Outline of Medicare Supplement Coverage

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "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

If You Are No Longer Able to Work

If You Are No Longer Able to Work If You Are No Longer Able o Work NY STRS A Guide for Making Disabiliy Reiremen Decisions INTRODUCTION If you re forced o sop working because of a serious illness or injury, you and your family will be

More information

Outline of Medicare Supplement Coverage

Outline of Medicare Supplement Coverage Outline of Medicare Supplement Coverage for Vermont residents Medicare supplement benefit plans with Dental and Vision: A, F, High Deductible F, K, and N Humana Reader s Digest Healthy Living Medicare

More information

OREGON Basic, including 100% Part B coinsurance. Skilled Nursing Facility Coinsurance Part A Deductible Part B. Deductible

OREGON Basic, including 100% Part B coinsurance. Skilled Nursing Facility Coinsurance Part A Deductible Part B. Deductible Oxford Life Benefit Chart of Medicare Supplement Plans sold on or after June 15, 2015 Insurance Company This chart shows the benefits included in each of the standard Medicare supplement plans. Every company

More information

Outline of Medicare Supplement Coverage

Outline of Medicare Supplement Coverage Outline of Medicare Supplement Coverage Cover page 1 of 2 Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010 Plans A, B, C, D, F, high deductible F, G, L, M This

More information

Plan F & Plan F* Skilled Nursing Facility Coinsurance Part A Deductible Part B. Deductible. Part B Excess (100%) Foreign Travel Emergency

Plan F & Plan F* Skilled Nursing Facility Coinsurance Part A Deductible Part B. Deductible. Part B Excess (100%) Foreign Travel Emergency Outline of Medicare Supplement Coverage By Reason of Age Cover Page: Benefit Plans A, F, High F and N See Outlines of Coverage sections for detail about all plans. This chart shows the benefits included

More information

A B C D F F* G K L M N Basic, including. Basic, including. coinsurance. 75% Skilled Nursing. Facility Coinsurance. 50% Part A. Deductible.

A B C D F F* G K L M N Basic, including. Basic, including. coinsurance. 75% Skilled Nursing. Facility Coinsurance. 50% Part A. Deductible. 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 in your state. AmeriHealth Insurance

More information

Plan F* Plan G. Basic, including 100% Basic, including 100% Basic, including 100% Part B coinsurance. Skilled nursing facility coinsurance

Plan F* Plan G. Basic, including 100% Basic, including 100% Basic, including 100% Part B coinsurance. Skilled nursing facility coinsurance Outline of Coverage UnitedHealthcare Insurance Company Overview of Available s Benefit Chart of Medicare Supplement s Sold on or After June 1, 2010 This chart shows the benefits included in each of the

More information

Basic, Including 100% Part B Coinsurance. Part B Coinsurance. Coinsurance* 50% Skilled Nursing Facility Coinsurance. Skilled Nursing Facility

Basic, Including 100% Part B Coinsurance. Part B Coinsurance. Coinsurance* 50% Skilled Nursing Facility Coinsurance. Skilled Nursing Facility AMERICAN RETIREMENT LIFE INSURANCE COMPANY P. O. BOX 26580 AUSTIN, TX 78755-0580 866-459-4272 Outline of Medicare Supplement Coverage - Benefit Plans A, F, G and N This chart shows the benefits included

More information

Benefit Chart of Medicare Supplement Plans Sold On or After June 1, 2015

Benefit Chart of Medicare Supplement Plans Sold On or After June 1, 2015 Outline of Medicare Supplement Coverage Benefit Chart of Medicare Supplement Plans Sold On or After June 1, 2015 This chart shows the benefits included in each of the standard Medicare Supplement plans.

More information

Medicare Supplement Outline of Coverage

Medicare Supplement Outline of Coverage Blue Cross and Blue Shield of Nebraska Medicare Supplement Outline of Coverage Benefit Plans: A, B, C, F, G and L Rates Valid: April 1, 2016 through March 31, 2017 For Plans Effective: January 1, 2016

More information

Child Protective Services. A Guide To Investigative Procedures

Child Protective Services. A Guide To Investigative Procedures Child Proecive Services A Guide To Invesigaive Procedures The purpose of his brochure is o help you undersand he Child Proecive Services (CPS) reporing and response process. Please conac your CPS worker

More information

A B C D F G Basic, including 100% Part B coinsurance. Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance

A B C D F G Basic, including 100% Part B coinsurance. Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance SOUTH CAROLINA HEALTH INSURANCE POOL (SCHIP) OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE 1 OF 2: STANDARDIZED MEDICARE SUPPLEMENT COVERAGE BENEFIT PLANS A and C AVAILABLE These charts show the benefits

More information

Outline of Medicare Supplement Coverage

Outline of Medicare Supplement Coverage Outline of Medicare Supplement Coverage Cover Page 1 of 2 ATTAINED AGE BENEFIT PLANS A, C, F, J These charts show the benefits included in each of the 1990 standardized Medicare Supplement plans. Every

More information

Texas Department of Insurance

Texas Department of Insurance Texas Department of Insurance Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010 This chart shows the benefits included in each of the standard Medicare supplement

More information

Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance

Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Group Health Options, Inc. Outline of Medicare Supplement Coverage - Cover Page Benefit Plans A, F, K and N See Outlines of Coverage sections for details about ALL plans These charts show the benefits

More information

A B C D F F* G K L M N. Basic Benefits. Basic Benefits* Skilled Nursing Facility Coinsurance Part A Deductible Part B. 50% Skilled Nursing Facility

A B C D F F* G K L M N. Basic Benefits. Basic Benefits* Skilled Nursing Facility Coinsurance Part A Deductible Part B. 50% Skilled Nursing Facility Outline of Medicare Supplement Coverage Standard Benefit for Plan A, Plan F, High Plan F*, Plan N, and Blue Plan65 Select Benefit for Plan F and Plan N This chart shows the benefits included in each of

More information

Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Basic, including 100% Part B coinsurance. 100% Part B coinsurance

Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Basic, including 100% Part B coinsurance. 100% Part B coinsurance Health First Insurance, Inc. OUTLINE OF COVERAGE 2014 Benefit Plans A, F, N Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010 This chart shows the benefits included in each of the

More information

TOI: H02I Individual Health - Accident Only Sub-TOI: H02I.000 Health - Accident Only Application for Accidental Death Policy/UAIN-TAP(03)

TOI: H02I Individual Health - Accident Only Sub-TOI: H02I.000 Health - Accident Only Application for Accidental Death Policy/UAIN-TAP(03) TOI: H02I Individual Healh - Acciden Only Sub-TOI: H02I.000 Healh - Acciden Only Produc Name: Projec Name/Number: / Filing a a Glance Company: Unied American Insurance Company Produc Name: Applicaion for

More information

Benefit Chart of Medicare Supplement Plans Sold on or After January 1, 2014

Benefit Chart of Medicare Supplement Plans Sold on or After January 1, 2014 Benefit Chart of Medicare Supplement Plans Sold on or After January 1, 2014 This chart shows the benefits included in each of the standard Medicare Supplement plans. Every company must make available Plans

More information

[COMPANY NAME] Outline of Medicare Supplement Coverage-Cover Page: 1 of 2 Benefit Plans [insert letters of plans being offered

[COMPANY NAME] Outline of Medicare Supplement Coverage-Cover Page: 1 of 2 Benefit Plans [insert letters of plans being offered Incorporated Document (6) [COMPANY NAME] Outline of Medicare Supplement Coverage-Cover Page: 1 of 2 Benefit Plans [insert letters of plans being offered These charts show the benefits included in each

More information

Offered by. Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010

Offered by. Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010 SecureBlue This chart shows the benefits included in each of the standard Medicare Supplement plans. Every company must make available Plans A, B and C or F. Some plans may not be available in your state.

More information

K L M N Basic, including Basic,

K L M N Basic, including Basic, Companion Life Insurance Company Administrative Office PO Box 14158 Clearwater, Florida 33766-4158 (888) 220-0466 Outline of Medicare Supplement Coverage Cover Page Benefit Plans A, F and G - See Outlines

More information

2015 Benefit Chart of Medicare Supplement Plans Outline of Coverage 1-888-708-0123 mhinsurance.com

2015 Benefit Chart of Medicare Supplement Plans Outline of Coverage 1-888-708-0123 mhinsurance.com 2015 Benefit Chart of Medicare Supplement Plans Outline of Coverage 1-888-708-0123 mhinsurance.com MEMBERS HEALTH INSURANCE COMPANY Home Office: P.O. Box 1424, Columbia, TN 38402-1424 1-888-708-0123;

More information

Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility. coinsurance.

Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility. coinsurance. Sentinel Security Life Insurance Company Administrative Office P.O. Box 16960, Clearwater, FL 33766-6960 (888) 510-0668 Outline of Medicare Supplement Coverage Cover Page Benefit Plans A, B, C #, D #,

More information

A B C D F F* G K L M N Basic,

A B C D F F* G K L M N Basic, Outline of Medicare Supplement Coverage Benefit Plans A, D, and F Corporate Office Omaha, NE Administrative Services PO Box 10386 Des Moines, IA 50306 www.gomedico.com Toll-Free 1-800-228-6080 This chart

More information

Skilled Nursing Facility Coinsurance. Skilled Nursing Facility Coinsurance Part A Deductible Part B. Part A Deductible Part B.

Skilled Nursing Facility Coinsurance. Skilled Nursing Facility Coinsurance Part A Deductible Part B. Part A Deductible Part B. Aetna Life Insurance Company Outline of Medicare Supplement Coverage Benefit Plans A, B, F, G and N are Offered Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010

More information

Outline of Medicare Supplement Coverage - Standard Benefits for Plans A, B, C, F, High Deductible Plan F*, G, K, L and N

Outline of Medicare Supplement Coverage - Standard Benefits for Plans A, B, C, F, High Deductible Plan F*, G, K, L and N Outline of Medicare Supplement Coverage - Standard Benefits for Plans A, B, C, F, High Deductible Plan F*, G, K, L and N This chart shows the benefits included in each of the standard Medicare supplement

More information

THE LAW SOCIETY OF THE AUSTRALIAN CAPITAL TERRITORY

THE LAW SOCIETY OF THE AUSTRALIAN CAPITAL TERRITORY Complee he form in BLOCK LETTERS Provide deails on separae shees if required To Responden Address THE LAW SOCIETY OF THE AUSTRALIAN CAPITAL TERRITORY Personal Injury Claim ificaion pursuan o he Civil Law

More information

Basic, Including 100% Part B Coinsurance. Part B Coinsurance. Coinsurance* 50% Skilled Nursing Facility Coinsurance. Skilled Nursing Facility

Basic, Including 100% Part B Coinsurance. Part B Coinsurance. Coinsurance* 50% Skilled Nursing Facility Coinsurance. Skilled Nursing Facility AMERICAN RETIREMENT LIFE INSURANCE COMPANY P. O. BOX 26580 AUSTIN, TX 78755-0580 866-459-4272 Outline of Medicare Supplement Coverage - Benefit Plans A, F, G and N This chart shows the benefits included

More information

MEDICARE SUPPLEMENT OUTLINE OF BENEFIT COVERAGE

MEDICARE SUPPLEMENT OUTLINE OF BENEFIT COVERAGE Shaded Sections show Benefit Plans A, B, C, F, High Deductible F*, M and N which are available These charts show the benefits included in each of the standard Medicare Supplement plans. Every company must

More information

A B C D F F* G K L M N Basic,

A B C D F F* G K L M N Basic, 1515 South 75th Street Omaha, Nebraska 68124 Outline of Medicare Supplement Coverage Benefit Plans A, D, and F www.gomedico.com Toll-Free 1-800-228-6080 This chart shows the benefits included in each of

More information

Aetna Individual Medicare Supplement PlanSM

Aetna Individual Medicare Supplement PlanSM Aetna Individual Medicare Supplement PlanSM Aetna Life Insurance Company Outline of Medicare Supplement Coverage Benefit Plans A, B and F OOC-MD 18.02.312.1 MD (8/04) Outline of Medicare Supplement Coverage

More information

Basic, including 100% Part B coinsurance. Foreign Travel Emergency

Basic, including 100% Part B coinsurance. Foreign Travel Emergency BLUE CROSS AND BLUE SHIELD OF SOUTH CAROLINA An Independent Licensee of the Blue Cross and Blue Shield Association OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE 1 of 2: BENEFIT PLANS A, C, L and N

More information

MediGap Plans A, C, F, & N 2016 OUTLINE OF MEDICARE SUPPLEMENT COVERAGE

MediGap Plans A, C, F, & N 2016 OUTLINE OF MEDICARE SUPPLEMENT COVERAGE MediGap Plans A, C, F, & N 2016 OUTLINE OF MEDICARE SUPPLEMENT COVERAGE This page was intentionally left blank. BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD FOR EFFECTIVE DATES ON OR AFTER JUNE 1, 2010

More information

A B C D F F* G K L M N Basic, Co-insurance. Skilled Nursing Facility Co-insurance 50% Part A. Skilled Nursing Facility. Part A Deductible Part B

A B C D F F* G K L M N Basic, Co-insurance. Skilled Nursing Facility Co-insurance 50% Part A. Skilled Nursing Facility. Part A Deductible Part B TRANSAMERICA PREMIER LIFE INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS A, F, G AND N SEE OUTLINES OF COVERAGE SECTIONS FOR DETAILS ABOUT ALL PLANS These charts show

More information

A B C D F F* G K L M N. Basic, including 100% Part B Coinsurance. Part B. 75% Skilled Nursing Facility. Part B. Deductible

A B C D F F* G K L M N. Basic, including 100% Part B Coinsurance. Part B. 75% Skilled Nursing Facility. Part B. Deductible This chart shows the benefits included in each of the standard supplement plans sold for effective dates on or after June 1, 2010. Every company must make Plan A available. Blue Cross and Blue Shield of

More information

Part B. Coinsurance. Skilled Nursing Facility. 50% Skilled Nursing Facility. Coinsurance. Coinsurance 75% Part A Deductible.

Part B. Coinsurance. Skilled Nursing Facility. 50% Skilled Nursing Facility. Coinsurance. Coinsurance 75% Part A Deductible. AMERICAN RETIREMENT LIFE INSURANCE COMPANY P. O. BOX 26580 AUSTIN, TX 78755-0580 866-459-4272 Outline of Medicare Supplement Coverage - Benefit Plans A, F, G and N This chart shows the benefits included

More information

Basic, including 100% Part B coinsurance. Foreign Travel Emergency

Basic, including 100% Part B coinsurance. Foreign Travel Emergency BLUE CROSS AND BLUE SHIELD OF SOUTH CAROLINA An Independent Licensee of the Blue Cross and Blue Shield Association OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE 1 of 2: BENEFIT PLANS A, B, D and F

More information

Basic, including 100% Part B coinsurance. Foreign Travel Emergency

Basic, including 100% Part B coinsurance. Foreign Travel Emergency BLUE CROSS AND BLUE SHIELD OF SOUTH CAROLINA An Independent Licensee of the Blue Cross and Blue Shield Association OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE 1 of 2: BENEFIT PLANS A, B, D and F

More information

Basic, including 100% Part B Coinsurance. Basic, including 100% Part B Coinsurance * Skilled Nursing Facility Coinsurance Part A Deductible Part B

Basic, including 100% Part B Coinsurance. Basic, including 100% Part B Coinsurance * Skilled Nursing Facility Coinsurance Part A Deductible Part B This chart shows the benefits included in each of the standard Medicare supplement plans sold for effective dates on or after June 1, 2010. Every company must make Plan A available. Blue Cross and Blue

More information

Basic, including 100% Part B Coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing.

Basic, including 100% Part B Coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing. GERBER LIFE INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS A, F, AND G This chart shows the benefits included in each of the standard Medicare supplement plans. Every

More information

Basic, including 100% Part B coinsurance. Skilled Nursing Facility Coinsuranc e Part A Deductible Part B

Basic, including 100% Part B coinsurance. Skilled Nursing Facility Coinsuranc e Part A Deductible Part B Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010 This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must

More information

Basic, including 100% Part B coinsurance* Basic, including 100% Part B coinsurance. Skilled Nursing Facility Coinsurance Part A Deductible

Basic, including 100% Part B coinsurance* Basic, including 100% Part B coinsurance. Skilled Nursing Facility Coinsurance Part A Deductible (Agency Note: Proposed new N.J.A.C. 11:4-23 Appendix Exhibit D reproduced below is not depicted in boldface, as would be the standard format for proposed new text, in order for the permanent boldfacing

More information

Benefit Chart of Medicare Supplement Plans Sold On or After January 1, 2015

Benefit Chart of Medicare Supplement Plans Sold On or After January 1, 2015 19 North Main Street, Wilkes-Barre, Pennsylvania, 18711 Blue Cross of Northeastern Pennsylvania Benefit Chart of Medicare Supplement Plans Sold On or After January 1, 2015 BlueCare Security Benefit Plans

More information

Regence Bridge. Medicare Supplement (Medigap) Plans

Regence Bridge. Medicare Supplement (Medigap) Plans OUTLINE OF COVERAGE Regence Bridge Medicare Supplement (Medigap) Plans Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association 07355rep06630-or OR

More information

OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT STANDARD PLANS A, B, C, D, F, J AND HIGH DEDUCTIBLE PLAN F

OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT STANDARD PLANS A, B, C, D, F, J AND HIGH DEDUCTIBLE PLAN F Anthem Blue Cross Blue Shield Connecticut Administrative Office: PO Box 1014 North Haven, CT 06473 Toll Free Telephone Number: 1-800-238-1143 OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT

More information

Outline of Medicare Supplement Coverage

Outline of Medicare Supplement Coverage Outline of Medicare Supplement Coverage Effective January 1, 2015 301 S. Vine St., Urbana, IL 61801-3347 1-800-965-4022 TTY 711 HealthAllianceMedicare.org med-msoutcov-11 med-2105msoutcov-1114 November

More information

Outline of Medicare Supplement Coverage Cover Page: 1 of 2 Benefit Plan A, Plan D, Plan F, Plan K and Plan L

Outline of Medicare Supplement Coverage Cover Page: 1 of 2 Benefit Plan A, Plan D, Plan F, Plan K and Plan L Outline of Medicare Supplement Coverage Cover Page: 1 of 2 Benefit Plan A, Plan D, Plan F, Plan K and Plan L Medicare Supplement insurance can be sold in only 12 standard plans plus two high-deductible

More information

HealthNow New York Inc. Mailing address: PO BOX 13599, Albany, New York 12214-5767 Physical address: 30 Century Hill Drive, Latham, New York 12110

HealthNow New York Inc. Mailing address: PO BOX 13599, Albany, New York 12214-5767 Physical address: 30 Century Hill Drive, Latham, New York 12110 HealthNow New York Inc. Mailing address: PO BOX 13599, Albany, New York 12214-5767 Physical address: 30 Century Hill Drive, Latham, New York 12110 Benefit Chart of Medicare Supplement Plans Sold for Effective

More information

Basic, including 100% 50% Skilled Nursing Facility. Skilled Nursing. Part A Deductible. Part A Deductible. Part B Excess (100%) Foreign Travel

Basic, including 100% 50% Skilled Nursing Facility. Skilled Nursing. Part A Deductible. Part A Deductible. Part B Excess (100%) Foreign Travel UNITED OF OMAHA LIFE INSURANCE COMPANY A Mutual of Omaha Company OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE STANDARDIZED BENEFIT PLAN A AND SELECT BENEFIT PLANS F AND G Benefit Chart of Medicare

More information

Medicare Supplement Coverage Options

Medicare Supplement Coverage Options Medicare Supplement Coverage Options Thank you for your interest in our Medicare Supplemental coverage options, also known as HealthNow New York Inc. Medicare Supplement (Medigap) plans. The Medicare Supplement

More information

A B C D F F* G K L M N. Basic Benefits. Basic Benefits* Skilled Nursing Facility Coinsurance Part A Deductible. 50% Skilled Nursing Facility

A B C D F F* G K L M N. Basic Benefits. Basic Benefits* Skilled Nursing Facility Coinsurance Part A Deductible. 50% Skilled Nursing Facility Outline of Medicare Supplement Coverage Standard Benefit for Plan A, Plan F, High Plan F*, Plan N, and Blue Plan65 Select SM Benefit for Plan F and Plan N This chart shows the benefits included in each

More information

APPLICATION FOR MEDICARE SUPPLEMENT INSURANCE ILLINOIS

APPLICATION FOR MEDICARE SUPPLEMENT INSURANCE ILLINOIS HEARTLAND NATIONAL LIFE INSURANCE COMPANY Medicare Supplement Administrative Office: PO Box 2878, Salt Lake City, UT 84110-2878 APPLICATION FOR MEDICARE SUPPLEMENT INSURANCE ILLINOIS HNAPP2013IL (2014)

More information

HealthNow New York Inc. Mailing address: PO BOX 15013, Albany, New York 12212-5012 Physical address: 30 Century Hill Drive, Latham, New York 12110

HealthNow New York Inc. Mailing address: PO BOX 15013, Albany, New York 12212-5012 Physical address: 30 Century Hill Drive, Latham, New York 12110 HealthNow New York Inc. Mailing address: PO BOX 15013, Albany, New York 12212-5012 Physical address: 30 Century Hill Drive, Latham, New York 12110 Benefit Chart of Medicare Supplement Plans Sold for Effective

More information

A B C D F F* G K L M N. Basic, including 100% Part B Coinsurance. Part B. 50% Skilled Nursing Facility. Part B. Deductible. Part B Excess (100%)

A B C D F F* G K L M N. Basic, including 100% Part B Coinsurance. Part B. 50% Skilled Nursing Facility. Part B. Deductible. Part B Excess (100%) This chart shows the benefits included in each of the standard Medicare supplement plans sold for effective dates on or after June 1, 2010. Every company must make Plan A available. Blue Cross and Blue

More information

A B C D F F* G K L M N Basic,

A B C D F F* G K L M N Basic, Outline of Medicare Supplement Coverage Benefit Plans A, D, and F Corporate Office Omaha, NE Administrative Services PO Box 10386 Des Moines, IA 50306 www.gomedico.com Toll-Free 1-800-228-6080 This chart

More information

UNITED AMERICAN INSURANCE COMPANY

UNITED AMERICAN INSURANCE COMPANY UNITED AMERICAN INSURANCE COMPANY A Nebraska Stock Company Administrative Offices: McKinney, Texas Outline of Medicare Supplement Coverage - Cover Page: 1 of 2 Benefit Plans B, HDF These charts show the

More information

MUTUAL OF OMAHA INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE BENEFIT PLANS A, C AND F

MUTUAL OF OMAHA INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE BENEFIT PLANS A, C AND F MUTUAL OF OMAHA INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE BENEFIT PLANS A, C AND F Medicare supplement insurance can be sold in only 10 standard plans plus two high deductible

More information

20:06:12:07. Guidelines for examination reports. The insurer's examination report shall be

20:06:12:07. Guidelines for examination reports. The insurer's examination report shall be 20:06:12:07. Guidelines for examination reports. The insurer's examination report shall be prepared in accordance with standards adopted by the National Association of Insurance Commissioners in the Financial

More information

OUTLINE OF MEDICARE SUPPLEMENT COVERAGE

OUTLINE OF MEDICARE SUPPLEMENT COVERAGE OUTLINE OF MEDICARE SUPPLEMENT COVERAGE Tufts Medicare Preferred Supplement Core Tufts Medicare Preferred Supplement One Outline of Medicare Supplement Coverage Cover Page: Benefit Plans Medicare Supplement

More information

2014 Outline of Medicare Supplement Coverage Cover Page (1 of 2) Plans A, F & N

2014 Outline of Medicare Supplement Coverage Cover Page (1 of 2) Plans A, F & N Anthem Blue Cross and Blue Shield Virginia Administrative Office: P.O. Box 27401, Richmond, VA 23279-7401 Toll Free Telephone Number: 1-800-916-2583 Benefit Chart of Medicare Supplement Plans Sold for

More information

Skilled Nursing Facility Coinsurance Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible

Skilled Nursing Facility Coinsurance Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible BLUE CROSS AND BLUE SHIELD OF SOUTH CAROLINA An Independent Licensee of the Blue Cross and Blue Shield Association OUTLINE OF BLUE SELECT COVERAGE COVER PAGE 1 of 2: BENEFIT PLANS TRADITIONAL A and BLUE

More information

Outline of Medicare Supplement Coverage

Outline of Medicare Supplement Coverage Outline of Medicare Supplement Coverage Benefit Plans A, C, F, L, N for 2016 Outline of Medicare Supplement Coverage Benefit Plans A, C, F, L, N for 2016 These charts show the benefits included in each

More information

MedicareBlue Supplement

MedicareBlue Supplement SM MedicareBlue Supplement Plans A, D, F, High Deductible F, and N 2015 Outlines of Coverage Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or after January 1, 2015 This chart shows

More information

HealthSelectSM. 2015 Medical Benefits Member Guide. Active employees. Retirees who are not eligible for Medicare. September 1, 2014 August 31, 2015

HealthSelectSM. 2015 Medical Benefits Member Guide. Active employees. Retirees who are not eligible for Medicare. September 1, 2014 August 31, 2015 HealhSelecSM www.healhselecofexas.com www.myuhc.com/hs of Texas 2015 Medical Benefis Member Guide Sepember 1, 2014 Augus 31, 2015 This guide is for: Acive employees Reirees who are no eligible for Medicare

More information

MUTUAL OF OMAHA INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE 1 BENEFIT PLANS A, C, D, F AND G

MUTUAL OF OMAHA INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE 1 BENEFIT PLANS A, C, D, F AND G OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE 1 BENEFIT PLANS A, C, D, F AND G These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make

More information

Basic, including 100% Part B Coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing.

Basic, including 100% Part B Coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing. OMAHA INSURANCE COMPANY A Mutual of Omaha Company OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS A, C, D, F, AND G This chart shows the benefits included in each of the standard Medicare

More information

Basic, including 100% Part B Coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing.

Basic, including 100% Part B Coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing. OMAHA INSURANCE COMPANY A Mutual of Omaha Company OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS A, C, D, F, AND G This chart shows the benefits included in each of the standard Medicare

More information

Medicare Supplement Coverage Options

Medicare Supplement Coverage Options Medicare Supplement Coverage Options Thank you for your interest in our Medicare Supplemental coverage options, also known as HealthNow New York Inc. Medicare Supplement (Medigap) plans. The Medicare Supplement

More information

2014 Outline of Medicare Supplement Coverage Cover Page (1 of 2) Plans A, F, High Deductible Plan F, G & N

2014 Outline of Medicare Supplement Coverage Cover Page (1 of 2) Plans A, F, High Deductible Plan F, G & N Anthem Blue Cross and Blue Shield Colorado Administrative Office: PO Box 9063, Oxnard, CA 93031-9063 Toll Free Telephone Number: 1-877-831-3000 Benefit Chart of Medicare Supplement Plans Sold for Effective

More information

OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE 1 BENEFIT PLANS A, F AND G

OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE 1 BENEFIT PLANS A, F AND G UNITED OF OMAHA LIFE INSURANCE COMPANY A Mutual of Omaha Company OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE 1 BENEFIT PLANS A, F AND G These charts show the benefits included in each of the standard

More information

Outline of coverage. January 2015 May 2015

Outline of coverage. January 2015 May 2015 January 2015 May 2015 Outline of coverage The federal government has asked us to provide this outline of coverage to help you decide which plan best fits your needs and meets your budget. D98, 10/14, SM

More information

Outline of coverage. June 2014 May 2015

Outline of coverage. June 2014 May 2015 June 2014 May 2015 Outline of coverage The federal government has asked us to provide this outline of coverage to help you decide which plan best fits your needs and meets your budget. D98, 3/14, SM Marks

More information

Outline of coverage. June 2015 - May 2016

Outline of coverage. June 2015 - May 2016 June 2015 - May 2016 Outline of coverage The federal government has asked us to provide this outline of coverage to help you decide which plan best fits your needs and meets your budget. D98, 2/15, SM

More information

Skilled Nursing Facility. Coinsurance. Skilled Nursing Facility. Coinsurance

Skilled Nursing Facility. Coinsurance. Skilled Nursing Facility. Coinsurance 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

More information

Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing

Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing MUTUAL OF OMAHA INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS A, B, C, D, F AND G These charts show the benefits included in each of the standard Medicare supplement

More information

MEDICARE SUPPLEMENT COVERAGE PENNSYLVANIA

MEDICARE SUPPLEMENT COVERAGE PENNSYLVANIA MEDICARE SUPPLEMENT COVERAGE PENNSYLVANIA The Insurance Plans of Choice for Medicare Supplemental Coverage Philadelphia American Life Insurance Company P.O. BOX 4884 Houston, TX 77210-4884 Plan Form Standard

More information

AFLAC MEDICARE SUPPLEMENT

AFLAC MEDICARE SUPPLEMENT AFLAC MEDICARE SUPPLEMENT P E N N S Y LVA N I A 2 0 13 IC(1/13) AMERICAN FAMILY LIFE ASSURANCE COMPANY OF COLUMBUS Outline of Medicare Supplement Coverage Benefit Plans A, B, C, D, F, G and N Benefit

More information

OUTLINE OF COVERAGE. Regence Bridge. Medicare Supplement (Medigap) Plans

OUTLINE OF COVERAGE. Regence Bridge. Medicare Supplement (Medigap) Plans OUTLINE OF COVERAGE Regence Bridge Medicare Supplement (Medigap) Plans Regence BlueCross BlueShield of Utah is an Independent Licensee of the Blue Cross and Blue Shield Association 09713rep07355-ut UT

More information

Humana Insurance Company Outline of Medicare Supplement Coverage - Cover Page: Benefit Plans Core and Supplement 1

Humana Insurance Company Outline of Medicare Supplement Coverage - Cover Page: Benefit Plans Core and Supplement 1 MA81077PD2 Page 1 Humana Insurance Company Outline of Medicare Supplement Coverage - Cover Page: Benefit Plans Core and Supplement 1 Medicare Supplement Insurance can be sold in only two standard plans.

More information

Outline of Medicare Supplement Coverage TUFTS MEDICARE PREFERRED SUPPLEMENT PLANS 2015

Outline of Medicare Supplement Coverage TUFTS MEDICARE PREFERRED SUPPLEMENT PLANS 2015 TUFTS MEDICARE PREFERRED SUPPLEMENT PLANS 2015 Outline of Medicare Supplement Coverage Tufts Medicare Preferred Supplement Core Tufts Medicare Preferred Supplement One Effective January 1, 2015 December

More information

Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing.

Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing. UNITED WORLD LIFE INSURANCE COMPANY A Mutual of Omaha Company OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS A, B, C, D, F, G, AND M These charts show the benefits included in each of

More information

2015 Outline of Medicare Supplement Coverage Cover Page (1 of 2) Plans A, F & N

2015 Outline of Medicare Supplement Coverage Cover Page (1 of 2) Plans A, F & N nthem Blue Cross and Blue Shield Connecticut dministrative Office: 370 Bassett Road, North Haven, CT 06473 Toll Free Telephone Number: 1-800-238-1143 2015 Outline of Medicare Supplement Coverage Cover

More information

MedicareBlue Supplement SM

MedicareBlue Supplement SM MedicareBlue Supplement SM Important Information about the enclosed premiums and Medicare deductibles and cost-sharing amounts The MedicareBlue Supplement information enclosed in this Outline of Coverage

More information

GERBER LIFE INSURANCE COMPANY WHITE PLAINS, NEW YORK OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE

GERBER LIFE INSURANCE COMPANY WHITE PLAINS, NEW YORK OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE GERBER LIFE INSURANCE COMPANY WHITE PLAINS, NEW YORK OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE BASIC AND EXTENDED BASIC PLANS The Commissioner of Insurance of the State of Minnesota has established

More information

Skilled Nursing Facility Coinsurance. Part A Deductible Part B. Deductible. Part B Excess- 100% Foreign Travel Emergency

Skilled Nursing Facility Coinsurance. Part A Deductible Part B. Deductible. Part B Excess- 100% Foreign Travel Emergency Aetna Life Insurance Company Outline of Medicare Supplement Coverage Benefit Plans A, B, F, G and N are Offered Benefit Chart of Medicare Supplement Plans Sold with an Effective Date for Coverage on or

More information

Coinsurance Part A. Deductible. Nursing. Benefits. Skilled. Part B. Coinsurance Part A. Deductible. Nursing. Benefits. Skilled. Coinsurance Part A

Coinsurance Part A. Deductible. Nursing. Benefits. Skilled. Part B. Coinsurance Part A. Deductible. Nursing. Benefits. Skilled. Coinsurance Part A Guarantee Trust Life Insurance Company Outline of Medicare Supplement Coverage Cover Page: 1 of 2 Benefit Plan(s) A, D, G These charts show the benefits included in each of the standard Medicare supplement

More information

PROFIT TEST MODELLING IN LIFE ASSURANCE USING SPREADSHEETS PART TWO

PROFIT TEST MODELLING IN LIFE ASSURANCE USING SPREADSHEETS PART TWO Profi Tes Modelling in Life Assurance Using Spreadshees, par wo PROFIT TEST MODELLING IN LIFE ASSURANCE USING SPREADSHEETS PART TWO Erik Alm Peer Millingon Profi Tes Modelling in Life Assurance Using Spreadshees,

More information

Skilled Nursing Facility. Coinsurance. Skilled Nursing Facility. Coinsurance

Skilled Nursing Facility. Coinsurance. Skilled Nursing Facility. Coinsurance 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

More information

A B C D F F* G K L M N. Basic, including 100% Part B Coinsurance. Part B. Skilled Nursing Facility Coinsurance Part A Deductible Part B

A B C D F F* G K L M N. Basic, including 100% Part B Coinsurance. Part B. Skilled Nursing Facility Coinsurance Part A Deductible Part B This chart shows the benefits included in each of the standard Medicare supplement plans sold for effective dates on or after June 1, 2010. Every company must make Plan A available. Blue Cross and Blue

More information

Basic, including 100% Part B Coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing.

Basic, including 100% Part B Coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing. OMAHA INSURANCE COMPANY A Mutual of Omaha Company OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS A, F, AND G This chart shows the benefits included in each of the standard Medicare supplement

More information

Health plans for every body

Health plans for every body Health plans for every body Supplemental coverage for Medicare members Medicare modahealth.com/medicare Available April 1 through Dec. 31, 2015 Hello. Welcome to Moda Health, the place you go when you

More information

Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing.

Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing. UNITED WORLD LIFE INSURANCE COMPANY A Mutual of Omaha Company OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS A, B, C, D, F, G, M AND N These charts show the benefits included in each

More information

2015 Outline of Coverage Security 65 Medicare Supplement Plans. Plan A Plan B Plan C Plan H Plan H with Drug

2015 Outline of Coverage Security 65 Medicare Supplement Plans. Plan A Plan B Plan C Plan H Plan H with Drug 2015 Outline of Coverage Security 65 Medicare Supplement Plans Plan A Plan B Plan C Plan H Plan H with Drug Independence Blue Cross and Highmark Blue Shield Outline of Medicare Supplement Coverage Security

More information

Harvard Pilgrim s Medicare Supplement Plan HPHC Insurance Company, Inc.

Harvard Pilgrim s Medicare Supplement Plan HPHC Insurance Company, Inc. Medicare Supplement Core Massachusetts 2015 Coverage underwritten by HPHC Insurance Company, an affiliate of Harvard Pilgrim Health Care. Harvard Pilgrim s Medicare Supplement Plan HPHC Insurance Company,

More information

Regence Bridge Medicare Supplement (Medigap) Plans. Decision Guide

Regence Bridge Medicare Supplement (Medigap) Plans. Decision Guide Decision Guide Regence Bridge Medicare Supplement (Medigap) Plans Regence BlueShield serves select counties in the state of Washington and is an Independent Licensee of the Blue Cross and Blue Shield Association

More information

Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010

Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010 Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010 This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make available Plans

More information

Simply BLUE MEDICARE SUPPLEMENT PLANS SR BRO 2015

Simply BLUE MEDICARE SUPPLEMENT PLANS SR BRO 2015 Simply BLUE MEDICARE SUPPLEMENT PLANS 2015 SR BRO 2015 Simply BLUE Table of Contents Standard Benefit Offerings...2 Disclosures...3 Important Facts to Consider...4 Supplement Plan Premiums...5 Benefit

More information

Medicare. Supplemental Coverage Outline. n Supplement-65 District of Columbia

Medicare. Supplemental Coverage Outline. n Supplement-65 District of Columbia Medicare Supplemental Coverage Outline n Supplement-65 District of Columbia SUDDCOB (1/09) Offered by Group Hospitalization and Medical Services, Inc.* d/b/a CareFirst BlueCross BlueShield 840 First Street,

More information

Basic, including. Hospitalization and preventive care paid. 50% Skilled Nursing. Part A Deductible. 50% Part A. Deductible

Basic, including. Hospitalization and preventive care paid. 50% Skilled Nursing. Part A Deductible. 50% Part A. Deductible United of Omaha Life Insurance Company A Mutual of Omaha Company OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS A, C, F, HIGH DEDUCTIBLE F, G, M AND N This chart shows the benefits included

More information