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800 Crescent Centre Dr. Suite 200
Franklin, TN 37067800 264.4000
aetnaseniorproducts.com
Outline of CoverageMedicare Supplement Insurance
Underwritten by
American Continental Insurance Company
©2012 Aetna Inc.
An Aetna Company
BENEFIT PLANS A, B, C, F, HIGH DEDUCTIBLE F, G, N,
MICHIGAN
ACIMS01068MI 04012014
ACIM
S010
68M
I
040
1201
4
AM
ER
ICA
N C
ON
TIN
EN
TA
L I
NS
UR
AN
CE
CO
MP
AN
Y
OU
TL
INE
OF
ME
DIC
AR
E S
UP
PL
EM
EN
T C
OV
ER
AG
E C
OV
ER
PA
GE
: P
ag
e 1
of
2
BE
NE
FIT
PL
AN
S A
VA
ILA
BL
E:
A,
B,
C,
F,
HIG
H D
ED
UC
TIB
LE
F,
G,
N
Thes
e ch
arts
sho
w th
e be
nefit
s in
clud
ed in
eac
h of
the
stan
dard
Med
icar
e su
pple
men
t pla
ns. E
ve
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.
Se
e O
utl
ines
of
Co
ve
rag
e S
ecti
on
s f
or
De
tail
s A
bo
ut
AL
L P
lan
s
Ba
sic
Ben
efi
ts:
H
ospi
taliz
atio
n: P
art A
coi
nsur
ance
plu
s co
vera
ge fo
r 365
add
ition
al d
ays
afte
r Med
icar
e be
nefit
s en
d.
Med
ical
Exp
ense
s: P
art B
coi
nsur
ance
(gen
eral
ly 2
0% o
f Med
icar
e-Ap
prov
ed e
xpen
ses)
or,
co-p
aym
ents
for h
ospi
tal o
utpa
tient
ser
vice
s. P
lans
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
Bloo
d: F
irst t
hree
pin
ts o
f blo
od e
ach
year
.
Hos
pice
-Par
t A c
oins
uran
ce
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 $[
4940
]; pa
id a
t 100
%
afte
r lim
it re
ache
d
Out
-of-p
ocke
t lim
it $[
2470
]; 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
[$21
40] 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
[$21
40].
Out
-of-p
ocke
t exp
ense
s fo
r thi
s de
duct
ible
ar
e ex
pens
es th
at w
ould
ord
inar
ily b
e pa
id b
y th
e po
licy.
The
se e
xpen
ses
incl
ude
the
Med
icar
e de
duct
ible
s fo
r Pa
rt A
and
Part
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
.
ACIM
S010
68M
I 04
0120
14
2
Att
ain
ed
No
n-S
mo
ke
rA
tta
ine
dS
mo
ke
r
Ag
eP
lan
AP
lan
BP
lan
CP
lan
FP
lan
HF
Pla
n G
Pla
n N
Ag
eP
lan
AP
lan
BP
lan
CP
lan
FP
lan
HF
Pla
n G
Pla
n N
Un
de
r 6
5n
/an
/a3
,62
6
n/a
n/a
n/a
n/a
Un
de
r 6
5n
/an
/a4
,03
0
n
/an
/an
/an
/a
6
51
,22
8
1
,54
8
1
,74
1
1,7
98
70
8
1,5
61
1,2
39
6
51
,36
4
1
,72
0
1
,93
5
1
,99
8
7
86
1
,73
3
1
,37
6
6
61
,22
8
1
,54
8
1
,74
1
1,7
98
70
8
1,5
61
1,2
39
6
61
,36
4
1
,72
0
1
,93
5
1
,99
8
7
86
1
,73
3
1
,37
6
6
71
,22
8
1
,54
8
1
,74
1
1,7
98
70
8
1,5
61
1,2
39
6
71
,36
4
1
,72
0
1
,93
5
1
,99
8
7
86
1
,73
3
1
,37
6
6
81
,28
1
1
,61
2
1
,81
8
1,8
73
73
6
1,6
25
1,2
91
6
81
,42
3
1
,79
2
2
,02
0
2
,08
0
8
19
1
,80
5
1
,43
4
6
91
,33
8
1
,68
6
1
,89
3
1,9
46
76
6
1,6
98
1,3
49
6
91
,48
6
1
,87
1
2
,10
4
2
,16
4
8
51
1
,88
7
1
,50
0
7
01
,39
0
1
,75
3
1
,96
5
2,0
18
79
4
1,7
65
1,4
02
7
01
,54
3
1
,94
7
2
,18
3
2
,24
2
8
83
1
,96
0
1
,55
9
7
11
,44
6
1
,82
0
2
,03
3
2,0
87
82
1
1,8
31
1,4
56
7
11
,60
4
2
,02
1
2
,26
0
2
,32
0
9
12
2
,03
6
1
,61
7
7
21
,49
4
1
,88
2
2
,09
7
2,1
52
84
7
1,8
96
1,5
06
7
21
,66
0
2
,09
1
2
,32
9
2
,39
2
9
42
2
,10
6
1
,67
3
7
31
,54
0
1
,94
2
2
,15
6
2,2
11
87
0
1,9
55
1,5
53
7
31
,71
2
2
,15
8
2
,39
7
2
,45
7
9
68
2
,17
4
1
,72
6
7
41
,58
7
1
,99
8
2
,21
3
2,2
68
89
2
2,0
13
1,5
97
7
41
,76
2
2
,21
8
2
,45
8
2
,52
0
9
91
2
,23
5
1
,77
7
7
51
,62
6
2
,05
0
2
,26
7
2,3
20
91
2
2,0
63
1,6
39
7
51
,80
5
2
,27
6
2
,51
7
2
,57
8
1
,01
4
2
,29
3
1
,82
1
7
61
,66
4
2
,09
6
2
,31
3
2,3
65
93
1
2,1
10
1,6
76
7
61
,84
7
2
,32
8
2
,57
1
2
,62
7
1
,03
4
2
,34
5
1
,86
2
7
71
,69
8
2
,13
9
2
,36
2
2,4
06
94
6
2,1
55
1,7
13
7
71
,88
9
2
,37
9
2
,62
7
2
,67
3
1
,05
0
2
,39
5
1
,90
5
7
81
,73
0
2
,18
2
2
,40
6
2,4
43
96
1
2,1
97
1,7
45
7
81
,92
6
2
,42
4
2
,67
3
2
,71
3
1
,06
8
2
,44
1
1
,94
0
7
91
,76
2
2
,21
8
2
,44
6
2,4
77
97
5
2,2
35
1,7
76
7
91
,95
8
2
,46
6
2
,71
9
2
,75
2
1
,08
2
2
,48
4
1
,97
3
8
01
,79
1
2
,25
4
2
,47
7
2,5
09
98
8
2,2
72
1,8
05
8
01
,98
9
2
,50
8
2
,75
3
2
,78
7
1
,09
6
2
,52
4
2
,00
6
8
11
,81
6
2
,28
7
2
,51
0
2,5
41
1,0
01
2,3
03
1,8
30
8
12
,01
8
2
,54
2
2
,78
8
2
,82
3
1
,10
9
2
,55
9
2
,03
6
8
21
,84
0
2
,31
9
2
,53
9
2,5
74
1,0
14
2,3
36
1,8
55
8
22
,04
4
2
,57
7
2
,82
1
2
,85
9
1
,12
6
2
,59
5
2
,06
1
8
31
,86
6
2
,34
8
2
,57
0
2,6
04
1,0
24
2,3
65
1,8
80
8
32
,07
2
2
,60
9
2
,85
4
2
,89
2
1
,13
9
2
,62
8
2
,08
9
8
41
,88
8
2
,37
7
2
,59
7
2,6
35
1,0
37
2,3
95
1,9
05
8
42
,09
7
2
,64
2
2
,88
6
2
,92
6
1
,15
2
2
,66
2
2
,11
3
8
51
,90
8
2
,40
6
2
,62
4
2,6
64
1,0
48
2,4
24
1,9
26
8
52
,12
0
2
,67
3
2
,91
5
2
,95
9
1
,16
5
2
,69
2
2
,13
9
8
61
,93
0
2
,43
2
2
,65
0
2,6
90
1,0
60
2,4
50
1,9
46
8
62
,14
5
2
,70
3
2
,94
5
2
,99
0
1
,17
6
2
,72
2
2
,16
3
8
71
,95
1
2
,45
8
2
,67
5
2,7
19
1,0
69
2,4
76
1,9
67
8
72
,16
9
2
,73
1
2
,97
1
3
,01
8
1
,18
8
2
,75
2
2
,18
7
8
81
,97
1
2
,48
4
2
,70
0
2,7
44
1,0
80
2,5
00
1,9
88
8
82
,18
9
2
,75
8
3
,00
0
3
,04
8
1
,19
9
2
,77
9
2
,20
7
8
91
,98
9
2
,50
8
2
,72
3
2,7
66
1,0
87
2,5
24
2,0
06
8
92
,21
0
2
,78
4
3
,02
7
3
,07
4
1
,21
0
2
,80
5
2
,22
9
90
2,0
07
2,5
28
2,7
47
2
,79
1
1
,09
7
2
,54
6
2
,02
4
90
2,2
31
2,8
11
3,0
50
3,0
98
1,2
19
2,8
31
2,2
49
91
2,0
23
2,5
50
2,7
68
2
,81
2
1
,10
6
2
,56
9
2
,03
9
91
2,2
48
2,8
32
3,0
74
3,1
21
1,2
28
2,8
53
2,2
67
92
2,0
38
2,5
71
2,7
88
2
,82
7
1
,11
2
2
,58
7
2
,05
6
92
2,2
67
2,8
54
3,0
98
3,1
44
1,2
37
2,8
74
2,2
83
93
2,0
53
2,5
87
2,8
04
2
,84
7
1
,12
1
2
,60
4
2
,07
0
93
2,2
80
2,8
76
3,1
19
3,1
64
1,2
45
2,8
95
2,3
00
94
2,0
66
2,6
04
2,8
23
2
,86
2
1
,12
6
2
,62
3
2
,08
2
94
2,2
96
2,8
92
3,1
36
3,1
81
1,2
52
2,9
15
2,3
15
95
2,0
79
2,6
17
2,8
39
2
,87
7
1
,13
0
2
,63
8
2
,09
6
95
2,3
10
2,9
10
3,1
53
3,1
95
1,2
58
2,9
29
2,3
28
96
2,0
90
2,6
35
2,8
53
2
,89
1
1
,13
9
2
,65
3
2
,10
7
96
2,3
22
2,9
26
3,1
69
3,2
13
1,2
63
2,9
48
2,3
41
97
2,1
03
2,6
49
2,8
70
2
,90
8
1
,14
3
2
,66
9
2
,11
9
97
2,3
36
2,9
45
3,1
88
3,2
28
1,2
71
2,9
64
2,3
55
98
2,1
15
2,6
64
2,8
85
2
,92
2
1
,14
9
2
,68
5
2
,13
1
98
2,3
49
2,9
62
3,2
05
3,2
47
1,2
78
2,9
83
2,3
68
9
92
,12
8
2
,68
1
2
,90
2
2,9
35
1,1
54
2,7
01
2,1
45
9
92
,36
5
2
,98
0
3
,22
4
3
,26
2
1
,28
3
3
,00
1
2
,38
4
Mo
da
l F
act
ors
:S
em
i-A
nn
ua
l:0
.52
00
Qu
art
erl
y:
0.2
65
0M
on
thly
:0
.08
33
3
**
NO
TE
: T
he
0-6
4 r
ate
s a
re a
va
ila
ble
to
th
ose
ap
pli
can
ts u
nd
er
the
ag
e o
f 6
5 w
ho
are
eit
he
r d
isa
ble
d,
SS
I M
ed
ica
re E
lig
ible
s, o
r
ES
RD
Eli
gib
les
du
rin
g t
he
op
en
en
roll
me
nt/
gu
ara
nte
e i
ssu
e p
eri
od
.
Th
e r
ate
s d
o n
ot
incl
ud
e t
he
$2
0 p
oli
cy f
ee
.
For
Use
in
ZIP
Co
de
s:
48
0-4
85
,48
6-4
89
, 4
92
Am
eri
can
Co
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Me
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Eli
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gib
les d
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ate
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licy
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n C
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ACIM
S010
68M
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040
1201
4
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NF
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d do
not
incr
ease
with
age
. Yo
u sh
ould
com
pare
Issu
e A
ge w
ith A
ttain
ed A
ge p
olic
ies.
P
rem
ium
s pa
yabl
e ot
her
than
an
nual
w
ill be
de
term
ined
ac
cord
ing
to th
e fo
llow
ing
fact
ors:
S
emi-a
nnua
l: 0.
5200
Qua
rterly
: 0.2
650
Mon
thly
EFT
: 0.0
833.
DIS
CL
OS
UR
ES
Use
thi
s ou
tline
to
com
pare
ben
efits
and
pre
miu
m a
mon
g po
licie
s.
RE
AD
YO
UR
PO
LIC
Y V
ER
Y C
AR
EF
UL
LY
Th
is i
s o
nly
an
ou
tlin
e d
escrib
ing y
ou
r p
olic
y’s
mo
st
imp
ort
an
t fe
atur
es.
The
polic
y is
you
r in
sura
nce
cont
ract
. You
mus
t rea
d th
e po
licy
itsel
f to
unde
rsta
nd a
ll of
the
right
s an
d du
ties
of b
oth
you
and
your
insu
ranc
e co
mpa
ny.
RIG
HT
TO
RE
TU
RN
PO
LIC
Y
If yo
u fin
d th
at y
ou a
re n
ot s
atis
fied
with
you
r po
licy,
you
may
re
turn
it to
Am
eric
an C
ontin
enta
l Ins
uran
ce C
ompa
ny, P
.O. B
ox
2368
, B
rent
woo
d, T
enne
ssee
370
24.
If yo
u se
nd t
he p
olic
y ba
ck t
o us
with
in 3
0 da
ys a
fter
you
rece
ive
it, w
e w
ill tre
at th
e po
licy
as
if it
had
neve
r be
en i
ssue
d an
d re
turn
all
your
pa
ymen
ts.
PO
LIC
Y R
EP
LA
CE
ME
NT
If yo
u ar
e re
plac
ing
anot
her
heal
th i
nsur
ance
pol
icy,
do
NO
T
canc
el it
unt
il yo
u ha
ve a
ctua
lly r
ecei
ved
your
new
pol
icy
and
are
sure
you
wan
t to
keep
it. N
OT
ICE
The
polic
y m
ay n
ot c
over
all
of y
our m
edic
al c
osts
.
Nei
ther
A
mer
ican
C
ontin
enta
l In
sura
nce
Com
pany
no
r its
ag
ents
are
con
nect
ed w
ith M
edic
are.
This
ou
tline
of
co
vera
ge
does
no
t gi
ve
all
the
deta
ils
of
Med
icar
e co
vera
ge. C
onta
ct y
our l
ocal
Soc
ial S
ecur
ity O
ffice
or
cons
ult M
ed
icare
& Y
ou
for m
ore
deta
ils.
CO
MP
LE
TE
AN
SW
ER
S A
RE
VE
RY
IM
PO
RT
AN
T
Whe
n yo
u fil
l out
the
appl
icat
ion
for
the
new
pol
icy,
be
sure
to
answ
er
truth
fully
an
d co
mpl
etel
y an
y qu
estio
ns a
bout
you
r m
edic
al a
nd h
ealth
his
tory
. Th
e co
mpa
ny m
ay c
ance
l yo
ur
polic
y an
d re
fuse
to
pay
any
clai
ms
if yo
u le
ave
out
or f
alsi
fy
impo
rtant
med
ical
info
rmat
ion.
Rev
iew
the
app
licat
ion
care
fully
bef
ore
you
sign
it.
Be
certa
in
that
all
info
rmat
ion
has
been
pro
perly
reco
rded
.
TH
E F
OL
LO
WIN
G C
HA
RT
S D
ES
CR
IBE
P
LA
NS
A
, B
, C
, F
,
HIG
H D
ED
UC
TIB
LE
F
, G
a
nd
N
O
FF
ER
ED
B
Y A
ME
RIC
AN
CO
NT
INE
NT
AL
IN
SU
RA
NC
E C
OM
PA
NY
.
ACIMS01068MI 04012014
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 [$1216] $0 [$1216] (Part A Deductible)
61st thru 90th day All but [$304] a day [$304] a day $0 91st day and after While using 60 lifetime reserve days All but [$608] a day [$608] 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 [$152] a day $0 Up to [$152] 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.
ACIMS01068MI 04012014 8
PLAN A
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR *Once you have been billed [$147] 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.
SERVICES MEDICARE
PAYS
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 [$147] of Medicare-Approved amounts*
$0 $0 [$147] (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 [$147] of Medicare-Approved amounts*
$0 $0 [$147] (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
PAYS
YOU
PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment
First [$147] of Medicare Approved amounts*
$0 $0 [$147] (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
ACIMS01068MI 04012014 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.
SERVICES MEDICARE
PAYS
PLAN
PAYS
YOU
PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but [$1216] [$1216] (Part A Deductible)
$0
61st thru 90th day All but [$304] a day [$304] a day $0 91st day and after While using 60 lifetime reserve days All but [$608] a day [$608] 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 [$152] a day $0 Up to [$152] 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 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.
ACIMS01068MI 04012014 10
PLAN B
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
* Once you have been billed [$147] 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.
SERVICES MEDICARE
PAYS
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 [$147] of Medicare-Approved amounts*
$0 $0 [$147] (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 [$147] of Medicare-Approved amounts*
$0 $0 [$147] (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
PAYS
YOU
PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment First [$147] of Medicare Approved amounts*
$0 $0 [$147] (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
ACIMS01068MI 04012014 11
PLAN C
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 [$1216] [$1216] (Part A Deductible)
$0
61st thru 90th day All but $304 a day [$304] a day $0 91st day and after While using 60 lifetime reserve days All but [$608] a day [$608] 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[ $152] a day Up to [$152] 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
**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.
ACIMS01068MI 04012014 12
PLAN C
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR *Once you have been billed [$147] 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.
SERVICES MEDICARE
PAYS
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 [$147] of Medicare-Approved amounts*
$0 [$147] (Part B Deductible)
$0
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 $0 $0 BLOOD First 3 pints $0 All costs $0 Next [$147] of Medicare-Approved amounts*
$0 [$147] (Part B Deductible)
$0
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
PAYS
YOU
PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment First [$147] of Medicare Approved amounts*
$0 [$147] (Part B Deductible)
$0
Remainder of Medicare Approved amounts 80% 20% $0
ACIMS01068MI 04012014 13
PLAN C
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE
PAYS
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
ACIMS01068MI 04012014 14
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.
SERVICES MEDICARE
PAYS
PLAN
PAYS
YOU
PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but [$1216] [$1216] (Part A Deductible)
$0
61st thru 90th day All but [$304] a day [$304] a day $0 91st day and after While using 60 lifetime reserve days All but [$608] a day [$608] 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 [$152] a day Up to [$152] 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
**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.
ACIMS01068MI 04012014 15
PLAN F
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR *Once you have been billed [$147] 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.
SERVICES MEDICARE
PAYS
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 [$147] of Medicare-Approved amounts*
$0 [$147] (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 [$147] of Medicare-Approved amounts*
$0 [$147] (Part B Deductible)
$0
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
PAYS
YOU
PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment First [$147] of Medicare Approved amounts*
$0 [$147] (Part B Deductible)
$0
Remainder of Medicare Approved amounts 80% 20% $0
ACIMS01068MI 04012014 16
PLAN F
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE
PAYS
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
ACIMS01068MI 04012014 17
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
[$2140] deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses
are [$2140]. 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
[$2140]
DEDUCTIBLE***
PLAN PAYS
IN ADDITION TO
[$2140]
DEDUCTIBLE***
YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but [$1216] [$1216] (Part A Deductible)
$0
61st thru 90th day All but [$304] a day [$304] a day $0 91st day and after While using 60 lifetime reserve days All but [$608] a day [$608] 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 [$152] a day Up to [$152] a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0
ACIMS01068MI 04012014 18
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 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.
ACIMS01068MI 04012014 19
HIGH DEDUCTIBLE PLAN F
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR *Once you have been billed [$147] 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
[$2140] deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses
are [$2140]. 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
[$2140]
DEDUCTIBLE***
PLAN PAYS
IN ADDITION TO
[$2140]
DEDUCTIBLE***
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 [$147] of Medicare-Approved amounts*
$0 [$147] (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 [$147] of Medicare-Approved amounts*
$0 [$147] (Part B Deductible)
$0
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY
SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
ACIMS01068MI 04012014 20
HIGH DEDUCTIBLE PLAN F
PARTS A & B
SERVICES
MEDICARE
PAYS
AFTER YOU PAY
[$2140]
DEDUCTIBLE***
PLAN PAYS
IN ADDITION TO
[$2140]
DEDUCTIBLE***
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment First [$147] of Medicare Approved amounts*
$0 [$147] (Part B Deductible)
$0
Remainder of Medicare Approved amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES
MEDICARE
PAYS
AFTER YOU PAY
[$2140]
DEDUCTIBLE**
PLAN PAYS
IN ADDITION TO
[$2140]
DEDUCTIBLE**
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
ACIMS01068MI 04012014 21
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.
SERVICES MEDICARE
PAYS
PLAN
PAYS
YOU
PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but [$1216] [$1216] (Part A Deductible)
$0
61st thru 90th day All but [$304] a day [$304] a day $0 91st day and after While using 60 lifetime reserve days All but [$608] a day [$608] 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 [$152] a day Up to [$152] 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
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 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.
ACIMS01068MI 04012014 22
PLAN G
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed [$147] 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.
SERVICES MEDICARE
PAYS
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 [$147] of Medicare-Approved amounts*
$0 $0 [$147] (Part B Deductible)
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 [$147] of Medicare-Approved amounts*
$0 $0 [$147] (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
PAYS
YOU
PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First [$147] of Medicare Approved amounts*
$0 $0 [$147] (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
ACIMS01068MI 04012014 23
PLAN G
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE
PAYS
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
ACIMS01068MI 04012014 24
PLAN N
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 [$1216] [$1216] (Part A Deductible)
$0
61st thru 90th day All but [$304] a day [$304] a day $0 91st day and after While using 60 lifetime reserve days All but [$608] a day [$608] 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 [$152] a day Up to [$152] 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
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare co-payment/ 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 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.
ACIMS01068MI 04012014 25
PLAN N
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed [$147] 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.
SERVICES MEDICARE
PAYS
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 [$147] of Medicare-Approved amounts*
$0 $0 [$147] (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 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 [$147] of Medicare-Approved amounts*
$0 $0 [$147] (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY
SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
ACIMS01068MI 04012014 26
PLAN N
PARTS A & B
SERVICES MEDICARE
PAYS
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 [$147] of Medicare Approved amounts*
$0 $0 [$147] (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE
PAYS
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
