great southern life insurance company outline of coverage medicare supplement … · 2019. 12....

GREAT SOUTHERN LIFE INSURANCE COMPANY Outline of Coverage

Medicare Supplement Benefit Plans A, F, High Deductible F, G, and N.

GAA500r-OC Effective: 03/01/2019

Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010. Every insurer must make available Plan “A.” Some plans may not be available in your state. See Outline of Coverage sections for details about ALL plans. “Basic Benefits” are: • Hospitalization – Part A coinsurance plus coverage for 365 additional days after Medicare Benefits end.• Medical Expenses – Part B coinsurance (generally 20% of Medicare approved amounts) or copayments for hospital outpatient services. Plans K, L, and N require

insured’s to pay a portion of Part B coinsurance or copayments.• Blood – First three pints of blood each year.• Hospice – Part A coinsurance• Only Medicare Supplement Benefit Plans A, F, High Deductible F, G, and N are offered by Great Southern Life Insurance Company.

A B C D F / F* G K L M N Basic including 100% Part B Coinsurance

Basic including 100% Part B Coinsurance





Hospitalization and preventative care paid at 100%; other Basic Benefits paid at 50%

Hospitalization and preventative care paid at 100%; other Basic Benefits paid at 75%


Basic including 100% Part B Coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for Emergency Room that don’t result in inpatient admission.

Skilled Nursing Facility Coinsurance




50% Skilled Nursing Facility Coinsurance

75% Skilled Nursing Facility Coinsurance



Part A Deductible Part A Deductible Part A Deductible

Part A Deductible

Part A Deductible

50% Part A Deductible



Part A Deductible

Part B Deductible Part B Deductible Part B Excess 100%

Part B Excess 100%

Foreign Travel Emergency






Out-of-Pocket limit $5,560; paid at 100% after limit reached.

Out–of-Pocket limit $2,780; paid at 100% after limit reached.

*Plan F also has an option called a High Deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year’s $2,300deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses exceed $2,300. Out-of-pocket expenses for this deductible are expenses thatwould have ordinarily been paid by the Policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate ForeignTravel Emergency deductible.

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For Annual Premium mode, multiply monthly rates by 12. For Class 1 rates multiply by 1.15. GNC500-OC RATES Household Premium Discount of 10% may apply. See Household Premium Discount description. Effective: 03/01/2019

RATES

Monthly Rates by Plan – North Carolina Zip Codes: All Zip Codes

Non-Tobacco Rates Attained

Age Plan A HD Plan F Plan F Plan G Plan N

Female Male Female Male Female Male Female Male Female Male0-64 325.48 374.30 NA NA 387.55 445.69 NA NA NA NA65 108.49 124.77 37.21 42.79 129.18 148.56 105.06 120.82 89.40 102.8166 108.49 124.77 37.21 42.79 129.18 148.56 105.06 120.82 89.40 102.8167 108.49 124.77 37.21 42.79 129.18 148.56 105.06 120.82 89.40 102.8168 108.49 124.77 37.21 42.79 129.18 148.56 105.06 120.82 89.40 102.8169 110.59 127.18 38.41 44.17 131.50 151.22 107.44 123.55 91.28 104.9870 114.72 131.92 40.30 46.34 136.06 156.47 111.61 128.35 94.75 108.9671 118.15 135.87 41.73 47.99 140.46 161.52 115.63 132.98 98.21 112.9472 121.58 139.82 43.16 49.63 144.85 166.58 119.65 137.60 101.66 116.9173 125.39 144.19 44.72 51.43 149.69 172.15 124.05 142.65 105.44 121.2574 129.22 148.60 46.29 53.24 154.57 177.75 128.46 147.73 109.23 125.6175 134.13 154.25 48.12 55.33 160.74 184.85 133.97 154.06 113.95 131.0476 137.66 158.31 49.60 57.04 166.04 190.94 138.64 159.44 118.10 135.8277 141.27 162.46 51.10 58.77 171.44 197.16 143.42 164.93 122.35 140.7078 145.08 166.85 52.63 60.53 177.14 203.71 148.44 170.71 126.81 145.8379 149.13 171.50 54.18 62.31 183.14 210.62 153.73 176.79 131.50 151.2280 153.26 176.25 55.75 64.11 189.29 217.68 159.14 183.02 136.30 156.7481 157.98 181.67 57.35 65.95 196.87 226.40 165.78 190.64 142.32 163.6782 162.83 187.25 58.98 67.82 204.70 235.41 172.62 198.52 148.54 170.8383 167.65 192.80 60.62 69.72 212.57 244.46 179.51 206.44 154.82 178.0484 172.60 198.50 62.29 71.64 220.68 253.78 186.62 214.61 161.29 185.4985 177.69 204.35 63.92 73.51 229.04 263.40 193.95 223.04 167.97 193.1786 182.18 209.51 65.31 75.10 236.60 272.09 200.54 230.62 173.99 200.0987 186.78 214.80 66.71 76.72 244.38 281.04 207.32 238.42 180.19 207.2288 191.49 220.21 68.13 78.35 252.39 290.24 214.30 246.45 186.57 214.5689 196.32 225.77 69.56 80.00 260.62 299.71 221.48 254.71 193.14 222.1190 201.26 231.45 71.01 81.66 269.08 309.45 228.87 263.20 199.91 229.8991 205.69 236.55 72.33 83.18 277.16 318.73 235.90 271.28 206.40 237.3692 209.40 240.80 73.67 84.72 284.34 326.99 242.16 278.49 212.24 244.0793 213.16 245.14 75.02 86.28 291.68 335.43 248.57 285.86 218.22 250.9594 217.00 249.55 76.39 87.85 299.19 344.06 255.13 293.40 224.34 257.9995 220.91 254.04 77.78 89.44 306.87 352.90 261.84 301.12 230.61 265.2096 224.22 257.85 78.32 90.07 311.47 358.19 265.77 305.64 234.07 269.1897 227.58 261.72 78.87 90.70 316.14 363.56 269.76 310.22 237.58 273.2198 231.00 265.65 79.42 91.33 320.88 369.02 273.80 314.88 241.14 277.3199 234.46 269.63 79.98 91.97 325.7 374.55 277.91 319.6 244.76 281.47

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For Annual Premium mode, multiply monthly rates by 12. For Class 1 rates multiply by 1.15. GNC500-OC RATES Household Premium Discount of 10% may apply. See Household Premium Discount description. Effective: 03/01/2019

RATES

Monthly Rates by Plan – North Carolina Zip Codes: All Zip Codes

Tobacco Rates Attained

Age Plan A HD Plan F Plan F Plan G Plan N

Female Male Female Male Female Male Female Male Female Male0-64 374.30 430.44 NA NA 445.69 512.54 NA NA NA NA65 124.77 143.48 42.79 49.21 148.56 170.85 120.82 138.94 102.81 118.2366 124.77 143.48 42.79 49.21 148.56 170.85 120.82 138.94 102.81 118.2367 124.77 143.48 42.79 49.21 148.56 170.85 120.82 138.94 102.81 118.2368 124.77 143.48 42.79 49.21 148.56 170.85 120.82 138.94 102.81 118.2369 127.18 146.25 44.17 50.80 151.22 173.90 123.55 142.08 104.98 120.7270 131.92 151.71 46.34 53.29 156.47 179.94 128.35 147.60 108.96 125.3171 135.87 156.25 47.99 55.18 161.52 185.75 132.98 152.92 112.94 129.8872 139.82 160.79 49.63 57.08 166.58 191.57 137.60 158.24 116.91 134.4573 144.19 165.82 51.43 59.14 172.15 197.97 142.65 164.05 121.25 139.4474 148.60 170.89 53.24 61.22 177.75 204.41 147.73 169.89 125.61 144.4675 154.25 177.38 55.33 63.63 184.85 212.58 154.06 177.17 131.04 150.6976 158.31 182.06 57.04 65.60 190.94 219.58 159.44 183.36 135.82 156.1977 162.46 186.83 58.77 67.59 197.16 226.74 164.93 189.67 140.70 161.8078 166.85 191.87 60.53 69.61 203.71 234.27 170.71 196.32 145.83 167.7079 171.50 197.22 62.31 71.65 210.62 242.21 176.79 203.31 151.22 173.9080 176.25 202.69 64.11 73.73 217.68 250.33 183.02 210.47 156.74 180.2681 181.67 208.93 65.95 75.85 226.40 260.36 190.64 219.24 163.67 188.2282 187.25 215.34 67.82 78.00 235.41 270.72 198.52 228.29 170.83 196.4583 192.80 221.72 69.72 80.18 244.46 281.13 206.44 237.41 178.04 204.7584 198.50 228.27 71.64 82.38 253.78 291.85 214.61 246.81 185.49 213.3185 204.35 235.00 73.51 84.54 263.40 302.90 223.04 256.49 193.17 222.1486 209.51 240.93 75.10 86.37 272.09 312.91 230.62 265.21 200.09 230.1087 214.80 247.02 76.72 88.22 281.04 323.20 238.42 274.18 207.22 238.3088 220.21 253.25 78.35 90.10 290.24 333.78 246.45 283.41 214.56 246.7489 225.77 259.63 80.00 91.99 299.71 344.67 254.71 292.91 222.11 255.4390 231.45 266.17 81.66 93.91 309.45 355.86 263.20 302.68 229.89 264.3891 236.55 272.03 83.18 95.66 318.73 366.54 271.28 311.97 237.36 272.9692 240.80 276.92 84.72 97.43 326.99 376.03 278.49 320.26 244.07 280.6893 245.14 281.91 86.28 99.22 335.43 385.74 285.86 328.74 250.95 288.5994 249.55 286.98 87.85 101.03 344.06 395.67 293.40 337.41 257.99 296.6995 254.04 292.15 89.44 102.86 352.90 405.83 301.12 346.29 265.20 304.9896 257.85 296.53 90.07 103.58 358.19 411.92 305.64 351.48 269.18 309.5597 261.72 300.98 90.70 104.30 363.56 418.10 310.22 356.75 273.21 314.1998 265.65 305.49 91.33 105.03 369.02 424.37 314.88 362.11 277.31 318.9199 269.63 310.08 91.97 105.77 374.55 430.74 319.6 367.54 281.47 323.69

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GAA500r-OC Effective: 03/01/2019

Premium Information. Great Southern Life Insurance Company can only raise your premium if we raise the premium for all policies like yours in the same geographic area of the state where you live. Until you are age 99, your premium may change each year. This change will only be made on the first renewal date that coincides with or follows each anniversary of the effective date. Schedules of rates may vary depending upon your effective date.

One time Policy Fee: $25.00

Disclosures. Use this outline to compare benefits and premiums among policies. Household Premium Discount. If you resided with at least one, but no more than three, other adults who are age 60 or older for the past year, you will be eligible for a household premium discount. The discounted premium will be priced 10% lower than the rates illustrated. Your policy's household premium discount will be removed if the other adult no longer resides with you (other than in the case of his or her death). 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 us.

Right to Return Policy. If you find that you are not satisfied with your policy, you may return it to us at our Medicare Supplement Administrative Offices: PO Box 10812, Clearwater, FL 33757-8812. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.

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

Notice. The policy may not fully cover all of your medical costs. Neither we nor our agents are connected with Medicare. This outline does not give all the details of Medicare coverage. Contact your local Social Security office or consult “Medicare & You” for more details.

Refund of Premium. In the event of cancellation or death, We will promptly return the unearned portion of any premium paid.

Complete Answers Are Very Important. When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. We 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.

No Health Review. No health review is required if you enroll within the first six months after you reach age 65 and enroll in Medicare Part B, or in other situations as required by law.

PLEASE REFER TO YOUR POLICY FOR DETAILS.

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GAA500r-OC Effective: 03/01/2019 Plan 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 carein any other facility for 60 days in a row.

Services Medicare Pays Plan A Pays You Pay Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,364 $0 $1,364 Part A Deductible 61st thru 90th day All but $341 a day $341 a day $0 91st day and after

- While using 60 lifetime reserve days- Once lifetime reserve days are used

Additional 365 days Beyond the additional 365 days

All but $682 a day

$0 $0

$682 a day

100% of Medicare Eligible Expenses $0

$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 21st thru 100th days 101st day and after

All approved amounts All but $170.50 a day $0

$0 $0 $0

$0 Up to $170.50 a day All Costs

Blood First 3 pints Additional amounts

$0 100%

3 pints $0

$0 $0

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

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

Medicare copayment/coinsurance $0

** When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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GAA500r-OC Effective: 03/01/2019 Plan A

Plan A Medicare Part B – Medical Services per Calendar Year *Once you have been billed $185 of Medicare Eligible Expenses for covered services, your Medicare Part B Deductible will have been met for the calendar year.

Services Medicare Pays Plan A 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 $185 of Medicare approved amounts* Remainder of Medicare approved amounts

$0 Generally 80%

$0 Generally 20%

$185 Part B Deductible $0

Part B Excess Charges (above Medicare approved amounts) $0 $0 All costs Blood First 3 pints Next $185 of Medicare approved amounts* Remainder of Medicare approved amounts

$0 $0 80%

All costs $0 20%

$0 $185 Part B Deductible $0

Clinical Laboratory Services – Tests for diagnostic services 100% $0 $0

Parts A & B Services Medicare Pays Plan A Pays You Pay Home Health Care Medicare Eligible Services - Medically necessary skilled care services and medical supplies- Durable medical equipment. First $185 of Medicare approved amounts*- Remainder of Medicare approved amounts

100% $0 80%

$0 $0 20%


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GAA500r-OC Effective: 03/01/2019 Plan F and High Deductible Plan F

Plan F and 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 skilledcare in any other facility for 60 days in a row.

Services Medicare Pays Plan F Pays You Pay

High Deductible Plan F Pays (after you pay $2,300

Deductible***

You Pay (In addition to

$2,300 Deductible***)

Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,364 $1,364 Part A

Deductible $0 $1,364 Part A Deductible $0

61st thru 90th day All but $341 a day $341 a day $0 $341 a day $0 91st day and after


Additional 365 days

Beyond the additional 365 days

All but $682 a day

$0 $0

$682 a day


$0

$0**

All Costs

$682 a day


$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

21st thru 100th days

101st day and after


$0

Up to $170.50 a day $0

$0

$0

All Costs

$0

Up to $170.50 a day

$0

$0

$0

All Costs

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Plan F and High Deductible Plan F Medicare Part A – Hospital Services Per Benefit Period (Continued)


High Deductible Plan F Pays (after you pay $2,300

Deductible***




$0 100%

3 pints $0

$0 $0

3 pints $0

$0 $0


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

Medicare copayment/ coinsurance

$0 Medicare copayment/coinsurance

$0

**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. ***High Deductible Plan F pays the same benefits as Plan F after one has paid a calendar year $2,300 deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses exceed $2,300. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy/certificate. These expenses include the Medicare deductibles for Pay A and Part B, but do not include the plan’s separate Foreign Travel Emergency deductible.

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Plan F and High Deductible Plan F Medicare Part B – Medical Services per Calendar Year *Once you have been billed $185 of Medicare Approved amounts for covered services, your Medicare Part B Deductible will have been met for the calendar year.


High Deductible Plan F Pays (after

you pay $2,300 Deductible***



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 $185 of Medicare approved amounts*

Remainder of Medicare approved amounts

$0

Generally 80%

$185 Part B Deductible Generally 20%

$0

$0

$185 Part B Deductible Generally 20%

$0

$0 Part B Excess Charges (above Medicare approved amounts)

$0 100% $0 100% $0

Blood First 3 pints Next $185 of Medicare approved amounts*

Remainder of Medicare approved amounts

$0 $0

80%

All costs $185 Part B Deductible 20%

$0 $0

$0

All costs $185 Part B Deductible 20%

$0 $0

$0 Clinical Laboratory Services – Tests for Diagnostic services

100% $0 $0 $0 $0

***High Deductible Plan F pays the same benefits as Plan F after one has paid a calendar year $2,300 deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses exceed $2,300. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy/certificate. These expenses include the Medicare deductibles for Pay A and Part B, but do not include the plan’s separate Foreign Travel Emergency deductible.

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Plan F and High Deductible Plan F Parts A & B

Services Medicare

Pays Plan F Pays You Pay



You Pay (In addition to $2,300

Deductible***) Home Health Care Medicare Eligible Services - Medically necessary skilled care services and

medical supplies- Durable medical equipment. First $185 of

Medicare approved amounts*- Remainder of Medicare approved amounts

100%

$0

80%

$0

$185 Part B Deductible 20%

$0

$0

$0

$0

$185 Part B Deductible 20%

$0

$0

$0

Other Benefits Not Covered by Medicare

Services Medicare

Pays Plan F Pays You Pay



You Pay (In addition to $2,300

Deductible***) Foreign Travel Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA. First $250 each calendar year Remainder of charges

$0 $0

$0 80% to a lifetime maximum benefit of $50,000.

$250 20% and amounts over the $50,000 lifetime maximum.



**High Deductible Plan F pays the same benefits as Plan F after one has paid a calendar year $2,300 deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses exceed $2,300. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy/certificate. These expenses include the Medicare deductibles for Pay A and Part B, but do not include the plan’s separate foreign travel emergency deductible.

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GAA500r-OC Effective: 03/01/2019 Plan G

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 skilledcare in any other facility for 60 days in a row.

Services Medicare Pays Plan G Pays You Pay *HospitalizationSemiprivate room and board, general nursing and miscellaneousservices and supplies.First 60 days All but $1,364 $1,364 Part A Deductible $0 61st thru 90th day All but $341 a day $341 a day $0 91st day and after



All but $682 a day

$0 $0

$682 a day


$0

$0** All Costs

*Skilled Nursing Facility CareYou must meet Medicare’s requirements, including having been in ahospital for at least 3 days and entered a Medicare approved facilitywithin 30 days after leaving the hospital.First 20 days21st thru 100 days101st day and after


$0 Up to $170.50 a day $0

$0 $0 All Costs


$0 100%

3 pints $0

$0 $0





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Plan G Medicare Part B – Medical Services per Calendar Year *Once you have been billed $185 of Medicare approved amounts for covered services, your Medicare Part B Deductible will have been met for the calendar year.

Services Medicare Pays Plan G Pays You Pay *Medical ExpensesIn 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 $185 of Medicare approved amounts* Remainder of Medicare approved amounts

$0 Generally 80%

$0 Generally 20%

$185 Part B Deductible $0

Part B Excess Charges (above Medicare approved amounts) $0 100% $0 Blood First 3 pints Next $185 of Medicare approved amounts* Remainder of Medicare approved amounts

$0 $0 80%

All costs $0 20%


Clinical Laboratory Services – Tests for Diagnostic services 100% $0 $0

Parts A & B Services Medicare Pays Plan G Pays You Pay Home Health Care Medicare Eligible Services - Medically necessary skilled care services and medical supplies- Durable medical equipment. First $185 of Medicare approved amounts*- Remainder of Medicare approved amounts

100% $0 80%

$0 $0 20%


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Plan G Other Benefits Not Covered by Medicare

Services Medicare Pays Plan G Pays You Pay Foreign Travel Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA. First $250 each calendar year Remainder of Charges

$0 $0



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GAA500r-OC Effective: 03/01/2019Plan N

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 skilledcare in any other facility for 60 days in a row.

Services Medicare Pays Plan N Pays You Pay Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,364 $1,364 Part A Deductible $0 61st thru 90th day All but $341 a day $341 a day $0 91st day and after



All but $682 a day

$0 $0

$682 a day


$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 21st thru 100 days 101st day and after


$0 $Up to $170.50 a day $0

$0 $0 All Costs


$0 100%

3 pints $0

$0 $0





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GAA500r-OC Effective: 03/01/2019Plan N

Plan N Medicare Part B – Medical Services per Calendar Year *Once you have been billed $185 of Medicare Approved amounts for covered services, your Medicare Part B Deductible will have been met for the calendar year.

Services Medicare Pays Plan N Pays You Pay *Medical ExpensesIn or out of the hospital and outpatient hospital treatment, such as Physician’sservices, inpatient and outpatient medical and surgical services and supplies,physical and speech therapy, diagnostic tests, durable medical equipmentFirst $185 of Medicare approved amounts*Remainder of Medicare approved amounts

$0 Generally 80%

$0 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.

$185 Part B Deductible 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 Next $185 of Medicare approved amounts* Remainder of Medicare approved amounts

$0 $0 80%

All costs $0 20%


Clinical Laboratory Services – Tests for diagnostic services 100% $0 $0 Parts A & B

Services Medicare Pays Plan N Pays You Pay Home Health Care Medicare Eligible Services - Medically necessary skilled care services and medical supplies- Durable medical equipment. First $185 of Medicare approved amounts- Remainder of Medicare approved amounts

100% $0 80%

$0 $0 20%


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GAA500r-OC Effective: 03/01/2019 Plan N

Plan N Other Benefits Not Covered by Medicare

Services Medicare Pays Plan N Pays You Pay Foreign Travel Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA. First $250 each calendar year Remainder of charges

$0 $0



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great southern life insurance company outline of coverage medicare supplement … · 2019. 12....

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