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Aetna Life Insurance Company Outline of Medicare Supplement Coverage

Benefit Plans A, B, F, G and N are Offered�

Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010

This chart show the benefits included in each of the standard Medicare supplement plans with an effective date for coverage on or after June 1, 2010. Every company must make Plan "A"

available. Some plans may not be available in your state.

Basic Benefits:

Hospitalization - Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

Medical Expenses - Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L and N require insured to pay a portion of Part B coinsurance or copayments.

Blood - First three pints of blood each year.

Hospice - Part A coinsurance.

A B C

D F l 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 preventive care paid at 100%; other basic benefits

paid at 50%

Hospitalization and preventive 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 copayment for $20

office visit, and up to $50 copayment for Skilled ER

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 50% 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

Effective 01-01-2016

GR-11613-03-OOC -OH 18.02.312.1-OH L (12/15)

••

••

(2)

Aetna Life Insurance Company Outline of Medicare Supplement Coverage

Benefit Plans A, B, F, G and N are Offered

*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 $ 2,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $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 does not include the Plan’s separate foreign travel emergency deductible.

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PREMIUM INFORMATION

Questions? We’re here to help.

Just call us at 1-800-345-6022 (TTY: 711)

We, Aetna Life Insurance Company, can only raise your premium if we raise the premium for all policies like yours in this state when your age

changes or to coincide with changes in Medicare.

The monthly premiums shown will apply when payment is made on a quarterly, semi-annual or annual basis or if you elect to have your

payments automatically deducted from your checking account (Electronic Funds Transfer program) or credit card account. To obtain

quarterly premium, multiply the monthly premium by 3. For semi-annual premium and annual premium, multiply the monthly premium by 6

or 12, respectively. If you elect to pay your premium on a monthly basis by check or money order, add $2 to the monthly premium shown to

calculate your monthly premium amount.

If you smoke and you enroll other than during the Medicare Supplement Open Enrollment and Guaranteed issue rights periods, a smoker

premium rate will apply. Please refer to the Guaranteed Issue Guidelines notice included in your enrollment materials for details on open

enrollment and guaranteed issue rights. Smoker premium rates are determined by multiplying the premium shown by a factor of 1.10.

Effective 01-01-2016

GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

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MONTHLY PREMIUMS Attained

Age

PLAN A

MALE FEMALE

PLAN B

MALE FEMALE

PLAN F

MALE FEMALE

PLAN G

MALE FEMALE

PLAN N MALE FEMALE 65 $138.99 $128.33 $154.66 $141.99 $174.66 $160.58 $158.66 $147.74 $124.16 $115.75 66 $144.16 $133.16 $160.41 $147.24 $181.16 $166.58 $166.33 $154.74 $130.41 $121.50 67 $149.33 $137.91 $166.24 $152.66 $187.74 $172.58 $173.99 $161.91 $136.41 $127.16 68 $155.41 $143.49 $173.99 $159.74 $196.66 $180.74 $181.49 $168.91 $142.49 $132.83 69 $161.41 $149.08 $181.58 $166.66 $205.49 $188.91 $189.08 $175.99 $148.58 $138.49 70 $167.49 $154.58 $189.16 $173.74 $214.24 $196.99 $196.66 $182.99 $154.66 $144.16 71 $173.41 $160.08 $196.83 $180.66 $223.07 $205.08 $204.16 $189.99 $160.66 $149.74 72 $179.33 $165.58 $204.33 $187.66 $231.74 $213.07 $211.66 $196.99 $166.66 $155.41 73 $183.41 $169.33 $210.82 $193.58 $239.41 $220.07 $220.07 $204.83 $173.58 $161.83 74 $187.49 $173.16 $217.07 $199.33 $246.82 $226.91 $228.32 $212.49 $180.33 $168.16 75 $191.49 $176.83 $223.41 $205.16 $254.32 $233.91 $236.66 $220.24 $187.08 $174.41 76 $195.49 $180.58 $229.74 $210.99 $261.91 $240.74 $244.99 $227.91 $193.91 $180.74 77 $199.58 $184.24 $236.07 $216.74 $269.32 $247.66 $253.07 $235.57 $200.58 $186.99 78 $202.49 $186.91 $240.32 $220.66 $274.74 $252.57 $260.16 $242.07 $206.49 $192.49 79 $205.33 $189.58 $244.66 $224.66 $280.07 $257.49 $267.07 $248.57 $212.41 $197.99 80 $208.08 $192.08 $248.74 $228.41 $285.32 $262.32 $273.91 $254.91 $218.24 $203.49 81 $210.74 $194.58 $252.91 $232.24 $290.57 $267.16 $280.82 $261.32 $224.16 $208.91 82 $213.32 $196.91 $257.07 $236.07 $295.74 $271.99 $287.74 $267.74 $229.99 $214.41 83 $214.91 $198.41 $262.07 $240.57 $302.82 $278.41 $301.24 $280.41 $242.07 $225.66 84 $216.57 $199.91 $266.91 $245.16 $309.82 $284.91 $314.90 $292.99 $254.16 $236.91 85 $218.07 $201.33 $272.16 $249.82 $317.24 $291.66 $326.74 $304.07 $264.91 $246.91 86 $219.49 $202.66 $276.32 $253.66 $323.57 $297.49 $339.15 $315.57 $276.16 $257.41 87 $220.82 $203.91 $280.41 $257.41 $328.40 $301.99 $351.90 $327.40 $287.82 $268.24 88 $222.24 $205.24 $284.57 $261.24 $333.40 $306.49 $365.15 $339.82 $299.90 $279.57 89

(5)

DISCLOSURES

Questions? We’re here to help.

Just call us at 1-800-345-6022 (TTY: 711)

Use this outline to compare benefits and premiums 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 Life Insurance

Company, PO Box 14770, Lexington, KY 40512. 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 of 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

This policy may not fully cover all of your medical costs. Neither Aetna 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 all

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.�

Effective 01-01-2016

GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

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PLAN A

Medicare (Part A) – Hospital Services – Per Benefit Period

Services Medicare Pays Plan A

Plan Pays You Pay

HOSPITALIZATION*

Semi-private 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

*A Benefit Period begins on the first day you receive care 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.

** 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.

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PLAN A (continued)

Medicare (Part A) – Hospital Services – Per Benefit Period

Services Medicare Pays Plan A

Plan Pays You Pay

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 a very limited copayment/

coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/

coinsurance $0

PLAN A

Medicare (Part B) – Medical Services – Per Calendar Year

Services Medicare Pays Plan A

Plan Pays You Pay

MEDICAL EXPENSES

IN OR OUT OF THE HOSPITAL AND

OUTPATIENT HOSPITAL TREATMENTS, 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

*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.

Effective 01-01-2016

GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

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PLAN A (continued)

Medicare (Part B) – Medical Services – Per Calendar Year

Services Medicare Pays Plan A

Plan Pays You Pay

• 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 A

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

*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.

- -

(9)

PLAN B

Medicare (Part A) – Hospital Services – Per Benefit Period

Services Medicare Pays Plan B

Plan Pays You Pay

HOSPITALIZATION*

Semi-private 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

*A Benefit Period begins on the first day you receive care 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.

**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.

Effective 01-01-2016

GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

(10)

PLAN B (continued)

Medicare (Part A) – Hospital Services – Per Benefit Period

Services Medicare Pays Plan B

Plan Pays You Pay

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

PLAN B

Medicare (Part B) – Medical Services – Per Calendar Year

Services Medicare Pays Plan B

Plan Pays You Pay

MEDICAL EXPENSES

IN OR OUT OF THE HOSPITAL AND

OUTPATIENT HOSPITAL TREATMENTS, 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

*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.

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PLAN B (continued)

Medicare (Part B) – Medical Services – Per Calendar Year

Services Medicare Pays Plan B

Plan Pays You Pay

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 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 $166 of Medicare-approved

amounts* $0 $0 $166

(Part B deductible) - Remainder of Medicare-approved

amounts 80% 20% $0

*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.

Effective 01-01-2016

GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

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PLAN F

Medicare (Part A) – Hospital Services – Per Benefit Period

Services Medicare Pays Plan F

Plan Pays You Pay

HOSPITALIZATION*

Semi-private 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

*A Benefit Period begins on the first day you receive care 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.

** 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.

(13)

PLAN F (continued)

Medicare (Part A) – Hospital Services – Per Benefit Period

Services Medicare Pays Plan F

Plan Pays You Pay

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

PLAN F

Medicare (Part B) – Medical Services – Per Calendar Year

Services Medicare Pays Plan F

Plan Pays You Pay

MEDICAL EXPENSES

IN OR OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENTS, 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 $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% of all costs $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

*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.

Effective 01-01-2016

GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

(14)

PLAN F (continued)

Medicare (Part B) – Medical Services – Per Calendar Year

Services Medicare Pays Plan F

Plan Pays You Pay

CLINICAL LABORATORY SERVICES

Tests for diagnostic services 100% $0 $0

PARTS A & B

Services Medicare Pays Plan F

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

OTHER BENEFITS – Not Covered by Medicare

Services Medicare Pays Plan F

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 such charges $0 80% to a lifetime

maximum benefit of

$50,000

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

(15)

PLAN G

Medicare (Part A) – Hospital Services – Per Benefit Period

Services Medicare Pays Plan G

Plan Pays You Pay

HOSPITALIZATION*

Semi-private 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

*A Benefit Period begins on the first day you receive care 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.

**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.

Effective 01-01-2016

GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

(16)

PLAN G

Medicare (Part B) – Medical Services – Per Calendar Year

Services Medicare Pays Plan G

Plan Pays You Pay

MEDICAL EXPENSES

IN OR OUT OF THE HOSPITAL AND

OUTPATIENT HOSPITAL TREATMENTS, 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) $0 100% of all costs $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

*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.

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PLAN G (continued)

PARTS A & B

Services Medicare Pays Plan G

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 G

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 such charges $0 80% to a lifetime

maximum benefit of

$50,000

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

*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.

Effective 01-01-2016

GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

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PLAN N

Medicare (Part A) – Hospital Services – Per Benefit Period

Services Medicare Pays Plan N

Plan Pays You Pay

HOSPITALIZATION*

Semi-private 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

*A Benefit Period begins on the first day you receive care 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.

**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.

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PLAN N

Medicare (Part B) – Medical Services – Per Calendar Year

Services Medicare Pays Plan N

Plan Pays You Pay

MEDICAL EXPENSES

IN OR OUT OF THE HOSPITAL AND

OUTPATIENT HOSPITAL TREATMENTS, 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% 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 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.

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

*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.

Effective 01-01-2016

GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)

(20)

PLAN N (continued)

PARTS A & B�

Services Medicare Pays Plan N

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 N

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 such charges $0 80% to a lifetime

maximum benefit of

$50,000

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

*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.

References

Related documents

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