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800 Crescent Centre Dr. Suite 200

Franklin, TN 37067 800 264.4000

aetnaseniorproducts.com

Outline of Coverage Medicare Supplement Insurance BENEFIT PLANS A, B, F, HIGH DEDUCTIBLE F, G, N

Underwritten by

American Continental Insurance Company

An Aetna Company

Iowa

ACIMS03827IA ©2016 Aetna Inc. Rates Effective: 08/2019 A

http://aetnaseniorproducts.com

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08/2

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A

American Continental Insurance Company Annual Premiums

For Use In: Entire State

Female Rates

Rates Effective 8/1/2019

Attained

Age

Preferred

Plan A Plan B Plan F Plan HF Plan G Plan N

65 1,050 1,234 1,544 618 1,144 967

66 1,050 1,234 1,544 618 1,144 967

67 1,050 1,234 1,544 618 1,144 967

68 1,063 1,248 1,564 625 1,158 978

69 1,085 1,275 1,597 638 1,182 999

70 1,113 1,310 1,639 656 1,214 1,025

71 1,148 1,349 1,689 675 1,250 1,056

72 1,184 1,391 1,741 696 1,289 1,090

73 1,221 1,435 1,797 719 1,331 1,125

74 1,265 1,486 1,862 744 1,378 1,164

75 1,311 1,541 1,929 771 1,428 1,206

76 1,358 1,595 1,997 799 1,479 1,249

77 1,404 1,648 2,064 825 1,529 1,291

78 1,448 1,702 2,131 853 1,578 1,333

79 1,496 1,757 2,200 880 1,629 1,377

80 1,543 1,813 2,270 908 1,681 1,420

81 1,591 1,871 2,341 936 1,733 1,465

82 1,642 1,928 2,415 967 1,787 1,511

83 1,692 1,988 2,488 996 1,843 1,557

84 1,743 2,049 2,565 1,026 1,900 1,605

85 1,805 2,120 2,655 1,062 1,965 1,661

86 1,857 2,181 2,730 1,092 2,021 1,708

87 1,908 2,243 2,808 1,123 2,079 1,756

88 1,962 2,306 2,886 1,156 2,137 1,806

89 2,017 2,370 2,966 1,187 2,196 1,856

90 2,073 2,435 3,049 1,219 2,257 1,907

91 2,130 2,501 3,131 1,253 2,318 1,959

92 2,187 2,569 3,216 1,286 2,381 2,012

93 2,245 2,636 3,302 1,321 2,444 2,065

94 2,304 2,706 3,389 1,355 2,509 2,120

95 2,364 2,778 3,477 1,391 2,575 2,175

96 2,425 2,849 3,567 1,427 2,640 2,231

97 2,487 2,921 3,658 1,463 2,708 2,289

98 2,550 2,996 3,751 1,500 2,777 2,347

99+ 2,614 3,070 3,844 1,538 2,846 2,405

Attained

Age

Standard


65 1,166 1,372 1,716 687 1,271 1,074

66 1,166 1,372 1,716 687 1,271 1,074

67 1,166 1,372 1,716 687 1,271 1,074

68 1,180 1,388 1,738 694 1,286 1,088

69 1,205 1,417 1,774 710 1,313 1,110

70 1,238 1,455 1,821 729 1,348 1,138

71 1,275 1,499 1,876 751 1,389 1,173

72 1,315 1,545 1,934 774 1,432 1,211

73 1,358 1,595 1,997 799 1,480 1,250

74 1,406 1,651 2,068 826 1,531 1,293

75 1,456 1,713 2,143 858 1,587 1,340

76 1,509 1,772 2,218 889 1,643 1,388

77 1,560 1,832 2,293 917 1,698 1,434

78 1,609 1,891 2,367 948 1,753 1,482

79 1,662 1,953 2,445 977 1,810 1,530

80 1,715 2,015 2,522 1,009 1,868 1,578

81 1,768 2,079 2,601 1,041 1,926 1,628

82 1,824 2,142 2,683 1,074 1,985 1,678

83 1,880 2,210 2,766 1,107 2,048 1,730

84 1,938 2,277 2,850 1,140 2,110 1,783

85 2,004 2,355 2,951 1,179 2,184 1,845

86 2,063 2,424 3,034 1,214 2,246 1,897

87 2,120 2,493 3,121 1,247 2,310 1,951

88 2,179 2,562 3,207 1,283 2,374 2,007

89 2,241 2,633 3,296 1,319 2,440 2,063

90 2,303 2,705 3,388 1,354 2,508 2,119

91 2,366 2,780 3,479 1,392 2,576 2,176

92 2,429 2,854 3,573 1,430 2,646 2,236

93 2,495 2,930 3,668 1,468 2,716 2,294

94 2,560 3,008 3,765 1,507 2,788 2,355

95 2,627 3,087 3,862 1,545 2,861 2,417

96 2,694 3,167 3,964 1,584 2,934 2,479

97 2,764 3,246 4,064 1,625 3,009 2,543

98 2,832 3,329 4,167 1,666 3,086 2,608

99+ 2,904 3,412 4,271 1,709 3,162 2,672

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.

ACIMS03827IA 2 08/2019 A

American Continental Insurance Company Annual Premiums

For Use In: Entire State

Male Rates

Rates Effective 8/1/2019

Attained

Age

Preferred


65 1,207 1,419 1,776 711 1,315 1,112

66 1,207 1,419 1,776 711 1,315 1,112

67 1,207 1,419 1,776 711 1,315 1,112

68 1,221 1,436 1,798 719 1,331 1,125

69 1,247 1,467 1,836 735 1,359 1,148

70 1,281 1,507 1,886 755 1,396 1,179

71 1,320 1,551 1,942 778 1,437 1,214

72 1,361 1,599 2,002 800 1,482 1,253

73 1,405 1,651 2,067 826 1,531 1,293

74 1,455 1,710 2,141 856 1,585 1,339

75 1,508 1,772 2,218 888 1,642 1,388

76 1,562 1,834 2,296 919 1,700 1,436

77 1,615 1,895 2,373 949 1,757 1,485

78 1,665 1,958 2,449 981 1,815 1,534

79 1,720 2,021 2,530 1,012 1,874 1,584

80 1,774 2,085 2,610 1,044 1,933 1,633

81 1,831 2,151 2,692 1,077 1,993 1,684

82 1,888 2,217 2,777 1,111 2,055 1,737

83 1,946 2,287 2,862 1,146 2,120 1,790

84 2,004 2,358 2,951 1,179 2,185 1,845

85 2,075 2,439 3,053 1,220 2,260 1,910

86 2,135 2,508 3,141 1,256 2,325 1,964

87 2,195 2,579 3,229 1,292 2,390 2,020

88 2,256 2,651 3,319 1,328 2,457 2,078

89 2,320 2,726 3,412 1,366 2,526 2,135

90 2,384 2,800 3,506 1,403 2,595 2,193

91 2,448 2,877 3,601 1,440 2,666 2,253

92 2,515 2,955 3,698 1,481 2,738 2,314

93 2,581 3,032 3,797 1,520 2,811 2,374

94 2,649 3,113 3,897 1,560 2,885 2,438

95 2,719 3,194 3,999 1,599 2,961 2,502

96 2,789 3,277 4,102 1,641 3,037 2,566

97 2,861 3,360 4,206 1,683 3,114 2,632

98 2,932 3,446 4,312 1,725 3,194 2,699

99+ 3,006 3,531 4,422 1,768 3,273 2,766

Attained

Age

Standard


65 1,341 1,578 1,973 789 1,462 1,235

66 1,341 1,578 1,973 789 1,462 1,235

67 1,341 1,578 1,973 789 1,462 1,235

68 1,358 1,596 1,999 799 1,479 1,251

69 1,387 1,630 2,041 816 1,511 1,276

70 1,423 1,674 2,095 839 1,551 1,309

71 1,467 1,723 2,158 863 1,597 1,349

72 1,512 1,778 2,226 890 1,647 1,392

73 1,562 1,834 2,296 919 1,701 1,437

74 1,617 1,898 2,379 950 1,761 1,487

75 1,675 1,969 2,465 986 1,825 1,541

76 1,736 2,038 2,552 1,022 1,890 1,595

77 1,793 2,106 2,636 1,054 1,953 1,649

78 1,851 2,175 2,723 1,090 2,016 1,704

79 1,912 2,246 2,811 1,124 2,082 1,759

80 1,972 2,317 2,900 1,160 2,148 1,815

81 2,034 2,390 2,992 1,197 2,215 1,872

82 2,097 2,463 3,084 1,236 2,283 1,929

83 2,161 2,541 3,181 1,273 2,355 1,990

84 2,228 2,618 3,279 1,311 2,427 2,050

85 2,306 2,710 3,393 1,356 2,511 2,122

86 2,372 2,787 3,489 1,395 2,583 2,183

87 2,439 2,866 3,589 1,435 2,656 2,244

88 2,507 2,946 3,687 1,475 2,731 2,308

89 2,578 3,028 3,791 1,517 2,806 2,372

90 2,648 3,110 3,896 1,557 2,884 2,437

91 2,722 3,197 4,001 1,601 2,963 2,503

92 2,793 3,282 4,108 1,644 3,042 2,571

93 2,868 3,370 4,218 1,687 3,123 2,638

94 2,943 3,458 4,330 1,732 3,207 2,708

95 3,020 3,549 4,442 1,778 3,290 2,779

96 3,097 3,642 4,558 1,823 3,374 2,851

97 3,178 3,734 4,674 1,869 3,461 2,925

98 3,257 3,829 4,792 1,916 3,549 2,999

99+ 3,340 3,924 4,912 1,965 3,636 3,073

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.

ACIMS03827IA 3 08/2019 A

PREMIUM INFORMATION

American Continental 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 bethe 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 annual 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 American Continental 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 a American Continental Insurance CompanyMedicare 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) 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 American Continental 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.

American Continental 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 newpolicy, 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 AMERICAN CONTINENTAL INSURANCE COMPANY.

ACIMS03827IA 4 08/2019 A

PLAN AMEDICARE (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 $1364 $0 $1364

(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 All but $682 a day $682 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 $170.50 a day $0 Up to $170.50 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.

ACIMS03827IA 5 08/2019 A

PLAN AMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

*Once you have been billed $185 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.


PLAN PAYS

YOU PAY

MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $185 of Medicare-Approved amounts*

$0 $0 $185 (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 $185 of Medicare-Approved amounts*


Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

PARTS A & B


PLAN PAYS

YOU PAY

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

100% $0 $0

•Durable medical equipment •First $185 of Medicare Approved amounts*


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

ACIMS03827IA 6 08/2019 A

PLAN BMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.


PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1364 $1364

(Part A Deductible) $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 $170.50 a day

$0 Up to $170.50 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.



$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 thepolicy’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.

ACIMS03827IA 7 08/2019 A

PLAN BMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

* Once you have been billed $185 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.


PLAN PAYS

YOU PAY



Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $185 of Medicare-Approved amounts*



PARTS A & B


PLAN PAYS

YOU PAY


100% $0 $0




ACIMS03827IA 8 08/2019 A

PLAN FMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY






amounts $0 $0


Up to $170.50 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.



$0


ACIMS03827IA 9 08/2019 A

PLAN FMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR



PLAN PAYS

YOU PAY


$0 $185 (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 $185 of Medicare-Approved amounts*


$0


PARTS A & B


PLAN PAYS

YOU PAY


100% $0 $0



$0


ACIMS03827IA 10 08/2019 A

PLAN F OTHER BENEFITS – NOT COVERED BY MEDICARE


PLAN PAYS

YOU PAY

FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime

maximum benefit of $50,000

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

ACIMS03827IA 11 08/2019 A

HIGH DEDUCTIBLE PLAN FMEDICARE (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 endsafter 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 ye ar $2300 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2300. 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 Aand Part B, but do not include the p lan’s separate foreign travel emergency deductible.


AFTER YOU PAY $2300

DEDUCTIBLE** PLAN PAYS

IN ADDITION TO $2300

DEDUCTIBLE** YOU PAY






amounts $0 $0


Up to $170.50 a day

$0

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

ACIMS03827IA 12 08/2019 A

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



$0


ACIMS03827IA 13 08/2019 A

HIGH DEDUCTIBLE PLAN FMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

*Once you have been billed $185 of Medicare-Approved amounts for covered services (which arenoted 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 ye ar $2300 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2300. 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 Aand Part B, but do not include the plan’s separate foreign travel emergency deductible.


AFTER YOU PAY $2300






$0



$0


ACIMS03827IA 14 08/2019 A

HIGH DEDUCTIBLE PLAN F

PARTS A & B


AFTER YOU PAY $2300





100% $0 $0



$0


OTHER BENEFITS – NOT COVERED BY MEDICARE


AFTER YOU PAY $2300







ACIMS03827IA 15 08/2019 A

PLAN GMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY






amounts $0 $0


Up to $170.50 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



$0


ACIMS03827IA 16 08/2019 A

PLAN GMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR



PLAN PAYS

YOU PAY






PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies 100% $0 $0 •Durable medical equipment •First $185 of Medicare Approved amounts*



ACIMS03827IA 17 08/2019 A

PLAN G


SERVICES MEDICARE PAYS PLAN PAYS YOU PAY




ACIMS03827IA 18 08/2019 A

PLAN NMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY






amounts $0 $0


Up to $170.50 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



$0


ACIMS03827IA 19 08/2019 A

PLAN NMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR



PLAN PAYS

YOU PAY



Remainder of Medicare-Approved amounts

Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The 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 $185 of Medicare-Approved amounts*



ACIMS03827IA 20 08/2019 A

PLAN N

PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies 100% $0 $0 •Durable medical equipment •First $185 of Medicare Approved amounts*





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


ACIMS03827IA 21 08/2019 A

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