MUTUAL OF OMAHA INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS A, F, AND G 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: coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses: coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of coinsurance or copayments. Blood: First 3 pints of blood each year. Hospice: coinsurance. Plan A Plan B Plan C Plan D Plan F F* Plan G Plan K Plan L Plan M Plan N Basic, Basic, Basic, Basic, Basic, Basic, Hospitalization and Hospitalization Basic, including 100% 100% 100% 100% 100% paid at 100%; other care paid at 100% Part including including including including including preventive care and preventive including 100% Coinsurancinsurancinsurancinsurance * insurance at 50% benefits paid at insurance Co- Co- Co- Co- basic benefits paid 100%; other basic B Co- Co- 75% insur- ance Facility Coinsurance Travel Facility Coinsurance Travel Facility Coinsurance Excess (100%) Travel Facility Coinsurance Excess (100%) Travel 50% Facility Coinsurance 50% Out-of-pocket limit $4,800; paid at 100% after limit reached 75% Facility Coinsurance 75% Out-of-pocket limit $2,400; paid at 100% after limit reached Facility Coinsurance 50% Travel Basic, including 100% Coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Facility Coinsurance Travel *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 $2,110 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,110. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy/certificate. These expenses include the Medicare deductibles for and, but do not include the plan's separate foreign travel emergency deductible. CP12 1 M27009_TN_0313
RP12.2.A-TN MONTHLY NON-TOBACCO PREMIUMS* ZIP CODES: 370-385 These premiums are used when applying during an Open Enrollment or Guaranteed Issue Period FEMALE MALE Plan A Plan F Plan G Attained Plan A Plan F Plan G MM20 MM24 MM25 Age MM20 MM24 MM25 334.51 484.79 397.53 Thru 64 369.32 535.24 438.90 91.40 132.46 108.62 65 100.90 146.24 119.92 91.40 132.46 108.62 66 100.90 146.24 119.92 91.40 132.46 108.62 67 100.90 146.24 119.92 94.79 137.39 112.66 68 104.67 151.69 124.39 98.21 142.32 116.71 69 108.42 157.14 128.85 101.62 147.27 120.75 70 112.19 162.60 133.33 105.02 152.20 124.80 71 115.94 168.04 137.79 108.42 157.14 128.85 72 119.71 173.50 142.27 112.52 163.06 133.71 73 124.22 180.03 147.63 116.61 168.99 138.56 74 128.73 186.57 152.99 120.69 174.91 143.43 75 133.25 193.11 158.35 124.77 180.83 148.28 76 137.76 199.66 163.72 128.86 186.76 153.14 77 142.28 206.19 169.08 132.95 192.68 158.00 78 146.78 212.74 174.44 137.04 198.61 162.86 79 151.30 219.27 179.81 141.13 204.52 167.71 80 155.81 225.81 185.17 145.21 210.44 172.56 81 160.33 232.35 190.54 149.30 216.37 177.42 82 164.84 238.90 195.90 153.38 222.29 182.28 83 169.36 245.43 201.26 157.47 228.22 187.15 84 173.86 251.97 206.62 160.62 232.79 190.89 85 177.34 257.01 210.75 163.83 237.44 194.70 86 180.89 262.15 214.96 167.11 242.19 198.59 87 184.51 267.39 219.26 170.45 247.03 202.57 88 188.20 272.74 223.65 173.86 251.97 206.62 89 191.96 278.20 228.12 176.46 255.75 209.72 90 194.83 282.37 231.55 179.11 259.59 212.86 91 197.76 286.61 235.03 181.80 263.48 216.05 92 200.72 290.90 238.54 184.53 267.44 219.29 93 203.73 295.27 242.12 187.30 271.45 222.58 94 206.78 299.70 245.76 190.10 275.52 225.92 95 209.89 304.20 249.44 192.95 279.65 229.32 96 213.05 308.76 253.18 195.85 283.85 232.75 97 216.24 313.39 256.98 198.79 288.10 236.24 98 219.48 318.09 260.84 201.77 292.42 239.78 99+ 222.77 322.86 264.74 *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating. Only individuals who are Disabled or have End Stage Renal Disease are eligible for coverage under the age of 65. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. 2 M27009_TN_0313
RP12.2.A-TN MONTHLY TOBACCO PREMIUMS* ZIP CODES: 370-385 FEMALE MALE Plan A Plan F Plan G Attained Plan A Plan F Plan G MM20 MM24 MM25 Age MM20 MM24 MM25 361.63 524.10 429.76 Thru 64 399.27 578.64 474.48 98.81 143.20 117.42 65 109.08 158.10 129.64 98.81 143.20 117.42 66 109.08 158.10 129.64 98.81 143.20 117.42 67 109.08 158.10 129.64 102.48 148.53 121.79 68 113.16 163.99 134.48 106.17 153.86 126.17 69 117.21 169.88 139.30 109.86 159.21 130.54 70 121.29 175.78 144.14 113.53 164.54 134.92 71 125.35 181.67 148.97 117.21 169.88 139.30 72 129.42 187.56 153.80 121.64 176.28 144.55 73 134.29 194.63 159.60 126.06 182.69 149.80 74 139.17 201.70 165.40 130.48 189.09 155.06 75 144.05 208.77 171.19 134.89 195.49 160.31 76 148.93 215.85 177.00 139.31 201.90 165.56 77 153.81 222.91 182.79 143.73 208.30 170.81 78 158.68 229.98 188.59 148.15 214.71 176.06 79 163.57 237.05 194.38 152.57 221.11 181.31 80 168.45 244.12 200.18 156.98 227.51 186.56 81 173.33 251.19 205.99 161.41 233.92 191.81 82 178.21 258.27 211.78 165.82 240.32 197.06 83 183.09 265.33 217.58 170.23 246.73 202.32 84 187.96 272.40 223.37 173.65 251.66 206.37 85 191.72 277.85 227.84 177.11 256.69 210.49 86 195.55 283.41 232.39 180.66 261.83 214.70 87 199.47 289.07 237.04 184.27 267.06 219.00 88 203.46 294.86 241.79 187.96 272.40 223.37 89 207.52 300.75 246.62 190.77 276.49 226.72 90 210.63 305.26 250.32 193.64 280.64 230.12 91 213.80 309.85 254.08 196.54 284.84 233.57 92 217.00 314.49 257.88 199.49 289.12 237.07 93 220.25 319.21 261.75 202.48 293.45 240.63 94 223.55 324.00 265.68 205.51 297.86 244.24 95 226.91 328.86 269.67 208.60 302.32 247.91 96 230.32 333.79 273.71 211.73 306.86 251.62 97 233.77 338.80 277.81 214.91 311.46 255.39 98 237.28 343.88 281.99 218.13 316.13 259.22 99+ 240.83 349.04 286.21 *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating. Only individuals who are Disabled or have End Stage Renal Disease are eligible for coverage under the age of 65. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. 3 M27009_TN_0313
Disclosures Use this outline to compare benefits and premiums among policies. Premium Information We, Mutual of Omaha, can only raise your premium if we raise the premium for all policies like yours in the same geographic area of the state where you live. Until you are age 99, your premium may change each year. This change will only be made on the first renewal date that coincides with or follows each anniversary of the policy date. Schedules of rates may vary depending upon your policy date. Risk Class Rating If, according to our underwriting standards, you are overweight or underweight for your height, you will be considered to be a greater insurable risk. In such a case, your premium will be priced either as Class I - 10% or Class II - 20% higher than the rates illustrated, based on your Body Mass Index (BMI) reading. Risk class rating will not be applicable when you apply for coverage during an open-enrollment or guaranteed-issue period. Household Premium Discount If you resided with at least one, but no more than three, other Medicare-eligible adults for the past year, or you are married, and at least one of those other adults or your spouse also owns or is issued a Medicare supplement policy underwritten by Mutual of Omaha or its affiliates, you will be eligible for a household premium discount. The discounted premium will be priced 7% lower than the rates illustrated. Your policy's household premium discount will be removed if your spouse or the other Medicare supplement policyholder chooses to terminate his or her Medicare supplement policy or he or she no longer resides with you (other than in the case of his or her death). 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 us. Right to Return Policy If you find that you are not satisfied with your policy, you may return it to us at Mutual of Omaha Plaza, Omaha, NE 68175. 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 The policy may not fully cover all of your medical costs. Neither we nor our agents are connected with Medicare. This outline does not give all the details of Medicare coverage. Contact your local Social Security office or consult "Medicare & You" 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. We may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded. DP1A99 4 M27009_TN_0313
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 $1,184 $0 $1,184 ( 61 st through 90 th day All but $296 a day $296 a day $0 91 st day and after: While using 60 lifetime reserve days All but $592 a day $592 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicareeligible $0** 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 $148 a day $0 Up to $148 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 **NOTICE: When your Medicare hospital benefits are exhausted, we stand in the place of Medicare and will pay whatever amount Medicare would have paid up to an additional 365 days as provided in the policy's/certificate'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. $0 5 M27009_TN_0313
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 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 ( Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 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 ( Remainder of Medicare-approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A AND 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 ( Remainder of Medicare-approved amounts 80% 20% $0 6 M27009_TN_0313
PLANS F AND 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 F Pays You Pay Plan G Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,184 $1,184 ( $0 $1,184 ( $0 61 st through 90 th day All but $296 a day $296 a day $0 $296 a day $0 91 st day and after: While using 60 lifetime reserve days All but $592 a day $592 a day $0 $592 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicareeligible expenses $0** 100% of Medicareeligible $0** expenses Beyond the additional 365 days $0 $0 All costs $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 $0 $0 21 st through 100 th day All but $148 a day Up to $148 a day $0 Up to $148 a day $0 101 st day and after $0 $0 All costs $0 All costs BLOOD First 3 pints $0 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 $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 Medicare copayment/ coinsurance **NOTICE: When your Medicare hospital benefits are exhausted, we stand in the place of Medicare and will pay whatever amount Medicare would have paid up to an additional 365 days as provided in the policy's/certificate'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. $0 7 M27009_TN_0313
PLANS F AND 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 deductible will have been met for the calendar year. Services Medicare Pays Plan F Pays You Pay 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 and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $147 of Medicare-approved amounts* $0 $147 ( $0 $0 $147 ( Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Generally 20% $0 Excess Charges (above Medicare-approved amounts) $0 100% $0 100% $0 BLOOD First 3 pints $0 All costs $0 All costs $0 Next $147 of Medicare-approved amounts* $0 $147 ( $0 $0 $147 ( Remainder of Medicare-approved amounts 80% 20% $0 20% $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 $0 $0 PARTS A AND B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 $0 $0 Durable medical equipment First $147 of Medicare-approved amounts* $0 $147 ( $0 $0 $147 ( Remainder of Medicare-approved amounts 80% 20% $0 20% $0 8 M27009_TN_0313
PLANS F AND G MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR OTHER BENEFITS NOT COVERED BY MEDICARE Services Medicare Pays Plan F Pays You Pay Plan G Pays You Pay 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 9 M27009_TN_0313