medigap - paramounthealthcare.com · 78 $185.25 $175.99 $242.12 $230.02 $253.45 $240.78 79 $191.67...

2020 MICHIGAN OUTLINE OF MEDICARE SUPPLEMENT COVERAGE

MediGapPlans A, C, F, G and N

This

cha

rt sh

ows

the

bene

fits

incl

uded

in e

ach

of th

e st

anda

rd M

edic

are

supp

lem

ent p

lans

with

an

effe

ctiv

e da

te fo

r cov

erag

e on

or a

fter J

une

1,

2010

. Eve

ry c

ompa

ny m

ust m

ake

avai

labl

e Pl

an “A

”. So

me

plan

s m

ay n

ot b

e av

aila

ble

in y

our s

tate

.

Basi

c Be

nefit

s:

• Hos

pita

lizat

ion

– Pa

rt A

coin

sura

nce

plus

cov

erag

e fo

r 365

add

itiona

l day

s af

ter M

edic

are

bene

fits

end.

• Med

ical

Exp

ense

s –

Part

B co

insu

ranc

e (g

ener

ally

20%

of M

edic

are-

appr

oved

exp

ense

s) o

r cop

aym

ents

for h

ospi

tal o

utpa

tient

se

rvic

es. P

lan

N re

quire

insu

reds

to p

ay a

por

tion

of P

art B

coi

nsur

ance

or c

opay

men

ts.

• Blo

od –

Firs

t thr

ee p

ints

of b

lood

eac

h ye

ar.

• Hos

pice

– P

art A

coi

nsur

ance

.

BENE

FIT

CHAR

T O

F M

EDIC

ARE

SUPP

LEM

ENT

PLAN

S

SOLD

FO

R EF

FECT

IVE

DATE

S O

N O

R AF

TER

JUNE

1, 2

010

*Pla

n F

has

an o

ptio

n ca

lled

a hi

gh d

educ

tible

pla

n F.

Thi

s hi

gh d

educ

tible

pla

n pa

ys th

e sa

me

bene

fits

as p

lan

F af

ter o

ne h

as p

aid

a ca

lend

ar y

ear

$2,3

40 d

educ

tible

. Ben

efits

from

hig

h de

duct

ible

pla

n F

will

not b

egin

unt

il out

-of-p

ocke

t exp

ense

s ex

ceed

$2,

340

Out

-of-p

ocke

t exp

ense

s fo

r thi

s de

duct

ible

are

exp

ense

s th

at w

ould

ord

inar

ily b

e pa

id b

y th

e po

licy.

Thes

e ex

pens

es in

clud

e th

e M

edic

are

dedu

ctib

les

for P

art A

and

Par

t B, b

ut d

o no

t inc

lude

the

Plan

’s se

para

te fo

reig

n tra

vel e

mer

genc

y de

duct

ible

.

AB

CD

FG

KL

MN

Bas

ic, i

nclu

din

g

100%

Par

t B

co

insu

ranc

e

Bas

ic, i

nclu

din

g

100%

Par

t B

co

insu

ranc

e

Bas

ic, i

nclu

din

g

100%

Par

t B

co

insu

ranc

e

Bas

ic, i

nclu

din

g

100%

Par

t B

co

insu

ranc

e

Bas

ic, i

nclu

din

g

100%

Par

t B

co

insu

ranc

e

Bas

ic, i

nclu

din

g

100%

Par

t B

co

insu

ranc

e

Hos

pita

lizat

ion

and

pre

vent

ive

care

pai

d a

t 10

0%; o

ther

b

asic

ben

efits

p

aid

at

50%

Hos

pita

lizat

ion

and

pre

vent

ive

care

pai

d a

t 10

0%; o

ther

b

asic

ben

efits

p

aid

at

75%

Bas

ic, i

nclu

din

g

100%

Par

t B

co

insu

ranc

e

Bas

ic,

incl

udin

g 1

00%

Pa

rt B

co

insu

ranc

e,

exce

pt

up t

o $2

0 co

pay

men

t fo

r of

fice

visi

t,

and

up

to

$50

cop

aym

ent

for

ER

Skill

ed N

ursi

ng

Faci

lity

Coi

nsur

ance

Skill

ed N

ursi

ng

Faci

lity

Coi

nsur

ance

Skill

ed N

ursi

ng

Faci

lity

Coi

nsur

ance

Skill

ed N

ursi

ng

Faci

lity

Coi

nsur

ance

50%

Ski

lled

N

ursi

ng F

acili

ty

Coi

nsur

ance

75%

Ski

lled

N

ursi

ng F

acili

ty

Coi

nsur

ance

Skill

ed N

ursi

ng

Faci

lity

Coi

nsur

ance

Skill

ed N

ursi

ng

Faci

lity

Coi

nsur

ance

Part

A

Ded

uctib

lePa

rt A

D

educ

tible

Part

A

Ded

uctib

lePa

rt A

D

educ

tible

Part

A

Ded

uctib

le50

% P

art

A

Ded

uctib

le75

% P

art

A

Ded

uctib

le50

% P

art

A

Ded

uctib

lePa

rt A

D

educ

tible

Part

B

Ded

uctib

lePa

rt B

D

educ

tible

Part

B E

xces

s (1

00%

)Pa

rt B

Exc

ess

(100

%)

Fore

ign

Trav

el

Emer

gen

cyFo

reig

n Tr

avel

Em

erg

ency

Fore

ign

Trav

el

Emer

gen

cyFo

reig

n Tr

avel

Em

erg

ency

Fore

ign

Trav

el

Emer

gen

cyFo

reig

n Tr

avel

Em

erg

ency

Out

-of-

Pock

et

Lim

it $5

,880

; p

aid

at

100%

af

ter

limit

reac

hed

Out

-of-

Pock

et

Lim

it $2

,940

; p

aid

at

100%

af

ter

limit

reac

hed

MEDICARE SUPPLEMENT PREMIUM INFORMATION THESE RATES ARE EFFECTIVE 01/01/2020

*Use the age 65 rate if You turned 65 this calendar year.

Paramount determines premiums for its Medicare Supplement policies based upon attained age. This means your premium will increase automatically as you get older. Your premium may also change if premiums for these policies change.If you choose to pay directly by check, you will be billed monthly for the applicable premium listed below. If you choose to pay your premium through our automated bank deduction program, premiums will be withdrawn from your bank monthly.To find the amount of premium you will pay, find your age as of December 31 of the previous year in the first column then choose the plan in which you are interested from one of the next five columns.

MICHIGAN 2020 MONTHLY MEDICARE SUPPLEMENT RATES

Age MediGap Plan A

without discount

MediGap Plan A

with discount

MediGapPlan C

without discount

MediGap Plan C

with discount

MediGap Plan F

without discount

MediGap Plan F

with discount

0 – 64 $277.47 $263.60 $362.66 $344.52 NA NA65* $107.03 $101.68 $139.89 $132.90 $146.44 $139.1266 $111.97 $106.38 $146.35 $139.03 $153.20 $145.5467 $116.91 $111.07 $152.81 $145.17 $159.96 $151.9668 $123.01 $116.86 $160.77 $152.73 $168.29 $159.8869 $129.10 $122.64 $168.73 $160.30 $176.63 $167.8070 $135.19 $128.43 $176.70 $167.86 $184.96 $175.7271 $141.28 $134.22 $184.66 $175.43 $193.30 $183.6472 $147.38 $140.01 $192.62 $182.99 $201.64 $191.5573 $153.47 $145.80 $200.59 $190.56 $209.97 $199.4774 $159.73 $151.74 $208.76 $198.33 $218.53 $207.6175 $165.98 $157.69 $216.94 $206.10 $227.09 $215.7476 $172.41 $163.79 $225.34 $214.07 $235.88 $224.0977 $178.83 $169.89 $233.73 $222.04 $244.67 $232.4378 $185.25 $175.99 $242.12 $230.02 $253.45 $240.7879 $191.67 $182.09 $250.52 $237.99 $262.24 $249.1380 $198.09 $188.19 $258.91 $245.96 $271.03 $257.4881 $204.52 $194.29 $267.30 $253.94 $279.81 $265.8282 $210.94 $200.39 $275.70 $261.91 $288.60 $274.1783 $217.20 $206.34 $283.88 $269.68 $297.16 $282.3084 $223.29 $212.12 $291.84 $277.25 $305.50 $290.2285 $229.22 $217.76 $299.59 $284.61 $313.61 $297.9386 $234.98 $223.23 $307.12 $291.76 $321.49 $305.4287 $239.92 $227.92 $313.58 $297.90 $328.25 $311.8488 $244.86 $232.62 $320.03 $304.03 $335.01 $318.2689 $249.80 $237.31 $326.49 $310.16 $341.77 $324.68

90+ $254.74 $242.00 $332.95 $316.30 $348.53 $331.10

5


MICHIGAN 2020 MONTHLY MEDICARE SUPPLEMENT RATES (Continued)

Age MediGap Plan G without

discount

MediGap Plan G with

discount

MediGapPlan N without

discount

MediGap Plan N with

discount

0 – 64 NA NA NA NA65* $125.21 $118.95 $116.66 $110.8266 $131.97 $125.37 $122.04 $115.9467 $138.73 $131.79 $127.42 $121.0568 $147.07 $139.72 $134.06 $127.3669 $155.40 $147.63 $140.71 $133.6770 $163.74 $155.55 $147.35 $139.9871 $172.07 $163.47 $153.99 $146.2972 $180.41 $171.39 $160.63 $152.5973 $188.75 $179.31 $167.27 $158.9074 $197.31 $187.44 $174.09 $165.3875 $205.87 $195.58 $180.91 $171.8676 $214.65 $203.92 $187.91 $178.5177 $223.44 $212.27 $194.91 $185.1678 $232.23 $220.62 $201.90 $191.8179 $241.01 $228.96 $208.90 $198.4680 $249.80 $237.31 $215.90 $205.1181 $258.59 $245.66 $222.90 $211.7682 $267.37 $254.00 $229.90 $218.4183 $275.93 $262.13 $236.72 $224.8984 $284.27 $270.06 $243.36 $231.1985 $292.38 $277.76 $249.82 $237.3386 $300.26 $285.25 $256.10 $243.3087 $307.02 $291.67 $261.49 $248.4188 $313.78 $298.09 $272.26 $253.5389 $320.54 $304.51 $277.64 $258.64

90+ $327.30 $310.94 $277.64 $263.76


*Use the age 65 rate if You turned 65 this calendar year.

6

Paramount Insurance Company 1901 Indian Wood Circle Maumee, Ohio 43537 419-887-2525 or 1-800-462-3589

PREMIUM INFORMATIONWe, Paramount Insurance Company, can only raise your premium if we raise the premium for all policies like yours in this State. Paramount determines premiums for its Medicare Supplement policies based upon attained age. This means your premium will increase automatically as you get older.

DISCLOSURESUse this outline to compare benefits and premiums among policies.

READ YOUR POLICY CAREFULLYThis 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 POLICYIf you find that you are not satisfied with your policy, you may return it to Paramount Insurance Company at our address listed above. 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 REPLACEMENTIf you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.

NOTICE• This policy may not fully cover all of your medical costs.• Neither Paramount 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 IMPORTANTWhen you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

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

MEDIGAP SUPPLEMENT COVERAGE BENEFIT PLANS A, C, F, G and N

7

MEDIGAP 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.

** 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.

Services Medicare Pays Plan A Pays You PayHOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies.• First 60 days

All but $1,408

$0

$1,408 (Part A deductible)

• Days 61–90 All but $352 a day $352 a day $0• Day 91 and after:

• While using 60 lifetime reserve days All but $704 a day

$704 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 costsSKILLED NURSING FACILITY CARE*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital.• First 20 days

All approved amounts

$0

$0

• Days 21–100 All but $176 a day

$0 Up to $176 a day

• Day 101 and after $0 $0 All costsBLOOD• First three pints $0 3 pints $0• Additional amounts 100% $0 $0

HOSPICE CAREYou 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

8

MEDIGAP PLAN A

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

*Once you have been billed $198 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 A Pays You PayMEDICAL 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, and durable medical equipment.• First $198 of Medicare-approved amounts*

$0

$0

$198 (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 three pints $0 All costs $0• Next $198 of Medicare-approved amounts* $0 $0 $198 (Part B

deductible)• Remainder of Medicare-approved amounts 80% 20% $0CLINICAL LABORATORY SERVICES• Tests for diagnostic services

100% $0 $0

PARTS A & BHOME HEALTH CARE Medicare-approved services• Medically necessary skilled care services and

medical supplies

100%

$0

$0

• Durable medical equipment: First $198 of Medicare-approved amounts*

$0 $0 $198 (Part B deductible)

• Remainder of Medicare-approved amounts 80% 20% $0

9

MEDIGAP PLAN C



** 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.

Services Medicare Pays Plan C Pays You PayHOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies.• First 60 days

All but $1,408


$0



$704 a day

$0



$0**



$0

$0


Up to $176 a day

$0

• Day 101 and after $0 $0 All costsBLOOD• First three pints $0 3 pints $0• Additional amounts 100% $0 $0HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness.



$0

10

MEDIGAP PLAN C



Services Medicare Pays Plan C Pays You PayMEDICAL 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, and durable medical equipment.• First $198 of Medicare-approved amounts*

$0


$0



BLOOD• First three pints $0 All costs $0• Next $198 of Medicare-approved amounts* $0 $198 (Part B

deductible)$0

• Remainder of Medicare-approved amounts 80% 20% $0CLINICAL LABORATORY SERVICES• Tests for diagnostic services

100% $0 $0


medical supplies

100%

$0

$0


$0 $198 (Part B deductible)

$0

• Remainder of Medicare-approved amounts 80% 20% $0OTHER BENEFITS – NOT COVERED BY MEDICARE

FOREIGN TRAVEL – Not covered by MedicareMedical emergency care services beginning during the first 60 days of each trip outside of 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

11

MEDIGAP PLAN F




Services Medicare Pays Plan F Pays You PayHOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies.• First 60 days

All but $1,408


$0



$704 a day

$0



$0**



$0

$0


Up to $176 a day

$0




$0

12

MEDIGAP PLAN F



Services Medicare Pays Plan F Pays You PayMEDICAL 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, and durable medical equipment.• First $198 of Medicare-approved amounts*

$0


$0


(above Medicare-approved amounts)$0 100% $0

BLOOD• First three pints $0 All costs $0• Next $198 of Medicare-approved amounts* $0 $198 (Part B

deductible)$0

• Remainder of Medicare-approved amounts 80% 20% $0CLINICAL LABORATORY SERVICES• Tests for diagnostic services

100% $0 $0


medical supplies

100%

$0

$0


$0 $198 (Part B deductible)

$0


OTHER BENEFITS – NOT COVERED BY MEDICAREFOREIGN TRAVEL – Not covered by MedicareMedical emergency care services beginning during the first 60 days of each trip outside of the USA.• First $250 each calendar year

$0

$0

$250



13

MEDIGAP PLAN G




Services Medicare Pays Plan G Pays You PayHOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies.• First 60 days

All but $1,408


$0



$704 a day

$0



$0**



$0

$0


Up to $176 a day

$0




$0

14

MEDIGAP PLAN G



Services Medicare Pays Plan G Pays You PayMEDICAL 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, and durable medical equipment.• First $198 of Medicare-approved amounts*

$0

$0

$198 (Part B dedctible)





100% $0 $0


medical supplies

100%

$0

$0



• Remainder of Medicare-approved amounts 80% 20% $0OTHER BENEFITS – NOT COVERED BY MEDICARE

FOREIGN TRAVEL – Not covered by MedicareMedical emergency care services beginning during the first 60 days of each trip outside of the USA.• First $250 each calendar year

$0

$0

$250



15

MEDIGAP PLAN N




Services Medicare Pays Plan N Pays You PayHOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies.• First 60 days

All but $1,408


$0



$704 a day

$0



$0**



$0

$0


Up to $176 a day

$0




$0

16

MEDIGAP PLAN N



Services Medicare Pays Plan N Pays You PayMEDICAL 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, and durable medical equipment.• First $198 of Medicare-approved amounts*

$0

$0

$198 (Part B dedctible)

• 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



100% $0 $0


medical supplies

100%

$0

$0




(CONT’D ON NEXT PAGE)

17

OTHER BENEFITS – NOT COVERED BY MEDICAREFOREIGN TRAVEL – Not covered by MedicareMedical emergency care services beginning during the first 60 days of each trip outside of the USA.• First $250 each calendar year

$0

$0

$250



medigap - paramounthealthcare.com · 78 $185.25 $175.99 $242.12 $230.02 $253.45 $240.78 79 $191.67...

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