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1 Equitable Life & Casualty Insurance Company Outline Of Medicare Supplement Plans Sold for Effective Date on or After June 1, 2010 These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan A. Some plans may not be available in your state. Plans E, H, I and J are no longer available Basic Benefits: Hospitalization - Part A plus coverage for 365 additional days after Medicare benefits end; Medical Expenses - Part B (generally 20% of Medicare-approved expenses) or co-payments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of the part B or copayments; Blood - First three pints of blood each year; Hospice - Part A. Av Part B B Part B C Part B D Part B Fv F* Part B G Part B K Hospitalization and preventive care paid at ; other basic benefits paid at 50% L Hospitalization and preventive care paid at ; other basic benefits paid at 50% M Basic, including Part B Nv Part B, except up to $20 co-payment for office visits and up to $50 co-payment for ER Skilled Nursing Facility Skilled Nursing Facility Skilled Nursing Facility Skilled Nursing Facility 50% Skilled Nursing Facility 75% Skilled Nursing Facility Skilled Nursing Facility Skilled Nursing Facility Part A Part A Part A Part A Part A 50% Part A 75% Part A 50% Part A Part A Part B Part B Part B Excess () Part B Excess () Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency vplans currently available for sale. *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 $2,110 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2,110. 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. Out-of-Pocket limit $4800; paid at after limit reached Out-of-Pocket limit $2400; paid at after limit reached Foreign Travel Emergency Foreign Travel Emergency OLC 2070 DE (2013-1) Page 1

2 Ultimate Premiums - Monthly Bank Draft Non-Tobacco All Zip Codes A one-time $20 policy fee applies to each application Plan A Plan F Plan N Age Male Female Male Female Male Female <65 1, , , , Modal Factors: Annual = MBD x 12; SA = (MBD x 12) x.520; Q = (MBD x 12) x.265 OLC 2070 DE (2013) Page 2

3 Ultimate Premiums - Monthly Bank Draft Tobacco All Zip Codes A one-time $20 policy fee applies to each application Plan A Plan F Plan N Age Male Female Male Female Male Female <65 1, , , , , , Modal Factors: Annual = MBD x 12; SA = (MBD x 12) x.520; Q = (MBD x 12) x.265 OLC 2070 DE (2013) Page 3

4 Standard Premiums - Monthly Bank Draft Non-Tobacco All Zip Codes A one-time $20 policy fee applies to each application Plan A Plan F Plan N Age Male Female Male Female Male Female <65 1, , , , , , Modal Factors: Annual = MBD x 12; SA = (MBD x 12) x.520; Q = (MBD x 12) x.265 OLC 2070 DE (2013) Page 4

5 Standard Premiums - Monthly Bank Draft Tobacco All Zip Codes A one-time $20 policy fee applies to each application Plan A Plan F Plan N Age Male Female Male Female Male Female <65 1, , , , , , Modal Factors: Annual = MBD x 12; SA = (MBD x 12) x.520; Q = (MBD x 12) x.265 OLC 2070 DE (2013) Page 5

6 Equitable Life & Casualty Insurance Company 3 Triad Center, Salt Lake City, UT PREMIUM INFORMATION We, Equitable Life & Casualty Insurance Company, can only raise your premium if we raise the premium for all policies like yours in this State. We will not change the premiums for this policy during your first year of coverage. Thereafter your premium will increase each year based on your age at that time. No rate adjustment may be made on an individual basis. Also, your renewal premiums may change on a renewal date following the Effective Date of any change in the deductible and/or amounts which you are required to pay under Medicare. Any such premium change will be based on the actuarial computations that we then use to determine the renewal premium. DISCLOSURE PAGE Use this outline to compare benefits and premiums among policies, certificates and contracts. This outline shows benefits and premiums of policies sold for effective dates on or after June 1, Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums. Plans E, H, I and J are no longer available for sale. 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 us at: 3 Triad Center, Salt Lake City, Utah 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 This policy may not fully cover all of your medical costs. Neither Equitable Life & Casualty 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 The Medicare Handbook 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 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. OLC 2070 DE (2013) Page 6

7 PLAN A MEDICARE (PART A) - HOSPITAL - 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. MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1184 $1184 (Part A deductible) 61st thru 90th day All but $296 a day $296 a day 91st day and after: -While using 60 lifetime reserve days All but $592 a day $592 a day -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days of Medicare eligible expenses *** 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 day 101st day and after All approved amounts All but $ a day Up to $ a day BLOOD First 3 pints Additional amounts 3 pints HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited copayment/ for outpatient drugs and inpatient respite care. Medicare copayment/ *** 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. OLC 2070 DE A (2013) Page 7

8 Plan A (continued) MEDICARE (Part B) - MEDICAL -PER CALENDAR YEAR ** Once you have been billed $147 of Medicare-Approved amounts for covered services (which are noted with a double asterisk), your Part B will have been met for the calendar year. MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES-IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $147 of Medicare Approved Amounts** Generally 80% Generally 20% $147 (Part B ) Part B Excess Charges (Above Medicare Approved Amounts) BLOOD First 3 pints Next $147 of Medicare Approved Amounts** 80% 20% $147 (Part B ) CLINICAL LABORATORY - TESTS FOR DIAGNOSTIC Part A & B HOME HEALTH CARE MEDICARE APPROVED -Medically necessary skilled care services and medical supplies -Durable medical equipment First $147 of Medicare Approved Amounts** 80% 20% $147 (Part B ) OLC 2070 DE A (2013) Page 8

9 PLAN F MEDICARE (PART A) - HOSPITAL - 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. MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: -While using 60 lifetime reserve days All but $1184 All but $296 a day All but $592 a day $1184 (Part A deductible) $296 a day $592 a day -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days of Medicare eligible expenses *** 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 day 101st day and after All approved amounts All but $ a day Up to $ a day BLOOD First 3 pints 3 pints Additional amounts HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited copayment/ for outpatient drugs and inpatient respite care. Medicare copayment/ *** 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. OLC 2070 DE F (2013) Page 9

10 Plan F (continued) MEDICARE (Part B) - MEDICAL -PER CALENDAR YEAR ** Once you have been billed $147 of Medicare-Approved amounts for covered services (which are noted with a double asterisk), your Part B will have been met for the calendar year. MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES-IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $147 of Medicare Approved Amounts** Generally 80% $147 (Part B ) Generally 20% Part B Excess Charges (Above Medicare Approved Amounts) BLOOD First 3 pints Next $147 of Medicare Approved Amounts** 80% $147 (Part B ) 20% CLINICAL LABORATORY - TESTS FOR DIAGNOSTIC Part A & B HOME HEALTH CARE - MEDICARE APPROVED -Medically necessary skilled care services and medical supplies -Durable medical equipment First $147 of Medicare Approved Amounts** 80% $147 (Part B ) 20% Other Benefits - Not Covered by Medicare 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 $250 Remainder of Charges 80% to a lifetime maximum 20% and amounts over benefit of $50,000 the $50,000 lifetime maximum OLC 2070 DE F (2013) Page 10

11 PLAN N MEDICARE (PART A) - HOSPITAL - 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. MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: -While using 60 lifetime reserve days All but $1184 All but $296 a day All but $592 a day $1184 (Part A deductible) $296 a day $592 a day -Once lifetime reserve days are used: -Additional 365 days -Beyond the additional 365 days of Medicare eligible expenses *** 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 day 101st day and after All approved amounts All but $ a day Up to $ a day BLOOD First 3 pints 3 pints Additional amounts HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited copayment/ for outpatient drugs and inpatient respite care. Medicare copayment/ *** 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. OLC 2070 DE N (2013) Page 11

12 Plan N (continued) MEDICARE (Part B) - MEDICAL -PER CALENDAR YEAR ** Once you have been billed $147 of Medicare-Approved amounts for covered services (which are noted with a double asterisk), your Part B will have been met for the calendar year. MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES-IN OR OUT OF THE HOSPITAL AND OUTPATIENT 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 $147 of Medicare Approved Amounts** Generally 80% $147 (Part B ) Balance, other than up to Up to $20 per office visit $20 per office visit and up and up to $50 per to $50 per emergency emergency room visit. The room visit. The copayment copayment of up to $50 is of up to $50 is waived if waived if the insured is the insured is admitted to admitted to any hospital any hospital and the emergency visit is covered as a covered as a Medicare and the emergency visit is Medicare Part A expense Part A expense. Part B Excess Charges (Above Medicare Approved Amounts) BLOOD First 3 pints Next $147 of Medicare Approved Amounts** CLINICAL LABORATORY - TESTS FOR DIAGNOSTIC 80% 20% $147 (Part B ) Part A & B HOME HEALTH CARE - MEDICARE APPROVED -Medically necessary skilled care services and medical supplies -Durable medical equipment First $147 of Medicare Approved Amounts** 80% 20% $147 (Part B ) Other Benefits - Not Covered by Medicare 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 $250 Remainder of Charges 80% to a lifetime maximum 20% and amounts over the benefit of $50,000 $50,000 lifetime maximum OLC 2070 DE N (2013) Page 12

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