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

Transcription

1 Outline of Medicare Supplement Coverage Benefit Chart of Medicare Supplement Plans Sold On or After June 1, 2015 This chart shows the benefits included in each of the standard Medicare Supplement plans. Every company must make Plan A available. Some plans may not be available in your state. BASIC BENEFITS: Hospitalization Part A plus coverage for 365 additional days after Medicare benefits end. Medical Expenses Part B (generally 20% of Medicare-approved expenses), or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B or copayments. Blood First three pints of blood each year. Hospice Part A. New West offers Plans A, C, D, F, High Deductible F, and N. (Gray-shaded plans are not offered.) A B C D F F* G Basic, including 100% Part B Basic, including 100% Part B Part A Deductible Basic, including 100% Part B Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Coinsurance Part A Deductible Part B Excess (100%) Foreign Travel Emergency *Plan F also has an option called a high deductible Plan F ($2,180). 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. Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility Coinsurance K L M N Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% 75% Skilled Nursing Facility Coinsurance Basic, including 100% Part B Skilled Nursing Facility Coinsurance Basic, including 100% Part B, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Coinsurance 50% Part A Deductible 75% Part A Deductible 50% Part A Deductible Part A Deductible Foreign Travel Foreign Travel Emergency Emergency Out-of-pocket limit $4,660; paid at 100% after limit reached Out-of-pocket limit $2,330; paid at 100% after limit reached MSUP-ACDFF*N /2015 1

2 PREMIUM INFORMATION New West Health Services can only raise your premium if we raise the premium for all policies like yours in this state. Your premium rates will change automatically each year according to your age on the policy renewal date. Current monthly premium are shown. Premiums for other payment frequencies (semi-annual and annual) are obtained by multiplying the stated premium by the number of months paid. Attained Age: NON-TOBACCO MONTHLY PREMIUM RATES PER PERSON Plan A Plan C Plan D Plan F Plan F* Plan N Under 65 $281 $391 $331 $392 $179 $ $95 $131 $111 $131 $60 $ $98 $137 $117 $137 $62 $ $102 $141 $121 $142 $64 $ $105 $146 $126 $147 $67 $ $109 $151 $131 $152 $69 $ $113 $158 $138 $158 $71 $ $118 $163 $144 $164 $75 $ $122 $169 $150 $170 $78 $ $126 $176 $156 $176 $81 $ $130 $183 $163 $183 $83 $ $133 $189 $170 $190 $86 $ $137 $195 $176 $196 $89 $ $140 $203 $184 $204 $92 $ $142 $210 $190 $210 $96 $ $144 $216 $197 $217 $99 $ $145 $224 $204 $224 $102 $194 Attained TOBACCO MONTHLY PREMIUM RATES PER PERSON Age: Plan A Plan C Plan D Plan F Plan F* Plan N Under 65 $332 $461 $391 $462 $210 $ $111 $155 $131 $155 $70 $ $116 $161 $137 $161 $74 $ $120 $166 $143 $167 $76 $ $124 $172 $149 $173 $79 $ $129 $179 $155 $180 $82 $ $133 $186 $162 $186 $85 $ $139 $192 $169 $193 $88 $ $144 $200 $176 $201 $91 $ $149 $208 $185 $208 $95 $ $153 $215 $192 $216 $99 $ $158 $223 $201 $224 $102 $ $162 $231 $209 $232 $105 $ $165 $239 $216 $239 $109 $ $168 $247 $225 $248 $112 $ $170 $255 $233 $256 $117 $ $171 $264 $240 $265 $121 $230 MSUP-ACDFF*N /2015 2

3 DISCLOSURES Use this outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY This is only an outline describing your policy s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to New West Health Services, PO Box 668, Kalispell MT 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 New West Health Services nor its agents are connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security office or consult The Medicare Handbook" for more 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 leave out or falsify important medical information. Review the application before you sign it. Be certain that all information has been properly recorded. MAY I REQUEST A REVIEW OF CLAIMS? If a person covered or claiming coverage or benefits from New West Health Services has a dispute or disagreement of any nature with us, please contact our Customer Service at (TTY 711). MSUP-ACDFF*N /2015 3

4 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. HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,260 $1,260 (Part A 61st through 90th day All but $315 per day $315 per day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days Beyond the additional 365 days All but $630 per day $630 per day 100% of Medicare eligible expenses ** All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including being in a hospital for at least 3 days and entering a Medicare-approved facility within 30 days after leaving the hospital. First 20 days All approved 21st through 100th day All but $ a day Up to $ a day 101st day & after All costs First 3 pints 3 pints Additional 100% HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare co-payment/ ** 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. 4

5 Plan A MEDICARE (PART B) MEDICAL SERVICES Per Calendar Year* * Once you have been billed $147 of Medicare-approved for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. 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, and durable medical equipment First $147 of Medicare approved Part B Excess Charges (above Medicare approved ) $147 (Part B Generally 80% Generally 20% All costs First 3 pints All costs Next $147 of Medicare approved CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES $147 (Part B 80% 20% 100% PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment 100% First $147 of Medicare approved $147 (Part B deductible) 80% 20% 5

6 Plan C 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. HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,260 $1,260 (Part A 61st through 90th day All but $315 per day $315 per day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days Beyond the additional 365 days All but $630 per day $630 per day 100% of Medicare eligible expenses ** All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including being in a hospital for at least 3 days and entering a Medicare-approved facility within 30 days after leaving the hospital. First 20 days All approved 21st through 100th day All but $ a day Up to $ a day 101st day & after All costs First 3 pints 3 pints Additional 100% HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare co-payment/ ** 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. 6

7 Plan C MEDICARE (PART B) MEDICAL SERVICES Per Calendar Year* * Once you have been billed $147 of Medicare-approved for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. 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, and durable medical equipment First $147 of Medicare approved Part B Excess Charges (above Medicare approved ) $147 (Part B Generally 80% Generally 20% All costs First 3 pints All costs Next $147 of Medicare approved CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES $147 (Part B 80% 20% 100% PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment 100% First $147 of Medicare approved $147 (Part B deductible) 80% 20% 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 $250 Remainder of Charges 80% to a lifetime maximum benefit of $50,000 20% and over the $50,000 lifetime maximum 7

8 Plan D 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. HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,260 $1,260 (Part A 61st through 90th day All but $315 per day $315 per day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days Beyond the additional 365 days All but $630 per day $630 per day 100% of Medicare eligible expenses ** All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including being in a hospital for at least 3 days and entering a Medicare-approved facility within 30 days after leaving the hospital. First 20 days All approved 21st through 100th day All but $ a day Up to $ a day 101st day & after All costs First 3 pints 3 pints Additional 100% HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare co-payment/ ** 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. 8

9 Plan D MEDICARE (PART B) MEDICAL SERVICES Per Calendar Year* * Once you have been billed $147 of Medicare-approved for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. 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, and durable medical equipment First $147 of Medicare approved Part B Excess Charges (above Medicare approved ) $147 (Part B Generally 80% Generally 20% All costs First 3 pints All costs Next $147 of Medicare approved CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES $147 (Part B 80% 20% 100% PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment 100% First $147 of Medicare approved $147 (Part B deductible) 80% 20% 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 $250 Remainder of Charges 80% to a lifetime maximum benefit of $50,000 20% and over the $50,000 lifetime maximum 9

10 Plan 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. HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,260 $1,260 (Part A 61st through 90th day All but $315 per day $315 per day 91st day and after: While using 60 lifetime reserve days All but $630 per day $630 per day Once lifetime reserve days are used: 100% of Medicare eligible expenses ** Additional 365 days Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including being in a hospital for at least 3 days and entering a Medicare-approved facility within 30 days after leaving the hospital. First 20 days All approved 21st through 100th day All but $ a day Up to $ a day 101st day & after All costs First 3 pints 3 pints Additional 100% HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare co-payment/ ** 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. 10

11 Plan F MEDICARE (PART B) MEDICAL SERVICES Per Calendar Year* * Once you have been billed $147 of Medicare-approved for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. 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, and durable medical equipment First $147 of Medicare approved Part B Excess Charges (above Medicare approved ) $147 (Part B Generally 80% Generally 20% 100% First 3 pints All costs Next $147 of Medicare approved CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES $147 (Part B 80% 20% 100% PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment 100% First $147 of Medicare approved $147 (Part B deductible) 80% 20% 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 $250 Remainder of Charges 80% to a lifetime maximum benefit of $50,000 20% and over the $50,000 lifetime maximum 11

12 Plan 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 After you pay $2,180 deductible*, Plan Pays In addition to $2,180 deductible*, You Pay HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,260 $1,260 (Part A 61st through 90th day All but $315 per day $315 per day 91st day and after: While using 60 lifetime reserve days All but $630 per day $630 per day Once lifetime reserve days are used: 100% of Medicare eligible expenses ** Additional 365 days Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including being in a hospital for at least 3 days and entering a Medicare-approved facility within 30 days after leaving the hospital. First 20 days All approved 21st through 100th day All but $ a day Up to $ a day 101st day & after All costs First 3 pints 3 pints Additional 100% HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare co-payment/ ** 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. 12

13 Plan F* MEDICARE (PART A) HOSPITAL SERVICES Per Benefit Period* * Once you have been billed $147 of Medicare-approved for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES Medicare Pays After you pay $2,180 deductible*, Plan Pays In addition to $2,180 deductible*, 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, and durable medical equipment First $147 of Medicare approved Part B Excess Charges (above Medicare approved ) $147 (Part B Generally 80% Generally 20% 100% First 3 pints All costs Next $147 of Medicare approved CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES $147 (Part B 80% 20% 100% PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment 100% First $147 of Medicare approved $147 (Part B deductible) 80% 20% 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 $250 Remainder of Charges 80% to a lifetime maximum benefit of $50,000 20% and over the $50,000 lifetime maximum 13

14 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. HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,260 $1,260 (Part A 61st through 90th day All but $315 per day $315 per day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days Beyond the additional 365 days All but $630 per day $630 per day 100% of Medicare eligible expenses ** All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including being in a hospital for at least 3 days and entering a Medicare-approved facility within 30 days after leaving the hospital. First 20 days All approved 21st through 100th day All but $ a day Up to $ a day 101st day & after All costs First 3 pints 3 pints Additional 100% HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare co-payment/ ** 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. 14

15 Plan N MEDICARE (PART B) MEDICAL SERVICES Per Calendar Year* * Once you have been billed $147 of Medicare-approved for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. 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, and durable medical equipment First $147 of Medicare approved Remainder of Medicare approved Part B Excess Charges (above Medicare approved ) $147 (Part B Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The co-payment 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. All costs Up to $20 per office visit and up to $50 per emergency room visit. The co-payment 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. First 3 pints All costs Next $147 of Medicare $147 (Part B approved Remainder of Medicare 80% 20% approved CLINICAL LABORATORY 100% SERVICES TESTS FOR DIAGNOSTIC SERVICES PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment 100% First $147 of Medicare $147 (Part B deductible) approved Remainder of Medicare 80% 20% approved 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 $250 Remainder of Charges 80% to a lifetime maximum benefit of $50,000 20% and over the $50,000 lifetime maximum 15