outline of coverage - aetna · 2019-07-01 · aetna health and life insurance company ....

Aetna Health and Life Insurance Company

Administrative Office 800 Crescent Centre Dr. Suite 200 Franklin, TN 37067 800 264.4000 aetnaseniorproducts.com

Outline of Coverage Medicare Supplement Insurance BENEFIT PLANS A, B, F, HIGH DEDUCTIBLE F, G, N

Underwritten by

Aetna Health and Life Insurance Company

Alabama

AHLMS03850AL ©2016 Aetna Inc. Rates Effective: 08/2019 A

http://aetnaseniorproducts.com

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Aetna Health and Life Insurance Company Annual Premiums

For Use in ZIP Codes: 350-352Female Rates

Rates Effective 08/01/2019

Attained Age

Preferred Plan A Plan B Plan F Plan HF Plan G Plan N

65 1,504 1,662 1,927 770 1,534 1,082 66 1,504 1,662 1,927 770 1,534 1,108 67 1,504 1,662 1,927 770 1,534 1,134 68 1,522 1,682 1,951 780 1,553 1,175 69 1,555 1,718 1,992 797 1,585 1,228 70 1,597 1,763 2,046 818 1,627 1,288 71 1,644 1,817 2,108 842 1,676 1,325 72 1,696 1,873 2,173 869 1,728 1,368 73 1,750 1,934 2,243 897 1,785 1,411 74 1,813 2,002 2,322 929 1,847 1,461 75 1,879 2,075 2,408 963 1,915 1,515 76 1,945 2,148 2,491 996 1,981 1,568 77 2,009 2,219 2,575 1,031 2,049 1,621 78 2,075 2,291 2,660 1,063 2,116 1,673 79 2,142 2,367 2,746 1,099 2,184 1,728 80 2,210 2,442 2,834 1,133 2,253 1,782 81 2,281 2,517 2,922 1,169 2,324 1,837 82 2,352 2,596 3,014 1,205 2,396 1,895 83 2,423 2,676 3,106 1,242 2,471 1,955 84 2,499 2,759 3,201 1,280 2,546 2,015 85 2,585 2,854 3,312 1,325 2,635 2,085 86 2,660 2,938 3,407 1,363 2,710 2,143 87 2,735 3,020 3,504 1,401 2,787 2,204 88 2,812 3,105 3,603 1,441 2,865 2,266 89 2,889 3,191 3,702 1,481 2,945 2,329 90 2,969 3,279 3,805 1,522 3,026 2,393 91 3,049 3,369 3,908 1,563 3,108 2,458 92 3,131 3,459 4,014 1,605 3,192 2,524 93 3,216 3,551 4,119 1,648 3,278 2,592 94 3,301 3,644 4,229 1,693 3,363 2,661 95 3,387 3,740 4,340 1,735 3,451 2,729 96 3,473 3,836 4,451 1,780 3,541 2,799 97 3,562 3,935 4,567 1,826 3,631 2,873 98 3,653 4,034 4,681 1,873 3,723 2,945

99+ 3,743 4,136 4,799 1,920 3,816 3,017

Attained Age

Standard Plan A Plan B Plan F Plan HF Plan G Plan N

65 1,672 1,846 2,141 857 1,704 1,202 66 1,672 1,846 2,141 857 1,704 1,231 67 1,672 1,846 2,141 857 1,704 1,260 68 1,692 1,869 2,168 866 1,725 1,305 69 1,728 1,908 2,214 887 1,762 1,364 70 1,775 1,959 2,272 910 1,808 1,430 71 1,827 2,018 2,341 937 1,863 1,473 72 1,884 2,081 2,414 966 1,920 1,520 73 1,946 2,149 2,492 996 1,982 1,568 74 2,015 2,226 2,581 1,032 2,052 1,624 75 2,087 2,304 2,675 1,070 2,128 1,684 76 2,160 2,385 2,768 1,107 2,201 1,743 77 2,233 2,465 2,862 1,144 2,277 1,800 78 2,304 2,545 2,955 1,182 2,351 1,858 79 2,381 2,631 3,051 1,221 2,426 1,919 80 2,456 2,714 3,148 1,260 2,503 1,980 81 2,533 2,797 3,248 1,299 2,583 2,042 82 2,613 2,886 3,349 1,340 2,662 2,106 83 2,693 2,974 3,452 1,381 2,746 2,171 84 2,777 3,066 3,558 1,423 2,829 2,238 85 2,873 3,172 3,682 1,473 2,928 2,315 86 2,955 3,263 3,786 1,515 3,010 2,381 87 3,039 3,356 3,893 1,557 3,097 2,449 88 3,124 3,451 4,004 1,601 3,183 2,517 89 3,210 3,546 4,114 1,646 3,272 2,589 90 3,299 3,643 4,227 1,692 3,361 2,660 91 3,388 3,742 4,342 1,736 3,453 2,732 92 3,480 3,844 4,460 1,784 3,546 2,805 93 3,573 3,945 4,577 1,830 3,641 2,879 94 3,667 4,049 4,700 1,880 3,737 2,956 95 3,763 4,156 4,823 1,928 3,835 3,034 96 3,859 4,264 4,946 1,979 3,935 3,111 97 3,958 4,371 5,073 2,029 4,034 3,190 98 4,058 4,481 5,201 2,081 4,136 3,272

99+ 4,159 4,595 5,332 2,133 4,240 3,352 Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833

The above rates do not include the $20 one-time policy fee.

To calculate a Household discount:Annual premium x modal factor = modal premium (round to nearest whole cent)Modal premium x .93 = discounted premium

AHLMS03850AL 2 08/2019 A


For Use in ZIP Codes: 350-352Male Rates


Attained Age


65 1,730 1,910 2,217 887 1,764 1,244 66 1,730 1,910 2,217 887 1,764 1,274 67 1,730 1,910 2,217 887 1,764 1,304 68 1,750 1,935 2,243 897 1,786 1,351 69 1,788 1,976 2,291 917 1,823 1,411 70 1,837 2,028 2,353 941 1,870 1,480 71 1,890 2,089 2,423 968 1,928 1,524 72 1,950 2,153 2,499 999 1,987 1,573 73 2,014 2,223 2,581 1,032 2,052 1,623 74 2,085 2,302 2,671 1,068 2,125 1,681 75 2,161 2,385 2,768 1,108 2,201 1,742 76 2,236 2,470 2,865 1,146 2,279 1,804 77 2,311 2,552 2,961 1,185 2,357 1,863 78 2,385 2,636 3,057 1,223 2,432 1,924 79 2,464 2,721 3,158 1,264 2,512 1,987 80 2,542 2,808 3,258 1,303 2,591 2,049 81 2,622 2,895 3,360 1,344 2,673 2,113 82 2,704 2,987 3,465 1,386 2,755 2,180 83 2,787 3,078 3,573 1,429 2,842 2,249 84 2,874 3,173 3,682 1,473 2,929 2,315 85 2,973 3,282 3,810 1,523 3,030 2,396 86 3,057 3,378 3,917 1,568 3,117 2,465 87 3,146 3,473 4,030 1,611 3,206 2,535 88 3,232 3,572 4,143 1,656 3,294 2,606 89 3,322 3,670 4,258 1,704 3,387 2,678 90 3,414 3,770 4,375 1,750 3,479 2,753 91 3,506 3,873 4,493 1,798 3,574 2,827 92 3,602 3,978 4,615 1,847 3,672 2,902 93 3,699 4,084 4,736 1,896 3,770 2,980 94 3,795 4,191 4,863 1,947 3,868 3,060 95 3,895 4,301 4,989 1,997 3,968 3,138 96 3,994 4,412 5,120 2,048 4,073 3,219 97 4,097 4,525 5,251 2,100 4,175 3,302 98 4,199 4,639 5,385 2,153 4,281 3,387

99+ 4,305 4,755 5,518 2,208 4,388 3,470

Attained Age


65 1,923 2,123 2,463 985 1,959 1,382 66 1,923 2,123 2,463 985 1,959 1,415 67 1,923 2,123 2,463 985 1,959 1,449 68 1,946 2,150 2,493 996 1,984 1,502 69 1,987 2,193 2,545 1,020 2,026 1,567 70 2,041 2,253 2,613 1,046 2,079 1,644 71 2,101 2,321 2,692 1,077 2,142 1,694 72 2,166 2,393 2,775 1,111 2,209 1,748 73 2,237 2,471 2,866 1,146 2,280 1,804 74 2,317 2,559 2,968 1,187 2,360 1,868 75 2,399 2,650 3,077 1,229 2,448 1,935 76 2,484 2,744 3,183 1,273 2,532 2,004 77 2,569 2,836 3,291 1,316 2,617 2,070 78 2,650 2,928 3,399 1,360 2,704 2,137 79 2,738 3,025 3,509 1,403 2,791 2,207 80 2,824 3,120 3,621 1,449 2,879 2,278 81 2,914 3,217 3,734 1,493 2,969 2,350 82 3,006 3,319 3,851 1,541 3,061 2,422 83 3,097 3,420 3,969 1,588 3,157 2,498 84 3,195 3,525 4,090 1,636 3,255 2,572 85 3,303 3,649 4,235 1,694 3,367 2,663 86 3,399 3,753 4,353 1,743 3,462 2,737 87 3,495 3,858 4,477 1,792 3,562 2,816 88 3,592 3,967 4,603 1,840 3,661 2,896 89 3,692 4,078 4,731 1,894 3,763 2,977 90 3,794 4,190 4,862 1,946 3,866 3,059 91 3,896 4,303 4,995 1,998 3,970 3,142 92 4,003 4,421 5,129 2,052 4,078 3,226 93 4,109 4,539 5,264 2,106 4,188 3,310 94 4,218 4,656 5,405 2,162 4,298 3,400 95 4,327 4,780 5,544 2,218 4,410 3,489 96 4,439 4,903 5,688 2,277 4,524 3,579 97 4,552 5,027 5,834 2,334 4,639 3,670 98 4,666 5,154 5,981 2,393 4,756 3,762



To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium

AHLMS03850AL 3 08/2019 A


For Use in: Rest of StateFemale Rates


Attained Age


65 1,355 1,497 1,736 694 1,382 975 66 1,355 1,497 1,736 694 1,382 998 67 1,355 1,497 1,736 694 1,382 1,022 68 1,371 1,515 1,758 703 1,399 1,059 69 1,401 1,548 1,795 718 1,428 1,106 70 1,439 1,588 1,843 737 1,466 1,160 71 1,481 1,637 1,899 759 1,510 1,194 72 1,528 1,687 1,958 783 1,557 1,232 73 1,577 1,742 2,021 808 1,608 1,271 74 1,633 1,804 2,092 837 1,664 1,316 75 1,693 1,869 2,169 868 1,725 1,365 76 1,752 1,935 2,244 897 1,785 1,413 77 1,810 1,999 2,320 929 1,846 1,460 78 1,869 2,064 2,396 958 1,906 1,507 79 1,930 2,132 2,474 990 1,968 1,557 80 1,991 2,200 2,553 1,021 2,030 1,605 81 2,055 2,268 2,632 1,053 2,094 1,655 82 2,119 2,339 2,715 1,086 2,159 1,707 83 2,183 2,411 2,798 1,119 2,226 1,761 84 2,251 2,486 2,884 1,153 2,294 1,815 85 2,329 2,571 2,984 1,194 2,374 1,878 86 2,396 2,647 3,069 1,228 2,441 1,931 87 2,464 2,721 3,157 1,262 2,511 1,986 88 2,533 2,797 3,246 1,298 2,581 2,041 89 2,603 2,875 3,335 1,334 2,653 2,098 90 2,675 2,954 3,428 1,371 2,726 2,156 91 2,747 3,035 3,521 1,408 2,800 2,214 92 2,821 3,116 3,616 1,446 2,876 2,274 93 2,897 3,199 3,711 1,485 2,953 2,335 94 2,974 3,283 3,810 1,525 3,030 2,397 95 3,051 3,369 3,910 1,563 3,109 2,459 96 3,129 3,456 4,010 1,604 3,190 2,522 97 3,209 3,545 4,114 1,645 3,271 2,588 98 3,291 3,634 4,217 1,687 3,354 2,653

99+ 3,372 3,726 4,323 1,730 3,438 2,718

Attained Age


65 1,506 1,663 1,929 772 1,535 1,083 66 1,506 1,663 1,929 772 1,535 1,109 67 1,506 1,663 1,929 772 1,535 1,135 68 1,524 1,684 1,953 780 1,554 1,176 69 1,557 1,719 1,995 799 1,587 1,229 70 1,599 1,765 2,047 820 1,629 1,288 71 1,646 1,818 2,109 844 1,678 1,327 72 1,697 1,875 2,175 870 1,730 1,369 73 1,753 1,936 2,245 897 1,786 1,413 74 1,815 2,005 2,325 930 1,849 1,463 75 1,880 2,076 2,410 964 1,917 1,517 76 1,946 2,149 2,494 997 1,983 1,570 77 2,012 2,221 2,578 1,031 2,051 1,622 78 2,076 2,293 2,662 1,065 2,118 1,674 79 2,145 2,370 2,749 1,100 2,186 1,729 80 2,213 2,445 2,836 1,135 2,255 1,784 81 2,282 2,520 2,926 1,170 2,327 1,840 82 2,354 2,600 3,017 1,207 2,398 1,897 83 2,426 2,679 3,110 1,244 2,474 1,956 84 2,502 2,762 3,205 1,282 2,549 2,016 85 2,588 2,858 3,317 1,327 2,638 2,086 86 2,662 2,940 3,411 1,365 2,712 2,145 87 2,738 3,023 3,507 1,403 2,790 2,206 88 2,814 3,109 3,607 1,442 2,868 2,268 89 2,892 3,195 3,706 1,483 2,948 2,332 90 2,972 3,282 3,808 1,524 3,028 2,396 91 3,052 3,371 3,912 1,564 3,111 2,461 92 3,135 3,463 4,018 1,607 3,195 2,527 93 3,219 3,554 4,123 1,649 3,280 2,594 94 3,304 3,648 4,234 1,694 3,367 2,663 95 3,390 3,744 4,345 1,737 3,455 2,733 96 3,477 3,841 4,456 1,783 3,545 2,803 97 3,566 3,938 4,570 1,828 3,634 2,874 98 3,656 4,037 4,686 1,875 3,726 2,948




AHLMS03850AL 4 08/2019 A


For Use in: Rest of StateMale Rates


Attained Age


65 1,559 1,721 1,997 799 1,589 1,121 66 1,559 1,721 1,997 799 1,589 1,148 67 1,559 1,721 1,997 799 1,589 1,175 68 1,577 1,743 2,021 808 1,609 1,217 69 1,611 1,780 2,064 826 1,642 1,271 70 1,655 1,827 2,120 848 1,685 1,333 71 1,703 1,882 2,183 872 1,737 1,373 72 1,757 1,940 2,251 900 1,790 1,417 73 1,814 2,003 2,325 930 1,849 1,462 74 1,878 2,074 2,406 962 1,914 1,514 75 1,947 2,149 2,494 998 1,983 1,569 76 2,014 2,225 2,581 1,032 2,053 1,625 77 2,082 2,299 2,668 1,068 2,123 1,678 78 2,149 2,375 2,754 1,102 2,191 1,733 79 2,220 2,451 2,845 1,139 2,263 1,790 80 2,290 2,530 2,935 1,174 2,334 1,846 81 2,362 2,608 3,027 1,211 2,408 1,904 82 2,436 2,691 3,122 1,249 2,482 1,964 83 2,511 2,773 3,219 1,287 2,560 2,026 84 2,589 2,859 3,317 1,327 2,639 2,086 85 2,678 2,957 3,432 1,372 2,730 2,159 86 2,754 3,043 3,529 1,413 2,808 2,221 87 2,834 3,129 3,631 1,451 2,888 2,284 88 2,912 3,218 3,732 1,492 2,968 2,348 89 2,993 3,306 3,836 1,535 3,051 2,413 90 3,076 3,396 3,941 1,577 3,134 2,480 91 3,159 3,489 4,048 1,620 3,220 2,547 92 3,245 3,584 4,158 1,664 3,308 2,614 93 3,332 3,679 4,267 1,708 3,396 2,685 94 3,419 3,776 4,381 1,754 3,485 2,757 95 3,509 3,875 4,495 1,799 3,575 2,827 96 3,598 3,975 4,613 1,845 3,669 2,900 97 3,691 4,077 4,731 1,892 3,761 2,975 98 3,783 4,179 4,851 1,940 3,857 3,051

99+ 3,878 4,284 4,971 1,989 3,953 3,126

Attained Age


65 1,732 1,913 2,219 887 1,765 1,245 66 1,732 1,913 2,219 887 1,765 1,275 67 1,732 1,913 2,219 887 1,765 1,305 68 1,753 1,937 2,246 897 1,787 1,353 69 1,790 1,976 2,293 919 1,825 1,412 70 1,839 2,030 2,354 942 1,873 1,481 71 1,893 2,091 2,425 970 1,930 1,526 72 1,951 2,156 2,500 1,001 1,990 1,575 73 2,015 2,226 2,582 1,032 2,054 1,625 74 2,087 2,305 2,674 1,069 2,126 1,683 75 2,161 2,387 2,772 1,107 2,205 1,743 76 2,238 2,472 2,868 1,147 2,281 1,805 77 2,314 2,555 2,965 1,186 2,358 1,865 78 2,387 2,638 3,062 1,225 2,436 1,925 79 2,467 2,725 3,161 1,264 2,514 1,988 80 2,544 2,811 3,262 1,305 2,594 2,052 81 2,625 2,898 3,364 1,345 2,675 2,117 82 2,708 2,990 3,469 1,388 2,758 2,182 83 2,790 3,081 3,576 1,431 2,844 2,250 84 2,878 3,176 3,685 1,474 2,932 2,317 85 2,976 3,287 3,815 1,526 3,033 2,399 86 3,062 3,381 3,922 1,570 3,119 2,466 87 3,149 3,476 4,033 1,614 3,209 2,537 88 3,236 3,574 4,147 1,658 3,298 2,609 89 3,326 3,674 4,262 1,706 3,390 2,682 90 3,418 3,775 4,380 1,753 3,483 2,756 91 3,510 3,877 4,500 1,800 3,577 2,831 92 3,606 3,983 4,621 1,849 3,674 2,906 93 3,702 4,089 4,742 1,897 3,773 2,982 94 3,800 4,195 4,869 1,948 3,872 3,063 95 3,898 4,306 4,995 1,998 3,973 3,143 96 3,999 4,417 5,124 2,051 4,076 3,224 97 4,101 4,529 5,256 2,103 4,179 3,306 98 4,204 4,643 5,388 2,156 4,285 3,389




AHLMS03850AL 5 08/2019 A

PREMIUM INFORMATION Aetna Health and Life Insurance Company can only raise your premium if we raise the premium for all policies like yours in this state. Premiums for this policy will increase due to the increase in your age. Upon attainment of an age requiring a rate increase, the renewal premium for the policy will be the renewal premium then in effect for your attained age. Other policies may be provided with Issue Age rating and do not increase with age. You should compare Issue Age with Attained Age policies. Premiums payable other than annually will be determined according to the following factors:

Semi-annual: 0.5200 Quarterly: 0.2650 Monthly EFT: 0.0833.

DISCLOSURES Use this outline to compare benefits and premium among policies.

HOUSEHOLD DISCOUNT In order to be eligible for the Household discount under an Aetna Health and Life Insurance Company Medicare supplement plan, you must apply for a Medicare supplement plan at the same time as another Medicare eligible adult or the other Medicare eligible adult must currently be covered by an Aetna Health and Life Insurance Company Medicare supplement policy. The Medicare eligible adult must be either (a) your spouse; (b) be someone with whom you are in a civil union partnership; and (c) be someone with whom you have continuously resided for the past 12 months. The household discount will only be applicable if a policy for each applicant is issued. The discounted rate will be 7 percent lower than the individual rates.

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 POLICYIf you find that you are not satisfied with your policy, you may return it to Aetna Health and Life Insurance Company, P.O. Box 14770, Lexington, KY 40512-4770. 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 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 cover all of your medical costs.

Neither Aetna Health and 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 any 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.

THE FOLLOWING CHARTS DESCRIBE PLANS A, B, F, HIGH DEDUCTIBLE F, G and N OFFERED BY AETNA HEALTH AND LIFE INSURANCE COMPANY.

AHLMS03850AL 6 08/2019 A

PLAN AMEDICARE (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 PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1364 $0 $1364

(Part A Deductible)

61st thru 90th day All but $341 a day $341 a day $0 91st day and after •While using 60 lifetime reserve days All but $682 a day $682 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 $170.50 a day $0 Up to $170.50 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.

AHLMS03850AL 7 08/2019 A

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

*Once you have been billed $185 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 andsupplies, physical and speech therapy, diagnostic tests, durable medical equipment First $185 of Medicare-Approved amounts*

$0 $0 $185 (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 $185 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 $185 of Medicare Approved amounts*


•Remainder of Medicare Approved amounts 80% 20% $0

AHLMS03850AL 8 08/2019 A

PLAN BMEDICARE (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

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1364 $1364

(Part A Deductible) $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 $170.50 a day

$0 Up to $170.50 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 thepolicy’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.

AHLMS03850AL 9 08/2019 A

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

* Once you have been billed $185 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 $185 of Medicare-Approved amounts*


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 $185 of Medicare-Approved amounts*



PARTS A & B


PLAN PAYS

YOU PAY


100% $0 $0




AHLMS03850AL 10 08/2019 A

PLAN FMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY






amounts $0 $0


Up to $170.50 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

**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.

AHLMS03850AL 11 08/2019 A

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



PLAN PAYS

YOU PAY


$0 $185 (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 $185 of Medicare-Approved amounts*


$0


PARTS A & B


PLAN PAYS

YOU PAY


100% $0 $0



$0


AHLMS03850AL 12 08/2019 A

PLAN FOTHER 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

AHLMS03850AL 13 08/2019 A

HIGH DEDUCTIBLE PLAN FMEDICARE (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 endsafter 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 $2300 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2300. 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.


AFTER YOU PAY $2300

DEDUCTIBLE*** PLAN PAYS

IN ADDITION TO $2300

DEDUCTIBLE*** YOU PAY



61st thru 90th day All but $341 a day $341 a day $0 91st day and after •While using 60 lifetime reservedays All but $682 a day $682 a day $0 •Once lifetime reserve days areused: •Additional 365 days $0 100% of Medicare



amounts $0 $0


Up to $170.50 a day

$0

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

AHLMS03850AL 14 08/2019 A

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



$0


AHLMS03850AL 15 08/2019 A

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

*Once you have been billed $185 of Medicare-Approved amounts for covered services (which arenoted 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 $2300 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2300. 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.


AFTER YOU PAY $2300






$0



$0


AHLMS03850AL 16 08/2019 A

HIGH DEDUCTIBLE PLAN F

PARTS A & B


AFTER YOU PAY $2300





100% $0 $0



$0


OTHER BENEFITS – NOT COVERED BY MEDICARE


AFTER YOU PAY $2300

DEDUCTIBLE** PLAN PAYS


DEDUCTIBLE** YOU PAY




AHLMS03850AL 17 08/2019 A

PLAN GMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY






amounts $0 $0


Up to $170.50 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


AHLMS03850AL 18 08/2019 A

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



PLAN PAYS

YOU PAY






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 $185 of Medicare Approved amounts*



AHLMS03850AL 19 08/2019 A

PLAN G


SERVICES MEDICARE PAYS PLAN PAYS YOU PAY




AHLMS03850AL 20 08/2019 A

PLAN NMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



PLAN PAYS

YOU PAY






amounts $0 $0


Up to $170.50 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


AHLMS03850AL 21 08/2019 A

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



PLAN PAYS

YOU PAY


$0 $0 $185

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.

(Part B Deductible) 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 $185 of Medicare-Approved amounts*



AHLMS03850AL 22 08/2019 A

PLAN N

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 $185 of Medicare Approved amounts*





PLAN PAYS

YOU PAY

FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during thefirst 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


AHLMS03850AL 23 08/2019 A

outline of coverage - aetna · 2019-07-01 · aetna health and life insurance company ....

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