benefit plans a, b, f, hf, g, & n - asp | home · outline of coverage medicare supplement...

800 Crescent Centre Dr. Suite 200

Franklin, TN 37067800 264.4000

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Outline of CoverageMedicare Supplement Insurance

Underwritten by

Continental Life Insurance Company of Brentwood, Tennessee

An Aetna Company

Rates Effective:

BENEFIT PLANS A, B, F, HF, G, & N

Kansas

CLIMS03988KS © 2017 Aetna Inc. 02/2018 A

CLI

MS0

3988

KS

02

/201

8 A

1

CO

NTI

NEN

TAL

LIFE

INSU

RAN

CE

CO

MPA

NY

OF

BR

ETW

OO

D, T

ENN

ESSE

E O

UTL

INE

OF

MED

ICAR

E SU

PPLE

MEN

T C

OVE

RAG

E C

OVE

R P

AGE

BEN

EFIT

PLA

NS

AVAI

LAB

LE: A

, B, F

, Hig

h D

educ

tible

F, G

, N

Th

ese

char

ts s

how

the b

enefits

in

clu

de

d in e

ach

of

the s

tand

ard

Me

dic

are

su

pp

lem

ent

pla

ns. E

ve

ry c

om

pa

ny m

ust m

ake

ava

ilable

Pla

n “

A.”

So

me

plan

s m

ay n

ot b

e av

aila

ble

in y

our s

tate

.

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

-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

Basi

c,

incl

udin

g 10

0%

Part

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 50%

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

Fa

cilit

y C

oins

uran

ce

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

Part

A D

educ

tible

Pa

rt A

Ded

uctib

le

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

240;

pa

id a

t 100

%

afte

r lim

it re

ache

d

Out

-of-p

ocke

t lim

it $2

620;

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 t

he s

ame

bene

fits

as P

lan

F af

ter

one

has

paid

a

cale

ndar

yea

r $2

240

dedu

ctib

le. B

enef

its fr

om h

igh

dedu

ctib

le p

lan

F w

ill no

t beg

in u

ntil

out-o

f-poc

ket e

xpen

ses

exce

ed $

2240

. O

ut-o

f-poc

ket

expe

nses

for t

his

dedu

ctib

le a

re e

xpen

ses

that

wou

ld o

rdin

arily

be

paid

by

the

polic

y. T

hese

exp

ense

s in

clud

e th

e M

edic

are

dedu

ctib

les

for P

art

A a

nd

Pa

rt B

, b

ut

do n

ot in

clu

de

th

e p

lan’s

se

para

te fo

reig

n tra

ve

l e

merg

ency d

ed

uctib

le.

CLI

MS0

3988

KS

02

/201

8 A

2

Att

ain

ed

Pre

ferr

ed

Att

ain

ed

Stan

dar

d

Age

Pla

n A

Pla

n B

Pla

n F

Hig

h F

Pla

n G

Pla

n N

Age

Pla

n A

Pla

n B

Pla

n F

Hig

h F

Pla

n G

Pla

n N

U

nd

er

651,

309

1,35

41,

618

647

1,36

41,

101

Un

de

r 65

1,45

51,

504

1,79

771

91,

515

1,22

3

65

1,30

91,

354

1,61

864

71,

364

1,10

165

1,45

51,

504

1,79

771

91,

515

1,22

3

66

1,30

91,

354

1,61

864

71,

364

1,10

166

1,45

51,

504

1,79

771

91,

515

1,22

3

67

1,30

91,

354

1,61

864

71,

364

1,10

167

1,45

51,

504

1,79

771

91,

515

1,22

3

68

1,32

51,

371

1,63

765

41,

380

1,11

368

1,47

21,

523

1,81

972

71,

534

1,23

8

69

1,35

31,

400

1,67

266

91,

409

1,13

769

1,50

31,

555

1,85

874

31,

566

1,26

4

70

1,38

91,

436

1,71

668

71,

447

1,16

770

1,54

31,

596

1,90

776

41,

608

1,29

7

71

1,43

11,

480

1,76

870

71,

490

1,20

271

1,59

01,

644

1,96

578

61,

656

1,33

6

72

1,47

51,

526

1,82

372

91,

537

1,24

072

1,63

91,

696

2,02

681

01,

707

1,37

8

73

1,52

41,

576

1,88

275

31,

587

1,28

173

1,69

31,

751

2,09

283

61,

763

1,42

3

74

1,57

71,

631

1,94

878

01,

643

1,32

574

1,75

21,

812

2,16

486

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825

1,47

2

75

1,63

51,

690

2,02

080

81,

702

1,37

475

1,81

71,

878

2,24

489

71,

891

1,52

6

76

1,69

21,

750

2,09

183

61,

763

1,42

276

1,88

01,

944

2,32

392

91,

958

1,58

0

77

1,74

91,

809

2,16

186

41,

822

1,47

077

1,94

32,

010

2,40

196

02,

024

1,63

3

78

1,80

61,

867

2,23

189

21,

881

1,51

778

2,00

72,

075

2,48

099

12,

091

1,68

6

79

1,86

51,

929

2,30

492

11,

943

1,56

779

2,07

32,

143

2,56

01,

024

2,15

91,

741

80

1,92

31,

989

2,37

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02,

003

1,61

780

2,13

72,

211

2,64

21,

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2,22

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796

81

1,98

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2,45

298

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1,66

881

2,20

42,

280

2,72

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2,29

71,

853

82

2,04

72,

116

2,52

71,

011

2,13

11,

719

822,

274

2,35

12,

808

1,12

32,

367

1,91

1

83

2,10

92,

182

2,60

61,

042

2,19

71,

772

832,

344

2,42

42,

895

1,15

82,

441

1,96

9

84

2,17

42,

249

2,68

61,

075

2,26

51,

826

842,

416

2,49

82,

984

1,19

42,

516

2,02

9

85

2,25

02,

326

2,77

91,

111

2,34

41,

890

852,

499

2,58

43,

088

1,23

42,

604

2,10

0

86

2,31

42,

393

2,85

91,

144

2,41

11,

944

862,

571

2,65

93,

176

1,27

12,

678

2,16

0

87

2,37

92,

461

2,94

01,

176

2,47

91,

999

872,

644

2,73

53,

266

1,30

72,

754

2,22

2

88

2,44

62,

529

3,02

21,

209

2,54

82,

055

882,

718

2,81

03,

358

1,34

22,

831

2,28

3

89

2,51

42,

600

3,10

61,

242

2,61

92,

112

892,

794

2,88

83,

452

1,38

02,

910

2,34

7

90

2,58

32,

672

3,19

11,

277

2,69

02,

171

902,

871

2,96

93,

546

1,41

82,

989

2,41

2

91

2,65

42,

744

3,27

91,

311

2,76

42,

230

912,

948

3,04

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643

1,45

73,

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2,47

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92

2,72

52,

818

3,36

71,

347

2,83

82,

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73,

154

2,54

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93

2,79

82,

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3,45

71,

382

2,91

42,

351

933,

109

3,21

53,

842

1,53

63,

238

2,61

3

94

2,87

22,

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3,54

81,

419

2,99

22,

413

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190

3,30

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1,57

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324

2,68

1

95

2,94

63,

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3,64

11,

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3,06

92,

476

953,

273

3,38

54,

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1,61

83,

411

2,75

2

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3,02

33,

126

3,73

51,

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3,14

82,

540

963,

359

3,47

34,

149

1,66

03,

498

2,82

2

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3,10

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3,83

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3,22

92,

605

973,

444

3,56

24,

255

1,70

33,

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2,89

4

98

3,17

83,

286

3,92

71,

570

3,31

02,

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983,

532

3,65

14,

363

1,74

53,

678

2,96

8

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+3,

257

3,36

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1,61

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1,79

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61

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2, 6

72

CLI

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3988

KS

02

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8 A

3

Att

ain

ed

Pre

ferr

ed

Att

ain

ed

Stan

dar

d

Age

Pla

n A

Pla

n B

Pla

n F

Hig

h F

Pla

n G

Pla

n N

Age

Pla

n A

Pla

n B

Pla

n F

Hig

h F

Pla

n G

Pla

n N

U

nd

er

651,

506

1,55

71,

861

744

1,56

81,

266

Un

de

r 65

1,67

31,

730

2,06

782

71,

742

1,40

6

65

1,50

61,

557

1,86

174

41,

568

1,26

665

1,67

31,

730

2,06

782

71,

742

1,40

6

66

1,50

61,

557

1,86

174

41,

568

1,26

666

1,67

31,

730

2,06

782

71,

742

1,40

6

67

1,50

61,

557

1,86

174

41,

568

1,26

667

1,67

31,

730

2,06

782

71,

742

1,40

6

68

1,52

41,

576

1,88

275

31,

588

1,28

168

1,69

21,

752

2,09

283

61,

764

1,42

3

69

1,55

61,

609

1,92

276

91,

621

1,30

869

1,72

91,

788

2,13

685

41,

801

1,45

4

70

1,59

71,

652

1,97

378

91,

664

1,34

270

1,77

41,

836

2,19

387

81,

849

1,49

1

71

1,64

61,

702

2,03

481

31,

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1,38

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1,82

81,

890

2,25

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1,53

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72

1,69

71,

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767

1,42

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1,88

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2,48

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1,69

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802,

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2,54

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2,62

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2,87

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1,37

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2,33

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2,58

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3,19

61,

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2,69

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174

852,

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2,97

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2,41

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2,66

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3,28

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2,77

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2,73

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CLIMS03988KS 02/2018 A 6

PREMIUM INFORMATION

Continental Life Insurance Company of Brentwood, Tennessee can only raise your premium if we raise the premium for all policies like yours in this state. Premiums for this policy will increase due to the increase in your age. Upon attainment of an age requiring a rate increase, the renewal premium for the policy will be the renewal premium then in effect for your attained age. Other policies may be provided with Issue Age rating and do not increase with age. You should compare Issue Age with Attained Age policies.

Premiums payable other than annually will be determined according to the following factors:

Semi-annual: 0.5200 Quarterly: 0.2650 Monthly EFT: 0.0833.

HOUSEHOLD DISCOUNT

In order to be eligible for the Household discount under a Continental Life Insurance Company of Brentwood, Tennessee Medicare supplement plan, you must apply for a Medicare supplement plan at the same time as another Medicare eligible adult or the other Medicare eligible adult must currently be covered by an Aetna Company Medicare supplement policy. The Medicare eligible adult must be either (a) your spouse; or (b) someone with whom you are in a civil union partnership; and (c) someone with whom you have continuously resided for the past 12 months. The household discount will only be applicable if a policy for each applicant is issued. The discounted rate will be 7 percent lower than the individual rates and will apply as long as both policies remain in force.

DISCLOSURES

Use this outline to compare benefits and premium among policies.

READ YOUR POLICY VERY CAREFULLY

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

RIGHT TO RETURN POLICY

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

POLICY REPLACEMENT

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

NOTICE The policy may not cover all of your medical costs.

Neither Continental Life Insurance Company of Brentwood, Tennessee 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.

CANCELLATION BY INSURED The insured may cancel this policy at any time by written notice delivered or mailed to the insurer, effective upon receipt of such notice or on such late date as may be specified in such notice. In the event of cancellation or death of the insured, the insurer will promptly return the unearned portion of any premium paid beyond the date of termination. The earned premium shall be computed by the use of the pro-rata method. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation.

GUARANTEED RENEWABLE You have the right to renew this policy, for consecutive terms, by payment of the required premium before the end of each grace period. You have the right to renew this policy regardless of changes in your physical, mental or health conditions.

COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new policy, be sure to answer truthfully and completely any questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

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

THE FOLLOWING CHARTS DESCRIBE PLANS A, B, F, HIGH DEDUCTIBLE F, G and N OFFERED BY CONTINENTAL LIFE INSURANCE COMPANY OF BRENTWOOD, TENNESSEE.

YOU HAVE PURCHASED PLAN __________. PREMIUM FOR THIS PLAN IS $___________. PREMIUM WILL BE PAID ________________. AGENT’S NAME:________________________ AGENT’S ADDRESS:____________________ ______________________________________

CLIMS03988KS 02/2018 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 $1340 $0 $1340 (Part A Deductible)

61st thru 90th day All but $335 a day $335 a day $0 91st day and after While using 60 lifetime reserve days All but $670 a day $670 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 $167.50 a day $0 Up to $167.50 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.

CLIMS03988KS 02/2018 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

CLIMS03988KS 02/2018 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 $1340 $1340 (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 $167.50 a day

$0 Up to $167.50 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 Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsurance for outpatient drugs and inpatient respite care

$0 $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.

CLIMS03988KS 02/2018 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*



CLIMS03988KS 02/2018 A 11

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



PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $167.50 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 Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsurance for outpatient drugs and inpatient respite care

$0 $0


CLIMS03988KS 02/2018 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


CLIMS03988KS 02/2018 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

CLIMS03988KS 02/2018 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 $2240 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2240. 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

$2240 DEDUCTIBLE***

PLAN PAYS

IN ADDITION TO $2240

DEDUCTIBLE*** YOU PAY



$0



$0**




$0 $0


Up to $167.50 a day

$0

101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0

CLIMS03988KS 02/2018 A 15

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


Medicare copayment/ coinsurance

$0


CLIMS03988KS 02/2018 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 $2240 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2240. 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

$2240 DEDUCTIBLE***

PLAN PAYS






$0



$0


CLIMS03988KS 02/2018 A 17

HIGH DEDUCTIBLE PLAN F

PARTS A & B

SERVICES MEDICARE

PAYS AFTER YOU PAY

$2240 DEDUCTIBLE***

PLAN PAYS





100% $0 $0



$0


OTHER BENEFITS – NOT COVERED BY MEDICARE

SERVICES MEDICARE

PAYS AFTER YOU PAY

$2240 DEDUCTIBLE**

PLAN PAYS


DEDUCTIBLE** YOU PAY





CLIMS03988KS 02/2018 A 18

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



PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $167.50 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 copayment/coinsurance

$0


CLIMS03988KS 02/2018 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*



CLIMS03988KS 02/2018 A 20

PLAN G


SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY





CLIMS03988KS 02/2018 A 21

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



PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $167.50 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


CLIMS03988KS 02/2018 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 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*



CLIMS03988KS 02/2018 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


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