Outline of Coverage - smsteam · Outline of Coverage Medicare Supplement Insurance Underwritten by...

Outline of CoverageMedicare Supplement Insurance

Underwritten by

American Continental Insurance Company

800 Crescent Centre Dr. Suite 200

Franklin, TN 37067800 264.4000

aetnaseniorproducts.com

An Aetna Company

Rates Effective:

BENEFIT PLANS A, B, F, HIGH DEDUCTIBLE F, G, N

ALABAMA

ACIMS01063AL ©2017 Aetna Inc. 06/2017 A

ACIM

S010

63A

L

06/

2017

A

AMER

ICAN

CO

NTI

NEN

TAL

INSU

RAN

CE

CO

MPA

NY

OU

TLIN

E O

F M

EDIC

ARE

SUPP

LEM

ENT

CO

VER

AGE

CO

VER

PAG

E: P

age

1 of

2

BEN

EFIT

PLA

NS

AVAI

LAB

LE: A

, B, 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

very

co

mp

an

y m

ust m

ake

ava

ilable

Pla

n “

A”

Som

e pl

ans

may

not

be

avai

labl

e in

you

r sta

te.

See

Out

lines

of C

over

age

sect

ions

for d

etai

ls a

bout

ALL

pla

ns

Bas

ic B

enef

its:

Hos

pita

lizat

ion:

Par

t A c

oins

uran

ce p

lus

cove

rage

for 3

65 a

dditi

onal

day

s af

ter M

edic

are

bene

fits

end.

M

edic

al E

xpen

ses:

Par

t B c

oins

uran

ce (g

ener

ally

20%

of M

edic

are-

Appr

oved

exp

ense

s) o

r, co

paym

ents

for h

ospi

tal o

utpa

tient

ser

vice

s. P

lans

K,

L, a

nd N

requ

ire in

sure

ds to

pay

a p

ortio

n of

coi

nsur

ance

or c

opay

men

ts

Bloo

d: F

irst t

hree

pin

ts o

f blo

od e

ach

year

.

Hos

pice

: Par

t A c

oins

uran

ce

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

co

paym

ent f

or o

ffice

vi

sit,

and

up to

$50

co

paym

ent f

or 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 o

ne h

as p

aid

a ca

lend

ar y

ear $

2200

de

duct

ible

. Be

nefit

s fro

m h

igh

dedu

ctib

le p

lan

F w

ill no

t be

gin

until

out

-of-p

ocke

t ex

pens

es e

xcee

d $2

200.

O

ut-o

f-poc

ket

expe

nses

for

thi

s de

duct

ible

are

ex

pens

es th

at w

ould

ord

inar

ily b

e pa

id b

y th

e po

licy.

The

se e

xpen

ses

incl

ude

the

Med

icar

e de

duct

ible

s fo

r Pa

rt A

and

Part

B, b

ut

do n

ot

inclu

de t

he p

lan’s

se

para

te fo

reig

n tra

vel e

mer

genc

y de

duct

ible

.

ACIM

S010

63A

L 06

/201

7 A

2

Att

ain

ed

Pre

ferr

ed

Att

ain

ed

Stan

dar

d

Age

Pla

n A

Pla

n B

Pla

n F

Pla

n H

FP

lan

GP

lan

NA

geP

lan

AP

lan

BP

lan

FP

lan

HF

Pla

n G

Pla

n N

65

1,30

0

1,63

7

1,95

6

683

1,49

8

1,14

0

65

1,44

5

1,82

0

2,17

5

759

1,66

6

1,26

6

66

1,31

3

1,65

6

1,97

6

691

1,51

4

1,15

2

66

1,45

7

1,84

0

2,19

7

765

1,68

3

1,27

8

67

1,32

6

1,67

3

1,99

6

697

1,53

0

1,16

2

67

1,47

4

1,85

9

2,21

8

774

1,70

0

1,29

3

68

1,38

2

1,74

1

2,07

9

727

1,59

3

1,21

3

68

1,53

6

1,93

5

2,31

0

806

1,77

1

1,34

6

69

1,44

5

1,82

0

2,16

0

755

1,66

6

1,26

5

69

1,60

4

2,02

1

2,40

1

840

1,85

1

1,40

8

70

1,50

2

1,89

5

2,24

1

783

1,73

3

1,31

7

70

1,66

6

2,10

2

2,49

1

869

1,92

5

1,46

3

71

1,55

8

1,96

4

2,31

7

809

1,79

8

1,36

7

71

1,73

3

2,18

2

2,57

6

899

1,99

9

1,51

8

72

1,61

2

2,03

4

2,39

2

835

1,86

0

1,41

4

72

1,79

1

2,25

6

2,65

7

927

2,06

7

1,57

2

73

1,66

3

2,09

6

2,45

5

857

1,91

9

1,45

8

73

1,85

0

2,32

9

2,73

0

953

2,13

3

1,62

2

74

1,71

0

2,15

7

2,51

8

879

1,97

4

1,49

9

74

1,90

3

2,39

8

2,79

8

978

2,19

5

1,66

7

75

1,75

5

2,21

3

2,57

6

899

2,02

4

1,53

9

75

1,94

8

2,45

8

2,86

2

1,00

1

2,24

9

1,70

9

76

1,79

4

2,26

1

2,62

6

920

2,07

1

1,57

5

76

1,99

5

2,51

4

2,91

6

1,01

7

2,30

0

1,74

9

77

1,83

8

2,31

1

2,67

0

933

2,11

4

1,61

0

77

2,03

8

2,56

7

2,96

6

1,03

6

2,35

2

1,78

8

78

1,86

7

2,35

7

2,71

1

947

2,15

7

1,63

9

78

2,07

8

2,61

7

3,01

1

1,05

3

2,39

7

1,82

2

79

1,90

3

2,39

8

2,74

9

961

2,19

5

1,66

6

79

2,11

5

2,66

5

3,05

3

1,06

8

2,43

8

1,85

2

80

1,93

3

2,43

6

2,78

3

974

2,22

9

1,69

6

80

2,14

7

2,70

7

3,09

4

1,08

0

2,47

6

1,88

4

81

1,96

2

2,46

9

2,82

0

986

2,26

1

1,71

9

81

2,17

9

2,74

5

3,13

4

1,09

4

2,51

3

1,91

1

82

1,98

7

2,50

3

2,85

5

1,00

0

2,29

1

1,74

2

82

2,20

8

2,78

4

3,17

3

1,10

9

2,54

7

1,93

5

83

2,01

3

2,53

7

2,89

0

1,01

1

2,32

2

1,76

5

83

2,23

9

2,81

8

3,21

0

1,12

2

2,57

9

1,96

0

84

2,03

7

2,56

6

2,92

3

1,02

0

2,35

0

1,78

8

84

2,26

5

2,85

4

3,25

0

1,13

4

2,61

1

1,98

5

85

2,06

0

2,59

8

2,95

6

1,03

4

2,37

7

1,80

8

85

2,29

0

2,88

5

3,28

7

1,14

9

2,64

3

2,00

9

86

2,08

5

2,62

8

2,98

6

1,04

4

2,40

5

1,82

8

86

2,31

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2,92

0

3,32

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1,16

0

2,67

1

2,03

1

87

2,10

5

2,65

5

3,01

8

1,05

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2,42

9

1,84

7

87

2,34

3

2,95

1

3,35

2

1,17

1

2,70

1

2,05

3

88

2,12

7

2,68

3

3,04

5

1,06

6

2,45

5

1,86

6

88

2,36

4

2,97

9

3,38

3

1,18

1

2,72

7

2,07

2

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2,14

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2,70

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3,07

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1,07

2

2,47

6

1,88

4

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2,38

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3,00

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3,41

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2,64

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2,01

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5

3,21

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3,62

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dal

Fac

tors

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mi-

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nu

al:

0.52

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y:0.

2650

Mo

nth

ly:

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33

The

ab

ove

rat

es

do

no

t in

clu

de

th

e $

20 a

pp

lica

tio

n f

ee

.

To c

alcu

late

a H

ou

seh

old

dis

cou

nt:

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nn

ual

pre

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m x

mo

dal

fac

tor

= m

od

al p

rem

ium

(ro

un

d t

o n

ear

est

wh

ole

ce

nt)

M

od

al p

rem

ium

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cou

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ium

If a

pp

lyin

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uri

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en

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nt

or

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rio

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se P

refe

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ate

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Rat

es E

ffec

tive

6/1

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17

For

Use

in

ZIP

Co

des

: 3

50

-35

2, 3

55

Am

eri

can

Co

nti

ne

nta

l In

sura

nce

Co

mp

any

An

nu

al A

ttai

ned

Age

Pre

miu

ms

Fem

ale

Rat

es

ACIM

S010

63A

L 06

/201

7 A

3

Att

ain

ed

Pre

ferr

ed

Att

ain

ed

Stan

dar

d

Age

Pla

n A

Pla

n B

Pla

n F

Pla

n H

FP

lan

GP

lan

NA

geP

lan

AP

lan

BP

lan

FP

lan

HF

Pla

n G

Pla

n N

65

1,49

6

1,88

5

2,25

0

786

1,72

3

1,31

0

65

1,66

1

2,09

3

2,50

0

874

1,91

3

1,45

5

66

1,51

0

1,90

3

2,27

4

795

1,74

2

1,32

5

66

1,67

7

2,11

6

2,52

6

881

1,93

6

1,47

1

67

1,52

7

1,92

3

2,29

3

802

1,75

9

1,33

8

67

1,69

6

2,13

7

2,55

2

893

1,95

4

1,48

6

68

1,58

9

2,00

2

2,39

2

835

1,83

2

1,39

4

68

1,76

6

2,22

4

2,65

7

927

2,03

6

1,54

9

69

1,66

1

2,09

3

2,48

4

868

1,91

5

1,45

6

69

1,84

4

2,32

6

2,76

2

964

2,12

8

1,61

9

70

1,72

7

2,17

7

2,57

6

900

1,99

1

1,51

4

70

1,91

9

2,41

9

2,86

2

1,00

1

2,21

3

1,68

3

71

1,79

2

2,25

6

2,66

6

931

2,06

7

1,57

2

71

1,99

3

2,51

1

2,96

2

1,03

5

2,29

7

1,74

6

72

1,85

5

2,33

7

2,74

9

961

2,13

9

1,62

6

72

2,06

0

2,59

8

3,05

3

1,06

8

2,37

6

1,80

8

73

1,91

3

2,40

9

2,82

2

986

2,20

8

1,67

8

73

2,12

6

2,67

9

3,13

6

1,09

5

2,45

3

1,86

5

74

1,96

9

2,48

1

2,89

8

1,01

3

2,27

0

1,72

7

74

2,18

6

2,75

8

3,21

8

1,12

5

2,52

3

1,91

8

75

2,01

9

2,54

1

2,96

2

1,03

5

2,32

8

1,76

9

75

2,24

3

2,82

5

3,29

2

1,15

1

2,58

7

1,96

7

76

2,06

4

2,60

1

3,01

8

1,05

5

2,38

1

1,81

0

76

2,29

5

2,89

0

3,35

3

1,17

3

2,64

6

2,01

2

77

2,10

7

2,65

8

3,07

0

1,07

2

2,43

4

1,84

9

77

2,34

5

2,95

3

3,41

3

1,19

3

2,70

2

2,05

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are

elig

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(a

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pous

e; (

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e so

meo

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hom

you

are

in a

civ

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a pe

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e ho

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old

disc

ount

will

onl

y be

app

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f a

polic

y fo

r ea

ch a

pplic

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s is

sued

. The

dis

coun

ted

rate

will

be 5

per

cent

lo

wer

than

the

indi

vidu

al ra

tes.

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D Y

OU

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itsel

f to

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ll of

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s an

d du

ties

of b

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you

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HT

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ETU

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u fin

d th

at y

ou a

re n

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atis

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you

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licy,

you

may

re

turn

it to

Am

eric

an C

ontin

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uran

ce C

ompa

ny, P

.O. B

ox

1477

0, L

exin

gton

, KY

4051

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70. I

f yo

u se

nd th

e po

licy

back

to

us

with

in 3

0 da

ys a

fter

you

rece

ive

it, w

e w

ill tr

eat t

he p

olic

y as

if it

had

nev

er b

een

issu

ed a

nd re

turn

all

your

pay

men

ts.

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LIC

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ENT

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ually

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y an

d ar

e su

re y

ou w

ant t

o ke

ep it

. NO

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polic

y m

ay n

ot c

over

all

of y

our m

edic

al c

osts

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ther

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mer

ican

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l In

sura

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Com

pany

no

r its

ag

ents

are

con

nect

ed w

ith M

edic

are.

This

out

line

of c

over

age

does

not

giv

e al

l the

det

ails

of M

edic

are

cove

rage

. C

onta

ct y

our

loca

l So

cial

Sec

urity

Offi

ce o

r co

nsul

t M

ed

icare

& Y

ou fo

r mor

e de

tails

.

CO

MPL

ETE

AN

SWER

S A

RE

VER

Y IM

POR

TAN

T

Whe

n yo

u fil

l out

the

appl

icat

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for

the

new

pol

icy,

be

sure

to

answ

er

truth

fully

an

d co

mpl

etel

y an

y qu

estio

ns

abou

t yo

ur

med

ical

and

hea

lth h

isto

ry.

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com

pany

may

can

cel

your

po

licy

and

refu

se t

o pa

y an

y cl

aim

s if

you

leav

e ou

t or

fal

sify

im

porta

nt m

edic

al in

form

atio

n.

Rev

iew

the

app

licat

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care

fully

bef

ore

you

sign

it.

Be

certa

in

that

all

info

rmat

ion

has

been

pro

perly

reco

rded

.

THE

FOLL

OW

ING

CH

AR

TS D

ESC

RIB

E PL

AN

S A

, B, F

, HIG

H

DED

UC

TIB

LE

F,

G

and

N

OFF

ERED

B

Y A

MER

ICA

N

CO

NTI

NEN

TAL

INSU

RA

NC

E C

OM

PAN

Y.

ACIMS01063AL 06/2017 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 $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 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.

ACIMS01063AL 06/2017 A 8

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

ACIMS01063AL 06/2017 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 $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 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.

ACIMS01063AL 06/2017 A 10

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 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



100% $0 $0

Durable medical equipment First $183 of Medicare Approved amounts*



ACIMS01063AL 06/2017 A 11

PLAN F 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.



$0


ACIMS01063AL 06/2017 A 12

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



PLAN PAYS

YOU PAY



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


$0


PARTS A & B


PLAN PAYS

YOU PAY



100% $0 $0



$0


ACIMS01063AL 06/2017 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

ACIMS01063AL 06/2017 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 $2200 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses are $2200. 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

$2200 DEDUCTIBLE***

PLAN PAYS

IN ADDITION TO $2200

DEDUCTIBLE*** 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

ACIMS01063AL 06/2017 A 15

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



$0


ACIMS01063AL 06/2017 A 16

HIGH DEDUCTIBLE 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. ***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2200 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses are $2200. 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

$2200 DEDUCTIBLE***

PLAN PAYS






$0



$0


ACIMS01063AL 06/2017 A 17

HIGH DEDUCTIBLE PLAN F

PARTS A & B

SERVICES MEDICARE

PAYS AFTER YOU PAY

$2200 DEDUCTIBLE***

PLAN PAYS





100% $0 $0



$0


OTHER BENEFITS – NOT COVERED BY MEDICARE

SERVICES MEDICARE

PAYS AFTER YOU PAY

$2200 DEDUCTIBLE**

PLAN PAYS


DEDUCTIBLE** YOU PAY





ACIMS01063AL 06/2017 A 18

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


ACIMS01063AL 06/2017 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 $183 of Medicare Approved amounts*



ACIMS01063AL 06/2017 A 20

PLAN G



PLAN PAYS

YOU PAY





ACIMS01063AL 06/2017 A 21

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



$0


ACIMS01063AL 06/2017 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 copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

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

Part B Excess Charges (Above Medicare-Approved amounts) $0 0% All costs BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*



ACIMS01063AL 06/2017 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 $183 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


Outline of Coverage - smsteam · Outline of Coverage Medicare Supplement Insurance Underwritten by...

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