2015 Standard Medicare Supplement Insurance Plans

Transcription

1 2015 Standard Medicare Supplement Insurance Plans Product Overview 77345_TX 0515

2 2015 MEDICARE SUPPLEMENT INSURANCE PLANS Like all Medicare Supplement insurance plans, Transamerica Premier Life Insurance Company s Medicare Supplement Insurance Plans to help with your out of pocket costs that Medicare does not cover for Parts A and B charges. WHAT S MORE, YOU HAVE: Multiple plans from which to select the coverage that best meets your needs. Virtually no claims paperwork to file. Put a Transamerica Premier Life Medicare Supplement Insurance Plan to work for you today! Medicare Supplement insurance is underwritten by: Transamerica Premier Life Insurance Company, Home Office: Cedar Rapids, IA All Medicare Supplement plans are available to qualified individuals under the age of 65. THIS IS A SOLICITATION FOR INSURANCE. Not connected with or endorsed by the U.S. Government or the federal Medicare program. CHOOSE THE MEDICARE SUPPLEMENT PLAN THAT S RIGHT FOR YOU.

3 WHICH MEDICARE SUPPLEMENT PLAN BEST MEETS YOUR NEEDS? SERVICES AND SUPPLIES MEDICARE PAYS PLAN A* PAYS PLAN F* PAYS PLAN G* PAYS PLAN N* PAYS MEDICARE PART A Hosptial Coverage Deductible $1,260 $1,260 $1,260 First 60 days All but $1,260 Co-Insurance days Co-Insurance days (Lifetime Reserve) Extended Hospital Coverage (up to an additional 365 days in your lifetime) Benefit for Blood All but $315 a day All but $630 a day All but First Three Pints $315 a day $630 a day Medicare Eligible Expenses $315 a day $630 a day Medicare Eligible Expenses $315 a day $630 a day Medicare Eligible Expenses $315 a day $630 a day Medicare Eligible Expenses First Three Pints First Three Pints First Three Pints First Three Pints Hospice Care All but very limited Co-insurance/Co-payment for outpatient drugs and inpatient respite care Medicare Co-Insurance / Co-Payment Medicare Co-Insurance / Co-Payment Medicare Co-Insurance / Co-Payment Medicare Co-Insurance / Co-Payment Skilled Nursing Facility Care First 20 days 100% of all approved amounts Co-Insurance days All but $ a day Up to $ a day Up to $ a day Up to $ a day MEDICARE PART B Physician s Services and Supplies Deductible $147 Co-Insurance Generally 80% Generally 20% Generally 20% Generally 20% Balance *** Excess Benefits Benefit for Blood 80% after first three pints and deductible are me 100% up to Medicare s limit 100% up to Medicare s limit First Three Pints First Three Pints First Three Pints First Three Pints Additional Benefits** Emergency Care Received Outside the U.S. 80% to lifetime max of $50,000 80% to lifetime max of $50,000 80% to lifetime max of $50,000 * Additional plans may be available in your state. Please consult your agent to receive complete information including benefits, costs, eligibility requirements, exclusions and limitations. ** Refer to the next page and your Outline of Coverage for more information. *** Balance, except up to a $20 co-payment per office visit and up to $50 co-payment per emergency room visit. The co-payment of $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. This Medicare Supplement Insurance plan is not connected with or endorsed by the U.S. Government or the Federal Medicare Program. This is a solicitation for Medicare Supplement insurance.

4 Medicare Supplement Plans COVERED BENEFITS MEDICARE PART A HOSPITAL COVERAGE Like all Medicare Supplement Insurance Plans, Transamerica Premier Standard Plan pays the $1,260 Part A (inpatient) deductible for plans F, G & N for each benefit period. First 60-days After the Part A Deductible, Medicare pays all eligible expenses for services from your first through 60th day of hospital confinement. Services include semi-private room and board, general nursing and miscellaneous hospital services and supplies. Co-insurance Standard Plans A, F, G & N pay $315 a day when you are hospitalized from the 61st day through the 90th day. When you are hospitalized from the 91st day through the 150th day, Standard Plans pay $630 a day for each Lifetime Reserve day used. Extended Hospital Coverage If you are in the hospital longer than 150 days during a benefit period and you have exhausted your 60 days of Medicare Lifetime Reserve Standard Plans A, F, G & N pay the Part A Medicare eligible expenses for hospitalization. Expenses are paid at the same rate Medicare would have paid had Medicare Part A hospital days not been exhausted, subject to a lifetime maximum benefit of an additional 365 days. Benefit for Blood Medicare has one calendar year deductible for blood that is the cost of the first three pints. Standard Plans A, F, G & N pay the deductible. Skilled Nursing Facility Care Medicare pays all eligible expenses for the first 20 days. Standard Plans F, G & N pay up to $ from the 21st through the 100th day during which you receive skilled nursing care. You must enter a Medicare certified skilled nursing facility generally within 30 days of being hospitalized for at least three days. Hospice Care Medicare pays all but a very limited co-insurance/ co-payment for outpatient drugs and inpatient respite care. Standard Plans A, F, G & N pay the co-insurance/co-payment. MEDICARE PART B PHYSICIAN SERVICES AND SUPPLIES Deductible Standard Plan F pays the $147 calendaryear deductible. Co-insurance After the Part B Deductible, Standard Plans A, F, G & N generally pay 20% of eligible expenses for physician s services, supplies, physical and speech therapy, diagnostic tests and durable medical equipment. After the Part B deductible, Plan N pays the balance of the eligible expenses for physician s services, supplies, physical and speech therapy, diagnostic tests and durable medical equipment except up to a $20 co-payment for office visits and up to a $50 co-payment for emergency room visits. For hospital outpatient services, the co-payment amount will be paid under a prospective payment system. If this system is not used, then 20% of eligible expenses will be paid. Excess Benefits Your bill for Part B services and supplies may exceed the Medicare eligible expense. When that occurs, Standard Plan F and G pay 100% up to the charge limitation established by Medicare. Benefit for Blood Standard Plans A, F, G & N pay expenses for the first three pints of blood. OTHER BENEFITS Emergency Care received outside the U.S. After you pay a $250 calendar-year deductible, Standard Plans F, G & N pay you 80% of eligible expenses for care which begins during the first 60 days of a trip up to a lifetime maximum of $50,000. Benefits are payable for health care you need because of a covered injury or illness.

5 Medicare Supplement Plans MEDICARE SUPPLEMENT PLANS A Standard Medicare Supplement insurance policy may help pay eligible expenses not paid for by Medicare Part A and Medicare Part B. There may be charges that exceed what Medicare and your Transamerica Premier Standard insurance policy will pay. Medicare Eligible Expenses means expenses covered by Medicare to the extent recognized as reasonable and medically necessary by Medicare. Medicare Part A Eligible Expenses for Hospital/Skilled Nursing Facility Care include expenses for semi-private room and board, general nursing and miscellaneous services and supplies. A Benefit Period begins the first full day you are hospitalized and ends when you have not been in a hospital or skilled nursing facility for 60 consecutive days. Medicare Part B Eligible Expenses for Medical Services include expenses for physician s services, hospital outpatient services and supplies, physical and speech therapy, diagnostic tests and durable medical equipment. Co-Insurance is the portion of the eligible expense not paid by Medicare and paid by Transamerica Premier Standard Medicare supplement. Benefits are paid to you, your hospital or doctor. Your policy is guaranteed renewable. Your policy cannot be canceled. It will be renewed as long as the premiums are paid on time and you have not made a material misrepresentation. You have 31 days from your renewal date to pay your premium. Your policy will stay inforce during this 31-day grace period. (c) that portion of any expense incurred which is paid for by Medicare; (d) any expense that duplicates payments made under any other provision of the policy; (e) services for non-medicare Eligible Expenses, including, but not limited to, routine exams, take-home drugs and eye refractions; (f) services for which a charge is not normally made in the absence of insurance; or (g) expenses which are not determined to be Medicare Eligible Expenses by the Federal Medicare Program or its administrators, except to the extent provided in the policy Open Enrollment is the period beginning from the first day of the month you turn 65 and are covered under Medicare Part B and continuing for the six (6) months after. If you are under age 65, you will also have a six (6) month Open Enrollment Period when you reach age 65. This is a brief description of your coverage. This brochure must be accompanied by the Outline of Coverage. For a complete description of benefits, exceptions and limitations, please read your outline of coverage and your policy. The first premium includes a one-time, non-commissionable enrollment fee of $25.00 paid by the applicant. (Not applicable in AR, MN, WA, WV) Benefits and premiums under this policy may be suspended for up to 24 months if you become entitled to benefits under Medicaid. You must request that your policy be suspended within 90 days of becoming entitled to Medicaid. If you lose (are no longer entitled to) benefits from Medicaid, this policy can be reinstated if you request reinstatement within 90 days of the loss of such benefits and pay the required premium. You cannot be singled out for a rate increase, no matter how many times you receive benefits. Your premium changes when the same premium change is made on all in-force Medicare supplement policies of the same form issued to persons of your classification in the same geographic area of your state. Transamerica Premier Standard Medicare Supplement will not pay for: (a) expense incurred while this policy is not in force, except as provided in the EXTENSION OF BENEFITS section; (b) expense incurred before your policy effective date.;

6 77345_TX 0515 Medicare Supplement Insurance policies issued by Transamerica Premier Life Insurance Company. Policy Form No. MSGHIA TX, MSGHIF TX, MSGHIG TX, and MSGHIN TX. This Medicare Supplement Insurance plan is not connected with or endorsed by the U.S. Government or Federal Medicare Program.

7 Medicare Supplement Insurance Texas

8 2015 MEDICARE SUPPLEMENT INSURANCE PLANS Like all Medicare Supplement insurance plans, Transamerica Premier Life Insurance Company s Medicare Supplement Plans which may help pay your Medicare Parts A and B charges Medicare doesn t cover. What s more, you have: Multiple plans from which to select the coverage that best meets your needs. The option to use any hospital or medical facility that accept medicare. Virtually no claims paperwork to file. Put a Transamerica Premier Life Insurance Company Medicare Supplement Plan on your team today. Medicare Supplement insurance is underwritten by: Transamerica Premier Life Insurance Company Home Office: 4333 Edgewood Road NE, Cedar Rapids, Iowa CHOOSE THE MEDICARE SUPPLEMENT PLAN THAT S RIGHT FOR YOU. This program is not connected with or endorsed by the U.S. Government or the Federal Medicare Program.

9 COVERED BENEFITS MEDICARE PART A HOSPITAL COVERAGE Like all Medicare Supplement insurance plans, the Transamerica Premier Standard Plan pays the $1,260 Part A (inpatient) deductible for plans F, G & N for each benefit period. First 60-days After the Part A Deductible, Medicare pays all eligible expenses for services from your first through 60th day of hospital confinement. Services include semiprivate room and board, general nursing and miscellaneous hospital services and supplies. Co-insurance Standard Plans A, F, G & N pay $315 a day when you are hospitalized from the 61st day through the 90th day. When you are hospitalized from the 91st day through the 150th day, Standard Plans pay $630 a day for each Lifetime Reserve day used. Extended Hospital Coverage If you are in the hospital longer than 150 days during a benefit period and you have exhausted your 60 days of Medicare Lifetime Reserve Standard Plans A, F, G & N pay the Part A Medicare eligible expenses for hospitalization, paid at the same rate Medicare would have paid had Medicare Part A hospital days not been exhausted, subject to a lifetime maximum benefit of an additional 365 days. Benefit for Blood Medicare has one calendar year deductible for blood that is the cost of the first three pints. Standard Plans A, F, G & N pay the deductible. Skilled Nursing Facility Care Medicare pays all eligible expenses for the first 20 days. Standard Plans F, G & N pay up to $ from the 21st through the 100th day during which you receive skilled nursing care. You must enter a Medicare certified skilled nursing facility within 30 days of being hospitalized for at least three days. Hospice Care Medicare pays all but a very limited Coinsurance/Co-payment for outpatient drugs and inpatient respite care. Standard Plans A, F, G & N pay the Coinsurance/Co-payment. MEDICARE PART B PHYSICIAN SERVICES AND SUPPLIES Deductible Standard Plan F pays the $147 calendaryear deductible. Co-insurance After the Part B Deductible, Standard Plans A, F, G & N generally pay 20% of eligible expenses for physician s services, supplies, physical and speech therapy and diagnostic tests and durable medical equipment. After the Part B deductible, Plan N pays balance of the eligible expenses for physician s services, supplies, physical and speech therapy, diagnostic tests and durable medical equipment except up to a $20 co-payment for office visits and up to a $50 co-payment for emergency room visits. For hospital outpatient services, the co-payment amount will be paid under a prospective payment system. If this system is not used, then 20% of eligible expenses will be paid. Excess Benefits Your bill for Part B services and supplies may exceed the Medicare eligible expense. When that occurs, Standard Plans F and G pays 100% up to the charge limitation established by Medicare. Benefit for Blood Standard Plans A, F, G & N pay expenses for the first three pints of blood. OTHER BENEFITS Emergency Care received outside the U.S. After you pay a $250 calendar-year deductible, Standard Plans F, G & N pay you 80% of eligible expenses for care which begins during the first 60 days of a trip up to a lifetime maximum of $50,000. Benefits are payable for health care you need because of a covered injury or illness.

10 TRANSAMERICA PREMIER LIFE INSURANCE COMPANY Home Office: 4333 Edgewood Rd. NE, Cedar Rapids, IA OPEN ENROLLMENT Open Enrollment is the 6 months period beginning on the first day of the month in which you are enrolled in Medicare Part B. If you are on Medicare under age 65, you will also have a 6 month open enrollment period when you reach 65. PREMIUM INFORMATION You cannot be singled out for a rate increase, no matter how many times you receive benefits. Your premium changes when the same premium change is made on all in-force Medicare Supplement policies of the same form issued to persons of your classification in the same geographic area of your state. DISCLOSURES Benefits will not be paid for any expenses, which are not determined to be Medicare Eligible Expenses by the Federal Medicare Program or its administrators, except as otherwise specified. Benefits and premiums under this policy may be suspended for up to 24 months if you become entitled to benefits under Medicaid. You must request that your policy be suspended within 90 days of becoming entitled to Medicaid. If you lose (are no longer entitled to) benefits from Medicaid, this policy can be reinstated if you request reinstatement within 90 days of the loss of such benefits and pay the required premium. READ YOUR POLICY VERY CAREFULLY This is only an outline describing your Policy s most important features. The Policy is the insurance contract. You must read the Policy itself to understand all of the rights and duties of both you and Transamerica Premier Life Insurance Company. RIGHT TO RETURN POLICY If you find that you are not satisfied with your Policy, you may return it to Transamerica Premier Life Insurance Company, 4333 Edgewood Road, Cedar Rapids, Iowa If you send the Policy back to us within 30 days after you receive it, we will treat the Policy as if it had never been issued and return all of your payments. 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 Transamerica Premier Life Insurance Company nor its agents are connected with or endorsed by the United States government of the federal Medicare program. The accompanying outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for details. COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new Policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your Policy and refuse to pay any claims if you make a material misrepresentation.

11 TRANSAMERICA PREMIER LIFE INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS A, F, G AND N These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan A. Some plans may not be available in your state. See Outlines of Coverage sections for details about ALL plans. 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 insured s 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, including 100% Par t B Co-insurance Basic, Including 100% Part B Co-insurance Part A Deductible Basic, including 100% Part B Co-insurance Skilled Nursing Facility Co-insurance Part A Deductible Part B Deductible Foreign Travel Emergency Basic, including 100% Part B Co-insurance Skilled Nursing Facility Co-insurance Part A Deductible Foreign Travel Emergency Basic, including 100% Part B Co-insurance Skilled Nursing Facility Co-insurance Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency Basic, including 100% Part B Co-insurance Skilled Nursing Facility Co-insurance 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 Co-insurance 50% Part A Deductible Out-of-pocket limit $4,940; paid at 100% after limit reached Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% 75% Skilled Nursing Facility Co-insurance 75% Part A Deductible Out-of-pocket limit $2,470; paid at 100% after limit reached Basic, including 100% Part B Co-insurance Skilled Nursing Facility Co-insurance 50% Part A Deductible Foreign Travel Emergency Basic, including 100% Part B Co-insurance, except up to $20 co-payment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Co-insurance 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. Please note: High deductible Plan F is currently not available as part of this program. MSH1O REV TX

12 Transamerica Premier Life Insurance Company Administrative Office: 4333 Edgewood Rd. NE Cedar Rapids, Iowa PREMIUM INFORMATION We, Transamerica Premium Life Insurance Company, can only raise your premium if we raise the premium for all policies like yours in this state. However, because the premium rate is based upon your attained age, the premium will increase as you age from age 65 through age 95. This annual change will occur on each Policy Renewal Date. There will be a one-time enrollment fee of $25.00 added to the first premium. Your policy contains a refund of premium statement that in the event of cancellation or death, upon receipt of timely notification, we will promptly return the unearned portion of any premium paid. RIGHT TO RETURN POLICY If you find that you are not satisfied with your Policy, you may return it to Transamerica Premier Life Insurance Company, 4333 Edgewood Road, Cedar Rapids, Iowa If you send the Policy back to us within 30 days after you receive it, we will treat the Policy as if it had never been issued and return all of your payments. DISCLOSURES Use this outline to compare benefits and premiums among policies. 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. COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new Policy, be sure to answer truthfully and completely all questions about your medical and health history. The company 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 the insurance contract. You must read the Policy itself to understand all of the rights and duties of both you and Transamerica Premium Life Insurance Company. NOTICE This policy may not fully cover all of your medical costs. Neither Transamerica Premier Life Insurance Company nor its agents are connected with Medicare. MSH1O REV TX

13 EXCLUSIONS Coverage is not provided for any expenses which are not Medicare approved, we will not pay benefits for: (a) expense incurred while this policy is not in force, except as provided in the EXTENSION OF BENEFITS section; (b) expense incurred before your policy effective date; (c) that portion of any expense incurred which is paid for by Medicare; (d) any expense that duplicates payments made under any other provision of the policy; (e) services for non-medicare Eligible Expenses, including, but not limited to, routine exams, take-home drugs and eye refractions; (f) services for which a charge is not normally made in the absence of insurance; or (g) loss or expense that is payable under any other Medicare supplement insurance policy or certificate. (h) expenses which are not determined to be Medicare Eligible Expenses by the Federal Medicare Program or its administrators, except to the extent provided in the policy. Please also reference EXTENSION OF BENEFITS provision on page 6 of your policy. MSH1O REV TX

14 PLAN A MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD *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. Services Medicare Pays Plan A Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,260 $0 $1,260 (Part A Deductible) 61 st through 90 th day All but $315 a day $315 a day $0 91 st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare $0** Eligible Expenses Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21 st through 100 th day All but $ a day $0 Up to $ a day 101 st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance $0 **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare 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 Medicare would have paid. MSH1O REV TX

15 PLAN A MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $147 of Medicare Approved amounts for covered services (which are noted with an asterisk), your Medicare Part B Deductible will have been met for the calendar year. Services Medicare Pays Plan A Pays You Pay MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND 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 First $147 of Medicare Approved Amounts* $0 $0 $147 (Part B Deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 Part B Excess Charges (above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $147 of Medicare Approved Amounts* $0 $0 $147 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $147 of Medicare Approved Amounts* $0 $0 $147 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 MSH1O REV TX

16 PLANS F MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD *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. Services Medicare Pays Plan F Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,260 $1,260 (Part A Deductible) 61 st through 90 th day All but $315 a day $315 a day $0 91 st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare $0** Eligible Expenses Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21 st through100 th day All but $ a day Up to $ a day $0 101 st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance $0 $0 **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare 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 Medicare would have paid. MSH1O REV TX

17 PLANS F MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $147 of Medicare Approved Amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. Services Medicare Pays Plan F Pays You Pay MEDICAL EXPENSES---IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s services, inpatient and outpatient medical and surgical services physical and speech therapy, diagnostic tests, and durable medical equipment First $147 of Medicare Approved Amounts* $0 $147 (Part B Deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 Part B Excess Charges (above Medicare Approved Amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $147 of Medicare Approved Amounts* $0 $147 (Part B $0 Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES---TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A & B HOME HEALTH CARE---MEDICARE APPROVED SERVICES Medically necessary skilled care services an d medical supplies 100% $0 $0 $0 $0 Durable medical equipment First $147 of Medicare Approved Amounts* $0 $147 (Part B Deductible) $0 $0 $147 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 20% $0 OTHER BENEFITS - NOT COVERED BY MEDICARE FOREIGN TRAVEL---NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 $0 $250 Remainder of charges $0 80% to a lifetime Maximum Benefit of $50,000 20% and amounts over the $50,000 lifetime Maximum Benefit $0 80% to a lifetime Maximum Benefit of $50,000 20% and amounts over the $50,000 lifetime Maximum Benefit MSH1O REV TX

18 PLANS G MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD *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. Services Medicare Pays Plan G Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,260 $1,260 (Part A Deductible) 61 st through 90 th day All but $315 a day $315 a day $0 91 st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21 st through100 th day All but $ a day Up to $ a day $0 101 st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance $0 $0** $0 **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare 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 Medicare would have paid. MSH1O REV TX

19 PLANS G MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $147 of Medicare Approved Amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. Services Medicare Pays Plan G Pays You Pay MEDICAL EXPENSES---IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s services, inpatient and outpatient medical and surgical services physical and speech therapy, diagnostic tests, and durable medical equipment First $147 of Medicare Approved Amounts* $0 $0 $147 (Part B Deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 Part B Excess Charges (above Medicare Approved Amounts) BLOOD $0 100% $0 First 3 pints $0 All costs $0 Next $147 of Medicare Approved Amounts* $0 $0 $147 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES---TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A & B HOME HEALTH CARE---MEDICARE APPROVED SERVICES Medically necessary skilled care services an d medical supplies 100% $0 $0 $0 $0 Durable medical equipment First $147 of Medicare Approved Amounts* $0 $147 (Part B Deductible) $0 $0 $147 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 20% $0 OTHER BENEFITS - NOT COVERED BY MEDICARE FOREIGN TRAVEL---NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 $0 $250 Remainder of charges $0 80% to a lifetime Maximum Benefit of $50,000 20% and amounts over the $50,000 lifetime Maximum Benefit 80% to a lifetime Maximum Benefit of $50,000 20% and amounts over the $50,000 lifetime Maximum Benefit MSH1O REV TX

20 PLAN N MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD *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. Services Medicare Pays Plan N Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies All but $1,260 $1,260 (Part A Deductible) $0 First 60 days 61 st through 90 th days All but $315 a day $315 a day $0 91 st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days BLOOD All approved amounts $0 $0 21 st through 100 th day All but $ a day Up to $ a day $0 101 st day and after $0 $0 All costs First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited copayment/coinsuranc e for outpatient drugs and inpatient respite care Medicare copayment/coinsurance $0** $0 **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare 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 Medicare would have paid. MSH1O REV TX

21 PLAN N MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $147 of Medicare Approved Amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. Services Medicare Pays Plan N Pays You Pay MEDICAL EXPENSES---IN OR OUT OF THE HOSPITAL AND 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 First $147 of Medicare Approved Amounts* $0 $0 $147 (Part B Deductible) Remainder of Medicare Approved Amounts Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. Part B Excess Charges (above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $147 of Medicare Approved Amounts* $0 $0 $147 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES---TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A & B HOME HEALTH CARE---MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $147 of Medicare Approved Amounts* $0 $0 $147 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE FOREIGN TRAVEL---NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime Maximum Benefit of $50,000 20% and amounts over the $50,000 lifetime Maximum Benefit MSH1O REV TX

22 AGENT CHECKLIST FOR COMPLETING THE MEDICARE SUPPLEMENT APPLICATION This packet contains the following forms needed to complete a Medicare Supplement application. Please tear out the application and all pages marked RETURN TO COMPANY and leave the remaining pages with the applicant(s). Please review the following information carefully and complete all needed forms: Application for Medicare Supplement and Life Insurance Agent Certification This form must be signed by the agent and by the applicant(s) Calculate Your Premium This form is used to calculate the correct Medicare Supplement premium. Tobacco rates apply during Open Enrollment and Guaranteed Issue Periods. Express Issue Cover Sheet Fill out document completely and remit with application paperwork HIPAA Form Must be completed only if applying outside Open Enrollment or a Guaranteed Issue period for Medicare Supplement insurance. If a husband and wife are both applying for coverage on the same application then both must sign the form. Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage This form must be completed if any replacement of an existing Medicare Supplement policy is involved. One signed copy must be returned to the Administrative Office and the other signed copy must be left with the applicant(s) Medical Information Bureau Disclosure Notice, Conditional Receipt Must be left with the applicant(s) Please note, you are also required to provide the applicant(s) with the following items: Outline of Coverage 2015 Choosing a Medigap Policy booklet, published by the federal government Agents can get this document (and the supplement with the 2015 deductibles and co-pays) through the agent website or from Premiums and Policy Fee Utilize the Medicare Supplement Rate Sheet to determine Medicare Supplement premiums: Determine ZIP code where the client resides and find the correct rate page for that ZIP code Determine Plan Determine if non-tobacco or tobacco Find Age/Gender Verify that the age and date of birth are the exact age as of the effective date, this will be your base monthly premium Use the Calculate Your Premium form to adjust the monthly premium for different modes and to add the policy fee There will be a one-time Medicare Supplement application fee of $25.00 that must be collected with each applicant s initial payment. For a husband and wife written on the same application, $50 in fees must be collected. This will not affect the renewal premiums and the application fee doesn t apply in AR, MN, WA & WV. Mailing Address Transamerica Premier Life Insurance Company 4333 Edgewood Road NE Cedar Rapids, IA FAX Number for New Business:

23 CALCULATE YOUR PREMIUM TRANSAMERICA PREMIER MEDICARE SUPPLEMENT Medicare Supplement Plan Before you begin: If Applicant is not in the open enrollment or guarantee issue period, please see the height and weight chart on following page to determine eligibility for coverage. Example Rate displayed is used for Applicant s Applicant B s Steps calculation purposes only. premium premium Premium Write in Medicare Supplement Plan s premium $ from the Outline of Coverage table. Risk Class Adjustment Refer to the Height/Weight Chart in order to $ x 1.0 = $ determine risk class adjustment factor. Multiply rate by applicable factor below: Standard = 1.0 Tier 1 = 1.1 Tier 2 = 1.2 Payment Options To determine other payment schedules, $ Monthly payment multiply monthly premium by: 3 to pay four times a year (quarterly) $ Quarterly payment 6 to pay twice a year (semi-annually) $ Semi-annual payment 12 to pay once a year (annually) $1, Annual payment Enrollment/Policy fee There is a one-time application fee of $25.00 $ $25.00 = $ (Not Applicable in AR, MN, WA & WV) This will be collected with initial payment and will NOT affect renewal premium. Example shows initial payment (monthly schedule)

24 HEIGHT AND WEIGHT CHART Eligibility (If Applicant is not in open enrollment or guarantee issue period) To determine whether Applicant is eligible to purchase coverage, locate height, then weight in the chart below. If weight is in the Decline column, Applicant is not eligible for coverage at this time. If an applicant s weight is in the decline column our guideline is that they would need to lose weight and have their weight stabilize for a period of 6 months to 1 year before we could reconsider them. Rate Adjustment: The column heading above weight will indicate appropriate rate adjustment, if any (risk class). Decline Tier 1 (10%) Standard Tier 1 (10%) Tier 2 (20%) Decline Height Weight Weight Weight Weight Weight Weight 4 5 < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < Medicare Supplement insurance is underwritten by Transamerica Premier Life Insurance Company. Home office: Cedar Rapids, IA For agent use only. Not for public distribution.

25 Transamerica Premier Life Insurance Company Home Office: 4333 Edgewood Road NE, Cedar Rapids, IA Medicare Supplement A. Please answer all questions completely. ONLY complete the Applicant B information if a second individual is applying for coverage. APPLICANT A 1. Name (First,MI,Last) APPLICANT B 1. Name (First,MI,Last) 2. Residence Address (Cannot be a P.O. Box) 2. Residence Address (Cannot be a P.O. Box) 3. City 3. City 4. State Zip 4. State Zip 5. Mailing Address (If different from residence address) 5. Mailing Address (If different from residence address) 6. City 6. City 7. State Zip 7. State Zip 8. Phone Number ( ) 9. Best time to call for a Personal History Interview a.m. p.m. 10. Current Age Date of Birth (MM/DD/YYYY) 8. Phone Number ( ) 9. Best time to call for a Personal History Interview a.m. p.m. 10. Current Age Date of Birth (MM/DD/YYYY) 11. Male U.S. State/Country of Birth Female 12. Social Security Number 11. Male U.S. State/Country of Birth Female 12. Social Security Number 13. Medicare Health Insurance Card Number 13. Medicare Health Insurance Card Number 14. Occupation 14. Occupation 15. Address 15. Address 16. Height Ft. In. Weight Lbs. 16. Height Ft. In. Weight Lbs. 17. Have you used tobacco in any form in the past 12 months? Yes No 18. Secondary Addressee: A secondary addressee may be named who will receive copies of premium notices and letters regarding possible lapse in coverage. Name (First, MI, Last) 17. Have you used tobacco in any form in the past 12 months? Yes No 18. Secondary Addressee: A secondary addressee may be named who will receive copies of premium notices and letters regarding possible lapse in coverage. Name (First, MI, Last) Address Address City, State, Zip City, State, Zip Phone Number Phone Number H 0714 TX 1

26 B. Plan Information (to be completed by Agent) APPLICANT A 1. Medicare Supplement Plan 2. Requested Effective Date 3. Mail Policy To: Owner Agent 4. Have you ever been declined or denied reinstatement for Medicare Supplement? Yes No If "YES," when and why? APPLICANT B 1. Medicare Supplement Plan 2. Requested Effective Date 3. Mail Policy To: Owner Agent 4. Have you ever been declined or denied reinstatement for Medicare Supplement? Yes No If "YES," when and why? C. Premium & Payment Method (must be completed) 1. Medicare Supplement Premium $ 2. Medicare Supplement One-Time Application Fee $ 3. Total Initial Premium $ Mode of Payment: EFT Direct Bill Annual Semiannual Quarterly Monthly (EFT Only) D. Please answer all of the following questions. 1. Have you received a copy of the Guide to Health Insurance for People with Medicare and the Outline of Coverage? 2. Are you eligible for Medicare due to disability? If "YES," are you disabled due to End Stage Renal Disease? To the Best of Your Knowledge: 3. Are you covered under Medicare Part A? If "YES," what is your Part A effective date? Applicant A 1. Medicare Supplement Premium $ 2. Medicare Supplement One-Time Application Fee $ 3. Total Initial Premium $ Applicant B Mode of Payment: EFT Direct Bill Annual Semiannual Quarterly Monthly (EFT Only) APPLICANT A APPLICANT B If "NO," what is your eligibility date? 4. Are you covered under Medicare Part B? If "YES," what is your Part B effective date? Applicant A Applicant A Applicant B Applicant B If "NO," indicate date you plan to enroll. Applicant A Applicant B 5. Are you applying during a guaranteed issue or open enrollment period? (NOTE: If the answer above is "YES," please attach proof of eligibility and DO NOT complete section F.) E. FOR YOUR PROTECTION, the National Association of Insurance Commissioners requests that we ask the following questions about insurance policies or certificates you may have. If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare Supplement insurance policy or certificate, or that you had certain rights to buy such a policy or certificate, you may be guaranteed acceptance in one or more of our Medicare Supplement plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS BELOW. Please mark "YES" or "NO" with an "X" to the questions below. To the Best of Your Knowledge: 1. Did you turn age 65 in the last six months? 2. Did you enroll in Medicare Part B in the last six months? If "YES," indicate your effective date. / Applicant A Applicant B 3. Are you covered for medical assistance through the state Medicaid program? (NOTE TO APPLICANT: If you are participating in a Spend-Down Program and have not met your Share of Cost, please answer NO to this question.) If "YES," a. Will Medicaid pay your premiums for this Medicare supplement policy? b. Do you receive any benefits from Medicaid OTHER THAN payment toward your Medicare Part B premium? H 0714 TX 2 APPLICANT A APPLICANT B

27 If you have had any other Medicare plan coverage as referenced below, not to include Medicare supplement, please complete questions (a-g) below. If not, skip to question #5. 4. If you had coverage from any Medicare plan other than original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates below. If you are still covered under this plan, leave END blank. START END / START END Applicant A Applicant B a. If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplement policy? b. If "YES," have you received a copy of the replacement notice? c. Reason for termination/disenrollment? / Applicant A Applicant B d. Planned date of termination/disenrollment? / Applicant A Applicant B e. Was this your first time in this type of Medicare plan? f. Did you drop a Medicare Supplement or Medicare Select policy/certificate to enroll in this Medicare plan? g. Is your former Medicare Supplement or Medicare Select policy/certificate still available? 5. Do you have another Medicare Supplement or Medicare Select policy/certificate in force? a. If "YES," with what company, and what plan do you have? APPLICANT A Name of Company APPLICANT B Name of Company APPLICANT A APPLICANT B Policy/Certificate Number Policy/Certificate Number Plan Plan Issue Date (MM/DD/YYYY) Issue Date (MM/DD/YYYY) b. If "YES," do you intend to replace your current Medicare Supplement policy/certificate with this policy? c. If "YES," indicate termination date. / Applicant A Applicant B d. If "YES," have you received a copy of the replacement notice? 6. Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union or individual non-medicare Supplement plan) a. If "YES," with what company and what kind of policy/certificate? (List below) APPLICANT A Name of Company Kind of Policy/Certificate APPLICANT B Name of Company APPLICANT A APPLICANT B Kind of Policy/Certificate b. What are your dates of coverage under the other policy/certificate? (If you are still covered under this plan, leave END blank.) START END / START END Applicant A Applicant B c. Reason for termination/disenrollment? / Applicant A Applicant B d. Planned date of termination/disenrollment? / Applicant A Applicant B H 0714 TX 3