Outline of CoverageMedicare Supplement Insurance
Underwritten by
Aetna Health and Life Insurance Company
Administrative Office800 Crescent Centre Dr.Suite 200Franklin, TN 37067800 264.4000aetnaseniorproducts.com
Aetna Health and Life Insurance Company
Rates Effective:
BENEFIT PLANS A, B, F, HIGH DEDUCTIBLE F, G, N
Louisiana
AHLMS03846LA © 2018 Aetna Inc. 08/2018 A
AHLM
S038
46LA
1
0
8/20
18 A
AEN
TA H
EALT
H A
ND
LIF
E IN
SUR
ANC
E C
OM
PAN
Y
OU
TLIN
E O
F M
EDIC
ARE
SUPP
LEM
ENT
CO
VER
AGE
CO
VER
PAG
E B
ENEF
IT P
LAN
S AV
AILA
BLE
: A, B
, F, H
IGH
DED
UC
TIB
LE F
, G, N
Th
ese
char
ts s
how
the
bene
fits
incl
uded
in e
ach
of th
e st
anda
rd M
edic
are
supp
lem
ent p
lans
. Eve
ry c
ompa
ny m
ust
ma
ke
ava
ilable
Pla
n “
A”
Som
e pl
ans
may
not
be
avai
labl
e in
you
r sta
te.
Bas
ic B
enef
its:
Hos
pita
lizat
ion:
Par
t A c
oins
uran
ce p
lus
cove
rage
for 3
65 a
dditi
onal
day
s af
ter M
edic
are
bene
fits
end.
M
edic
al E
xpen
ses:
Par
t B c
oins
uran
ce (g
ener
ally
20%
of M
edic
are-
Appr
oved
exp
ense
s) o
r, co
paym
ents
for h
ospi
tal o
utpa
tient
ser
vice
s. P
lans
K,
L, a
nd N
requ
ire in
sure
ds to
pay
a p
ortio
n of
coi
nsur
ance
or c
opay
men
ts
Bloo
d: F
irst t
hree
pin
ts o
f blo
od e
ach
year
.
Hos
pice
-Par
t A c
oins
uran
ce
A B
C
D
F/
F*
G
K
L M
N
Ba
sic,
in
clud
ing
100%
Par
t B
coin
sura
nce
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Hos
pita
lizat
ion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basi
c be
nefit
s pa
id a
t 50%
Hos
pita
lizat
ion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basi
c be
nefit
s pa
id a
t 75%
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c, in
clud
ing
100%
Par
t B
coin
sura
nce,
exc
ept
up to
$20
cop
aym
ent
for o
ffice
vis
it, a
nd
up to
$50
cop
aym
ent
for E
R
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
50%
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
75%
Ski
lled
Nur
sing
Fac
ility
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Pa
rt A
Ded
uctib
le
Part
A D
educ
tible
Pa
rt A
Ded
uctib
le
Part
A D
educ
tible
Pa
rt A
Ded
uctib
le
50%
Par
t A
Ded
uctib
le
75%
Par
t A
Ded
uctib
le
50%
Par
t A
Ded
uctib
le
Part
A D
educ
tible
Part
B D
educ
tible
Part
B D
educ
tible
Part
B Ex
cess
(1
00%
)
Part
B Ex
cess
(1
00%
)
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Out
-of-p
ocke
t lim
it $5
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
ns F
als
o ha
s an
opt
ion
calle
d a
high
ded
uctib
le p
lan
F. T
his
high
ded
uctib
le p
lan
pays
the
sam
e be
nefit
s as
Pla
n F
afte
r one
has
pai
d a
cale
ndar
yea
r $22
40
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 e
xpen
ses
for t
his
dedu
ctib
le a
re
expe
nses
that
wou
ld o
rdin
arily
be
paid
by
the p
olic
y. T
hese e
xpenses inclu
de the M
edic
are
deductible
s f
or
Part
A a
nd P
art
B, but do n
ot in
clu
de the p
lan’s
se
para
te fo
reig
n tra
vel e
mer
genc
y de
duct
ible
.
AHLMS03846LA 08/2018 A 07/2017 C 2
Attained Preferred Attained Standard
Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N
Under 65 3,587 4,078 5,201 2,081 4,084 3,444 Under 65 3,985 4,530 5,778 2,312 4,538 3,826
65 1,481 1,683 2,148 859 1,686 1,420 65 1,645 1,871 2,387 953 1,873 1,579
66 1,481 1,683 2,148 859 1,686 1,420 66 1,645 1,871 2,387 953 1,873 1,579
67 1,481 1,683 2,148 859 1,686 1,420 67 1,645 1,871 2,387 953 1,873 1,579
68 1,499 1,705 2,174 869 1,707 1,438 68 1,667 1,895 2,415 966 1,896 1,598
69 1,531 1,742 2,220 889 1,743 1,469 69 1,702 1,935 2,466 987 1,938 1,633
70 1,571 1,788 2,279 912 1,789 1,509 70 1,745 1,987 2,534 1,013 1,988 1,677
71 1,619 1,841 2,348 939 1,842 1,553 71 1,798 2,046 2,608 1,044 2,047 1,726
72 1,669 1,899 2,420 969 1,900 1,602 72 1,854 2,110 2,690 1,076 2,112 1,780
73 1,723 1,960 2,499 1,000 1,961 1,654 73 1,914 2,178 2,777 1,111 2,179 1,838
74 1,784 2,029 2,588 1,035 2,032 1,712 74 1,981 2,254 2,874 1,149 2,258 1,901
75 1,849 2,104 2,682 1,073 2,105 1,776 75 2,055 2,337 2,980 1,192 2,339 1,974
76 1,914 2,176 2,775 1,111 2,179 1,837 76 2,127 2,419 3,084 1,235 2,421 2,041
77 1,979 2,251 2,869 1,147 2,252 1,899 77 2,198 2,501 3,188 1,275 2,503 2,110
78 2,042 2,325 2,962 1,186 2,326 1,961 78 2,270 2,583 3,292 1,317 2,584 2,179
79 2,110 2,401 3,060 1,224 2,402 2,025 79 2,345 2,666 3,400 1,360 2,669 2,250
80 2,176 2,474 3,157 1,263 2,477 2,089 80 2,419 2,750 3,506 1,404 2,753 2,321
81 2,245 2,553 3,255 1,302 2,554 2,156 81 2,494 2,837 3,617 1,446 2,839 2,394
82 2,314 2,633 3,357 1,343 2,634 2,221 82 2,572 2,926 3,729 1,491 2,927 2,468
83 2,387 2,714 3,461 1,384 2,715 2,291 83 2,652 3,016 3,845 1,539 3,017 2,545
84 2,460 2,797 3,567 1,427 2,799 2,361 84 2,734 3,108 3,963 1,585 3,111 2,624
85 2,545 2,895 3,691 1,477 2,897 2,442 85 2,828 3,216 4,101 1,641 3,220 2,713
86 2,619 2,977 3,796 1,518 2,980 2,513 86 2,909 3,308 4,218 1,687 3,310 2,792
87 2,691 3,061 3,904 1,562 3,064 2,583 87 2,990 3,402 4,337 1,735 3,404 2,870
88 2,767 3,148 4,013 1,605 3,150 2,656 88 3,075 3,497 4,460 1,784 3,500 2,952
89 2,844 3,234 4,124 1,650 3,238 2,730 89 3,161 3,594 4,582 1,833 3,598 3,033
90 2,923 3,324 4,238 1,696 3,327 2,806 90 3,248 3,693 4,710 1,885 3,696 3,117
91 3,002 3,415 4,354 1,742 3,417 2,881 91 3,335 3,794 4,838 1,935 3,796 3,200
92 3,083 3,506 4,471 1,788 3,510 2,958 92 3,425 3,897 4,968 1,987 3,900 3,287
93 3,166 3,600 4,590 1,837 3,603 3,038 93 3,518 4,000 5,101 2,041 4,004 3,376
94 3,248 3,695 4,711 1,885 3,698 3,118 94 3,608 4,106 5,234 2,094 4,109 3,465
95 3,333 3,791 4,834 1,934 3,795 3,199 95 3,704 4,213 5,372 2,149 4,217 3,554
96 3,420 3,891 4,959 1,984 3,893 3,282 96 3,800 4,323 5,510 2,205 4,325 3,647
97 3,506 3,989 5,086 2,034 3,991 3,366 97 3,897 4,432 5,651 2,260 4,435 3,740
98 3,597 4,091 5,215 2,086 4,093 3,451 98 3,996 4,546 5,795 2,318 4,549 3,835
99+ 3,686 4,193 5,344 2,138 4,195 3,537 99+ 4,094 4,658 5,938 2,375 4,661 3,929
Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833
The above rates do not include the $20 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.
Rates Effective 8/1/2018
Female Rates
Aetna Health and Life Insurance CompanyAnnual Premiums
For Use in ZIP Codes: 700-701, 704, 707-708
AHLMS03846LA 08/2018 A 07/2017 C 3
Attained Preferred Attained Standard
Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N
Under 65 4,125 4,692 5,982 2,393 4,696 3,960 Under 65 4,583 5,210 6,645 2,657 5,218 4,400
65 1,703 1,935 2,470 987 1,940 1,633 65 1,891 2,150 2,744 1,098 2,154 1,816
66 1,703 1,935 2,470 987 1,940 1,633 66 1,891 2,150 2,744 1,098 2,154 1,816
67 1,703 1,935 2,470 987 1,940 1,633 67 1,891 2,150 2,744 1,098 2,154 1,816
68 1,725 1,961 2,500 1,000 1,962 1,654 68 1,917 2,179 2,777 1,111 2,181 1,838
69 1,761 2,003 2,553 1,022 2,005 1,690 69 1,956 2,225 2,837 1,135 2,228 1,878
70 1,807 2,056 2,621 1,049 2,058 1,735 70 2,007 2,285 2,914 1,165 2,286 1,929
71 1,861 2,117 2,700 1,080 2,118 1,787 71 2,068 2,353 3,001 1,200 2,354 1,984
72 1,920 2,184 2,784 1,113 2,185 1,842 72 2,132 2,428 3,093 1,237 2,429 2,047
73 1,981 2,254 2,874 1,149 2,255 1,901 73 2,201 2,504 3,194 1,277 2,506 2,114
74 2,052 2,334 2,976 1,191 2,336 1,970 74 2,278 2,593 3,305 1,322 2,597 2,188
75 2,127 2,419 3,084 1,235 2,420 2,042 75 2,363 2,688 3,428 1,371 2,690 2,270
76 2,201 2,503 3,191 1,277 2,506 2,112 76 2,446 2,783 3,548 1,419 2,785 2,348
77 2,276 2,589 3,300 1,320 2,590 2,184 77 2,527 2,877 3,665 1,465 2,878 2,428
78 2,349 2,673 3,407 1,362 2,675 2,255 78 2,610 2,971 3,786 1,514 2,972 2,506
79 2,428 2,761 3,519 1,409 2,762 2,328 79 2,697 3,066 3,910 1,565 3,069 2,588
80 2,503 2,846 3,630 1,453 2,848 2,402 80 2,783 3,163 4,033 1,614 3,166 2,669
81 2,581 2,936 3,742 1,496 2,937 2,479 81 2,868 3,261 4,160 1,663 3,265 2,754
82 2,661 3,029 3,861 1,544 3,030 2,554 82 2,958 3,364 4,288 1,714 3,366 2,838
83 2,744 3,122 3,980 1,592 3,123 2,634 83 3,051 3,469 4,422 1,769 3,470 2,927
84 2,828 3,217 4,101 1,641 3,220 2,714 84 3,144 3,573 4,558 1,823 3,578 3,017
85 2,927 3,329 4,245 1,699 3,332 2,808 85 3,252 3,698 4,716 1,887 3,704 3,119
86 3,011 3,424 4,365 1,745 3,428 2,890 86 3,346 3,803 4,850 1,941 3,808 3,211
87 3,095 3,520 4,489 1,796 3,523 2,971 87 3,439 3,911 4,987 1,996 3,915 3,301
88 3,181 3,621 4,614 1,846 3,624 3,055 88 3,537 4,021 5,128 2,052 4,026 3,394
89 3,271 3,719 4,743 1,898 3,723 3,139 89 3,634 4,133 5,270 2,108 4,137 3,488
90 3,362 3,822 4,874 1,950 3,825 3,226 90 3,736 4,248 5,417 2,167 4,251 3,584
91 3,451 3,927 5,006 2,003 3,929 3,313 91 3,835 4,363 5,562 2,225 4,365 3,680
92 3,545 4,033 5,142 2,056 4,036 3,403 92 3,938 4,481 5,713 2,285 4,485 3,781
93 3,640 4,141 5,279 2,112 4,143 3,493 93 4,045 4,600 5,867 2,348 4,604 3,882
94 3,736 4,249 5,418 2,167 4,253 3,585 94 4,150 4,721 6,019 2,408 4,724 3,985
95 3,834 4,360 5,559 2,224 4,364 3,679 95 4,258 4,845 6,178 2,472 4,849 4,088
96 3,933 4,474 5,703 2,282 4,476 3,773 96 4,371 4,972 6,336 2,536 4,974 4,194
97 4,033 4,587 5,849 2,339 4,590 3,871 97 4,481 5,097 6,499 2,599 5,099 4,301
98 4,136 4,705 5,997 2,399 4,707 3,969 98 4,596 5,227 6,664 2,665 5,231 4,411
99+ 4,238 4,821 6,147 2,459 4,825 4,067 99+ 4,709 5,357 6,829 2,731 5,360 4,519
Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833
The above rates do not include the $20 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.
Rates Effective 8/1/2018
Male Rates
Aetna Health and Life Insurance CompanyAnnual Premiums
For Use in ZIP Codes: 700-701, 704, 707-708
AHLMS03846LA 08/2018 A 07/2017 C 4
Attained Preferred Attained Standard
Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N
Under 65 2,781 3,161 4,032 1,613 3,166 2,670 Under 65 3,089 3,512 4,479 1,792 3,518 2,966
65 1,148 1,305 1,665 666 1,307 1,101 65 1,275 1,450 1,850 739 1,452 1,224
66 1,148 1,305 1,665 666 1,307 1,101 66 1,275 1,450 1,850 739 1,452 1,224
67 1,148 1,305 1,665 666 1,307 1,101 67 1,275 1,450 1,850 739 1,452 1,224
68 1,162 1,322 1,685 674 1,323 1,115 68 1,292 1,469 1,872 749 1,470 1,239
69 1,187 1,350 1,721 689 1,351 1,139 69 1,319 1,500 1,912 765 1,502 1,266
70 1,218 1,386 1,767 707 1,387 1,170 70 1,353 1,540 1,964 785 1,541 1,300
71 1,255 1,427 1,820 728 1,428 1,204 71 1,394 1,586 2,022 809 1,587 1,338
72 1,294 1,472 1,876 751 1,473 1,242 72 1,437 1,636 2,085 834 1,637 1,380
73 1,336 1,519 1,937 775 1,520 1,282 73 1,484 1,688 2,153 861 1,689 1,425
74 1,383 1,573 2,006 802 1,575 1,327 74 1,536 1,747 2,228 891 1,750 1,474
75 1,433 1,631 2,079 832 1,632 1,377 75 1,593 1,812 2,310 924 1,813 1,530
76 1,484 1,687 2,151 861 1,689 1,424 76 1,649 1,875 2,391 957 1,877 1,582
77 1,534 1,745 2,224 889 1,746 1,472 77 1,704 1,939 2,471 988 1,940 1,636
78 1,583 1,802 2,296 919 1,803 1,520 78 1,760 2,002 2,552 1,021 2,003 1,689
79 1,636 1,861 2,372 949 1,862 1,570 79 1,818 2,067 2,636 1,054 2,069 1,744
80 1,687 1,918 2,447 979 1,920 1,619 80 1,875 2,132 2,718 1,088 2,134 1,799
81 1,740 1,979 2,523 1,009 1,980 1,671 81 1,933 2,199 2,804 1,121 2,201 1,856
82 1,794 2,041 2,602 1,041 2,042 1,722 82 1,994 2,268 2,891 1,156 2,269 1,913
83 1,850 2,104 2,683 1,073 2,105 1,776 83 2,056 2,338 2,981 1,193 2,339 1,973
84 1,907 2,168 2,765 1,106 2,170 1,830 84 2,119 2,409 3,072 1,229 2,412 2,034
85 1,973 2,244 2,861 1,145 2,246 1,893 85 2,192 2,493 3,179 1,272 2,496 2,103
86 2,030 2,308 2,943 1,177 2,310 1,948 86 2,255 2,564 3,270 1,308 2,566 2,164
87 2,086 2,373 3,026 1,211 2,375 2,002 87 2,318 2,637 3,362 1,345 2,639 2,225
88 2,145 2,440 3,111 1,244 2,442 2,059 88 2,384 2,711 3,457 1,383 2,713 2,288
89 2,205 2,507 3,197 1,279 2,510 2,116 89 2,450 2,786 3,552 1,421 2,789 2,351
90 2,266 2,577 3,285 1,315 2,579 2,175 90 2,518 2,863 3,651 1,461 2,865 2,416
91 2,327 2,647 3,375 1,350 2,649 2,233 91 2,585 2,941 3,750 1,500 2,943 2,481
92 2,390 2,718 3,466 1,386 2,721 2,293 92 2,655 3,021 3,851 1,540 3,023 2,548
93 2,454 2,791 3,558 1,424 2,793 2,355 93 2,727 3,101 3,954 1,582 3,104 2,617
94 2,518 2,864 3,652 1,461 2,867 2,417 94 2,797 3,183 4,057 1,623 3,185 2,686
95 2,584 2,939 3,747 1,499 2,942 2,480 95 2,871 3,266 4,164 1,666 3,269 2,755
96 2,651 3,016 3,844 1,538 3,018 2,544 96 2,946 3,351 4,271 1,709 3,353 2,827
97 2,718 3,092 3,943 1,577 3,094 2,609 97 3,021 3,436 4,381 1,752 3,438 2,899
98 2,788 3,171 4,043 1,617 3,173 2,675 98 3,098 3,524 4,492 1,797 3,526 2,973
99+ 2,857 3,250 4,143 1,657 3,252 2,742 99+ 3,174 3,611 4,603 1,841 3,613 3,046
Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833
The above rates do not include the $20 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.
Rates Effective 8/1/2018
Female Rates
Aetna Health and Life Insurance CompanyAnnual Premiums
For Use in: Rest of State
AHLMS03846LA 08/2018 A 07/2017 C 5
Attained Preferred Attained Standard
Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N
Under 65 3,198 3,637 4,637 1,855 3,640 3,070 Under 65 3,553 4,039 5,151 2,060 4,045 3,411
65 1,320 1,500 1,915 765 1,504 1,266 65 1,466 1,667 2,127 851 1,670 1,408
66 1,320 1,500 1,915 765 1,504 1,266 66 1,466 1,667 2,127 851 1,670 1,408
67 1,320 1,500 1,915 765 1,504 1,266 67 1,466 1,667 2,127 851 1,670 1,408
68 1,337 1,520 1,938 775 1,521 1,282 68 1,486 1,689 2,153 861 1,691 1,425
69 1,365 1,553 1,979 792 1,554 1,310 69 1,516 1,725 2,199 880 1,727 1,456
70 1,401 1,594 2,032 813 1,595 1,345 70 1,556 1,771 2,259 903 1,772 1,495
71 1,443 1,641 2,093 837 1,642 1,385 71 1,603 1,824 2,326 930 1,825 1,538
72 1,488 1,693 2,158 863 1,694 1,428 72 1,653 1,882 2,398 959 1,883 1,587
73 1,536 1,747 2,228 891 1,748 1,474 73 1,706 1,941 2,476 990 1,943 1,639
74 1,591 1,809 2,307 923 1,811 1,527 74 1,766 2,010 2,562 1,025 2,013 1,696
75 1,649 1,875 2,391 957 1,876 1,583 75 1,832 2,084 2,657 1,063 2,085 1,760
76 1,706 1,940 2,474 990 1,943 1,637 76 1,896 2,157 2,750 1,100 2,159 1,820
77 1,764 2,007 2,558 1,023 2,008 1,693 77 1,959 2,230 2,841 1,136 2,231 1,882
78 1,821 2,072 2,641 1,056 2,074 1,748 78 2,023 2,303 2,935 1,174 2,304 1,943
79 1,882 2,140 2,728 1,092 2,141 1,805 79 2,091 2,377 3,031 1,213 2,379 2,006
80 1,940 2,206 2,814 1,126 2,208 1,862 80 2,157 2,452 3,126 1,251 2,454 2,069
81 2,001 2,276 2,901 1,160 2,277 1,922 81 2,223 2,528 3,225 1,289 2,531 2,135
82 2,063 2,348 2,993 1,197 2,349 1,980 82 2,293 2,608 3,324 1,329 2,609 2,200
83 2,127 2,420 3,085 1,234 2,421 2,042 83 2,365 2,689 3,428 1,371 2,690 2,269
84 2,192 2,494 3,179 1,272 2,496 2,104 84 2,437 2,770 3,533 1,413 2,774 2,339
85 2,269 2,581 3,291 1,317 2,583 2,177 85 2,521 2,867 3,656 1,463 2,871 2,418
86 2,334 2,654 3,384 1,353 2,657 2,240 86 2,594 2,948 3,760 1,505 2,952 2,489
87 2,399 2,729 3,480 1,392 2,731 2,303 87 2,666 3,032 3,866 1,547 3,035 2,559
88 2,466 2,807 3,577 1,431 2,809 2,368 88 2,742 3,117 3,975 1,591 3,121 2,631
89 2,536 2,883 3,677 1,471 2,886 2,433 89 2,817 3,204 4,085 1,634 3,207 2,704
90 2,606 2,963 3,778 1,512 2,965 2,501 90 2,896 3,293 4,199 1,680 3,295 2,778
91 2,675 3,044 3,881 1,553 3,046 2,568 91 2,973 3,382 4,312 1,725 3,384 2,853
92 2,748 3,126 3,986 1,594 3,129 2,638 92 3,053 3,474 4,429 1,771 3,477 2,931
93 2,822 3,210 4,092 1,637 3,212 2,708 93 3,136 3,566 4,548 1,820 3,569 3,009
94 2,896 3,294 4,200 1,680 3,297 2,779 94 3,217 3,660 4,666 1,867 3,662 3,089
95 2,972 3,380 4,309 1,724 3,383 2,852 95 3,301 3,756 4,789 1,916 3,759 3,169
96 3,049 3,468 4,421 1,769 3,470 2,925 96 3,388 3,854 4,912 1,966 3,856 3,251
97 3,126 3,556 4,534 1,813 3,558 3,001 97 3,474 3,951 5,038 2,015 3,953 3,334
98 3,206 3,647 4,649 1,860 3,649 3,077 98 3,563 4,052 5,166 2,066 4,055 3,419
99+ 3,285 3,737 4,765 1,906 3,740 3,153 99+ 3,650 4,153 5,294 2,117 4,155 3,503
Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833
The above rates do not include the $20 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.
Rates Effective 8/1/2018
Male Rates
Aetna Health and Life Insurance CompanyAnnual Premiums
For Use in: Rest of State
AHLMS03846LA 08/2018 A 6
PREMIUM INFORMATION
Aetna Health and Life Insurance Company 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 an Aetna Health and Life Insurance Company 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 Health and Life Insurance Company Medicare supplement policy. The Medicare eligible adult must be either (a) your spouse; (b) be someone with whom you are in a civil union partnership; and (c) be 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 Aetna Health and Life Insurance Company, 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 Aetna Health and 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 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 AENTA HEALTH AND LIFE INSURANCE COMPANY.
AHLMS03846LA 08/2018 A 7
PLAN A MEDICARE (PART A) – HOSPITAL SERVICES – PER CALENDAR YEAR
*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.
AHLMS03846LA 08/2018 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.
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 $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*
$0 $0 $183 (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 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*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
AHLMS03846LA 08/2018 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.
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 $1340 (Part A Deductible)
$0
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 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.
AHLMS03846LA 08/2018 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.
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 $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*
$0 $0 $183 (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 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*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
AHLMS03846LA 08/2018 A 11
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.
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 $1340 (Part A Deductible)
$0
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
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.
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 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.
AHLMS03846LA 08/2018 A 12
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.
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 $183 of Medicare-Approved amounts*
$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 $183 (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
SERVICES MEDICARE PAYS
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*
$0 $183 (Part B Deductible)
$0
Remainder of Medicare Approved amounts 80% 20% $0
AHLMS03846LA 08/2018 A 13
PLAN F
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS
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
AHLMS03846LA 08/2018 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
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1340 $1340 (Part A Deductible)
$0
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
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
AHLMS03846LA 08/2018 A 15
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 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.
AHLMS03846LA 08/2018 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
IN ADDITION TO $2240
DEDUCTIBLE*** 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 $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 $183 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
AHLMS03846LA 08/2018 A 17
HIGH DEDUCTIBLE PLAN F
PARTS A & B
SERVICES
MEDICARE PAYS
AFTER YOU PAY $2240
DEDUCTIBLE*** PLAN PAYS
IN ADDITION TO $2240
DEDUCTIBLE*** 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*
$0 $183 (Part B Deductible)
$0
Remainder of Medicare Approved amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES
MEDICARE PAYS
AFTER YOU PAY $2240
DEDUCTIBLE** PLAN PAYS
IN ADDITION TO $2240
DEDUCTIBLE** 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
AHLMS03846LA 08/2018 A 18
PLAN G
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 $1340 (Part A Deductible)
$0
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
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
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 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.
AHLMS03846LA 08/2018 A 19
PLAN G
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.
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 $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) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*
$0 $0 $183 (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 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*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
AHLMS03846LA 08/2018 A 20
PLAN G
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS
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
AHLMS03846LA 08/2018 A 21
PLAN N 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 $1340 (Part A Deductible)
$0
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
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
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 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.
AHLMS03846LA 08/2018 A 22
PLAN N
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.
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 $183 of Medicare-Approved amounts*
$0 $0 $183 (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 copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
Part B Excess Charges (Above Medicare-Approved amounts) $0 0% All costs BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
AHLMS03846LA 08/2018 A 23
PLAN N
PARTS A & B
SERVICES MEDICARE PAYS
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*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS
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