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Outline of CoverageMedicare Supplement Insurance

Underwritten by

Aetna Health and Life Insurance Company

Administrative Office800 Crescent Centre Dr.Suite 200Franklin, TN 37067800 264.4000aetnaseniorproducts.com

Aetna Health and Life Insurance Company

Rates Effective:

BENEFIT PLANS: A, B, F, HF, G, & N

TENNESSEE

AHLMS03614TN ©2017 Aetna Inc. 01/2017A

AH

LMS0

3614

TN

1 01

/201

7 A

AETN

A H

EALT

H A

ND

LIF

E IN

SUR

ANC

E C

OM

PAN

Y O

UTL

INE

OF

MED

ICAR

E SU

PPLE

MEN

T C

OVE

RAG

E C

OVE

R P

AGE:

Pag

e 1

of 2

B

ENEF

IT P

LAN

S AV

AILA

BLE

: A, B

, F, H

IGH

DED

UC

TIB

LE F

, G, N

Th

ese

char

ts s

how

the

bene

fits

incl

uded

in e

ach

of th

e st

anda

rd M

edic

are

supp

lem

ent p

lans

. Eve

ry c

om

pa

ny m

ust

ma

ke

ava

ilable

Pla

n “

A”

Som

e pl

ans

may

not

be

avai

labl

e in

you

r sta

te.

See

Out

lines

of C

over

age

sect

ions

for d

etai

ls a

bout

ALL

pla

ns

Bas

ic B

enef

its:

Hos

pita

lizat

ion:

Par

t A c

oins

uran

ce p

lus

cove

rage

for 3

65 a

dditi

onal

day

s af

ter M

edic

are

bene

fits

end.

M

edic

al E

xpen

ses:

Par

t B c

oins

uran

ce (g

ener

ally

20%

of M

edic

are-

Appr

oved

exp

ense

s) o

r, co

-pay

men

ts fo

r hos

pita

l out

patie

nt s

ervi

ces.

Pla

ns

K, L

, and

N re

quire

insu

reds

to p

ay a

por

tion

of c

oins

uran

ce o

r cop

aym

ents

Bl

ood:

Firs

t thr

ee p

ints

of b

lood

eac

h ye

ar.

H

ospi

ce-P

art A

coi

nsur

ance

A

B

C

D

F/F*

G

K

L

M

N

Basi

c,

incl

udin

g 10

0% P

art B

co

insu

ranc

e

Basi

c,

incl

udin

g 10

0% P

art B

co

insu

ranc

e

Basi

c,

incl

udin

g 10

0% P

art B

co

insu

ranc

e

Basi

c,

incl

udin

g 10

0% P

art B

co

insu

ranc

e

Basi

c,

incl

udin

g 10

0% P

art B

co

insu

ranc

e

Basi

c,

incl

udin

g 10

0% P

art B

co

insu

ranc

e

Hos

pita

lizat

ion

and

prev

entiv

e ca

re p

aid

at

100%

; oth

er

basi

c be

nefit

s pa

id a

t 50%

Hos

pita

lizat

ion

and

prev

entiv

e ca

re p

aid

at

100%

; oth

er

basi

c be

nefit

s pa

id a

t 75%

Basi

c,

incl

udin

g 10

0% P

art B

co

insu

ranc

e

Basi

c, in

clud

ing

100%

Par

t B

coin

sura

nce,

exc

ept

up to

$20

cop

aym

ent

for o

ffice

vis

it, a

nd

up to

$50

cop

aym

ent

for E

R

Skille

d N

ursi

ng

Faci

lity

Coi

nsur

ance

Skille

d N

ursi

ng

Faci

lity

Coi

nsur

ance

Skille

d N

ursi

ng

Faci

lity

Coi

nsur

ance

Skille

d N

ursi

ng

Faci

lity

Coi

nsur

ance

50%

Ski

lled

Nur

sing

Fa

cilit

y C

oins

uran

ce

75%

Ski

lled

Nur

sing

Fac

ility

Coi

nsur

ance

Skille

d N

ursi

ng

Faci

lity

Coi

nsur

ance

Skille

d N

ursi

ng

Faci

lity

Coi

nsur

ance

Pa

rt A

Ded

uctib

le

Part

A D

educ

tible

Pa

rt A

Ded

uctib

le

Part

A D

educ

tible

Pa

rt A

Ded

uctib

le

50%

Par

t A

Ded

uctib

le

75%

Par

t A

Ded

uctib

le

50%

Par

t A

Ded

uctib

le

Part

A D

educ

tible

Part

B D

educ

tible

Part

B D

educ

tible

Part

B Ex

cess

(1

00%

)

Part

B Ex

cess

(1

00%

)

Fore

ign

Trav

el

Emer

genc

y

Fore

ign

Trav

el

Emer

genc

y

Fore

ign

Trav

el

Emer

genc

y

Fore

ign

Trav

el

Emer

genc

y

Fore

ign

Trav

el

Emer

genc

y

Fore

ign

Trav

el

Emer

genc

y

Out

-of-p

ocke

t lim

it $5

,120

; pa

id a

t 100

%

afte

r lim

it re

ache

d

Out

-of-p

ocke

t lim

it $2

,560

; pa

id a

t 100

%

afte

r lim

it re

ache

d

*Pla

ns F

als

o ha

s an

opt

ion

calle

d a

high

ded

uctib

le p

lan

F. T

his

high

ded

uctib

le p

lan

pays

the

sam

e be

nefit

s as

Pla

n F

afte

r on

e ha

s pa

id a

cal

enda

r ye

ar

$2,2

00 d

educ

tible

. Ben

efits

from

hig

h de

duct

ible

pla

n F

will

not b

egin

unt

il ou

t-of-p

ocke

t exp

ense

s ex

ceed

$2,

200.

O

ut-o

f-poc

ket e

xpen

ses

for

this

ded

uctib

le

are

expe

nses

that

wou

ld o

rdin

arily

be

paid

by

the

polic

y. T

hese

exp

ense

s in

clud

e th

e M

edic

are

dedu

ctib

les

for

Part

A an

d Pa

rt B

, but

do n

ot

inclu

de t

he p

lan’s

se

para

te fo

reig

n tra

vel e

mer

genc

y de

duct

ible

.

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FP

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HF

Pla

n G

Pla

n N

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lan

AP

lan

BP

lan

FP

lan

HF

Pla

n G

Pla

n N

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r 6

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8

4,5

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n/a

n/a

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AHLMS03614TN 5 01/2017 A

PLAN A MEDICARE (PART A) – MEDICAL SERVICES – PER CALENDAR YEAR

*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 PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1316 $0 $1316 (Part A Deductible)

61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 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 $164.50 a day $0 Up to $164.50 a

day 101st 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.

AHLMS03614TN 6 01/2017 A

PLAN A

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR *Once you have been billed $183 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 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 $183 of Medicare-Approved amounts*

$0 $0 $183 (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 BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*


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 $183 of Medicare Approved amounts*


Remainder of Medicare Approved amounts 80% 20% $0

AHLMS03614TN 7 01/2017 A

PLAN B 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.


PLAN PAYS

YOU PAY


First 60 days All but $1316 $1316 (Part A Deductible)

$0



$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 $164.50 a day

$0 Up to $164.50 a day

101st 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.



$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 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.

AHLMS03614TN 8 01/2017 A

PLAN B MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

* Once you have been billed $183 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 PAYS

YOU PAY




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 $183 of Medicare-Approved amounts*


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



100% $0 $0

Durable medical equipment First $183 of Medicare Approved amounts*



AHLMS03614TN 9 01/2017 A

PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $164.50 a day

$0

101st 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.



$0


AHLMS03614TN 10 01/2017 A

PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

*Once you have been billed $183 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 PAYS

YOU PAY



$0 $183 (Part B Deductible)

$0

Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*


$0


PARTS A & B


PLAN PAYS

YOU PAY



100% $0 $0



$0


AHLMS03614TN 11 01/2017 A

PLAN F

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 charges $0 80% to a lifetime

maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum

AHLMS03614TN 12 01/2017 A

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. ***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,200 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses are $2,200. 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.

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2,200

DEDUCTIBLE*** PLAN PAYS

IN ADDITION TO $2,200

DEDUCTIBLE*** YOU PAY



$0



$0**




$0 $0


Up to $164.50 a day

$0

101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0

AHLMS03614TN 13 01/2017 A

HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.



$0


AHLMS03614TN 14 01/2017 A

HIGH DEDUCTIBLE PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

*Once you have been billed $183 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. ***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,200 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses are $2,200. 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.

SERVICES

MEDICARE PAYS








$0



$0


AHLMS03614TN 15 01/2017 A

HIGH DEDUCTIBLE PLAN F

PARTS A & B

SERVICES

MEDICARE PAYS







100% $0 $0



$0



SERVICES

MEDICARE PAYS


DEDUCTIBLE** PLAN PAYS


DEDUCTIBLE** YOU PAY





AHLMS03614TN 16 01/2017 A

PLAN 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.


PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $164.50 a day

$0

101st 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 services



$0


AHLMS03614TN 17 01/2017 A

PLAN G MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

*Once you have been billed $183 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 PAYS

YOU PAY







PARTS A & B


PLAN PAYS

YOU PAY


Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $183 of Medicare Approved amounts*



AHLMS03614TN 18 01/2017 A

PLAN G



PLAN PAYS

YOU PAY





AHLMS03614TN 19 01/2017 A

PLAN N MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $164.50 a day

$0

101st 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 services


Medicare co-payment/ coinsurance

$0


AHLMS03614TN 20 01/2017 A

PLAN N

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR *Once you have been billed $183 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 PAYS

YOU PAY




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 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 $183 of Medicare-Approved amounts*



AHLMS03614TN 21 01/2017 A

PLAN N

PARTS A & B


PLAN PAYS

YOU PAY


Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $183 of Medicare Approved amounts*





PLAN PAYS

YOU PAY


First $250 each calendar year $0 $0 $250

Remainder of charges $0 80% to a lifetime maximum benefit of $50,000


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