AMERICAN CONTINENTAL INSURANCE COMPANY OUTLINE OF …
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ACIMS01067AZ 03012014 AMERICAN CONTINENTAL INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE: Page 1 of 2 BENEFIT PLANS AVAILABLE: A, B, F, HIGH DEDUCTIBLE F, G, N These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan “A” 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, co-payments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of coinsurance or copayments Blood: First three pints of blood each year. Hospice-Part A coinsurance A B C D F/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 $[4940]; paid at 100% after limit reached Out-of-pocket limit $[2470]; paid at 100% after limit reached *Plans 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 [$2140] deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed [$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.
Transcript of AMERICAN CONTINENTAL INSURANCE COMPANY OUTLINE OF …
ACIMS01067AZ 03012014
AMERICAN CONTINENTAL INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE: Page 1 of 2
BENEFIT PLANS AVAILABLE: A, B, F, HIGH DEDUCTIBLE F, G, N These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan “A” 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, co-payments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of coinsurance or copayments Blood: First three pints of blood each year. Hospice-Part A coinsurance
A B C D F/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 $[4940]; paid at 100% after limit reached
Out-of-pocket limit $[2470]; paid at 100% after limit reached
*Plans 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 [$2140] deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed [$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.
ACIMS01067AZ 03012014 2
Attained Non-Smoker Attained Smoker
Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N
Under 65 n/a n/a n/a n/a n/a n/a Under 65 n/a n/a n/a n/a n/a n/a
65 1,331 1,678 1,918 765 1,626 1,291 65 1,478 1,863 2,131 851 1,807 1,434
66 1,331 1,678 1,918 765 1,626 1,291 66 1,478 1,863 2,131 851 1,807 1,434
67 1,331 1,678 1,918 765 1,626 1,291 67 1,478 1,863 2,131 851 1,807 1,434
68 1,369 1,723 1,970 787 1,671 1,328 68 1,520 1,915 2,187 874 1,857 1,475
69 1,411 1,777 2,019 807 1,724 1,370 69 1,566 1,975 2,246 898 1,917 1,523
70 1,448 1,826 2,065 827 1,769 1,406 70 1,609 2,027 2,297 918 1,965 1,563
71 1,485 1,869 2,110 843 1,812 1,440 71 1,648 2,078 2,345 937 2,015 1,600
72 1,517 1,911 2,148 859 1,854 1,472 72 1,686 2,124 2,387 956 2,060 1,635
73 1,546 1,947 2,178 872 1,889 1,501 73 1,717 2,164 2,421 969 2,098 1,668
74 1,572 1,981 2,207 883 1,921 1,525 74 1,746 2,200 2,453 982 2,133 1,695
75 1,595 2,008 2,230 895 1,947 1,547 75 1,770 2,231 2,479 994 2,164 1,718
76 1,612 2,031 2,251 903 1,970 1,565 76 1,791 2,256 2,500 1,001 2,188 1,738
77 1,630 2,050 2,270 906 1,990 1,581 77 1,811 2,279 2,521 1,009 2,211 1,758
78 1,643 2,073 2,291 913 2,010 1,597 78 1,829 2,302 2,545 1,014 2,234 1,776
79 1,661 2,093 2,309 919 2,029 1,611 79 1,845 2,325 2,565 1,020 2,254 1,789
80 1,677 2,110 2,324 925 2,047 1,627 80 1,862 2,346 2,581 1,025 2,275 1,808
81 1,689 2,128 2,341 930 2,064 1,641 81 1,876 2,364 2,601 1,032 2,293 1,823
82 1,702 2,145 2,361 937 2,082 1,654 82 1,892 2,385 2,622 1,041 2,313 1,838
83 1,718 2,163 2,378 944 2,098 1,666 83 1,908 2,404 2,643 1,049 2,331 1,852
84 1,728 2,178 2,398 949 2,111 1,681 84 1,922 2,422 2,666 1,055 2,347 1,864
85 1,740 2,193 2,418 956 2,128 1,689 85 1,932 2,437 2,688 1,060 2,364 1,877
86 1,751 2,207 2,436 960 2,140 1,700 86 1,946 2,453 2,706 1,067 2,378 1,889
87 1,761 2,220 2,453 965 2,151 1,709 87 1,957 2,464 2,726 1,072 2,392 1,900
88 1,777 2,240 2,474 974 2,172 1,727 88 1,975 2,487 2,749 1,082 2,414 1,917
89 1,794 2,261 2,494 981 2,192 1,742 89 1,993 2,510 2,770 1,090 2,436 1,935
90 1,810 2,279 2,516 989 2,211 1,756 90 2,011 2,533 2,793 1,099 2,458 1,952
91 1,825 2,299 2,535 996 2,230 1,771 91 2,027 2,553 2,814 1,107 2,478 1,968
92 1,838 2,317 2,551 1,004 2,246 1,784 92 2,044 2,574 2,836 1,116 2,496 1,984
93 1,850 2,333 2,567 1,010 2,262 1,797 93 2,056 2,592 2,853 1,122 2,514 1,998
94 1,864 2,347 2,579 1,014 2,278 1,809 94 2,070 2,608 2,868 1,129 2,530 2,010
95 1,875 2,361 2,593 1,020 2,291 1,819 95 2,083 2,624 2,883 1,134 2,544 2,023
96 1,885 2,376 2,608 1,026 2,303 1,830 96 2,094 2,639 2,897 1,139 2,560 2,032
97 1,896 2,390 2,622 1,030 2,318 1,841 97 2,108 2,655 2,912 1,145 2,574 2,045
98 1,907 2,404 2,636 1,037 2,331 1,850 98 2,118 2,670 2,928 1,151 2,590 2,057
99 1,919 2,418 2,646 1,041 2,345 1,863 99 2,132 2,686 2,943 1,158 2,606 2,070
Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.08333
The rates do not include the $20 policy fee.
For Use in ZIP Codes: 850
American Continental Insurance CompanyAnnual Attained Age Premiums
Female Rates
ACIMS01067AZ 03012014 3
Attained Non-Smoker Attained Smoker
Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N
Under 65 n/a n/a n/a n/a n/a n/a Under 65 n/a n/a n/a n/a n/a n/a
65 1,531 1,926 2,207 882 1,869 1,486 65 1,701 2,141 2,452 979 2,078 1,650
66 1,531 1,926 2,207 882 1,869 1,486 66 1,701 2,141 2,452 979 2,078 1,650
67 1,531 1,926 2,207 882 1,869 1,486 67 1,701 2,141 2,452 979 2,078 1,650
68 1,573 1,983 2,263 904 1,923 1,527 68 1,749 2,202 2,516 1,006 2,136 1,696
69 1,622 2,045 2,324 929 1,984 1,576 69 1,802 2,270 2,581 1,030 2,205 1,749
70 1,664 2,098 2,377 951 2,037 1,617 70 1,850 2,332 2,640 1,056 2,261 1,797
71 1,707 2,149 2,428 972 2,085 1,655 71 1,896 2,389 2,698 1,078 2,317 1,841
72 1,745 2,199 2,473 989 2,131 1,694 72 1,938 2,443 2,746 1,098 2,368 1,883
73 1,777 2,239 2,504 1,004 2,172 1,726 73 1,975 2,487 2,783 1,116 2,413 1,917
74 1,806 2,277 2,539 1,018 2,209 1,754 74 2,007 2,530 2,820 1,130 2,453 1,949
75 1,833 2,308 2,566 1,028 2,239 1,778 75 2,036 2,565 2,851 1,144 2,487 1,977
76 1,853 2,335 2,588 1,036 2,266 1,800 76 2,060 2,593 2,875 1,151 2,516 2,000
77 1,870 2,360 2,608 1,043 2,289 1,817 77 2,080 2,622 2,899 1,159 2,542 2,018
78 1,892 2,384 2,635 1,051 2,313 1,838 78 2,101 2,646 2,924 1,165 2,568 2,041
79 1,909 2,405 2,657 1,056 2,332 1,854 79 2,122 2,673 2,950 1,173 2,592 2,057
80 1,926 2,427 2,671 1,061 2,354 1,870 80 2,140 2,697 2,968 1,180 2,615 2,078
81 1,941 2,447 2,692 1,070 2,374 1,885 81 2,157 2,720 2,995 1,187 2,638 2,095
82 1,958 2,468 2,714 1,076 2,393 1,901 82 2,176 2,742 3,015 1,197 2,660 2,111
83 1,975 2,487 2,735 1,084 2,413 1,917 83 2,193 2,763 3,041 1,206 2,681 2,130
84 1,988 2,504 2,759 1,091 2,430 1,930 84 2,208 2,783 3,065 1,213 2,700 2,145
85 2,002 2,521 2,781 1,098 2,447 1,944 85 2,224 2,801 3,090 1,221 2,719 2,159
86 2,014 2,537 2,800 1,104 2,461 1,956 86 2,238 2,821 3,112 1,227 2,735 2,171
87 2,024 2,551 2,821 1,109 2,475 1,965 87 2,249 2,835 3,134 1,232 2,751 2,184
88 2,045 2,576 2,845 1,120 2,498 1,985 88 2,271 2,861 3,161 1,243 2,775 2,206
89 2,062 2,601 2,869 1,129 2,521 2,004 89 2,292 2,888 3,188 1,255 2,801 2,225
90 2,082 2,622 2,891 1,136 2,543 2,019 90 2,312 2,913 3,213 1,263 2,827 2,246
91 2,099 2,643 2,913 1,145 2,565 2,038 91 2,332 2,938 3,238 1,273 2,850 2,264
92 2,114 2,665 2,933 1,153 2,583 2,052 92 2,349 2,960 3,259 1,282 2,870 2,282
93 2,129 2,684 2,952 1,162 2,601 2,067 93 2,366 2,981 3,279 1,290 2,890 2,297
94 2,142 2,700 2,968 1,167 2,619 2,080 94 2,381 2,999 3,297 1,298 2,911 2,312
95 2,155 2,715 2,983 1,174 2,635 2,092 95 2,394 3,018 3,313 1,304 2,927 2,324
96 2,169 2,731 2,998 1,179 2,648 2,105 96 2,409 3,036 3,333 1,310 2,944 2,338
97 2,179 2,747 3,013 1,186 2,666 2,118 97 2,423 3,053 3,348 1,317 2,961 2,353
98 2,193 2,762 3,029 1,193 2,681 2,130 98 2,438 3,072 3,366 1,324 2,977 2,367
99 2,207 2,780 3,044 1,197 2,696 2,142 99 2,452 3,089 3,382 1,331 2,997 2,379
Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.08333
The rates do not include the $20 policy fee.
American Continental Insurance CompanyAnnual Attained Age Premiums
For Use in ZIP Codes: 850
Male Rates
ACIMS01067AZ 03012014 4
Attained Non-Smoker Attained Smoker
Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N
Under 65 n/a n/a n/a n/a n/a n/a Under 65 n/a n/a n/a n/a n/a n/a
65 1,088 1,371 1,568 625 1,329 1,056 65 1,208 1,523 1,742 696 1,477 1,172
66 1,088 1,371 1,568 625 1,329 1,056 66 1,208 1,523 1,742 696 1,477 1,172
67 1,088 1,371 1,568 625 1,329 1,056 67 1,208 1,523 1,742 696 1,477 1,172
68 1,119 1,408 1,610 643 1,366 1,086 68 1,243 1,565 1,788 714 1,518 1,206
69 1,153 1,452 1,651 660 1,409 1,120 69 1,280 1,614 1,836 734 1,567 1,245
70 1,183 1,493 1,688 676 1,446 1,150 70 1,315 1,657 1,877 750 1,606 1,277
71 1,214 1,528 1,725 689 1,481 1,177 71 1,347 1,699 1,917 766 1,647 1,308
72 1,240 1,562 1,756 702 1,515 1,203 72 1,378 1,736 1,951 781 1,684 1,337
73 1,263 1,591 1,780 713 1,544 1,227 73 1,403 1,769 1,979 792 1,715 1,363
74 1,285 1,620 1,804 722 1,570 1,246 74 1,427 1,798 2,005 803 1,744 1,386
75 1,304 1,641 1,823 731 1,591 1,264 75 1,447 1,824 2,027 812 1,769 1,404
76 1,318 1,660 1,840 738 1,610 1,279 76 1,464 1,844 2,044 818 1,789 1,420
77 1,332 1,676 1,856 741 1,626 1,293 77 1,481 1,863 2,060 824 1,808 1,437
78 1,343 1,695 1,872 746 1,643 1,306 78 1,495 1,882 2,080 829 1,826 1,451
79 1,357 1,711 1,888 751 1,658 1,317 79 1,508 1,901 2,096 834 1,842 1,463
80 1,371 1,725 1,900 756 1,673 1,330 80 1,522 1,918 2,109 838 1,859 1,478
81 1,381 1,739 1,914 760 1,687 1,341 81 1,533 1,933 2,126 843 1,874 1,490
82 1,391 1,753 1,930 766 1,701 1,352 82 1,546 1,950 2,143 851 1,890 1,502
83 1,404 1,768 1,944 772 1,715 1,362 83 1,559 1,965 2,160 857 1,905 1,513
84 1,413 1,780 1,960 776 1,726 1,374 84 1,571 1,980 2,179 862 1,919 1,524
85 1,422 1,793 1,977 781 1,739 1,381 85 1,579 1,992 2,197 867 1,933 1,534
86 1,432 1,804 1,991 785 1,749 1,389 86 1,590 2,005 2,212 872 1,944 1,544
87 1,439 1,814 2,005 789 1,758 1,397 87 1,600 2,014 2,228 876 1,955 1,553
88 1,452 1,831 2,022 796 1,776 1,412 88 1,614 2,033 2,247 885 1,973 1,567
89 1,466 1,848 2,039 802 1,792 1,424 89 1,629 2,052 2,264 891 1,991 1,582
90 1,480 1,863 2,057 808 1,808 1,435 90 1,644 2,071 2,283 899 2,009 1,595
91 1,492 1,879 2,072 814 1,823 1,448 91 1,657 2,087 2,300 905 2,026 1,608
92 1,502 1,894 2,085 821 1,836 1,458 92 1,670 2,104 2,318 912 2,040 1,622
93 1,512 1,907 2,098 825 1,849 1,469 93 1,681 2,119 2,332 917 2,055 1,633
94 1,524 1,919 2,108 829 1,862 1,479 94 1,692 2,132 2,344 923 2,068 1,643
95 1,532 1,930 2,120 834 1,872 1,487 95 1,702 2,145 2,357 927 2,079 1,653
96 1,541 1,942 2,132 838 1,883 1,496 96 1,712 2,157 2,368 931 2,092 1,661
97 1,550 1,953 2,143 842 1,895 1,505 97 1,723 2,170 2,380 936 2,104 1,671
98 1,559 1,965 2,154 848 1,905 1,512 98 1,731 2,183 2,393 941 2,117 1,682
99 1,569 1,977 2,163 851 1,917 1,523 99 1,743 2,196 2,405 947 2,130 1,692
Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.08333
The rates do not include the $20 policy fee.
Female Rates
American Continental Insurance CompanyAnnual Attained Age Premiums
For Use in ZIP Codes: Rest of State
ACIMS01067AZ 03012014 5
Attained Non-Smoker Attained Smoker
Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N
Under 65 n/a n/a n/a n/a n/a n/a Under 65 n/a n/a n/a n/a n/a n/a
65 1,251 1,575 1,804 721 1,528 1,214 65 1,390 1,750 2,004 800 1,699 1,349
66 1,251 1,575 1,804 721 1,528 1,214 66 1,390 1,750 2,004 800 1,699 1,349
67 1,251 1,575 1,804 721 1,528 1,214 67 1,390 1,750 2,004 800 1,699 1,349
68 1,286 1,621 1,850 739 1,572 1,248 68 1,430 1,800 2,057 823 1,746 1,387
69 1,325 1,671 1,900 760 1,622 1,288 69 1,473 1,856 2,109 842 1,802 1,430
70 1,360 1,715 1,943 777 1,665 1,322 70 1,512 1,906 2,158 863 1,848 1,469
71 1,395 1,757 1,984 794 1,704 1,353 71 1,550 1,952 2,205 881 1,894 1,505
72 1,426 1,797 2,021 808 1,742 1,385 72 1,584 1,997 2,245 898 1,935 1,539
73 1,452 1,830 2,046 821 1,776 1,411 73 1,614 2,033 2,275 912 1,972 1,567
74 1,476 1,861 2,076 832 1,806 1,434 74 1,640 2,068 2,305 924 2,005 1,593
75 1,498 1,887 2,097 840 1,830 1,453 75 1,664 2,096 2,330 935 2,033 1,616
76 1,514 1,908 2,115 847 1,852 1,471 76 1,684 2,120 2,350 941 2,057 1,635
77 1,528 1,929 2,132 853 1,871 1,485 77 1,700 2,143 2,370 948 2,077 1,650
78 1,546 1,949 2,154 859 1,890 1,502 78 1,717 2,163 2,390 952 2,099 1,669
79 1,560 1,966 2,171 863 1,906 1,515 79 1,734 2,185 2,411 959 2,119 1,682
80 1,575 1,983 2,184 868 1,924 1,528 80 1,749 2,204 2,426 964 2,138 1,699
81 1,587 2,000 2,201 874 1,940 1,541 81 1,763 2,223 2,448 970 2,156 1,713
82 1,601 2,017 2,218 880 1,956 1,554 82 1,778 2,241 2,465 979 2,174 1,726
83 1,614 2,033 2,235 886 1,972 1,567 83 1,793 2,259 2,485 986 2,191 1,741
84 1,625 2,046 2,255 892 1,986 1,577 84 1,805 2,275 2,505 992 2,207 1,753
85 1,637 2,060 2,273 898 2,000 1,589 85 1,818 2,290 2,526 998 2,222 1,764
86 1,646 2,074 2,289 902 2,012 1,599 86 1,829 2,306 2,544 1,003 2,235 1,775
87 1,654 2,085 2,306 906 2,023 1,606 87 1,839 2,317 2,562 1,007 2,248 1,785
88 1,671 2,106 2,326 916 2,042 1,622 88 1,857 2,339 2,584 1,016 2,268 1,803
89 1,685 2,126 2,345 923 2,060 1,638 89 1,873 2,360 2,606 1,026 2,290 1,819
90 1,701 2,143 2,363 929 2,078 1,651 90 1,889 2,381 2,626 1,032 2,311 1,836
91 1,716 2,160 2,381 936 2,096 1,666 91 1,906 2,402 2,647 1,041 2,329 1,851
92 1,728 2,178 2,397 943 2,111 1,677 92 1,920 2,420 2,664 1,048 2,346 1,865
93 1,740 2,194 2,413 949 2,126 1,689 93 1,934 2,436 2,680 1,055 2,362 1,877
94 1,751 2,207 2,426 954 2,140 1,700 94 1,946 2,452 2,695 1,061 2,379 1,889
95 1,762 2,219 2,438 960 2,154 1,710 95 1,957 2,467 2,708 1,066 2,392 1,900
96 1,773 2,233 2,451 964 2,165 1,720 96 1,969 2,482 2,724 1,071 2,406 1,911
97 1,781 2,246 2,463 969 2,179 1,731 97 1,981 2,496 2,736 1,076 2,421 1,923
98 1,793 2,258 2,476 975 2,191 1,741 98 1,993 2,511 2,751 1,082 2,434 1,935
99 1,804 2,272 2,488 979 2,203 1,751 99 2,004 2,525 2,765 1,088 2,450 1,945
Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.08333
The rates do not include the $20 policy fee.
Male Rates
American Continental Insurance CompanyAnnual Attained Age Premiums
For Use in ZIP Codes: Rest of State
ACIMS01067AZ 03012014
PREMIUM INFORMATION
American Continental Insurance Company can only raise your premium if we raise the premium for all policies like yours in this state. Premiums for this policy will increase due to the increase in your age. Upon attainment of an age requiring a rate increase, the renewal premium for the policy will be the renewal premium then in effect for your attained age. Other policies may be provided with Issue Age rating and do not increase with age. You should compare Issue Age with Attained Age policies. Premiums payable other than annual will be determined according to the following factors: 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 American Continental Insurance Company, P.O.Box 2368, Brentwood, Tennessee 37024. 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 American Continental Insurance Company nor its agents are connected with Medicare.
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare & You for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT
When you fill out the application for the new policy, be sure to answer truthfully and completely any questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
THE FOLLOWING CHARTS DESCRIBE PLANS A, B, F, HIGH DEDUCTIBLE F, G and N OFFERED BY AMERICAN CONTINENTAL INSURANCE COMPANY.
ACIMS01067AZ 03012014
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.
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
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.
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
11
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.
12
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
13
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
14
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
15
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.
16
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
17
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
18
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.
19
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
20
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
21
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.
22
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
23
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
