ssiacims05029nd outline medsup nd 062019a · 2019. 10. 24. · outline of coverage medicare...

Outline of coverage Medicare Supplement Insurance

Benefit plans: A, B, F, HF, G, N

North Dakota

Underwritten by

American Continental

Insurance Company

An Aetna Company

aetnaseniorproducts.com ACIMS05029ND ©2019 Aetna Inc. Rates effective: 06/2019 A

http://aetnaseniorproducts.com

AMERICAN CONTIENTNAL INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE:

BENEFIT PLANS AVAILABLE: A, B, F, HF, G, & N

This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan "A" available. Some plans may not be available. Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F. Note: A ✓ means 100% of the benefit is paid.

Benefits Plans Available to All Applicants

A B D G1 K L M N

Medicare

first eligible

before 2020 only

C F1

Medicare Part A coinsurance and

hospital coverage (up to an

additional 365 days after Medicare benefits are used up)

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Medicare Part B coinsurance or

copayment ✓ ✓ ✓ ✓ 50% 75% ✓

✓

copays

apply3 ✓ ✓

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

Part A hospice care coinsurance or

copayment ✓ ✓ ✓ ✓ 50% 75% ✓ ✓ ✓ ✓

Skilled nursing facility coinsurance ✓ ✓ 50% 75% ✓ ✓ ✓ ✓

Medicare Part A deductible ✓ ✓ ✓ 50% 75% 50% ✓ ✓ ✓

Medicare Part B deductible ✓ ✓

Medicare Part B excess charges ✓ ✓

Foreign travel emergency (up to

plan limits) ✓ ✓ ✓ ✓ ✓ ✓

Out-of-pocket limit in 2019 2

$5,5602 $2,7802

1 Plans F and G also have a high deductible option, which require first paying a plan deductible of

$2,300 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered

services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B

deductible. However, high deductible plans F and G count your payment of the Medicare Part B

deductible toward meeting the plan deductible.

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

of-pocket yearly limit.

3 Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office

visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission.

ACIMS05029ND 1 06/2019 A

ACIMS05029ND 06/2019 A 2

American Continental Insurance CompanyAnnual Attained Age Premiums

For Use in ZIP Codes: Entire State

Female Rates

Rates Effective 6/1/2019

Attained

Age

Non-Tobacco

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

65 1,431 1,802 2,151 699 1,295 1,029

66 1,431 1,802 2,151 699 1,295 1,029

67 1,431 1,802 2,151 699 1,295 1,029

68 1,490 1,877 2,240 728 1,348 1,072

69 1,556 1,963 2,326 757 1,408 1,119

70 1,618 2,041 2,412 784 1,464 1,165

71 1,680 2,117 2,496 812 1,520 1,209

72 1,739 2,190 2,576 836 1,574 1,251

73 1,794 2,259 2,645 859 1,624 1,290

74 1,848 2,326 2,713 881 1,669 1,327

75 1,892 2,385 2,774 902 1,713 1,362

76 1,936 2,439 2,828 921 1,751 1,393

77 1,977 2,491 2,878 934 1,788 1,424

78 2,013 2,537 2,921 950 1,823 1,451

79 2,053 2,584 2,963 963 1,856 1,475

80 2,085 2,625 3,000 975 1,885 1,499

81 2,113 2,659 3,038 988 1,913 1,521

82 2,141 2,697 3,077 1,002 1,937 1,541

83 2,172 2,734 3,114 1,013 1,962 1,561

84 2,196 2,766 3,151 1,025 1,986 1,581

85 2,220 2,801 3,186 1,036 2,010 1,599

86 2,247 2,831 3,218 1,046 2,033 1,616

87 2,270 2,861 3,251 1,057 2,053 1,634

88 2,294 2,890 3,279 1,068 2,076 1,651

89 2,314 2,918 3,307 1,075 2,096 1,666

90 2,334 2,943 3,336 1,085 2,113 1,681

91 2,355 2,967 3,362 1,092 2,132 1,694

92 2,372 2,990 3,384 1,100 2,146 1,706

93 2,388 3,011 3,404 1,108 2,162 1,720

94 2,407 3,029 3,421 1,112 2,177 1,730

95 2,419 3,046 3,441 1,119 2,190 1,741

96 2,434 3,066 3,458 1,125 2,202 1,751

97 2,448 3,084 3,477 1,131 2,214 1,760

98 2,461 3,101 3,494 1,136 2,227 1,771

99 2,477 3,120 3,511 1,142 2,242 1,782

Attained

Age

Tobacco

Plan A Plan B Plan F Plan HF

Plan G Plan N

65 1,589 2,003 2,390 777 1,437 1,143

66 1,589 2,003 2,390 777 1,437 1,143

67 1,589 2,003 2,390 777 1,437 1,143

68 1,657 2,086 2,488 809 1,498 1,192

69 1,730 2,179 2,588 842 1,567 1,245

70 1,798 2,266 2,681 870 1,628 1,294

71 1,865 2,355 2,774 902 1,689 1,342

72 1,933 2,434 2,859 930 1,749 1,390

73 1,992 2,510 2,939 955 1,804 1,434

74 2,053 2,584 3,014 981 1,856 1,476

75 2,100 2,648 3,084 1,003 1,901 1,512

76 2,151 2,710 3,140 1,021 1,945 1,547

77 2,197 2,767 3,197 1,039 1,988 1,581

78 2,239 2,822 3,247 1,056 2,026 1,611

79 2,278 2,870 3,290 1,069 2,061 1,638

80 2,314 2,918 3,333 1,084 2,096 1,666

81 2,347 2,957 3,375 1,098 2,125 1,691

82 2,379 2,999 3,419 1,112 2,154 1,713

83 2,410 3,038 3,460 1,125 2,181 1,734

84 2,440 3,074 3,501 1,136 2,209 1,755

85 2,468 3,111 3,540 1,150 2,235 1,776

86 2,496 3,146 3,576 1,164 2,259 1,797

87 2,524 3,177 3,611 1,174 2,283 1,816

88 2,547 3,210 3,644 1,185 2,306 1,833

89 2,572 3,241 3,675 1,196 2,327 1,850

90 2,598 3,269 3,706 1,205 2,348 1,867

91 2,616 3,296 3,734 1,214 2,367 1,881

92 2,635 3,322 3,761 1,223 2,385 1,897

93 2,655 3,344 3,783 1,230 2,401 1,909

94 2,673 3,366 3,804 1,238 2,417 1,924

95 2,689 3,387 3,822 1,243 2,431 1,935

96 2,701 3,407 3,842 1,250 2,446 1,945

97 2,720 3,427 3,862 1,256 2,460 1,956

98 2,734 3,446 3,884 1,262 2,474 1,967

99 2,752 3,468 3,904 1,269 2,490 1,981

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

The above rates do not include the $20 application fee.

If applying during Open Enrollment or Guaranteed Issue Period, use Non-Tobacco rates.

ACIMS05029ND 06/2019 A 3

American Continental Insurance CompanyAnnual Attained Age Premiums

For Use in ZIP Codes: Entire State

Male Rates

Rates Effective 6/1/2019

Attained

Age

Non-Tobacco


65 1,645 2,071 2,474 804 1,488

1,183

66 1,645 2,071 2,474 804 1,488 1,183

67 1,645 2,071 2,474 804 1,488 1,183

68 1,712 2,160 2,576 836 1,550 1,233

69 1,789 2,257 2,676 870 1,621 1,289

70 1,862 2,345 2,775 903 1,685 1,340

71 1,935 2,434 2,871 933 1,749 1,390

72 2,001 2,519 2,963 963 1,809 1,438

73 2,062 2,599 3,040 988 1,866 1,484

74 2,122 2,675 3,122 1,016 1,921 1,527

75 2,176 2,740 3,191 1,037 1,969 1,566

76 2,224 2,803 3,251 1,057 2,013 1,601

77 2,272 2,864 3,307 1,075 2,059 1,635

78 2,319 2,920 3,361 1,092 2,097 1,668

79 2,357 2,969 3,407 1,108 2,133 1,697

80 2,396 3,019 3,450 1,122 2,168 1,724

81 2,429 3,063 3,494 1,136 2,198 1,748

82 2,462 3,103 3,540 1,150 2,229 1,771

83 2,496 3,145 3,582 1,165 2,257 1,794

84 2,525 3,179 3,623 1,178 2,285 1,816

85 2,556 3,219 3,664 1,192 2,311 1,839

86 2,584 3,254 3,700 1,203 2,338 1,859

87 2,611 3,291 3,738 1,216 2,363 1,878

88 2,638 3,323 3,771 1,227 2,387 1,898

89 2,659 3,355 3,808 1,238 2,410 1,917

90 2,687 3,385 3,837 1,246 2,430 1,932

91 2,709 3,412 3,864 1,256 2,451 1,948

92 2,726 3,438 3,890 1,264 2,470 1,963

93 2,748 3,463 3,916 1,274 2,485 1,977

94 2,765 3,486 3,937 1,281 2,502 1,990

95 2,780 3,504 3,958 1,286 2,517 2,002

96 2,798 3,524 3,976 1,294 2,531 2,013

97 2,814 3,544 3,996 1,300 2,546 2,025

98 2,831 3,566 4,018 1,306 2,561 2,037

99 2,848 3,587 4,038 1,311 2,576 2,049

Attained

Age

Tobacco


65 1,828 2,301 2,748 893 1,652 1,315

66 1,828 2,301 2,748 893 1,652 1,315

67 1,828 2,301 2,748 893 1,652 1,315

68 1,904 2,399 2,860 930 1,722 1,369

69 1,987 2,506 2,974 967 1,799 1,431

70 2,069 2,605 3,084 1,003 1,871 1,489

71 2,148 2,706 3,191 1,037 1,943 1,544

72 2,220 2,801 3,290 1,069 2,010 1,599

73 2,292 2,888 3,379 1,099 2,073 1,648

74 2,357 2,969 3,466 1,127 2,133 1,697

75 2,417 3,045 3,544 1,153 2,187 1,740

76 2,474 3,116 3,612 1,176 2,237 1,780

77 2,525 3,186 3,675 1,196 2,285 1,816

78 2,573 3,243 3,733 1,213 2,329 1,852

79 2,620 3,300 3,785 1,230 2,369 1,884

80 2,659 3,353 3,832 1,246 2,409 1,916

81 2,700 3,402 3,885 1,262 2,445 1,943

82 2,736 3,447 3,932 1,280 2,476 1,968

83 2,773 3,491 3,980 1,295 2,508 1,994

84 2,805 3,534 4,026 1,308 2,539 2,020

85 2,839 3,576 4,071 1,323 2,570 2,042

86 2,870 3,619 4,113 1,338 2,598 2,065

87 2,899 3,654 4,152 1,350 2,626 2,088

88 2,931 3,691 4,192 1,363 2,652 2,109

89 2,957 3,726 4,229 1,374 2,677 2,128

90 2,981 3,759 4,262 1,386 2,702 2,148

91 3,010 3,792 4,295 1,396 2,722 2,166

92 3,033 3,821 4,324 1,405 2,743 2,183

93 3,053 3,845 4,350 1,414 2,763 2,196

94 3,073 3,869 4,374 1,423 2,780 2,211

95 3,091 3,896 4,397 1,431 2,797 2,223

96 3,109 3,918 4,420 1,436 2,812 2,236

97 3,128 3,941 4,440 1,444 2,830 2,250

98 3,146 3,963 4,463 1,452 2,848 2,264

99 3,163 3,987 4,485 1,458 2,864 2,276

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

The above rates do not include the $20 application fee.

If applying during Open Enrollment or Guaranteed Issue Period, use Non-Tobacco rates.

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 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.

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.

Neither 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 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 AMERICAN

CONTINENTAL INSURANCE COMPANY.

ACIMS05029ND 4 06/2019 A

PLAN A

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

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

SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 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.

ACIMS05029ND 5 06/2019 A

PLAN A

MEDICARE (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.

SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY

MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic test, durable medical equipment First $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

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 $185 of Medicare Approved amounts*


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

ACIMS05029ND 6 06/2019 A

PLAN B


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

SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY

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

(Part A Deductible) $0





$0**


SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 daysafter 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





$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.

ACIMS05029ND 7 06/2019 A

PLAN B


* 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.

SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY




Part B Excess Charges (Above Medicare-Approved amounts) $0 $0 All costs





PARTS A & B

SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY



100% $0 $0





ACIMS05029ND 8 06/2019 A

PLAN F



SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY




•While using 60 lifetime reservedays All but $682 a day $682 a day $0



$0**


SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital First 20 days All approved

amounts $0 $0


Up to $170.50 a day

$0






$0


ACIMS05029ND 9 06/2019 A

PLAN F



SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY


$0 $185 (Part B Deductible)

$0


Part B Excess Charges (Above Medicare-Approved amounts) $0 100% $0



$0



PARTS A & B

SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY



100% $0 $0




$0


ACIMS05029ND 10 06/2019 A

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

ACIMS05029ND 11 06/2019 A

HIGH DEDUCTIBLE PLAN F



***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $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 A and Part B, but do not include the plan’s separate foreign travel emergency deductible.

SERVICES MEDICARE PAYS

AFTER YOU PAY $2300

DEDUCTIBLE*** PLAN PAYS

IN ADDITION TO $2300

DEDUCTIBLE*** YOU PAY



61st thru 90th day All but $341 a day

$341 a day $0 91st day and after




$0**



amounts $0 $0


Up to $170.50 a day

$0



ACIMS05029ND 12 06/2019 A




$0


ACIMS05029ND 13 06/2019 A




***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $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 A and Part B, but do not include the plan’s separate foreign travel emergency deductible.

SERVICES MEDICARE

PAYS

AFTER YOU PAY $2300






$0





$0



ACIMS05029ND 14 06/2019 A


PARTS A & B


AFTER YOU PAY $2300






100% $0 $0




$0




AFTER YOU PAY $2300

DEDUCTIBLE** PLAN PAYS


DEDUCTIBLE** YOU PAY

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



ACIMS05029ND 15 06/2019 A

PLAN G



SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY


(Part A Deductible)$0





$0**



amounts $0 $0


Up to $170.50 a day

$0



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



$0


ACIMS05029ND 16 06/2019 A

PLAN G



SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY









PARTS A & B

SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY


•Medically necessary skilled care services and medical supplies 100% $0 $0





ACIMS05029ND 17 06/2019 A

PLAN G


SERVICES MEDICARE

PAYS PLAN PAYS YOU PAY

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



ACIMS05029ND 18 06/2019 A

PLAN N



SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY







$0**



amounts $0 $0


Up to $170.50 a day

$0



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



$0


ACIMS05029ND 19 06/2019 A

PLAN N



SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY


$0 $0 $185

Remainder of Medicare-Approved amounts

Generally 80%

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

(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





ACIMS05029ND 20 06/2019 A

PLAN N

PARTS A & B

SERVICES MEDICARE

PAYS PLAN PAYS

YOU PAY


• Medically necessary skilled care services and medical supplies 100% $0 $0


• First $185 of Medicare Approved amounts*




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


ACIMS05029ND 06/2019 A 21

Outline of coverage AMERICAN CONTIENTNAL INSURANCE COMPANY. OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE:. BENEFIT PLANS AVAILABLE: A, B, F, HF, G, & N. American Continental Insurance CompanyPREMIUM INFORMATIONPLAN A MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD PLAN A MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR PLAN B MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD PLAN B MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR HIGH DEDUCTIBLE PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD PLAN G MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD PLAN N MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

ssiacims05029nd outline medsup nd 062019a · 2019. 10. 24. · outline of coverage medicare...

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