Outline of Coverage - Aetna · 2016-08-30 · Outline of Coverage Medicare Supplement Insurance...
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Outline of Coverage Medicare Supplement Insurance Underwritten by Aetna Health and Life Insurance Company Administrative Office 800 Crescent Centre Dr. Suite 200 Franklin, TN 37067 800 264.4000 aetnaseniorproducts.com Aetna Health and Life Insurance Company Rates Effective: BENEFIT PLANS A, B, F, HIGH DEDUCTIBLE F, G, N ILLINOIS AHLMS02763IL ©2016 Aetna Inc. 09/2016 A
Transcript of Outline of Coverage - Aetna · 2016-08-30 · Outline of Coverage Medicare Supplement Insurance...
Outline of CoverageMedicare Supplement Insurance
Underwritten by
Aetna Health and Life Insurance Company
Administrative Office800 Crescent Centre Dr.Suite 200Franklin, TN 37067800 264.4000aetnaseniorproducts.com
Aetna Health and Life Insurance Company
Rates Effective:
BENEFIT PLANS A, B, F, HIGH DEDUCTIBLE F, G, N
ILLINOIS
AHLMS02763IL ©2016 Aetna Inc. 09/2016 A
AHLM
S027
63IL
1
09
/201
6 A
AETN
A H
EALT
H A
ND
LIF
E 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
, D, F
, HIG
H D
EDU
CTI
BLE
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
ve
ry c
om
pa
ny m
ust
ma
ke
ava
ilable
Pla
n “
A”
Som
e pl
ans
may
not
be
avai
labl
e in
you
r sta
te.
Bas
ic B
enef
its:
Hos
pita
lizat
ion:
Par
t A c
oins
uran
ce p
lus
cove
rage
for 3
65 a
dditi
onal
day
s af
ter M
edic
are
bene
fits
end.
M
edic
al E
xpen
ses:
Par
t B c
oins
uran
ce (g
ener
ally
20%
of M
edic
are-
Appr
oved
exp
ense
s) o
r, co
-pay
men
ts fo
r hos
pita
l out
patie
nt s
ervi
ces.
Pl
ans
K, L
, and
N re
quire
insu
reds
to p
ay a
por
tion
of c
oins
uran
ce o
r cop
aym
ents
Bl
ood:
Firs
t thr
ee p
ints
of b
lood
eac
h ye
ar.
H
ospi
ce-P
art A
coi
nsur
ance
A
B
C
D
F/F*
G
K
L
M
N
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Hos
pita
lizat
ion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basi
c be
nefit
s pa
id a
t 50%
Hos
pita
lizat
ion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basi
c be
nefit
s pa
id a
t 75%
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c, in
clud
ing
100%
Par
t B
coin
sura
nce,
exc
ept
up to
$20
cop
aym
ent
for o
ffice
vis
it, a
nd
up to
$50
cop
aym
ent
for E
R
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
50%
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
75%
Ski
lled
Nur
sing
Fac
ility
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Pa
rt A
Ded
uctib
le
Part
A D
educ
tible
Pa
rt A
Ded
uctib
le
Part
A D
educ
tible
Pa
rt A
Ded
uctib
le
50%
Par
t A
Ded
uctib
le
75%
Par
t A
Ded
uctib
le
50%
Par
t A
Ded
uctib
le
Part
A D
educ
tible
Part
B D
educ
tible
Part
B D
educ
tible
Part
B Ex
cess
(1
00%
)
Part
B Ex
cess
(1
00%
)
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Out
-of-p
ocke
t lim
it $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 one
has
pai
d a
cale
ndar
yea
r $2
,180
ded
uctib
le.
Bene
fits
from
hig
h de
duct
ible
pla
n F
will
not
begi
n un
til o
ut-o
f-poc
ket
expe
nses
exc
eed
$2,1
80.
Out
-of-p
ocke
t ex
pens
es f
or t
his
dedu
ctib
le a
re e
xpen
ses
that
wou
ld o
rdin
arily
be
paid
by
the
polic
y. T
hese
exp
ense
s in
clud
e th
e M
edic
are
dedu
ctib
les
for
Part
A an
d Pa
rt B,
but
do
not
inclu
de the p
lan’s
separa
te f
ore
ign tra
vel em
erg
ency d
eductible
.
AHLM
S027
63IL
2
09
/201
6 A
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Sta
nd
ard
Ag
eP
lan
AP
lan
BP
lan
DP
lan
FH
igh
FP
lan
GP
lan
NA
ge
Pla
n A
Pla
n B
Pla
n D
Pla
n F
Hig
h F
Pla
n G
Pla
n N
U
nd
er
65
2,6
95
3,9
56
3,1
20
4,6
48
1,8
60
3,6
90
3,0
76
Un
de
r 6
52
,99
44
,39
63
,46
75
,16
52
,06
54
,09
93
,41
8
6
51
,47
71
,52
51
,37
21
,79
37
16
1,4
22
1,1
86
65
1,6
40
1,6
94
1,5
24
1,9
92
79
71
,58
01
,31
8
6
61
,50
71
,56
41
,38
41
,83
77
36
1,4
59
1,2
16
66
1,6
75
1,7
38
1,5
37
2,0
40
81
71
,62
01
,35
1
6
71
,53
81
,60
41
,40
81
,88
47
54
1,4
96
1,2
47
67
1,7
09
1,7
82
1,5
64
2,0
94
83
61
,66
21
,38
5
6
81
,57
01
,64
51
,43
41
,93
27
72
1,5
34
1,2
78
68
1,7
44
1,8
28
1,5
94
2,1
47
85
71
,70
41
,42
1
6
91
,60
21
,68
61
,46
31
,98
07
92
1,5
72
1,3
12
69
1,7
80
1,8
72
1,6
25
2,2
01
88
11
,74
61
,45
8
7
01
,63
41
,72
91
,49
32
,03
28
12
1,6
13
1,3
44
70
1,8
17
1,9
21
1,6
58
2,2
56
90
41
,79
31
,49
3
7
11
,66
81
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91
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72
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28
41
1,6
70
1,3
92
71
1,8
53
1,9
88
1,7
18
2,3
36
93
41
,85
61
,54
7
7
21
,70
01
,85
31
,60
22
,17
88
71
1,7
29
1,4
41
72
1,8
90
2,0
59
1,7
80
2,4
19
96
81
,92
11
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2
7
31
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61
,92
01
,66
12
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59
02
1,7
89
1,4
92
73
1,9
30
2,1
34
1,8
46
2,5
06
1,0
02
1,9
88
1,6
57
7
41
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21
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81
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02
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59
34
1,8
54
1,5
46
74
1,9
69
2,2
09
1,9
10
2,5
94
1,0
38
2,0
60
1,7
17
7
51
,80
82
,05
91
,78
22
,41
99
68
1,9
21
1,6
00
75
2,0
10
2,2
88
1,9
80
2,6
88
1,0
76
2,1
35
1,7
78
7
61
,84
62
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21
,84
72
,50
41
,00
21
,98
81
,65
77
62
,05
12
,36
92
,05
22
,78
31
,11
52
,20
91
,84
2
7
71
,88
42
,20
81
,91
42
,59
41
,03
82
,05
91
,71
77
72
,09
42
,45
42
,12
62
,88
41
,15
32
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81
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8
7
81
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42
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81
,98
22
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81
,07
52
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51
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87
82
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72
,54
32
,20
32
,98
71
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42
,37
11
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5
7
91
,96
42
,37
02
,05
42
,78
41
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52
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01
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37
92
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32
,63
32
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23
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41
,23
72
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62
,04
8
8
02
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62
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62
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92
,88
51
,15
32
,29
11
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98
02
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82
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02
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53
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51
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22
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52
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2
8
12
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72
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22
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52
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71
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42
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01
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68
12
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42
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42
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83
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91
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72
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32
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7
8
22
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72
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82
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03
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81
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52
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22
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28
22
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82
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12
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93
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11
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32
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32
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9
8
32
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42
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02
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73
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71
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82
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82
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68
32
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03
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42
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23
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21
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12
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02
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1
8
42
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92
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52
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33
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71
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22
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62
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98
42
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03
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82
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53
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41
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02
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72
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2
8
52
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92
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02
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03
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71
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22
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52
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58
52
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53
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22
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73
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61
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33
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52
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6
8
62
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62
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62
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43
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61
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32
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42
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28
62
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73
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72
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73
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61
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03
,09
42
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0
8
72
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43
,07
02
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83
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61
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22
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22
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78
72
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93
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02
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74
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71
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33
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02
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1
8
82
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33
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22
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03
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41
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22
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02
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28
82
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23
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22
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64
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61
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63
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62
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3
8
92
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03
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52
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33
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01
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03
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72
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58
92
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33
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52
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54
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31
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03
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32
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5
9
02
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53
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62
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63
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61
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93
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22
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99
02
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23
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52
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44
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81
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23
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62
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4
9
12
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23
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62
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83
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91
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63
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72
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19
12
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33
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43
,03
14
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21
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43
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02
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4
9
22
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73
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42
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94
,08
01
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23
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02
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09
22
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23
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93
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84
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41
,81
43
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03
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1
9
32
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03
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02
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04
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11
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83
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12
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09
32
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03
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43
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44
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41
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33
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93
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7
9
42
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43
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42
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04
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81
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33
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92
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89
42
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64
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73
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04
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01
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23
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53
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1
9
52
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63
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52
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04
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21
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63
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82
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49
52
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24
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63
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64
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41
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03
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03
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3
9
62
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83
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62
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04
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31
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93
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22
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79
62
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84
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33
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14
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41
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73
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23
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2
9
72
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83
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23
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84
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11
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13
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42
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09
72
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04
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83
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45
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22
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03
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03
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0
9
82
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83
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53
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44
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71
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03
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23
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99
82
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44
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73
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65
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62
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44
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63
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6
9
9+
2,6
95
3,9
56
3,1
20
4,6
48
1,8
60
3,6
90
3,0
76
99
+2
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44
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63
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75
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52
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54
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93
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8
Mo
da
l F
acto
rs:
Se
mi-
An
nu
al:
0.5
20
0Q
ua
rte
rly
:0
.26
50
Mo
nth
ly:
0.0
83
3
Th
e a
bo
ve
ra
tes d
o n
ot
inclu
de
th
e $
20
ap
pli
ca
tio
n f
ee
.
To
ca
lcu
late
a H
ou
se
ho
ld d
isco
un
t:
A
nn
ua
l p
rem
ium
x m
od
al
facto
r =
mo
da
l p
rem
ium
(ro
un
d t
o n
ea
rest
wh
ole
ce
nt)
M
od
al
pre
miu
m x
.9
3 =
dis
co
un
ted
pre
miu
m
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
ara
nte
ed
Issu
e P
eri
od
, u
se
Pre
ferr
ed
ra
tes.
Ra
tes E
ffe
cti
ve
9/1
/20
16
Fe
ma
le R
ate
s
Ae
tna
He
alt
h a
nd
Lif
e I
nsu
ran
ce
Co
mp
an
yA
nn
ua
l A
tta
ine
d A
ge
Pre
miu
ms
Fo
r U
se
in
ZIP
Co
de
s:
60
0-6
08
AHLM
S027
63IL
3
09
/201
6 A
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Sta
nd
ard
Ag
eP
lan
AP
lan
BP
lan
DP
lan
FH
igh
FP
lan
GP
lan
NA
ge
Pla
n A
Pla
n B
Pla
n D
Pla
n F
Hig
h F
Pla
n G
Pla
n N
U
nd
er
65
3,1
00
4,5
50
3,5
88
5,3
45
2,1
38
4,2
43
3,5
38
Un
de
r 6
53
,44
35
,05
43
,98
65
,93
92
,37
64
,71
43
,93
0
6
51
,69
81
,75
41
,57
72
,06
08
23
1,6
36
1,3
63
65
1,8
88
1,9
49
1,7
53
2,2
91
91
61
,81
71
,51
4
6
61
,73
41
,79
81
,59
12
,11
38
46
1,6
78
1,3
98
66
1,9
27
1,9
98
1,7
68
2,3
47
93
81
,86
41
,55
3
6
71
,76
81
,84
41
,61
92
,16
68
66
1,7
20
1,4
34
67
1,9
64
2,0
50
1,7
98
2,4
08
96
21
,91
21
,59
2
6
81
,80
51
,89
11
,64
92
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AHLMS02763IL 6 09/2016 A
PREMIUM INFORMATION
Aetna Health and Life 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.
HOUSEHOLD DISCOUNT
In order to be eligible for the Household discount under an Aetna Health and Life Insurance Company Medicare supplement plan, you must apply for a Medicare supplement plan at the same time as another Medicare eligible adult or the other Medicare eligible adult must currently be covered by an Aetna Health and Life Insurance Company Medicare supplement policy. The Medicare eligible adult must be either (a) your spouse; (b) be someone with whom you are in a civil union partnership; or (c) be a permanent resident in your home. The household discount will only be applicable if a policy for each applicant is issued. The discounted rate will be 7 percent lower than the individual rates and will apply as long as both policies remain in force.
DISCLOSURES
Use this outline to compare benefits and premium among policies.
READ YOUR POLICY VERY CAREFULLY
This is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.
RIGHT TO RETURN POLICY
If you find that you are not satisfied with your policy, you may return it to Aetna Health and Life Insurance Company, P.O. Box 14770, Lexington, Kentucky 40512-4770. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all your payments.
POLICY REPLACEMENT
If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
NOTICE
The policy may not cover all of your medical costs.
Neither Aetna Health and Life 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, D, F, HIGH DEDUCTIBLE F, G and N OFFERED BY AETNA HEALTH AND LIFE INSURANCE COMPANY.
AHLMS02763IL 7 09/2016 A
PLAN A
MEDICARE (PART A) – HOSPITAL SERVICES – PER CALENDAR YEAR *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $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.
AHLMS02763IL 09/2016 A 8
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
AHLMS02763IL 09/2016 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.
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.
AHLMS02763IL 09/2016 A 10
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
AHLMS02763IL 09/2016 A 11
PLAN D
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 61st thru 90th day 91st day and after •While using 60 lifetime reserve days •Once lifetime reserve days are used: •Additional 365 days •Beyond the Additional 365 days
All but $1,288 All but $322 a day
All but $644 a day
$0 $0
$1,288 (Part A Deductible) $322 a day
$644 a day
100% of Medicare Eligible Expenses $0
$0 $0
$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 21st thru 100th day 101st day and after
All approved amounts All but $161 a day $0
$0 Up to $161 a day $0
$0 $0 All costs
BLOOD First 3 pints Additional amounts
$0 100%
3 pints $0
$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.
AHLMS02763IL 09/2016 A 12
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 test, durable medical equipment First $166 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts
$0
Generally 80%
$0
Generally 20%
$166 (Part B deductible) $0
Part B Excess Charges (Above Medicare-Approved amounts)
$0
$0
All Costs BLOOD First 3 pints Next $166 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts
$0 $0
80%
All costs $0
20%
$0 $166 (Part B deductible) $0
CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES
100%
$0
$0
PA RTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies •Durable medical equipment •First $166 of Medicare Approved amounts* •Remainder of Medicare Approved amounts
100%
$0
80%
$0
$0
20%
$0
$166 (Part B deductible)
$0
AHLMS02763IL 09/2016 A 13
PLAN D 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 Remainder of charges
$0 $0
$0 80% to a lifetime maximum benefit of $50,000
$250 20% and amounts over the $50,000 lifetime maximum
AHLMS02763IL 09/2016 A 14
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.
AHLMS02763IL 09/2016 A 15
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 test, 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
AHLMS02763IL 09/2016 A 16
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
AHLMS02763IL 09/2016 A 17
High Deductible F
MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. ***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2,180. 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 $2,180
DEDUCTIBLE*** PLAN PAYS
IN ADDITION TO $2,180
DEDUCTIBLE*** 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
AHLMS02763IL 09/2016 A 18
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.
AHLMS02763IL 09/2016 A 19
HIGH DEDUCTIBLE 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. ***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2,180. 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 $2,180
DEDUCTIBLE*** PLAN PAYS
IN ADDITION TO $2,180
DEDUCTIBLE*** 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 $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
AHLMS02763IL 09/2016 A 20
HIGH DEDUCTIBLE PLAN F
PARTS A & B
SERVICES
MEDICARE
PAYS
AFTER YOU PAY $2,180
DEDUCTIBLE*** PLAN PAYS
IN ADDITION TO $2,180
DEDUCTIBLE*** 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
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES
MEDICARE
PAYS
AFTER YOU PAY $2,180
DEDUCTIBLE** PLAN PAYS
IN ADDITION TO $2,180
DEDUCTIBLE** 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
AHLMS02763IL 09/2016 A 21
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.
AHLMS02763IL 09/2016 A 22
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 test, 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
AHLMS02763IL 09/2016 A 23
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
AHLMS02763IL 09/2016 A 24
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.
AHLMS02763IL 09/2016 A 25
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 test, 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 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 $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
AHLMS02763IL 09/2016 A 26
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
