Stonebridge Coverage Outline Thank you for your interest in applying for the Stonebridge Life Medicare Supplement plan! Attached is a copy of the policy Outline of Coverage and we have supplied you with a link to a printable copy of the Enrollment Form. Should you decide to apply by upload/mail/fax/email, the printable application needs to be reviewed and signed by an Agent before it can be submitted to Stonebridge Life. You may upload, email, fax or mail it in to CDA Insurance: Fax: 1.541.284.2994 Email: client.services@cda-insurance.com Secure File Upload: Click here Mail: CDA Insurance LLC PO Box 26540 Eugene, Oregon 97402 Other Important Information Download Medicare s Choosing a Medigap Policy Guide (.pdf) Download Policy Outline (.pdf) Download Application (.pdf) Our website: http://www.medicare-utah.net If you should have any questions on the application, please call us at 1.800.884.2343 or 1.541.434.9613.
2015 MEDICARE SUPPLEMENT INSURANCE PLANS You can rely on Stonebridge Life Insurance Company s Medicare Supplement Plans to 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. Your choice of physicians and specialists for your personalized care. The option to use any hospital or medical facility. Virtually no claims paperwork to file. Put a Stonebridge Life Insurance Company Medicare Supplement Plan on your team today. Medicare Supplement insurance is underwritten by: Stonebridge Life Insurance Company Administrative Office: 4333 Edgewood Road NE, Cedar Rapids, Iowa 52499 Home Office: Rutland, VT 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.
COVERED BENEFITS MEDICARE PART A HOSPITAL COVERAGE The Stonebridge 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, 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. Stonebridge 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, Stonebridge 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 the Stonebridge 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. Stonebridge Standard Plans A, F, G & N pay the deductible. Skilled Nursing Facility Care Medicare pays all eligible expenses for the first 20 days. Stonebridge Standard Plans F, G & N pay up to $157.50 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. Stonebridge Standard Plans A, F, G & N pay the /Co-payment. MEDICARE PART B PHYSICIAN SERVICES AND SUPPLIES - Stonebridge Standard Plan F pays the $147 calendar-year deductible. After the Part B, Stonebridge 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, Stonebridge Standard Plans F and G pays 100% up to the charge limitation established by Medicare. Benefit for Blood Stonebridge Standard Plans A, F, G & N pay expenses for the first three pints of blood. ADDITIONAL BENEFITS** Emergency Care received outside the U.S. After you pay a $250 calendar-year deductible, Stonebridge 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.
STONEBRIDGE LIFE INSURANCE COMPANY Administrative Office: 4333 Edgewood Rd. NE, Cedar Rapids, IA 52499 Home Office: Rutland, VT 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 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 the insurance contract. You must read the Policy itself to understand all of the rights and duties of both you and Stonebridge Life Insurance Company. RIGHT TO RETURN POLICY If you find that you are not satisfied with your Policy, you may return it to Stonebridge Life Insurance Company, 4333 Edgewood Road, Cedar Rapids, Iowa 52499. 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 Stonebridge 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 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 leave out or falsify important medical information.
STONEBRIDGE 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 Basic, Including 100% Part B Part A Basic, including 100% Part B Skilled Nursing Facility Part A Part B Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Part A Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Part A Part B Part B Excess (100%) Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Part A Part B Excess (100%) Foreign Travel Emergency Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility 50% Part A 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 75% Part A Out-of-pocket limit $2,470; paid at 100% after limit reached Basic, including 100% Part B Skilled Nursing Facility 50% Part A Foreign Travel Emergency Basic, including 100% Part B, except up to $20 co-payment for office visit, and up to $50copayment for ER Skilled Nursing Facility Part A 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
Monthly Rates by Plan - Utah Non-Tobacco Rates Tobacco Rates Plan A Plan F Plan G Plan N Attained Plan A Plan F Plan G Plan N Female Male Female Male Female Male Female Male Age Female Male Female Male Female Male Female Male 68.26 72.93 115.34 123.24 106.36 113.64 88.88 94.97 65 75.08 80.22 126.88 135.56 116.99 125.00 97.77 104.47 69.28 74.13 117.07 125.28 107.95 115.52 90.21 96.54 66 76.20 81.55 128.78 137.80 118.74 127.07 99.23 106.20 70.30 75.27 118.79 127.18 109.54 117.28 91.55 98.01 67 77.33 82.79 130.67 139.90 120.49 129.01 100.70 107.81 72.63 77.90 122.75 131.64 113.19 121.39 94.59 101.45 68 79.90 85.69 135.02 144.81 124.51 133.53 104.05 111.60 74.87 80.13 126.52 135.41 116.67 124.86 97.50 104.35 69 82.35 88.15 139.17 148.95 128.34 137.34 107.25 114.78 77.03 82.43 130.17 139.28 120.03 128.43 100.32 107.33 70 84.73 90.67 143.19 153.21 132.04 141.27 110.35 118.07 79.21 85.35 133.86 144.23 123.44 132.99 103.16 111.14 71 87.14 93.89 147.25 158.65 135.78 146.29 113.48 122.26 81.67 88.75 138.02 149.97 127.27 138.29 106.36 115.57 72 89.84 97.62 151.82 164.96 140.00 152.12 116.99 127.12 84.28 92.47 142.42 156.26 131.33 144.10 109.75 120.42 73 92.71 101.72 156.66 171.89 144.46 158.51 120.73 132.47 86.82 96.28 146.72 162.69 135.28 150.01 113.06 125.37 74 95.50 105.91 161.38 178.96 148.81 165.02 124.36 137.90 89.12 99.92 150.60 168.85 138.87 155.69 116.06 130.12 75 98.03 109.92 165.67 185.73 152.77 171.26 127.66 143.14 91.10 103.26 153.94 174.50 141.94 160.91 118.63 134.48 76 100.20 113.59 169.33 191.95 156.14 177.00 130.49 147.92 92.79 106.26 156.80 179.57 144.59 165.59 120.84 138.38 77 102.07 116.89 172.48 197.53 159.05 182.14 132.93 152.22 94.56 109.23 159.80 184.58 147.36 170.20 123.14 142.24 78 104.02 120.16 175.79 203.04 162.10 187.22 135.46 156.47 96.35 112.00 162.81 189.25 150.13 174.51 125.47 145.84 79 105.99 123.20 179.09 208.17 165.15 191.96 138.02 160.43 98.98 115.47 167.26 195.14 154.23 179.94 128.89 150.38 80 108.87 127.02 183.99 214.65 169.66 197.93 141.78 165.41 101.85 118.93 172.10 200.98 158.70 185.32 132.63 154.88 81 112.04 130.83 189.31 221.07 174.57 203.86 145.89 170.36 104.92 122.38 177.30 206.81 163.49 190.70 136.63 159.36 82 115.41 134.62 195.02 227.49 179.84 209.77 150.30 175.30 108.14 125.79 182.74 212.56 168.50 196.00 140.82 163.80 83 118.95 138.36 201.02 233.81 185.35 215.61 154.91 180.18 111.41 129.12 188.27 218.20 173.60 201.21 145.08 168.15 84 122.55 142.04 207.10 240.02 190.96 221.33 159.59 184.97 114.70 132.39 193.83 223.71 178.73 206.27 149.37 172.39 85 126.17 145.63 213.21 246.08 196.61 226.90 164.30 189.63 118.02 135.62 199.44 229.17 183.91 211.32 153.69 176.60 86 129.83 149.19 219.38 252.09 202.30 232.46 169.07 194.26 121.43 138.90 205.20 234.73 189.22 216.44 158.13 180.89 87 133.58 152.80 225.73 258.20 208.14 238.09 173.94 198.97 124.96 142.30 211.17 240.47 194.72 221.73 162.73 185.30 88 137.46 156.53 232.28 264.52 214.19 243.90 179.00 203.84 128.48 145.73 217.12 246.26 200.21 227.07 167.31 189.77 89 141.33 160.30 238.83 270.88 220.23 249.78 184.04 208.75 131.56 148.93 222.32 251.67 205.00 232.07 171.32 193.94 90 144.72 163.82 244.56 276.84 225.50 255.28 188.46 213.33 132.81 150.66 224.43 254.60 206.95 234.77 172.95 196.20 91 146.09 165.73 246.87 280.06 227.64 258.25 190.25 215.82 134.18 152.75 226.75 258.11 209.08 238.01 174.74 198.90 92 147.60 168.02 249.42 283.93 229.99 261.80 192.21 218.79 135.64 154.99 229.21 261.92 211.35 241.52 176.63 201.84 93 149.21 170.49 252.13 288.11 232.49 265.67 194.30 222.02 137.19 157.45 231.84 266.06 213.77 245.33 178.65 205.03 94 150.91 173.20 255.02 292.66 235.15 269.86 196.52 225.53 138.85 160.09 234.64 270.53 216.36 249.46 180.82 208.48 95+ 152.73 176.10 258.10 297.59 238.00 274.41 198.90 229.33 For Quarterly, Semi-Annual and Annual Premium Modes, multiply monthly rates by 3, 6 and 12 respectively For Tier 1 rates multiply by 1.1 and for Tier 2 rates multiply by 1.2 Rates quoted are per person and based upon individual age. Rates increase every year as you grow older. Neither Stonebridge Life or its agents are connected with Medicare. FOR AGENT USE ONLY. NOT FOR PUBLIC DISTRIBUTION. Rates effective as of 11/01/14. 78025_UT
Stonebridge Life Insurance Company Administrative Office: 4333 Edgewood Rd. NE Cedar Rapids, Iowa 52499 PREMIUM INFORMATION RIGHT TO RETURN POLICY This outline of coverage does not We, Stonebridge Life Insurance Company, can If you find that you are not satisfied with your give all the details of Medicare only raise your premium if we raise the premium Policy, you may return it to Stonebridge Life coverage. Contact your local Social for all policies like yours in this state. Insurance Company, 4333 Edgewood Road, Security Office or consult Medicare Cedar Rapids, Iowa 52499. and You for details. However, because the premium rate is based upon your attained age, the premium will increase as you If you send the Policy back to us within 30 COMPLETE ANSWERS ARE age from age 65 through age 95. This annual change days after you receive it, we will treat the VERY IMPORTANT will occur on each Policy Renewal Date. Policy as if it had never been issued and When you fill out the application for return all of your payments. the new Policy, be sure to answer There will be a one-time enrollment fee of $25.00 truthfully and completely all added to the first premium. POLICY REPLACEMENT questions about your medical and If you are replacing another health health history. The company may DISCLOSURES insurance Policy, do NOT cancel it until you cancel your Policy and refuse to Use this outline to compare benefits and premiums have actually received your new Policy and pay any claims if you leave out or among policies. are sure you want to keep it. falsify important medical information. READ YOUR POLICY VERY CAREFULLY NOTICE Review the application carefully This is only an outline describing your Policy s most This Policy may not fully cover all of your before you sign it. Be certain that important features. The Policy is the insurance medical costs. all information has been properly contract. You must read the Policy itself to understand recorded. all of the rights and duties of both you and Stonebridge Life Insurance Company. Neither Stonebridge Life Insurance Company nor its agents are connected with Medicare. MSH1O
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 ) 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 $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 $157.50 a day $0 Up to $157.50 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
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 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 ) 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 ) 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 ) Remainder of Medicare Approved Amounts 80% 20% $0 MSH1O
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 $1,260 $1,260 (Part A ) $0 $1,260 (Part A ) 61 st through 90 th day All but $315 a day $315 a day $0 $315 a day $0 91 st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 $630 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses $0** 100% of Medicare 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 Medicare approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 $0 $0 21 st through100 th day All but $157.50 a day Up to $157.50 a day $0 Up to $157.50 a day $0 101 st day and after $0 $0 All costs $0 All costs BLOOD First 3 pints $0 3 pints $0 3pints $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 $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
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 Part B 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 medical equipment First $147 of Medicare Approved Amounts* $0 $147 (Part B ) $0 $0 $147 (Part B ) 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 $147 of Medicare Approved Amounts* $0 $147 (Part B ) $0 $0 $147 (Part B ) Remainder of Medicare Approved Amounts 80% 20% $0 20% $0 CLINICAL LABORATORY SERVICES---TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 $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 ) $0 $0 $147 (Part B ) 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
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 $1,260 $1,260 (Part A ) $0 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 $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 $157.50 a day Up to $157.50 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, 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
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 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 ) 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 ) 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 ) 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
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 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 do not 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 www.medicare.gov 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 Stonebridge Life Insurance Company 4333 Edgewood Road NE Cedar Rapids, IA 52499 FAX Number for New Business: 1-866-834-0437
CALCULATE YOUR PREMIUM STONEBRIDGE 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 A s Applicant B s Steps calculation purposes only. premium premium Premium Write in Medicare Supplement Plan s premium $128.52 from the Outline of Coverage table. Risk Class Adjustment Refer to the Height/Weight Chart in order to $128.52 x 1.0 = $128.52 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, $128.52 Monthly payment multiply monthly premium by: 3 to pay four times a year (quarterly) $385.56 Quarterly payment 6 to pay twice a year (semi-annually) $771.12 Semi-annual payment 12 to pay once a year (annually) $1,542.24 Annual payment Enrollment/Policy fee There is a one-time application fee of $25.00 $128.52 + $25.00 = $153.52 (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)
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). Diabetes Decline Tier 1 (10%) Standard Tier 1 (10%) Tier 2 (20%) Decline Maximum Height Weight Weight Weight Weight Weight Weight Weight 4 5 <66 66-70 71-158 159-163 164-168 169+ 124 4 6 <69 69-73 74-164 165-169 170-174 175+ 129 4 7 <72 72-76 77-170 171-175 176-180 181+ 133 4 8 <75 75-79 80-176 177-181 182-186 187+ 138 4 9 <77 77-81 82-184 185-189 190-194 195+ 143 4 10 <80 80-84 85-190 191-195 196-200 201+ 148 4 11 <83 83-87 88-196 197-201 202-206 207+ 154 5 0 <86 86-90 91-202 203-207 208-212 213+ 159 5 1 <88 88-92 93-208 209-213 214-218 219+ 164 5 2 <91 91-95 96-217 218-222 223-227 228+ 170 5 3 <94 94-98 99-224 225-229 230-234 235+ 175 5 4 <96 96-100 101-231 232-236 237-241 242+ 181 5 5 <99 99-103 104-238 239-243 244-248 249+ 186 5 6 <101 101-105 106-246 247-251 252-256 257+ 192 5 7 <103 103-107 108-253 254-258 259-263 264+ 198 5 8 <106 106-110 111-262 263-267 268-272 273+ 204 5 9 <109 109-113 114-270 271-275 276-280 281+ 210 5 10 <112 112-116 117-279 280-284 285-289 290+ 216 5 11 <115 115-119 120-286 287-291 292-296 297+ 222 6 0 <118 118-122 123-294 295-299 300-304 305+ 229 6 1 <121 121-125 126-302 303-307 308-312 313+ 235 6 2 <124 124-128 129-313 314-318 319-323 324+ 241 6 3 <128 128-132 133-321 322-326 327-331 332+ 248 6 4 <131 131-135 136-329 330-334 335-339 340+ 255 6 5 <134 134-138 139-338 339-343 344-348 349+ 261 6 6 <137 137-141 142-347 348-352 353-357 358+ 268 6 7 <142 142-146 147-355 356-360 361-365 366+ 275 6 8 <145 145-149 150-365 366-370 371-375 376+ 282 6 9 <148 148-152 153-375 376-380 381-385 386+ 289 6 10 <151 151-155 156-385 386-390 391-395 396+ 297 6 11 <154 154-158 159-393 394-398 399-403 404+ 304 7 0 <158 158-162 163-403 404-408 409-413 414+ 311 Medicare Supplement insurance is underwritten by Stonebridge Life Insurance Company. Home office: Rutland, VT