Outline of Coverage - Aetna Senior Products · PDF file1,691 82 1,556 1,822 ... This outline of coverage does not give all the ... medical equipment First $183 of Medicare-Approved

Outline of CoverageMedicare Supplement Insurance

Underwritten by

Aetna Health and Life Insurance Company

Administrative Office800 Crescent Centre Dr.Suite 200Franklin, TN 37067800 264.4000aetnaseniorproducts.com

Aetna Health and Life Insurance Company

Rates Effective:

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

Idaho

AHLMS03829ID © 2018 Aetna Inc. 01/2018 A

AHLM

S038

29ID

01

/201

8 A

1

AETN

A H

EALT

H A

ND

LIF

E IN

SUR

ANC

E C

OM

PAN

Y

OU

TLIN

E O

F M

EDIC

ARE

SUPP

LEM

ENT

CO

VER

AGE

CO

VER

PAG

E

BEN

EFIT

PLA

NS

AVAI

LAB

LE: A

, B, F

, HIG

H D

EDU

CTI

BLE

F, G

, N

Thes

e ch

arts

sho

w th

e be

nefit

s 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.

Basi

c Be

nefit

s:

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. 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

co

paym

ent f

or o

ffice

vi

sit,

and

up to

$50

co

paym

ent f

or E

R

Skille

d N

ursi

ng

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lity

Coi

nsur

ance

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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%

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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 $5

240;

pa

id a

t 100

%

afte

r lim

it re

ache

d

Out

-of-p

ocke

t lim

it $2

620;

pa

id a

t 100

%

afte

r lim

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

tible

pla

n pa

ys t

he s

ame

bene

fits

as P

lan

F af

ter

one

has

paid

a

cale

ndar

yea

r $2

,240

ded

uctib

le. B

enef

its fr

om h

igh

dedu

ctib

le p

lan

F w

ill n

ot b

egin

unt

il ou

t-of-p

ocke

t exp

ense

s ex

ceed

$2,

240.

Out

-of-p

ocke

t ex

pens

es fo

r thi

s de

duct

ible

are

exp

ense

s 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 Par

t A

and

Pa

rt B

, b

ut

do n

ot in

clu

de

th

e p

lan’s

se

para

te fo

reig

n tra

ve

l e

merg

ency d

ed

uctib

le

AHLM

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an B

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FPl

an H

FPl

an G

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an A

Plan

BPl

an F

Plan

HF

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an N

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241

1,82

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2,03

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1,

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1,79

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8

Mo

dal F

acto

rs:

Sem

i-A

nnua

l:0.

5200

Qua

rter

ly:

0.26

50M

ont

hly:

0.08

33

The

abo

ve r

ates

do

no

t in

clud

e th

e $2

0 o

ne-t

ime

polic

y fe

e.

If a

pply

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duri

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pen

Enr

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or

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rant

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se P

refe

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rat

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Rat

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tna

He

alth

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Pre

miu

ms

For

Use

in E

nti

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tate

AHLMS03829ID 3 01/2018 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.

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

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, KY 40512-4770. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all your payments.

POLICY REPLACEMENT

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

NOTICE

The policy may not cover all of your medical costs.

Neither Aetna Health and Life Insurance Company nor its agents are connected with Medicare.

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare & You for more details.

COMPLETE ANSWERS ARE VERY IMPORTANT

When you fill out the application for the new policy, be sure to answer truthfully and completely any questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

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

EXCLUSIONS

We will not pay for:

1. Loss incurred while your policy is not in force, except as provided in the Extension of Benefits section of your policy;

2. Hospital or Skilled Nursing Facility confinement incurred during a Medicare Part A Benefit Period that begins while this policy is not in force;

3. That portion of any Loss incurred which is paid for by Medicare;

4. Services for non-Medicare Eligible Expenses, including, but not limited to, routine exams, take-home drugs and eye refractions;

5. Services for which a charge is not normally made in the absence of insurance;

THE FOLLOWING CHARTS DESCRIBE THE FOLLOWING PLANS OFFERED BY AETNA HEALTH AND LIFE INSURANCE COMPANY: A (AHLMSP17A ID) B (AHLMSP17B ID) F (AHLMSP17F ID) HIGH DEDUCTIBLE F (AHLMSP17HF ID) G (AHLMSP17G ID) and N (AHLMSP17N ID)

AHLMS03829ID 4 01/2018 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 $1,340 $0 $1,340 (Part A Deductible)

61st thru 90th day All but $335 a day $335 a day $0 91st day and after While using 60 lifetime reserve days All but $670 a day $670 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 $167.50 a day $0 Up to $167.50 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.

AHLMS03829ID 5 01/2018 A

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

AHLMS03829ID 6 01/2018 A

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 $1,340 $1,340 (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 $167.50 a day

$0 Up to $167.50 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.

AHLMS03829ID 7 01/2018 A

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*



AHLMS03829ID 8 01/2018 A

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



PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $167.50 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


AHLMS03829ID 9 01/2018 A

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.


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



$0


AHLMS03829ID 10 01/2018 A

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

AHLMS03829ID 11 01/2018 A

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 $2,240 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2,240. 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 $2,240

DEDUCTIBLE** PLAN PAYS

IN ADDITION TO $2,240

DEDUCTIBLE** YOU PAY



$0



$0**




$0 $0


Up to $167.50 a day

$0

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

AHLMS03829ID 12 01/2018 A

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



$0


AHLMS03829ID 13 01/2018 A

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 $2,240 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2,240. 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


AHLMS03829ID 14 01/2018 A

HIGH DEDUCTIBLE PLAN F

PARTS A & B

SERVICES

MEDICARE PAYS







100% $0 $0



$0


OTHER BENEFITS – NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS









AHLMS03829ID 15 01/2018 A

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



PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $167.50 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


AHLMS03829ID 16 01/2018 A

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*



AHLMS03829ID 17 01/2018 A

PLAN G



PLAN PAYS

YOU PAY





AHLMS03829ID 18 01/2018 A

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



PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $167.50 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


AHLMS03829ID 19 01/2018 A

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*



AHLMS03829ID 20 01/2018 A

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


Documents

Outline of Coverage - Aetna Senior Products · PDF file1,691 82 1,556 1,822 ... This outline of coverage does not give all the ... medical equipment First $183 of Medicare-Approved