aetna life insurance company outline of medicare ...€¦ · benefit plans a, b, c , f, g and n are...

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Aetna Life Insurance Company

Outline of Medicare Supplement Coverage

Benefit Plans A, B, C , F, G and N are Offered�This chart shows the benefits included in each of the standard Medicare supplement plans. Every insurer must make available Plan "A." 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 insured to pay a portion of Part B coinsurance or copayments.

Blood - First three pints of blood each year.

Hospice - Part A coinsurance.

A B C D F l F*

G K** L** M N

Basic

including

100% Part B

coinsurance

Basic

including

100% Part B

coinsurance

Basic

including

100% Part B

coinsurance

Basic including

100% Part B

coinsurance

Basic including

100% Part B

coinsurance *

Basic including

100% Part B

coinsurance

Hospitalization

and preventive

care paid at

100%; other

basic benefits

paid at 50%

Hospitalization

and

preventive

care paid at

100%; other

basic benefits

paid at 75%

Basic including

100% Part B

coinsurance

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

Skilled Nursing

Facility

Coinsurance

Skilled Nursing

Facility

Coinsurance

Skilled Nursing

Facility

Coinsurance

50% Skilled

Nursing Facility

Coinsurance

75% Skilled

Nursing

Facility

Coinsurance

Skilled Nursing

Facility

Coinsurance

Skilled Nursing

Facility

Coinsurance

Part A

Deductible

Part A

Deductible

Part A

Deductible

Part A

Deductible

Part A

Deductible

50% Part A

Deductible

75% Part A

Deductible

50% Part A

Deductible

Part A

Deductible

Part B

Deductible

Part B

Deductible

Part B Excess-

100%

Part B Excess-

100%

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Out-of-pocket

limit $4,960;

paid at 100%

after limit

reached***

Out-of-pocket

limit $2,480;

paid at 100%

after limit

reached***

GR-11613-03-OOC –MI Effective 01-01-2016

18.02.312.1-MI K (12/15)

Aetna Life Insurance Company

Outline of Medicare Supplement Coverage

Benefit Plans A, B, C, F, G and N are Offered�

*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.

**Plans K and L provide for different cost-sharing for items and services than the other plans.

Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance, and deductibles for the rest of the calendar year. The out-of-

pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called “Excess Charges.” You will be responsible for

payment of excess charges.

***The out-of-pocket annual limit will increase each year for inflation.


18.02.312.1-MI K (12/15)

PREMIUM INFORMATION Questions? We’re here to help.

Just call us at 1-800-345-6022

(TTY: 711)

We, Aetna Life Insurance Company, can only raise your premium if we raise the premium for all policies like yours in this state, when your age changes or to

coincide with changes in Medicare. Aetna will send a written notice at least 31 days before the change becomes effective.

The monthly premiums shown will apply when payment is made on a quarterly, semi-annual or annual basis or if you elect to have your payments

automatically deducted from your checking account (Electronic Funds Transfer program) or credit card account. To obtain quarterly premium, multiply the

monthly premium by 3. For semi-annual premium and annual premium, multiply the monthly premium by 6 or 12, respectively. If you elect to pay your

premium on a monthly basis by check or money order, add $2 to the monthly premium shown to calculate your monthly premium amount.

If you use tobacco and you enroll other than during the Medicare Supplement Open Enrollment and Guaranteed issue rights periods, a tobacco use premium

rate will apply. Please refer to the Guaranteed Issue Guidelines notice included in your enrollment materials for details on open enrollment and guaranteed

issue rights. Tobacco use premium rates are determined by multiplying the premium shown by a factor of 1.10.


18.02.312.1-MI K (12/15)

MONTHLY PREMIUMS The rates in the table below apply to the following ZIP CODES: 48600 through 49299�

Attained Age

PLAN A

Male Female

PLAN B

Male Female

PLAN C

Male Female

PLAN F

Male Female

PLAN G

Male Female

PLAN N

Male Female

65 $140.91 $130.08 $156.83 $143.99 $181.41 $166.74 $182.16 $167.41 $160.49 $149.41 $125.49 $117.00

66 $146.16 $134.99 $162.66 $149.41 $188.16 $173.08 $188.99 $173.74 $168.16 $156.49 $131.58 $122.66

67 $151.49 $139.83 $168.49 $154.74 $194.91 $179.24 $195.74 $179.99 $175.91 $163.66 $137.74 $128.41

68 $157.58 $145.41 $176.41 $161.91 $204.16 $187.74 $204.99 $188.49 $183.58 $170.83 $143.91 $134.16

69 $163.66 $151.08 $184.16 $168.99 $213.41 $196.24 $214.24 $196.99 $191.24 $177.91 $149.99 $139.83

70 $169.74 $156.74 $191.91 $176.08 $222.49 $204.66 $223.41 $205.41 $198.83 $185.08 $156.16 $145.58

71 $175.83 $162.33 $199.58 $183.24 $231.66 $212.99 $232.57 $213.82 $206.49 $192.16 $162.24 $151.16

72 $181.83 $167.83 $207.24 $190.24 $240.74 $221.32 $241.66 $222.24 $214.07 $199.16 $168.33 $156.91

73 $185.99 $171.74 $213.66 $196.16 $248.66 $228.57 $249.57 $229.49 $222.57 $207.08 $175.16 $163.33

74 $190.08 $175.49 $220.07 $202.08 $256.41 $235.74 $257.41 $236.74 $230.91 $214.91 $182.08 $169.74

75 $194.16 $179.24 $226.57 $207.99 $264.16 $242.99 $265.24 $243.91 $239.32 $222.66 $188.91 $176.08

76 $198.24 $183.08 $232.99 $213.91 $271.99 $250.16 $273.07 $251.07 $247.66 $230.49 $195.74 $182.49

77 $202.33 $186.74 $239.32 $219.74 $279.74 $257.24 $280.91 $258.24 $256.07 $238.24 $202.58 $188.83

78 $205.33 $189.49 $243.74 $223.74 $285.49 $262.49 $286.49 $263.41 $263.07 $244.82 $208.57 $194.33

79 $208.24 $192.16 $247.99 $227.66 $290.99 $267.57 $292.15 $268.57 $270.07 $251.32 $214.49 $199.91

80 $210.99 $194.83 $252.24 $231.57 $296.40 $272.66 $297.57 $273.57 $276.99 $257.74 $220.32 $205.41

81 $213.66 $197.24 $256.41 $235.41 $301.90 $277.57 $302.99 $278.66 $283.99 $264.24 $226.32 $210.99

82 $216.24 $199.66 $260.66 $239.32 $307.40 $282.66 $308.49 $283.66 $290.91 $270.74 $232.24 $216.41

83 $217.99 $201.16 $265.74 $243.91 $314.74 $289.41 $315.82 $290.41 $304.65 $283.49 $244.49 $227.82

84 $219.57 $202.66 $270.66 $248.49 $321.99 $296.15 $323.15 $297.15 $318.49 $296.40 $256.57 $239.24

85 $221.07 $204.16 $275.91 $253.41 $329.74 $303.24 $330.82 $304.24 $330.49 $307.49 $267.41 $249.32

86 $222.57 $205.41 $280.16 $257.16 $336.40 $309.24 $337.49 $310.32 $342.90 $319.07 $278.74 $259.91

87 $223.91 $206.66 $284.32 $260.99 $341.32 $313.99 $342.57 $314.90 $355.90 $331.15 $290.49 $270.82

88 $225.41 $208.08 $288.49 $264.91 $346.49 $318.65 $347.74 $319.65 $369.24 $343.65 $302.82 $282.32

89 $226.82 $209.32 $292.90 $268.91 $351.74 $323.40 $352.90 $324.49 $383.15 $356.57 $315.65 $294.24

90+ $228.24 $210.66 $297.32 $272.91 $356.99 $328.32 $358.24 $329.32 $397.57 $369.99 $328.90 $306.65

Under 65 $389.98 $360.07 N/A N/A $516.23 $474.81 N/A N/A N/A N/A N/A N/A


18.02.312.1-MI K (12/15)

MONTHLY PREMIUMS The rates in the table below apply to the following ZIP CODES: 49300 through 49999�

Attained Age

PLAN A

Male Female

PLAN B

Male Female

PLAN C

Male Female

PLAN F

Male Female

PLAN G

Male Female

PLAN N

Male Female

65 $133.87 $123.57 $148.99 $136.79 $172.34 $158.41 $173.05 $159.04 $152.47 $141.94 $119.22 $111.15

66 $138.85 $128.24 $154.53 $141.94 $178.75 $164.42 $179.54 $165.06 $159.75 $148.67 $125.00 $116.53

67 $143.92 $132.84 $160.07 $147.01 $185.16 $170.28 $185.96 $170.99 $167.11 $155.48 $130.86 $121.99

68 $149.70 $138.14 $167.59 $153.81 $193.95 $178.36 $194.74 $179.07 $174.40 $162.29 $136.72 $127.45

69 $155.48 $143.52 $174.95 $160.54 $202.74 $186.43 $203.53 $187.14 $181.68 $169.01 $142.49 $132.84

70 $161.26 $148.91 $182.31 $167.27 $211.37 $194.43 $212.24 $195.14 $188.88 $175.82 $148.35 $138.30

71 $167.03 $154.21 $189.60 $174.08 $220.07 $202.34 $220.95 $203.13 $196.17 $182.55 $154.13 $143.60

72 $172.73 $159.44 $196.88 $180.73 $228.70 $210.26 $229.57 $211.13 $203.37 $189.20 $159.91 $149.06

73 $176.69 $163.16 $202.98 $186.35 $236.22 $217.15 $237.09 $218.02 $211.45 $196.72 $166.40 $155.16

74 $180.57 $166.72 $209.07 $191.97 $243.59 $223.95 $244.54 $224.90 $219.36 $204.16 $172.97 $161.26

75 $184.45 $170.28 $215.25 $197.59 $250.95 $230.84 $251.98 $231.71 $227.36 $211.52 $179.46 $167.27

76 $188.33 $173.92 $221.34 $203.21 $258.39 $237.65 $259.42 $238.52 $235.27 $218.97 $185.96 $173.37

77 $192.21 $177.41 $227.36 $208.75 $265.75 $244.38 $266.86 $245.33 $243.27 $226.33 $192.45 $179.38

78 $195.06 $180.02 $231.55 $212.55 $271.21 $249.37 $272.16 $250.24 $249.92 $232.58 $198.15 $184.61

79 $197.83 $182.55 $235.59 $216.27 $276.44 $254.19 $277.55 $255.14 $256.57 $238.76 $203.77 $189.91

80 $200.44 $185.08 $239.63 $220.00 $281.58 $259.02 $282.69 $259.89 $263.14 $244.85 $209.31 $195.14

81 $202.98 $187.38 $243.59 $223.64 $286.81 $263.69 $287.84 $264.72 $269.79 $251.03 $215.01 $200.44

82 $205.43 $189.68 $247.62 $227.36 $292.03 $268.52 $293.06 $269.47 $276.36 $257.20 $220.63 $205.59

83 $207.09 $191.10 $252.45 $231.71 $299.00 $274.93 $300.03 $275.88 $289.42 $269.31 $232.27 $216.43

84 $208.60 $192.53 $257.12 $236.07 $305.89 $281.35 $307.00 $282.30 $302.56 $281.58 $243.74 $227.28

85 $210.02 $193.95 $262.11 $240.74 $313.25 $288.08 $314.28 $289.03 $313.96 $292.11 $254.04 $236.86

86 $211.45 $195.14 $266.15 $244.30 $319.58 $293.78 $320.61 $294.80 $325.76 $303.12 $264.80 $246.91

87 $212.71 $196.33 $270.11 $247.94 $324.25 $298.29 $325.44 $299.16 $338.11 $314.60 $275.96 $257.28

88 $214.14 $197.67 $274.06 $251.66 $329.16 $302.72 $330.35 $303.67 $350.77 $326.47 $287.68 $268.21

89 $215.48 $198.86 $278.26 $255.46 $334.15 $307.23 $335.26 $308.26 $363.99 $338.74 $299.87 $279.53

90+ $216.83 $200.13 $282.46 $259.26 $339.14 $311.90 $340.32 $312.85 $377.69 $351.49 $312.46 $291.32



18.02.312.1-MI K (12/15)

MONTHLY PREMIUMS

The rates in the table below apply to the following ZIP CODES: 48000 through 48599�

Attained Age

PLAN A

Male Female

PLAN B

Male Female

PLAN C

Male Female

PLAN F

Male Female

PLAN G

Male Female

PLAN N

Male Female

65 $170.50 $157.39 $189.76 $174.23 $219.51 $201.76 $220.41 $202.57 $194.20 $180.79 $151.85 $141.56

66 $176.85 $163.34 $196.82 $180.79 $227.67 $209.42 $228.68 $210.23 $203.47 $189.36 $159.21 $148.42

67 $183.31 $169.19 $203.88 $187.24 $235.84 $216.88 $236.85 $217.79 $212.85 $198.03 $166.67 $155.38

68 $190.67 $175.95 $213.46 $195.91 $247.03 $227.17 $248.04 $228.08 $222.13 $206.70 $174.13 $162.34

69 $198.03 $182.80 $222.83 $204.48 $258.22 $237.45 $259.23 $238.36 $231.40 $215.27 $169.19

70 $205.39 $189.66 $232.21 $213.05 $269.21 $247.64 $270.32 $248.54 $240.58 $223.94 $188.95 $176.15

71 $212.75 $196.42 $241.49 $221.72 $280.31 $257.72 $281.41 $258.73 $249.86 $232.51 $196.31 $182.90

72 $220.01 $203.07 $250.76 $230.19 $291.30 $267.80 $292.40 $268.91 $259.03 $240.98 $203.68 $189.86

73 $225.05 $207.81 $258.53 $237.35 $300.87 $276.57 $301.98 $277.68 $269.32 $250.56 $211.94 $197.63

74 $229.99 $212.35 $266.29 $244.51 $310.25 $285.25 $311.46 $286.46 $279.40 $260.04 $220.31 $205.39

75 $234.93 $216.88 $274.15 $251.67 $319.63 $294.02 $320.94 $295.13 $289.58 $269.42 $228.58 $213.05

76 $239.87 $221.52 $281.92 $258.83 $329.11 $302.69 $330.42 $303.80 $299.66 $278.89 $236.85 $220.82

77 $244.81 $225.96 $289.58 $265.89 $338.48 $311.26 $339.90 $312.47 $309.85 $288.27 $245.12 $228.48

78 $248.44 $229.29 $294.93 $270.73 $345.44 $317.61 $346.65 $318.72 $318.32 $296.24 $252.38 $235.13

79 $251.97 $232.51 $300.07 $275.47 $352.10 $323.76 $353.51 $324.97 $326.79 $304.10 $259.53 $241.89

80 $255.30 $235.74 $305.21 $280.20 $358.65 $329.91 $360.06 $331.02 $335.16 $311.87 $266.59 $248.54

81 $258.53 $238.66 $310.25 $284.84 $365.30 $335.86 $366.62 $337.17 $343.63 $319.73 $273.85 $255.30

82 $261.65 $241.59 $315.39 $289.58 $371.96 $342.01 $373.27 $343.22 $352.00 $327.59 $281.01 $261.85

83 $263.77 $243.40 $321.54 $295.13 $380.83 $350.18 $382.14 $351.39 $368.63 $343.02 $295.83 $275.67

84 $265.69 $245.22 $327.49 $300.67 $389.60 $358.35 $391.02 $359.56 $385.37 $358.65 $310.45 $289.48

85 $267.50 $247.03 $333.85 $306.62 $398.98 $366.92 $400.29 $368.13 $399.89 $372.06 $323.56 $301.68

86 $269.32 $248.54 $338.99 $311.16 $407.05 $374.18 $408.36 $375.49 $414.91 $386.08 $337.27 $314.49

87 $270.93 $250.06 $344.03 $315.80 $413.00 $379.92 $414.51 $381.03 $430.64 $400.70 $351.49 $327.70

88 $272.74 $251.77 $349.07 $320.54 $419.25 $385.57 $420.76 $386.78 $446.77 $415.82 $366.41 $341.61

89 $274.46 $253.28 $354.41 $325.38 $425.60 $391.32 $427.01 $392.63 $463.61 $431.45 $381.94 $356.03

90+ $276.17 $254.90 $359.76 $330.22 $431.95 $397.27 $433.47 $398.48 $481.06 $447.68 $397.97 $371.05



18.02.312.1-MI K (12/15)

DISCLOSURES Questions? We’re here to help.


(TTY: 711)

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 Aetna

Life Insurance Company.

RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to Aetna Life Insurance

Company, PO Box 14770, Lexington, KY 40512. 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 Aetna 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.�


18.02.312.1-MI K (12/15)

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PLAN A

Medicare (Part A) – Hospital Services – Per Benefit Period

Services Medicare Pays Plan A

Plan Pays You Pay

HOSPITALIZATION*

Semi-private room and board, general nursing

and miscellaneous services and supplies

First 60 days All but $1,288 $0 $1,288

(Part A deductible)

61st thru 90th day All but $322 a day $322 a day $0

91st 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 Medicare-approved

facility within 30 days after leaving the

hospital

First 20 days All approved amounts $0 $0

21st thru 100th day All but $161

a day

$0 Up to $161

a day

101st day and after $0 $0 All costs

*A Benefit Period begins on the first day you receive care 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.

** 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.


18.02.312.1-MI K (12/15)

PLAN A (continued)



Plan Pays You Pay

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 a very limited

copayment/

coinsurance for

outpatient drugs and

inpatient respite care

Medicare

copayment/

coinsurance

$0

PLAN A

Medicare (Part B) – Medical Services – Per Calendar Year


Plan Pays You Pay

MEDICAL EXPENSES

IN OR OUT OF THE HOSPITAL AND

OUTPATIENT HOSPITAL TREATMENTS, 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% Generally 20% $0

Part B excess charges (above Medicare-

approved amounts) $0 $0 All costs

*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.


18.02.312.1-MI K (12/15)

PLAN A (continued)


•

•


Plan Pays You Pay

BLOOD

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

PARTS A & B


Plan Pays You Pay

HOME HEALTH CARE

Medicare-Approved Services

Medically necessary skilled care services

and medical supplies 100% $0 $0

Durable medical equipment:

-

-

First $166 of Medicare-approved

amounts*

$0 $0 $166

(Part B deductible)

Remainder of Medicare-approved

amounts

80% 20% $0




18.02.312.1-MI K (12/15)

•

•

PLAN B


Services Medicare Pays Plan B

Plan Pays You Pay

HOSPITALIZATION*



First 60 days All but $1,288 $1,288

(Part A deductible)

$0


91st day and after:



-

-


eligible expenses

$0**






facility within 30 days after leaving the hospital



a day

$0 Up to $161

a day




** NOTICE – When your Medicare Part A Hospital benefits are exhausted, the insurer stands in the place of Medicare





18.02.312.1-MI K (12/15)

PLAN B (continued)



Plan Pays You Pay

BLOOD



HOSPICE CARE

You must meet Medicare’s requirements


illness

All but very limited

copayment/

coinsurance for



Medicare copayment/

coinsurance

$0

PLAN B



Plan Pays You Pay

MEDICAL EXPENSES



physician’s services, inpatient and outpatient




First $166 of Medicare-approved amounts* $0 $0 $166

(Part B deductible)


Part B Excess Charges (above Medicare-





18.02.312.1-MI K (12/15)

PLAN B (continued)



Plan Pays You Pay

BLOOD


Next $166 of Medicare-approved amounts* $0 $0 $166

(Part B deductible)




PARTS A & B


Plan Pays You Pay

HOME HEALTH CARE


•

•


and medical supplies

100% $0 $0


-

-


amounts*

$0 $0 $166

(Part B deductible)


amounts

80% 20% $0




18.02.312.1-MI K (12/15)

•

•

PLAN C


Services Medicare Pays Plan C

Plan Pays You Pay

HOSPITALIZATION*




(Part A deductible)

$0


91st day and after:



-

-


eligible expenses

$0**







First 20 days

All approved amounts $0 $0


a day

Up to $161

a day

$0









18.02.312.1-MI K (12/15)

PLAN C (continued)



Plan Pays You Pay

BLOOD



HOSPICE CARE

You must meet Medicare’s requirements


illness


copayment/

coinsurance for



Medicare copayment/

coinsurance

$0

PLAN C



Plan Pays You Pay

MEDICAL EXPENSES



physician’s services, inpatient and outpatient




First $166 of Medicare-approved amounts* $0 $166

(Part B deductible)

$0







18.02.312.1-MI K (12/15)

PLAN C (continued)



Plan Pays You Pay

BLOOD


Next $166 of Medicare-approved amounts* $0 $166

(Part B deductible)

$0




PARTS A & B


Plan Pays You Pay

HOME HEALTH CARE


•

•



100% $0 $0


-

-


amounts*

$0 $166

(Part B deductible)

$0


amounts

80% 20% $0




18.02.312.1-MI K (12/15)

PLAN C OTHER BENEFITS – Not Covered by Medicare


Plan 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 such charges $0 80% to a lifetime

maximum benefit of

$50,000

20% and amounts

over the $50,000

lifetime maximum




18.02.312.1-MI K (12/15)

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PLAN F


Services Medicare Pays Plan F

Plan Pays You Pay

HOSPITALIZATION*




(Part A deductible)

$0


91st day and after:



-

-


eligible expenses

$0**









a day

Up to $161

a day

$0









18.02.312.1-MI K (12/15)

PLAN F (continued)



Plan Pays You Pay

BLOOD



HOSPICE CARE



illness


copayment/

coinsurance for



Medicare

copayment/

coinsurance

$0



Plan Pays You Pay

MEDICAL EXPENSES

IN OR OF THE HOSPITAL AND OUTPATIENT

HOSPITAL TREATMENTS, 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



approved amounts) $0 100% of all costs $0

BLOOD


Next $166 of Medicare-approved amounts* $0 $166

(Part B deductible)

$0





18.02.312.1-MI K (12/15)

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PLAN F (continued)



Plan Pays You Pay



PARTS A & B


Plan Pays You Pay

HOME HEALTH CARE




100% $0 $0


-

-


amounts*

$0 $166

(Part B deductible)

$0


amounts

80% 20% $0

OTHER BENEFITS – Not Covered by Medicare


Plan Pays You Pay

FOREIGN TRAVEL -




outside the USA



maximum benefit of

$50,000

20% and amounts

over the $50,000

lifetime maximum




18.02.312.1-MI K (12/15)

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PLAN G


Services Medicare Pays Plan G

Plan Pays You Pay

HOSPITALIZATION*




(Part A deductible)

$0


91st day and after:



-

-


eligible expenses

$0**







hospital


21st thru 100th day All but $161 a day Up to $161 a day $0


BLOOD



HOSPICE CARE



illness


copayment/coinsurance

for outpatient drugs and


Medicare copayment/

coinsurance

$0



**NOTICE – When your Medicare Part A Hospital benefits are exhausted, the insurer stands in the place of Medicare





18.02.312.1-MI K (12/15)

PLAN G



Plan Pays You Pay

MEDICAL EXPENSES


OUTPATIENT HOSPITAL TREATMENTS, 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)



approved amounts) $0 100% of all costs $0

BLOOD


Next $166 of Medicare-approved amounts* $0 $0 $166 (Part B

deductible)





asterisk), your Part B Deductible will have been met for the calendar year.


18.02.312.1-MI K (12/15)

•

•

PLAN G PARTS A & B


Plan Pays You Pay

HOME HEALTH CARE




100% $0 $0


-

-


amounts*

$0 $0 $166 (Part B

deductible)


amounts

80% 20% $0



Plan Pays You Pay

FOREIGN TRAVEL




outside the USA



maximum benefit of

$50,000

20% and amounts

over the $50,000

lifetime maximum

*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.


18.02.312.1-MI K (12/15)

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•

PLAN N


Services Medicare Pays Plan N

Plan Pays You Pay

HOSPITALIZATION*




(Part A deductible)

$0


91st day and after:



-

-


eligible expenses

$0**







hospital


21st thru 100th day All but $161 a day Up to $161 a day $0


BLOOD



HOSPICE CARE



illness


copayment/coinsurance

for outpatient drugs and


Medicare copayment/

coinsurance

$0



**NOTICE – When your Medicare Part A Hospital benefits are exhausted, the insurer stands in the place of Medicare





18.02.312.1-MI K (12/15)

PLAN N



Plan Pays You Pay

MEDICAL EXPENSES


OUTPATIENT HOSPITAL TREATMENTS, 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 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.

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.



BLOOD


Next $166 of Medicare-approved amounts* $0 $0 $166 (Part B

deductible)







18.02.312.1-MI K (12/15)

PLAN N PARTS A & B�


Plan Pays You Pay

HOME HEALTH CARE


•

•



100% $0 $0


-

-


Amounts*

$0 $0 $166 (Part B

Deductible)


amounts

80% 20% $0



Plan Pays You Pay

FOREIGN TRAVEL




outside the USA



maximum benefit of

$50,000

20% and amounts

over the $50,000

lifetime maximum




18.02.312.1-MI K (12/15)

•

•

•

•

•

Guaranteed Issue Guidelines Questions? We’re here to help.


(TTY: 711)

FOR INDIVIDUALS WHO ARE 65 YEARS OF AGE OR OLDER AT THE TIME OF ENROLLMENT:

In some situations, you are eligible for Guaranteed Issue of a Medicare Supplement Plan. If one of the following

conditions applies to you, you are eligible for an Aetna Individual Medicare Supplement PlanSM

on a guaranteed issue

basis (“Eligible Person”) and you will not be required to complete the Statement of Health Questions section of the

Application.

Open Enrollment - You are eligible for Guaranteed Issue if you are at least age 65 and apply for an Aetna Individual

Medicare Supplement Plan insurance policy prior to or during the six-month period beginning with the first day of the

month in which you are enrolled for benefits under Medicare Part B. You must submit evidence that you have Medicare

Parts A and B with your Application.

Other Situations - You are eligible for Guaranteed Issue for an Aetna Individual Medicare Supplement Plan insurance

policy if you apply for the policy in the guarantee issue time periods described below, you submit evidence of the date

of termination or disenrollment with the Application, and you meet one of the following conditions:

1. You are enrolled in an employee welfare benefit plan that provides health benefits that supplement the benefits

under Medicare, and the plan terminates or ceases to provide such supplemental health benefits to you;

2. You are enrolled with a Medicare Advantage organization under a Medicare Advantage Plan (the “Plan”) under

Medicare Part C or under a Program of All-Inclusive Care for the Elderly (PACE) and any of the following apply:

The certification of the organization or plan under this part has been terminated; or

The organization has terminated or otherwise discontinued providing the Plan in the area in which you

reside; or

You are no longer eligible to elect the Plan because:

(i) of a change in your place of residence or other change in circumstances specified by the Secretary of

the Department of Health and Human Services (the “Secretary”), excluding those circumstances

where you were disenrolled from the Plan for any of the reasons described in Section 1851 (g)(3)(B) of

the federal Social Security Act (e.g., where you have not paid premiums on a timely basis, or you have

engaged in disruptive behavior as specified in standards under Section 1856); or

(ii) the Plan is terminated for all enrollees residing within a particular residential service area; or

You demonstrate, in accordance with guidelines established by the Secretary, that:

(i) The organization offering the Plan substantially violated a material provision of the organization’s

contract with the Centers for Medicare and Medicaid Services in relation to you, including the failure

to provide you, on a timely basis, with medically necessary care for which benefits are available under

the Plan, or the failure to provide such covered care in accordance with applicable quality standards;

or

(ii) The organization or agent or other entity acting on the organization’s behalf, materially

misrepresented the Plan’s provisions in marketing the Plan to you; or

You meet such other exceptional conditions as the Secretary may provide.

GR-11613-05 – OOC GI – MI � 18.03.700.1–MI E (12/13)

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3. You are enrolled with:

An eligible organization under a contract under Section 1876 (Medicare cost); a similar organization

operating under demonstration project authority, effective for periods before April 1, 1999; an organization

under agreement under section 1833(a)(1 )(A) (health care prepayment plan); or an organization under a

Medicare SELECT policy; and

Your enrollment ceases under the same circumstances that would permit discontinuance of an individual’s

election of coverage under Section 2 above.

4. You are enrolled in a Medicare supplement policy and the enrollment ceases because:

Of the insolvency of the issuer or bankruptcy of the non-issuer organization; or

Of other involuntary termination of coverage or enrollment under the policy; or

The issuer of the policy substantially violated a material provision of the policy; or

The issuer or an agent or other entity acting on the issuer’s behalf, materially misrepresented the policy’s

provisions in marketing the policy to you.

5. You were enrolled under a Medicare supplement policy and you terminate enrollment and subsequently enroll, for

the first time, with; (1) any Medicare Advantage organization under a Medicare Advantage Plan under Medicare Part

C; (2) any eligible organization under a contract under Section 1876 (Medicare cost); (3) any similar organization

operating under demonstration project authority; (4) any PACE program under Section 1894 of the Social Security

Act; (5) any organization under an agreement under Section 1833(a)(1)(A) (health care prepayment plan); or (6) a

Medicare SELECT policy, and enrollment under this section is terminated by you during any period within the first 12

months of such subsequent enrollment (during which you are permitted to terminate such subsequent enrollment

under Section 1851(e) of the federal Social Security Act).

6. You, upon first becoming enrolled for benefits under Medicare Part A at age sixty-five or older, enroll in a Medicare

Advantage Plan under Medicare Part C, or in a PACE program under Section 1894 of the Social Security Act, and

disenroll from the plan by not later than 12 months after the effective date of enrollment.

7. You enroll in a Medicare Part D plan during the initial enrollment period and, at the time of enrollment in Part D,

were enrolled under a Medicare supplement policy that covers outpatient prescription drugs and you terminate

enrollment in the Medicare supplement policy and submit evidence of enrollment in Medicare Part D along with the

application for a policy.

Guaranteed Issue Time Periods

In the case of an individual described in situation #1, the guaranteed issue period begins on the later of: (i) the

date you receive a notice of termination or cessation of all supplemental health benefits (or, if a notice is not

received, notice that a claim has been denied because of such a termination or cessation); or (ii) the date that

the applicable coverage terminates or ceases; and ends sixty-three (63) days after the date of the applicable

notice;

In the case of an individual described in situations #2, #3, #5 or #6 whose enrollment terminated involuntarily,

the guaranteed issue period begins on the date that you receive a notice of termination and ends sixty-three

(63) days after the date the applicable coverage is terminated;

In the case of an individual described in situation #4 (insolvency of the issuer or bankruptcy of the non-issuer

organization), the guaranteed issue period begins on the earlier of: (i) the date that you receive a notice of

termination, a notice of the issuer’s bankruptcy or insolvency, or other such similar notice if any, and (ii) the

date that the applicable coverage is terminated, and ends on the date that is sixty-three (63) days after the date

the coverage is terminated;

GR-11613-05 – OOC GI – MI� 18.03.700.1–MI E (12/13)

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In the case of an individual described in situations #2, #4 (issuer or the policy substantially violated a material

provision of the policy), #4 (the issuer or an agent or other entity acting on the issuer’s behalf, materially

misrepresented the policy’s provisions in marketing the policy to you), #5 or #6, who disenrolls voluntarily, the

guaranteed issue period begins on the date that is sixty (60) days before the effective date of the disenrollment

and ends on the date that is sixty-three (63) days after the effective date;

In the case of an individual described in situation #7, the guaranteed issue period begins on the date you receive

notice from the Medicare supplement issuer during the sixty (60) day period immediately preceding the Part D

enrollment period and ends on the date that is sixty-three (63) days after the effective date of the individual’s

coverage under Medicare Part D; and

In the case of an individual described in this Guaranteed Issue Guide but not described in the preceding

situations, the guaranteed issue period begins on the effective date of disenrollment and ends on the date that

is sixty-three (63) days after the effective date.

Extended Medigap Access for Interrupted Trial Periods

In the case of an individual described in situation #5 whose enrollment with an organization or provider

described in item (1) is involuntarily terminated within the first twelve (12) months of enrollment, and who,

without an intervening enrollment, enrolls with another such organization or provider, the subsequent

enrollment shall be deemed to be an initial enrollment;

In the case of an individual described in situation #6, whose enrollment with a plan or in a program described in

situation #6 is involuntarily terminated within the first twelve (12) months of enrollment, and who, without an

intervening enrollment, enrolls in another such plan or program, the subsequent enrollment shall be deemed to

be an initial enrollment; and

For the purposes of situations #5 and #6, no enrollment of an individual with an organization or provider

described in #5 (1 through 6), or with a plan or in a program described in #6, may be deemed to be an initial

enrollment under this paragraph after the two-year period beginning on the date on which you first enrolled

with such an organization, provider, plan or program.

Products to which Eligible Persons are Entitled

The Aetna Individual Medicare Supplement Plan insurance policy to which Eligible Persons are entitled.

During Open Enrollment

An Eligible Person may enroll in Aetna Individual Medicare Supplement Plan insurance policy A, B, C, F, G or N.

During Other Situations

Under situations #1, #2, #3 and #4, an Eligible Person may enroll in a Medicare supplement policy which has a benefit

package classified as plan A, B, C, F or G.

Under situation #5, an Eligible Person may enroll in the same Medicare supplement policy in which you were most

recently previously enrolled, if available, or, if not so available, a policy described as plan A, B, C, F or G.

Under situation #6, an Eligible Person may enroll in any Medicare supplement policy offered by Aetna Life Insurance

Company.

Under situation #7, an Eligible Person may enroll in a Medicare supplement policy that has a benefit package classified

as Plan A, B, C or F and that is offered and is available for issuance to new enrollees by the same issuer that issued the

GR-11613-05 – OOC GI – MI� 18.03.700.1–MI E (12/13)

individual's Medicare supplement policy with outpatient prescription drug coverage.

FOR INDIVIDUALS WHO ARE LESS THAN AGE 65 AT THE TIME OF ENROLLMENT:

You may be eligible for Guaranteed Issue of a Medicare Supplement Plan. If the following applies to you, you are eligible

for an Aetna Individual Medicare Supplement PlanSM

on a guaranteed issue basis (“Eligible Person”).

Enrollment for under age 65 individuals is permitted only for the policies referenced below:

Open Enrollment - You are eligible for Guaranteed Issue if you become eligible for Medicare by reason of disability and

you apply for an Aetna Individual Medicare Supplement Plan insurance policy prior to or during the six-month period

beginning with the first day of the month in which you are enrolled for benefits under Medicare Part B. You must

submit evidence that you have Medicare Parts A and B with your Application.

You are also eligible for Guaranteed Issue if you are already enrolled in Medicare by reason of disability. You must

submit evidence that you have Medicare Parts A and B with your Application.

An Eligible Person may enroll in Aetna Individual Medicare Supplement Plan insurance policy A or C.

GR-11613-05 – OOC GI – MI 18.03.700.1–MI E (12/13)

aetna life insurance company outline of medicare ...€¦ · benefit plans a, b, c , f, g and n are...

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