Medicare Supplement Insurance

Transcription

1 Supplement Insurance South Dakota Outline of Coverage AveraHealthPlans.com Effective: July 016

2 Benefit Chart of Supplement Insurance Plans Standard Supplement Plans A, B, C, F, G, K and L and Select Supplement Plans A, B, C, F, G, K and L are available. These charts show the benefits included in each of the standard supplement plans. Every company must make Plan A available. Some plans may not be available in your state. The plans in bold type listed below (A, B, C, F, G, K and L) are also available as Select Plans. Select plans contain restrictions on your use of specific hospitals and, in some cases, specific doctors or other healthcare providers to get full coverage. See Outline of Coverage sections for details about ALL plans. Basic Benefits for Plans A N: o Hospitalization: Part A coinsurance plus coverage for 365 additional days after benefits end. o Medical Expenses: Part B coinsurance (generally of -approved expenses) or co-payments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or co-payments. o Blood: First three pints of blood each year. o Hospice: Part A coinsurance This table describes: A B C D F F 1 G Basic, including Part B coinsurance Basic, including Part B coinsurance Basic, including Part B coinsurance Basic, including Part B coinsurance Basic, including Part B coinsurance* Basic, including Part B coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part B Deductible Part B Deductible Part B Excess () Part B Excess () Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency 1 Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plans F after the policyholder has paid a calendar year $,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the deductibles for Part A and Part B, but do not include the plan s separate foreign travel emergency deductible. SD-OC (07016) 1 Page 3 Page

3 Benefit Chart of Supplement Insurance Plans Basic benefits for Plans K and L include similar services as Plans A G, but cost-sharing for the basic benefits is at different levels. K L M N Hospitalization and preventative care Basic, including Part B paid at ; other basic benefits coinsurance paid at 75% Hospitalization and preventative care paid at ; other basic benefits paid at 50% 50% Skilled Nursing Facility Coinsurance 75% Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Basic, including Part B coinsurance, except up to $0 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Coinsurance 50% Part A deductible 75% Part A Deductible 50% Part A Deductible Part A Deductible Out-of-pocket annual limit $4,960 benefits paid at after limit reached Out-of -pocket annual limit $,480 benefits paid at after limit reached Foreign Travel Emergency Foreign Travel Emergency Service Area Standard Plan Service Area: All counties in South Dakota are included in the service area for the Standard Plan. Select Plan Service Area: Aurora, Beadle, Bon Homme, Brookings, Brown, Brule, Buffalo, Butte, Campbell, Charles Mix, Clark, Clay, Codington, Corson, Custer, Davison, Day, Deuel, Dewey, Douglas, Edmunds, Fall River, Faulk, Grant, Gregory, Haakon, Hamlin, Hand, Hanson, Harding, Hughes, Hutchinson, Hyde, Jackson, Jerauld, Jones, Kingsbury, Lake, Lawrence, Lincoln, Lyman, Marshall, McCook, McPherson, Meade, Mellette, Miner, Minnehaha, Moody, Pennington, Perkins, Potter, Roberts, Sanborn, Shannon, Spink, Stanley, Sully, Todd, Tripp, Turner, Union, Walworth, Yankton and Ziebach Counties. (Updated /19/014) Premium Information Avera Health Plans can only raise your premium if we raise the premium for all policies like yours in this state. Your premiums are based on your attained age on the annual effective date of your policy. Plans K and L provide for different cost-sharing for items and services than Plans A-G. After you reach the annual limit, the plan pays of the copayments, coinsurance and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed -approved amounts, called Excess Charges. You will be responsible for paying excess charges. The out-of-pocket annual limit will increase each year for inflation. 4 PPage

4 ATTAINED AGE Monthly Premium Standard Plan A Select Plan A Standard Plan B Select Plan B Standard Plan C Select Plan C Male Female Male Female Male Female Male Female Male Female Male Female Under PageP age

5 ATTAINED AGE Standard Plan F Select Plan F Standard Plan G Smoker Monthly Premium Standard Plan G Non-Smoker Select Plan G Smoker Select Plan G Non-Smoker Male Female Male Female Male Female Male Female Male Female Male Female Under Page

6 ATTAINED AGE Monthly Premium Standard Plan K Select Plan K Standard Plan L Select Plan L Male Female Male Female Male Female Male Female Under PPage

7 DISCLOSURES Use this Outline of Coverage to compare benefits and premiums among policies. This outline shows benefits of policies sold for effective dates on or after January 1, 016. Policies sold for effective dates prior to January 1, 016 may have different premiums. You do not need more than one Supplement Insurance policy. You must be enrolled in Part A and Part B coverage and use a -approved hospital. COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new policy, be sure to answer truthfully and complete all questions about your medical and health history. We may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded. READ YOUR POLICY VERY CAREFULLY This is only an outline describing your policy s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and Avera Health Plans. RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to our Service Center at Avera Health Plans, 3816 S. Elmwood Ave. Suite 100, Sioux Falls, SD or your agent. If you send your policy back to us within 30 days after you receive it, we will treat your policy as if it had never been issued and return all of your payments. REFUND OF PREMIUM If termination is due to you ceasing to be eligible for this plan or we receive written notice that you wish to terminate your coverage, the date of termination will be the first day of the month following the event. Any premium paid beyond the termination date will be refunded to you. POLICY REPLACEMENT If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. NOTICE This policy may not fully cover all of your medical costs. Neither Avera Health Plans nor its agents are connected with. This Outline of Coverage does not give all the details of coverage. Contact your local Social Security Office or consult & You handbook for more details. We offer Supplement plans, which do not restrict your use of hospitals. You have the right to purchase Standard Plan A, B, C, F, G, K or L at any time. LIMITATIONS AND EXCLUSIONS Your coverage is conditional on s approval of Eligible Expenses. Services eligible for coverage must be deemed as medically necessary by. If does not consider services rendered or expenses incurred as medically necessary, no benefits will be paid. We will not place any limitations on benefits that are more restrictive than s limitations and restrictions, except as noted in the Network Hospital Restrictions. No benefits will be paid under Part A which duplicates payments under Part B. No benefits will be paid under Part B which duplicates payments under Part A. No benefits will duplicate payment made directly by. 68 PPage

8 NETWORK HOSPITAL RESTRICTIONS (Applies to Select Products Only) Benefit Plans A, B, C, F, G, K and L are Select Supplement Insurance policies. Services for outpatient surgery will be covered only if performed at an Avera owned or operated network hospital or outpatient surgery center which has a written agreement with Avera Health Plans to provide services. Services for renal dialysis will be covered only if performed at a network hospital or dialysis center which has either a written agreement with Avera Health Plans or a written agreement with a network hospital to facilitate the network hospital s dialysis services. Both inpatient and outpatient services provided and billed by any non-network hospital will NOT be covered except as described below. Full benefits of your coverage will be paid if: 1. Services are provided in the following places: a physician s office, in another office setting (other than an outpatient surgery center); or at a skilled nursing facility.. The services are provided for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury or a condition and it is not reasonable to obtain such services through the network hospitals. 3. While traveling outside the service area, services will be covered from the first day you receive non-emergency services at a non-network hospital, up to 90 consecutive days, once per calendar year. Please refer to the Calendar Year Travel Benefit outlined in the next section. Travel must be for purposes other than the receipt of medical care. CALENDAR YEAR TRAVEL BENEFITS You are entitled to a 90-consecutive-day travel benefit, once per calendar year. This travel benefit allows you to receive the full benefits of your coverage at a non-network hospital outside of the service area for nonemergency services. Your 90 days begins on the first day you receive nonemergency services from a non-network hospital. NETWORK HOSPITALS A network hospital is one that has a written agreement with Avera Health Plans Supplement product and has been designated by us to provide hospital services to our members under this policy. You may use any network hospital listed on your current Avera Health Plans Supplement Insurance Network Hospital Directory. This directory is updated periodically. To verify the status of a hospital, please call toll-free at between 8 a.m. to 5 p.m. CT, Monday through Friday or refer to our website at AveraHealthPlans.com and click Options. NON-NETWORK HOSPITAL ADMISSION PROCEDURES Prior to admission to a non-network hospital, you or your physician should call our Service Center at between 8 a.m. and 5 p.m. CT. We will confirm if the required services are available from a network hospital, and if not available, we will assist you in locating a hospital that provides the necessary service. Calling Avera Health Plans Service Center prior to use of a non-network hospital eliminates the need for retrospective inquiry. These non-network hospital admission procedures do not apply in emergency situations or while you are traveling outside of the service area during your Calendar Year Travel Benefit period, as outlined above. Travel must be for purposes other than the receipt of medical care. 4. Required services are not available at a network hospital in your service area. Other than hospital inpatient, hospital outpatient and facility services for outpatient surgery as noted above, you have no restrictions on benefits for services received in a non-hospital setting beyond standard limitations of this policy. 79 PPage

9 CONTINUATION OF COVERAGE Any claim for continuous loss that begins while this policy is in force will not be affected by the ending of this policy. However, benefits for such continuous loss may be conditional upon your continuous total disability, and are limited to the duration of the Benefit Period, if any, or the maximum benefits payable. Receipt of Part D benefits will not be considered in determining a continuous loss. If the authority to issue Select policies is discontinued for whatever reason or the service area no longer exists, your coverage can continue. Coverage will be continued under any other Supplement Insurance policy we have available continuing comparable or lesser benefits and which does not contain Restricted Network Provisions. You will not need to provide evidence of insurability. CONVERSION PRIVILEGE MEDICARE Select PRODUCTS ONLY You may request to convert this policy to a policy that does not contain a Network Hospital Restriction without submission of evidence of insurance at any time. Your request must be received by Avera Health Plans on or before the 0 th day of the month, and will be effective the first day of the following month. The conversion will be to a Supplement Insurance policy with comparable or lesser benefits which is offered by us. Conversion is subject to the availability of an Avera Health Plans Supplement Insurance policy for sale in your state. If you choose to convert back to a network hospital restricted plan, you will be subject to medical underwriting. QUALITY ASSURANCE When you purchase an Avera Health Plans Supplement Insurance plan, you agree to use a Network Hospital or Outpatient Surgical Center whenever possible. Our goal is to ensure access to high quality health care and we are continually striving to improve our services. To achieve this goal, our Quality Improvement Program allows us to monitor and evaluate the quality of care received by our insured. In addition, Avera Health Plans requires the network hospitals to meet or exceed acceptable standards of quality care for their field and to maintain a quality assurance program that conforms to local and nationally recognized quality of care standards. COMPLAINT AND APPEALS PHILOSOPHY We seek to provide quality administration and services to insureds of our Supplement Insurance plans and network hospitals. There may be a time you are not fully satisfied with the administration, claims practices or services we provide or provided by a network hospital. It is the policy of Avera Health Plans to make reasonable efforts to resolve member and provider complaints. If you or your authorized representative is not satisfied, you have the right to file a complaint or grievance. You may submit a complaint or grievance within 180 days from the date you were notified of the action that is causing the complaint. COMPLAINTS WHILE STAYING AT A NETWORK HOSPITAL If, while staying at a network hospital, you have a complaint regarding the hospital s services, you may contact our Service Center by phone at , 8 a.m. to 5 p.m. CT, Monday through Friday to express the complaint. The complaint will be researched and you will receive a response within 30 days. Calls received by our Service Center between 5 p.m. and 8 a.m., weekends and holidays, will be transferred to our afterhours answering service, where you may leave your name, policyholder identification number and phone number. Return calls will be placed the following business day. OTHER COMPLAINTS If you have questions or are dissatisfied with the quality of service received from Avera Health Plans, care received from a network hospital, have a complaint or want to contest the disposition of a claim, you may direct such inquires to Avera Health Plans Service Center, 3816 S. Elmwood Ave. Suite 100, Sioux Falls, SD , or you can call toll-free at , 8 a.m. to 5 p.m. CT, Monday through Friday without initiating a formal grievance. You will receive acknowledgement within three business days of receipt of the complaint. A written response will be sent to you within 30 business days of the complaint PPage

10 GRIEVANCE PROCEDURE MEDICARE SELECT PRODUCTS ONLY In the event you are dissatisfied with the response received to a complaint or with the disposition of a claim, you may submit a formal grievance by writing to Avera Health Plans Complaint and Appeals Coordinator, 3816 S. Elmwood Ave. Suite 100, Sioux Falls, SD Formal grievances in all other areas should be submitted to us in writing at the same address. A grievance must clearly state this is a grievance, or other words that clearly state that the intention of the written communication is to serve as a written grievance to be handled according to this procedure Acknowledgement of receipt of the grievance will be mailed within three business days and the grievance will be investigated. A response will be sent within 30 days following the date the grievance is received and shall explain in detail the reasons for the determination. If you are dissatisfied with an adverse outcome on a complaint or a grievance, you have the right to contact the South Dakota Division of Insurance by phone at or at the address below: South Dakota Division of Insurance 14 S. Euclid Ave., nd Floor Pierre, SD PPage

11 HOSPITALIZATION Semiprivate room and board, general nursing and miscellaneous services and supplies PLAN A MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD First 60 days 61 st day through 90 th day 91 st day and after (While using 60 lifetime reserve days) All but $1,88 All but $3 per day All but $644 per day $3 per day $644 per day $1,88 (Part A Deductible) Once lifetime reserve days are used -Additional 365 days -Beyond the Additional 365 days SKILLED NURSING FACILITY CARE You must meet s requirements, including having been in a hospital for at least 3 days and entered a -approved facility within 30 days after leaving the hospital. Eligible Expense 3 First 0 days 1 st thru 100 th day 101 st day and after Additional amounts HOSPICE CARE You must meet s requirements, including a doctor s certification of terminal illness All approved amounts All but $161 per day All but very limited for outpatient drugs and inpatient respite care. 3 pints Up to $161 per day A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. 3 When your Part A hospital benefits are exhausted, the insurer stands in the place of and will pay whatever amount would have paid for up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount would have paid. (07016) 1 10 Page Page

12 OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable PLAN A medical equipment MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR SERVICES MEDICARE PAYS PLAN PAYS YOU PAY First $166 of -Approved Amounts 1 MEDICAL EXPENSES - IN Remainder OR OUT OF of THE -Approved HOSPITAL AND Amounts Generally Generally OUTPATIENT HOSPITAL TREATMENT, such as physician's services, PART B inpatient EXCESS and CHARGES outpatient medical and surgical services and Above -Approved Amounts supplies, physical and speech therapy, diagnostic tests, durable medical equipment All costs First Next $166 $166 of of -Approved -Approved Amounts Amounts $166 $166 (Part (Part B B Deductible) Deductible) Remainder Remainder of of -Approved -Approved Amounts Amounts Generally Generally CLINICAL LABORATORY SERVICE PART B EXCESS CHARGES Tests For Diagnostic Services Above -Approved Amounts MEDICARE First (PARTS 3 pints A and B) MEDICAL SERVICES PER CALENDAR YEAR All costs HOME HEALTH CARE Next $166 of -Approved Amounts MEDICARE-APPROVED Remainder SERVICES of -Approved Amounts CLINICAL LABORATORY SERVICE -Medically necessary skilled care Tests services For and Diagnostic medical Services supplies Durable medical equipment First $166 of -Approved MEDICARE (PARTS Amounts A and B) MEDICAL SERVICES PER CALENDAR YEAR HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies Durable medical equipment First $166 of -Approved Amounts After you have been billed $166 of approved amounts for covered services, your Part B deductible will have been met for the calendar year. 11 P age After you have been billed $166 of approved amounts for covered services, your Part B deductible will have been met for the calendar year. 13 Page 11 Page

13 PLAN B PLAN B MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD MEDICARE SERVICES (PART A) HOSPITAL MEDICARE SERVICES PAYS PER BENEFIT PERIOD PLAN PAYS YOU PAY 1 HOSPITALIZATION HOSPITALIZATION Semiprivate room and board, general nursing and miscellaneous Semiprivate services and room supplies and board, general nursing and miscellaneous services and supplies First 60 days All but $1,88 $1,88 (Part A Deductible) 61 st day through First th days day All but All $3 but per $1,88 day $1,88 (Part A $3 Deductible) per day 91 st day and after (While using st lifetime day through reserve 90 days) th day All All but but $3 $644 per per day day $3 $644 per per day day 91 st day and after (While using 60 lifetime reserve days) All but $644 per day $644 per day Once lifetime reserve days are used Once lifetime reserve -Additional days 365 are used days Eligible Expense 3 -Beyond the -Additional Additional days days Eligible Expense SKILLED NURSING FACILITY CARE 3 -Beyond the Additional 365 days SKILLED You must meet NURSING s FACILITY requirements, CARE including having been in a You hospital must for meet at least s 3 days and requirements, entered a -approved including having been facility in a hospital within 30 for days at least after 3 leaving days and the entered hospital. a -approved facility within 30 days after leaving the hospital. First 0 days All approved amounts 1 st thru First th days day All All approved but $161 amounts per day Up to $161 per day st st thru day 100 and th after day All but $161 per day Up to $161 All per Costs day 101 st day and after 3 pints Additional First amounts 3 pints 3 pints HOSPICE CARE Additional amounts HOSPICE You must meet CARE s requirements, including a doctor s You certification must meet of terminal s illness requirements, including a doctor s certification of terminal illness All but very limited All but very limited for outpatient drugs and inpatient for outpatient drugs and respite inpatient care respite care 1 A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled Indicates your liability for covered charges. You are responsible for all other non-covered charges. care in any other facility for 60 days in a row. 3 A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled When your Part A hospital benefits are exhausted, the insurer stands in the place of and will pay whatever amount would have paid for care in any other facility for 60 days in a row. 3 up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any When your Part A hospital benefits are exhausted, the insurer stands in the place of and will pay whatever amount would have paid for difference between its billed charges and the amount would have paid. up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any SD-OC difference (07/016) between its billed charges and the amount would have paid. 1 Page 14 Page 1 Page

14 OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment PLAN B MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR First $166 of -Approved SERVICES Amounts MEDICARE PAYS PLAN PAYS $166 (Part B YOU Deductible) PAY 1 Generally Generally MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT PART B EXCESS HOSPITAL CHARGES TREATMENT, such as physician's services, inpatient and outpatient Above medical -Approved and surgical services Amounts and All costs supplies, physical and speech therapy, diagnostic tests, durable medical equipment All costs Next $166 of -Approved Amounts Remainder First $166 of of -Approved Amounts CLINICAL LABORATORY Remainder SERVICE of -Approved Amounts Generally Generally PART B EXCESS CHARGES Tests For Diagnostic Services Above -Approved Amounts All costs MEDICARE (PARTS A and B) MEDICAL SERVICES PER CALENDAR YEAR HOME HEALTH CARE All costs MEDICARE-APPROVED SERVICES Next $166 of -Approved Amounts CLINICAL -Medically LABORATORY necessary skilled SERVICE care services and medical supplies Tests For Diagnostic Services Durable medical equipment First $166 of -Approved Amounts MEDICARE (PARTS A and B) MEDICAL SERVICES PER CALENDAR YEAR HOME HEALTH CARE MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies Durable medical equipment First $166 of -Approved Amounts After you have been billed $166 of approved amounts for covered services, your Part B deductible will have been met for the calendar year. 13 P age After you have been billed $166 of approved amounts for covered services, your Part B deductible will have been met for the calendar year. 15 Page 13 Page

15 MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD PLAN C HOSPITALIZATION MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD Semiprivate room and board, general nursing and miscellaneous services and supplies HOSPITALIZATION Semiprivate room and board, general nursing and miscellaneous First 60 days All but $1,88 $1,88 (Part A Deductible) services and supplies 61 st day through 90 th day All but $3 per day $3 per day 91 st day and after (While using 60 lifetime reserve days) All but $644 per day $644 per day First 60 days All but $1,88 $1,88 (Part A Deductible) Once lifetime 61reserve st day through days are 90 th used day All but $3 per day $3 per day 91 st day and after (While using 60 lifetime -Additional reserve 365 days) All but $644 per day Eligible $644 Expense per day -Beyond the Additional 365 days SKILLED NURSING FACILITY CARE Once lifetime reserve days are used You must meet s requirements, including -Additional having been 365 in days a Eligible Expense 3 hospital for at least 3 days and entered -Beyond a -approved the Additional 365 facility days SKILLED within 30 days NURSING after leaving FACILITY the hospital. CARE You must meet s requirements, including having been in a hospital for at least 3 days and entered a -approved First facility 0 days All approved amounts within 30 days after leaving the hospital. 1 st thru 100 th day 101 st day and after All but $161 per day Up to $161 per day First 0 days All approved amounts 1 st thru First 1003 th pints day All but $161 per day Up to $161 per 3 pints day Additional 101 st day and amounts after HOSPICE CARE You must meet s requirements, including a doctor s 3 pints certification of terminal illness Additional amounts HOSPICE CARE All but very limited You must meet s requirements, including a doctor s certification of terminal illness for outpatient drugs and inpatient All but respite very limited care for outpatient drugs and inpatient respite care A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. 13 Indicates When your your liability Part for covered A hospital charges. benefits You are are exhausted, responsible the for insurer all other stands non-covered in the place charges. of and will pay whatever amount would have paid for up A to benefit an additional period begins 365 days on the as provided first day you in the receive policy s service Core as Benefits. an inpatient During a this hospital time, and the ends hospital after is you prohibited have been from out billing of the you hospital for the and balance have based not received on any skilled care difference in any between other facility its billed for 60 charges days in and a row. the amount would have paid. 3 SD-OC When your (07/016) Part A hospital benefits are exhausted, the insurer stands in the place of and will pay whatever amount would have paid 14 for Page up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount would have paid. 16 Page 14 Page

16 PLAN C PLAN C MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR MEDICARE SERVICES (PART B) MEDICAL MEDICARE SERVICES PAYS PER CALENDAR YEAR PLAN PAYS YOU PAY 1 SERVICES MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND MEDICARE PAYS PLAN PAYS YOU PAY 1 OUTPATIENT HOSPITAL TREATMENT, such as physician's MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND services, inpatient and outpatient medical and surgical services and OUTPATIENT HOSPITAL TREATMENT, such as physician's supplies, physical and speech therapy, diagnostic tests, durable services, inpatient and outpatient medical and surgical services and medical equipment supplies, physical and speech therapy, diagnostic tests, durable First $166 of -Approved Amounts medical equipment Generally Generally First $166 of -Approved Amounts PART B EXCESS CHARGES Generally Generally Above -Approved Amounts All costs PART B EXCESS CHARGES Above -Approved Amounts All costs All costs Next $166 of -Approved Amounts All costs Next $166 of -Approved Amounts CLINICAL LABORATORY SERVICE Tests For Diagnostic Services CLINICAL LABORATORY SERVICE Tests For Diagnostic Services MEDICARE (PARTS A and B) MEDICAL SERVICES PER CALENDAR YEAR HOME HEALTH CARE MEDICARE (PARTS A and B) MEDICAL SERVICES PER CALENDAR YEAR MEDICARE-APPROVED SERVICES HOME HEALTH CARE -Medically necessary skilled care services and medical supplies MEDICARE-APPROVED SERVICES -Medically necessary skilled care services and medical supplies Durable medical equipment First $166 of -Approved Amounts Durable medical equipment First $166 of -Approved Amounts FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically Necessary Emergency care services beginning during the FOREIGN TRAVEL- NOT COVERED BY MEDICARE first 60 days of each trip outside the USA. Medically Necessary Emergency care services beginning during the first 60 days of each trip outside the USA. First $50 each Calendar Year $50 Remainder of Charges to a lifetime maximum and amounts over the First $50 each Calendar Year $50 benefit of $50,000 $50,000 lifetime maximum Remainder of Charges to a lifetime maximum benefit of $50,000 and amounts over the $50,000 lifetime maximum 1 After you have been billed $166 of approved amounts for covered services, your Part B deductible will have been met for the calendar year. Indicates your liability for covered charges. You are responsible for all other non-covered charges. SD-OC After you (07/016) have been billed $166 of approved amounts for covered services, your Part B deductible will have been met for the calendar year. 15 Page 17 Page 15 Page

17 101 st day First and 0 days after 1 st thru 100 th day 101 st day First and 3 pints after Additional amounts HOSPICE CARE You must meet s requirements, including Additional a doctor s amounts HOSPICE certification CARE of terminal illness You must meet s requirements, including a doctor s certification of terminal illness PLAN F MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD PLAN F HOSPITALIZATION MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD Semiprivate room and board, general nursing and miscellaneous HOSPITALIZATION services and supplies Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,88 $1,88 (Part A Deductible) 61 st day through 90 th day All but $3 per day $3 per day 91 st day and after (While using 60 lifetime reserve First 60 days) All but All $644 but per $1,88 day $1,88 (Part A $644 Deductible) per day 61 st day through 90 th day All but $3 per day $3 per day 91 st day and after (While Once using lifetime 60 reserve lifetime days reserve are days) used All but $644 per day $644 per day -Additional 365 days Eligible Expense 3 Once -Beyond lifetime the reserve Additional days 365 are used days SKILLED NURSING FACILITY CARE -Additional 365 days Eligible Expense 3 You must meet s requirements, -Beyond including the Additional having been 365 in days a SKILLED hospital for NURSING at least 3 FACILITY days and entered CARE a -approved facility You within must 30 days meet after s leaving requirements, the hospital. including having been in a hospital for at least 3 days and entered a -approved facility within 30 days after leaving the hospital. First 0 days 1 st thru 100 th day All approved amounts All but $161 per day All approved amounts All but $161 per day All but very limited for outpatient drugs All but and very inpatient limited respite care for outpatient drugs and inpatient respite care Up to $161 per day Up to $161 per day 3 pints 3 pints A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care 1 Indicates in any your other liability facility for for covered 60 days charges. in a row. You are responsible for all other non-covered charges. 3 A When benefit your period begins Part on A the hospital first day benefits you receive are exhausted, service as the an insurer inpatient stands in a hospital in the place and ends of after you and have will been pay whatever out of the amount hospital and have would not received have paid skilled for care up to in an any additional other facility 365 days for 60 as days provided in a row. in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any 3 difference When your between its billed Part A charges hospital and benefits the amount are exhausted, the would insurer have stands paid. in the place of and will pay whatever amount would have paid for SD-OC up to an (07/016) additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any 16 Page difference between its billed charges and the amount would have paid. 18 Page 16 Page

18 PLAN F MEDICARE SERVICES (PART B) MEDICAL MEDICARE SERVICES PAYS PER CALENDAR YEAR PLAN PAYS YOU PAY 1 MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's MEDICAL services, inpatient EXPENSES and outpatient - IN OR OUT medical OF THE and HOSPITAL surgical services AND and supplies, OUTPATIENT physical HOSPITAL and speech TREATMENT, therapy, diagnostic such as tests, physician's durable medical services, equipment inpatient and outpatient medical and surgical services and supplies, physical and speech First therapy, $166 of -Approved diagnostic tests, durable Amounts medical equipment Generally Generally First $166 of -Approved Amounts PART B EXCESS CHARGES Generally Generally Above -Approved Amounts of Eligible Costs PART B EXCESS CHARGES Above -Approved Amounts of Eligible Costs All costs Next $166 of -Approved Amounts $166 (Part B Deductible All costs Next $166 of -Approved Amounts $166 (Part B Deductible CLINICAL LABORATORY SERVICE Tests For Diagnostic Services CLINICAL LABORATORY SERVICE Tests For Diagnostic Services MEDICARE (PARTS A and B) MEDICAL SERVICES PER CALENDAR YEAR HOME HEALTH CARE MEDICARE (PARTS A and B) MEDICAL SERVICES PER CALENDAR YEAR MEDICARE-APPROVED SERVICES HOME HEALTH CARE MEDICARE-APPROVED -Medically necessary SERVICES skilled care services and medical supplies -Medically necessary skilled care services Durable and medical medical equipment supplies First $166 of -Approved Amounts Durable medical equipment Remainder First $166 of of -Approved -Approved Amounts Amounts FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically Necessary Emergency Remainder care of services -Approved beginning during Amounts the FOREIGN first 60 days TRAVELof each trip NOT outside COVERED the USA. BY MEDICARE Medically Necessary Emergency care services beginning during the first 60 days of each trip outside the USA. First $50 each Calendar Year Remainder of Charges First $50 each Calendar Year Remainder of Charges PLAN F MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR to a lifetime maximum benefit of $50,000 to a lifetime maximum benefit of $50,000 $50 and amounts over the $50,000 lifetime maximum $50 and amounts over the $50,000 lifetime maximum After you have been billed $166 of approved amounts for covered services, your Part B deductible will have been met for the calendar year. SD-OC After (07/016) you have been billed $166 of approved amounts for covered services, your Part B deductible will have been met for the calendar year. 17 Page 19 Page 17 Page

19 MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD PLAN G HOSPITALIZATION MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD Semiprivate room and board, general nursing and miscellaneous services and supplies HOSPITALIZATION Semiprivate room and board, general nursing and miscellaneous First 60 days All but $1,88 $1,88 (Part A Deductible) services and supplies 61 st day through 90 th day All but $3 per day $3 per day 91 st day and after (While using 60 lifetime reserve days) All but $644 per day $644 per day First 60 days All but $1,88 $1,88 (Part A Deductible) Once lifetime 61 st reserve day through days 90 are th used day All but $3 per day $3 per day 91 st day and after (While using 60 lifetime -Additional reserve 365 days) All but $644 per day Eligible $644 Expense per day 3 -Beyond the Additional 365 days SKILLED NURSING FACILITY CARE Once lifetime reserve days are used You must meet s requirements, including -Additional having been 365 days in a Eligible Expense 3 hospital for at least 3 days and entered -Beyond a -approved the Additional 365 facility days SKILLED within 30 NURSING days after leaving FACILITY the CARE hospital. You must meet s requirements, including having been in a hospital for at least 3 days and entered a -approved First facility 0 days All approved amounts within 30 days after leaving the hospital. 1 st thru 100 th day All but $161 per day Up to $161 per day 101 st day and after First 0 days All approved amounts 1 st thru 100 th day All but $161 per day Up to $161 per day 3 pints 101 st day and after Additional amounts HOSPICE CARE 3 pints You must meet s requirements, including Additional a doctor s amounts certification of terminal illness All but very limited HOSPICE CARE for You must meet s requirements, including a doctor s outpatient drugs and inpatient certification of terminal illness All but respite very limited care. for outpatient drugs and inpatient respite care. A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. 13 Indicates When your your liability for Part covered A hospital charges. benefits You are are exhausted, responsible the for insurer all other stands non-covered in the place charges. of and will pay whatever amount would have paid for up A benefit to an additional period begins 365 days on the as first provided day you in the receive policy s service Core as Benefits. an inpatient During a hospital this time, and the ends hospital after is you prohibited have been from out billing of the you hospital for the and balance have not based received on any skilled care difference in any other between facility its billed for 60 charges days in and a row. the amount would have paid. 3 When your Part A hospital benefits are exhausted, the insurer stands in the place of and will pay whatever amount would have paid for 18 Page up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount would have paid. 0 Page 18 Page

20 PLAN G PLAN G MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR MEDICARE SERVICES (PART B) MEDICAL MEDICARE SERVICES PAYS PER CALENDAR YEAR PLAN PAYS YOU PAY 1 MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL SERVICES AND MEDICARE PAYS PLAN PAYS YOU PAY 1 MEDICAL OUTPATIENT EXPENSES HOSPITAL - IN TREATMENT, OR OUT OF THE such HOSPITAL as physician's AND OUTPATIENT services, inpatient HOSPITAL and outpatient TREATMENT, medical and such surgical as physician's services and supplies, services, physical inpatient and and speech outpatient therapy, medical diagnostic and surgical tests, services durable and medical supplies, equipment physical and speech therapy, diagnostic tests, durable medical equipment First $166 of -Approved Amounts Remainder First $166 of of -Approved -Approved Amounts Amounts Generally Generally PART B EXCESS CHARGES Generally Generally PART B EXCESS CHARGES Above -Approved Amounts Above -Approved Amounts Eligible Costs Eligible Costs All costs Next $166 of -Approved First Amounts 3 pints All costs Next Remainder $166 of of -Approved -Approved Amounts Amounts CLINICAL LABORATORY Remainder SERVICE of -Approved Amounts CLINICAL LABORATORY SERVICE Tests For Diagnostic Services Tests For Diagnostic Services MEDICARE (PARTS A and B) MEDICAL SERVICES PER CALENDAR YEAR HOME HEALTH CARE MEDICARE (PARTS A and B) MEDICAL SERVICES PER CALENDAR YEAR HOME MEDICARE-APPROVED HEALTH CARE SERVICES MEDICARE-APPROVED -Medically necessary SERVICES skilled care services and medical supplies -Medically necessary skilled care services and medical supplies Durable medical equipment First $166 of -Approved Durable medical equipment Amounts First $166 of -Approved Amounts FOREIGN TRAVEL- NOT Remainder COVERED of BY -Approved MEDICARE Amounts FOREIGN Medically Necessary TRAVEL- NOT Emergency COVERED care services BY MEDICARE beginning during the Medically first 60 days Necessary of each trip Emergency outside the care USA. services beginning during the first 60 days of each trip outside the USA. First $50 each Calendar Year First $50 Remainder each Calendar of Charges Year to a lifetime maximum Remainder of Charges to a benefit lifetime of maximum $50,000 benefit of $50,000 $50 and amounts over $50 the $50,000 and lifetime amounts maximum over the $50,000 lifetime maximum 1 After you have been billed $166 of approved amounts for covered services, your Part B deductible will have been met for the calendar year. Indicates your liability for covered charges. You are responsible for all other non-covered charges. SD-OC After you (07/016) have been billed $166 of approved amounts for covered services, your Part B deductible will have been met for the calendar year. 19 Page 1 Page 19 Page

21 PLAN K PLAN K MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD You will pay one-half the coinsurance / copayment MEDICARE of some covered (PART services A) HOSPITAL until you reach SERVICES the annual PER out-of-pocket BENEFIT limit PERIOD of $4,960 each calendar year. The amounts that apply You toward will your pay annual one-half limit the are coinsurance noted with / copayment diamonds ( ) of some in the covered chart below. services Once until you you reach reach the the annual annual limit, out-of-pocket the plan pays limit of $4,960 of your each calendar co-payment year. The and amounts coinsurance that apply for the toward rest your of the annual calendar limit are year. noted However, with diamonds this limit ( ) does in the NOT chart include below. charges Once you from reach your the annual provider limit, that the exceed plan pays -approved of your amounts co-payment (these are and called coinsurance Excess for the Charges ) rest of and the calendar you will be year. responsible However, for this paying limit does this difference NOT include the charges amount from charged your by provider your provider that exceed and the -approved amount paid by amounts for (these item are or called service. Excess Charges ) and you will be responsible for paying this difference SERVICES in the amount charged MEDICARE by your PAYS provider and the amount PLAN paid by PAYS for the item or service. YOU PAY 1 HOSPITALIZATION HOSPITALIZATION Semiprivate room and board, general nursing and miscellaneous Semiprivate services and room supplies and board, general nursing and miscellaneous services and supplies First 60 days 61 st day through First days All but $1,88 All but All $3 but per $1,88 day $644 (50% Part A Deductible) $644 (50% Part A $3 Deductible) per day $644 (50% Part A Deductible) $644 (50% Part A Deductible) 91 st day and after (While using st lifetime day through reserve 90days) th 91 st day and after (While using 60 lifetime reserve days) Once lifetime reserve days are used All but $3 $644 per day All but $644 per day $3 $644 per day $644 per day Once lifetime reserve -Additional days 365 are used days -Beyond the -Additional 365 days SKILLED NURSING FACILITY CARE -Beyond the Additional 365 days Eligible Expense Eligible Expense 3 3 SKILLED You must meet NURSING s FACILITY requirements, CARE including having been in a You hospital must for meet at least s 3 days and requirements, entered a -approved including having been facility in a hospital within 30 for days at least after 3 leaving days and the entered hospital. a -approved facility within 30 days after leaving the hospital. First 0 days All approved amounts 1 st thru First days st thru day 100 and th after day All All approved but $161 amounts per day All but $161 per day 50% of Part A Coinsurance 50% of Part A Coinsurance 50% of Part A Coinsurance 50% of Part A Coinsurance 101 st day and after HOSPICE CARE Additional First amounts 3 pints Additional amounts 50% 50% 50% 50% HOSPICE You must meet CARE s requirements, including a doctor s You certification must meet of terminal s illness requirements, including a doctor s certification of terminal illness All but very limited All but very limited for outpatient drugs and inpatient for outpatient drugs and respite inpatient care. respite care. 50% of 50% of 50% of 50% of 1 Indicates A benefit your period liability begins for on covered the first charges. day you You receive are responsible service as an for inpatient all other in non-covered a hospital and charges. ends after you have been out of the hospital and have not received skilled care A benefit in any period other facility begins for on 60 the days first in day a row. you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled 3 care When in any your other facility Part for A 60 hospital days in benefits a row. are exhausted, the insurer stands in the place of and will pay whatever amount would have paid for 3 up When to an your additional 365 Part days A as hospital provided benefits in the are policy s exhausted, Core Benefits. the insurer During stands this in the time, place the hospital of is prohibited and will pay from whatever billing you amount for the balance based would on have any paid for up difference to an additional between 365 its billed days as charges provided and in the the amount policy s Core Benefits. would have During paid. this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount would have paid. 0 Page Page 0 Page