CLIMS04883TN OUTLINE MEDSUP TN 032021A

Outline of coverage Medicare Supplement Insurance

Benefit plans: A, B, F, G, High Deductible G, N

Tennessee

Underwritten by

Continental Life Insurance Company of Brentwood, Tennessee

An Aetna Company

aetnaseniorproducts.com CLIMS04883TN ©2022 Aetna Inc. Rates effective: 03/2021 B

http://aetnaseniorproducts.com

CONTINENTAL LIFE INSURANCE COMPANY OF BRENTWOOD, TENNESSEE OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS AVAILABLE: A, B, F, G, HIGH DEDUCTIBLE G, 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 ✓ means 100% of the benefit is paid.

Benefits

Plans Available to All Applicants

A B D G1 K L M N

Medicare first eligible before

2020 only C F1

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Medicare Part B coinsurance or copayment ✓ ✓ ✓ ✓ 50% 75% ✓

✓ copays apply3

✓ ✓

Blood (first three pints) ✓ ✓ ✓ ✓ 50% 75% ✓ ✓ ✓ ✓

Part A hospice care coinsurance or copayment ✓ ✓ ✓ ✓ 50% 75% ✓ ✓ ✓ ✓

Skilled nursing facility coinsurance ✓ ✓ 50% 75% ✓ ✓ ✓ ✓

Medicare Part A deductible ✓ ✓ ✓ 50% 75% 50% ✓ ✓ ✓

Medicare Part B deductible ✓ ✓ Medicare Part B excess charges ✓ ✓

Foreign travel emergency (up to plan limits) ✓ ✓ ✓ ✓ ✓ ✓

Out-of-pocket limit in 20222 $6,6202 $3,3102

1 Plans F and G also have a high deductible option, which require first paying a plan deductible of $2,490 before the planbegins 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.

2 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.

3 Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission.

CLIMS04883TN 1 03/2021 B

Continental Life Insurance Company of Brentwood, Tennessee Annual Premiums

For Use in ALL Zip Codes Female Rates

Rates Effective 3/1/2021

Attained Age

Preferred Plan A Plan B Plan F Plan G Plan HG Plan N

Under 65 4,725 5,549 6,649 5,633 2,106 4,601 65 1,048 1,232 1,475 1,250 467 963 66 1,048 1,232 1,475 1,250 467 963 67 1,048 1,232 1,475 1,250 467 963 68 1,059 1,244 1,491 1,263 472 998 69 1,084 1,273 1,525 1,292 483 1,038 70 1,113 1,306 1,566 1,326 496 1,078 71 1,146 1,346 1,613 1,366 511 1,116 72 1,182 1,388 1,662 1,408 527 1,154 73 1,220 1,433 1,717 1,454 544 1,193 74 1,263 1,484 1,777 1,506 563 1,234 75 1,307 1,535 1,840 1,558 582 1,273 76 1,353 1,589 1,904 1,613 603 1,314 77 1,401 1,645 1,971 1,669 624 1,358 78 1,448 1,701 2,037 1,726 645 1,403 79 1,494 1,754 2,101 1,780 665 1,448 80 1,540 1,809 2,167 1,837 686 1,496 81 1,589 1,866 2,235 1,894 708 1,544 82 1,636 1,922 2,302 1,950 729 1,590 83 1,687 1,981 2,373 2,010 751 1,638 84 1,736 2,039 2,442 2,070 773 1,686 85 1,799 2,113 2,531 2,144 801 1,747 86 1,851 2,174 2,603 2,206 824 1,798 87 1,903 2,234 2,678 2,268 848 1,848 88 1,956 2,297 2,752 2,332 872 1,901 89 2,011 2,361 2,829 2,397 896 1,953 90 2,066 2,427 2,906 2,463 920 2,007 91 2,122 2,492 2,985 2,529 945 2,061 92 2,180 2,559 3,066 2,598 971 2,117 93 2,238 2,627 3,148 2,668 997 2,174 94 2,296 2,696 3,231 2,737 1,023 2,231 95 2,356 2,767 3,315 2,809 1,050 2,289 96 2,417 2,838 3,401 2,882 1,077 2,348 97 2,479 2,912 3,488 2,956 1,104 2,409 98 2,542 2,985 3,576 3,030 1,132 2,470

99+ 2,605 3,060 3,666 3,105 1,161 2,531

Attained Age

Standard Plan A Plan B Plan F Plan G Plan HG Plan N

Under 65 5,250 6,166 7,388 6,259 2,340 5,112 65 1,164 1,368 1,639 1,389 519 1,070 66 1,164 1,368 1,639 1,389 519 1,070 67 1,164 1,368 1,639 1,389 519 1,070 68 1,177 1,383 1,657 1,403 524 1,109 69 1,204 1,414 1,694 1,435 537 1,154 70 1,237 1,451 1,740 1,474 551 1,198 71 1,273 1,495 1,792 1,517 568 1,240 72 1,314 1,542 1,847 1,564 586 1,282 73 1,356 1,593 1,908 1,615 604 1,325 74 1,404 1,649 1,974 1,673 626 1,371 75 1,452 1,705 2,044 1,731 647 1,414 76 1,504 1,765 2,115 1,792 670 1,460 77 1,556 1,828 2,190 1,854 693 1,509 78 1,609 1,890 2,264 1,918 717 1,558 79 1,660 1,949 2,334 1,978 739 1,609 80 1,712 2,010 2,408 2,040 762 1,662 81 1,765 2,073 2,484 2,104 787 1,715 82 1,818 2,135 2,558 2,166 810 1,766 83 1,875 2,202 2,637 2,234 834 1,820 84 1,929 2,266 2,713 2,299 859 1,873 85 1,998 2,348 2,812 2,383 890 1,941 86 2,057 2,415 2,892 2,451 916 1,997 87 2,114 2,482 2,975 2,520 942 2,054 88 2,174 2,553 3,058 2,591 969 2,112 89 2,234 2,624 3,143 2,663 996 2,170 90 2,296 2,696 3,230 2,736 1,022 2,229 91 2,358 2,769 3,317 2,810 1,050 2,290 92 2,422 2,843 3,406 2,887 1,079 2,352 93 2,486 2,919 3,498 2,964 1,108 2,415 94 2,552 2,996 3,590 3,041 1,137 2,479 95 2,618 3,074 3,683 3,121 1,167 2,543 96 2,686 3,153 3,779 3,202 1,197 2,608 97 2,754 3,235 3,876 3,284 1,227 2,676 98 2,825 3,317 3,973 3,366 1,258 2,744

99+ 2,895 3,400 4,073 3,451 1,290 2,812 Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833

The above rates do not include the $20 one-time policy fee.

To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium

If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates.

CLIMS04883TN 2 03/2021 B

Continental Life Insurance Company of Brentwood, Tennessee Annual Premiums

For Use in ALL Zip Codes Male Rates

Rates Effective 3/1/2021

Attained Age

Preferred Plan A Plan B Plan F Plan G Plan HG Plan N

Under 65 5,434 6,382 7,646 6,477 2,422 5,291 65 1,205 1,416 1,697 1,437 537 1,108 66 1,205 1,416 1,697 1,437 537 1,108 67 1,205 1,416 1,697 1,437 537 1,108 68 1,218 1,431 1,715 1,452 543 1,148 69 1,246 1,464 1,754 1,485 555 1,194 70 1,280 1,503 1,801 1,525 570 1,240 71 1,318 1,548 1,854 1,570 588 1,283 72 1,360 1,596 1,911 1,619 606 1,327 73 1,403 1,649 1,974 1,672 626 1,371 74 1,452 1,706 2,043 1,732 647 1,419 75 1,504 1,765 2,116 1,792 669 1,464 76 1,556 1,827 2,189 1,855 693 1,511 77 1,611 1,892 2,267 1,920 718 1,561 78 1,665 1,956 2,343 1,985 742 1,613 79 1,718 2,017 2,416 2,048 765 1,665 80 1,771 2,080 2,493 2,112 789 1,721 81 1,827 2,146 2,570 2,178 814 1,776 82 1,882 2,210 2,647 2,242 838 1,828 83 1,940 2,279 2,729 2,312 864 1,884 84 1,996 2,345 2,809 2,381 889 1,939 85 2,069 2,430 2,911 2,466 921 2,010 86 2,128 2,500 2,994 2,537 948 2,067 87 2,188 2,569 3,080 2,608 975 2,125 88 2,249 2,642 3,165 2,681 1,003 2,186 89 2,312 2,715 3,253 2,757 1,030 2,246 90 2,376 2,791 3,342 2,832 1,058 2,308 91 2,440 2,865 3,432 2,909 1,087 2,370 92 2,506 2,943 3,526 2,988 1,117 2,434 93 2,574 3,021 3,620 3,068 1,147 2,500 94 2,641 3,101 3,716 3,148 1,176 2,566 95 2,710 3,182 3,813 3,230 1,208 2,632 96 2,779 3,263 3,911 3,314 1,239 2,700 97 2,851 3,348 4,011 3,399 1,270 2,770 98 2,923 3,432 4,113 3,484 1,302 2,840

99+ 2,996 3,519 4,216 3,571 1,335 2,911

Attained Age

Standard Plan A Plan B Plan F Plan G Plan HG Plan N

Under 65 6,038 7,091 8,496 7,198 2,691 5,879 65 1,339 1,573 1,885 1,597 597 1,231 66 1,339 1,573 1,885 1,597 597 1,231 67 1,339 1,573 1,885 1,597 597 1,231 68 1,353 1,591 1,906 1,613 603 1,275 69 1,385 1,626 1,948 1,650 618 1,327 70 1,423 1,668 2,001 1,695 634 1,378 71 1,464 1,720 2,061 1,745 653 1,426 72 1,511 1,773 2,124 1,799 674 1,474 73 1,559 1,832 2,195 1,857 695 1,524 74 1,615 1,896 2,270 1,924 720 1,577 75 1,670 1,961 2,351 1,991 744 1,626 76 1,729 2,030 2,432 2,060 771 1,679 77 1,789 2,102 2,519 2,132 797 1,736 78 1,850 2,174 2,603 2,206 825 1,792 79 1,909 2,241 2,684 2,274 850 1,850 80 1,969 2,311 2,769 2,346 876 1,911 81 2,030 2,384 2,857 2,419 905 1,972 82 2,091 2,455 2,941 2,491 932 2,031 83 2,157 2,533 3,032 2,569 959 2,093 84 2,219 2,606 3,121 2,645 988 2,155 85 2,297 2,700 3,234 2,740 1,024 2,232 86 2,366 2,777 3,325 2,819 1,053 2,296 87 2,431 2,855 3,421 2,897 1,083 2,361 88 2,500 2,936 3,516 2,980 1,114 2,429 89 2,569 3,018 3,614 3,063 1,145 2,496 90 2,641 3,101 3,714 3,147 1,175 2,563 91 2,712 3,185 3,815 3,231 1,208 2,633 92 2,786 3,270 3,918 3,320 1,241 2,705 93 2,859 3,357 4,023 3,409 1,274 2,777 94 2,935 3,445 4,129 3,498 1,308 2,851 95 3,010 3,535 4,236 3,589 1,342 2,924 96 3,089 3,626 4,346 3,683 1,377 3,000 97 3,167 3,720 4,457 3,777 1,411 3,078 98 3,249 3,815 4,570 3,872 1,447 3,155

99+ 3,330 3,910 4,684 3,969 1,484 3,234 Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833

The above rates do not include the $20 one-time policy fee.

To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent)Modal premium x .93 = discounted premium

If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates.

Standard/Preferred rating classes are used, but all applicants in their open enrollment period or a specified guarantee issue period will receive Preferred rates.

CLIMS04883TN 3 03/2021 B

PREMIUM INFORMATION Continental Life Insurance Company of Brentwood, Tennessee will increase premiums due to the increase in your age on each annual anniversary of your Effective Date. The renewal premium for this policy will be the renewal premium then in effect for your attained age. The premium may also change for other reasons. Any change in premium will apply to all covered persons in your same class based on the issue state of your policy. For any premium change under this paragraph, we will give you at least 30 days advance notice in writing of such premium change.

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 a 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 have a Medicare supplement policy with an Aetna company. The Medicare eligible adult must be either (a) your spouse or someone with whom you are in a civil union partnership; and (b) 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 rates 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, KY 40512-4770. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all your payments.

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

NOTICE

The policy may not cover all of your medical costs.

Neither 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, G, HIGH DEDUCTIBLE G, and N OFFERED BY CONTINENTAL LIFE INSURANCE COMPANY OF BRENTWOOD, TENNESSEE.

CLIMS04883TN 4 03/2021 B

PLAN A

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

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

SERVICES MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,556 $0 $1,556

(Part A Deductible) 61st thru 90th day All but $389 a day $389 a day $0 91st day and after ●While using 60 lifetime reserve days All but $778 a day $778 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

$194.50 a day $0 Up to $194.50 a day

101st day and after $0 All cost

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.

CLIMS04883TN 5 03/2021 B

PLAN A

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

*Once you have been billed $233 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.


PLAN PAYS

YOU PAY

MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $233 of Medicare-Approved amounts*

$0 $0 $233 (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 $233 of Medicare-Approved amounts*


Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES ●Medically necessary skilled care services and medical supplies

100% $0 $0

●Durable medical equipment ●First $233 of Medicare Approved amounts*


●Remainder of Medicare Approved amounts 80% 20% $0

CLIMS04883TN 6 03/2021 B

PLAN B


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


PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,556 $1,556

(Part A Deductible) $0

61st thru 90th day All but $389 a day $389 a day $0 91st day and after ●While using 60 lifetime reserve days All but $778 a day $778 a day $0 ●Once lifetime reserve days are used: ●Additional 365 days $0 100% of Medicare


●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 $194.50 a day

$0 Up to $194.50 a day 101st day and after $0 $0 All costs

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



$0


CLIMS04883TN 7 03/2021 B

PLAN B


* Once you have been billed $233 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.


PLAN PAYS

YOU PAY



Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $233 of Medicare-Approved amounts*



PARTS A & B


PLAN PAYS

YOU PAY


100% $0 $0




CLIMS04883TN 8 03/2021 B

PLAN F




PLAN PAYS

YOU PAY






amounts$0 $0


Up to $194.50 a day

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



$0


CLIMS04883TN 9 03/2021 B

PLAN F




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 $233 of Medicare-Approved amounts*

$0 $233 (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 $233 of Medicare-Approved amounts*


$0


PARTS A & B


PLAN PAYS

YOU PAY


100% $0 $0



$0


CLIMS04883TN 10 03/2021 B

PLAN F

OTHER BENEFITS – NOT COVERED BY MEDICARE


PLAN PAYS

YOU PAY

FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime

maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum

CLIMS04883TN 11 03/2021 B

PLAN G




PLAN PAYS

YOU PAY






amounts $0 $0


Up to $194.50 a day

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



$0


CLIMS04883TN 12 03/2021 B

PLAN G




PLAN PAYS

YOU PAY






PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES ●Medically necessary skilled care services and medical supplies 100% $0 $0 ●Durable medical equipment ●First $233 of Medicare Approved amounts*



CLIMS04883TN 13 03/2021 B

PLAN G


SERVICES MEDICARE PAYS PLAN PAYS YOU PAY




CLIMS04883TN 14 03/2021 B

HIGH DEDUCTIBLE PLAN G



***This high deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,490 deductible. Benefits from high deductible plan G will not begin until out-of-pocket expenses are $2,490. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan’s separate foreign travel emergency deductible.


AFTER YOU PAY $2,490

DEDUCTIBLE*** PLAN PAYS

IN ADDITION TO $2,490

DEDUCTIBLE*** YOU PAY



61st thru 90th day All but $389 a day $389 a day $0 91st day and after *While using 60 lifetime reserve days All but $778 a day $778 a day $0 *Once lifetime reserve days are used: *Additional 365 days $0 100% of Medicare


*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


Up to $194.50 a day

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

CLIMS04883TN 15 03/2021 B

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



$0


CLIMS04883TN 16 03/2021 B




***This high deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,490 deductible. Benefits from high deductible plan G will not begin until out-of-pocket expenses are $2,490. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan’s separate foreign travel emergency deductible.







$0 $0 $233 (Unless Part B Deductible has been met)




CLIMS04883TN 17 03/2021 B


PARTS A & B






HOME HEALTH CARE – MEDICARE APPROVED SERVICES *Medically necessary skilled care services and medical supplies

100% $0 $0

*Durable medical equipment *First $233 of Medicare Approved amounts*


*Remainder of Medicare Approved amounts 80% 20% $0




DEDUCTIBLE** PLAN PAYS


DEDUCTIBLE** YOU PAY




CLIMS04883TN 18 03/2021 B

PLAN N




PLAN PAYS

YOU PAY



61st thru 90th day All but $389 a day $389 a day $0 91st day and after *While using 60 lifetime reserve days All but $778 a day $778 a day $0 *Once lifetime reserve days are used: *Additional 365 days $0 100% of Medicare


*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 $0 $0 21st thru 100th day amounts All but Up to $194.50 a $0 101st day and after $194.50 a day $0 day $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


Medicare co-payment/ coinsurance

$0


CLIMS04883TN 19 03/2021 B

PLAN N




PLAN PAYS

YOU PAY



Remainder of Medicare-Approved amounts

Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Up to $20 per office visit and up to $50 per emergency room visit. The 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.

Part B Excess Charges (Above Medicare-Approved amounts) $0 0% All costs BLOOD First 3 pints $0 All costs $0 Next $233 of Medicare-Approved amounts*



CLIMS04883TN 20 03/2021 B

PLAN N

PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES ●Medically necessary skilled care services and medical supplies 100% $0 $0 *Durable medical equipment ●First $233 of Medicare

Approved amounts* $0 $0 $233

(Part B Deductible) *Remainder of Medicare

Approved amounts 80% 20% $0



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


CLIMS04883TN 21 03/2021 B

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CLIMS04883TN OUTLINE MEDSUP TN 032021A

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