Outline of Coverage - AetnaOutline of Coverage Insured by Aetna Life Insurance Company Medicare Supplement Insurance ... PAUNAWA: Kung nagsasalita ka ng Tagalog, may makukuhang libreng

Medicare Supplement Insurance Office

800 Crescent Centre Dr. Suite 200

Franklin, TN 37067855-663-2204

aetnaseniorproducts.com

An Aetna Company

Outline of Coverage

Insured by

Aetna Life Insurance Company

Medicare Supplement Insurance

American Grandparents Association

Rates Effective:

BENEFIT PLANS A, B, F, G & N

DELAWARE

ALCGP01923DE ©2017 Aetna Inc. 07/2016 B

Aetna Life Insurance Company, Coventry Health and Life Insurance Company, and First Health Life and Health Insurance Company comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Aetna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Aetna:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: - Qualified sign language interpreters - Written information in other formats (large print, audio, accessible electronic formats, other

formats) • Provides free language services to people whose primary language is not English, such as:

- Qualified interpreters - Information written in other languages

If you need these services, call 1-866-465-1023.

If you believe that Aetna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Aetna Medicare Grievance Department, P.O. Box 14067, Lexington, KY 40512. You can also file a grievance by phone by calling 1-855-348-1369. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1–800–368–1019, 800–537–7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. You can also contact the Aetna Civil Rights Coordinator by phone at 1-855-348-1369, by email at [email protected], or by writing to Aetna Medicare Grievance Department, ATTN: Civil Rights Coordinator, P.O. Box 14067, Lexington, KY 40512.

TTY: 711

ENGLISH: ATTENTION: If you speak a language other than English, free language assistance services are available. Visit our website at www.aetnaseniorproducts.com or call the phone number listed in this material.

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https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

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�हदी (HINDI):

ध्या द�: अगर आप बयत करा ेम� सकम ह �हदी, तो ा शुलक भयषय सहय्तय सेवयएं उपलब् ह � हमयरी वेबसयइट www.aetnaseniorproducts.com पर िविजट कर� ्य इस सयम�ी म� सूचीब� फोा ांबर पर कॉल कर��

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PORTUGUÊS (PORTUGUESE): ATENÇÃO: Se você fala português, serviços gratuitos de ajuda para esse idioma estão disponíveis. Visite nosso site www.aetnaseniorproducts.com ou ligue para o número listado neste material.

KREYOL AYISYEN (FRENCH CREOLE): ATANSYON: Si ou pale Kreyòl Ayisyen, gen sèvis èd gratis nan lang ki disponib pou ou. Ale sou sitwèb nan www.aetnaseniorproducts.com oswa rele nimewo telefòn ki endike nan dokiman sa a.

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日本語 (JAPANESE): ご注意：日本語を話す方を対象に、無料の言語支援サービスを用意しております。当社ウェブサイト

www.aetnaseniorproducts.com をご覧いただくか、本書に記載の電話番号までお電話ください。

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791

1,36

866

1,59

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835

2,15

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970

1,50

5

67

1,48

61,

722

2,02

11,

852

1,41

667

1,63

51,

895

2,22

22,

037

1,55

8

68

1,52

71,

776

2,08

61,

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1,46

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1,68

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2,29

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1,61

1

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1,56

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1,51

269

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272

1,85

32,

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2,57

52,

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73

1,72

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1,70

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242

2,65

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74

1,75

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2,47

72,

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1,93

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1,78

72,

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12,

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72,

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1,85

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ALCGP01923DE 07/2016 B 4

PREMIUM INFORMATION Aetna Life Insurance Company can only raise your premium if we raise the premium for all certificates like yours in this state. Premiums for this certificate will increase due to the increase in your age. Upon attainment of an age requiring a rate increase, the renewal premium for the certificate will be the renewal premium then in effect for your attained age. Other certificates may be provided with Issue Age rating and do not increase with age. You should compare Issue Age with Attained Age certificates. Premiums payable other than annually will be determined according to the following factors: Semi-annual: 0.5000 Quarterly: 0.2500 Monthly EFT: 0.0833.

HOUSEHOLD DISCOUNT In order to be eligible for the Household discount under an Aetna 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 a member of the American Grandparents Association and covered by an Aetna Life Insurance Company Medicare supplement certificate. 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 certificate for each applicant is issued. The discounted rate will be 5 percent lower than the individual rates and will apply as long as both certificates remain in force.

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

READ YOUR CERTIFICATE VERY CAREFULLY

This is only an outline describing your certificate’s most important features. The certificate is your insurance contract. You must read the certificate itself to understand all of the rights and duties of both you and your insurance company.

RIGHT TO RETURN CERTIFICATE If you find that you are not satisfied with your certificate, you may return it to Aetna Life Insurance Company, P.O. Box 14770, Lexington, KY 40512-4770. If you send the certificate back to us within 30 days after you receive it, we will treat the certificate as if it had never been issued and return all your payments.

CERTIFICATE REPLACEMENT If you are replacing another health insurance certificate, do NOT cancel it until you have actually received your new certificate and are sure you want to keep it.

NOTICE

The certificate may not 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 enrollment form for the new certificate, be sure to answer truthfully and completely any questions about your medical and health history. The company may cancel your certificate and refuse to pay any claims if you leave out or falsify important medical information.

Review the enrollment form carefully before you sign it. Be certain that all information has been properly recorded.

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

ALCGP01923DE 07/2016 B 5

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 $1316 $0 $1316 (Part A Deductible)

61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day $0 Once lifetime reserve days are used:

Additional 365 days $0 100% of Medicare Eligible Expenses

$0**

Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital

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

day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.

All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/ coinsurance

$0

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the certificate’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.

ALCGP01923DE 07/2016 B 6

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

ALCGP01923DE 07/2016 B 7

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

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.


PLAN PAYS

YOU PAY


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

$0



$0**

Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital

First 20 days All approved amounts

$0 $0

21st thru 100th day All but $164.50 a day

$0 Up to $164.50 a day

101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.



$0

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the certificate’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.

ALCGP01923DE 07/2016 B 8

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

* Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.


PLAN PAYS

YOU PAY




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


Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES –

TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

PARTS A & B


PLAN PAYS

YOU PAY



100% $0 $0

Durable medical equipment First $183 of Medicare Approved amounts*



ALCGP01923DE 07/2016 B 9

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


ALCGP01923DE 07/2016 B 10

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



PLAN PAYS

YOU PAY



$0 $183 (Part B Deductible)

$0

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


$0


PARTS A & B


PLAN PAYS

YOU PAY



100% $0 $0

Durable medical equipment First $183 of Medicare Approved amounts*


$0


ALCGP01923DE 07/2016 B 11

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

ALCGP01923DE 07/2016 B 12

PLAN G 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



$0


ALCGP01923DE 07/2016 B 13

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



PLAN PAYS

YOU PAY




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



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*



ALCGP01923DE 07/2016 B 14

PLAN G

OTHER BENEFITS – NOT COVERED BY MEDICARE


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


ALCGP01923DE 07/2016 B 15

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



$0


ALCGP01923DE 07/2016 B 16

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 co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Part B Excess Charges (Above Medicare-Approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*



ALCGP01923DE 07/2016 B 17

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*



OTHER BENEFITS – NOT COVERED BY MEDICARE


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


Documents

Outline of Coverage - AetnaOutline of Coverage Insured by Aetna Life Insurance Company Medicare Supplement Insurance ... PAUNAWA: Kung nagsasalita ka ng Tagalog, may makukuhang libreng