Outline of Coverage - Aetna...Outline of Coverage Insured by Aetna Health and Life Insurance Company...

American Automobile Association (AAA)

Medicare Supplement Insurance Office

800 Crescent Centre Dr. Suite 200

Franklin, TN 37067855 663.2201

aetnaseniorproducts.com

An Aetna Company

Outline of Coverage

Insured by

Aetna Health and Life Insurance Company

Medicare Supplement Insurance

AAA Medicare Supplement Plans

Rates Effective:

BENEFIT PLANS: A, B, C, F, G, & N

NEW JERSEY

AHLAA02728NJ ©2017 Aetna Inc. 02/2016 B

AHLA

A027

28N

J 02

/201

6 B

1

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

, C, 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 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.

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.

Hos

pice

-Par

t A c

oins

uran

ce

A B

C

D

F/

F*

G

K

L M

N

Ba

sic,

in

clud

ing

100%

Par

t B

coin

sura

nce

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 $5

120;

pa

id a

t 100

%

afte

r lim

it re

ache

d

Out

-of-p

ocke

t lim

it $2

560;

pa

id a

t 100

%

afte

r lim

it re

ache

d

*Pla

n F

also

has

an

optio

n ca

lled

a hi

gh d

educ

tible

pla

n F.

Thi

s hi

gh d

educ

tible

pla

n pa

ys th

e sa

me

bene

fits

as P

lan

F af

ter

one

has

paid

a c

alen

dar

year

$22

00 d

educ

tible

. B

enef

its fr

om h

igh

dedu

ctib

le p

lan

F w

ill n

ot b

egin

unt

il ou

t-of-p

ocke

t exp

ense

s ex

ceed

$22

00.

Out

-of-p

ocke

t exp

ense

s fo

r thi

s de

duct

ible

are

exp

ense

s th

at w

ould

ord

inar

ily b

e pa

id b

y th

e ce

rtific

ate.

Th

ese

exp

en

se

s in

clu

de

th

e M

ed

ica

re d

ed

uctib

les f

or

Pa

rt A

an

d P

art

B,

bu

t d

o n

ot

inclu

de

th

e p

lan

’s s

ep

ara

te f

ore

ign

tra

ve

l em

erge

ncy

dedu

ctib

le.

***D

educ

tible

am

ount

s an

d ou

t-of-p

ocke

t lim

its a

nnou

nced

ann

ually

by

CM

S

AHLA

A027

28N

J 02

/201

6 B

2

Att

ain

ed

Pre

ferr

ed

Att

ain

ed

Stan

dar

d

Age

Pla

n A

Pla

n B

Pla

n C

Pla

n F

Pla

n G

Pla

n N

Age

Pla

n A

Pla

n B

Pla

n C

Pla

n F

Pla

n G

Pla

n N

50-6

4-

-

1,

758

-

-

-

50-6

4-

-

1,

934

-

-

-

65

1,37

11,

573

1,75

81,

849

1,69

41,

310

651,

508

1,73

01,

934

2,03

41,

863

1,44

1

66

1,41

11,

627

1,82

01,

914

1,75

51,

359

661,

552

1,79

02,

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2,10

51,

931

1,49

5

67

1,45

11,

679

1,88

21,

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1,81

61,

407

671,

596

1,84

72,

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2,17

71,

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1,54

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1,49

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1,94

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043

1,87

61,

455

681,

640

1,90

52,

137

2,24

72,

064

1,60

1

69

1,53

01,

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2,00

32,

107

1,93

61,

503

691,

683

1,96

22,

203

2,31

82,

130

1,65

3

70

1,56

91,

835

2,06

22,

169

1,99

41,

549

701,

726

2,01

92,

268

2,38

62,

193

1,70

4

71

1,60

71,

885

2,12

12,

231

2,05

21,

595

711,

768

2,07

42,

333

2,45

42,

257

1,75

5

72

1,64

51,

936

2,18

02,

293

2,11

01,

641

721,

810

2,13

02,

398

2,52

22,

321

1,80

5

73

1,67

91,

988

2,24

42,

359

2,17

41,

693

731,

847

2,18

72,

468

2,59

52,

391

1,86

2

74

1,71

32,

041

2,30

72,

426

2,23

71,

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741,

884

2,24

52,

538

2,66

92,

461

1,92

0

75

1,74

52,

090

2,36

72,

488

2,29

71,

793

751,

920

2,29

92,

604

2,73

72,

527

1,97

2

76

1,77

82,

141

2,42

82,

553

2,35

81,

844

761,

956

2,35

52,

671

2,80

82,

594

2,02

8

77

1,81

12,

192

2,48

92,

617

2,42

01,

893

771,

992

2,41

12,

738

2,87

92,

662

2,08

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78

1,82

52,

230

2,54

02,

670

2,47

21,

938

782,

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2,45

32,

794

2,93

72,

719

2,13

2

79

1,84

02,

269

2,59

02,

723

2,52

51,

983

792,

024

2,49

62,

849

2,99

52,

778

2,18

1

80

1,84

92,

301

2,63

42,

769

2,57

02,

022

802,

034

2,53

12,

897

3,04

62,

827

2,22

4

81

1,86

32,

339

2,68

32,

821

2,62

22,

066

812,

049

2,57

32,

951

3,10

32,

884

2,27

3

82

1,87

72,

376

2,73

22,

872

2,67

32,

109

822,

065

2,61

43,

005

3,15

92,

940

2,32

0

83

1,89

22,

442

2,82

82,

972

2,77

62,

201

832,

081

2,68

63,

111

3,26

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054

2,42

1

84

1,90

62,

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2,92

33,

071

2,87

92,

292

842,

097

2,75

83,

215

3,37

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167

2,52

1

85

1,92

12,

555

2,99

93,

151

2,96

32,

369

852,

113

2,81

13,

299

3,46

63,

259

2,60

6

86

1,93

52,

604

3,07

63,

232

3,05

02,

448

862,

129

2,86

43,

384

3,55

53,

355

2,69

3

87

1,95

02,

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3,15

63,

315

3,13

92,

531

872,

145

2,91

83,

472

3,64

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453

2,78

4

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1,96

52,

704

3,23

83,

401

3,23

12,

616

882,

162

2,97

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3,74

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2,87

8

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1,98

02,

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3,32

23,

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3,32

62,

704

892,

178

3,03

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3,83

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2,97

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3,57

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423

2,79

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3,08

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Pla

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Age

Pla

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Pla

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50-6

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1,49

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AHLAA02728NJ 02/2016 B 4

PREMIUM INFORMATION

Aetna Health and Life Insurance Company can only raise your premium if we raise the premium for all certificates like yours in this state. Premiums for this certificate will increase due to the increase in your age. Upon attainment of an age requiring a rate increase, the renewal premium for the certificate will be the renewal premium then in effect for your attained age. Other certificates may be provided with Issue Age rating and do not increase with age. You should compare Issue Age with Attained Age certificates. Premiums payable other than annually will be determined according to the following factors: Semi-annual: 0.5000 Quarterly: 0.2500 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 a Aetna Health and Life Insurance Company Medicare supplement certificate. 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 certificate for each applicant is issued. The discounted rate will be 5 percent lower than the individual rates and will apply as long as both certificates remain in force.

DISCLOSURES

Use this outline to compare benefits and premium among policies.

READ YOUR CERTIFICATE VERY CAREFULLY

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

RIGHT TO RETURN CERTIFICATE

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

CERTIFICATE REPLACEMENT

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

NOTICE

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

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

THE FOLLOWING CHARTS DESCRIBE PLANS A, B, C, F, G and N OFFERED BY AETNA HEALTH AND LIFE INSURANCE COMPANY.

AHLAA02728NJ 02/2016 B 5

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 $1316 $0 $1316 (Part A Deductible)

61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 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 $164.50 a day $0 Up to $164.50 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 certificate’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.

***Deductible amounts announced annually by CMS

AHLAA02728NJ 02/2016 B 6

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

*Once you have been billed $183 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 tests, durable medical equipment

First $183 of Medicare-Approved amounts*

$0 $0 $183 (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 $183 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 $183 of Medicare Approved amounts*


Remainder of Medicare Approved amounts 80% 20% $0 ***Deductible amounts announced annually by CMS

AHLAA02728NJ 02/2016 B 7

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 $1316 $1316 (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 $164.50 a day

$0 Up to $164.50 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 certificate’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.


AHLAA02728NJ 02/2016 B 8

PLAN B

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR * Once you have been billed $183 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 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 $183 of Medicare Approved amounts*


Remainder of Medicare Approved amounts 80% 20% $0

AHLAA02728NJ 02/2016 B 9

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



PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $164.50 a day

$0




$0



AHLAA02728NJ 02/2016 B 10

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

*Once you have been billed $183 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



$0 $183 (Part B Deductible)

$0



$0


PARTS A & B


PLAN PAYS

YOU PAY



100% $0 $0



$0


AHLAA02728NJ 02/2016 B 11

PLAN C

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

AHLAA02728NJ 02/2016 B 12

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.


PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $164.50 a day

$0




$0



AHLAA02728NJ 02/2016 B 13

PLAN F

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR *Once you have been billed $183 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




$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 $183 of Medicare-Approved amounts*


$0


PARTS A & B


PLAN PAYS

YOU PAY



100% $0 $0



$0


AHLAA02728NJ 02/2016 B 14

PLAN F



PLAN PAYS

YOU PAY






AHLAA02728NJ 02/2016 B 15

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



PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $164.50 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



AHLAA02728NJ 02/2016 B 16

PLAN G



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



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 $183 of Medicare-Approved amounts*



PARTS A & B


PLAN PAYS

YOU PAY


Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $183 of Medicare Approved amounts*



AHLAA02728NJ 02/2016 B 17

PLAN G



PLAN PAYS

YOU PAY






AHLAA02728NJ 02/2016 B 18

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



PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $164.50 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


Medicare co-payment/ coinsurance

$0



AHLAA02728NJ 02/2016 B 19

PLAN N



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 $183 of Medicare-Approved amounts*


Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 *** Deductible amounts announced annually by CMS

AHLAA02728NJ 02/2016 B 20

PLAN N

PARTS A & B


PLAN PAYS

YOU PAY


Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $183 of Medicare Approved amounts*


Remainder of Medicare Approved amounts 80% 20% $0



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



Outline of Coverage - Aetna...Outline of Coverage Insured by Aetna Health and Life Insurance Company...

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