United of Omaha Life Insurance Company A Mutual of Omaha Company OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS A, C, F, HIGH DEDUCTIBLE F, G, M AND N This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan A available. Some plans may not be available in your state. Basic Benefits: Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or copayments. Blood: First 3 pints of blood each year. Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan F F* Plan G Plan K Plan L Plan M Plan N Basic, including Basic, including Basic, including Basic, including Basic, including Basic, including Hospitalization and preventive care paid Hospitalization and preventive care paid Basic, including 100% Part B Coinsurance 100% Part B 100% Part B 100% Part B 100% Part B 100% Part B 100% Part B at 100%; other basic at 100%; other basic Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance* Coinsurance benefits paid at 50% benefits paid at 75% Part A Deductible Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Foreign Travel Emergency Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency Skilled Skilled Nursing Nursing Facility Coinsurancinsurance Facility Co- Part A Part A Deductible Deductible Part B Deductible Part B Excess Part B Excess (100%) Foreign Travel Emergency (100%) Foreign Travel Emergency 50% Skilled Nursing Facility Coinsurance 50% Part A Deductible Out-of-pocket limit $4,960; paid at 100% after limit reached 75% Skilled Nursing Facility Coinsurance 75% Part A Deductible Out-of-pocket limit $2,480; paid at 100% after limit reached Skilled Nursing Facility Coinsurance 50% Part A Deductible Foreign Travel Emergency Basic, including 100% Part B Coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency *Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy/certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible. 1 NJ_UOO_AGY_070116
Plan A UM20 Plan C UM21 Plan F UM23 MONTHLY NON-TOBACCO PREMIUMS* ZIP CODES: 070-089 These premiums are used when applying during an Open Enrollment or Guaranteed Issue Period FEMALE MALE Plan High Plan G Plan M Plan N Attained Plan A Plan C Plan F Plan High F UM24 UM30 UM35 Age UM20 UM21 UM23 F UM34 UM34 202.59 50-64 210.80 151.40 202.59 178.91 53.55 144.96 160.06 113.10 65 157.54 210.80 186.16 55.73 150.84 166.54 117.68 151.40 202.59 178.91 53.55 144.96 160.06 113.10 66 157.54 210.80 186.16 55.73 150.84 166.54 117.68 157.30 210.50 185.89 53.55 150.61 166.30 113.10 67 165.44 221.38 195.49 55.73 158.39 174.90 117.68 163.46 218.73 193.16 55.19 156.51 172.81 116.55 68 173.75 232.51 205.32 57.43 166.37 183.69 121.28 169.85 227.30 200.71 57.00 162.64 179.57 120.36 69 182.53 244.23 215.67 59.31 174.75 192.95 125.25 176.15 235.71 208.15 58.81 168.64 186.21 124.18 70 191.35 256.05 226.13 61.19 183.22 202.30 129.21 183.23 245.19 216.51 60.77 175.43 193.70 128.32 71 201.24 269.28 237.80 63.23 192.68 212.75 133.53 190.49 254.90 225.08 62.73 182.38 201.37 132.48 72 211.59 283.11 250.00 65.27 202.57 223.67 137.85 197.81 264.69 233.75 64.87 189.39 209.11 136.99 73 222.20 297.34 262.59 67.50 212.75 234.91 142.54 205.20 274.58 242.47 67.00 196.44 216.92 141.49 74 233.16 311.98 275.51 69.71 223.23 246.48 147.22 212.23 283.99 250.78 69.30 203.19 224.35 146.34 75 243.93 326.45 288.27 72.11 233.57 257.90 152.27 221.16 295.95 261.34 71.59 211.74 233.79 151.18 76 257.18 344.13 303.88 74.49 246.22 271.86 157.31 228.87 306.27 270.45 74.05 219.14 241.97 156.37 77 266.19 356.22 314.55 77.05 254.87 281.42 162.72 236.80 316.87 279.81 76.50 226.72 250.35 161.57 78 275.39 368.50 325.41 79.62 263.66 291.13 168.12 245.29 328.23 289.86 79.13 234.85 259.31 167.11 79 285.23 381.71 337.07 82.34 273.11 301.57 173.89 253.79 339.60 299.90 81.76 242.98 268.30 172.65 80 295.15 394.95 348.77 85.07 282.58 312.03 179.65 264.34 353.72 312.35 84.54 253.08 279.43 178.54 81 303.83 406.58 359.03 87.97 290.90 321.21 185.78 275.00 367.98 324.96 87.33 263.30 290.73 184.41 82 312.46 418.11 369.22 90.87 299.16 330.33 191.89 285.74 382.37 337.66 90.28 273.59 302.08 190.65 83 320.98 429.52 379.30 93.94 307.33 339.34 198.38 296.60 396.90 350.49 93.24 283.98 313.56 196.88 84 329.43 440.83 389.29 97.01 315.42 348.27 204.87 307.53 411.52 363.41 96.51 294.45 325.11 203.82 85 337.79 452.00 399.15 100.43 323.41 357.09 212.08 318.49 426.19 376.35 99.96 304.94 336.71 211.08 86 345.99 462.98 408.84 104.01 331.26 365.77 219.64 329.52 440.94 389.37 103.57 315.49 348.35 218.71 87 354.06 473.79 418.39 107.77 338.99 374.31 227.58 340.51 455.65 402.38 107.17 326.02 359.97 226.32 88 361.91 484.31 427.66 111.52 346.52 382.63 235.51 351.47 470.31 415.32 110.93 336.52 371.57 234.28 89 369.62 494.59 436.77 115.44 353.87 390.75 243.77 362.32 484.82 428.13 114.71 346.89 383.02 242.25 90 377.00 504.51 445.50 119.37 360.97 398.58 252.07 362.32 484.82 428.13 118.65 346.89 383.02 250.56 91 377.00 504.51 445.50 123.46 360.97 398.58 260.72 362.32 484.82 428.13 122.59 346.89 383.02 258.87 92 377.00 504.51 445.50 127.56 360.97 398.58 269.37 362.32 484.82 428.13 126.68 346.89 383.02 267.53 93 377.00 504.51 445.50 131.82 360.97 398.58 278.38 362.32 484.82 428.13 130.78 346.89 383.02 276.18 94 377.00 504.51 445.50 136.09 360.97 398.58 287.39 362.32 484.82 428.13 134.88 346.89 383.02 284.84 95 377.00 504.51 445.50 140.35 360.97 398.58 296.39 362.32 484.82 428.13 139.14 346.89 383.02 293.84 96 377.00 504.51 445.50 144.79 360.97 398.58 305.75 362.32 484.82 428.13 143.40 346.89 383.02 302.84 97 377.00 504.51 445.50 149.23 360.97 398.58 315.13 362.32 484.82 428.13 147.67 346.89 383.02 311.85 98 377.00 504.51 445.50 153.67 360.97 398.58 324.50 362.32 484.82 428.13 152.09 346.89 383.02 321.19 99+ 377.00 504.51 445.50 158.26 360.97 398.58 334.22 *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. Plan G UM24 Plan M UM30 2 NJ_UOO_AGY_070116 Plan N UM35
MONTHLY TOBACCO PREMIUMS* ZIP CODES: 070-089 FEMALE MALE Plan A UM20 Plan C UM21 Plan F UM23 Plan High F Plan G UM24 Plan M UM30 Plan N UM35 Attained Age Plan A UM20 Plan C UM21 Plan F UM23 Plan High F Plan G UM24 Plan M UM30 Plan N UM35 UM34 UM34 219.01 50-64 227.90 163.68 219.01 193.41 57.89 156.71 173.03 122.27 65 170.32 227.90 201.26 60.25 163.07 180.04 127.22 163.68 219.01 193.41 57.89 156.71 173.03 122.27 66 170.32 227.90 201.26 60.25 163.07 180.04 127.22 170.05 227.56 200.96 57.89 162.82 179.79 122.27 67 178.86 239.32 211.34 60.25 171.23 189.08 127.22 176.71 236.46 208.82 59.67 169.20 186.82 126.00 68 187.83 251.36 221.97 62.08 179.85 198.58 131.11 183.63 245.73 216.98 61.62 175.83 194.13 130.12 69 197.32 264.03 233.16 64.12 188.92 208.59 135.40 190.44 254.82 225.03 63.57 182.31 201.31 134.24 70 206.86 276.81 244.46 66.15 198.08 218.70 139.69 198.08 265.07 234.06 65.69 189.65 209.41 138.73 71 217.56 291.12 257.08 68.36 208.31 230.00 144.35 205.93 275.57 243.33 67.82 197.17 217.69 143.22 72 228.74 306.06 270.28 70.57 218.99 241.80 149.03 213.85 286.15 252.70 70.13 204.74 226.06 148.10 73 240.22 321.45 283.88 72.97 230.00 253.95 154.10 221.83 296.85 262.13 72.43 212.37 234.51 152.96 74 252.06 337.28 297.85 75.36 241.33 266.47 159.15 229.43 307.01 271.11 74.92 219.67 242.54 158.20 75 263.71 352.92 311.64 77.96 252.51 278.81 164.62 239.10 319.94 282.53 77.40 228.91 252.75 163.44 76 278.03 372.03 328.52 80.53 266.18 293.90 170.07 247.43 331.10 292.38 80.06 236.91 261.59 169.05 77 287.77 385.10 340.05 83.30 275.54 304.24 175.91 256.00 342.56 302.50 82.71 245.10 270.65 174.67 78 297.72 398.38 351.79 86.07 285.04 314.74 181.75 265.17 354.84 313.36 85.55 253.90 280.34 180.66 79 308.36 412.66 364.40 89.02 295.25 326.02 187.99 274.37 367.14 324.22 88.39 262.68 290.05 186.65 80 319.08 426.97 377.05 91.97 305.49 337.33 194.22 285.77 382.39 337.68 91.40 273.60 302.09 193.01 81 328.46 439.55 388.14 95.10 314.49 347.25 200.84 297.29 397.81 351.31 94.41 284.65 314.30 199.37 82 337.79 452.01 399.16 98.24 323.42 357.11 207.45 308.91 413.37 365.04 97.60 295.77 326.57 206.11 83 347.01 464.34 410.05 101.56 332.24 366.85 214.46 320.65 429.08 378.91 100.80 307.00 338.99 212.85 84 356.14 476.58 420.85 104.88 340.99 376.50 221.48 332.46 444.89 392.87 104.34 318.33 351.47 220.34 85 365.18 488.65 431.52 108.58 349.63 386.04 229.27 344.32 460.75 406.87 108.06 329.66 364.01 228.20 86 374.04 500.52 441.99 112.44 358.12 395.43 237.45 356.24 476.69 420.95 111.97 341.07 376.59 236.45 87 382.76 512.20 452.31 116.51 366.47 404.66 246.03 368.12 492.59 435.01 115.86 352.45 389.16 244.67 88 391.26 523.57 462.34 120.56 374.61 413.65 254.60 379.97 508.44 449.00 119.93 363.80 401.70 253.27 89 399.59 534.69 472.19 124.80 382.57 422.44 263.54 391.69 524.13 462.84 124.01 375.01 414.08 261.90 90 407.57 545.41 481.62 129.05 390.24 430.89 272.51 391.69 524.13 462.84 128.27 375.01 414.08 270.87 91 407.57 545.41 481.62 133.48 390.24 430.89 281.86 391.69 524.13 462.84 132.53 375.01 414.08 279.86 92 407.57 545.41 481.62 137.90 390.24 430.89 291.21 391.69 524.13 462.84 136.95 375.01 414.08 289.22 93 407.57 545.41 481.62 142.51 390.24 430.89 300.95 391.69 524.13 462.84 141.39 375.01 414.08 298.58 94 407.57 545.41 481.62 147.13 390.24 430.89 310.69 391.69 524.13 462.84 145.82 375.01 414.08 307.93 95 407.57 545.41 481.62 151.73 390.24 430.89 320.43 391.69 524.13 462.84 150.42 375.01 414.08 317.66 96 407.57 545.41 481.62 156.53 390.24 430.89 330.54 391.69 524.13 462.84 155.03 375.01 414.08 327.40 97 407.57 545.41 481.62 161.33 390.24 430.89 340.68 391.69 524.13 462.84 159.65 375.01 414.08 337.14 98 407.57 545.41 481.62 166.13 390.24 430.89 350.81 391.69 524.13 462.84 164.43 375.01 414.08 347.23 99+ 407.57 545.41 481.62 171.10 390.24 430.89 361.32 *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. 3 NJ_UOO_AGY_070116
Disclosures Use this outline to compare benefits and premiums among policies. Premium Information We, United of Omaha Life Insurance Company, can only raise your premium if we raise the premium for all the 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. 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 You are eligible for a household premium discount if: (a) you have resided with at least one, but no more than three, other Medicare-eligible adults for the past year and at least one of the other adults also owns or is issued a Medicare supplement policy written the Company or its affiliates, or (b) you are married or in a civil union partnership and your spouse/partner also owns a Medicare supplement policy written by the Company or its affiliates. The discounted premium will be priced 7% lower than the rates illustrated. The policy s household premium discount will be removed if the other adult or spouse 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 your insurance company. Right to Return Policy If you find that you are not satisfied with your policy, you may return it to 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 United of Omaha Life Insurance Company 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 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. 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. Exclusions Exclusions apply to your coverage. Please be sure to review the exclusions in your policy. This policy does not cover Part A benefits for benefit periods that begin while this policy is not in force, and other exclusions apply. 4 NJ_UOO_AGY_070116
PLANS A AND 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. Services Medicare Pays Plan A Pays You Pay Plan C Pays You Pay HOSPITALIZATION* - Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,288 $0 $1,288 (Part A $1,288 (Part A $0 deductible) deductible) 61 st through 90 th day All but $322 a day $322 a day $0 $322 a day $0 91 st day and after (while using 60 lifetime reserve days): All but $644 a day $644 a day $0 $644 a day $0 Once lifetime reserve days are used (Additional 365 days): $0 100% of Medicareeligible $0** 100% of Medicare- $0** expenses eligible 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 Medicareapproved 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 $161.00 a day $0 Up to $161.00 a Up to $161.00 a $0 day day 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 Part A 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 NJ_UOO_AGY_070116
PLANS A AND C MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $166 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 A Pays You Pay Plan C Pays You Pay MEDICAL EXPENSES - IN OUR OUT OF THE HOSPTIAL 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 $166 of Medicare-approved amounts * $0 $0 $166 (Part B deductible) $166 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Generally 20% $0 Part B Excess Charges (above Medicare-approved amounts) $0 $0 All costs $0 All costs BLOOD First 3 pints $0 All costs $0 All costs $0 Next $166 of Medicare-approved amounts * $0 $0 $166 (Part B deductible) $166 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 20% $0 CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 $0 $0 HOME HEALTH CARE MEDICARE-APPROVED SERVICES PARTS A AND B Medically necessary skilled care services and medical supplies 100% $0 $0 $0 $0 DURABLE MEDICAL EQUIPTMENT First $166 of Medicare-approved amounts $0 $0 $166 (Part B deductible) $166 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 20% $0 6 NJ_UOO_AGY_070116
PLANS A AND C MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR OTHER BENEFITS NOT COVERED BY MEDICARE Services Medicare Pays Plan A Pays You Pay Plan C 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 N/A All Costs $0 $250 Remainder of charges $0 N/A All Costs 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum benefit 7 NJ_UOO_AGY_070116
PLANS F AND HIGH DEDUCTIBLE 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 Plan High Deductible F Pays (After you pay $2,180 deductible***) You Pay (In addition to $2,180 deductible***) HOSPITALIZATION* - Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,288 $1,288 (Part A $0 $1,288 (Part A $0 deductible) deductible) 61 st through 90 th day All but $322 a day $322 a day $0 $322 a day $0 91 st day and after (while using 60 lifetime reserve days): All but $644 a day $644 a day $0 $644 a day $0 Once lifetime reserve days are used 100% of Medicareeligible 100% of Medicare- $0** (Additional 365 days): $0 expenses $0** eligible 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 Medicareapproved 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 $161.00 a day Up to $161 a day $0 Up to $161 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 Part A 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. *** High deductible plan F 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/certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible. $0 8 NJ_UOO_AGY_070116
PLANS F AND HIGH DEDUCTIBLE F MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $166 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. Plan High Deductible F Pays (After you pay $2,180 deductible***) You Pay (In addition to $2,180 deductible***) Services Medicare Pays Plan F Pays You Pay MEDICAL EXPENSES - IN OUR OUT OF THE HOSPTIAL 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 $166 of Medicare-approved amounts * $0 $166 (Part B deductible) $0 $166 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Generally 20% $0 Part B Excess Charges (above Medicare-approved amounts) $0 100% $0 100% $0 BLOOD First 3 pints $0 All costs $0 All costs $0 Next $166 of Medicare-approved amounts * $0 $166 (Part B deductible) $0 $166 (Part B deductible) $0 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 $166 of Medicare-approved amounts $0 $166 (Part B deductible) $0 $166 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 20% $0 *** 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/ certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible. 9 NJ_UOO_AGY_070116
PLANS F AND HIGH DEDUCTIBLE F MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR OTHER BENEFITS NOT COVERED BY MEDICARE Services Medicare Pays Plan F Pays You Pay Plan High Deductible F Pays (After you pay $2,180 deductible***) 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 You Pay (In addition to $2,180 deductible***) 20% and amounts over the $50,000 lifetime maximum benefit *** 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/certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible. 10 NJ_UOO_AGY_070116
PLANS G AND M 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 Plan M Pays You Pay HOSPITALIZATION* - Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,288 $1,288 (Part A $0 $644 (50% Part A $0 deductible) deductible) 61 st through 90 th day All but $322 a day $322 a day $0 $322 a day $0 91 st day and after (while using 60 lifetime reserve days): All but $644 a day $644 a day $0 $644 a day $0 Once lifetime reserve days are used (Additional 365 days): $0 100% of Medicareeligible expenses $0** 100% of Medicareeligible expenses $0** 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 Medicareapproved 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 $161.00 a day Up to $161 a day $0 Up to $161 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 $0 ** NOTICE: When your Medicare Part A 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. 11 NJ_UOO_AGY_070116
PLANS G AND M MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $166 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 Plan M Pays You Pay MEDICAL EXPENSES - IN OUR OUT OF THE HOSPTIAL 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 $166 of Medicare-approved $0 $0 $166 (Part B $0 $166 (Part B deductible) amounts * Remainder of Medicare-approved amounts deductible) Generally 80% Generally 20% $0 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. Part B Excess Charges (above Medicare-approved amounts) $0 100% $0 $0 All costs BLOOD First 3 pints $0 All costs $0 All costs $0 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. Next $166 of Medicare-approved $0 $0 $166 (Part B $0 $166 (Part B deductible) amounts * deductible) Remainder of Medicare-approved 80% 20% $0 20% $0 amounts CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 $0 $0 12 NJ_UOO_AGY_070116
PLANS G AND M MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR PARTS A AND B Services Medicare Pays Plan G Pays You Pay Plan M Pays You Pay HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 $0 $0 DURABLE MEDICAL EQUPMENT First $166 of Medicare-approved $0 $0 $166 (Part B $0 $166 (Part B deductible) amounts Remainder of Medicare-approved amounts deductible) 80% 20% $0 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE Services Medicare Pays Plan G Pays You Pay Plan M 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 13 NJ_UOO_AGY_070116
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 First 60 days All but $1,288 $1,288 (Part A deductible) $0 61 st through 90 th day All but $322 a day $322 a day $0 91 std day and after (while using 60 lifetime reserve days): All but $644 a day $644 a day $0 Once lifetime reserve days are used (Additional 365 days): $0 100% of Medicare-eligible expenses $0** 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 Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21 st through 100 th day All but $161.00 a day Up to $161.00 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 ** NOTICE: When your Medicare Part A 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. 14 NJ_UOO_AGY_070116
PLAN N MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $166 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 OUR OUT OF THE HOSPTIAL 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 $166 of Medicare-approved amounts * $0 $0 $166 (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) BLOOD $0 $0 All costs First 3 pints $0 All costs $0 Next $166 of Medicare-approved amounts * $0 $0 $166 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 15 NJ_UOO_AGY_070116
HOME HEALTH CARE MEDICARE-APPROVED SERVICES PLAN N MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR PARTS A AND B Medically necessary skilled care services and medical supplies 100% $0 $0 DURABLE MEDICAL EQUIPTMENT First $166 of Medicare-approved amounts $0 $0 $166 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE Services Medicare Pays Plan N 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] Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum benefit 16 NJ_UOO_AGY_070116