Medicare Supplement Coverage Options

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Medicare Supplement Coverage Options

Thank you for your interest in our Medicare Supplemental coverage options, also known as HealthNow New York Inc. Medicare Supplement (Medigap) plans. The Medicare Supplement Plans, when combined with payments made by Medicare, are designed to reduce your out-of-pocket costs for most Medicare-covered services. We offer five Medicare Supplemental policies – you choose the benefit design that best meets your needs.

Why Do I Need a Medicare Supplemental (Medigap) Policy?

A Medicare Supplemental policy provides coverage for health care expenses that Medicare does not cover. These policies pay most, if not all, of the Original Medicare Plan coinsurance and outpatient copayment amounts. Some policies also cover the Original Medicare Plan deductibles. Please refer to the enclosed “Outline of Medicare Supplemental Coverage Benefit Plans” for details about the benefits of each plan.

Your cost-sharing is nominal and with some plans, there is none at all. There is no need for you to get referrals and there are no networks. Plan members can receive medical care from any doctor, specialist, or hospital that participates with Medicare.

How to Enroll

Enrolling is simple. To enroll in a HealthNow New York Inc. Medicare Supplement (Medigap) plan, complete and return your application to us in the enclosed envelope. Do not include payment at this time. We will process your application and bill you at a later date.

You will also promptly receive a policy and identification card. If you are not completely satisfied, return the policy and membership card within 30 days from the day you received the card. Any premium payments you have made will be refunded in full. In the event you have filed a claim within this 30-day period, you will be responsible for the cost of any services you received.

Questions?

Please call our Government Program Sales Department at 1-888-989-9905 if you have any questions.

If you are a current member you may call our Customer Service Department at 1-888-787-2390.

For more information about Medicare coverage and Medigap policies, you may want to review the

“Guide To Health Insurance For People With Medicare.” You may obtain this guide from your local Social Security office, or from the Medicare web site at www.medicare.gov.

CG1D3F0385

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H eal thN ow N ew Y or k I nc.

Mailing address: PO BOX 15013, Albany, New York 12212-5012 Physical address: 40 Century Hill Drive, Latham, New York 12110

B enef it C har t of M edi car e S uppl em ent P lans S ol d f or E ff ect ive D at es on or A ft er Januar y 1, 2016

This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make available Plans A & B and either C or F. Some plans may not be available in your state. The plans we sell are A, B, C, F and F*. BASIC BENEFITS: Hospitalization: Medical Expenses: Blood: Hospice:

Part A coinsurance plus coverage for 365 additional days in your lifetime after Medicare benefits end. Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. First three pints of blood each year. Part A coinsurance

A B C D F/ F* G K L M N

Basic, including 100% Part B coinsurance

Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance

Hospitalization and preventative care paid at 100%; other basic benefits paid at 50%

Hospitalization and preventative care paid at 100%; other basic benefits paid at 75%

Basic, including 100% Part B coinsurance

Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Coinsurance

Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance 50% Skilled Nursing Facility Coinsurance 75% Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance

Skilled Nursing Facility Coinsurance Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible 50% Part A Deductible 75% Part A Deductible Part A Deductible Part A Deductible Part B Deductible Part B Deductible Part B Excess (100%)

Part B Excess (100%) Foreign Travel Emergency

Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency

Foreign Travel Emergency Out-of-Pocket Limit $4,960 paid at 100% after limit reached

Out-of-Pocket Limit $2,480 paid at 100% after limit reached *Plan "F" also has an option called a high deductible Plan "F". This high deductible plan pays the same benefits as Plan "F" after one has paid a calendar year $2,160 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses are $2,160. 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. CG1D3F0385 Page 1 of 14

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PREMIUM INFORMATION HealthNow New York Inc. can only raise your premium if we raise the premium for all policies like yours in this state. Service Area Rockland, Westchester, Bronx, New York, Kings, Queens, Richmond, Nassau, Suffolk PLAN TYPE MONTHLY PREMIUM QUARTERLY PREMIUM SEMI-ANNUAL PREMIUM ANNUAL PREMIUM Plan A $263.59 $790.77 $1,581.54 $3,163.08 Plan B $328.18 $984.54 $1,969.08 $3,938.16 Plan C $393.64 $1,180.92 $2,361.84 $4,723.68 Plan F $395.38 $1,186.14 $2,372.28 $4,744.56 Plan F* $167.35 $502.05 $1,004.10 $2,008.20 Rates effective 01/01/2016 CG1D3F0385 Page 2 of 14

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DI S CL OS URE S

Use this outline to compare benefits and premiums among policies. This outline shows benefits and premiums of policies sold for effective dates on or after January 1, 2016. Policies sold for effective dates prior to January 1, 2016 have different benefits and premiums.

READ YO UR PO L ICY VERY CAREF UL L Y Thi s i s onl y an out line des c ri bi ng y our pol ic y 's m os t i m por tant f eat ur es . The pol ic y i s y our i ns ur anc e c ont rac t. Y ou m us t r ead t he pol ic y it s el f t o under s tand al l of t he r ight s and dut ies of bot h y ou and y our i ns ur anc e c om pany . RI G HT T O RET URN PO L ICY If y ou f ind t hat y ou ar e not s at is fi ed w it h y our pol ic y , y ou m ay r et ur n i t t o He a lt h No w Ne w Yo rk I n c ., A tt ent ion: M ar k et ing D epar tm e n t, PO Bo x 15013 , Alb a n y , Ne w Yo rk 12212 -5012 . I f y ou s end t he pol ic y bac k t o us w it hi n 30 day s af ter y ou r ec ei v e i t, w e w ill t reat t he pol ic y as i f i t had nev er been i s s ued and r et ur n al l of y our pay m ent s . PO L ICY REPL ACEM ENT If y ou ar e r epl ac ing anot her heal th i ns ur anc e pol ic y , do N O T c anc el i t unt il y ou hav e ac tual ly r ec ei v ed y our new pol ic y and ar e s ur e y ou w ant t o k eep i t. NO T ICE Thi s pol ic y m ay not f ul ly c ov er al l of y our m edi c al c os ts . N ei ther He a lt h No w Ne w Yo rk I n c ., nor i ts agent s ar e c onnec ted w it h M edi c ar e. Thi s O ut li ne of C over age does not gi v e al l t he det ai ls of M edi c ar e c ov er age. C ont ac t y our l oc al S oc ial S ec ur it y of fi c e or c ons ul t

"Medicare and You"

for m or e det ai ls . CO M PL ET E ANSW ERS ARE VERY I M PO RT ANT R ev iew t he appl ic at ion c ar ef ul ly bef or e y ou s ign i t. B e c er tai n t hat al l i nf or m at ion has been pr oper ly r ec or ded.

CG1D3F0385 Page 3 of 14

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PLA N A M EDI CARE ( PART A) HO SPI T AL SERVI CES PER BENEF IT PERI O D

*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 A PAYS WITH PLAN A 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 (lifetime) -Beyond the additional 365 days

All but $1,288 All but $322 a day All but $644 a day $0 $0

$0 $322 a day $644 a day 100% of Medicare- eligible expenses $0

$1,288 (Part A deductible) $0 $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least three 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 $0 $0

$0 Up to $161 a day All costs BLOOD (per calendar year) First three pints Additional amounts

$0 100%

Three 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 copayments/coinsurance $0 CG1D3F0385 Page 4 of 14

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PLA N A M EDI CARE ( PART B) M EDI CAL SERVI CES PER CAL ENDAR 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 A PAYS WITH PLAN A 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* 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 three 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 MEDICARE PARTS A & B 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 CG1D3F0385 Page 5 of 14

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PLA N B M EDI CARE ( PART A) HO SPI T AL SERVI CES PER BENEF IT PERI O D

*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 B PAYS WITH PLAN B 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 (lifetime) -Beyond the additional 365 days

$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 three 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

$0 $0 $0

$0 Up to $161 a day All costs BLOOD (per calendar year) First three pints Additional amounts

$0 100%

Three pints $0

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PLA N B M EDI CARE ( PART B) M EDI CAL SERVI CES PER CAL ENDAR 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 B PAYS WITH PLAN B 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* 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 three 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 BLOOD TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 MEDICARE PARTS A & B 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 CG1D3F0385 Page 7 of 14

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PLA N C M EDI CARE ( PART A) HO SPI T AL SERVI CES PER BENEF IT PERI O D

*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 C PAYS WITH PLAN C 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 (lifetime) -Beyond the additional 365 days

$1,288 (Part A deductible) $322 a day $644 a day 100% of Medicare-eligible expenses $0

$0 Up to $161 a day $0

$0 $0 All costs BLOOD (per calendar year) First three pints Additional amounts

$0 100%

Three pints $0

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PLA N C M EDI CARE ( PART B) M EDI CAL SERVI CES PER CAL ENDAR 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 C PAYS WITH PLAN C 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* Remainder of Medicare-approved amounts

$0 Generally 80%

$166 (Part B deductible) Generally 20% $0 $0 Part B excess charges (Above Medicare-approved amounts) $0 $0 All costs BLOOD First three pints Next $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 $0 80%

All costs $166 (Part B deductible) 20%

$0 $0 $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 MEDICARE PARTS A & B 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 $166 (Part B deductible) 20%

$0 $0 $0 OTHER BENEFITS NOT COVERED BY MEDICARE 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 CG1D3F0385 Page 9 of 14

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PLA N F M EDI CARE ( PART A) HO SPI T AL SERVI CES PER BENEF IT PERI O D

*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 F PAYS WITH PLAN F 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 (lifetime) -Beyond the additional 365 days

$0 Up to $161 a day $0

$0 100%

Three pints $0

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PLA N F M EDI CARE ( PART B) M EDI CAL SERVI CES PER CAL ENDAR 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 F PAYS WITH PLAN F 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* Remainder of Medicare-approved amounts

$0 Generally 80%

$166 (Part B deductible) Generally 20% $0 $0 Part B excess charges (Above Medicare-approved amounts) $0 All costs $0 BLOOD First three pints Next $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 $0 80%

$0 $0 $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 MEDICARE PARTS A & B 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 $0 80% to a lifetime Maximum Benefit of $50,000

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HIGH DE DUCT IBL E P L AN F M EDI CARE ( PART A) HO SPI T AL SERVI CES PER BENEF IT PERI O D

*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 $2,160 deductible. Benefits from the high deductible F plan will not begin until out-of-pocket expenses are $2,160. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by this policy. This includes Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible. SERVICES MEDICARE PAYS PLAN F+ PAYS WITH PLAN F+ 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 (lifetime) -Beyond the additional 365 days

$0 Up to $161 a day $0

$0 100%

Three pints $0

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayments/coinsurance $0 CG1D3F0385 Page 12 of 14

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HIGH DE DUCT IBL E P L AN F M EDI CARE ( PART B) M EDI CAL SERVI CES PER CAL ENDAR 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 $2,160 deductible. Benefits from the high deductible F plan will not begin until out-of-pocket expenses are $2,160. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by this policy. This includes Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible. SERVICES MEDICARE PAYS PLAN F+ PAYS WITH PLAN F+ 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* Remainder of Medicare-approved amounts

$0 Generally 80%

$166 (Part B deductible) Generally 20% $0 $0 Part B excess charges (Above Medicare-approved amounts) $0 All costs $0 BLOOD First three pints Next $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 $0 80%

$0 $0 $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 CG1D3F0385 Page 13 of 14

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HIGH DE DUCT IBL E P L AN F M EDI CARE ( PART B) M EDI CAL SERVI CES PER CAL ENDAR 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 $2,160 deductible. Benefits from the high deductible F plan will not begin until out-of-pocket expenses are $2,160. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by this policy. This includes Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible. MEDICARE PARTS A & B 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

$0 80% to a lifetime Maximum Benefit of $50,000