Outline of Medicare Supplement Coverage

Transcription

1 Underwrien by Serling Life Insurance Company Ouline of Medicare Supplemen Coverage Benefi Char of Medicare Supplemen Plans Sold wih Effecive Daes on or afer June 1, 2010 TX OC (09/11) Medicare Supplemen Adminisraive Offices/Cusomer Service, P.O. Box 5348, Bellingham, WA

2 Sandard and SELECT Medicare Supplemen Plans A, B, C, F, Innovaive F, G, K and N are available. (Medicare SELECT plans conain resricions on your use of provider.) BASIC BENEFITS for Plans A-N: This char show he benefis included in each of he sandard Medicare supplemen plans. Every company mus make Plan A available. Some plans may no be available in Your sae. Hospializaion Par A coinsurance plus coverage for 365 addiional days afer Medicare benefis end. Medical Expenses Par B coinsurance (generally 20% of Medicare-approved expenses), or copaymens for hospial oupaien services. Plans K, L and N require insureds o pay a porion of Par B coinsurance or copaymens. Blood Firs hree pins of blood each year. Hospice Par A coinsurance. s A s B s sc D F s s F *F* s Innovaive F s G s sk L M N Basic, including 100% Par B coinsurance Basic, including 100% Par B coinsurance Par A Deducible Basic, including 100% Par B coinsurance Skilled Nursing Faciliy Coinsurance Par A Deducible Par B Deducible Foreign Travel Emergency Basic, including 100% Par B coinsurance Skilled Nursing Faciliy Coinsurance Par A Deducible Foreign Travel Emergency Basic, including 100% Par B coinsurance* Skilled Nursing Faciliy Coinsurance Par A Deducible Par B Deducible Par B Excess (100%) Foreign Travel Emergency +Basic Benefis Skilled Nursing Faciliy Coinsurance Par A Deducible Par B Deducible Par B Excess (100%) Foreign Travel Emergency +Innovaive Benefis+ Basic, including 100% Par B coinsurance Skilled Nursing Faciliy Coinsurance Par A Deducible Par B Excess (100%) Foreign Travel Emergency Hospializaion and prevenaive care paid a 100%; oher basic benefis paid a 50% 50% Skilled Nursing Faciliy Coinsurance 50% Par A Deducible Ou-of-pocke limi $4,660; benefis paid a 100% afer limi reached Hospializaion and prevenaive care paid a 100%; oher basic benefis paid a 75% 75% Skilled Nursing Faciliy Coinsurance 75% Par A Deducible Ou-of -pocke limi $2,330; benefis paid a 100% afer limi reached Basic, including 100% Par B coinsurance Skilled Nursing Faciliy Coinsurance 50% Par A Deducible Foreign Travel Emergency Basic, including 100% Par B coinsurance, excep up o $20 copaymen for office visi, and up o $50 copaymen for ER Skilled Nursing Faciliy Coinsurance Par A Deducible Foreign Travel Emergency *Plan F also has an opion called a high deducible Plan F. This high deducible plan pays he same benefis as Plans F afer one has paid a calendar year $2,070 deducible. Benefis from high deducible Plan F will no begin unil ou-of-pocke expenses exceed $2,070. Ou-of-pocke expenses for his deducible are expenses ha would ordinarily be paid by he policy. These expenses include he Medicare deducibles for Par A and Par B, bu do no include he plan s separae foreign ravel emergency deducible. +Innovaive F includes innovaive benefis no conained in oher sandardized Medicare Supplemen Plans. They include, subjec o plan limiaions: (a) access o nurse advice elephone service, (b) annual physical examinaion, (c) prevenive denal care, (d) rouing vision care, and (e) rouine hearing exam. Basic Benefis for Plans K and L include similar services as Plans A-G, bu cos sharing for he basic benefis are a differen levels. TX OC (09/11) 2

3 Inser PIP here Pages 3-3L TX OC (09/11) 3 (Rev. 01/12)

4 DISCLOSURES Use his ouline o compare benefis and premiums among policies. This ouline shows benefis and premiums of policies sold for effecive daes on or afer June 1, Policies sold for effecive daes prior o June 1, 2010, have differen benefis and premiums. Plans E, H, I and J are no longer available for sale afer June 1, READ YOUR POLICY VERY CAREFULLY This is only an ouline describing Your policy's mos imporan feaures. The policy is Your insurance conrac. You mus read he policy iself o undersand all of he righs and duies of boh You and Serling Life Insurance Company. RIGHT TO RETURN POLICY If You are no saisfied wih Your policy, You may reurn i o P.O. Box 5348, Bellingham, WA If You send he policy back o Us wihin 30 days afer You receive i, We will rea he policy as if i had never been issued and reurn all of Your paymens. POLICY REPLACEMENT If You are replacing anoher healh insurance policy do NOT cancel i unil You have acually received Your new policy and are sure You wan o keep i. NOTICE This policy may no fully cover all of Your medical coss. Neiher Serling Life Insurance Company nor is agens are conneced wih Medicare. This Ouline of Coverage does no give all he deails of Medicare coverage. Conac Your local Social Securiy Office or consul Medicare & You for more deails. LIMITATIONS AND EXCLUSIONS This is a Medicare supplemen policy. Wih he excepion of Innovaive Benefis conained in our Innovaive Plan F, Your coverage is condiional on Medicare's approval of Medicare Eligible Expenses. Wih he excepion of Innovaive Benefis conained in our Innovaive Plan F, services eligible for coverage mus herefore be deemed as medically necessary by Medicare. Wih he excepion of Innovaive Benefis conained in our Innovaive Plan F, if Medicare does no consider services rendered or expenses incurred as medically necessary, no benefis will be paid. We will no place any limiaions on benefis ha are more resricive han Medicare s limiaions and resricions, excep as noed in he Nework Hospial Resricions. No benefis will be paid under Medicare Par A which duplicaes paymens under Medicare Par B. No benefis will be paid under Medicare Par B which duplicaes paymens under Medicare Par A. No benefis will duplicae paymen made direcly by Medicare. TX OC (09/11) 4 (Rev. 01/12)

5 REFUND OF PREMIUM If We receive wrien noice ha You wish o erminae Your coverage, or if you are deceased, he dae of erminaion will be he firs day of he monh following he even. Any premium paid beyond he erminaion dae will be refunded o You or Your esae. GRIEVANCE PROCEDURE MEDICARE SELECT PRODUCTS ONLY In he even You are dissaisfied wih he response received o a complain or wih he disposiion of a claim, You may submi a formal grievance by wriing o he Claims Adminisraor a P.O. Box 5348, Bellingham, WA Formal grievances in all oher areas should be submied o Us in wriing a he same address. A grievance mus clearly sae This is a grievance, or oher words ha clearly sae ha he inenion of he wrien communicaion is o serve as a wrien grievance o be handled according o his procedure. Acknowledgmen of receip of he grievance will be mailed wihin hree (3) business days and he grievance will be invesigaed. A response will be sen wihin hiry (30) days following he dae he grievance is received and shall explain in deail he reasons for he deerminaion. If Serling upholds he grievance, correcive acion will be aken promply o remedy he siuaion. Grievance Appeal Commiee. In he even You are no saisfied wih he resuls of Our deerminaion, You have he righ o file an appeal by wrien reques wih Serling. The appeal should be submied o he Grievance Appeal Commiee of Serling wihin sixy (60) days from he dae You are noified of he complain procedure resuls. The Grievance Appeal Commiee shall be made up of individuals no involved in he decision making process of he original grievance or reques for deerminaion. The Grievance Appeal Commiee shall schedule a hearing on he grievance wihin sixy (60) days of is receip. Boh You and he person or organizaion agains whom he complain has been made shall be noified of he ime and place of he Grievance Appeal Commiee hearing a which ime such individuals shall have he righ o appear in person or by elephone and presen any informaion which suppors heir posiion. A he close of he hearing, he Grievance Appeal Commiee shall make findings and issue a wrien decision wihin fifeen (15) business days afer he hearing is held unless addiional informaion is needed. If You are dissaisfied wih he decision, You should submi a wrien complain o he Texas Deparmen of Insurance, 333 Guadalupe Sree, Ausin, TX or call COMPLETE ANSWERS ARE VERY IMPORTANT When you fill ou he applicaion for he new policy, be sure o answer ruhfully and compleely all quesions abou your medical and healh hisory. The company may cancel your policy and refuse o pay any claims if you leave ou or falsify imporan medical informaion. Review he applicaion carefully before You sign i. Be cerain ha all informaion has been properly recorded. TX OC (09/11) 5 (Rev. 01/12)

6 Plan A - Benefis Char MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD HOSPITALIZATION*, *** Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,156 $0 $1,156 (Par A Deducible) 61s hru 90h day All bu $289 a day $289 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $578 a day $578 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0** -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE* You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $ a day $0 Up o $ a day 101s day and afer $0 $0 All Coss BLOOD*** Firs 3 pins $0 3 pins $0 Addiional amouns 100% $0 $0 HOSPICE CARE You mus mee Medicare s requiremens, including a docor s cerificaion of erminal illness All bu very limied copaymen/ coinsurance for oupaien drugs and inpaien respie care Medicare copaymen/coinsurance $0 * A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy for 60 days in a row. ** NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. *** If you have Medicare Selec plan and you do no uilize a nework provider, you are responsible for all charges. TX OC (09/11) 6

7 Plan A - Benefis Char MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDER YEAR MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $140 of Medicare-Approved $0 $0 $140 (Par B Deducible) Amouns* Amouns Generally 80% Generally 20% $0 PART B EXCESS CHARGES Above Medicare-Approved Amouns $0 $0 All Coss BLOOD Firs 3 pins $0 All Coss $0 Nex $140 of Medicare-Approved Amouns* Amouns CLINICAL LABORATORY SERVICES $0 $0 $140 (Par B Deducible) 80% 20% $0 Tess For Diagnosic Services 100% $0 $0 HOME HEALTH CARE MEDICARE-APPROVED SERVICES PARTS A & B Medically necessary skilled care services and medical supplies 100% $0 $0 Durable Medical Equipmen Firs $140 of Medicare-Approved Amouns* Amouns $0 $0 $140 (Par B Deducible) 80% 20% $0 * Once you have been billed $140 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. TX OC (09/11) 7

8 Plan B - Benefis Char MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD HOSPITALIZATION*, *** Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,156 $1,156 (Par A Deducible) $0 61s hru 90h day All bu $289 a day $289 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $578 a day $578 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0** -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE* You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $ a day $0 Up o $ a day 101s day and afer $0 $0 All Coss BLOOD*** Firs 3 pins $0 3 pins $0 Addiional amouns 100% $0 $0 HOSPICE CARE You mus mee Medicare s requiremens, including a docor s cerificaion of erminal illness All bu very limied copaymen/ coinsurance for oupaien drugs and inpaien respie care Medicare copaymen/coinsurance $0 * A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy for 60 days in a row. ** NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. *** If you have Medicare Selec plan and you do no uilize a nework provider, you are responsible for all charges. TX OC (09/11) 8

9 Plan B - Benefis Char MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDER YEAR MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $140 of Medicare-Approved $0 $0 $140 (Par B Deducible) Amouns* Amouns Generally 80% Generally 20% $0 PART B EXCESS CHARGES Above Medicare-Approved Amouns $0 $0 All Coss BLOOD Firs 3 pins $0 All Coss $0 Nex $140 of Medicare-Approved Amouns* Amouns CLINICAL LABORATORY SERVICES $0 $0 $140 (Par B Deducible) 80% 20% $0 Tess For Diagnosic Services 100% $0 $0 HOME HEALTH CARE MEDICARE-APPROVED SERVICES PARTS A & B Medically necessary skilled care services and medical supplies 100% $0 $0 Durable Medical Equipmen Firs $140 of Medicare-Approved Amouns* Amouns $0 $0 $140 (Par B Deducible) 80% 20% $0 * Once you have been billed $140 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. TX OC (09/11) 9

10 Plan C - Benefis Char MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD HOSPITALIZATION*, *** Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,156 $1,156 (Par A Deducible) $0 61s hru 90h day All bu $289 a day $289 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $578 a day $578 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0** -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE* You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $ a day Up o $ a day $0 101s day and afer $0 $0 All Coss BLOOD*** Firs 3 pins $0 3 pins $0 Addiional amouns 100% $0 $0 HOSPICE CARE You mus mee Medicare s requiremens, including a docor s cerificaion of erminal illness All bu very limied copaymen/ coinsurance for oupaien drugs and inpaien respie care Medicare copaymen/coinsurance $0 * A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy for 60 days in a row. ** NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. *** If you have Medicare Selec plan and you do no uilize a nework provider, you are responsible for all charges. TX OC (09/11) 10

11 Plan C - Benefis Char MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDER YEAR MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $140 of Medicare-Approved Amouns* $0 $140 (Par B Deducible) $0 Amouns Generally 80% Generally 20% $0 PART B EXCESS CHARGES Above Medicare-Approved Amouns $0 $0 All Coss BLOOD Firs 3 pins $0 All Coss $0 Nex $140 of Medicare-Approved Amouns* $0 $140 (Par B Deducible) $0 Amouns 80% 20% $0 CLINICAL LABORATORY SERVICES Tess For Diagnosic Services 100% $0 $0 HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable Medical Equipmen PARTS A & B 100% $0 $0 Firs $140 of Medicare-Approved Amouns* $0 $140 (Par B Deducible) $0 Amouns 80% 20% $0 FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically Necessary Emergency care services beginning during he firs 60 days of each rip ouside he USA Firs $250 each Calendar Year $0 $0 $250 Remainder of Charges $0 80% o a Lifeime Maximum Benefi of $50,000 20% and amouns over he $50,000 Lifeime Maximum Benefi * Once you have been billed $140 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. TX OC (09/11) 11

12 Plan F - Benefis Char MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD HOSPITALIZATION*, *** Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,156 $1,156 (Par A Deducible) $0 61s hru 90h day All bu $289 a day $289 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $578 a day $578 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0** -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE* You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $ a day Up o $ a day $0 101s day and afer $0 $0 All Coss BLOOD*** Firs 3 pins $0 3 pins $0 Addiional amouns 100% $0 $0 HOSPICE CARE You mus mee Medicare s requiremens, including a docor s cerificaion of erminal illness All bu very limied copaymen/coinsurance for oupaien drugs and inpaien respie care Medicare copaymen/coinsurance $0 * A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy for 60 days in a row. ** NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. *** If you have Medicare Selec plan and you do no uilize a nework provider, you are responsible for all charges. TX OC (09/11) 12

13 Plan F - Benefis Char MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDER YEAR MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $140 of Medicare-Approved Amouns* $0 $140 (Par B Deducible) $0 Amouns Generally 80% Generally 20% $0 PART B EXCESS CHARGES Above Medicare-Approved Amouns $0 100% $0 BLOOD Firs 3 pins $0 All Coss $0 Nex $140 of Medicare-Approved Amouns* $0 $140 (Par B Deducible) $0 Amouns 80% 20% $0 CLINICAL LABORATORY SERVICES Tess For Diagnosic Services 100% $0 $0 HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable Medical Equipmen PARTS A & B 100% $0 $0 Firs $140 of Medicare-Approved Amouns* $0 $140 (Par B Deducible) $0 Amouns 80% 20% $0 FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically Necessary Emergency care services beginning during he firs 60 days of each rip ouside he USA Firs $250 each Calendar Year $0 $0 $250 Remainder of Charges $0 80% o a Lifeime Maximum Benefi of $50,000 20% and amouns over he $50,000 Lifeime Maximum Benefi * Once you have been billed $140 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. TX OC (09/11) 13

14 Innovaive Benefi Plan F - Benefis Char MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD HOSPITALIZATION*, *** Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,156 $1,156 (Par A Deducible) $0 61s hru 90h day All bu $289 a day $289 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $578 a day $578 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0** -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE* You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $ a day Up o $ a day $0 101s day and afer $0 $0 All Coss BLOOD*** Firs 3 pins $0 3 pins $0 Addiional amouns 100% $0 $0 HOSPICE CARE You mus mee Medicare s requiremens, including a docor s cerificaion of erminal illness All bu very limied copaymen/coinsurance for oupaien drugs and inpaien respie care Medicare copaymen/coinsurance $0 * A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy for 60 days in a row. ** NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. *** If you have Medicare Selec plan and you do no uilize a nework provider, you are responsible for all charges. TX OC (09/11) 14

15 Innovaive Benefi Plan F - Benefis Char MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services,inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $140 of Medicare-Approved Amouns* $0 $140 (Par B Deducible) $0 Amouns Generally 80% Generally 20% $0 PART B EXCESS CHARGES Above Medicare-Approved Amouns $0 100% $0 BLOOD Firs 3 pins $0 All Coss $0 Nex $140 of Medicare-Approved Amouns* $0 $140 (Par B Deducible) $0 Amouns 80% 20% $0 CLINICAL LABORATORY SERVICES Tess For Diagnosic Services 100% $0 $0 HOME HEALTH CARE MEDICARE-APPROVED SERVICES PARTS A & B Medically necessary skilled care services and medical supplies 100% $0 $0 Durable Medical Equipmen Firs $140 of Medicare-Approved Amouns* $0 $140 (Par B Deducible) $0 Amouns 80% 20% $0 FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically Necessary Emergency care services beginning during he firs 60 days of each rip ouside he USA Firs $250 each Calendar Year $0 $0 $250 Remainder of Charges $0 80% o a Lifeime Maximum Benefi of $50,000 20% and amouns over he $50,000 Lifeime Maximum Benefi * Once you have been billed $140 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. TX OC (09/11) 15

16 Innovaive Benefi Plan F - Benefis Char INNOVATIVE BENEFITS - NOT COVERED BY MEDICARE OR STANDARDIZED MEDICARE SUPPLEMENT PLANS NURSE ADVICE TELEPHONE LINE Coverage for access o our elephone Nurse Advice Line for answers o healh-relaed quesions. $0 All Coss $0 ANNUAL PHYSICAL EXAMINATION Coverage for up o $100 for one (1) rouine physical examinaion every year, including rouine lab ess billed as par of he rouine physical exam. You are responsible for any charges above he $100 rouine physical exam allowance, including lab ess. This benefi is separae from he one-ime physical examinaion covered by Medicare wihin he firs 12 monhs of Par B enrollmen. $0 All Coss $0 PREVENTIVE DENTAL BENEFIT Coverage for up o $500 per calendar year for prevenive denal care, limied o American Denal Associaion codes , as well as Coverage is limied o: A. Oral Examinaions - Limied o one ime every six monhs $0 All Coss $0 B. Bie Wing Radiographs - Limied o 1 series of films per calendar year $0 All Coss $0 C. Complee Series of Panorex Radiographs - Limied o one ime per $0 All Coss $0 36 monhs D. Denal Prophylaxis - Limied o one ime per every six monhs $0 All Coss $0 E. Diagnosic Cass - Limied o one ime per 24 monhs $0 All Coss $0 F. Exraoral Radiographs - Limied o 2 films per calendar year $0 All Coss $0 ROUTINE VISION CARE Coverage for up o $100 for one (1) rouine eye examinaion every year. This is separae from diagnosic eye examinaions and relaed charges as covered by Medicare. $0 All Coss $0 ROUTINE HEARING EXAMINATIONS Coverage for up o $100 for one (1) rouine hearing es every year. This is separae from diagnosic hearing examinaions and relaed charges as covered by Medicare. $0 All Coss $0 * Once you have been billed $140 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. TX OC (09/11) 16

17 Plan G - Benefis Char MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD HOSPITALIZATION*, *** Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,156 $1,156 (Par A Deducible) $0 61s hru 90h day All bu $289 a day $289 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $578 a day $578 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0** -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE* You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $ a day Up o $ a day $0 101s day and afer $0 $0 All Coss BLOOD*** Firs 3 pins $0 3 pins $0 Addiional amouns 100% $0 $0 HOSPICE CARE You mus mee Medicare s requiremens, including a docor s cerificaion of erminal illness All bu very limied copaymen/ coinsurance for oupaien drugs and inpaien respie care Medicare copaymen/coinsurance $0 * A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy for 60 days in a row. ** NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. *** If you have Medicare Selec plan and you do no uilize a nework provider, you are responsible for all charges. TX OC (09/11) 17

18 Plan G - Benefis Char MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDER YEAR MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $140 of Medicare-Approved Amouns* $0 $0 $140 (Par B Deducible) Amouns Generally 80% Generally 20% $0 PART B EXCESS CHARGES Above Medicare-Approved Amouns $0 100% $0 BLOOD Firs 3 pins $0 All Coss $0 Nex $140 of Medicare-Approved Amouns* $0 $0 $140 (Par B Deducible) Amouns 80% 20% $0 CLINICAL LABORATORY SERVICES Tess For Diagnosic Services 100% $0 $0 HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable Medical Equipmen PARTS A & B 100% $0 $0 Firs $140 of Medicare-Approved Amouns* $0 $0 $140 (Par B Deducible) Amouns 80% 20% $0 FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically Necessary Emergency care services beginning during he firs 60 days of each rip ouside he USA Firs $250 each Calendar Year $0 $0 $250 Remainder of Charges $0 80% o a Lifeime Maximum Benefi of $50,000 20% and amouns over he $50,000 Lifeime Maximum Benefi * Once you have been billed $140 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. TX OC (09/11) 18

19 Plan K - Benefis Char MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD * HOSPITALIZATION**, **** Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,156 $578 (50% of Par A Deducible) $578 (50% of Par A Deducible) F 61s hru 90h day All bu $289 a day $289 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $578 a day $578 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0*** -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE** You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $ a day Up o $72.25 a day Up o $72.25 a day F 101s day and afer $0 $0 All Coss BLOOD**** Firs 3 pins $0 50% 50% F Addiional amouns 100% $0 $0 HOSPICE CARE You mus mee Medicare s requiremens, including a docor s cerificaion of erminal illness All bu very limied copaymen/ coinsurance for oupaien drugs and inpaien respie care 50% of copaymen/coinsurance 50% of copaymen/coinsurance F * You will pay half he cos sharing of some covered services unil you reach he annual ou-of-pocke limi of $4,660 each calendar year. The amouns ha coun oward your annual limi are noed wih he diamonds (F) in he char above. Once you reach he annual limi, he plan pays 100% of your Medicare copaymen and coinsurance for he res of he calendar year. However, his limi does NOT include charges from your provider ha exceed Medicare-approved amouns (hese are called Excess Charges ) and you will be responsible for paying his difference in he amoun charged by your provider and he amoun paid by Medicare for he iem or service. ** A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy for 60 days in a row. *** NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. **** If you have Medicare Selec plan and you do no uilize a nework provider, you are responsible for all charges. TX OC (09/11) 19

20 Plan K - Benefis Char MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDER YEAR * MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $140 of Medicare-Approved Amouns***** $0 $0 $140 (Par B Deducible)*****F Prevenive Benefis for Medicare covered services Generally 75% or more of Medicare- Approved amouns amouns All coss above Medicare-Approved amouns Generally 80% Generally 10% Generally 10% F Amouns PART B EXCESS CHARGES Above Medicare-Approved Amouns $0 $0 All coss (and hey do no coun oward annual ou-of-pocke limi of $4,660)* BLOOD Firs 3 pins $0 50% 50% F Nex $140 of Medicare-Approved Amouns***** $0 $0 $140 (Par B Deducible)*****F Amouns Generally 80% Generally 10% Generally 10% F CLINICAL LABORATORY SERVICES Tess For Diagnosic Services 100% $0 $0 PARTS A & B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable Medical Equipmen Firs $140 of Medicare-Approved Amouns****** Amouns 100% $0 $0 $0 $0 $140 (Par B Deducible)*F 80% 10% 10% F *This plan limis your annual ou-of-pocke paymens for Medicare-approved amouns o $4,660 per year. However, his limi does NOT include charges from your provider ha exceed Medicare-approved amouns (hese are called Excess Charges ) and you will be responsible for paying his difference in he amoun charged by your provider and he amoun paid by Medicare for he iem or service. ***** Once you have been billed $140 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. ****** Medicare benefis are subjec o change. Please consul he laes Guide o Healh Insurance for People Wih Medicare. TX OC (09/11) 20

21 Plan N - Benefis Char MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD HOSPITALIZATION*, *** Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,156 $1,156 (Par A Deducible) $0 61s hru 90h day All bu $289 a day $289 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $578 a day $578 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0** -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE* You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $ a day Up o $ a day $0 101s day and afer $0 $0 All Coss BLOOD*** Firs 3 pins $0 3 pins $0 Addiional amouns 100% $0 $0 HOSPICE CARE You mus mee Medicare s requiremens, including a docor s cerificaion of erminal illness All bu very limied copaymen/ coinsurance for oupaien drugs and inpaien respie care Medicare cos sharing $0 * A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy for 60 days in a row. ** NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. *** If you have Medicare Selec plan and you do no uilize a nework provider, you are responsible for all charges. TX OC (09/11) 21

22 MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $140 of Medicare-Approved Amouns* $0 $0 $140 (Par B Deducible) Amouns Generally 80% Balance, oher han up o $20 per office visi and up o $50 per emergency room visi. The copaymen of up o $50 is waived if he insured is admied o any hospial and he emergency visi is covered as a Medicare Par A expense. PART B EXCESS CHARGES Above Medicare-Approved Amouns $0 $0 All Coss Up o $20 per office visi and up o $50 per emergency visi. The copaymen of up o $50 is waived if he insured is admied o any hospial and he emergency room visi is covered as a Medicare Par A expense. BLOOD Firs 3 pins $0 All Coss $0 Nex $140 of Medicare-Approved Amouns* $0 $0 $140 (Par B Deducible) Amouns 80% 20% $0 CLINICAL LABORATORY SERVICES Tess For Diagnosic Services 100% $0 $0 HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable Medical Equipmen Plan N - Benefis Char MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDER YEAR PARTS A & B 100% $0 $0 Firs $140 of Medicare-Approved Amouns* $0 $0 $140 (Par B Deducible) Amouns 80% 20% $0 FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically Necessary Emergency care services beginning during he firs 60 days of each rip ouside he USA Firs $250 each Calendar Year $0 $0 $250 Remainder of Charges $0 80% o a Lifeime Maximum Benefi of $50,000 20% and amouns over he $50,000 Lifeime Maximum Benefi * Once you have been billed $140 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. TX OC (09/11) 22