MUTUAL OF OMAHA INSURANCE COMPANY OUTLINE OF …
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OH MOO AGY 001 1 OH_MOO_AGY_090121 MUTUAL OF OMAHA INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE – COVER PAGE BENEFIT PLANS A, F, G, HIGH DEDUCTIBLE G AND N This chart shows the benefits included in each of the standard Medicare supplement plans. Some plans may not be available. Only applicants’ first eligible for Medicare before 2020 may purchase Plans C, F and High Deductible F. Note: A ü means 100% of the benefit is paid. Benefits Plans Available to All Applicants Medicare first eligible before 2020 only PLAN A PLAN B PLAN D PLAN G * PLAN K PLAN L PLAN M PLAN N PLAN C PLAN F* Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up) ü ü ü ü ü ü ü ü ü ü Medicare Part B coinsurance or Copayment ü ü ü ü 50% 75% ü ü copays apply 3 ü ü Blood (first three pints each year) ü ü ü ü 50% 75% ü ü ü ü Part A hospice care coinsurance or copayment ü ü ü ü 50% 75% ü ü ü ü Skilled nursing facility coinsurance ü ü 50% 75% ü ü ü ü Medicare Part A deductible ü ü ü 50% 75% 50% ü ü ü Medicare Part B deductible ü ü Medicare Part B excess charges ü ü Foreign travel emergency (up to plan limits) ü ü ü ü ü ü Out-of-pocket limit in 2021 2 $6,220 ** $3,110 ** * Plans F and G also have a high deductible options which require first paying a plan deductible $2,370 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible. **Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit. ***Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that do not result in an inpatient admission.
Transcript of MUTUAL OF OMAHA INSURANCE COMPANY OUTLINE OF …
OH MOO AGY 001 1 OH_MOO_AGY_090121
MUTUAL OF OMAHA INSURANCE COMPANYOUTLINE OF MEDICARE SUPPLEMENT COVERAGE – COVER PAGE
BENEFIT PLANS A, F, G, HIGH DEDUCTIBLE G AND NThis chart shows the benefits included in each of the standard Medicare supplement plans. Some plans may not be available. Only applicants’ first eligible for Medicarebefore 2020 may purchase Plans C, F and High Deductible F.
Note: Aü means 100% of the benefit is paid.
BenefitsPlans Available to All Applicants
Medicare first eligiblebefore 2020 only
PLAN A PLAN B PLAN D PLAN G * PLAN K PLAN L PLAN M PLAN N PLAN C PLAN F*Medicare Part A coinsurance andhospital coverage (up to anadditional 365 days after Medicarebenefits are used up)
ü ü ü ü ü ü ü ü ü ü
Medicare Part B coinsurance orCopayment ü ü ü ü 50% 75% ü
ücopaysapply3
ü ü
Blood (first three pints each year) ü ü ü ü 50% 75% ü ü ü üPart A hospice care coinsuranceor copayment ü ü ü ü 50% 75% ü ü ü ü
Skilled nursing facility coinsurance ü ü 50% 75% ü ü ü üMedicare Part A deductible ü ü ü 50% 75% 50% ü ü üMedicare Part B deductible ü üMedicare Part B excess charges ü üForeign travel emergency (up toplan limits) ü ü ü ü ü ü
Out-of-pocket limit in 2021 2 $6,220** $3,110**
*Plans F and G also have a high deductible options which require first paying a plan deductible $2,370 before the plan begins to pay. Once the plan deductible is met, theplan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductibleplans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.**Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.***Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that donot result in an inpatient admission.
OH MOO AGY 001 2 OH_MOO_AGY_090121
MONTHLY NON-TOBACCO PREMIUMS*ZIP CODES: 430-435, 437-439, 446-449, 455-458
FEMALE MALEPlan AMM20
Plan FMM24
Plan GMM25
Plan High GMM36
Plan NMM35
AttainedAge
Plan AMM20
Plan FMM24
Plan GMM25
Plan High GMM36
Plan NMM35
89.68 122.85 104.07 40.58 81.01 65 103.13 141.27 119.67 46.66 93.1789.68 122.85 104.07 40.58 81.01 66 103.13 141.27 119.67 46.66 93.1789.68 122.85 104.07 40.58 81.01 67 103.13 141.27 119.67 46.66 93.1791.48 125.31 106.76 41.80 84.42 68 105.19 144.10 122.79 48.06 97.0893.27 127.77 109.48 43.01 87.82 69 107.26 146.93 125.89 49.47 101.0095.05 130.22 112.18 44.23 91.23 70 109.32 149.75 129.01 50.86 104.9196.85 132.67 114.89 45.45 94.62 71 111.38 152.58 132.12 52.27 108.8398.65 135.13 117.59 46.66 98.03 72 113.45 155.40 135.23 53.67 112.74102.60 140.54 121.82 48.17 100.97 73 117.98 161.62 140.10 55.39 116.12106.54 145.94 126.06 49.66 103.91 74 122.52 167.83 144.96 57.11 119.50110.49 151.35 130.29 51.15 106.85 75 127.06 174.05 149.83 58.82 122.88114.43 156.75 134.53 52.65 109.80 76 131.60 180.27 154.70 60.54 126.26118.38 162.16 138.76 54.13 112.74 77 136.13 186.48 159.57 62.25 129.64122.63 167.99 144.03 55.98 117.02 78 141.03 193.20 165.63 64.37 134.57126.90 173.83 149.30 57.82 121.31 79 145.93 199.91 171.69 66.49 139.50131.16 179.67 154.57 59.66 125.59 80 150.84 206.62 177.75 68.60 144.42135.43 185.51 159.85 61.50 129.87 81 155.74 213.34 183.82 70.72 149.35139.68 191.35 165.12 63.34 134.15 82 160.64 220.05 189.89 72.84 154.28144.72 198.24 171.06 64.74 138.98 83 166.42 227.98 196.73 74.44 159.83149.75 205.13 177.01 66.12 143.81 84 172.20 235.89 203.56 76.04 165.39154.77 212.02 182.95 67.51 148.64 85 177.99 243.81 210.39 77.64 170.94159.80 218.91 188.90 68.91 153.48 86 183.77 251.74 217.23 79.25 176.49164.83 225.79 194.84 70.31 158.30 87 189.55 259.66 224.06 80.85 182.05168.12 230.31 198.74 71.71 161.47 88 193.35 264.85 228.55 82.46 185.69171.49 234.91 202.72 73.15 164.70 89 197.21 270.15 233.12 84.12 189.40174.91 239.61 206.77 74.61 167.99 90 201.15 275.55 237.78 85.79 193.19178.42 244.40 210.90 76.11 171.35 91 205.18 281.07 242.54 87.52 197.05181.99 249.29 215.12 77.62 174.78 92 209.28 286.68 247.39 89.26 200.99185.62 254.27 219.42 79.18 178.27 93 213.46 292.42 252.33 91.05 205.02189.34 259.37 223.81 80.76 181.84 94 217.74 298.27 257.38 92.88 209.11193.12 264.55 228.29 82.37 185.48 95 222.09 304.23 262.53 94.74 213.30196.98 269.84 232.85 84.02 189.19 96 226.54 310.32 267.78 96.62 217.56200.92 275.24 237.50 85.70 192.97 97 231.06 316.52 273.14 98.55 221.91204.94 280.74 242.26 87.41 196.83 98 235.68 322.85 278.60 100.53 226.35209.04 286.36 247.11 89.17 200.77 99+ 240.40 329.31 284.17 102.54 230.88
*See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively.
OH MOO AGY 001 3 OH_MOO_AGY_090121
MONTHLY TOBACCO PREMIUMS*ZIP CODES: 430-435, 437-439, 446-449, 455-458
FEMALE MALEPlan AMM20
Plan FMM24
Plan GMM25
Plan High GMM36
Plan NMM35
AttainedAge
Plan AMM20
Plan FMM24
Plan GMM25
Plan High GMM36
Plan NMM35
96.95 132.81 112.51 43.87 87.58 65 111.49 152.73 129.37 50.45 100.7296.95 132.81 112.51 43.87 87.58 66 111.49 152.73 129.37 50.45 100.7296.95 132.81 112.51 43.87 87.58 67 111.49 152.73 129.37 50.45 100.7298.89 135.47 115.42 45.18 91.26 68 113.72 155.78 132.74 51.96 104.95100.84 138.13 118.35 46.50 94.94 69 115.95 158.84 136.10 53.48 109.19102.76 140.77 121.28 47.82 98.63 70 118.18 161.90 139.47 54.99 113.42104.71 143.43 124.20 49.13 102.30 71 120.41 164.95 142.83 56.51 117.65106.65 146.09 127.13 50.45 105.98 72 122.65 168.00 146.19 58.02 121.88110.91 151.94 131.70 52.07 109.16 73 127.55 174.73 151.46 59.88 125.53115.18 157.78 136.28 53.68 112.33 74 132.46 181.44 156.72 61.74 129.19119.45 163.62 140.85 55.30 115.52 75 137.36 188.16 161.98 63.59 132.84123.71 169.46 145.44 56.92 118.70 76 142.27 194.89 167.24 65.45 136.50127.98 175.31 150.01 58.52 121.88 77 147.17 201.60 172.51 67.30 140.15132.58 181.62 155.70 60.52 126.51 78 152.47 208.86 179.06 69.59 145.49137.19 187.93 161.41 62.51 131.14 79 157.77 216.12 185.61 71.88 150.81141.80 194.24 167.11 64.49 135.77 80 163.07 223.38 192.17 74.17 156.13146.41 200.55 172.81 66.49 140.40 81 168.36 230.64 198.73 76.45 161.46151.01 206.86 178.51 68.47 145.03 82 173.66 237.89 205.28 78.75 166.79156.45 214.31 184.93 69.99 150.25 83 179.91 246.46 212.68 80.47 172.79161.89 221.76 191.36 71.48 155.47 84 186.16 255.02 220.07 82.21 178.79167.32 229.21 197.78 72.99 160.69 85 192.42 263.58 227.45 83.94 184.80172.76 236.66 204.22 74.50 165.92 86 198.67 272.15 234.84 85.67 190.80178.19 244.09 210.64 76.01 171.14 87 204.92 280.71 242.23 87.40 196.81181.75 248.98 214.85 77.53 174.56 88 209.02 286.33 247.08 89.15 200.74185.39 253.96 219.15 79.08 178.05 89 213.20 292.06 252.02 90.94 204.76189.10 259.04 223.53 80.66 181.62 90 217.46 297.90 257.06 92.75 208.85192.88 264.22 228.00 82.28 185.24 91 221.81 303.86 262.21 94.62 213.03196.74 269.51 232.56 83.91 188.95 92 226.25 309.93 267.45 96.50 217.29200.67 274.89 237.21 85.60 192.73 93 230.77 316.13 272.79 98.43 221.64204.69 280.39 241.96 87.31 196.58 94 235.39 322.45 278.24 100.41 226.07208.78 286.00 246.79 89.05 200.52 95 240.10 328.90 283.82 102.42 230.59212.95 291.72 251.73 90.83 204.53 96 244.90 335.48 289.49 104.46 235.20217.21 297.55 256.76 92.65 208.62 97 249.80 342.19 295.28 106.55 239.91221.55 303.50 261.90 94.50 212.79 98 254.79 349.03 301.19 108.68 244.70225.99 309.57 267.14 96.40 217.05 99+ 259.89 356.01 307.21 110.85 249.60
*See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively.
OH MOO AGY 001 4 OH_MOO_AGY_090121
MONTHLY NON-TOBACCO PREMIUMS*ZIP CODES: 450-454, 459
FEMALE MALEPlan AMM20
Plan FMM24
Plan GMM25
Plan High GMM36
Plan NMM35
AttainedAge
Plan AMM20
Plan FMM24
Plan GMM25
Plan High GMM36
Plan NMM35
93.85 128.56 108.91 42.47 84.78 65 107.93 147.84 125.23 48.84 97.5093.85 128.56 108.91 42.47 84.78 66 107.93 147.84 125.23 48.84 97.5093.85 128.56 108.91 42.47 84.78 67 107.93 147.84 125.23 48.84 97.5095.73 131.14 111.73 43.74 88.35 68 110.08 150.80 128.50 50.30 101.6097.61 133.71 114.57 45.01 91.91 69 112.25 153.76 131.74 51.77 105.6999.48 136.27 117.40 46.29 95.47 70 114.40 156.72 135.01 53.23 109.79101.36 138.84 120.23 47.56 99.03 71 116.56 159.67 138.26 54.70 113.89103.24 141.42 123.06 48.84 102.59 72 118.72 162.63 141.52 56.16 117.98107.37 147.08 127.49 50.41 105.67 73 123.47 169.14 146.61 57.97 121.52111.50 152.73 131.92 51.97 108.74 74 128.22 175.64 151.71 59.77 125.06115.63 158.39 136.35 53.53 111.82 75 132.97 182.14 156.80 61.56 128.60119.76 164.04 140.78 55.09 114.90 76 137.72 188.65 161.90 63.35 132.14123.88 169.71 145.21 56.65 117.98 77 142.47 195.16 166.99 65.14 135.67128.34 175.81 150.72 58.58 122.46 78 147.59 202.18 173.34 67.37 140.83132.80 181.92 156.24 60.51 126.95 79 152.72 209.21 179.68 69.58 145.99137.26 188.03 161.76 62.43 131.43 80 157.85 216.23 186.02 71.80 151.14141.73 194.14 167.28 64.36 135.91 81 162.98 223.26 192.37 74.01 156.29146.18 200.25 172.80 66.28 140.39 82 168.11 230.29 198.72 76.23 161.46151.45 207.46 179.02 67.75 145.45 83 174.16 238.58 205.88 77.90 167.27156.71 214.67 185.24 69.20 150.50 84 180.21 246.86 213.03 79.58 173.08161.97 221.88 191.46 70.66 155.55 85 186.26 255.15 220.18 81.25 178.89167.23 229.09 197.69 72.12 160.61 86 192.32 263.45 227.33 82.93 184.70172.49 236.29 203.90 73.58 165.67 87 198.37 271.74 234.48 84.61 190.52175.94 241.02 207.98 75.05 168.98 88 202.34 277.17 239.18 86.30 194.32179.46 245.84 212.15 76.55 172.36 89 206.39 282.72 243.96 88.03 198.21183.05 250.76 216.38 78.08 175.81 90 210.51 288.37 248.84 89.79 202.17186.71 255.77 220.71 79.65 179.32 91 214.72 294.14 253.82 91.59 206.22190.45 260.89 225.13 81.23 182.91 92 219.01 300.02 258.90 93.42 210.34194.26 266.10 229.63 82.86 186.56 93 223.39 306.02 264.07 95.28 214.55198.14 271.43 234.22 84.52 190.29 94 227.86 312.14 269.35 97.19 218.84202.11 276.86 238.90 86.21 194.11 95 232.42 318.38 274.74 99.14 223.22206.14 282.39 243.68 87.93 197.99 96 237.07 324.75 280.24 101.12 227.68210.27 288.04 248.55 89.69 201.95 97 241.81 331.24 285.84 103.14 232.23214.47 293.80 253.53 91.48 205.99 98 246.65 337.87 291.56 105.20 236.88218.76 299.68 258.60 93.32 210.11 99+ 251.58 344.63 297.39 107.31 241.62
*See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively.
OH MOO AGY 001 5 OH_MOO_AGY_090121
MONTHLY TOBACCO PREMIUMS*ZIP CODES: 450-454, 459
FEMALE MALEPlan AMM20
Plan FMM24
Plan GMM25
Plan High GMM36
Plan NMM35
AttainedAge
Plan AMM20
Plan FMM24
Plan GMM25
Plan High GMM36
Plan NMM35
101.46 138.99 117.74 45.91 91.66 65 116.68 159.83 135.39 52.79 105.41101.46 138.99 117.74 45.91 91.66 66 116.68 159.83 135.39 52.79 105.41101.46 138.99 117.74 45.91 91.66 67 116.68 159.83 135.39 52.79 105.41103.49 141.77 120.79 47.29 95.51 68 119.01 163.03 138.92 54.38 109.84105.53 144.55 123.86 48.66 99.36 69 121.35 166.23 142.43 55.97 114.26107.54 147.32 126.92 50.04 103.21 70 123.68 169.43 145.95 57.55 118.69109.58 150.10 129.98 51.42 107.06 71 126.01 172.62 149.47 59.14 123.12111.61 152.88 133.04 52.79 110.91 72 128.35 175.82 152.99 60.71 127.55116.07 159.00 137.83 54.50 114.24 73 133.48 182.85 158.50 62.67 131.37120.54 165.11 142.61 56.18 117.56 74 138.62 189.88 164.01 64.61 135.20125.00 171.23 147.40 57.87 120.89 75 143.75 196.91 169.52 66.55 139.02129.47 177.35 152.20 59.56 124.22 76 148.89 203.95 175.02 68.49 142.85133.93 183.47 156.99 61.25 127.55 77 154.02 210.98 180.53 70.43 146.67138.74 190.06 162.95 63.33 132.39 78 159.56 218.57 187.39 72.83 152.25143.57 196.67 168.91 65.41 137.24 79 165.11 226.17 194.25 75.22 157.82148.39 203.27 174.88 67.49 142.08 80 170.65 233.77 201.11 77.62 163.40153.22 209.88 180.85 69.58 146.93 81 176.19 241.36 207.97 80.01 168.97158.03 216.49 186.81 71.66 151.78 82 181.74 248.96 214.83 82.41 174.55163.73 224.28 193.54 73.24 157.24 83 188.28 257.92 222.57 84.21 180.83169.42 232.07 200.26 74.81 162.70 84 194.82 266.88 230.30 86.03 187.11175.10 239.87 206.98 76.38 168.17 85 201.37 275.84 238.03 87.84 193.39180.79 247.66 213.71 77.97 173.64 86 207.91 284.81 245.76 89.66 199.67186.48 255.45 220.44 79.54 179.10 87 214.45 293.77 253.49 91.47 205.97190.21 260.56 224.85 81.14 182.68 88 218.75 299.65 258.57 93.29 210.08194.01 265.77 229.35 82.76 186.34 89 223.12 305.64 263.75 95.17 214.28197.89 271.09 233.93 84.41 190.06 90 227.57 311.75 269.02 97.07 218.57201.85 276.51 238.61 86.10 193.86 91 232.13 317.99 274.40 99.02 222.94205.89 282.04 243.38 87.81 197.74 92 236.77 324.34 279.89 100.99 227.39210.01 287.68 248.25 89.58 201.69 93 241.51 330.83 285.48 103.01 231.95214.21 293.44 253.22 91.37 205.72 94 246.34 337.45 291.19 105.08 236.58218.49 299.30 258.27 93.20 209.84 95 251.26 344.20 297.02 107.18 241.32222.86 305.29 263.44 95.06 214.04 96 256.29 351.08 302.96 109.31 246.14227.31 311.39 268.70 96.96 218.32 97 261.41 358.10 309.02 111.50 251.06231.86 317.62 274.09 98.89 222.69 98 266.64 365.27 315.20 113.73 256.09236.50 323.97 279.57 100.88 227.14 99+ 271.98 372.57 321.50 116.01 261.21
*See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively.
OH MOO AGY 001 6 OH_MOO_AGY_090121
MONTHLY NON-TOBACCO PREMIUMS*ZIP CODES: 436, 440 - 445
FEMALE MALEPlan AMM20
Plan FMM24
Plan GMM25
Plan High GMM36
Plan NMM35
AttainedAge
Plan AMM20
Plan FMM24
Plan GMM25
Plan High GMM36
Plan NMM35
99.06 135.71 114.96 44.83 89.49 65 113.92 156.06 132.19 51.55 102.9299.06 135.71 114.96 44.83 89.49 66 113.92 156.06 132.19 51.55 102.9299.06 135.71 114.96 44.83 89.49 67 113.92 156.06 132.19 51.55 102.92101.05 138.42 117.94 46.17 93.25 68 116.20 159.18 135.64 53.09 107.24103.03 141.14 120.93 47.51 97.01 69 118.48 162.31 139.06 54.65 111.57105.00 143.84 123.92 48.86 100.78 70 120.76 165.43 142.51 56.19 115.89106.99 146.56 126.91 50.20 104.53 71 123.03 168.54 145.94 57.74 120.21108.97 149.27 129.90 51.55 108.29 72 125.32 171.66 149.38 59.28 124.54113.33 155.25 134.57 53.21 111.54 73 130.33 178.54 154.76 61.19 128.27117.69 161.22 139.25 54.85 114.78 74 135.35 185.40 160.13 63.09 132.01122.05 167.19 143.92 56.50 118.03 75 140.35 192.26 165.51 64.98 135.74126.41 173.16 148.61 58.16 121.29 76 145.37 199.13 170.89 66.87 139.48130.77 179.13 153.28 59.80 124.54 77 150.38 206.00 176.27 68.76 143.21135.47 185.57 159.10 61.84 129.26 78 155.79 213.41 182.96 71.11 148.66140.18 192.03 164.92 63.87 134.00 79 161.21 220.83 189.66 73.45 154.10144.89 198.47 170.75 65.90 138.73 80 166.62 228.25 196.36 75.78 159.54149.60 204.92 176.58 67.94 143.46 81 172.03 235.66 203.06 78.12 164.98154.30 211.38 182.40 69.97 148.19 82 177.45 243.08 209.76 80.47 170.43159.86 218.98 188.97 71.51 153.53 83 183.83 251.83 217.32 82.23 176.56165.42 226.59 195.53 73.04 158.86 84 190.22 260.58 224.86 84.00 182.69170.97 234.21 202.10 74.58 164.19 85 196.61 269.33 232.41 85.77 188.83176.52 241.81 208.67 76.13 169.54 86 203.00 278.08 239.96 87.54 194.96182.08 249.42 215.23 77.66 174.87 87 209.39 286.83 247.51 89.31 201.10185.72 254.41 219.54 79.22 178.37 88 213.58 292.57 252.47 91.09 205.12189.43 259.50 223.93 80.80 181.94 89 217.85 298.42 257.52 92.92 209.22193.22 264.69 228.41 82.42 185.57 90 222.20 304.39 262.67 94.77 213.40197.09 269.98 232.97 84.07 189.28 91 226.65 310.48 267.92 96.68 217.68201.03 275.38 237.63 85.74 193.07 92 231.18 316.68 273.28 98.60 222.03205.05 280.88 242.39 87.46 196.93 93 235.80 323.02 278.74 100.57 226.47209.15 286.51 247.24 89.21 200.86 94 240.52 329.48 284.31 102.59 231.00213.33 292.24 252.18 90.99 204.89 95 245.33 336.07 290.01 104.65 235.62217.60 298.08 257.22 92.81 208.98 96 250.24 342.79 295.81 106.73 240.33221.95 304.04 262.36 94.67 213.17 97 255.24 349.65 301.72 108.87 245.14226.38 310.12 267.62 96.56 217.43 98 260.35 356.64 307.76 111.05 250.04230.92 316.32 272.97 98.50 221.78 99+ 265.56 363.78 313.91 113.27 255.04
*See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively.
OH MOO AGY 001 7 OH_MOO_AGY_090121
MONTHLY TOBACCO PREMIUMS*ZIP CODES: 436, 440 - 445
FEMALE MALEPlan AMM20
Plan FMM24
Plan GMM25
Plan High GMM36
Plan NMM35
AttainedAge
Plan AMM20
Plan FMM24
Plan GMM25
Plan High GMM36
Plan NMM35
107.09 146.71 124.28 48.46 96.75 65 123.16 168.71 142.91 55.73 111.26107.09 146.71 124.28 48.46 96.75 66 123.16 168.71 142.91 55.73 111.26107.09 146.71 124.28 48.46 96.75 67 123.16 168.71 142.91 55.73 111.26109.24 149.64 127.50 49.91 100.81 68 125.62 172.08 146.63 57.40 115.94111.39 152.58 130.74 51.37 104.88 69 128.09 175.47 150.34 59.08 120.61113.52 155.51 133.97 52.82 108.95 70 130.55 178.84 154.06 60.74 125.29115.66 158.44 137.20 54.27 113.00 71 133.01 182.21 157.78 62.42 129.96117.81 161.38 140.43 55.73 117.07 72 135.48 185.58 161.49 64.09 134.63122.52 167.84 145.48 57.52 120.58 73 140.89 193.01 167.30 66.15 138.67127.23 174.29 150.54 59.30 124.09 74 146.32 200.43 173.12 68.20 142.71131.95 180.75 155.59 61.09 127.60 75 151.73 207.85 178.93 70.24 146.75136.66 187.20 160.65 62.87 131.12 76 157.16 215.28 184.75 72.30 150.78141.37 193.66 165.71 64.65 134.63 77 162.57 222.70 190.56 74.34 154.82146.45 200.62 172.00 66.85 139.75 78 168.43 230.72 197.80 76.87 160.71151.54 207.59 178.30 69.05 144.87 79 174.28 238.74 205.04 79.40 166.59156.64 214.57 184.59 71.24 149.98 80 180.13 246.75 212.28 81.93 172.47161.73 221.54 190.89 73.44 155.10 81 185.98 254.77 219.53 84.46 178.35166.81 228.51 197.19 75.64 160.21 82 191.83 262.79 226.77 86.99 184.24172.82 236.74 204.29 77.31 165.97 83 198.74 272.25 234.94 88.89 190.87178.83 244.97 211.38 78.96 171.74 84 205.65 281.70 243.10 90.81 197.51184.83 253.19 218.48 80.63 177.51 85 212.55 291.17 251.26 92.72 204.14190.84 261.42 225.59 82.30 183.28 86 219.46 300.63 259.42 94.64 210.77196.84 269.64 232.68 83.96 189.05 87 226.37 310.09 267.58 96.55 217.41200.77 275.03 237.34 85.64 192.83 88 230.90 316.29 272.94 98.48 221.75204.79 280.54 242.09 87.35 196.69 89 235.51 322.62 278.40 100.45 226.19208.89 286.15 246.92 89.10 200.62 90 240.22 329.07 283.96 102.46 230.71213.07 291.87 251.86 90.89 204.63 91 245.02 335.65 289.65 104.52 235.32217.33 297.71 256.90 92.69 208.72 92 249.93 342.36 295.44 106.60 240.03221.67 303.66 262.04 94.55 212.90 93 254.92 349.21 301.34 108.73 244.83226.11 309.74 267.28 96.44 217.15 94 260.02 356.19 307.36 110.91 249.73230.63 315.93 272.62 98.37 221.50 95 265.22 363.32 313.52 113.14 254.72235.24 322.25 278.07 100.34 225.93 96 270.53 370.59 319.79 115.39 259.82239.94 328.69 283.63 102.34 230.45 97 275.94 378.00 326.18 117.70 265.01244.74 335.26 289.31 104.39 235.06 98 281.46 385.56 332.71 120.05 270.31249.64 341.97 295.10 106.49 239.76 99+ 287.09 393.27 339.36 122.46 275.72
*See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively.
OH MOO AGY 001 8 OH_MOO_AGY_090121
PREMIUM INFORMATIONWe, Mutual of Omaha Insurance Company, can only raise your premium if we raise the premium for all policies like yours in this State. Until you are age 99, yourpremium may change each year.
HOUSEHOLD PREMIUM DISCOUNTYou are eligible for a household premium discount if for the past year you have resided with at least one, but no more than three, other Medicare-eligible adults whois your legal spouse, we will waive the one-year requirement. For the purposes of this discount, a civil union partner or domestic partner will be considered a legalspouse when such partnerships are valid and recognized in your state of residence. The discounted premium will be priced 7% lower than the rates illustrated. Thepolicy’s household premium discount will be removed if the other Medicare supplement policyholder longer has a Medicare supplement policy with us or one of ouraffiliates, or he or she no longer resides with you.
TOBACCO PREMIUMSNon-tobacco premiums are lower than tobacco premiums.
RISK CLASS RATINGIf, according to our underwriting standards, you are overweight or underweight for your height, you will be considered to be a greater insurable risk. In such a case,your premium will be priced either as Class I – 10% or Class II – 20% higher than the rates illustrated, based on your Body Mass Index (BMI) reading. Risk classrating will not be applicable when you apply for coverage during an open enrollment or guaranteed issue period.
DISCLOSURESUse this outline to compare benefits and premiums among policies.
READ YOUR POLICY VERY CAREFULLYThis 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 therights and duties of both you and your insurance company.
RIGHT TO RETURN POLICYIf you find that you are not satisfied with your policy, you may return it to 3300 Mutual of Omaha Plaza, Omaha, NE 68175. If you send the policy back to us within 30days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.
POLICY REPLACEMENTIf 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.
NOTICEThe policy may not fully cover all of your medical costs. Neither Mutual of Omaha Insurance Company nor its agents are connected with Medicare. This outline ofcoverage 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 IMPORTANTWhen you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The Companymay 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. Becertain that all information has been properly recorded.
OH MOO AGY 001 9 OH_MOO_AGY_090121
PLAN AMEDICARE (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 carein any other facility for 60 days in a row.
SERVICES MEDICARE PAYS PLAN A PAYS YOU PAYHOSPITALIZATION*Semiprivate room and board, general nursing, andmiscellaneous services and supplies
First 60 days All but $1,484 $0 $1,484 (Part A deductible)61st through 90th day All but $371 a day $371 a day $091st day and after:
While using 60 lifetime reserve days All but $742 a day $742 a day $0Once 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, includinghaving been in a hospital for at least 3 days andentered a Medicare-approved facility within 30 daysafter leaving the hospital.
First 20 days All approved amounts $0 $021st through 100th day All but $185.50 a day $0 Up to $185.50 a day101st day and after $0 $0 All costs
BLOODFirst 3 pints $0 3 pints $0Additional amounts 100% $0 $0
HOSPICE CAREYou must meet Medicare’s requirements, including adoctor’s certification of terminal illness
All but very limitedcopayment/coinsurance for outpatientdrugs 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 havepaid 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 anydifference between its billed charges and the amount Medicare would have paid.
OH MOO AGY 001 10 OH_MOO_AGY_090121
PLAN AMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $203 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for thecalendar year.
SERVICES MEDICARE PAYS PLAN A PAYS YOU PAYMEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL ANDOUTPATIENT HOSPITAL TREATMENT, such as physician’sservices, inpatient and outpatient medical and surgical servicesand supplies, physical and speech therapy, diagnostic tests,durable medical equipment
First $203 of Medicare-approved amounts* $0 $0 $203 (Part B deductible)Remainder of Medicare-approved amounts Generally 80% Generally 20% $0
Part B Excess Charges (above Medicare-approved amounts) $0 $0 All costsBLOOD
First 3 pints $0 All costs $0Next $203 of Medicare-approved amounts* $0 $0 $203 (Part B deductible)Remainder of Medicare-approved amounts 80% 20% $0
CLINICAL LABORATORY SERVICES – TESTS FORDIAGNOSTIC SERVICES 100% $0 $0
PARTS A AND BHOME HEALTH CARE – MEDICARE-APPROVED SERVICESMedically necessary skilled care services and medical supplies 100% $0 $0DURABLE MEDICAL EQUIPMENT
First $203 of Medicare-approved amounts* $0 $0 $203 (Part B deductible)Remainder of Medicare-approved amounts 80% 20% $0
OH MOO AGY 001 11 OH_MOO_AGY_090121
PLAN FMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
Medicare first eligible before 2020 only*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 carein any other facility for 60 days in a row.
SERVICES MEDICARE PAYS PLAN F PAYS YOU PAYHOSPITALIZATION*Semiprivate room and board, general nursing, andmiscellaneous services and supplies
First 60 days All but $1,484 $1,484 (Part A deductible) $061st through 90th day All but $371 a day $371 a day $091st day and after:
While using 60 lifetime reserve days All but $742 a day $742 a day $0Once 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 havingbeen 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 $021st through 100th day All but $185.50 a day Up to $185.50 a day $0101st day and after $0 $0 All costs
BLOODFirst 3 pints $0 3 pints $0Additional amounts 100% $0 $0
HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’scertification of terminal illness
All but very limitedcopayment/coinsurance foroutpatient drugs and inpatientrespite 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 havepaid 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 anydifference between its billed charges and the amount Medicare would have paid.
OH MOO AGY 001 12 OH_MOO_AGY_090121
PLAN FMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
Medicare first eligible before 2020 only
SERVICES MEDICARE PAYS PLAN F PAYS YOU PAYMEDICAL EXPENSES – IN OR OUT OF THE HOSPITALAND OUTPATIENT HOSPITAL TREATMENT, such asphysician’s services, inpatient and outpatient medical andsurgical services and supplies, physical and speech therapy,diagnostic tests, durable medical equipment
First $203 of Medicare-approved amounts $0 $203 (Part B deductible) $0Remainder of Medicare-approved amounts Generally 80% Generally 20% $0
Part B Excess Charges (above Medicare-approved amounts) $0 100% $0BLOOD
First 3 pints $0 All costs $0Next $203 of Medicare-approved amounts $0 $203 (Part B deductible) $0Remainder of Medicare-approved amounts 80% 20% $0
CLINICAL LABORATORY SERVICES – TESTS FORDIAGNOSTIC SERVICES 100% $0 $0
PARTS A AND BHOME HEALTH CARE – MEDICARE-APPROVEDSERVICESMedically necessary skilled care services and medicalsupplies
100% $0 $0
DURABLE MEDICAL EQUIPMENTFirst $203 of Medicare-approved amounts $0 $203 (Part B deductible) $0Remainder of Medicare-approved amounts 80% 20% $0
OH MOO AGY 001 13 OH_MOO_AGY_090121
PLAN FMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
Medicare first eligible before 2020 only
OTHER BENEFITS – NOT COVERED BY MEDICARESERVICES MEDICARE PAYS PLAN F PAYS YOU PAY
FOREIGN TRAVEL – NOT COVERED BY MEDICAREMedically necessary emergency care services beginningduring the first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250Remainder of charges $0 80% to a lifetime maximum benefit
of $50,00020% and amounts over the$50,000 lifetime maximumbenefit
OH MOO AGY 001 14 OH_MOO_AGY_090121
PLAN GMEDICARE (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 skilledcare in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS PLAN G PAYS YOU PAYHOSPITALIZATION*Semiprivate room and board, general nursing, andmiscellaneous services and supplies
First 60 days All but $1,484 $1,484 (Part A deductible) $061st through 90th day All but $371 a day $371 a day $091st day and after:
While using 60 lifetime reserve days All but $742 a day $742 a day $0Once 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 havingbeen 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 $021st through 100th day All but $185.50 a day Up to $185.50 a day $0101st day and after $0 $0 All costs
BLOODFirst 3 pints $0 3 pints $0Additional amounts 100% $0 $0
HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’scertification of terminal illness
All but very limitedcopayment/coinsurance foroutpatient drugs and inpatientrespite 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 havepaid 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 anydifference between its billed charges and the amount Medicare would have paid.
OH MOO AGY 001 15 OH_MOO_AGY_090121
PLAN GMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $203 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for thecalendar year.
SERVICES MEDICARE PAYS PLAN G PAYS YOU PAYMEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL ANDOUTPATIENT HOSPITAL TREATMENT, such as physician’sservices, inpatient and outpatient medical and surgical servicesand supplies, physical and speech therapy, diagnostic tests,durable medical equipment
First $203 of Medicare-approved amounts* $0 $0 $203 (Part B deductible)Remainder of Medicare-approved amounts Generally 80% Generally 20% $0
Part B Excess Charges (above Medicare-approved amounts) $0 100% $0BLOOD
First 3 pints $0 All costs $0Next $203 of Medicare-approved amounts* $0 $0 $203 (Part B deductible)Remainder of Medicare-approved amounts 80% 20% $0
CLINICAL LABORATORY SERVICES – TESTS FORDIAGNOSTIC SERVICES 100% $0 $0
PARTS A AND BHOME HEALTH CARE – MEDICARE-APPROVED SERVICESMedically necessary skilled care services and medical supplies 100% $0 $0DURABLE MEDICAL EQUIPMENT
First $203 of Medicare-approved amounts* $0 $0 $203 (Part B deductible)Remainder of Medicare-approved amounts 80% 20% $0
OH MOO AGY 001 16 OH_MOO_AGY_090121
PLAN GMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
OTHER BENEFITS – NOT COVERED BY MEDICARESERVICES MEDICARE PAYS PLAN G PAYS YOU PAY
FOREIGN TRAVEL – NOT COVERED BY MEDICAREMedically necessary emergency care services beginning duringthe first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250Remainder of charges $0 80% to a lifetime maximum benefit
of $50,00020% and amounts over the$50,000 lifetime maximumbenefit
OH MOO AGY 001 17 OH_MOO_AGY_090121
HIGH DEDUCTIBLE PLAN GMEDICARE (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 skilledcare in any other facility for 60 days in a row.***This high deductible plan pays the same benefits as Plan G after you have paid a calendar year $2,370 deductible. Benefits from the high deductible Plan G will notbegin until out-of-pocket expenses are $2,370. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that wouldordinarily be paid by the policy. This does not include the plan’s separate foreign travel emergency deductible.
SERVICES MEDICARE PAYS
AFTER YOU PAY $2,370DEDUCTIBLE***
PLAN PAYS
IN ADDITION TO $2,370DEDUCTIBLE***
YOU PAYHOSPITALIZATION*Semiprivate room and board, general nursing, andmiscellaneous services and supplies
First 60 days All but $1,484 $1,484 (Part A deductible) $061st through 90th day All but $371 a day $371 a day $091st day and after:
While using 60 lifetime reserve days All but $742 a day $742 a day $0Once 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 havingbeen 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 $021st through 100th day All but $185.50 a day Up to $185.50 a day $0101st day and after $0 $0 All costs
BLOODFirst 3 pints $0 3 pints $0Additional amounts 100% $0 $0
HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’scertification of terminal illness
All but very limitedcopayment/coinsurance foroutpatient drugs and inpatientrespite care
Medicare copayment/coinsurance $0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stand in the place of Medicare and will pay whatever amount Medicare would have paidup 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 differencebetween its billed charges and the amount Medicare would have paid.
OH MOO AGY 001 18 OH_MOO_AGY_090121
HIGH DEDUCTIBLE PLAN GMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $203 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for thecalendar year.***This high deductible plan pays the same benefits as Plan G after you have paid a calendar year $2,370 deductible. Benefits from the high deductible Plan G will notbegin until out-of-pocket expenses are $2,370. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that wouldordinarily be paid by the policy. This does not include the plan’s separate foreign travel emergency deductible.
SERVICES MEDICARE PAYS
AFTER YOU PAY $2,370DEDUCTIBLE***
PLAN PAYS
IN ADDITION TO $2,370DEDUCTIBLE***
YOU PAYMEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL ANDOUTPATIENT HOSPITAL TREATMENT, such as physician’sservices, inpatient and outpatient medical and surgical servicesand supplies, physical and speech therapy, diagnostic tests,durable medical equipment
First $203 of Medicare-approved amounts* $0 $0 $203 (Unless Part Bdeductible has been met)
Remainder of Medicare-approved amounts Generally 80% Generally 20% $0Part B Excess Charges (above Medicare-approved amounts) $0 100% $0BLOOD
First 3 pints $0 All costs $0Next $203 of Medicare-approved amounts* $0 $0 $203 (Unless Part B
deductible has been met)Remainder of Medicare-approved amounts 80% 20% $0
CLINICAL LABORATORY SERVICES – TESTS FORDIAGNOSTIC SERVICES 100% $0 $0
PARTS A AND BHOME HEALTH CARE –MEDICARE APPROVED SERVICESMedically necessary skilled care services and medical supplies
100% $0 $0
DURABLE MEDICAL EQUIPMENTFirst $203 of Medicare-approved amounts* $0 $0 $203 (Unless Part B
deductible has been met)Remainder of Medicare-approved amounts 80% 20% $0
OH MOO AGY 001 19 OH_MOO_AGY_090121
HIGH DEDUCTIBLE PLAN GMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
***This high deductible plan pays the same benefits as Plan G after you have paid a calendar year $2,370 deductible. Benefits from the high deductible Plan G will notbegin until out-of-pocket expenses are $2,370. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that wouldordinarily be paid by the policy. This does not include the plan’s separate foreign travel emergency deductible.
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS
AFTER YOU PAY $2,370DEDUCTIBLE***
PLAN PAYS
IN ADDITION TO $2,370DEDUCTIBLE***
YOU PAYFOREIGN TRAVEL – NOT COVERED BY MEDICAREMedically necessary emergency care services beginning duringthe first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250Remainder of charges $0 80% to a lifetime maximum benefit
of $50,00020% and amounts over the$50,000 lifetime maximumbenefit
OH MOO AGY 001 20 OH_MOO_AGY_090121
PLAN NMEDICARE (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 carein any other facility for 60 days in a row.
SERVICES MEDICARE PAYS PLAN N PAYS YOU PAYHOSPITALIZATION*Semiprivate room and board, general nursing, andmiscellaneous services and supplies
First 60 days All but $1,484 $1,484 (Part A deductible) $061st through 90th day All but $371 a day $371 a day $091st day and after:
While using 60 lifetime reserve days All but $742 a day $742 a day $0Once 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 havingbeen in a hospital for at least 3 days and entered aMedicare-approved facility within 30 days after leaving thehospital.
First 20 days All approved amounts $0 $021st through 100th day All but $185.50 a day Up to $185.50 a day $0101st day and after $0 $0 All costs
BLOODFirst 3 pints $0 3 pints $0Additional amounts 100% $0 $0
HOSPICE CAREYou must meet Medicare’s requirements, including adoctor’s certification of terminal illness.
All but very limitedcopayment/coinsurance foroutpatient drugs and inpatientrespite 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 havepaid 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 anydifference between its billed charges and the amount Medicare would have paid.
OH MOO AGY 001 21 OH_MOO_AGY_090121
PLAN NMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $203 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for thecalendar year.
SERVICES MEDICARE PAYS PLAN N PAYS YOU PAYMEDICAL EXPENSES – IN OR OUT OF THEHOSPITAL AND OUTPATIENT HOSPITALTREATMENT, such as physician’s services, inpatientand outpatient medical and surgical services andsupplies, physical and speech therapy, diagnostic tests,durable medical equipment
First $203 of Medicare-approved amounts* $0 $0 $203 (Part B deductible)
Remainder of Medicare-approved amounts Generally 80% Balance, other than up to $20 peroffice visit and up to $50 peremergency room visit. Thecopayment of up to $50 is waivedif the insured is admitted to anyhospital and the emergency visitis covered as a Medicare Part Aexpense
Up to $20 per office visit and upto $50 per emergency roomvisit. The copayment of up to$50 is waived if the insured isadmitted to any hospital and theemergency visit is covered as aMedicare Part A expense
Part B Excess Charges (above Medicare-approvedamounts)
$0 $0 All costs
BLOODFirst 3 pints $0 All costs $0Next $203 of Medicare-approved amounts* $0 $0 $203 (Part B deductible)Remainder of Medicare-approved amounts 80% 20% $0
CLINICAL LABORATORY SERVICES – TESTS FORDIAGNOSTIC SERVICES 100% $0 $0
OH MOO AGY 001 22 OH_MOO_AGY_090121
PLAN NMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
PARTS A AND BSERVICES MEDICARE PAYS PLAN N PAYS YOU PAY
HOME HEALTH CARE – MEDICARE-APPROVEDSERVICESMedically necessary skilled care services and medicalsupplies
100% $0 $0
DURABLE MEDICAL EQUIPMENTFirst $203 of Medicare-approved amounts* $0 $0 $203 (Part B deductible)Remainder of Medicare-approved amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARESERVICES MEDICARE PAYS PLAN N PAYS YOU PAY
FOREIGN TRAVEL – NOT COVERED BY MEDICAREMedically necessary emergency care services beginningduring the first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250Remainder of charges $0 80% to a lifetime maximum
benefit of $50,00020% and amounts over the$50,000 lifetime maximumbenefit
