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BENEFIT PLANS A, B, D, F, HIGH DEDUCTIBLE F, G, N

ILLINOIS

AHLMS02763IL ©2017 Aetna Inc. 05/2017 A

AHLM

S027

63IL

1

05

/201

7 A

AETN

A H

EALT

H A

ND

LIF

E IN

SUR

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E C

OM

PAN

Y

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TLIN

E O

F M

EDIC

ARE

SUPP

LEM

ENT

CO

VER

AGE

CO

VER

PAG

E: P

age

1 of

2

BEN

EFIT

PLA

NS

AVAI

LAB

LE: A

, B, D

, F, H

IGH

DED

UC

TIB

LE F

, G, N

Th

ese

char

ts s

how

the b

enefits

in

clu

de

d in e

ach

of

the s

tand

ard

Me

dic

are

su

pp

lem

ent

pla

ns. E

ve

ry c

om

pa

ny m

ust m

ake

ava

ilable

Pla

n “

A”

Som

e pl

ans

may

not

be

avai

labl

e in

you

r sta

te.

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

paym

ents

for h

ospi

tal o

utpa

tient

ser

vice

s.

Plan

s K,

L, a

nd N

requ

ire in

sure

ds to

pay

a p

ortio

n of

coi

nsur

ance

or c

opay

men

ts

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d: F

irst t

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pin

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f blo

od e

ach

year

.

Hos

pice

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t A c

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ce

A

B

C

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F/F*

G

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L

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g 10

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co

insu

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incl

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g 10

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Basi

c,

incl

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g 10

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co

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Basi

c,

incl

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g 10

0% P

art B

co

insu

ranc

e

Basi

c,

incl

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g 10

0% P

art B

co

insu

ranc

e

Hos

pita

lizat

ion

and

prev

entiv

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re p

aid

at

100%

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er

basi

c be

nefit

s pa

id a

t 50%

Hos

pita

lizat

ion

and

prev

entiv

e ca

re p

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at

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; oth

er

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co

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Basi

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t B

coin

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paym

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or o

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up to

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co

paym

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or E

R

Skille

d N

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nsur

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Faci

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nsur

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lity

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Faci

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nsur

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50%

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cilit

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Part

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Part

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Out

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it $2

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it re

ache

d

*Pla

n F

also

has

an

optio

n ca

lled

a hi

gh d

educ

tible

pla

n F.

Thi

s hi

gh d

educ

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pla

n pa

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e sa

me

bene

fits

as P

lan

F af

ter

one

has

paid

a c

alen

dar

year

$2

,200

ded

uctib

le.

Bene

fits

from

hig

h de

duct

ible

pla

n F

will

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n un

til o

ut-o

f-poc

ket

expe

nses

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00.

Out

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pens

es f

or t

his

dedu

ctib

le a

re e

xpen

ses

that

wou

ld o

rdin

arily

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paid

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the

polic

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exp

ense

s in

clud

e th

e M

edic

are

dedu

ctib

les

for

Part

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d Pa

rt B,

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do

not

inclu

de t

he p

lan’s

se

para

te f

ore

ign tra

ve

l em

erg

ency d

eductible

.

AHLM

S027

63IL

2

05

/201

7 A

Att

ain

ed

Pre

ferr

ed

Att

ain

ed

Stan

dar

d

Age

Pla

n A

Pla

n B

Pla

n D

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n F

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n G

Pla

n N

Age

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n A

Pla

n B

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n D

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n F

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n G

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n N

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999

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AHLM

S027

63IL

3

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7 A

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2,10

5

82

2,19

02,

758

2,14

73,

298

1,18

42,

513

1,95

882

2,43

33,

064

2,38

53,

666

1,31

52,

793

2,17

5

83

2,23

92,

856

2,20

13,

415

1,22

52,

602

2,02

783

2,48

73,

173

2,44

63,

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1,36

22,

892

2,25

3

84

2,28

62,

954

2,25

53,

533

1,26

82,

692

2,09

884

2,53

93,

283

2,50

63,

926

1,40

92,

991

2,33

1

85

2,32

83,

043

2,30

93,

640

1,30

62,

773

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185

2,58

73,

381

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64,

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86

2,36

73,

133

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2,63

13,

481

2,62

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53,

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2,40

93,

221

2,41

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1,38

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687

2,67

53,

578

2,68

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282

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63,

261

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88

2,44

83,

308

2,46

33,

958

1,42

03,

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2,34

988

2,72

13,

675

2,73

74,

398

1,57

73,

349

2,61

0

89

2,48

73,

393

2,51

44,

061

1,45

63,

094

2,41

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2,76

43,

772

2,79

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512

1,61

93,

438

2,67

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53,

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54,

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190

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1,69

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2,71

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AHLMS02763IL 6 05/2017 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.

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; or (c) be a permanent resident in your home. 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 and will apply as long as both policies remain in force.

DISCLOSURES

Use this outline to compare benefits and premium 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 your insurance company.

RIGHT TO RETURN POLICY

If 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, Kentucky 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, D, F, HIGH DEDUCTIBLE F, G and N OFFERED BY AETNA HEALTH AND LIFE INSURANCE COMPANY.

AHLMS02763IL 7 05/2017 A

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 PAYS

YOU PAY

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

First 60 days All but $1,316 $0 $1,316 (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.

AHLMS02763IL 05/2017 A 8

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

AHLMS02763IL 05/2017 A 9

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 $1,316 $1,316 (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.

AHLMS02763IL 05/2017 A 10

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

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



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




AHLMS02763IL 05/2017 A 11

PLAN D 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

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after •While using 60 lifetime reserve days •Once lifetime reserve days are used: •Additional 365 days •Beyond the Additional 365 days

All but $1,316 All but $329 a day

All but $658 a day

$0 $0

$1,316 (Part A Deductible) $329 a day

$658 a day

100% of Medicare Eligible Expenses $0

$0 $0

$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 21st thru 100th day 101st day and after

All approved amounts All but $164.50 a day $0

$0 Up to $164.50 a day $0

$0 $0 All costs

BLOOD First 3 pints Additional amounts

$0 100%

3 pints $0

$0 $0

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



$0


AHLMS02763IL 05/2017 A 12

PLAN D MEDICARE (PART B) – MEDICAL SERVICES – PER 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 test, durable medical equipment First $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts

$0

Generally 80%

$0

Generally 20%

$183 (Part B deductible) $0

Part B Excess Charges (Above Medicare-Approved amounts)

$0

$0

All Costs BLOOD First 3 pints Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts

$0 $0

80%

All costs $0

20%

$0 $183 (Part B deductible) $0

CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PA RTS A & B


PLAN PAYS YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies •Durable medical equipment •First $183 of Medicare Approved amounts* •Remainder of Medicare Approved amounts

100%

$0

80%

$0

$0

20%

$0

$183 (Part B deductible)

$0

AHLMS02763IL 05/2017 A 13

PLAN D 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 Remainder of charges

$0 $0

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

$250 20% and amounts over the $50,000 lifetime maximum

AHLMS02763IL 05/2017 A 14

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


AHLMS02763IL 05/2017 A 15

PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER 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 test, durable medical equipment


$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


AHLMS02763IL 05/2017 A 16

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

AHLMS02763IL 05/2017 A 17

HIGH DEDUCTIBLE PLAN 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

AHLMS02763IL 05/2017 A 18

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



$0


AHLMS02763IL 05/2017 A 19

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


AHLMS02763IL 05/2017 A 20

HIGH DEDUCTIBLE PLAN F

PARTS A & B

SERVICES

MEDICARE PAYS







100% $0 $0



$0


OTHER BENEFITS – NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS


DEDUCTIBLE** PLAN PAYS


DEDUCTIBLE** YOU PAY





AHLMS02763IL 05/2017 A 21

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



PLAN PAYS

YOU PAY



$0



$0**



First 20 days All approved amounts $0 $0 21st thru 100th day All but $164.50 a day 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


AHLMS02763IL 05/2017 A 22

PLAN G MEDICARE (PART B) – MEDICAL SERVICES – PER 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*



AHLMS02763IL 05/2017 A 23

PLAN G



PLAN PAYS

YOU PAY





AHLMS02763IL 05/2017 A 24

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


AHLMS02763IL 05/2017 A 25

PLAN N MEDICARE (PART B) – MEDICAL SERVICES – PER 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 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 $183 of Medicare-Approved amounts*



AHLMS02763IL 05/2017 A 26

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


outline of coverage - aetna€¦ · aetna health and life insurance company administrative office...

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