2,768 3,133 1,211 1,927 1,511 80 2,442 3,074 3,483 1,344 2,139 1,678 81 2,228 2,805 3,174 1,226 1,954 1,531 81 2,475 3,120 3,525 1,362 2,170 1,702 82 2,255 2,845 3,215 1,242 1,978 1,552 82 2,509 3,161 3,571 1,380 2,198 1,725 83 2,288 2,883 3,252 1,258 2,005 1,572 83 2,541 3,201 3,614 1,396 2,228 1,747 84 2,316 2,917 3,290 1,272 2,030 1,593 84 2,573 3,241 3,658 1,414 2,256 1,768 85 2,343 2,953 3,328 1,287 2,053 1,610 85 2,601 3,278 3,697 1,429 2,282 1,789 86 2,369 2,983 3,360 1,299 2,077 1,627 86 2,632 3,317 3,734 1,442 2,309 1,811 87 2,393 3,015 3,395 1,312 2,100 1,645 87 2,658 3,351 3,772 1,456 2,332 1,829 88 2,417 3,047 3,427 1,325 2,120 1,663 88 2,688 3,385 3,808 1,471 2,356 1,847 89 2,442 3,074 3,453 1,334 2,139 1,678 89 2,711 3,416 3,841 1,483 2,377 1,864

90 2,461 3,100 3,485 1,345 2,158 1,694 90 2,739 3,449 3,872 1,494 2,399 1,881 91 2,482 3,130 3,512 1,357 2,176 1,706 91 2,759 3,474 3,900 1,507 2,420 1,894 92 2,499 3,153 3,535 1,365 2,193 1,719 92 2,781 3,501 3,928 1,520 2,437 1,911 93 2,517 3,174 3,557 1,377 2,209 1,732 93 2,798 3,527 3,951 1,527 2,454 1,923 94 2,536 3,194 3,576 1,380 2,224 1,742 94 2,818 3,550 3,974 1,535 2,470 1,937 95 2,550 3,211 3,594 1,389 2,237 1,754 95 2,834 3,573 3,993 1,543 2,483 1,949 96 2,567 3,231 3,613 1,396 2,249 1,764 96 2,849 3,591 4,015 1,549 2,498 1,959 97 2,580 3,249 3,632 1,403 2,262 1,773 97 2,868 3,613 4,036 1,560 2,513 1,969 98 2,594 3,270 3,651 1,412 2,275 1,784 98 2,884 3,632 4,057 1,566 2,528 1,982

99 2,612 3,290 3,667 1,416 2,289 1,795 99 2,901 3,657 4,076 1,575 2,544 1,995 Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833

The above rates do not include the $20 application fee.

If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates.

Rates Effective 10/01/2019

For Use in ZIP Codes: 870-872

American Continental Insurance CompanyAnnual Attained Age Premiums

Female Rates

ACIMS05030NM 10/2019 A 3


Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N 65 1,734 2,184 2,585 1,000 1,520 1,192 65 1,926 2,425 2,869 1,109 1,689 1,325 66 1,734 2,184 2,585 1,000 1,520 1,192 66 1,926 2,425 2,869 1,109 1,689 1,325 67 1,734 2,184 2,585 1,000 1,520 1,192 67 1,926 2,425 2,869 1,109 1,689 1,325 68 1,806 2,278 2,689 1,039 1,583 1,242 68 2,005 2,528 2,990 1,153 1,759 1,379 69 1,887 2,380 2,797 1,080 1,655 1,299 69 2,095 2,642 3,106 1,201 1,839 1,442 70 1,964 2,473 2,899 1,119 1,721 1,349 70 2,182 2,747 3,221 1,244 1,913 1,500 71 2,039 2,567 2,999 1,162 1,786 1,400 71 2,265 2,851 3,334 1,288 1,986 1,556 72 2,109 2,656 3,095 1,196 1,848 1,449 72 2,343 2,953 3,437 1,327 2,052 1,610 73 2,175 2,741 3,176 1,226 1,906 1,495 73 2,417 3,045 3,528 1,364 2,119 1,661 74 2,236 2,819 3,259 1,262 1,962 1,538 74 2,485 3,132 3,621 1,400 2,178 1,709 75 2,294 2,888 3,334 1,288 2,012 1,577 75 2,547 3,210 3,702 1,432 2,233 1,753 76 2,346 2,957 3,395 1,312 2,058 1,612 76 2,607 3,283 3,774 1,458 2,286 1,793 77 2,395 3,018 3,453 1,334 2,101 1,648 77 2,662 3,358 3,841 1,483 2,335 1,830 78 2,443 3,080 3,511 1,357 2,140 1,681 78 2,713 3,420 3,898 1,506 2,379 1,866 79 2,485 3,132 3,559 1,377 2,178 1,709 79 2,761 3,483 3,953 1,527 2,421 1,898 80 2,528 3,183 3,602 1,393 2,213 1,737 80 2,805 3,535 4,003 1,546 2,460 1,929 81 2,561 3,228 3,651 1,412 2,247 1,761 81 2,846 3,588 4,057 1,566 2,497 1,957 82 2,598 3,271 3,697 1,429 2,276 1,785 82 2,885 3,634 4,108 1,589 2,530 1,983 83 2,632 3,316 3,741 1,446 2,306 1,806 83 2,924 3,682 4,160 1,607 2,562 2,009 84 2,661 3,352 3,785 1,463 2,335 1,830 84 2,958 3,725 4,205 1,625 2,594 2,034 85 2,694 3,392 3,828 1,477 2,361 1,853 85 2,993 3,772 4,253 1,643 2,624 2,057 86 2,724 3,431 3,865 1,493 2,387 1,872 86 3,028 3,815 4,294 1,661 2,654 2,080 87 2,750 3,470 3,904 1,508 2,413 1,891 87 3,058 3,853 4,336 1,676 2,683 2,102 88 2,782 3,502 3,940 1,522 2,438 1,912 88 3,088 3,891 4,379 1,691 2,709 2,124 89 2,805 3,537 3,976 1,535 2,460 1,930 89 3,120 3,928 4,418 1,705 2,733 2,144

90 2,833 3,566 4,005 1,546 2,482 1,947 90 3,144 3,964 4,453 1,720 2,759 2,163 91 2,855 3,595 4,037 1,560 2,502 1,963 91 3,173 3,997 4,487 1,734 2,782 2,182 92 2,875 3,624 4,062 1,571 2,522 1,977 92 3,199 4,025 4,515 1,742 2,802 2,198 93 2,899 3,652 4,091 1,579 2,538 1,991 93 3,221 4,054 4,544 1,756 2,821 2,213 94 2,913 3,674 4,113 1,590 2,556 2,004 94 3,240 4,081 4,567 1,765 2,841 2,227 95 2,931 3,695 4,133 1,597 2,571 2,017 95 3,259 4,108 4,589 1,773 2,857 2,239 96 2,948 3,716 4,153 1,604 2,585 2,027 96 3,278 4,130 4,617 1,783 2,873 2,252 97 2,967 3,736 4,174 1,613 2,601 2,040 97 3,297 4,154 4,639 1,793 2,891 2,266 98 2,983 3,760 4,198 1,623 2,616 2,052 98 3,317 4,178 4,662 1,801 2,907 2,280





American Continental Insurance CompanyAnnual Attained Age PremiumsFor Use in ZIP Codes: 870-872

Male Rates

ACIMS05030NM 10/2019 A 4


Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N65 1,269 1,599 1,892 730 1,114 873 65 1,411 1,778 2,102 812 1,237 970

66 1,269 1,599 1,892 730 1,114 873 66 1,411 1,778 2,102 812 1,237 970 67 1,269 1,599 1,892 730 1,114 873 67 1,411 1,778 2,102 812 1,237 970 68 1,324 1,666 1,970 760 1,160 909 68 1,469 1,851 2,188 846 1,288 1,011 69 1,382 1,742 2,046 791 1,211 950 69 1,535 1,934 2,277 879 1,347 1,056 70 1,436 1,813 2,122 821 1,259 988 70 1,596 2,011 2,358 910 1,401 1,098 71 1,492 1,878 2,196 847 1,307 1,025 71 1,657 2,090 2,441 942 1,454 1,138 72 1,544 1,946 2,265 875 1,353 1,062 72 1,715 2,162 2,517 971 1,504 1,179 73 1,592 2,007 2,326 899 1,396 1,094 73 1,767 2,229 2,585 999 1,551 1,216 74 1,640 2,064 2,386 922 1,435 1,126 74 1,821 2,294 2,652 1,026 1,597 1,252 75 1,679 2,116 2,441 942 1,472 1,155 75 1,866 2,353 2,712 1,047 1,636 1,283 76 1,719 2,165 2,489 962 1,506 1,182 76 1,908 2,406 2,763 1,067 1,674 1,313 77 1,755 2,210 2,532 978 1,539 1,208 77 1,950 2,458 2,811 1,087 1,710 1,342 78 1,788 2,254 2,570 994 1,570 1,231 78 1,987 2,504 2,856 1,103 1,744 1,366 79 1,821 2,294 2,606 1,007 1,597 1,251 79 2,024 2,550 2,894 1,118 1,773 1,390 80 1,850 2,331 2,638 1,020 1,622 1,272 80 2,056 2,589 2,933 1,132 1,802 1,413 81 1,876 2,362 2,673 1,033 1,646 1,290 81 2,084 2,627 2,968 1,147 1,827 1,434 82 1,899 2,396 2,707 1,046 1,666 1,307 82 2,113 2,662 3,007 1,162 1,851 1,453 83 1,926 2,428 2,738 1,059 1,688 1,324 83 2,140 2,695 3,043 1,175 1,876 1,471 84 1,950 2,457 2,770 1,071 1,710 1,342 84 2,166 2,730 3,080 1,190 1,900 1,489 85 1,973 2,486 2,802 1,084 1,729 1,356 85 2,190 2,761 3,114 1,203 1,922 1,506 86 1,995 2,512 2,830 1,094 1,749 1,370 86 2,217 2,794 3,145 1,214 1,944 1,525 87 2,015 2,539 2,859 1,105 1,768 1,386 87 2,238 2,822 3,176 1,226 1,964 1,540 88 2,035 2,566 2,886 1,116 1,786 1,400 88 2,263 2,850 3,206 1,238 1,984 1,555 89 2,056 2,589 2,908 1,123 1,802 1,413 89 2,283 2,877 3,234 1,249 2,002 1,570

90 2,072 2,610 2,934 1,133 1,818 1,426 90 2,306 2,904 3,261 1,258 2,020 1,584 91 2,090 2,636 2,958 1,142 1,833 1,437 91 2,323 2,926 3,284 1,269 2,038 1,595 92 2,105 2,655 2,977 1,150 1,846 1,447 92 2,342 2,948 3,308 1,280 2,052 1,610 93 2,119 2,673 2,995 1,159 1,860 1,458 93 2,356 2,970 3,327 1,286 2,066 1,619 94 2,135 2,690 3,011 1,162 1,873 1,467 94 2,373 2,990 3,346 1,293 2,080 1,631 95 2,147 2,704 3,026 1,170 1,884 1,477 95 2,386 3,009 3,362 1,299 2,091 1,642 96 2,162 2,721 3,042 1,175 1,894 1,486 96 2,399 3,024 3,381 1,304 2,103 1,650 97 2,173 2,736 3,058 1,182 1,905 1,493 97 2,415 3,042 3,398 1,314 2,116 1,658 98 2,184 2,754 3,074 1,189 1,916 1,502 98 2,429 3,058 3,416 1,318 2,129 1,669





Female Rates


For Use in ZIP Codes: Rest of State

ACIMS05030NM 10/2019 A 5


Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N 65 1,460 1,839 2,177 842 1,280 1,004 65 1,622 2,042 2,416 934 1,422 1,116 66 1,460 1,839 2,177 842 1,280 1,004 66 1,622 2,042 2,416 934 1,422 1,116 67 1,460 1,839 2,177 842 1,280 1,004 67 1,622 2,042 2,416 934 1,422 1,116 68 1,521 1,918 2,265 875 1,333 1,046 68 1,689 2,129 2,518 971 1,482 1,162 69 1,589 2,004 2,355 910 1,394 1,094 69 1,764 2,225 2,615 1,011 1,549 1,214 70 1,654 2,082 2,442 942 1,450 1,136 70 1,838 2,314 2,712 1,047 1,611 1,263 71 1,717 2,162 2,526 978 1,504 1,179 71 1,907 2,401 2,807 1,085 1,672 1,310 72 1,776 2,237 2,606 1,007 1,556 1,220 72 1,973 2,486 2,894 1,118 1,728 1,356 73 1,831 2,308 2,674 1,033 1,605 1,259 73 2,035 2,564 2,971 1,149 1,784 1,398 74 1,883 2,374 2,745 1,062 1,652 1,295 74 2,093 2,638 3,050 1,179 1,834 1,439 75 1,932 2,432 2,807 1,085 1,694 1,328 75 2,145 2,703 3,118 1,206 1,881 1,476 76 1,975 2,490 2,859 1,105 1,733 1,358 76 2,195 2,765 3,178 1,228 1,925 1,510 77 2,017 2,542 2,908 1,123 1,770 1,388 77 2,242 2,828 3,234 1,249 1,966 1,541 78 2,058 2,594 2,957 1,142 1,802 1,415 78 2,285 2,880 3,282 1,268 2,003 1,571 79 2,093 2,638 2,997 1,159 1,834 1,439 79 2,325 2,933 3,329 1,286 2,038 1,598 80 2,129 2,680 3,034 1,173 1,863 1,462 80 2,362 2,977 3,371 1,302 2,071 1,625 81 2,157 2,718 3,074 1,189 1,892 1,483 81 2,397 3,022 3,416 1,318 2,102 1,648 82 2,188 2,754 3,114 1,203 1,917 1,503 82 2,430 3,060 3,459 1,338 2,130 1,670 83 2,216 2,792 3,150 1,218 1,942 1,521 83 2,462 3,101 3,503 1,354 2,158 1,692 84 2,241 2,822 3,187 1,232 1,966 1,541 84 2,491 3,137 3,541 1,369 2,184 1,713 85 2,269 2,856 3,223 1,244 1,988 1,560 85 2,521 3,177 3,582 1,383 2,210 1,732 86 2,294 2,890 3,254 1,258 2,010 1,577 86 2,550 3,213 3,616 1,398 2,235 1,751 87 2,316 2,922 3,287 1,270 2,032 1,593 87 2,575 3,245 3,651 1,411 2,259 1,770 88 2,342 2,949 3,318 1,282 2,053 1,610 88 2,600 3,277 3,687 1,424 2,282 1,789 89 2,362 2,978 3,348 1,293 2,071 1,626 89 2,627 3,308 3,720 1,436 2,302 1,806

90 2,386 3,003 3,373 1,302 2,090 1,639 90 2,647 3,338 3,750 1,448 2,323 1,822 91 2,404 3,027 3,399 1,314 2,107 1,653 91 2,672 3,366 3,778 1,460 2,342 1,838 92 2,421 3,052 3,421 1,323 2,124 1,665 92 2,694 3,390 3,802 1,467 2,359 1,851 93 2,442 3,075 3,445 1,330 2,138 1,677 93 2,713 3,414 3,826 1,478 2,375 1,863 94 2,453 3,094 3,463 1,339 2,153 1,687 94 2,729 3,437 3,846 1,486 2,392 1,875 95 2,468 3,111 3,481 1,345 2,165 1,698 95 2,745 3,459 3,865 1,493 2,406 1,886 96 2,482 3,130 3,498 1,350 2,177 1,707 96 2,760 3,478 3,888 1,502 2,419 1,897 97 2,498 3,146 3,515 1,358 2,190 1,718 97 2,777 3,498 3,906 1,510 2,434 1,908 98 2,512 3,166 3,535 1,366 2,203 1,728 98 2,794 3,518 3,926 1,517 2,448 1,920





Male Rates


For Use in ZIP Codes: Rest of State

ACIMS05030NM 10/2019 A 6

PREMIUM INFORMATION

American Continental Insurance Company can only raise your premium if we raise the premium for all policies like yours in this state. Premiums for this policy will increase due to the increase in your age. Upon attainment of an age requiring a rate increase, the renewal premium for the policy will be the renewal premium then in effect for your attained age. Other policies may be provided with Issue Age rating and do not increase with age. You should compare Issue Age with Attained Age policies. Premiums payable other than annually will be determined according to the following factors: Semi-annual: 0.5200 Quarterly: 0.2650 Monthly EFT: 0.0833.

DISCLOSURES

Use this outline to compare benefits and premium among policies.

READ YOUR POLICY VERY CAREFULLY

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

RIGHT TO RETURN POLICY

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

POLICY REPLACEMENT

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

NOTICE

The policy may not cover all of your medical costs.

Neither American Continental Insurance Company nor its agents are connected with Medicare.

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

COMPLETE ANSWERS ARE VERY IMPORTANT

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

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

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

ACIMS05030NM 10/2019 A 7

PLAN A 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 $1364 $0 $1364 (Part A Deductible)

61st thru 90th day All but $341 a day $341 a day $0 91st day and after •While using 60 lifetime reserve days All but $682 a day $682 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 $170.50 a day $0 Up to $170.50 a

day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.

All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/ coinsurance

$0

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

ACIMS05030NM 10/2019 A 8

PLAN A MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

*Once you have been billed $185 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.


PLAN PAYS

YOU PAY

MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic test, durable medical equipment

First $185 of Medicare-Approved amounts*

$0 $0 $185 (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 $185 of Medicare-Approved amounts*


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

PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES

•Medically necessary skilled care services and medical supplies

100% $0 $0

•Durable medical equipment

•First $185 of Medicare Approved amounts*


•Remainder of Medicare Approved amounts 80% 20% $0

ACIMS05030NM 10/2019 A 9

PLAN B MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.


PLAN PAYS

YOU PAY


First 60 days All but $1364 $1364 (Part A Deductible)

$0



$0**

•Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital

First 20 days All approved amounts

$0 $0

21st thru 100th day All but $170.50 a day

$0 Up to $170.50 a day

101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.



$0

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

ACIMS05030NM 10/2019 A 10

PLAN B MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

* Once you have been billed $185 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.


PLAN PAYS

YOU PAY




Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $185 of Medicare-Approved amounts*


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

TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

PARTS A & B


PLAN PAYS

YOU PAY



100% $0 $0

•Durable medical equipment •First $185 of Medicare Approved amounts*



ACIMS05030NM 10/2019 A 11

PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $170.50 a day

$0

101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.



$0


ACIMS05030NM 10/2019 A 12

PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR



PLAN PAYS

YOU PAY



$0 $185 (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 $185 of Medicare-Approved amounts*


$0


PARTS A & B


PLAN PAYS

YOU PAY



100% $0 $0



$0


ACIMS05030NM 10/2019 A 13

PLAN F OTHER BENEFITS – NOT COVERED BY MEDICARE


PLAN PAYS

YOU PAY

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

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

maximum benefit of $50,000

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

ACIMS05030NM 10/2019 A 14

HIGH DEDUCTIBLE PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. ***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2300 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2300. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2300

DEDUCTIBLE*** PLAN PAYS

IN ADDITION TO $2300

DEDUCTIBLE*** YOU PAY



$0



$0**




$0 $0


Up to $170.50 a day

$0

101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0

ACIMS05030NM 10/2019 A 15

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



$0


ACIMS05030NM 10/2019 A 16

HIGH DEDUCTIBLE PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

*Once you have been billed $185 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. ***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2300 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2300. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2300







$0



$0


ACIMS05030NM 10/2019 A 17

HIGH DEDUCTIBLE PLAN F

PARTS A & B

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2300






100% $0 $0



$0


OTHER BENEFITS – NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2300

DEDUCTIBLE** PLAN PAYS


DEDUCTIBLE** YOU PAY





ACIMS05030NM 10/2019 A 18

PLAN G MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $170.50 a day

$0

101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness services



$0


ACIMS05030NM 10/2019 A 19

PLAN G MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR



PLAN PAYS

YOU PAY







PARTS A & B


PLAN PAYS

YOU PAY


• Medically necessary skilled care services and medical supplies 100% $0 $0 •Durable medical equipment • First $185 of Medicare Approved amounts*



ACIMS05030NM 10/2019 A 20

PLAN G



PLAN PAYS

YOU PAY





ACIMS05030NM 10/2019 A 21

PLAN N MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $170.50 a day

$0

101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness services



$0


ACIMS05030NM 10/2019 A 22

PLAN N MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR



PLAN PAYS

YOU PAY




Remainder of Medicare-Approved amounts

Generally 80%

Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Part B Excess Charges (Above Medicare-Approved amounts) $0 0% All costs BLOOD First 3 pints $0 All costs $0 Next $185 of Medicare-Approved amounts*



ACIMS05030NM 10/2019 A 23

PLAN N

PARTS A & B


PLAN PAYS

YOU PAY


• Medically necessary skilled care services and medical supplies 100% $0 $0 •Durable medical equipment • First $185 of Medicare Approved amounts*





PLAN PAYS

YOU PAY


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

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


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