Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor =...
Transcript of Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor =...
![Page 1: Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium](https://reader030.fdocuments.net/reader030/viewer/2022011817/5e8061fd96d3d97df6130a69/html5/thumbnails/1.jpg)
800 Crescent Centre Dr. Suite 200
Franklin, TN 37067800 264.4000
aetnaseniorproducts.com
Outline of CoverageMedicare Supplement Insurance
Underwritten by
Continental Life Insurance Company of Brentwood, Tennessee
An Aetna Company
Rates Effective:
BENEFIT PLANS: A, B, F, HF, G, & N
SOUTH CAROLINA
CLIMS03706SC ©2017 Aetna Inc. 05/2017 A
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CLI
MS0
3706
SC
1
05/2
017
A
CO
NTI
NEN
TAL
LIFE
INSU
RAN
CE
CO
MPA
NY
OF
BR
ENTW
OO
D, T
ENN
ESSE
E O
UTL
INE
OF
MED
ICAR
E SU
PPLE
MEN
T C
OVE
RAG
E C
OVE
R P
AGE:
Pag
e 1
of 1
B
ENEF
IT P
LAN
S AV
AILA
BLE
: A, B
, F, H
IGH
DED
UC
TIB
LE F
, G, N
Th
ese
char
ts s
how
the
bene
fits
incl
uded
in e
ach
of th
e st
anda
rd M
edic
are
sup
ple
me
nt
pla
ns.
Eve
ry c
om
pa
ny m
ust
ma
ke
ava
ilable
Pla
n “
A”
Som
e pl
ans
may
not
be
avai
labl
e in
you
r sta
te.
Bas
ic B
enef
its:
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
-pay
men
ts fo
r hos
pita
l out
patie
nt s
ervi
ces.
Pl
ans
K, L
, and
N re
quire
insu
reds
to p
ay a
por
tion
of c
oins
uran
ce o
r cop
aym
ents
Bl
ood:
Firs
t thr
ee p
ints
of b
lood
eac
h ye
ar.
H
ospi
ce-P
art A
coi
nsur
ance
A
B
C
D
F/F*
G
K
L
M
N
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Hos
pita
lizat
ion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basi
c be
nefit
s pa
id a
t 50%
Hos
pita
lizat
ion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basi
c be
nefit
s pa
id a
t 75%
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c, in
clud
ing
100%
Par
t B
coin
sura
nce,
exc
ept
up to
$20
cop
aym
ent
for o
ffice
vis
it, a
nd
up to
$50
cop
aym
ent
for E
R
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
50%
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
75%
Ski
lled
Nur
sing
Fac
ility
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Pa
rt A
Ded
uctib
le
Part
A D
educ
tible
Pa
rt A
Ded
uctib
le
Part
A D
educ
tible
Pa
rt A
Ded
uctib
le
50%
Par
t A
Ded
uctib
le
75%
Par
t A
Ded
uctib
le
50%
Par
t A
Ded
uctib
le
Part
A D
educ
tible
Part
B D
educ
tible
Part
B D
educ
tible
Part
B Ex
cess
(1
00%
)
Part
B Ex
cess
(1
00%
)
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Out
-of-p
ocke
t lim
it $5
120;
pa
id a
t 100
%
afte
r lim
it re
ache
d
Out
-of-p
ocke
t lim
it $2
560;
pa
id a
t 100
%
afte
r lim
it re
ache
d
*Pla
ns F
als
o ha
s an
opt
ion
calle
d a
high
ded
uctib
le p
lan
F. T
his
high
ded
uctib
le p
lan
pays
the
sam
e be
nefit
s as
Pla
n F
afte
r one
has
pai
d a
cale
ndar
yea
r $2
200
dedu
ctib
le. B
enef
its fr
om h
igh
dedu
ctib
le p
lan
F w
ill no
t beg
in u
ntil
out-o
f-poc
ket e
xpen
ses
exce
ed $
2200
. O
ut-o
f-poc
ket e
xpen
ses
for t
his
dedu
ctib
le
are
expe
nses
that
wou
ld o
rdin
arily
be
paid
by
the
polic
y. T
hese
exp
ense
s in
clud
e th
e M
edic
are
dedu
ctib
les
for
Part
A an
d Pa
rt B,
but
do
not i
nclu
de th
e pla
n’s
separa
te f
ore
ign tra
vel em
erg
ency d
eductible
.
![Page 3: Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium](https://reader030.fdocuments.net/reader030/viewer/2022011817/5e8061fd96d3d97df6130a69/html5/thumbnails/3.jpg)
CLI
MS0
3706
SC
2
05/2
017
A
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n H
FP
lan
GP
lan
NA
geP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
65
1,03
7
1,
222
1,54
1
61
6
1,22
3
1,
034
651,
152
1,35
8
1,
711
685
1,
359
1,14
9
66
1,03
7
1,
222
1,54
1
61
6
1,22
3
1,
034
661,
152
1,35
8
1,
711
685
1,
359
1,14
9
67
1,03
7
1,
222
1,54
1
61
6
1,22
3
1,
034
671,
152
1,35
8
1,
711
685
1,
359
1,14
9
68
1,04
9
1,
237
1,55
9
62
4
1,23
8
1,
046
681,
165
1,37
5
1,
732
693
1,
376
1,16
2
69
1,07
2
1,
264
1,59
2
63
7
1,26
5
1,
068
691,
191
1,40
4
1,
770
708
1,
405
1,18
6
70
1,10
0
1,
298
1,63
5
65
4
1,29
9
1,
096
701,
223
1,44
2
1,
817
726
1,
443
1,21
8
71
1,13
3
1,
336
1,68
4
67
3
1,33
7
1,
129
711,
259
1,48
5
1,
871
748
1,
486
1,25
5
72
1,17
1
1,
380
1,73
9
69
5
1,38
1
1,
166
721,
301
1,53
3
1,
932
773
1,
534
1,29
5
73
1,21
1
1,
428
1,79
9
71
9
1,42
9
1,
207
731,
346
1,58
7
1,
999
799
1,
588
1,34
0
74
1,25
8
1,
484
1,86
9
74
8
1,48
5
1,
254
741,
398
1,64
9
2,
077
831
1,
650
1,39
3
75
1,31
1
1,
545
1,94
7
77
9
1,54
6
1,
305
751,
456
1,71
7
2,
164
865
1,
718
1,45
0
76
1,36
3
1,
606
2,02
5
81
0
1,60
9
1,
358
761,
514
1,78
5
2,
249
900
1,
787
1,50
9
77
1,41
4
1,
667
2,10
1
84
0
1,66
9
1,
409
771,
570
1,85
2
2,
335
933
1,
854
1,56
6
78
1,46
3
1,
726
2,17
5
86
9
1,72
7
1,
459
781,
625
1,91
7
2,
417
966
1,
918
1,62
1
79
1,51
3
1,
784
2,24
8
89
9
1,78
6
1,
508
791,
682
1,98
2
2,
498
999
1,
984
1,67
5
80
1,56
0
1,
840
2,31
9
92
7
1,84
2
1,
555
801,
733
2,04
4
2,
577
1,03
0
2,
047
1,72
8
81
1,61
0
1,
898
2,39
1
95
7
1,90
0
1,
604
811,
788
2,10
9
2,
658
1,06
3
2,
111
1,78
3
82
1,66
0
1,
957
2,46
7
98
7
1,95
9
1,
655
821,
844
2,17
5
2,
741
1,09
6
2,
177
1,83
9
83
1,71
1
2,
018
2,54
3
1,
017
2,01
9
1,
705
831,
902
2,24
3
2,
825
1,13
0
2,
244
1,89
4
84
1,76
4
2,
079
2,62
0
1,
048
2,08
2
1,
757
841,
960
2,31
0
2,
912
1,16
4
2,
313
1,95
2
85
1,82
5
2,
152
2,71
2
1,
085
2,15
4
1,
819
852,
028
2,39
0
3,
013
1,20
6
2,
394
2,02
1
86
1,87
7
2,
213
2,78
9
1,
116
2,21
5
1,
871
862,
085
2,45
9
3,
099
1,24
0
2,
462
2,07
9
87
1,93
0
2,
275
2,86
9
1,
148
2,27
9
1,
924
872,
145
2,52
8
3,
188
1,27
5
2,
532
2,13
7
88
1,98
4
2,
340
2,94
9
1,
179
2,34
2
1,
978
882,
204
2,60
0
3,
276
1,31
1
2,
603
2,19
8
89
2,04
0
2,
405
3,03
1
1,
212
2,40
8
2,
033
892,
267
2,67
2
3,
368
1,34
7
2,
675
2,25
9
902,
096
2,47
1
3,
114
1,24
6
2,
474
2,08
9
90
2,32
9
2,
746
3,46
0
1,
384
2,74
8
2,
321
912,
153
2,53
8
3,
198
1,28
0
2,
540
2,14
6
91
2,39
1
2,
821
3,55
4
1,
422
2,82
3
2,
385
922,
211
2,60
6
3,
285
1,31
4
2,
609
2,20
3
92
2,45
6
2,
895
3,65
0
1,
460
2,90
0
2,
448
932,
270
2,67
6
3,
373
1,34
9
2,
679
2,26
2
93
2,52
2
2,
974
3,74
7
1,
499
2,97
7
2,
514
942,
329
2,74
6
3,
461
1,38
5
2,
750
2,32
2
94
2,58
7
3,
052
3,84
6
1,
540
3,05
5
2,
581
952,
390
2,81
9
3,
552
1,42
1
2,
822
2,38
3
95
2,65
6
3,
132
3,94
6
1,
579
3,13
5
2,
648
962,
452
2,89
1
3,
644
1,45
7
2,
894
2,44
4
96
2,72
4
3,
212
4,04
9
1,
620
3,21
6
2,
716
972,
514
2,96
5
3,
737
1,49
5
2,
969
2,50
6
97
2,79
3
3,
295
4,15
2
1,
661
3,29
8
2,
785
982,
579
3,04
0
3,
831
1,53
3
3,
043
2,57
0
98
2,86
6
3,
377
4,25
7
1,
704
3,38
1
2,
856
99
2,64
2
3,
116
3,92
7
1,
571
3,12
0
2,
635
992,
936
3,46
2
4,
362
1,74
5
3,
467
2,92
7
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.52
00Q
uar
terl
y:0.
2650
Mo
nth
ly:
0.08
330
The
ab
ove
rat
es
do
no
t in
clu
de
th
e $
20 a
pp
lica
tio
n f
ee
.
To c
alcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ual
pre
miu
m x
mo
dal
fac
tor
= m
od
al p
rem
ium
(ro
un
d t
o n
ear
est
wh
ole
ce
nt)
M
od
al p
rem
ium
x .9
3 =
dis
cou
nte
d p
rem
ium
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d, u
se P
refe
rre
d r
ate
s.
Rat
es E
ffec
tive
05/
01/2
017
Fem
ale
Rat
es
Co
nti
ne
nta
l Lif
e In
sura
nce
Co
mp
any
of
Bre
ntw
oo
d, T
en
ne
sse
eA
nnua
l Att
aine
d A
ge P
rem
ium
s
For
Use
in Z
IP C
odes
: 29
4-29
5, 2
98-2
99
![Page 4: Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium](https://reader030.fdocuments.net/reader030/viewer/2022011817/5e8061fd96d3d97df6130a69/html5/thumbnails/4.jpg)
CLI
MS0
3706
SC
3
05/2
017
A
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n H
FP
lan
GP
lan
NA
geP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
65
1,19
2
1,
405
1,77
2
70
8
1,40
7
1,
189
651,
325
1,56
1
1,
968
788
1,
563
1,32
1
66
1,19
2
1,
405
1,77
2
70
8
1,40
7
1,
189
661,
325
1,56
1
1,
968
788
1,
563
1,32
1
67
1,19
2
1,
405
1,77
2
70
8
1,40
7
1,
189
671,
325
1,56
1
1,
968
788
1,
563
1,32
1
68
1,20
7
1,
424
1,79
4
71
8
1,42
5
1,
202
681,
340
1,58
1
1,
992
797
1,
583
1,33
6
69
1,23
3
1,
453
1,83
1
73
3
1,45
4
1,
227
691,
370
1,61
4
2,
035
815
1,
615
1,36
3
70
1,26
6
1,
492
1,88
0
75
2
1,49
4
1,
260
701,
407
1,65
9
2,
089
834
1,
660
1,40
1
71
1,30
3
1,
536
1,93
7
77
4
1,53
7
1,
299
711,
449
1,70
7
2,
152
860
1,
709
1,44
3
72
1,34
6
1,
587
1,99
9
79
9
1,58
8
1,
341
721,
496
1,76
3
2,
222
889
1,
764
1,48
9
73
1,39
3
1,
643
2,06
8
82
8
1,64
4
1,
387
731,
547
1,82
4
2,
300
920
1,
826
1,54
2
74
1,44
6
1,
706
2,14
9
86
0
1,70
7
1,
442
741,
609
1,89
7
2,
389
956
1,
898
1,60
2
75
1,50
8
1,
777
2,23
9
89
6
1,77
8
1,
501
751,
675
1,97
4
2,
488
995
1,
975
1,66
8
76
1,56
8
1,
847
2,32
8
93
2
1,84
9
1,
561
761,
741
2,05
3
2,
586
1,03
5
2,
055
1,73
6
77
1,62
6
1,
916
2,41
7
96
6
1,92
0
1,
621
771,
806
2,13
0
2,
685
1,07
3
2,
132
1,80
1
78
1,68
2
1,
984
2,50
1
1,
000
1,98
6
1,
678
781,
869
2,20
5
2,
779
1,11
0
2,
206
1,86
4
79
1,74
0
2,
051
2,58
5
1,
034
2,05
4
1,
734
791,
934
2,28
0
2,
872
1,14
9
2,
282
1,92
7
80
1,79
5
2,
116
2,66
7
1,
067
2,11
8
1,
788
801,
993
2,35
1
2,
963
1,18
5
2,
353
1,98
7
81
1,85
2
2,
182
2,75
1
1,
100
2,18
5
1,
845
812,
056
2,42
5
3,
056
1,22
3
2,
428
2,05
0
82
1,90
9
2,
250
2,83
7
1,
134
2,25
2
1,
903
822,
121
2,50
1
3,
151
1,26
0
2,
503
2,11
4
83
1,96
8
2,
320
2,92
4
1,
169
2,32
2
1,
961
832,
188
2,57
9
3,
249
1,30
0
2,
580
2,17
9
84
2,02
9
2,
391
3,01
3
1,
206
2,39
4
2,
021
842,
255
2,65
8
3,
349
1,33
8
2,
660
2,24
5
85
2,09
9
2,
475
3,12
0
1,
248
2,47
7
2,
091
852,
332
2,74
8
3,
466
1,38
6
2,
753
2,32
5
86
2,15
8
2,
545
3,20
7
1,
283
2,54
7
2,
152
862,
398
2,82
8
3,
564
1,42
6
2,
831
2,39
1
87
2,22
0
2,
617
3,29
9
1,
319
2,62
0
2,
213
872,
467
2,90
7
3,
666
1,46
6
2,
912
2,45
8
88
2,28
2
2,
692
3,39
1
1,
357
2,69
4
2,
274
882,
535
2,98
9
3,
768
1,50
8
2,
994
2,52
7
89
2,34
5
2,
765
3,48
5
1,
394
2,76
9
2,
339
892,
607
3,07
3
3,
873
1,54
9
3,
076
2,59
7
902,
410
2,84
3
3,
582
1,43
3
2,
845
2,40
2
90
2,67
8
3,
158
3,97
9
1,
592
3,16
1
2,
670
912,
476
2,91
9
3,
678
1,47
2
2,
921
2,46
8
91
2,75
1
3,
243
4,08
8
1,
636
3,24
7
2,
743
922,
543
2,99
7
3,
778
1,51
1
3,
000
2,53
4
92
2,82
4
3,
330
4,19
7
1,
679
3,33
4
2,
815
932,
610
3,07
8
3,
878
1,55
2
3,
081
2,60
2
93
2,90
0
3,
420
4,30
9
1,
724
3,42
4
2,
891
942,
678
3,15
8
3,
980
1,59
3
3,
162
2,67
1
94
2,97
5
3,
509
4,42
3
1,
771
3,51
4
2,
969
952,
748
3,24
1
4,
085
1,63
5
3,
246
2,74
0
95
3,05
5
3,
601
4,53
9
1,
816
3,60
5
3,
045
962,
820
3,32
4
4,
191
1,67
6
3,
328
2,81
1
96
3,13
3
3,
693
4,65
7
1,
863
3,69
9
3,
123
972,
891
3,41
0
4,
298
1,71
9
3,
414
2,88
2
97
3,21
3
3,
789
4,77
5
1,
911
3,79
3
3,
202
982,
965
3,49
5
4,
406
1,76
3
3,
500
2,95
5
98
3,29
6
3,
884
4,89
6
1,
959
3,88
8
3,
284
99
3,03
9
3,
584
4,51
6
1,
807
3,58
7
3,
030
993,
376
3,98
1
5,
017
2,00
7
3,
987
3,36
6
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.52
00Q
uar
terl
y:0.
2650
Mo
nth
ly:
0.08
330
The
ab
ove
rat
es
do
no
t in
clu
de
th
e $
20 a
pp
lica
tio
n f
ee
.
To c
alcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ual
pre
miu
m x
mo
dal
fac
tor
= m
od
al p
rem
ium
(ro
un
d t
o n
ear
est
wh
ole
ce
nt)
M
od
al p
rem
ium
x .9
3 =
dis
cou
nte
d p
rem
ium
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d, u
se P
refe
rre
d r
ate
s.
Rat
es E
ffec
tive
05/
01/2
017
Mal
e R
ates
Co
nti
ne
nta
l Lif
e In
sura
nce
Co
mp
any
of
Bre
ntw
oo
d, T
en
ne
sse
eA
nnua
l Att
aine
d A
ge P
rem
ium
s
For
Use
in Z
IP C
odes
: 29
4-29
5, 2
98-2
99
![Page 5: Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium](https://reader030.fdocuments.net/reader030/viewer/2022011817/5e8061fd96d3d97df6130a69/html5/thumbnails/5.jpg)
CLI
MS0
3706
SC
4
05/2
017
A
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n H
FP
lan
GP
lan
NA
geP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
65
947
1,
116
1,40
7
56
3
1,11
7
94
4
651,
052
1,24
0
1,
563
626
1,
241
1,04
9
66
947
1,
116
1,40
7
56
3
1,11
7
94
4
661,
052
1,24
0
1,
563
626
1,
241
1,04
9
67
947
1,
116
1,40
7
56
3
1,11
7
94
4
671,
052
1,24
0
1,
563
626
1,
241
1,04
9
68
958
1,
130
1,42
4
57
0
1,13
1
95
5
681,
064
1,25
6
1,
582
633
1,
257
1,06
1
69
979
1,
154
1,45
4
58
2
1,15
5
97
5
691,
088
1,28
2
1,
616
647
1,
283
1,08
3
70
1,00
5
1,
185
1,49
3
59
7
1,18
6
1,
001
701,
117
1,31
7
1,
659
663
1,
318
1,11
2
71
1,03
5
1,
220
1,53
8
61
5
1,22
1
1,
031
711,
150
1,35
6
1,
709
683
1,
357
1,14
6
72
1,06
9
1,
260
1,58
8
63
5
1,26
1
1,
065
721,
188
1,40
0
1,
764
706
1,
401
1,18
3
73
1,10
6
1,
304
1,64
3
65
7
1,30
5
1,
102
731,
229
1,44
9
1,
826
730
1,
450
1,22
4
74
1,14
9
1,
355
1,70
7
68
3
1,35
6
1,
145
741,
277
1,50
6
1,
897
759
1,
507
1,27
2
75
1,19
7
1,
411
1,77
8
71
1
1,41
2
1,
192
751,
330
1,56
8
1,
976
790
1,
569
1,32
4
76
1,24
5
1,
467
1,84
9
74
0
1,46
9
1,
240
761,
383
1,63
0
2,
054
822
1,
632
1,37
8
77
1,29
1
1,
522
1,91
9
76
7
1,52
4
1,
287
771,
434
1,69
1
2,
132
852
1,
693
1,43
0
78
1,33
6
1,
576
1,98
6
79
4
1,57
7
1,
332
781,
484
1,75
1
2,
207
882
1,
752
1,48
0
79
1,38
2
1,
629
2,05
3
82
1
1,63
1
1,
377
791,
536
1,81
0
2,
281
912
1,
812
1,53
0
80
1,42
5
1,
680
2,11
8
84
7
1,68
2
1,
420
801,
583
1,86
7
2,
353
941
1,
869
1,57
8
81
1,47
0
1,
733
2,18
4
87
4
1,73
5
1,
465
811,
633
1,92
6
2,
427
971
1,
928
1,62
8
82
1,51
6
1,
787
2,25
3
90
1
1,78
9
1,
511
821,
684
1,98
6
2,
503
1,00
1
1,
988
1,67
9
83
1,56
3
1,
843
2,32
2
92
9
1,84
4
1,
557
831,
737
2,04
8
2,
580
1,03
2
2,
049
1,73
0
84
1,61
1
1,
899
2,39
3
95
7
1,90
1
1,
605
841,
790
2,11
0
2,
659
1,06
3
2,
112
1,78
3
85
1,66
7
1,
965
2,47
7
99
1
1,96
7
1,
661
851,
852
2,18
3
2,
752
1,10
1
2,
186
1,84
6
86
1,71
4
2,
021
2,54
7
1,
019
2,02
3
1,
709
861,
904
2,24
6
2,
830
1,13
2
2,
248
1,89
9
87
1,76
3
2,
078
2,62
0
1,
048
2,08
1
1,
757
871,
959
2,30
9
2,
911
1,16
4
2,
312
1,95
2
88
1,81
2
2,
137
2,69
3
1,
077
2,13
9
1,
806
882,
013
2,37
4
2,
992
1,19
7
2,
377
2,00
7
89
1,86
3
2,
196
2,76
8
1,
107
2,19
9
1,
857
892,
070
2,44
0
3,
076
1,23
0
2,
443
2,06
3
901,
914
2,25
7
2,
844
1,13
8
2,
259
1,90
8
90
2,12
7
2,
508
3,16
0
1,
264
2,51
0
2,
120
911,
966
2,31
8
2,
921
1,16
9
2,
320
1,96
0
91
2,18
4
2,
576
3,24
6
1,
299
2,57
8
2,
178
922,
019
2,38
0
3,
000
1,20
0
2,
383
2,01
2
92
2,24
3
2,
644
3,33
3
1,
333
2,64
8
2,
236
932,
073
2,44
4
3,
080
1,23
2
2,
447
2,06
6
93
2,30
3
2,
716
3,42
2
1,
369
2,71
9
2,
296
942,
127
2,50
8
3,
161
1,26
5
2,
511
2,12
1
94
2,36
3
2,
787
3,51
2
1,
406
2,79
0
2,
357
952,
183
2,57
4
3,
244
1,29
8
2,
577
2,17
6
95
2,42
6
2,
860
3,60
4
1,
442
2,86
3
2,
418
962,
239
2,64
0
3,
328
1,33
1
2,
643
2,23
2
96
2,48
8
2,
933
3,69
8
1,
479
2,93
7
2,
480
972,
296
2,70
8
3,
413
1,36
5
2,
711
2,28
9
97
2,55
1
3,
009
3,79
2
1,
517
3,01
2
2,
543
982,
355
2,77
6
3,
499
1,40
0
2,
779
2,34
7
98
2,61
7
3,
084
3,88
8
1,
556
3,08
8
2,
608
99
2,41
3
2,
846
3,58
6
1,
435
2,84
9
2,
406
992,
681
3,16
2
3,
984
1,59
4
3,
166
2,67
3
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.52
00Q
uar
terl
y:0.
2650
Mo
nth
ly:
0.08
330
The
ab
ove
rat
es
do
no
t in
clu
de
th
e $
20 a
pp
lica
tio
n f
ee
.
To c
alcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ual
pre
miu
m x
mo
dal
fac
tor
= m
od
al p
rem
ium
(ro
un
d t
o n
ear
est
wh
ole
ce
nt)
M
od
al p
rem
ium
x .9
3 =
dis
cou
nte
d p
rem
ium
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d, u
se P
refe
rre
d r
ate
s.
Rat
es E
ffec
tive
05/
01/2
017
For
Use
in Z
IP C
odes
: R
est
of s
tate
Co
nti
ne
nta
l Lif
e In
sura
nce
Co
mp
any
of
Bre
ntw
oo
d, T
en
ne
sse
eA
nnua
l Att
aine
d A
ge P
rem
ium
s
Fem
ale
Rat
es
![Page 6: Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium](https://reader030.fdocuments.net/reader030/viewer/2022011817/5e8061fd96d3d97df6130a69/html5/thumbnails/6.jpg)
CLI
MS0
3706
SC
5
05/2
017
A
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n H
FP
lan
GP
lan
NA
geP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
65
1,08
9
1,
283
1,61
8
64
7
1,28
5
1,
086
651,
210
1,42
6
1,
797
720
1,
427
1,20
6
66
1,08
9
1,
283
1,61
8
64
7
1,28
5
1,
086
661,
210
1,42
6
1,
797
720
1,
427
1,20
6
67
1,08
9
1,
283
1,61
8
64
7
1,28
5
1,
086
671,
210
1,42
6
1,
797
720
1,
427
1,20
6
68
1,10
2
1,
300
1,63
8
65
6
1,30
1
1,
098
681,
224
1,44
4
1,
819
728
1,
446
1,22
0
69
1,12
6
1,
327
1,67
2
66
9
1,32
8
1,
121
691,
251
1,47
4
1,
858
744
1,
475
1,24
5
70
1,15
6
1,
363
1,71
7
68
7
1,36
4
1,
151
701,
285
1,51
5
1,
908
762
1,
516
1,27
9
71
1,19
0
1,
403
1,76
9
70
7
1,40
4
1,
186
711,
323
1,55
9
1,
965
785
1,
561
1,31
8
72
1,22
9
1,
449
1,82
6
73
0
1,45
0
1,
225
721,
366
1,61
0
2,
029
812
1,
611
1,36
0
73
1,27
2
1,
500
1,88
9
75
6
1,50
1
1,
267
731,
413
1,66
6
2,
100
840
1,
668
1,40
8
74
1,32
1
1,
558
1,96
3
78
5
1,55
9
1,
317
741,
469
1,73
2
2,
182
873
1,
733
1,46
3
75
1,37
7
1,
623
2,04
5
81
8
1,62
4
1,
371
751,
530
1,80
3
2,
272
909
1,
804
1,52
3
76
1,43
2
1,
687
2,12
6
85
1
1,68
9
1,
426
761,
590
1,87
5
2,
362
945
1,
877
1,58
5
77
1,48
5
1,
750
2,20
7
88
2
1,75
3
1,
480
771,
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CLIMS03706SC 6 05/2017 A
PREMIUM INFORMATION
Continental Life Insurance Company of Brentwood, Tennessee 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 annually will be determined according to the following factors:
Semi-annual: 0.5200 Quarterly: 0.2650 Monthly EFT: 0.0833.
HOUSEHOLD DISCOUNT
In order to be eligible for the Household discount under an Continental Life Insurance Company of Brentwood, Tennessee Medicare supplement plan, you must apply for a Medicare supplement plan at the same time as another Medicare eligible adult or the other Medicare eligible adult must currently be covered by an Continental Life Insurance Company of Brentwood, Tennessee Medicare supplement policy. The Medicare eligible adult must be either (a) your spouse; (b) be someone with whom you are in a civil union partnership; or (c) someone with whom you have continuously resided for the past 12 months. The household discount will only be applicable if a policy for each applicant is issued. The discounted rate will be 7 percent lower than the individual rates and will apply as long as both policies remain in force.
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 Continental Life Insurance Company of Brentwood, Tennessee P.O. Box 14770, Lexington, Kentucky 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 Continental Life Insurance Company of Brentwood, Tennessee 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 CONTINENTAL LIFE INSURANCE COMPANY OF BRENTWOOD TENNESSEE.
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CLIMS03706SC 7 05/2017 A
PLAN A
MEDICARE (PART A) – HOSPITAL 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 $1316 $0 $1316 (Part A Deductible)
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $329 a day $329 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts $0 $0 21st thru 100th day All but $164.50 a day $0 Up to $164.50 a
day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the 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.
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CLIMS03706SC 05/2017 A 8
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.
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 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*
$0 $0 $183 (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 $183 of Medicare Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
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CLIMS03706SC 05/2017 A 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 $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $329 a day $329 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day
$0 Up to $164.50 a day
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 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.
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CLIMS03706SC 05/2017 A 10
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.
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 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*
$0 $0 $183 (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 $183 of Medicare Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
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CLIMS03706SC 05/2017 A 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 $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $329 a day $329 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day
Up to $164.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
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.
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CLIMS03706SC 05/2017 A 12
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.
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 tests, durable medical equipment
First $183 of Medicare-Approved amounts*
$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 $183 (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 $183 of Medicare Approved amounts*
$0 $183 (Part B Deductible)
$0
Remainder of Medicare Approved amounts 80% 20% $0
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CLIMS03706SC 05/2017 A 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
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CLIMS03706SC 05/2017 A 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 $2200 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2200. 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 $2200
DEDUCTIBLE*** PLAN PAYS
IN ADDITION TO $2200
DEDUCTIBLE*** YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $329 a day $329 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day
Up to $164.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0
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CLIMS03706SC 05/2017 A 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.
![Page 17: Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium](https://reader030.fdocuments.net/reader030/viewer/2022011817/5e8061fd96d3d97df6130a69/html5/thumbnails/17.jpg)
CLIMS03706SC 05/2017 A 16
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 $2200 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2200. 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 $2200
DEDUCTIBLE*** PLAN PAYS
IN ADDITION TO $2200
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 tests, durable medical equipment
First $183 of Medicare-Approved amounts*
$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 $183 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
![Page 18: Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium](https://reader030.fdocuments.net/reader030/viewer/2022011817/5e8061fd96d3d97df6130a69/html5/thumbnails/18.jpg)
CLIMS03706SC 05/2017 A 17
HIGH DEDUCTIBLE PLAN F
PARTS A & B
SERVICES
MEDICARE
PAYS
AFTER YOU PAY $2200
DEDUCTIBLE*** PLAN PAYS
IN ADDITION TO $2200
DEDUCTIBLE*** 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*
$0 $183 (Part B Deductible)
$0
Remainder of Medicare Approved amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES
MEDICARE
PAYS
AFTER YOU PAY $2200
DEDUCTIBLE** PLAN PAYS
IN ADDITION TO $2200
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
![Page 19: Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium](https://reader030.fdocuments.net/reader030/viewer/2022011817/5e8061fd96d3d97df6130a69/html5/thumbnails/19.jpg)
CLIMS03706SC 05/2017 A 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 $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $329 a day $329 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts $0 $0 21st thru 100th day All but $164.50 a day Up to $164.50 a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness services
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.
![Page 20: Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium](https://reader030.fdocuments.net/reader030/viewer/2022011817/5e8061fd96d3d97df6130a69/html5/thumbnails/20.jpg)
CLIMS03706SC 05/2017 A 19
PLAN G
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.
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 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) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*
$0 $0 $183 (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 $183 of Medicare Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
![Page 21: Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium](https://reader030.fdocuments.net/reader030/viewer/2022011817/5e8061fd96d3d97df6130a69/html5/thumbnails/21.jpg)
CLIMS03706SC 05/2017 A 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
![Page 22: Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium](https://reader030.fdocuments.net/reader030/viewer/2022011817/5e8061fd96d3d97df6130a69/html5/thumbnails/22.jpg)
CLIMS03706SC 05/2017 A 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 $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $329 a day $329 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day
Up to $164.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness services
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.
![Page 23: Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium](https://reader030.fdocuments.net/reader030/viewer/2022011817/5e8061fd96d3d97df6130a69/html5/thumbnails/23.jpg)
CLIMS03706SC 05/2017 A 22
PLAN N
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.
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 tests, durable medical equipment
First $183 of Medicare-Approved amounts*
$0 $0 $183 (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 $183 of Medicare-Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
![Page 24: Outline of Coverage - smsteam · To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium](https://reader030.fdocuments.net/reader030/viewer/2022011817/5e8061fd96d3d97df6130a69/html5/thumbnails/24.jpg)
CLIMS03706SC 05/2017 A 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 $183 of Medicare Approved amounts*
$0 $0 $183 (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