SHIIP Medicare Supplement Comparison Guide

Transcription

1 SHIIP edicare Supplement Comparison Guide North Carolina Department of Insurance Seniors Health Insurance Information Program

2

3 June 2012 Dear Consumer: The North Carolina Department of Insurance s Seniors Health Insurance Information Program (SHIIP) developed this guide to help you understand edicare and the private insurance policies that provide coverage to supplement your edicare plans. Federal legislation simplified your choices by creating standardized edicare supplement policies. These standard policies are designed to help you avoid purchasing more supplemental coverage than you need. Please note, if you purchased a edicare supplement policy before June 2010, you do not have to switch to one of the newer 2010 standardized policies. Another source of information tailored to individual needs is the interactive edicare Supplement Premium Comparison Database available on SHIIP s Web site at With this free service you will find specific information regarding supplemental plans available for your age and gender. Additional information regarding your choice for edicare coverage may be found on SHIIP s Web site. The edicare Prescription Drug Improvement and odernization Act of 2003 (A) offers you choices regarding your prescription drug coverage. You may search our Web site or call SHIIP to get detailed information regarding the edicare Prescription Drug Plans available in North Carolina. Contact the SHIIP office at or at shiip@ncdoi.gov if you have any questions about this material. SHIIP staff is available from 8 a.m. until 5 p.m., onday through Friday to provide free, unbiased assistance. Additionally, SHIIP volunteer counselors are available to meet with you one-on-one in your own county. SHIIP counselors will not try to sell you insurance or recommend a particular policy, but they can provide you with information about edicare coverage and answer questions regarding your health insurance options. Your North Carolina Department of Insurance is committed to helping consumers make wise insurance choices. We want to help you gain the knowledge and information you need to protect your rights and make informed decisions regarding your insurance coverage. Sincerely, Wayne Goodwin Insurance Commissioner

4 TABLE OF CONTENTS Introduction edicare Part A Chart... 3 edicare Part B Chart... 4 edicare Supplement Changes in Tips for Purchasing edicare Supplement Insurance... 6 Laws Concerning edicare Supplement Insurance... 7 Licensed edicare Supplement Insurance Companies A Note to the Consumer Premium Charts Column Data Explained edicare Supplement Companies and the Plans They Offer edicare SELECT Plans Glossary edicare Advantage and edicare Prescription Drug Plans... 8 Guarantee Issue Laws from the Balanced Budget Act of Options for Disabled People with edicare Younger than Standardized edicare Supplement Plans Chart Standardized edicare Supplement Plan Benefits Explained... 13

5 edicare does not pay all of a person s medical expenses. To fill the gaps many people purchase a ediare supplement (edigap) policy or they join a edicare Advantage plan. This guide is designed to provide you with the facts necessary to make informed decisions regarding supplemental insurance. Within the pages of this guide you will find: an outline of edicare benefits, important insurance tips, laws governing supplement insurance, a description of the types of health insurance available to people with edicare, and a glossary of commonly used terms. The most important part of this guide provides information regarding the benefits offered by edicare supplement insurance policies sold in North Carolina. The companies listed in this guide are licensed in North Carolina. These plans meet all legal requirements. For information tailored to individual needs the interactive edicare Supplement Premium Comparison Database is available at onthly, quarterly, semi-annual and annual premium rates for edicare supplement plans offered by Introduction companies licensed in North Carolina are available on the Web site. The information offered is specific to supplemental plans, age and gender. Details regarding individual plans are available with the click of a mouse, and the service is free to users. Information regarding edicare Advantage Plans offered in North Carolina is also available on the Web site. The Seniors Health Insurance Information Program (SHIIP) is dedicated to providing information and advice on edicare, edicare supplement insurance, edicare Advantage, edicare Prescription Drug Plans, edicare fraud and abuse and long-term care insurance to our North Carolina citizens. Trained SHIIP volunteer counselors are available statewide to provide FREE, local, one-on-one assistance to people with edicare. If you have questions concerning the information in this book or if you need to meet with a SHIIP counselor, call SHIIP toll free at THIS GUIDE REFLECTS EDICARE BENEFITS AND THE OST RECENTLY FILED AND APPROVED PREIUS AS OF THE DATE OF THIS PRINTING, WHICH ARE SUBJECT TO CHANGE. CHECK THE SHIIP WEB SITE FOR THE OST CURRENT INFORATION. SHIIP edicare Supplement Comparison Guide Page 1

6 edicare Part A (Hospital Insurance) & edicare Part B (edical Insurance) SHIIP edicare Supplement Comparison Guide Page 2

7 2012 EDICARE PART A (HOSPITAL INSURANCE) - COVERED SERVICES PER BENEFIT PERIOD Services Benefit edicare Pays (1) You Pay (1) HOSPITALIZATION Semiprivate room and board, general nursing and miscellaneous hospital services and supplies. (1) First 60 days 61 st to 90 th day 91 st to 150 th day (2) All but $1,156 All but $289 a day All but $578 a day $1,156 $289 a day $578 a day POST HOSPITAL SKILLED NURSING FACILITY CARE You must have been in a hospital for at least three days, enter a edicareapproved facility generally within 30 days after hospital discharge and meet other program requirements. (3) HOE HEALTH CARE edically necessary skilled nursing care, home health aide services, medical supplies, etc. after a three-day inpatient hospital stay, for visits HOSPICE CARE Full scope of pain relief and support services available to the terminally ill. Beyond 150 days First 20 days Additional days Beyond 100 days 100% part-time or intermittent nursing care and other services for as long as you meet criteria for benefits As long as doctor certifies need Nothing 100% of approved amount All but $ a day Nothing 100% of approved amount; % of approved amount for durable medical equipment All but limited costs for outpatient drugs and inpatient respite care BLOOD Blood All but first three pints per calendar year All costs Nothing Up to $ a day All costs Nothing for services; 20% of approved amount for durable medical equipment Limited cost sharing for outpatient drugs and inpatient respite care For first three pints (4) (1) These figures are for 2012 and are subject to change each year. (2) Lifetime reserve days may be used only once. (3) Neither edicare nor edigap insurance will pay for most nursing home care. (4) When the blood deductible is met under one part of edicare during the calendar year, it does not have to be met under the other part. NOTE: The edicare Part A premium is $0 for eligible people with edicare. For those who are ineligible the edicare Part A premium is $451 per month for those who worked less than 30 quarters or $248 per month for those who worked between 30 and 39 quarters. 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 or skilled nursing facility for 60 consecutive days or remain in a skilled nursing facility but do not receive skilled care there for 60 consecutive days in a row. SHIIP edicare Supplement Comparison Guide Page 3

8 EDICARE PART B (EDICAL INSURANCE) COVERED SERVICES PER CALENDAR YEAR Services Benefit edicare Pays You Pay EDICAL EXPENSE Physicians services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnotic tests, durable medical equipment, etc. edicare pays for medical services in or out of the hospital. % of approved amount (after $140 deductible) 60% of approved charges for most outpatient mental health services $140 deductible (a) 20% of approved amount and charges above approved amount (b) 40% of approved charges for mental health services CLINICAL LABORATORY SERVICES Blood tests, biopsies, urinalysis, etc. Generally 100% of approved amount Nothing HOE HEALTH CARE edically necessary skilled nursing care, home health aide services, medical supplies, etc. after a three-day inpatient hospital stay beginning with visit 101 or beginning day one if there is no previous hospital stay. OUTPATIENT HOSPITAL TREATENT Reasonable and necessary services for the diagnosis or treatment of an illness or injury. 100% part-time or intermittent nursing care and other services for as long as you meet criteria for benefits Unlimited if medically necessary % of approved amount % of approved amount for durable medical equipment % of approved amount (after $140 deductible) BLOOD Blood % of approved amount (after $140 deductible and starting with the 4th pint) The monthly Part B premium for 2012 is $99.90* Nothing $140 deductible (a) 20% of approved amount for durable medical equipment $140 deductible (a) Subject to deductible plus 20% of billed amount $140 deductible (a) First three pints plus 20% of approved amount for additional pints (c) (a) Once you have had $140 of expense for covered services, the Part B deductible does not apply to any other covered service(s) you receive for the rest of the year. (b) The amount by which a physician s charge can exceed the edicare-approved amount. This amount is limited by law. (c) When the blood deductible is met under one part of edicare during the calendar year, it does not have to be met under the other part. *Premium may be higher based on income. SHIIP edicare Supplement Comparison Guide Page 4

9 edicare Supplement Changes in 2010 The odel Changed Effective June 1, 2010 The National Association of Insurance of Commissioners (NAIC) was encouraged to review and modernize the 1990 Standardized edicare supplement model because edicare supplements had not kept up with some of edicare s improvements under Parts A and B in the past years. In July 2008, Congress passed the edicare Improvements for Patients and Providers Act (IPPA) that authorized states to implement the NAIC s recommendations, effective June 1, 2010, creating the 2010 Standardized edicare supplement model. Benefits and Plans Eliminated The Preventive Care benefit offered by Plans E and J was eliminated because it became outdated due to the enhanced benefits available for preventive care under edicare Part B. The At-Home Recovery benefit offered by Plans D, G, I, and J was also eliminated because it was underutilized. Plans E, H, I, J, and high-deductible Plan J were no longer available for sale, effective June 1, The NAIC enhancements to the edicare supplement model made these plans duplicative of others. Benefits and Plans Added Two new plans, and N, were added, effective June 1, Plan covers 50% of the Part A inpatient hospital deductible. It does not cover the Part B deductible. Plan N covers 100% of the Part A inpatient hospital deductible. It does not cover the Part B deductible. Coverage for the Part B coinsurance is subject to a new copayment structure, up to $20 co-payment for office visits and up to $50 co-payment for emergency room visits. Co-payment amounts may change each year. SHIIP edicare Supplement Comparison Guide Page 5

10 Tips for Purchasing edicare Supplement Insurance There are laws which require an agent who sells a edicare supplement policy to anyone who already has a edicare supplement policy to have the applicant sign a replacement form agreeing to drop all other individual edicare standardized supplement policies. Experts say that one good edicare supplement is sufficient health insurance to complement edicare Part A and Part B. Answer all health questions accurately yourself. A policyholder has a 30-day free-look period during which time he/she can return the policy for a full refund. If purchasing the policy through a local insurance agent, remember to get the company s address and telephone number as well as the address and phone number of the insurance agent. When purchasing a edicare supplement policy through an insurance agent, always write the check payable to the insurance company. Do not make the check payable to the insurance agent, and do not pay with cash. Ask the local insurance agent about any special rates or discount features. Providers may not always file claims on edicare supplement insurance. It is your responsibility to make sure the claims are filed. Persons eligible for edicare younger than age due to disability have limited access to edicare supplement insurance. Contact SHIIP for information. edicare supplement policies sold after January 1992 are standardized. There are no differences in the standardized plans among insurance carriers. Benefits in older plans issued prior to 1992 may differ from company-to-company. edicare supplement standardized Plans and N were added in 2010 as additional options. If you are enrolled in a edicare Advanatage plan, an agent may not sell you a edicare supplement plan unless you are disenrolling from the edicare Advantage plan. SHIIP edicare Supplement Comparison Guide Page 6

11 FREE-LOOK PERIOD A free-look period of 30 days is required during which time the applicant may return the policy to the insurance company and receive a full refund. The free-look period begins from the date the applicant actually receives the certificate or policy not from the date of application. GUARANTEED RENEWABLE All edicare supplement policies are guaranteed renewable. This means that the insurance company agrees to continue insuring the policyholder for as long as the premium is paid. OUTLINE OF COVERAGE An outline of coverage must be given to each applicant for a edicare supplement policy. It must clearly show which benefits edicare pays, which benefits the policy pays and the limitations that are not covered. NAIC/CS BUYER S GUIDE The Centers for edicare and edicaid Services (CS)/National Association of Insurance Commissioners (NAIC) buyer s guide must be given to each applicant. This is called 2010 Choosing a edigap Policy: A Guide to Health Insurance for People with edicare. SUSPENSION OF SUPPLEENT WHILE ON EDICAID Section 1992(q) (5) of OBRA-90 states that insurers must suspend edicare supplement premiums and benefits upon request of the policyholder (within 90 days of edicaid eligibility) for a period of 24 months during the time the policyholder is entitled to edicaid. The insurer must reinstate policy benefits upon request when edicaid entitlement ends as long as it is within two years of the date of suspension. The policyholder is responsible for informing the insurer of edicaid eligibility. This law applies only to policies sold after SALES OF DUPLICATE OR ULTIPLE POLICIES FORBIDDEN No policy in North Carolina may duplicate edicare. No agent in North Carolina may sell a new edicare supplement policy to anyone who already has a standardized edicare supplement policy unless that applicant agrees to drop his/her current insurance. Laws Concerning edicare Supplement Insurance effective dates for your Part A and/or Part B coverage. Open enrollment provides you a limited time frame to purchase the edicare supplement policy of your choice regardless of your health condition. During this six-month open enrollment period, you can buy any edicare supplement policy sold by any insurer selling edicare supplement insurance in your state. The company cannot deny issuance of the policy or discriminate in the pricing of a policy because of your medical history, health status or claims experience. However, the company can impose up to a sixmonth pre-existing condition waiting period. The pre-existing condition waiting period may be waived if you have creditable insurance coverage. edicare-eligible due to disability (younger than ) In North Carolina people with edicare younger than can purchase edicare supplement plans A, C or F during their first six months of eligibility for edicare Part B from any company selling these plans. Insurers cannot deny issuance of a policy but may impose up to a six-month pre-existing condition waiting period. The pre-existing condition waiting period may be waived if you have creditable insurance coverage. Insurers may develop premium rates specific to the disabled population. This may result in higher premiums than those for people with edicare age and older. IPORTANT NOTE: You will have another open enrollment period upon turning age that will allow you to purchase any edicare supplement plan being offered in North Carolina regardless of your health condition. PRE-EXISTING CONDITION WAITING PERIOD A pre-existing condition waiting period may extend no longer than six months for health conditions diagnosed or treated within the six months immediately prior to the policy application. The medical questionnaire accompanying an application should have accurate information and be completed by the applicant, not the agent. The pre-existing condition waiting period does not apply for applicants replacing a edicare supplement policy or applicants who have had creditable insurance coverage for the previous six months. Creditable insurance coverage is any previous health insurance coverage that can be used to shorten the pre-existing condition waiting period, such as coverage under group plans, individual health policies, edicare, edicaid or federal/military retiree programs. For replacement policies the applicant is required to sign a replacement form indicating that he/she understands the OPEN ENROLLENT PERIOD d and older State and federal laws guarantee open enrollment for a period of six months. This period begins on the first day of the month in which you are age or older and enrolled in edicare Part B. Your edicare card shows the risks of changing policies. SHIIP edicare Supplement Comparison Guide Page 7

12 edicare Advantage and edicare Prescription Drug Plans edicare Advantage A edicare Advantage plan is a health insurance option available to people to receive their edicare coverage. They are sometimes referred to as edicare Part C or simply A or APD plans. The plans are offered by private companies who have contracted with edicare to provide edicare Part A and edicare Part B coverage. There are different types of edicare Advantage plans, and they may or may not include edicare Prescription Drug coverage. The types of edicare Advante plans which may be available to a person covered by edicare are: Health aintentance Organizations (HOs), Preferred Provider Organizations (PPOs), Special Needs Plans (SNPs), Private Fee-for Service (PFFSs) and edicare Savings Accounts (SAs). Each year people with edicare may choose among the edicare Advantage plan choices available in their area. No matter which edicare Advantage plan a person may chose to enroll into, they will continue to pay the edicare Part B premium and any additional monthly premium charged for the edicare Advantage plan. It is important to remember the available plans may change from year to year as well as the benefits, copayments, coinsurance and premium. All edicare Advantage plan options may not be offered in North Carolina, and those offered may not be available in every county. edicare Advantage plans have to accept all people with edicare unless they have End Stage Renal Disease (permanent kidney failure). Please note edicare Supplement (edigap) plans will not coordinate with any edicare Advantage plan. In fact, if you are enrolled in a edicare Advantage plan, an agent is not permitted to sell you a edicare Supplement policy unless you are disenrolling from the edicare Advantage plan. The edicare Advantage plans are described in the 2011 edicare & You Handbook published by the Centers for edicare & edicaid Services. SHIIP edicare Supplement Comparison Guide Page 8

13 edicare Prescription Drug Coverage Prescription drug coverage first became available through edicare starting January 1, A person may get edicare prescription drug coverage by joining a standalone edicare prescription drug plan or by joining a edicare Advantage plan that includes the edicare prescription drug coverage. Like edicare Advantage plans, the edicare prescription drug coverage is provided through private companies contracted with edicare. The copayments, coinsurance, deductible, drugs covered and monthly premium will vary from plan to plan. It is important to note that if you do not obtain edicare prescription drug coverage when you are first eligible and you do not have other creditable prescription drug coverage, you may have to pay a Late Enrollment Penalty if you join a plan at a later date. People with limited income and assets (including your savings and stocks, but not counting your home) may qualify to receive Extra Help to pay for edicare prescrip- tion drug costs. People with edicare who quailfy for Extra Help assistance will only pay a small copayment for each prescription they need; and depending on income and asset levels, the premiums and deductibles may be covered or lowered. Also if a person qualifies for the Extra Help assistance, there is no Late Enrollment Penalty. Some people who have edicare may automatically qualify for the Extra Help assistance if they are also receiving full edicaid coverage or get help from their state edicaid program with paying their edicare Part B premiums (through a edicare Savings Program) or if they get Supplemental Security Income benefits. To learn more about edicare Prescription Drug coverage, please see your 2012 edicare & You Handbook published by the Centers for edicare & edicaid Services or by calling SHIIP at SHIIP can also help people with applying for the Extra Help Assistance. SHIIP edicare Supplement Comparison Guide Page 9

14 Guarantee Issue Laws from the Balanced Budget Act of 1997 Under the Balanced Budget Act of 1997 (BBA), several guarantee coverage provisions were added to the edicare supplement regulations. Guaranteed Coverage for Certain edicare Advantage Enrollees Newly Eligible edicare Beneficiaries The BBA allows for people with edicare to try a edicare Advantage organization without jeopardizing their open enrollment for edicare supplement insurance policies. For an individual who enrolls directly into a edicare Advantage plan when they first become eligible for edicare at age and disenrolls from that edicare Advantage program within the first 12 months - the legislation guarantees the individual issuance of any edicare supplement standardized plan. edicare Supplement Policyholders Any edicare supplement policyholder with one of the standardized edicare supplement policies can terminate their edicare supplement policy to enroll in a edicare Advantage plan. If the person with edicare disenrolls from the edicare Advantage plan within the first 12 months of enrolling, they will be able to reinstate their edicare supplement policy if it is still available. 63-Day Guarantee Issue Period for edicare Supplement Plans A, B, C, F, K and L In addition to the initial six-month open enrollment for edicare supplement insurance policies, the BBA guarantees issuance of edicare supplement policies A, B, C, F, K and L (plans A and C for the disabled in North Carolina) without a pre-existing condition waiting period under the following circumstances: An individual whose coverage under an employer group health plan that provides health benefits to supplement edicare is terminated. People with edicare enrolled under a edicare supplement policy that terminates due to bankruptcy or insolvency of the insurance company. People with edicare enrolled in a edicare Advantage program or edicare SELECT policy that is discontinued because: the organization terminates its edicare contract, the person with edicare moves outside the plan s service area, or the person with edicare disenrolls from the plan with due cause. Applicants must enroll within 63 days of termination of their previous plan. SHIIP edicare Supplement Comparison Guide Page 10

15 Options for Disabled People with edicare Younger than The regulations regarding edicare supplement insurance are different for people with edicare who receive Social Security Disability benefits and are younger than. Disabled persons on edicare have limited access to supplement insurance. Open Enrollment In North Carolina people with edicare younger than can purchase edicare Supplement Plans A, C, and F from companies selling these plans during their first six months of eligibility for edicare Part B. Insurers cannot deny issuance of a policy but may impose up to a six-month preexisting condition waiting period. The pre-existing condition waiting period may be waived if you have creditable insurance coverage. Insurers may develop premium rates specific to the disabled population. This may result in higher premiums than those for people older than. Some companies listed in this Guide may consider offering edicare supplement plans to individuals outside their open enrollment period; however only A, C and F are guaranteed issue during the open enrollment period. edicare Advantage edicare Advantage plans are another option for people on edicare due to disability. edicare Advantage plans have to accept all people with edicare unless they have End Stage Renal Disease (ESRD). PLEASE NOTE: It is important to remember that people with edicare due to disability have a second six-month open enrollment period at age just like anyone becoming eligible for edicare for the first time. This means that at age all edicare supplement plans sold in NC are available to anyone on edicare who is covered under edicare Part B. SHIIP edicare Supplement Comparison Guide Page 11

16 Plan A Basic benefits including 100% Part B coinsurance Plan B Basic benefits including 100% Part B coinsurance Part A Deductible 2011 STANDARDIZED EDICARE SUPPLEENT PLANS CHART Plan C Basic benefits including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Foreign Travel Emergency Plan D Basic benefits including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency Plan F or F Prime w/ $2,0 Deductible 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 Part A Hospital $289/day $578/day (lifetime reserve days) Beyond 150 days 100% for 3 days Part A and B Blood Deductible (1 st three pints) Part B Coinsurance 20% of edicare approved charges Part A Hospice Care Coinsurance or Copayment Plan G Basic benefits including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part B Excess (100%) Foreign Travel Emergency Plan K 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 of $4,660; paid at 100% after limit reached Plan L Hospitalization and preventive care paid at 100%; other basic benefits paid at % % Skilled Nursing Facility Coinsurance % Part A Deductible Out-of pocket limit of $2,330; paid at 100% after limit reached Plan Basic benefits including 100% Part B coinsurance Skilled Nursing Facility Coinsurance 50% Part A Deductible Foreign Travel Emergency Part A Deductible for 2012 is $1,156. Part B Deductible for 2012 is $140. Plan N Basic benefits including 100% Part B coinsurance except up to $20 copayment fo office visit and up to $50 copayment for ER Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency SHIIP edicare Supplement Comparison Guide Page 12

17 Standardized edicare Supplement Plan Benefits Explained SHIIP edicare Supplement Comparison Guide Page 13

18 Plan A Basic Benefits Coverage for the Part A coinsurance amount ($289 per day in 2012) for the 61st through the 90th day of hospitalization in each edicare benefit period. Coverage for the Part A coinsurance amount ($578 per day in 2012) for each of edicare s 60 non-renewable lifetime hospital inpatient reserve days used (days ). After all edicare hospital benefits are exhausted, coverage for 100% of the edicare Part A eligible hospital expenses. Coverage is limited to a maximum of 3 days of additional inpatient hospital care during the policyholder s lifetime. This benefit is paid either at the rate edicare pays hospitals under its Prospective Payment System (PPS) or under another standard of payment for hospitals not subject to the PPS. Coverage for the coinsurance amount for Part B services (generally 20% of approved amount; 40% of approved charges for outpatient mental health services) after $140 annual deductible is met. Coverage for the first three pints of blood deductible. Coverage of cost sharing for all Part A eligible hospice and respite care expenses. SHIIP edicare Supplement Comparison Guide Page 14

19 Plan B Basic Benefits Coverage for the Part A coinsurance amount ($289 per day in 2012) for the 61st through the 90th day of hospitalization in each edicare benefit period. Coverage for the Part A coinsurance amount ($578 per day in 2012) for each of edicare s 60 non-renewable lifetime hospital inpatient reserve days used (days ). After all edicare hospital benefits are exhausted, coverage for 100% of the edicare Part A eligible hospital expenses. Coverage is limited to a maximum of 3 days of additional inpatient hospital care during the policyholder s lifetime. This benefit is paid either at the rate edicare pays hospitals under its Prospective Payment System (PPS) or under another standard of payment for hospitals not subject to the PPS. Coverage for the coinsurance amount for Part B services (generally 20% of approved amount; 40% of approved charges for outpatient mental health services) after $140 annual deductible is met. Coverage for the first three pints of blood deductible. Coverage of cost sharing for all Part A eligible hospice and respite care expenses. Additional Benefits Coverage for the edicare Part A deductible ($1,156 per benefit period in 2012). SHIIP edicare Supplement Comparison Guide Page 15

20 Plan C Basic Benefits Coverage for the Part A coinsurance amount ($289 per day in 2012) for the 61st through the 90th day of hospitalization in each edicare benefit period. Coverage for the Part A coinsurance amount ($578 per day in 2012) for each of edicare s 60 non-renewable lifetime hospital inpatient reserve days used (days ). After all edicare hospital benefits are exhausted, coverage for 100% of the edicare Part A eligible hospital expenses. Coverage is limited to a maximum of 3 days of additional inpatient hospital care during the policyholder s lifetime. This benefit is paid either at the rate edicare pays hospitals under its Prospective Payment System (PPS) or under another standard of payment for hospitals not subject to the PPS. Coverage for the coinsurance amount for Part B services (generally 20% of approved amount; 40% of approved charges for outpatient mental health services) after $140 annual deductible is met. Coverage for the first three pints of blood deductible. Coverage of cost sharing for all Part A eligible hospice and respite care expenses. Additional Benefits Coverage for the edicare Part A deductible ($1,156 per benefit period in 2012). Coverage for the skilled nursing facility care coinsurance amount ($ per day for days per benefit period in 2012). Coverage for the edicare Part B deductible ($140 per calendar year in 2012). Eighty percent coverage for medically necessary emergency care in a foreign country after a $250 calendar year deductible. The lifetime maximum benefit is $50,000. SHIIP edicare Supplement Comparison Guide Page 16

21 Plan D Basic Benefits Coverage for the Part A coinsurance amount ($289 per day in 2012) for the 61st through the 90th day of hospitalization in each edicare benefit period. Coverage for the Part A coinsurance amount ($578 per day in 2012) for each of edicare s 60 non-renewable lifetime hospital inpatient reserve days used (days ). After all edicare hospital benefits are exhausted, coverage for 100% of the edicare Part A eligible hospital expenses. Coverage is limited to a maximum of 3 days of additional inpatient hospital care during the policyholder s lifetime. This benefit is paid either at the rate edicare pays hospitals under its Prospective Payment System (PPS) or under another standard of payment for hospitals not subject to the PPS. Coverage for the coinsurance amount for Part B services (generally 20% of approved amount; 40% of approved charges for outpatient mental health services) after $140 annual deductible is met. Coverage for the first three pints of blood deductible. Coverage of cost sharing for all Part A eligible hospice and respite care expenses. Additional Benefits Coverage for the edicare Part A deductible ($1,156 per benefit period in 2012). Coverage for the skilled nursing facility care coinsurance amount ($ per day for days per benefit period in 2012). Eighty percent coverage for medically necessary emergency care in a foreign country after a $250 calendar year deductible. The lifetime maximum benefit is $50,000. SHIIP edicare Supplement Comparison Guide Page 17

22 Plan F Basic Benefits Coverage for the Part A coinsurance amount ($289 per day in 2012) for the 61st through the 90th day of hospitalization in each edicare benefit period. Coverage for the Part A coinsurance amount ($578 per day in 2012) for each of edicare s 60 non-renewable lifetime hospital inpatient reserve days used (days ). After all edicare hospital benefits are exhausted, coverage for 100% of the edicare Part A eligible hospital expenses. Coverage is limited to a maximum of 3 days of additional inpatient hospital care during the policyholder s lifetime. This benefit is paid either at the rate edicare pays hospitals under its Prospective Payment System (PPS) or under another standard of payment for hospitals not subject to the PPS. Coverage for the coinsurance amount for Part B services (generally 20% of approved amount; 40% of approved charges for outpatient mental health services) after $140 annual deductible is met. Coverage for the first three pints of blood deductible. Coverage of cost sharing for all Part A eligible hospice and respite care expenses. Additional Benefits Coverage for the edicare Part A deductible ($1,156 per benefit period in 2012). Coverage for the skilled nursing facility care coinsurance amount ($ per day for days per benefit period in 2012). Coverage for the edicare Part B deductible ($140 per calendar year in 2012) Eighty percent coverage for medically necessary emergency care in a foreign country after a $250 calendar year deductible. The lifetime maximum benefit is $50,000. Coverage for 100% for edicare Part B excess charges. The edicare Part B excess charge is the additional 15% a physician can charge if the claim is non-assigned. SHIIP edicare Supplement Comparison Guide Page 18

23 Plan G Basic Benefits Coverage for the Part A coinsurance amount ($289 per day in 2012) for the 61st through the 90th day of hospitalization in each edicare benefit period. Coverage for the Part A coinsurance amount ($578 per day in 2012) for each of edicare s 60 non-renewable lifetime hospital inpatient reserve days used (days ). After all edicare hospital benefits are exhausted, coverage for 100% of the edicare Part A eligible hospital expenses. Coverage is limited to a maximum of 3 days of additional inpatient hospital care during the policyholder s lifetime. This benefit is paid either at the rate edicare pays hospitals under its Prospective Payment System (PPS) or under another standard of payment for hospitals not subject to the PPS. Coverage for the coinsurance amount for Part B services (generally 20% of approved amount; 40% of approved charges for outpatient mental health services) after $140 annual deductible is met. Coverage for the first three pints of blood deductible. Coverage of cost sharing for all Part A eligible hospice and respite care expenses. Additional Benefits Coverage for the edicare Part A deductible ($1,156 per benefit period in 2012). Coverage for the skilled nursing facility care coinsurance amount ($ per day for days per benefit period in 2012). Eighty percent coverage for medically necessary emergency care in a foreign country after a $250 calendar year deductible. The lifetime maximum benefit is $50,000. Coverage for 100% for edicare Part B excess charges. The edicare Part B excess charge is the additional 15% a physician can charge if the claim is non-assigned. SHIIP edicare Supplement Comparison Guide Page 19

24 edicare Supplement Plans K and L North Carolina has several companies that market edicare Supplement Plans K and L. These plans require cost sharing for Part A and Part B expenses at 50% and %, respectively. Plan K has a $4,660 out-of-pocket limit while Plan L has a $2,330 out-of-pocket limit each year. These plans exclude the Part B deductible. Once you reach the annual limit, the plan pays 100% of the edicare copayments, coinsurance and deductibles for the remainder of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed edicare approved amounts (excess charges). You will be responsible for paying excess charges. Since cost sharing is higher under these plans, premiums may be more cost effective than traditional plans. The annual out-of-pocket limit may increase each year. Plan K o 100% of Part A Hospitalization Coinsurance ($289 per day in 2012 for days 61-90; $578 per day in 2012 for days ) plus coverage for 3 days after edicare Benefits end Plan L o 100% of Part A Hospitalization Coinsurance ($289 per day in 2012 for days 61-90; $578 per day in 2012 for days ) plus coverage for 3 days after edicare Benefits end o 50% of Part A Deductible ($1,156 per benefit period in 2012) o % of Part A Deductible ($1,156 per benefit period in 2012) o 50% of Skilled Nursing Facility Coinsurance ($ per day for days in 2012) o 50% of Hospice cost sharing o 50% of edicare eligible expenses for the first three pints of blood o 50% of Part B Coinsurance (100% coinsurance for preventive services only) after Part B deductible ($140 in 2012) is met o $4,660 Out-of-Pocket Annual Limit o % of Skilled Nursing Facility Coinsurance ($ per day for days in 2012) o % of Hospice cost sharing o % of edicare eligible expenses for the first three pints of blood o % of Part B Coinsurance (100% coinsurance for preventive services only) after Part B deductible ($140 in 2012) is met o $2,330 Out-of-Pocket Annual Limit SHIIP edicare Supplement Comparison Guide Page 20

25 Plan Basic Benefits Coverage for the Part A coinsurance amount ($289 per day in 2012) for the 61st through the 90th day of hospitalization in each edicare benefit period. Coverage for the Part A coinsurance amount ($578 per day in 2012) for each of edicare s 60 non-renewable lifetime hospital inpatient reserve days used (days ). After all edicare hospital benefits are exhausted, coverage for 100% of the edicare Part A eligible hospital expenses. Coverage is limited to a maximum of 3 days of additional inpatient hospital care during the policyholder s lifetime. This benefit is paid either at the rate edicare pays hospitals under its Prospective Payment System (PPS) or under another standard of payment for hospitals not subject to the PPS. Coverage for the coinsurance amount for Part B services (generally 20% of approved amount; 40% of approved charges for outpatient mental health services) after $140 annual deductible is met. Coverage for the first three pints of blood deductible. Coverage of cost sharing for all Part A eligible hospice and respite care expenses. Additional Benefits Coverage for 50% of the edicare Part A deductible ($1,156 per benefit period in 2012). Coverage for the skilled nursing facility care coinsurance amount ($ per day for days per benefit period in 2012). Eighty percent coverage for medically necessary emergency care in a foreign country after a $250 calendar year deductible. The lifetime maximum benefit is $50,000. SHIIP edicare Supplement Comparison Guide Page 21

26 Plan N Basic Benefits Coverage for the Part A coinsurance amount ($289 per day in 2012) for the 61st through the 90th day of hospitalization in each edicare benefit period. Coverage for the Part A coinsurance amount ($578 per day in 2012) for each of edicare s 60 non-renewable lifetime hospital inpatient reserve days used (days ). After all edicare hospital benefits are exhausted, coverage for 100% of the edicare Part A eligible hospital expenses. Coverage is limited to a maximum of 3 days of additional inpatient hospital care during the policyholder s lifetime. This benefit is paid either at the rate edicare pays hospitals under its Prospective Payment System (PPS) or under another standard of payment for hospitals not subject to the PPS. Coverage for the coinsurance amount for Part B services (generally 20% of approved amount; 40% of approved charges for outpatient mental health services) after $140 annual deductible is met. o Except up to $20 copayment for office visits and up to $50 copayment for ER visits (ER copay waived if admitted as inpatient and ER visit becomes a Part A covered expense). Copayment amounts may change each year. Coverage for the first three pints of blood deductible. Coverage of cost sharing for all Part A eligible hospice and respite care expenses. Additional Benefits Coverage for the edicare Part A deductible ($1,156 per benefit period in 2012). Coverage for the skilled nursing facility care coinsurance amount ($ per day for days per benefit period in 2012). Eighty percent coverage for medically necessary emergency care in a foreign country after a $250 calendar year deductible. The lifetime maximum benefit is $50,000. SHIIP edicare Supplement Comparison Guide Page 22

27 Licensed edicare Supplement Insurance Companies At the time of this printing the companies listed have been approved by the North Carolina Department of Insurance to sell edicare supplement policies in North Carolina. Some new policies may have entered the marketplace since this publication was printed and will not be included. Visit the edicare Supplement Premium Comparison Database at to find the most recent premiums for all approved companies. AARP/UnitedHealthcare Insurance Company SOLD ONLY TO AARP EBERS PO Box 1017 ontgomeryville, Pennsylvania Aetna Life Insurance Company 151 Farmington Avenue S 3128 Hartford, Connecticut American Continental Insurance Company PO Box 1188 Brentwood, Tennessee American Republic Corp Insurance Company P.O. Box Des oines, Iowa American Republic Insurance Company PO Box 1 Des oines, Iowa (Company chose not to print their rates in this guide.) Bankers Fidelity Life Insurance Company PO Box 1051 Atlanta, Georgia Blue Cross Blue Shield of North Carolina PO Box Durham, North Carolina Central States Indemnity Company of Omaha PO Box Omaha, NE Colonial Penn Life Insurance Company North Pennsylvania Street Carmel, Indiana Columbian utual Life Insurance Company PO Box 2620 Omaha, Nebraska SHIIP edicare Supplement Comparison Guide Page 23

28 Combined Insurance Company of America 1000 ilwaukee Avenue - 6 th Floor Glenview, Illinois Constitution Life Insurance Company 1001 Heathrow Park Lane Suite 5001 Lake ary, Florida Continental General Insurance Company Lakeline Boulevard Suite 100 Austin, Texas (Company chose not to print their rates in this guide.) Equitable Life & Casualty Insurance Company 3 Triad Center Salt Lake City, Utah Family Life Insurance Company PO Box Houston, Texas Forethought Life Insurance Company PO Box 149 Clearwater, Florida Gerber Life Insurance Company PO Box 2271 Omaha, Nebraska Globe Life and Accident Insurance Company DIRECT SOLICITATION RESPONSE PRODUCT PO Box 2440 ckinney, Texas Government Personnel utual Life Insurance Company PO Box 2679 Omaha, Nebraska Humana Insurance Company 500 West ain Street Louisville, Kentucky Liberty National Life Insurance Company PO Box ckinney, Texas Loyal American Life Insurance Company Lakeline Boulevard Suite 100 Austin, Texas edico Insurance Company 1515 South th Street Omaha, Nebraska Order of United Commercial Travelers of America 11 Watermark Drive Suite 100 Columbus, Ohio SHIIP edicare Supplement Comparison Guide Page 24

29 Oxford Life Insurance Company 2721 North Central Avenue Phoenix, Arizona Philadelphia American Life Insurance Company PO Box 4884 Houston, Texas (Company chose not to print their rates in this guide.) Physicians utual Insurance Company 2600 Dodge Street Omaha, Nebraska Reserve National Insurance Company 601 East Britton Road Oklahoma City, Oklahoma Royal Neighbors of America th Street Rock Island, Illinois Secure Horizons/UnitedHealthcare Insurance Company PO Box Pensacola, Florida Sentinel Security Life Insurance Company PO Box Clearwater, Florida Standard Life and Accident Insurance Company One oody Plaza Galveston, Texas Standard Security Life Insurance Company of New York 4 adison Avenue New York, New York State Farm utual Automobile Insurance Company Corporate Headquarters One State Farm Plaza Bloomington, Illinois Contact Your Local State Farm nt State utual Insurance Company 210 East Second Avenue Suite 301 Rome, Georgia (ust call the company directly or enroll through their Web site) Sterling Investors Life Insurance Company 210 East Second Avenue Suite 105 Rome, Georgia Sterling Life Insurance Company PO Box 5348 Bellingham, Washington SHIIP edicare Supplement Comparison Guide Page 25

30 Thrivent Financial for Lutherans SOLD ONLY TO LUTHERANS AND THEIR FAILIES 4321 North Ballard Road Appleton, Wisconsin United American Insurance Company PO Box ckinney, Texas United of Omaha Life Insurance Company utual of Omaha Plaza Omaha, Nebraska USAA Life Insurance Company DIRECT SOLICATION RESPONSE PRODUCT 90 Fredericksburg Road San Antonio, Texas Washington National Insurance Company North Pennsylvania Street Carmel, Indiana World Corp Insurance Company PO Box Des oines, Iowa SHIIP edicare Supplement Comparison Guide Page 26

31 A Note to the Consumer The following section summarizes the benefits of the edicare supplement policies approved by the North Carolina Department of Insurance for sale in This information was obtained through our Web site database and a survey of insurers licensed to do business in North Carolina. The results were compiled by the Seniors Health Insurance Information Program (SHIIP). Do not be alarmed if your edicare supplement policy does not appear in this book. Please note that new policies may have entered the marketplace since this publication was printed and will not be included. Visit and click on the edicare Supplement Premium Comparison Database to find the most recent premiums for these companies. If you have questions about a specific company, please contact SHIIP at for more information. Prices for these policies may also change during the year. We recommend you verify prices with the company prior to your purchase. Certain companies may also vary policy prices by zip code, gender and tobacco use. If you purchased a policy before June 1, 2010, it is no longer available to first-time buyers. However, you may keep old policies as long as you pay the premiums. Refer to the policy for the complete and actual terms of coverage. The policy is the contract between the insurer and the insured and will be the basis of any final determination. Publication of this guide is for information only. Its purpose is to assist and educate people shopping for edicare supplement insurance policies. Inclusion of a policy or plan in this guide does not in any way constitute an endorsement of that policy, plan or insurance company by the North Carolina Department of Insurance. SHIIP edicare Supplement Comparison Guide Page 27

32 Premium Charts Column Data Explained AGE: Premiums shown are for five representative ages for those years of age and older. For disabled people with edicare (younger than ) the premium is the same regardless of age. APPLICATION FEE: If an amount appears in the Comments column, the company charges a one-time fee for expenses incurred for issuing a policy. ATTAINED AGE: If appears in the Comments column, premiums automatically increase as you get older. CALL COPANY: If CC appears in the Premium column, under age rates were not yet approved by the North Carolina Department of Insurance. Please call the company for additional information. CROSSOVER: If appears in the Comments column, the company has signed a crossover agreement with edicare allowing a person s claim to be sent automatically from edicare s computer to the supplement insurance company s computer. This agreement eliminates your need to file claims with the insurance company. ISSUE AGE: If Issue appears in the Comments column, the premium will always be based on your age when you first enrolled. /F: If /F appears in the column, premiums are the same for males and females. An indicates that premiums differ for males and females, and the premium shown is for male policyholders. ale rates may be higher than female rates. ONTHLY PREIUS: Premiums are based on the policy type (individual or group) and marketing method (agent or direct response) representing the largest number of insureds in North Carolina. Premiums are rounded to the highest dollar amount. You need to contact the company or local agent for premium information specific to your age and the policy being considered. Premiums shown may have changed since the date stated. Check with the company, the SHIIP edicare Premium Comparison Database or a local agent for current rates. NO AGE: If No appears in the Comments column, premiums are the same for all ages based on the plan purchased. PRE-X: Pre-existing condition waiting periods are time frames that apply to people who have health conditions or problems that were identified and treated before health insurance was purchased. The definition and waiting period before these conditions are covered varies from policy to policy. However, there is a maximum six-month waiting period for edicare supplement policies. Treatment must have been received in the preceding six months for the condition to be considered pre-existing. RATES EFFECTIVE: The date the company rates were deemed effective through the North Carolina Department of Insurance. SIPLE/DETAILED: These terms refer to the company s questionnaire for underwriting. Persons may want to call to see if underwriting applies only to specific plans or time periods. SHIIP edicare Supplement Comparison Guide Page 28

33 edicare Supplement Companies and the Plans They Offer SHIIP edicare Supplement Comparison Guide Page 29

34 ONTHLY PREIUS Company /F A B C D F G K L N F+ Comments Notes AARP/UnitedHealthcare Insurance Company (Sold only to AARP members) Rates effective: 1/1/12 Aetna Life Insurance Company Rates effective: 1/1/12 (A, B, F) 6/2/11 (G & N) /F /F /F < 68+ $212 $118 $118 $155 $155 $325 $186 $186 $187 $187 $78 $78 $115 $115 $125 $125 No AARP/UnitedHealthcare Insurance Company offers annual payer and early enrollment discounts. < $343 $124 $149 $171 $1 $194 $138 $169 $199 $222 $243 $640 $156 $191 $227 $254 $283 $117 $145 $1 $203 $242 $ 92 $115 $139 $162 $196 Detailed Detailed Pre-X: 3 onths Bank draft discount available. Tobacco use rates vary. Pre-X: 6 onths Tobacco use rates vary. American Continental Insurance Company Rates effective: 2/23/12 < $149 $ 86 $ 97 $114 $125 $134 $108 $123 $143 $158 $168 $205 $126 $141 $162 $176 $186 $110 $125 $146 $160 $171 $ 87 $ 99 $116 $127 $136 $50 $56 $64 $69 $73 $20 Rates vary by zip code. American Republic Corp Insurance Company Rates effective: 6/1/12 < $314 $157 $176 $213 $246 $278 $413 $207 $232 $281 $323 $366 $108 $121 $147 $1 $192 $149 $167 $203 $233 $264 $ 88 $ 99 $120 $138 $156 Detailed Bank draft & couple discounts available. Rates vary by zip code. American Republic Insurance Company Rates effective: 4/1/12 Call Company for plans and rates offered. SHIIP edicare Supplement Comparison Guide Page 30

35 ONTHLY PREIUS Company /F A B C D F G K L N F+ Comments Notes Bankers Fidelity Life Insurance Company Rates effective: 6/1/12 /F /F /F /F /F /F < $429 $118 $131 $147 $159 $166 $514 $162 $1 $204 $219 $232 $114 $134 $160 $179 $194 $ 62 $ 73 $ 87 $ 99 $107 $54 $60 $67 $72 $77 (G&K) Issue (A,F&F+) Bank draft discount available. Tobacco use rates vary. Blue Cross Blue Shield of NC Rates effective: 6/1/12 /F /F /F /F < + $388 $ 88 $111 $137 $442 $109 $137 $169 $556 $131 $166 $205 $118 $150 $1 $122 $155 $191 $110 $139 $172 $62 $79 $97 $ 84 $107 $131 $108 $137 $169 $106 $135 $166 $47 $59 $73 Pre-X: 6 months No Pre-X during 6-month open enrollment. Central States Indemnity Company of Omaha Rates effective: 10/6/11 < $210 $ 84 $100 $119 $135 $147 $ 98 $117 $139 $158 $172 $295 $118 $140 $169 $192 $209 $122 $144 $172 $194 $211 $ 86 $101 $120 $136 $147 Tobacco use rates vary. Colonial Penn Life Insurance Company Rates effective: 1/1/12 < $394 $126 $154 $187 $218 $248 $155 $188 $228 $266 $304 $538 $173 $210 $255 $303 $357 $157 $193 $238 $287 $341 $ 67 $ 82 $103 $126 $151 $109 $130 $159 $191 $224 $136 $168 $208 $249 $290 $ 99 $128 $163 $203 $247 $42 $51 $62 $74 $86 Detailed Bank draft discount available. Tobacco use rates vary. APPLICATION FEE: If an amount appears in the Comments column, the company charges a one-time fee for expenses incurred in issuing a policy. ATTAINED AGE: If appears in the Comments column, premiums automatically increase as you get older. CC: If CC appears in the Premium column, under age rates were not yet approved with the North Carolina Department of Insurance. Please call the company for additional information. CROSSOVER: If appears in the Comments column, the company has signed a crossover agreement with edicare allowing a person s claim to be sent automatically from edicare s computer to the supplement insurance company s computer. This agreement eliminates your need to file claims with the insurance company. F+: F Prime covers the same benefits as the standardized edicare Supplement Plan F, however, there is a $2,0 deductible in 2012 which leads to lower monthly premiums. The deductible may increase annually at the same rate as the Consumer Price Index. ISSUE AGE: If Issue appears in the Comments column, the premium will always be based on your age when you first enrolled. /F: If /F appears in this column, premiums are the same for males and females. An indicates that premiums differ for males and females, and the premium shown is for male policyholders. ale rates are generally higher than female rates. NO AGE: If the words No appear in the Comments column, premiums are the same for all ages, based on the plan purchased. PRE-X: Pre-existing condition waiting periods are time frames that apply to people who have health conditions or problems that were identified and treated before health insurance was purchased. The definition and waiting period before these conditions are covered varies from policy to policy. However, there is a maximum six-month waiting period for edicare supplement policies. Usually treatment must have been received in the preceding six months for the condition to be considered pre-existing. SIPLE/DETAILED: These terms refer to the company s questionnaire for underwriting. Persons may want to call to see if underwriting applies only to specific plans or time periods. SHIIP edicare Supplement Comparison Guide Page 31

36 ONTHLY PREIUS Company /F A B C D F G K L N F+ Comments Notes Columbian utual Life Insurance Company Rates effective: 8/9/11 Combined Insurance Company of America Rates effective: 5/12/11 Constitution Life Insurance Company Rates effective: 12/12/11 < < < $226 $ 96 $111 $124 $135 $143 $328 $140 $161 $183 $204 $220 $111 $128 $146 $163 $177 onthly premium payments must be via electronic funds transfer. $288 $133 $174 $212 $239 $251 $347 $160 $209 $255 $288 $302 onthly premium payments must be via electronic funds transfer. $1 $118 $148 $163 $1 $1 $137 $174 $196 $206 $207 $268 $156 $194 $226 $251 $268 $133 $1 $200 $224 $241 $156 $195 $226 $252 $269 $112 $146 $178 $202 $211 $105 $137 $1 $191 $211 $25 Detailed Detailed $25 Rates vary by zip code. Pre-X: 6 onths Tobacco use rates vary. Bank draft discount available. Continental General Insurance Company Rates effective: 1/1/12 Call Company for plans and rates offered. Equitable Life & Casualty Insurance Company Rates effective: 7/1/11 < $212 $125 $134 $147 $156 $161 $300 $177 $191 $210 $224 $233 $125 $135 $148 $158 $164 Detailed $20 Bank draft discount available. SHIIP edicare Supplement Comparison Guide Page 32

37 ONTHLY PREIUS Company /F A B C D F G K L N F+ Comments Notes Family Life Insurance < $199 $282 Company $114 $138 $159 $145 $1 $146 $131 $116 Tobacco use $135 $1 $189 $173 $194 $173 $155 $136 rates vary. $161 $196 $228 $205 $233 $206 $184 $163 Detailed $183 $222 $259 $233 $263 $234 $210 $184 Spousal discount Rates effective: 4/1/12 $199 $241 $282 $253 $284 $255 $228 $199 $25 offered. Forethought Life Insurance Company Rates effective: 10/1/11 Gerber Life Insurance Company Rates effective: 8/9/11 /F /F /F /F /F /F < < $238 $101 $116 $130 $142 $151 $314 $134 $153 $174 $195 $212 $137 $157 $179 $199 $217 $105 $121 $138 $154 $168 onthly premium payment must be via electronic funds transfer. $239 $102 $120 $134 $142 $148 $343 $146 $173 $195 $212 $226 $123 $146 $1 $1 $192 $ 93 $107 $122 $137 $150 Detailed $25 $25 Rates vary by zip code. Tobacco use rates vary. Globe Life and Accident Insurance Company Rates effective: 4/1/12 /F /F /F /F /F < + $189 $ 77 $ 97 $106 $108 $114 $145 $161 $166 $269 $136 $171 $193 $216 $137 $173 $194 $218 DIRECT SOLICITATION RESPONSE PRODUCT Pre-X: 2 months (6 months for disability) Bank draft discount available. APPLICATION FEE: If an amount appears in the Comments column, the company charges a one-time fee for expenses incurred in issuing a policy. ATTAINED AGE: If appears in the Comments column, premiums automatically increase as you get older. CROSSOVER: If appears in the Comments column, the company has signed a crossover agreement with edicare allowing a person s claim to be sent automatically from edicare s computer to the supplement insurance company s computer. This agreement eliminates your need to file claims with the insurance company. F+: F Prime covers the same benefits as the standardized edicare Supplement Plan F, however, there is a $2,0 deductible in 2012 which leads to lower monthly premiums. The deductible may increase annually at the same rate as the Consumer Price Index. ISSUE AGE: If Issue appears in the Comments column, the premium will always be based on your age when you first enrolled. /F: If /F appears in this column, premiums are the same for males and females. An indicates that premiums differ for males and females, and the premium shown is for male policyholders. ale rates are generally higher than female rates. NO AGE: If the words No appear in the Comments column, premiums are the same for all ages, based on the plan purchased. PRE-X: Pre-existing condition waiting periods are time frames that apply to people who have health conditions or problems that were identified and treated before health insurance was purchased. The definition and waiting period before these conditions are covered varies from policy to policy. However, there is a maximum six-month waiting period for edicare supplement policies. Usually treatment must have been received in the preceding six months for the condition to be considered pre-existing. SIPLE/DETAILED: These terms refer to the company s questionnaire for underwriting. Persons may want to call to see if underwriting applies only to specific plans or time periods. SHIIP edicare Supplement Comparison Guide Page 33

38 ONTHLY PREIUS Company /F A B C D F G K L N F+ Comments Notes Government Personnel utual Life Insurance Company Rates effective: 9/1/11 (A,F,G,N); 11/4/11 (C) < $232 $ 98 $107 $127 $148 $1 $306 $130 $143 $173 $205 $234 $133 $147 $177 $210 $239 $101 $111 $134 $160 $182 $ 89 $ 98 $119 $142 $163 Detailed $25 Humana Insurance Company Rates effective: 7/1/12 < $308 $124 $151 $183 $216 $250 $135 $164 $199 $235 $272 $393 $158 $192 $233 $2 $319 $161 $196 $238 $281 $325 $ 74 $ 89 $108 $127 $147 $104 $126 $153 $1 $209 $100 $122 $147 $174 $201 $ 57 $ 69 $ 83 $ 98 $113 Pre-X: 3 onths Bank draft discount available. Rates vary by zip code. Liberty National Life Insurance Company Rates effective: 1/1/12 < + $367 $140 $167 $172 $172 $457 $197 $243 $258 $258 $467 $225 $2 $310 $325 $173 $221 $247 $2 $47 $64 $83 $94 (except < - Issue ) Pre-X: 60 Days (6 onths for Disability) Rates vary by zip code. Loyal American Life Insurance Company Rates effective: 10/1/11 < $194 $105 $119 $142 $161 $1 $123 $139 $1 $188 $205 $272 $147 $167 $201 $228 $249 $129 $146 $173 $197 $214 $152 $171 $205 $232 $251 $132 $150 $178 $202 $220 $107 $120 $144 $162 $176 $25 Pre-X: 6 onths Tobacco use rates vary. Rates vary by zip code. edico Insurance Company Rates effective 5/1/12 < $194 $102 $116 $141 $156 $160 $266 $140 $160 $198 $232 $261 $ 99 $114 $143 $172 $194 Detailed Bank draft discount available. Tobacco use rates vary. SHIIP edicare Supplement Comparison Guide Page 34

39 ONTHLY PREIUS Company /F A B C D F G K L N F+ Comments Notes Order of United Commercial Travelers of America Rates effective: 2/1/12 Oxford Life Insurance Company Rates effective: 8/31/10 < $341 $178 $223 $261 $287 $306 $231 $289 $337 $372 $397 $451 $249 $310 $356 $3 $409 $225 $281 $328 $362 $386 $254 $309 $355 $384 $408 $186 $232 $271 $299 $318 $174 $216 $249 $269 $2 You must be a member of The Order of United Commercial Travelers of America to purchase policy. /F /F /F /F /F /F < $381 $115 $136 $162 $179 $1 $420 $130 $154 $181 $208 $239 $ 92 $109 $129 $149 $172 $15 Tobacco use rates vary. Bank draft discount available. Rates vary by zip code. Philadelphia American Life Insurance Company Rates effective: 7/1/12 Call Company for plans and rates offered. Physicians utual Insurance Company Rates effective: 6/1/12 /F /F /F /F /F /F < $303 $122 $144 $160 $174 $187 $436 $182 $212 $253 $292 $330 SHIIP edicare Supplement Comparison Guide Page 35 $150 $1 $209 $242 $273 $125 $157 $196 $237 $2 $ 63 $ 78 $ 98 $122 $149 (Issue age rates also available.) Rates vary by zip code. Tobacco use rates vary. Bank draft discount available. Spousal discount offered. APPLICATION FEE: If an amount appears in the Comments column, the company charges a one-time fee for expenses incurred in issuing a policy. ATTAINED AGE: If appears in the Comments column, premiums automatically increase as you get older. CROSSOVER: If appears in the Comments column, the company has signed a crossover agreement with edicare allowing a person s claim to be sent automatically from edicare s computer to the supplement insurance company s computer. This agreement eliminates your need to file claims with the insurance company. F+: F Prime covers the same benefits as the standardized edicare Supplement Plan F, however, there is a $2,0 deductible in 2012 which leads to lower monthly premiums. The deductible may increase annually at the same rate as the Consumer Price Index. ISSUE AGE: If Issue appears in the Comments column, the premium will always be based on your age when you first enrolled. /F: If /F appears in this column, premiums are the same for males and females. An indicates that premiums differ for males and females, and the premium shown is for male policyholders. ale rates are generally higher than female rates. NO AGE: If the words No appear in the Comments column, premiums are the same for all ages, based on the plan purchased. PRE-X: Pre-existing condition waiting periods are time frames that apply to people who have health conditions or problems that were identified and treated before health insurance was purchased. The definition and waiting period before these conditions are covered varies from policy to policy. However, there is a maximum six-month waiting period for edicare supplement policies. Usually treatment must have been received in the preceding six months for the condition to be considered pre-existing. SIPLE/DETAILED: These terms refer to the company s questionnaire for underwriting. Persons may want to call to see if underwriting applies only to specific plans or time periods.

40 ONTHLY PREIUS Company /F A B C D F G K L N F+ Comments Notes Reserve National Insurance Company Rates effective: 5/17/12 (A,C,F,F+,N); 3/14/12 (G) Royal Neighbors of America Rates effective: 7/12/11 Secure Horizons/UnitedHealthcare Insurance Company Rates effective: 4/11/12 Sentinel Security Life Insurance Company Rates effective: 10/1/11 Standard Life and Accident Insurance Company Rates effective: 1/1/12 < < $230 $120 $143 $168 $195 $215 $263 $106 $121 $138 $158 $181 $133 $152 $174 $199 $227 $342 $178 $212 $249 $289 $319 $386 $155 $177 $203 $232 $2 $124 $142 $162 $186 $212 $299 $156 $1 $218 $252 $279 $156 $178 $203 $233 $266 $230 $120 $143 $168 $194 $215 $125 $143 $163 $186 $213 $217 $113 $134 $158 $183 $202 $86 $45 $53 $63 $73 $ Detailed $15 Reserve National Insurance Company monthly premium payments must be via electronic funds transfer or pre-authorized credit card. /F /F /F /F /F /F /F /F /F /F /F /F < < < ust be a member of Royal Neighbors of American to purchase policy. $137 $ 99 $116 $129 $131 $137 $248 $133 $160 $193 $221 $248 $120 $146 $178 $205 $231 $ 63 $ 74 $ 86 $ 90 $109 $ 87 $104 $126 $145 $164 onthly premium payments must be via electronic funds transfer. $231 $ 98 $116 $130 $142 $151 $514 $188 $217 $250 $300 $377 $107 $126 $143 $159 $171 $214 $247 $284 $341 $429 $304 $129 $153 $1 $195 $212 $666 $243 $281 $323 $388 $488 $107 $127 $145 $162 $177 $146 $169 $195 $234 $294 $133 $157 $179 $200 $217 $200 $231 $266 $319 $402 $148 $171 $190 $227 $284 $ 89 $112 $139 $163 $1 $ 95 $113 $129 $145 $159 $ 96 $112 $128 $154 $194 $43 $54 $69 $84 $97 $29 $34 $39 $46 $58 $20 $25 Detailed Standard Life and Accident Insurance Company monthly premium payments must be via electronic funds transfer and rates may vary by zip code. Pre-X: 6 onths Tobacco use rates vary. Bank draft discount available. Tobacco use rates vary. Tobacco use rates vary. Bank draft discount available. Tobacco use rates vary. Bank draft discount available. SHIIP edicare Supplement Comparison Guide Page 36

41 ONTHLY PREIUS Company /F A B C D F G K L N F+ Comments Notes Standard Security Life Insurance Company of New York Rates effective: 1/5/11 < + $317 $106 $122 $136 $150 $123 $145 $166 $194 $432 $144 $1 $196 $230 $132 $157 $181 $214 $115 $137 $159 $189 Tobacco use rates vary. Rates vary by zip code. State Farm utual Automobile Insurance Company CALL YOUR LOCAL STATE FAR AGENT Rates effective: 2/1/12 /F /F /F /F /F /F < $207 $ 92 $116 $134 $151 $157 $312 $139 $174 $202 $227 $237 $140 $176 $204 $229 $239 State utual Insurance < $171 $240 Company $ 89 $103 $124 $108 $129 $109 $ 98 $ 90 $51 $105 $123 $147 $129 $151 $130 $116 $106 $ $125 $146 $177 $153 $181 $154 $138 $127 $71 Tobacco use rates $142 $166 $201 $174 $204 $1 $157 $143 $ vary. $155 $181 $220 $189 $221 $190 $1 $155 $87 Rates effective: 7/1/12 $20 Application fee waived if submitted via the internet. ust call the company directly or enroll through their Web site as they have no North Carolina agents. APPLICATION FEE: If an amount appears in the Comments column, the company charges a one-time fee for expenses incurred in issuing a policy. ATTAINED AGE: If appears in the Comments column, premiums automatically increase as you get older. CROSSOVER: If appears in the Comments column, the company has signed a crossover agreement with edicare allowing a person s claim to be sent automatically from edicare s computer to the supplement insurance company s computer. This agreement eliminates your need to file claims with the insurance company. F+: F Prime covers the same benefits as the standardized edicare Supplement Plan F, however, there is a $2,0 deductible in 2012 which leads to lower monthly premiums. The deductible may increase annually at the same rate as the Consumer Price Index. ISSUE AGE: If Issue appears in the Comments column, the premium will always be based on your age when you first enrolled. /F: If /F appears in this column, premiums are the same for males and females. An indicates that premiums differ for males and females, and the premium shown is for male policyholders. ale rates are generally higher than female rates. NO AGE: If the words No appear in the Comments column, premiums are the same for all ages, based on the plan purchased. PRE-X: Pre-existing condition waiting periods are time frames that apply to people who have health conditions or problems that were identified and treated before health insurance was purchased. The definition and waiting period before these conditions are covered varies from policy to policy. However, there is a maximum six-month waiting period for edicare supplement policies. Usually treatment must have been received in the preceding six months for the condition to be considered pre-existing. SIPLE/DETAILED: These terms refer to the company s questionnaire for underwriting. Persons may want to call to see if underwriting applies only to specific plans or time periods. SHIIP edicare Supplement Comparison Guide Page 37

42 ONTHLY PREIUS Company /F A B C D F G K L N F+ Comments Notes Sterling Investors Life Insurance Company Rates effective: 5/1/12 < $176 $ 91 $108 $129 $146 $159 $106 $126 $150 $171 $186 $247 $127 $152 $182 $207 $226 $111 $132 $157 $179 $194 $132 $155 $186 $210 $228 $112 $133 $158 $1 $195 $100 $119 $142 $161 $1 $ 93 $109 $130 $147 $159 $52 $61 $73 $83 $90 $20 Tobacco use rates vary. Sterling Life Insurance Company Rates effective: 10/13/11 < + $305 $136 $155 $169 $178 $158 $184 $206 $227 $393 $177 $209 $236 $264 $168 $199 $224 $251 $152 $181 $205 $230 $ 72 $ $ 97 $110 $134 $159 $181 $204 Rates vary by zip code. Thrivent Financial for Lutherans Rates effective: 2/7/12 United American Insurance Company Rates effective: 1/1/12 /F /F /F /F /F /F < $239 $ 95 $109 $125 $138 $149 $113 $129 $147 $163 $177 $366 $146 $167 $191 $212 $229 $126 $144 $164 $182 $197 $147 $168 $191 $212 $230 $129 $148 $169 $187 $202 $ 90 $103 $118 $130 $141 $117 $131 $149 $1 $179 $48 $55 $63 $69 $ Detailed Plans available only to Lutherans and their families and monthly premium payments must be via electronic funds transfer. < + $350 $120 $143 $148 $148 $428 $176 $217 $230 $230 $445 $203 $253 $279 $292 $188 $239 $2 $278 $204 $254 $2 $293 $190 $240 $266 $279 $ 92 $122 $137 $146 $128 $172 $192 $205 $156 $199 $223 $237 $200 $ 43 $ 56 $ 68 $ 72 (except < -Issue ) Rates vary by zip code. Tobacco use rates vary. Pre-X: 2 onths (6 onths for Disability) Offers Disability Plans A, B & F Prime outside of open enrollment. United of Omaha Life Insurance Company Rates effective: 8/1/11 < $219 $ $ 96 $122 $142 $157 $317 $115 $139 $177 $206 $227 $ 98 $118 $150 $1 $193 $ 90 $109 $138 $161 $177 Risk Class Premium of 10% or 20% based on height/weight chart may apply. Tobacco use rates vary. Bank draft discount available. Household discount available. SHIIP edicare Supplement Comparison Guide Page 38

43 ONTHLY PREIUS Company /F A B C D F G K L N F+ Comments Notes USAA Life Insurance Company DIRECT SOLITICATION RESPONSE PRODUCT Rates effective: 9/1/12 /F /F /F /F /F /F < $234 $131 $154 $183 $212 $234 $222 $125 $145 $173 $201 $222 Tobacco use rates vary. Washington National Insurance Company Rates effective: 6/1/12 Call Company for plans and rates offered. Adverse health factors and tobacco use may increase rates. World Corp Insurance Company Rates effective: 4/1/12 < $279 $139 $159 $189 $218 $247 $363 $182 $204 $247 $284 $322 $ 72 $ 81 $ 98 $113 $127 Detailed Rates vary by zip code. Bank draft discount available. Couple discount available. APPLICATION FEE: If an amount appears in the Comments column, the company charges a one-time fee for expenses incurred in issuing a policy. ATTAINED AGE: If appears in the Comments column, premiums automatically increase as you get older. CROSSOVER: If appears in the Comments column, the company has signed a crossover agreement with edicare allowing a person s claim to be sent automatically from edicare s computer to the supplement insurance company s computer. This agreement eliminates your need to file claims with the insurance company. F+: F Prime covers the same benefits as the standardized edicare Supplement Plan F, however, there is a $2,0 deductible in 2012 which leads to lower monthly premiums. The deductible may increase annually at the same rate as the Consumer Price Index. ISSUE AGE: If Issue appears in the Comments column, the premium will always be based on your age when you first enrolled. /F: If /F appears in this column, premiums are the same for males and females. An indicates that premiums differ for males and females, and the premium shown is for male policyholders. ale rates are generally higher than female rates. NO AGE: If the words No appear in the Comments column, premiums are the same for all ages, based on the plan purchased. PRE-X: Pre-existing condition waiting periods are time frames that apply to people who have health conditions or problems that were identified and treated before health insurance was purchased. The definition and waiting period before these conditions are covered varies from policy to policy. However, there is a maximum six-month waiting period for edicare supplement policies. Usually treatment must have been received in the preceding six months for the condition to be considered pre-existing. SIPLE/DETAILED: These terms refer to the company s questionnaire for underwriting. Persons may want to call to see if underwriting applies only to specific plans or time periods. SHIIP edicare Supplement Comparison Guide Page 39

44 edicare SELECT Plans SHIIP edicare Supplement Comparison Guide Page 40

45 edicare SELECT Plans A edicare SELECT policy has the same benefits as the standardized edicare supplement plans. There is only one difference. An insurance company selling edicare SELECT policies has established participating contracts with certain hospitals, doctors and other medical providers, as in a PPO. Therefore, to receive benefits from the SELECT policy, the person with edicare is required to use the providers listed in the company s restricted provider network. Usually lower priced premiums are the incentive to purchase a edicare SELECT supplemental policy. Regardless of whether the person with edicare uses the preferred provider, edicare will pay the appropriate share of the approved charge. Generally, the edicare SELECT policy will not pay any benefits for non-participating providers with the exception of emergency services. ONTHLY PREIUS Company /F A B C D F G K L N F+ Comments Notes AARP/UnitedHealthcare Insurance Company Rates effective: 1/1/12 Gerber Life Insurance Company Rates effective: 8/9/11 /F /F 68+ $135 $135 $136 $136 No AARP/UnitedHealthcare Insurance Company offers annual payer and early enrollment discounts. < $239 $102 $120 $134 $142 $148 $2 $121 $143 $162 $176 $188 $102 $121 $137 $149 $160 Detailed $25 Pre-X: 3 onths Bank draft discount available. Sentinel Security Life Insurance Company Rates effective: 10/1/11 < $109 $129 $147 $164 $178 $ 91 $108 $123 $138 $150 $112 $132 $150 $168 $183 $ 81 $ 96 $109 $123 $134 $25 APPLICATION FEE: If an amount appears in the Comments column, the company charges a one-time fee for expenses incurred in issuing a policy. ATTAINED AGE: If appears in the Comments column, premiums automatically increase as you get older. CROSSOVER: If appears in the Comments column, the company has signed a crossover agreement with edicare allowing a person s claim to be sent automatically from edicare s computer to the supplement insurance company s computer. This agreement eliminates your need to file claims with the insurance company. GUARANTEED COVERAGE: If the letters GC appear in the Notes column, the plans listed will be issued regardless of the applicant s age or health problems, even if the person is outside INSURANCE COPANY NAE/TELEPHONE NUBER: Companies included in this guide are found in the edicare Supplement Premium Comparison Database on the SHIIP web site. Company addresses and phone numbers begin on page 32. ISSUE AGE: If Issue appears in the Comments column, the premium will always be based on your age when you first enrolled. /F: If /F appears in this column, premiums are the same for males and females. An indicates that premiums differ for males and females, and the premium shown is for male policyholders. ale rates are generally higher than female rates. PRE-X: Pre-existing condition waiting periods are time frames that apply to people who have health conditions or problems that were identified and treated before health insurance was purchased. The definition and waiting period before these conditions are covered varies from policy to policy. However, there is a maximum six-month waiting period for edicare supplement policies. Usually treatment must have been received in the preceding six months for the condition to be considered pre-existing. SIPLE/DETAILED: These terms refer to the company s questionnaire for underwriting. Persons may want to call to see if underwriting applies only to specific plans or time periods. SHIIP edicare Supplement Comparison Guide Page 41

46 Glossary ACTUAL CHARGE is the amount a physician or health care provider bills a patient for a particular medical service or supply. The actual charge may differ from the edicare-approved amount or the amount approved by other insurance programs. APPROVED CHARGES are also known as allowable charges, edicareeligible expenses or edicare-covered charges. This term applies to the specific dollar amount edicare will base its payment on for every medical procedure under the Part B program. edicare will pay percent of this approved amount. Approved charges are currently averaging only 60- percent of the actual bill received from your doctor. You and your insurance plan are responsible for the balance of the approved amount. The approved amount is taken from a national fee schedule that assigns a dollar value to all physician services covered by edicare. ASSIGNENT is the way doctors or suppliers receive payment directly from edicare. When assignment is taken, the doctor or supplier agrees that his or her total charge for the covered service will be the charge approved by the edicare carrier. edicare then pays your doctor or supplier percent of the approved charge, after subtracting any part of the $140 annual deductible you have not met. You and your insurance plan are responsible for the 20 percent of the approved amount not paid by edicare. Accepting assignment means that the doctor or supplier will not bill you for the difference between the actual charge and the edicare-approved amount. Find out in advance whether your doctor or supplier will accept assignment. Using doctors or suppliers who accept assignment will save you money. Any physician may take assignment on a case-by-case basis whether he is a participating provider or not. ATTAINED AGE PREIU is a premium based on the policyholder s nearest attained age. Therefore, the premium rate will increase as the policyholder s age increases. The company can price each age differently or group several ages together into one premium class. COORDINATION OF BENEFITS (COB) means that one of your health insurance companies may reduce its benefits if you are also covered by another insurance plan. IPORTANT: This usually applies only for employer sponsored plans. Individual edicare supplements have no COB regardless of how many policies you have. COPAYENT is the amount that you or your insurance plan must pay to supplement edicare's payments for Part A and Part B expenses. For example, you will have a $289 per day copayment for days 61 through 90 and a $578 per day copayment for days 91 through 150 while in a hospital in There is also a copayment of $ for skilled nursing days 21 through 100 and a 20 percent copayment for all Part B services in COSTWISE is a special arrangement between physicians and Blue Cross/Blue Shield (BCBS) in which the physician agrees to file claims for the patient and agrees to charge only what BCBS calculated as usual, customary or reasonable. Costwise does not mean that the physician will accept edicare assignment. Note, however, that the Costwise doctor will receive the BCBS payment whether he takes edicare assignment or not. CREDITABLE INSURANCE COVERAGE is any previous health coverage that can be used to shorten the pre-existing condition waiting period, such as coverage under group plans, individual health policies, edicare, edicaid or federal/military retiree programs. CROSSOVER is an arrangement between edicare Part B and a private edicare supplement insurance company whereby edicare Part B would automatically forward claims to the edicare supplement insurance company for payment of benefits. Under this scenario it is not necessary for the person with edicare to file his/her own claims to the edicare supplement company. DEDUCTIBLE is the amount that you will have to pay before either edicare or your insurance plan will begin paying benefits. Your edicare Part A deductible is $1,156 per benefit period for Your edicare Part B deductible for 2012 is $140 of approved charges for the calendar year. DURABLE EDICAL EQUIPENT EDICARE ADINISTRATIVE CONTRACTOR (DE AC) is the edicare contractor to process claims for durable medical equipment, prosthetic, orthotic and supply services in a specific geographic area of the United States. North Carolina's DE AC is CIGNA Government Services (CGS). For questions regarding claims call EFFECTIVE DATE is the date your policy takes effect. The insurer will determine the effective date, so you must ask for that information. SHIIP edicare Supplement Comparison Guide Page 42

47 EXCLUSIONS OR EXCEPTIONS is the list of specific conditions or circumstances which are not covered by a policy. The exceptions in edicare supplements are limited by state law and cannot exclude or limit coverage for any specific health condition for more than six months. EXPERIENCE RATING is a method of adjusting the premium based on past loss experience. FREE-LOOK is the period of time after you receive a policy in which you can review its benefits. State law requires insurance companies to give the consumer 30 days to review edicare supplement policies. If you return the policy within the 30-day free-look period, you will get a full refund. GRACE PERIOD is the period of time, usually 31 days, for the payment of an overdue premium during which time the policy remains in force. HOSPICE is a program for the terminally ill. edicare does reimburse most hospice expenses if the edicare patient chooses to take hospice benefits instead of regular Part A and Part B benefits. There may be a copayment for outpatient drugs and inpatient respite care. Care must be provided through certified hospice organizations. ISSUE AGE PREIU is a premium that does not increase solely because of increasing age. LIITING CHARGE is the maximum amount a physician may charge a person with edicare for a covered service if the physician does not accept assignment of the edicare claim. The limit is 15 percent more than the edicare-approved amount for non-participating physicians. The edicare-approved amounts for non-participating physicians are 5 percent less than those amounts for participating physicians. Limiting charge information appears on the edicare Summary Notice (SN). EDICARE ADINISTRATIVE CONTRACTOR (AC) is the edicare Part A and Part B claims processor (also home health and hospice claims). In North Carolina the AC is Palmetto Government Benefits Administrators (Palmetto GBA). For questions about claims payments contact EDICAID is a federal, state and county government program that provides health insurance benefits for low-income, disabled and blind individuals and families. There are strict income and asset eligibility guidelines, and applications for edicaid programs must be made at the local Department of Social Services. EDICARE SAVINGS PROGRA is a edicaid program which helps lowincome people with edicare. Blind, disabled or elderly people whose income falls below the federal poverty guideline and have less than allowed asset reserves may qualify for edicare Savings Programs through their local Department of Social Services. For people who qualify edicaid money may be used to pay for edicare deductibles, copayments and premiums. NON-PARTICIPATING PHYSICIANS are doctors who have not contracted with edicare to accept assignment for all edicare patients. Non-participating physicians may accept assignment on a case-by-case basis should he/she choose. PARTICIPATING PHYSICIANS are doctors who have contracted with edicare to accept assignment for all edicare patients. PRE-EXISTING CONDITIONS are health conditions, which have been diagnosed or treated during a set amount of time before your policy's effective date of coverage. North Carolina law allows edicare supplement policies to consider a person s health history six months back from the effective date of coverage. Some insurance companies do not cover pre-existing health problems for a certain number of months following the effective date of coverage. PRE-EXISTING CONDITION WAITING PERIOD is the amount of time after your effective date of coverage during which your insurance plan will not cover any pre-existing conditions. edicare supplement law in North Carolina restricts the period to no longer than six months. any insurers offer plans with shorter waiting periods or none at all. QUALITY IPROVEENT ORGANIZATIONS (QIO) are groups of doctors and health care professionals who are paid by the federal government to review edicare hospital admissions and reimbursements and to monitor inpatient quality of care. QIOs have the authority to deny hospital payments if the care is not medically necessary. QIOs also handle appeals and complaints the patient makes regarding non-payment of service or quality of care. If you have any questions, you can contact the QIO in North Carolina: The Carolinas Center for edical Excellence, located at 100 Regency Forest Drive, Suite 200, Cary, NC, The telephone number is Their Web site is UNDERWRITING is a method of determining the probability that an applicant will have more claims than expected. A health questionnaire is usually the method used for underwriting on health insurance. USUAL, CUSTOARY AND REASONABLE (UCR) typically means the fees most frequently charged in a geographic area by providers with similar training and experience for the same or like service or supply. SHIIP edicare Supplement Comparison Guide Page 43

48 SHIIP NC Department of Insurance 11 South Boylan Avenue Raleigh, NC nationwide (919) (919) facsimile 7,500 copies of this public document were printed at a cost of $1, This publication has been created or produced by North Carolina with financial assistance, in whole or in part, through a grant from the Centers for edicare & edicaid Services, the federal edicare agency. NCDOI SCG12 Published June 2012