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Aetna Life Insurance Company
Outline of Medicare Supplement Coverage
Benefit Plans A, B, F, G and N are Offered�Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010
This chart show the benefits included in each of the standard Medicare supplement plans with an effective date for coverage on or after June 1, 2010. Every company must make Plan "A"
available. 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
Effective 01-01-2016
GR-11613-03-OOC -OH 18.02.312.1-OH L (12/15)
•
•
•
•
Aetna Life Insurance Company Outline of Medicare Supplement Coverage
Benefit Plans A, B, 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 does not include the Plan’s
separate foreign travel emergency deductible.
Effective 01-01-2016
GR-11613-03-OOC -OH 18.02.312.1-OH L (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.
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 smoke and you enroll other than during the Medicare Supplement Open Enrollment and Guaranteed issue rights periods, a smoker
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. Smoker premium rates are determined by multiplying the premium shown by a factor of 1.10.
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
MONTHLY PREMIUMS
Attained
Age
PLAN A
MALE FEMALE
PLAN B
MALE FEMALE
PLAN F
MALE FEMALE
PLAN G
MALE FEMALE
PLAN N
MALE FEMALE
65 $138.99 $128.33 $154.66 $141.99 $174.66 $160.58 $158.66 $147.74 $124.16 $115.75
66 $144.16 $133.16 $160.41 $147.24 $181.16 $166.58 $166.33 $154.74 $130.41 $121.50
67 $149.33 $137.91 $166.24 $152.66 $187.74 $172.58 $173.99 $161.91 $136.41 $127.16
68 $155.41 $143.49 $173.99 $159.74 $196.66 $180.74 $181.49 $168.91 $142.49 $132.83
69 $161.41 $149.08 $181.58 $166.66 $205.49 $188.91 $189.08 $175.99 $148.58 $138.49
70 $167.49 $154.58 $189.16 $173.74 $214.24 $196.99 $196.66 $182.99 $154.66 $144.16
71 $173.41 $160.08 $196.83 $180.66 $223.07 $205.08 $204.16 $189.99 $160.66 $149.74
72 $179.33 $165.58 $204.33 $187.66 $231.74 $213.07 $211.66 $196.99 $166.66 $155.41
73 $183.41 $169.33 $210.82 $193.58 $239.41 $220.07 $220.07 $204.83 $173.58 $161.83
74 $187.49 $173.16 $217.07 $199.33 $246.82 $226.91 $228.32 $212.49 $180.33 $168.16
75 $191.49 $176.83 $223.41 $205.16 $254.32 $233.91 $236.66 $220.24 $187.08 $174.41
76 $195.49 $180.58 $229.74 $210.99 $261.91 $240.74 $244.99 $227.91 $193.91 $180.74
77 $199.58 $184.24 $236.07 $216.74 $269.32 $247.66 $253.07 $235.57 $200.58 $186.99
78 $202.49 $186.91 $240.32 $220.66 $274.74 $252.57 $260.16 $242.07 $206.49 $192.49
79 $205.33 $189.58 $244.66 $224.66 $280.07 $257.49 $267.07 $248.57 $212.41 $197.99
80 $208.08 $192.08 $248.74 $228.41 $285.32 $262.32 $273.91 $254.91 $218.24 $203.49
81 $210.74 $194.58 $252.91 $232.24 $290.57 $267.16 $280.82 $261.32 $224.16 $208.91
82 $213.32 $196.91 $257.07 $236.07 $295.74 $271.99 $287.74 $267.74 $229.99 $214.41
83 $214.91 $198.41 $262.07 $240.57 $302.82 $278.41 $301.24 $280.41 $242.07 $225.66
84 $216.57 $199.91 $266.91 $245.16 $309.82 $284.91 $314.90 $292.99 $254.16 $236.91
85 $218.07 $201.33 $272.16 $249.82 $317.24 $291.66 $326.74 $304.07 $264.91 $246.91
86 $219.49 $202.66 $276.32 $253.66 $323.57 $297.49 $339.15 $315.57 $276.16 $257.41
87 $220.82 $203.91 $280.41 $257.41 $328.40 $301.99 $351.90 $327.40 $287.82 $268.24
88 $222.24 $205.24 $284.57 $261.24 $333.40 $306.49 $365.15 $339.82 $299.90 $279.57
89 $223.66 $206.49 $288.82 $265.24 $338.32 $311.15 $378.90 $352.57 $312.57 $291.41
90+ $225.07 $207.91 $293.15 $269.16 $343.40 $315.74 $393.15 $365.90 $325.82 $303.74
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
DISCLOSURES Questions? We’re here to help.
Just call us at 1-800-345-6022
(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 your
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.�
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
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.
PLAN A (continued)
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan A
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
Services Medicare Pays Plan A
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.
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
PLAN A (continued)
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan A
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
Services Medicare Pays Plan A
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
*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.
Effective 01-01-2016
-
-
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
PLAN B
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan B
Plan Pays You Pay
HOSPITALIZATION*
Semi-private room and board, general
nursing and miscellaneous services and
supplies
First 60 days All but $1,288 $1,288
(Part A deductible)
$0
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.
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
PLAN B (continued)
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan B
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 very limited
copayment/
coinsurance for
outpatient drugs and
inpatient respite care
Medicare copayment/
coinsurance
$0
PLAN B
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan B
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.
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
PLAN B (continued)
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan B
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
Services Medicare Pays Plan 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
*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.
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
PLAN F
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan F
Plan Pays You Pay
HOSPITALIZATION*
Semi-private room and board, general
nursing and miscellaneous services and
supplies
First 60 days All but $1,288 $1,288
(Part A deductible)
$0
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
Up to $161
a day
$0
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.
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
PLAN F (continued)
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan F
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 very limited
copayment/
coinsurance for
outpatient drugs and
inpatient respite care
Medicare copayment/
coinsurance
$0
PLAN F
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan F
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
Remainder of Medicare-approved amounts Generally 80% Generally 20% $0
Part B Excess Charges (above Medicare-
approved amounts) $0 100% of all costs $0
BLOOD
First 3 pints $0 All costs $0
Next $166 of Medicare-approved amounts* $0 $166
(Part B deductible)
$0
Remainder of Medicare-approved amounts 80% 20% $0
*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.
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
PLAN F (continued)
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan F
Plan Pays You Pay
CLINICAL LABORATORY SERVICES
Tests for diagnostic services 100% $0 $0
PARTS A & B
Services Medicare Pays Plan F
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 $166
(Part B deductible)
$0
- Remainder of Medicare-approved
amounts
80% 20% $0
OTHER BENEFITS – Not Covered by Medicare
Services Medicare Pays Plan F
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
*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.
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
PLAN G
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan G
Plan Pays You Pay
HOSPITALIZATION*
Semi-private room and board, general nursing
and miscellaneous services and supplies
First 60 days All but $1,288 $1,288
(Part A deductible)
$0
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 Up to $161 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
All but very limited
copayment/coinsurance
for outpatient drugs and
inpatient respite care
Medicare copayment/
coinsurance
$0
*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.
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
PLAN G
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan G
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) $0 100% of all costs $0
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
*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.
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
PLAN G (continued) PARTS A & B
Services Medicare Pays Plan G
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
OTHER BENEFITS – Not Covered by Medicare
Services Medicare Pays Plan G
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
*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.
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
PLAN N
Medicare (Part A) – Hospital Services – Per Benefit Period
Services Medicare Pays Plan N
Plan Pays You Pay
HOSPITALIZATION*
Semi-private room and board, general nursing
and miscellaneous services and supplies
First 60 days All but $1,288 $1,288
(Part A deductible)
$0
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 Up to $161 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
All but very limited
copayment/coinsurance
for outpatient drugs and
inpatient respite care
Medicare copayment/
coinsurance
$0
*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.
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
PLAN N
Medicare (Part B) – Medical Services – Per Calendar Year
Services Medicare Pays Plan N
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% 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.
Part B Excess Charges (above Medicare-
approved amounts) $0 $0 All costs
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
*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.
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)
PLAN N (continued)
PARTS A & B�
Services Medicare Pays Plan N
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
OTHER BENEFITS – Not Covered by Medicare
Services Medicare Pays Plan N
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
*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.
Effective 01-01-2016
GR-11613-03 OOC-OH 18.02.312.1-OH L (12/15)