clims04880ms outline medsup ms 032021a

Outline of coverage Medicare Supplement Insurance

Benefit plans: A, B, F, G, High Deductible G, N

Mississippi

Underwritten by

Continental Life Insurance Company of Brentwood, Tennessee

An Aetna Company

aetnaseniorproducts.com CLIMS04880MS 2021 Aetna Inc. Rates effective: 03/2021 A

http://aetnaseniorproducts.com

CONTINENTAL LIFE INSURANCE COMPANY OFBRENTWOOD, TENNESSEE OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS AVAILABLE: A, B, F, G, HIGH DEDUCTIBLE G, N

This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan "A" available. Some plans may not be available. Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F.

Note: A ✔ means 100% of the benefit is paid.

Benefits

Plans Available to All Applicants

A B D G1 K L M N

Medicare first

eligible before 2020 only C F1

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)

✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Medicare Part B coinsurance or copayment ✔ ✔ ✔ ✔ 50% 75% ✔

✔ copays apply3

✔ ✔

Blood (first three pints) ✔ ✔ ✔ ✔ 50% 75% ✔ ✔ ✔ ✔

Part A hospice care coinsurance or copayment

✔ ✔ ✔ ✔ 50% 75% ✔ ✔ ✔ ✔

Skilled nursing facility coinsurance ✔ ✔ 50% 75% ✔ ✔ ✔ ✔

Medicare Part A deductible ✔ ✔ ✔ 50% 75% 50% ✔ ✔ ✔

Medicare Part B deductible ✔ ✔ Medicare Part B excess

charges ✔ ✔

Foreign travel emergency (up to plan limits)

✔ ✔ ✔ ✔ ✔ ✔

Out-of-pocket limit in 20212 $6,220 $3,1102

1 Plans F and G also have a high deductible option, which require first paying a plan deductible of $2,370 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.

2 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly

limit.

3 Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission.

CLIMS04880MS 1 03/2021A

The above rates do not include the $6 one-time policy fee.

To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium

If applying during Open Enrollment or Guaranteed Issue Period use Preferred rates.

Continental Life Insurance Company of Brentwood, Tennessee Annual Premiums

For Use in: Rest of State Female Rates

Rates Effective 3/1/2021

AttainedAge

Preferred Plan A Plan B Plan F Plan G Plan HG Plan N

Under 65 4,567 5,354 6,129 5,000 2,107 4,034 65 1,081 1,267 1,450 1,183 499 901 66 1,081 1,267 1,450 1,183 499 901 67 1,081 1,267 1,450 1,183 499 901 68 1,093 1,281 1,467 1,196 504 933 69 1,118 1,310 1,500 1,223 516 971 70 1,147 1,345 1,539 1,256 529 1,008 71 1,182 1,385 1,585 1,293 545 1,044 72 1,218 1,428 1,635 1,334 562 1,079 73 1,258 1,474 1,688 1,377 580 1,115 74 1,302 1,526 1,747 1,426 601 1,153 75 1,348 1,580 1,809 1,476 622 1,190 76 1,395 1,635 1,873 1,527 644 1,228 77 1,444 1,692 1,939 1,581 666 1,270 78 1,494 1,751 2,004 1,635 689 1,312 79 1,540 1,805 2,067 1,686 710 1,354 80 1,589 1,862 2,132 1,739 733 1,399 81 1,638 1,920 2,199 1,794 756 1,443 82 1,687 1,977 2,265 1,847 778 1,486 83 1,739 2,039 2,334 1,904 802 1,532 84 1,790 2,098 2,402 1,960 826 1,577 85 1,855 2,174 2,489 2,031 856 1,634 86 1,908 2,237 2,561 2,089 880 1,681 87 1,962 2,299 2,633 2,148 905 1,729 88 2,017 2,364 2,708 2,208 931 1,777 89 2,074 2,430 2,782 2,269 956 1,826 90 2,131 2,497 2,859 2,332 983 1,877 91 2,188 2,565 2,937 2,395 1,009 1,928 92 2,247 2,634 3,015 2,460 1,037 1,980 93 2,307 2,704 3,096 2,526 1,064 2,032 94 2,368 2,776 3,177 2,592 1,093 2,086 95 2,430 2,848 3,261 2,660 1,121 2,141 96 2,493 2,921 3,345 2,729 1,150 2,196 97 2,556 2,996 3,430 2,798 1,179 2,252 98 2,621 3,072 3,518 2,869 1,209 2,309 99+ 2,687 3,148 3,605 2,941 1,239 2,367

Attained Age

Standard Plan A Plan B Plan F Plan G Plan HG Plan N

Under 65 5,075 5,949 6,810 5,556 2,341 4,482 65 1,201 1,407 1,611 1,314 554 1,001 66 1,201 1,407 1,611 1,314 554 1,001 67 1,201 1,407 1,611 1,314 554 1,001 68 1,214 1,423 1,630 1,329 560 1,037 69 1,242 1,456 1,666 1,359 573 1,079 70 1,274 1,494 1,710 1,396 588 1,120 71 1,313 1,538 1,761 1,437 606 1,160 72 1,353 1,587 1,817 1,482 624 1,199 73 1,398 1,638 1,876 1,530 644 1,239 74 1,447 1,696 1,942 1,584 668 1,281 75 1,498 1,756 2,010 1,640 691 1,322 76 1,551 1,817 2,081 1,697 716 1,364 77 1,605 1,880 2,154 1,757 740 1,411 78 1,660 1,945 2,227 1,817 766 1,458 79 1,711 2,006 2,297 1,873 789 1,504 80 1,765 2,069 2,368 1,932 814 1,554 81 1,821 2,134 2,443 1,993 840 1,603 82 1,875 2,197 2,516 2,052 864 1,651 83 1,932 2,266 2,593 2,116 891 1,702 84 1,988 2,332 2,669 2,178 918 1,752 85 2,062 2,416 2,766 2,257 951 1,816 86 2,120 2,485 2,845 2,321 978 1,868 87 2,181 2,555 2,926 2,387 1,006 1,921 88 2,242 2,627 3,009 2,453 1,034 1,974 89 2,304 2,700 3,091 2,521 1,062 2,029 90 2,367 2,775 3,176 2,591 1,092 2,086 91 2,431 2,850 3,263 2,661 1,121 2,142 92 2,497 2,927 3,350 2,733 1,152 2,200 93 2,563 3,005 3,441 2,807 1,182 2,258 94 2,632 3,084 3,531 2,880 1,214 2,318 95 2,700 3,164 3,622 2,956 1,246 2,379 96 2,769 3,246 3,716 3,032 1,278 2,440 97 2,840 3,329 3,811 3,109 1,310 2,502 98 2,913 3,413 3,909 3,188 1,343 2,566 99+ 2,985 3,498 4,006 3,268 1,377 2,630

Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833

CLIMS04880MS 2 03/2021 A





For Use in: Rest of State Male Rates


Attained Age


Under 65 5,252 6,157 7,048 5,750 2,423 4,639 65 1,243 1,457 1,668 1,360 574 1,036 66 1,243 1,457 1,668 1,360 574 1,036 67 1,243 1,457 1,668 1,360 574 1,036 68 1,257 1,473 1,687 1,375 580 1,073 69 1,285 1,507 1,725 1,406 593 1,117 70 1,319 1,547 1,770 1,444 608 1,159 71 1,359 1,592 1,823 1,487 627 1,201 72 1,401 1,642 1,880 1,534 646 1,241 73 1,447 1,696 1,941 1,584 667 1,282 74 1,498 1,755 2,010 1,640 691 1,326 75 1,550 1,817 2,080 1,697 715 1,369 76 1,605 1,880 2,154 1,756 741 1,412 77 1,661 1,946 2,229 1,818 766 1,461 78 1,717 2,013 2,305 1,880 792 1,509 79 1,771 2,076 2,377 1,939 817 1,557 80 1,827 2,142 2,452 2,000 843 1,609 81 1,885 2,209 2,528 2,063 869 1,659 82 1,940 2,274 2,605 2,124 895 1,709 83 2,000 2,345 2,684 2,190 922 1,762 84 2,058 2,413 2,763 2,254 950 1,814 85 2,134 2,500 2,863 2,336 984 1,879 86 2,195 2,573 2,945 2,402 1,012 1,933 87 2,257 2,644 3,028 2,470 1,041 1,988 88 2,320 2,718 3,114 2,539 1,071 2,044 89 2,385 2,795 3,199 2,609 1,099 2,100 90 2,451 2,872 3,288 2,682 1,130 2,159 91 2,516 2,949 3,377 2,754 1,160 2,217 92 2,584 3,029 3,468 2,829 1,193 2,277 93 2,652 3,110 3,561 2,905 1,224 2,337 94 2,724 3,192 3,654 2,981 1,257 2,399 95 2,795 3,276 3,750 3,059 1,289 2,462 96 2,866 3,360 3,847 3,138 1,323 2,525 97 2,940 3,445 3,944 3,218 1,356 2,590 98 3,014 3,533 4,046 3,299 1,390 2,655 99+ 3,090 3,620 4,146 3,382 1,425 2,722

Attained Age


Under 65 5,836 6,841 7,832 6,389 2,692 5,154 65 1,381 1,618 1,853 1,511 637 1,151 66 1,381 1,618 1,853 1,511 637 1,151 67 1,381 1,618 1,853 1,511 637 1,151 68 1,396 1,637 1,874 1,528 644 1,193 69 1,429 1,674 1,916 1,563 659 1,241 70 1,466 1,717 1,966 1,605 676 1,288 71 1,510 1,769 2,026 1,653 697 1,334 72 1,556 1,824 2,089 1,704 718 1,379 73 1,607 1,885 2,158 1,760 741 1,425 74 1,664 1,950 2,233 1,822 768 1,473 75 1,723 2,020 2,311 1,886 795 1,520 76 1,783 2,089 2,393 1,952 823 1,569 77 1,846 2,162 2,476 2,021 851 1,623 78 1,909 2,237 2,561 2,090 881 1,677 79 1,968 2,307 2,642 2,154 907 1,730 80 2,029 2,379 2,724 2,222 936 1,787 81 2,094 2,454 2,809 2,292 966 1,843 82 2,156 2,526 2,894 2,360 994 1,899 83 2,222 2,606 2,982 2,433 1,025 1,957 84 2,286 2,682 3,069 2,505 1,056 2,015 85 2,371 2,779 3,181 2,596 1,094 2,088 86 2,438 2,858 3,271 2,669 1,125 2,148 87 2,508 2,939 3,364 2,745 1,157 2,209 88 2,578 3,021 3,460 2,821 1,189 2,270 89 2,649 3,105 3,554 2,899 1,221 2,333 90 2,723 3,190 3,653 2,980 1,256 2,399 91 2,796 3,278 3,752 3,060 1,289 2,463 92 2,872 3,366 3,852 3,143 1,325 2,530 93 2,947 3,455 3,957 3,228 1,359 2,597 94 3,027 3,547 4,060 3,312 1,396 2,666 95 3,105 3,640 4,166 3,399 1,433 2,736 96 3,185 3,734 4,274 3,487 1,470 2,806 97 3,267 3,828 4,383 3,575 1,507 2,877 98 3,350 3,925 4,495 3,666 1,544 2,951 99+ 3,433 4,023 4,606 3,758 1,584 3,025


CLIMS04880MS 3 03/2021 A


For Use in ZIP Codes: 394-395 Female Rates


Attained Age


Under 65 5,161 6,050 6,926 5,650 2,381 4,558 65 1,222 1,432 1,639 1,337 564 1,018 66 1,222 1,432 1,639 1,337 564 1,018 67 1,222 1,432 1,639 1,337 564 1,018 68 1,235 1,448 1,658 1,351 570 1,054 69 1,263 1,480 1,695 1,382 583 1,097 70 1,296 1,520 1,739 1,419 598 1,139 71 1,336 1,565 1,791 1,461 616 1,180 72 1,376 1,614 1,848 1,507 635 1,219 73 1,422 1,666 1,907 1,556 655 1,260 74 1,471 1,724 1,974 1,611 679 1,303 75 1,523 1,785 2,044 1,668 703 1,345 76 1,576 1,848 2,116 1,726 728 1,388 77 1,632 1,912 2,191 1,787 753 1,435 78 1,688 1,979 2,265 1,848 779 1,483 79 1,740 2,040 2,336 1,905 802 1,530 80 1,796 2,104 2,409 1,965 828 1,581 81 1,851 2,170 2,485 2,027 854 1,631 82 1,906 2,234 2,559 2,087 879 1,679 83 1,965 2,304 2,637 2,152 906 1,731 84 2,023 2,371 2,714 2,215 933 1,782 85 2,096 2,457 2,813 2,295 967 1,846 86 2,156 2,528 2,894 2,361 994 1,900 87 2,217 2,598 2,975 2,427 1,023 1,954 88 2,279 2,671 3,060 2,495 1,052 2,008 89 2,344 2,746 3,144 2,564 1,080 2,063 90 2,408 2,822 3,231 2,635 1,111 2,121 91 2,472 2,898 3,319 2,706 1,140 2,179 92 2,539 2,976 3,407 2,780 1,172 2,237 93 2,607 3,056 3,498 2,854 1,202 2,296 94 2,676 3,137 3,590 2,929 1,235 2,357 95 2,746 3,218 3,685 3,006 1,267 2,419 96 2,817 3,301 3,780 3,084 1,300 2,481 97 2,888 3,385 3,876 3,162 1,332 2,545 98 2,962 3,471 3,975 3,242 1,366 2,609 99+ 3,036 3,557 4,074 3,323 1,400 2,675

Attained Age


Under 65 5,735 6,722 7,695 6,278 2,645 5,065 65 1,357 1,590 1,820 1,485 626 1,131 66 1,357 1,590 1,820 1,485 626 1,131 67 1,357 1,590 1,820 1,485 626 1,131 68 1,372 1,608 1,842 1,502 633 1,172 69 1,403 1,645 1,883 1,536 647 1,219 70 1,440 1,688 1,932 1,577 664 1,266 71 1,484 1,738 1,990 1,624 685 1,311 72 1,529 1,793 2,053 1,675 705 1,355 73 1,580 1,851 2,120 1,729 728 1,400 74 1,635 1,916 2,194 1,790 755 1,448 75 1,693 1,984 2,271 1,853 781 1,494 76 1,753 2,053 2,352 1,918 809 1,541 77 1,814 2,124 2,434 1,985 836 1,594 78 1,876 2,198 2,517 2,053 866 1,648 79 1,933 2,267 2,596 2,116 892 1,700 80 1,994 2,338 2,676 2,183 920 1,756 81 2,058 2,411 2,761 2,252 949 1,811 82 2,119 2,483 2,843 2,319 976 1,866 83 2,183 2,561 2,930 2,391 1,007 1,923 84 2,246 2,635 3,016 2,461 1,037 1,980 85 2,330 2,730 3,126 2,550 1,075 2,052 86 2,396 2,808 3,215 2,623 1,105 2,111 87 2,465 2,887 3,306 2,697 1,137 2,171 88 2,533 2,969 3,400 2,772 1,168 2,231 89 2,604 3,051 3,493 2,849 1,200 2,293 90 2,675 3,136 3,589 2,928 1,234 2,357 91 2,747 3,221 3,687 3,007 1,267 2,420 92 2,822 3,308 3,786 3,088 1,302 2,486 93 2,896 3,396 3,888 3,172 1,336 2,552 94 2,974 3,485 3,990 3,254 1,372 2,619 95 3,051 3,575 4,093 3,340 1,408 2,688 96 3,129 3,668 4,199 3,426 1,444 2,757 97 3,209 3,762 4,306 3,513 1,480 2,827 98 3,292 3,857 4,417 3,602 1,518 2,900 99+ 3,373 3,953 4,527 3,693 1,556 2,972





CLIMS04880MS 4 03/2021 A

Male Rates

Attained Age


Under 65 5,935 6,957 7,964 6,498 2,738 5,24265 1,405 1,646 1,885 1,537 649 1,17166 1,405 1,646 1,885 1,537 649 1,17167 1,405 1,646 1,885 1,537 649 1,17168 1,420 1,664 1,906 1,554 655 1,21269 1,452 1,703 1,949 1,589 670 1,26270 1,490 1,748 2,000 1,632 687 1,31071 1,536 1,799 2,060 1,680 709 1,35772 1,583 1,855 2,124 1,733 730 1,40273 1,635 1,916 2,193 1,790 754 1,44974 1,693 1,983 2,271 1,853 781 1,49875 1,752 2,053 2,350 1,918 808 1,54776 1,814 2,124 2,434 1,984 837 1,59677 1,877 2,199 2,519 2,054 866 1,65178 1,940 2,275 2,605 2,124 895 1,70579 2,001 2,346 2,686 2,191 923 1,75980 2,065 2,420 2,771 2,260 953 1,81881 2,130 2,496 2,857 2,331 982 1,87582 2,192 2,570 2,944 2,400 1,011 1,93183 2,260 2,650 3,033 2,475 1,042 1,99184 2,326 2,727 3,122 2,547 1,074 2,05085 2,411 2,825 3,235 2,640 1,112 2,12386 2,480 2,907 3,328 2,714 1,144 2,18487 2,550 2,988 3,422 2,791 1,176 2,24688 2,622 3,071 3,519 2,869 1,210 2,31089 2,695 3,158 3,615 2,948 1,242 2,37390 2,770 3,245 3,715 3,031 1,277 2,44091 2,843 3,332 3,816 3,112 1,311 2,50592 2,920 3,423 3,919 3,197 1,348 2,57393 2,997 3,514 4,024 3,283 1,383 2,64194 3,078 3,607 4,129 3,369 1,420 2,71195 3,158 3,702 4,238 3,457 1,457 2,78296 3,239 3,797 4,347 3,546 1,495 2,85397 3,322 3,893 4,457 3,636 1,532 2,92798 3,406 3,992 4,572 3,728 1,571 3,00099+ 3,492 4,091 4,685 3,822 1,610 3,076

AttainedAge


Under 65 6,595 7,730 8,850 7,220 3,042 5,824 65 1,561 1,828 2,094 1,707 720 1,301 66 1,561 1,828 2,094 1,707 720 1,301 67 1,561 1,828 2,094 1,707 720 1,301 68 1,577 1,850 2,118 1,727 728 1,348 69 1,615 1,892 2,165 1,766 745 1,402 70 1,657 1,940 2,222 1,814 764 1,455 71 1,706 1,999 2,289 1,868 788 1,507 72 1,758 2,061 2,361 1,926 811 1,558 73 1,816 2,130 2,439 1,989 837 1,610 74 1,880 2,204 2,523 2,059 868 1,664 75 1,947 2,283 2,611 2,131 898 1,718 76 2,015 2,361 2,704 2,206 930 1,773 77 2,086 2,443 2,798 2,284 962 1,834 78 2,157 2,528 2,894 2,362 996 1,895 79 2,224 2,607 2,985 2,434 1,025 1,955 80 2,293 2,688 3,078 2,511 1,058 2,019 81 2,366 2,773 3,174 2,590 1,092 2,083 82 2,436 2,854 3,270 2,667 1,123 2,146 83 2,511 2,945 3,370 2,749 1,158 2,211 84 2,583 3,031 3,468 2,831 1,193 2,277 85 2,679 3,140 3,595 2,933 1,236 2,359 86 2,755 3,230 3,696 3,016 1,271 2,427 87 2,834 3,321 3,801 3,102 1,307 2,496 88 2,913 3,414 3,910 3,188 1,344 2,565 89 2,993 3,509 4,016 3,276 1,380 2,636 90 3,077 3,605 4,128 3,367 1,419 2,711 91 3,159 3,704 4,240 3,458 1,457 2,783 92 3,245 3,804 4,353 3,552 1,497 2,859 93 3,330 3,904 4,471 3,648 1,536 2,935 94 3,421 4,008 4,588 3,743 1,577 3,013 95 3,509 4,113 4,708 3,841 1,619 3,092 96 3,599 4,219 4,830 3,940 1,661 3,171 97 3,692 4,326 4,953 4,040 1,703 3,251 98 3,786 4,435 5,079 4,143 1,745 3,335 99+ 3,879 4,546 5,205 4,247 1,790 3,418


For Use in ZIP Codes: 394-395






CLIMS04880MS 5 03/2021 A

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 have a Medicare supplement policy with an Aetna company. The Medicare eligible adult must be

either (a) your spouse or someone with whom you are in a civil union partnership; and (b) 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 rates 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.

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, G, HIGH DEDUCTIBLE G, and N OFFERED BY

CONTINENTAL LIFE INSURANCE COMPANY OF BRENTWOOD, TENNESSEE.

CLIMS04880MS 6 03/2021 A

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 d ays All but $1,484 $0 $1,484 (Part A Deductible)

61st thru 90th day

91st day and after

All but $371 a day $371 a day $0

•While using 60 lifetime reserve days

•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 $185.50 a day $0 Up to $185.50 a day

101st day and after $0 $0 All costs

BLOOD First 3 p ints $0 3 p ints $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.

CLIMS04880MS 7 03/2021 A

PLAN A

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

*Once you have been billed $203 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 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 $203 of Medicare-Approved amounts*

$0 $0 $203 (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 p ints $0 All costs $0 Next $203 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

SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES

•Medically necessary skilled care services and medical supplies

•Durable medical equipment

100% $0 $0

•First $203 of Medicare

Approved amounts*

$0 $0 $203

(Part B Deductible)

•Remainder of Medicare Approved amounts 80% 20% $0

CLIMS04880MS 8 03/2021 A

PLAN B


* 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 $1,484 $1,484

(Part A Deductible)

$0

61st thru 90th day 91st day and after






$0**


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 $185.50 a day $0 Up to $185.50 a day 101st day and after $0 $0 All costs

BLOOD First 3 p ints $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


$0


CLIMS04880MS 9 03/2021 A

PLAN B


* Once you have been billed $203 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 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 $203 of Medicare-Approved amounts*


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 p ints $0 All costs $0 Next $203 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

SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES

•Medically necessary skilled care services and medical supplies

•Durable medical equipment

100% $0 $0

•First $203 of Medicare Approved amounts*


•Remainder of Medicare

Approved amounts 80% 20% $0

CLIMS04880MS 10 03/2021 A

PLAN F


*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 d ays All but $1,484 $1,484

(Part A Deductible)

$0







$0**


SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 d ays and

entered a Medicare-Approved facility within 30 d ays after leaving the hospital

First 20 d ays All approved amounts $0 $0 21st thru 100th day All but $185.50 a day Up to $185.50 a day $0 101st day and after $0 $0 All costs

BLOOD First 3 p ints $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


$0


CLIMS04880MS 11 03/2021 A

PLAN F


*Once you have been billed $203 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 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 test, durable medical equipment First $203 of Medicare-Approved amounts*

$0 $203 (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 $203 of Medicare-Approved amounts*

$0 $203 (Part B Deductible)

$0

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 •Durable medical equipment

100% $0 $0


$0 $203

(Part B Deductible) $0


CLIMS04880MS 12 03/2021 A

PLAN F

OTHER BENEFITS – NOT COVERED BY MEDICARE


PLAN PAYS

YOU PAY

FOREIGN TRAVEL – NOT CO VERED 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

CLIMS04880MS 13 03/2021 A

PLAN G




PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,484 $1,484

(Part A Deductible) $0



•While using 60 lifetime reserve days •Once lifetime reserve days are used:



$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 $185.50 a day Up to $185.50 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

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


$0


CLIMS04880MS 14 03/2021 A

PLAN G




PLAN PAYS

YOU PAY

MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $203 of Medicare-Approved amounts*





PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies •Durable medical equipment

100% $0 $0




CLIMS04880MS 15 03/2021 A

PLAN G


SERVICES MEDICARE PAYS PLAN PAYS YOU PAY




CLIMS04880MS 16 03/2021 A

HIGH DEDUCTIBLE PLAN G



***This high deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,370 deductible. Benefits from high deductible plan G will not begin until out-of-pocket expenses are $2,370. Out-of-pocket expenses for this deductible includeexpenses for theMedicarePart B deductible, and expenses thatwouldordinarily bepaid by thepolicy. This does not include theplan’s separate foreign travelemergencydeductible.


AFTER YOU PAY $2,370

DEDUCTIBLE*** PLAN PAYS

IN ADDITION TO $2,370

DEDUCTIBLE*** YOU PAY





*While using 60 lifetime reserve days *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 $185.50 a day Up to $185.50 a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0

CLIMS04880MS 17 03/2021 A

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



$0


CLIMS04880MS 18 03/2021 A




***This high deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,370 deductible. Benefits from high deductible plan G will not begin until out-of-pocket expenses are $2,370. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by thepolicy. This does not include theplan’s separate foreign travelemergencydeductible.







$0 $0 $203 (Unless Part B Deductible has been met)




CLIMS04880MS 19 03/2021 A


PARTS A & B






HOME HEALTH CARE – MEDICARE APPROVED SERVICES *Medically necessary skilled care services and medical supplies *Durable medical equipment

100% $0 $0

*First $203 of Medicare Approved amounts*


*Remainder of Medicare Approved amounts 80% 20% $0




DEDUCTIBLE** PLAN PAYS


DEDUCTIBLE** YOU PAY




CLIMS04880MS 20 03/2021 A

PLAN N




PLAN PAYS

YOU PAY





*While using 60 lifetime reserve days *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 $185.50 a day Up to $185.50 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


CLIMS04880MS 21 03/2021 A

PLAN N




PLAN PAYS

YOU PAY



Remainder of Medicare-Approved amounts

Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Up to $20 per office visit and up to $50 per emergency room visit. The 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 $203 of Medicare-Approved amounts*



CLIMS04880MS 22 03/2021 A

PLAN N

PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies *Durable medical equipment

100% $0 $0



*Remainder of Medicare Approved amounts 80% 20% $0



PLAN PAYS

YOU PAY

FOREIGN TRAVEL – NOT CO VERED 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


CLIMS04880MS 23 03/2021 A

clims04880ms outline medsup ms 032021a

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