Basic Benefits, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for Emergency Room

Transcription

1 available in your state. BASIC BENEFITS Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses), or copayments for hospital outpatient services. Plans K L, and N require insureds to pay a portion of Part B coinsurance or copayments. Blood: First 3 pints of blood each year. Hospice: Part A coinsurance. A B C D F F* G K L M N Basic Benefits, including 100% Part B coinsurance Basic Benefits, including 100% Part B coinsurance Part A Deductible Basic Benefits, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Foreign Travel Emergency Basic Benefits, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency Basic Benefits, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency Basic Benefits, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part B Excess (100%) Foreign Travel Emergency Hospitalization and Preventive Care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility Coinsurance 50% Part A Deductible Out-of-pocket limit $4,960; paid at 100% after limit reached Hospitalization and Preventive Care paid at 100%; other basic benefits paid at 75% 75% Skilled Nursing Facility Coinsurance 75% Part A Deductible Out-of-pocket limit $2,480; paid at 100% after limit reached Basic Benefits, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance 50% Part A Deductible Foreign Travel Emergency Basic Benefits, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for Emergency Room Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan s separate foreign travel emergency deductible. LIFE INSURANCE COMPANY Corporate Office Omaha, NE Administrative Services PO Box Des Moines, IA Toll-Free Outline of Medicare Supplement Coverage - Benefit Plans A, F, G and N This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan A available. Some plans may not be NE

2 Plan A ZIP Codes: & over

3 Plan A ZIP Codes: 681, & over

4 Plan A ZIP Codes: & over

5 Plan A ZIP Codes: & over

6 Plan A ZIP Codes: & over

7 Plan A ZIP Codes: , & over

8 Plan A ZIP Codes: & over

9 Plan A ZIP Codes: 690, & over

10 Plan A ZIP Codes: All Others & over

11 Plan F ZIP Codes: & over

12 Plan F ZIP Codes: 681, & over

13 Plan F ZIP Codes: & over

14 Plan F ZIP Codes: & over

15 Plan F ZIP Codes: & over

16 Plan F ZIP Codes: , & over

17 Plan F ZIP Codes: & over

18 Plan F ZIP Codes: 690, & over

19 Plan F ZIP Codes: All Others & over

20 Plan G ZIP Codes: & over

21 Plan G ZIP Codes: 681, & over

22 Plan G ZIP Codes: & over

23 Plan G ZIP Codes: & over

24 Plan G ZIP Codes: & over

25 Plan G ZIP Codes: , & over

26 Plan G ZIP Codes: & over

27 Plan G ZIP Codes: 690, & over

28 Plan G ZIP Codes: All Others & over

29 Plan N ZIP Codes: & over

30 Plan N ZIP Codes: 681, & over

31 Plan N ZIP Codes: & over

32 Plan N ZIP Codes: & over