MACRA outline of coverage generic · 2020. 6. 23. · CIGNA NATIONAL HEALTH INSURANCE COMPANY . PO...

CNHIC-OC-2020-PA 902464 7/27/20

Cigna Medicare Supplement Insurance Cigna National Health Insurance Company

OUTLINE OF COVERAGE AND RATES FOR PENNSYLVANIA RESIDENTS

Medicare Supplement benefit plans A, B, F, G, and N

CIGNA NATIONAL HEALTH INSURANCE COMPANY PO Box 5700, Scranton, PA 18505-5700 • 866-459-4272

Outline of Medicare Supplement Coverage – Benefit Plans A, B, F, G, and N This chart shows the benefits included in each of the standard Medicare Supplement plans. Every company must make Plan A, B, and D or G available. Some plans may not be available in your state. Only Applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high-deductible F.

Benefits

Note: A means 100% of the benefit is paid

Plans available

Plans available only if first Medicare

eligible before 2020 A B D G1 HDG1 K L M N C F1 HDF1

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 20202 $5,8802 $2,9402

1Plans F and G also have a high-deductible option which requires first paying a plan deductible of $2,340 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. These expenses include the Medicare deductibles for Part A and Part B, but do not include the Plan’s separate foreign travel emergency deductible.

2Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit. 3Plan 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.

CNHIC-OC-2020-PA 1 7/27/20

THIS PAGE INTENTIONALLY LEFT BLANK

CNHIC-OC-2020-PA 2 7/27/20

Locate appropriate Area according to the Applicant’s ZIP Code in the chart below. PENNSYLVANIA ZIP CODES Area 3-digit ZIP Codes Area I 155, 157–188, 195–196 Area II 150–154, 156 Area III 189–194

CNHIC-OC-2020-PA 3 7/27/20

Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly2,414.87 201.16 2,728.04 227.25 3,343.64 278.53 2,826.99 235.49 2,121.70 176.74 Under 65 UW 2,680.50 223.29 3,028.13 252.24 3,711.44 309.16 3,137.96 261.39 2,355.08 196.181,289.53 107.42 1,456.77 121.35 1,883.29 156.88 1,509.60 125.75 1,037.02 86.38 Under 65 OE 1,431.38 119.23 1,617.01 134.70 2,090.45 174.13 1,675.66 139.58 1,151.09 95.891,289.53 107.42 1,456.77 121.35 1,883.29 156.88 1,509.60 125.75 1,037.02 86.38 65 1,431.38 119.23 1,617.01 134.70 2,090.45 174.13 1,675.66 139.58 1,151.09 95.891,289.53 107.42 1,456.77 121.35 1,883.29 156.88 1,509.60 125.75 1,068.07 88.97 66 1,431.38 119.23 1,617.01 134.70 2,090.45 174.13 1,675.66 139.58 1,185.55 98.761,289.53 107.42 1,456.77 121.35 1,883.29 156.88 1,509.60 125.75 1,100.04 91.63 67 1,431.38 119.23 1,617.01 134.70 2,090.45 174.13 1,675.66 139.58 1,221.05 101.711,289.53 107.42 1,456.77 121.35 1,883.29 156.88 1,509.60 125.75 1,132.98 94.38 68 1,431.38 119.23 1,617.01 134.70 2,090.45 174.13 1,675.66 139.58 1,257.61 104.761,328.14 110.63 1,500.38 124.98 1,933.39 161.05 1,554.80 129.51 1,166.90 97.20 69 1,474.23 122.80 1,665.42 138.73 2,146.06 178.77 1,725.83 143.76 1,295.26 107.901,367.90 113.95 1,545.30 128.72 1,984.99 165.35 1,601.35 133.39 1,201.84 100.11 70 1,518.37 126.48 1,715.28 142.88 2,203.34 183.54 1,777.50 148.07 1,334.04 111.131,408.86 117.36 1,591.57 132.58 2,038.14 169.78 1,649.29 137.39 1,237.82 103.11 71 1,563.83 130.27 1,766.64 147.16 2,262.34 188.45 1,830.71 152.50 1,373.98 114.451,451.04 120.87 1,639.22 136.55 2,092.88 174.34 1,698.67 141.50 1,274.88 106.20 72 1,610.65 134.17 1,819.53 151.57 2,323.09 193.51 1,885.53 157.06 1,415.11 117.881,494.48 124.49 1,688.30 140.63 2,149.25 179.03 1,749.53 145.74 1,313.05 109.38 73 1,658.87 138.18 1,874.01 156.10 2,385.67 198.73 1,941.98 161.77 1,457.48 121.411,539.22 128.22 1,738.84 144.85 2,207.32 183.87 1,801.91 150.10 1,352.36 112.65 74 1,708.54 142.32 1,930.11 160.78 2,450.12 204.10 2,000.12 166.61 1,501.12 125.041,585.31 132.06 1,790.90 149.18 2,267.12 188.85 1,855.86 154.59 1,392.85 116.02 75 1,759.69 146.58 1,987.90 165.59 2,516.50 209.62 2,060.00 171.60 1,546.06 128.791,632.77 136.01 1,844.52 153.65 2,328.71 193.98 1,911.42 159.22 1,434.55 119.50 76 1,812.38 150.97 2,047.42 170.55 2,584.87 215.32 2,121.68 176.74 1,592.35 132.641,681.66 140.08 1,899.74 158.25 2,392.15 199.27 1,968.65 163.99 1,477.50 123.08 77 1,866.64 155.49 2,108.72 175.66 2,655.29 221.19 2,185.20 182.03 1,640.02 136.611,732.00 144.28 1,956.62 162.99 2,457.49 204.71 2,027.59 168.90 1,521.73 126.76 78 1,922.52 160.15 2,171.85 180.92 2,727.81 227.23 2,250.62 187.48 1,689.12 140.701,783.86 148.60 2,015.20 167.87 2,524.78 210.31 2,088.29 173.95 1,567.29 130.56 79 1,980.08 164.94 2,236.87 186.33 2,802.51 233.45 2,318.00 193.09 1,739.70 144.921,837.27 153.04 2,075.54 172.89 2,594.09 216.09 2,150.81 179.16 1,614.22 134.46 80 2,039.37 169.88 2,303.84 191.91 2,879.44 239.86 2,387.40 198.87 1,791.78 149.261,892.27 157.63 2,137.68 178.07 2,665.47 222.03 2,215.21 184.53 1,662.55 138.49 81 2,100.42 174.97 2,372.82 197.66 2,958.67 246.46 2,458.88 204.82 1,845.43 153.721,948.93 162.35 2,201.68 183.40 2,738.99 228.16 2,281.53 190.05 1,712.32 142.64 82 2,163.31 180.20 2,443.86 203.57 3,040.28 253.26 2,532.50 210.96 1,900.68 158.332,007.28 167.21 2,267.59 188.89 2,814.71 234.47 2,349.84 195.74 1,763.59 146.91 83 2,228.08 185.60 2,517.03 209.67 3,124.33 260.26 2,608.32 217.27 1,957.58 163.072,067.37 172.21 2,335.48 194.55 2,892.70 240.96 2,420.19 201.60 1,816.39 151.31 84 2,294.78 191.16 2,592.39 215.95 3,210.89 267.47 2,686.41 223.78 2,016.19 167.952,129.27 177.37 2,405.41 200.37 2,973.02 247.65 2,492.65 207.64 1,870.77 155.84 85 2,363.49 196.88 2,670.00 222.41 3,300.05 274.89 2,766.84 230.48 2,076.55 172.982,193.02 182.68 2,477.42 206.37 3,055.75 254.54 2,567.28 213.85 1,926.78 160.50 86 2,434.25 202.77 2,749.94 229.07 3,391.88 282.54 2,849.68 237.38 2,138.73 178.162,220.82 184.99 2,508.83 208.99 3,091.83 257.55 2,599.82 216.57 1,951.21 162.54 87 2,465.11 205.34 2,784.80 231.97 3,431.93 285.88 2,885.81 240.39 2,165.84 180.412,248.62 187.31 2,540.24 211.60 3,127.90 260.55 2,632.37 219.28 1,975.63 164.57 88 2,495.97 207.91 2,819.66 234.88 3,471.97 289.22 2,921.93 243.40 2,192.95 182.672,276.42 189.63 2,571.64 214.22 3,163.98 263.56 2,664.92 221.99 2,000.06 166.60 89 2,526.83 210.48 2,854.53 237.78 3,512.02 292.55 2,958.06 246.41 2,220.06 184.932,304.22 191.94 2,603.05 216.83 3,200.06 266.56 2,697.46 224.70 2,024.48 168.64 90 2,557.69 213.06 2,889.39 240.69 3,552.07 295.89 2,994.18 249.42 2,247.18 187.192,326.35 193.79 2,628.05 218.92 3,228.78 268.96 2,723.37 226.86 2,043.93 170.26 91 2,582.25 215.10 2,917.14 243.00 3,583.94 298.54 3,022.94 251.81 2,268.76 188.992,348.48 195.63 2,653.05 221.00 3,257.49 271.35 2,749.27 229.01 2,063.37 171.88 92 2,606.81 217.15 2,944.88 245.31 3,615.82 301.20 3,051.69 254.21 2,290.34 190.792,370.61 197.47 2,678.05 223.08 3,286.21 273.74 2,775.18 231.17 2,082.81 173.50 93 2,631.38 219.19 2,972.63 247.62 3,647.69 303.85 3,080.45 256.60 2,311.92 192.582,392.74 199.32 2,703.05 225.16 3,314.92 276.13 2,801.08 233.33 2,102.25 175.12 94 2,655.94 221.24 3,000.38 249.93 3,679.57 306.51 3,109.20 259.00 2,333.50 194.382,414.87 201.16 2,728.04 227.25 3,343.64 278.53 2,826.99 235.49 2,121.70 176.74 95 2,680.50 223.29 3,028.13 252.24 3,711.44 309.16 3,137.96 261.39 2,355.08 196.182,414.87 201.16 2,728.04 227.25 3,343.64 278.53 2,826.99 235.49 2,121.70 176.74 96 2,680.50 223.29 3,028.13 252.24 3,711.44 309.16 3,137.96 261.39 2,355.08 196.182,414.87 201.16 2,728.04 227.25 3,343.64 278.53 2,826.99 235.49 2,121.70 176.74 97 2,680.50 223.29 3,028.13 252.24 3,711.44 309.16 3,137.96 261.39 2,355.08 196.182,414.87 201.16 2,728.04 227.25 3,343.64 278.53 2,826.99 235.49 2,121.70 176.74 98 2,680.50 223.29 3,028.13 252.24 3,711.44 309.16 3,137.96 261.39 2,355.08 196.182,414.87 201.16 2,728.04 227.25 3,343.64 278.53 2,826.99 235.49 2,121.70 176.74 99 2,680.50 223.29 3,028.13 252.24 3,711.44 309.16 3,137.96 261.39 2,355.08 196.18

Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply the above-quoted annual premium by 0.52. To obtain quarterly premiums, multiply the above quoted premium by 0.265.

During open enrollment and guaranteed issue periods, Preferred rates will apply.

Cigna National Health Insurance CompanyMEDICARE SUPPLEMENT

PENNSYLVANIA - POLICY FORM SERIES CNHIC-MS-AAAttained Age Rates -- Effective 7/27/2020 -- Area I (155, 157-188, 195-196)

PREFERRED ANNUAL & MONTHLY BANK DRAFT RATES

FEMALE RATES MALE RATESPlan A Plan B Plan F Plan G Plan N

Attained AgePlan A Plan B Plan F Plan G Plan N

If both insureds have a Medicare Supplement policy with Cigna then add an additional 9% discount (multiply rates above by 0.85)Applicants who reside with legal spouse (including civil union/domestic partner) apply a 6% discount to the rates above (multiply rates above by 0.94)

CNHIC-OC-2020-PA 4 7/27/20




Cigna National Health Insurance Company

STANDARD ANNUAL & MONTHLY BANK DRAFT RATES

MEDICARE SUPPLEMENTPENNSYLVANIA - POLICY FORM SERIES CNHIC-MS-AA

Plan AFEMALE RATES MALE RATES

Plan B Plan F Plan G Plan N

Attained Age Rates -- Effective 7/27/2020 -- Area I (155, 157-188, 195-196)

Plan G Plan NPlan A Plan B Plan F

Applicants who reside with legal spouse (including civil union/domestic partner) apply a 6% discount to the rates above (multiply rates above by 0.94)

Attained Age

If both insureds have a Medicare Supplement policy with Cigna then add an additional 9% discount (multiply rates above by 0.85)

CNHIC-OC-2020-PA 5 7/27/20

Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly

1,934.30 161.13 2,185.15 182.02 2,824.94 235.32 2,264.40 188.62 1,555.53 129.58 65 2,147.07 178.85 2,425.52 202.05 3,135.68 261.20 2,513.49 209.37 1,726.64 143.831,934.30 161.13 2,185.15 182.02 2,824.94 235.32 2,264.40 188.62 1,602.10 133.45 66 2,147.07 178.85 2,425.52 202.05 3,135.68 261.20 2,513.49 209.37 1,778.33 148.131,934.30 161.13 2,185.15 182.02 2,824.94 235.32 2,264.40 188.62 1,650.07 137.45 67 2,147.07 178.85 2,425.52 202.05 3,135.68 261.20 2,513.49 209.37 1,831.57 152.571,934.30 161.13 2,185.15 182.02 2,824.94 235.32 2,264.40 188.62 1,699.47 141.57 68 2,147.07 178.85 2,425.52 202.05 3,135.68 261.20 2,513.49 209.37 1,886.41 157.141,992.21 165.95 2,250.57 187.47 2,900.09 241.58 2,332.20 194.27 1,750.35 145.80 69 2,211.35 184.21 2,498.13 208.09 3,219.10 268.15 2,588.74 215.64 1,942.89 161.842,051.85 170.92 2,317.95 193.09 2,977.49 248.02 2,402.02 200.09 1,802.75 150.17 70 2,277.56 189.72 2,572.93 214.32 3,305.01 275.31 2,666.25 222.10 2,001.06 166.692,113.29 176.04 2,387.35 198.87 3,057.21 254.67 2,473.94 206.08 1,856.73 154.67 71 2,345.75 195.40 2,649.96 220.74 3,393.50 282.68 2,746.07 228.75 2,060.97 171.682,176.56 181.31 2,458.83 204.82 3,139.32 261.51 2,548.01 212.25 1,912.32 159.30 72 2,415.98 201.25 2,729.30 227.35 3,484.64 290.27 2,828.29 235.60 2,122.67 176.822,241.72 186.74 2,532.44 210.95 3,223.88 268.55 2,624.29 218.60 1,969.57 164.07 73 2,488.31 207.28 2,811.01 234.16 3,578.51 298.09 2,912.97 242.65 2,186.22 182.112,308.84 192.33 2,608.26 217.27 3,310.98 275.80 2,702.86 225.15 2,028.54 168.98 74 2,562.81 213.48 2,895.17 241.17 3,675.18 306.14 3,000.18 249.91 2,251.68 187.562,377.96 198.08 2,686.35 223.77 3,400.68 283.28 2,783.78 231.89 2,089.27 174.04 75 2,639.54 219.87 2,981.85 248.39 3,774.76 314.44 3,090.00 257.40 2,319.09 193.182,449.16 204.01 2,766.78 230.47 3,493.07 290.97 2,867.13 238.83 2,151.82 179.25 76 2,718.56 226.46 3,071.13 255.82 3,877.31 322.98 3,182.51 265.10 2,388.52 198.962,522.48 210.12 2,849.62 237.37 3,588.23 298.90 2,952.97 245.98 2,216.25 184.61 77 2,799.96 233.24 3,163.07 263.48 3,982.93 331.78 3,277.80 273.04 2,460.03 204.922,598.01 216.41 2,934.93 244.48 3,686.23 307.06 3,041.38 253.35 2,282.60 190.14 78 2,883.79 240.22 3,257.77 271.37 4,091.72 340.84 3,375.93 281.22 2,533.69 211.062,675.79 222.89 3,022.80 251.80 3,787.17 315.47 3,132.44 260.93 2,350.94 195.83 79 2,970.12 247.41 3,355.31 279.50 4,203.76 350.17 3,477.01 289.63 2,609.54 217.372,755.90 229.57 3,113.30 259.34 3,891.13 324.13 3,226.22 268.74 2,421.33 201.70 80 3,059.05 254.82 3,455.77 287.87 4,319.16 359.79 3,581.11 298.31 2,687.67 223.882,838.41 236.44 3,206.51 267.10 3,998.20 333.05 3,322.81 276.79 2,493.82 207.74 81 3,150.63 262.45 3,559.23 296.48 4,438.01 369.69 3,688.32 307.24 2,768.14 230.592,923.39 243.52 3,302.52 275.10 4,108.48 342.24 3,422.30 285.08 2,568.48 213.95 82 3,244.96 270.31 3,665.79 305.36 4,560.42 379.88 3,798.75 316.44 2,851.02 237.493,010.91 250.81 3,401.39 283.34 4,222.06 351.70 3,524.76 293.61 2,645.38 220.36 83 3,342.12 278.40 3,775.54 314.50 4,686.49 390.38 3,912.48 325.91 2,936.37 244.603,101.06 258.32 3,503.23 291.82 4,339.05 361.44 3,630.29 302.40 2,724.58 226.96 84 3,442.18 286.73 3,888.58 323.92 4,816.34 401.20 4,029.62 335.67 3,024.29 251.923,193.90 266.05 3,608.11 300.56 4,459.53 371.48 3,738.97 311.46 2,806.15 233.75 85 3,545.23 295.32 4,005.00 333.62 4,950.08 412.34 4,150.26 345.72 3,114.83 259.473,289.53 274.02 3,716.14 309.55 4,583.62 381.82 3,850.92 320.78 2,890.17 240.75 86 3,651.38 304.16 4,124.91 343.61 5,087.82 423.82 4,274.52 356.07 3,208.09 267.233,331.23 277.49 3,763.25 313.48 4,637.74 386.32 3,899.74 324.85 2,926.81 243.80 87 3,697.66 308.02 4,177.20 347.96 5,147.89 428.82 4,328.71 360.58 3,248.76 270.623,372.93 280.97 3,810.36 317.40 4,691.85 390.83 3,948.56 328.91 2,963.45 246.86 88 3,743.95 311.87 4,229.50 352.32 5,207.96 433.82 4,382.90 365.10 3,289.43 274.013,414.63 284.44 3,857.47 321.33 4,745.97 395.34 3,997.37 332.98 3,000.09 249.91 89 3,790.24 315.73 4,281.79 356.67 5,268.03 438.83 4,437.09 369.61 3,330.10 277.403,456.34 287.91 3,904.58 325.25 4,800.09 399.85 4,046.19 337.05 3,036.73 252.96 90 3,836.53 319.58 4,334.08 361.03 5,328.10 443.83 4,491.27 374.12 3,370.77 280.783,489.53 290.68 3,942.07 328.37 4,843.16 403.44 4,085.05 340.28 3,065.89 255.39 91 3,873.38 322.65 4,375.70 364.50 5,375.91 447.81 4,534.41 377.72 3,403.14 283.483,522.72 293.44 3,979.57 331.50 4,886.24 407.02 4,123.91 343.52 3,095.05 257.82 92 3,910.22 325.72 4,417.33 367.96 5,423.72 451.80 4,577.54 381.31 3,435.51 286.183,555.91 296.21 4,017.07 334.62 4,929.31 410.61 4,162.77 346.76 3,124.22 260.25 93 3,947.07 328.79 4,458.95 371.43 5,471.54 455.78 4,620.67 384.90 3,467.88 288.873,589.11 298.97 4,054.57 337.75 4,972.39 414.20 4,201.62 350.00 3,153.38 262.68 94 3,983.91 331.86 4,500.57 374.90 5,519.35 459.76 4,663.80 388.49 3,500.25 291.573,622.30 301.74 4,092.07 340.87 5,015.46 417.79 4,240.48 353.23 3,182.54 265.11 95 4,020.75 334.93 4,542.19 378.36 5,567.16 463.74 4,706.94 392.09 3,532.62 294.273,622.30 301.74 4,092.07 340.87 5,015.46 417.79 4,240.48 353.23 3,182.54 265.11 96 4,020.75 334.93 4,542.19 378.36 5,567.16 463.74 4,706.94 392.09 3,532.62 294.273,622.30 301.74 4,092.07 340.87 5,015.46 417.79 4,240.48 353.23 3,182.54 265.11 97 4,020.75 334.93 4,542.19 378.36 5,567.16 463.74 4,706.94 392.09 3,532.62 294.273,622.30 301.74 4,092.07 340.87 5,015.46 417.79 4,240.48 353.23 3,182.54 265.11 98 4,020.75 334.93 4,542.19 378.36 5,567.16 463.74 4,706.94 392.09 3,532.62 294.273,622.30 301.74 4,092.07 340.87 5,015.46 417.79 4,240.48 353.23 3,182.54 265.11 99 4,020.75 334.93 4,542.19 378.36 5,567.16 463.74 4,706.94 392.09 3,532.62 294.27





STANDARD II ANNUAL & MONTHLY BANK DRAFT RATES




CNHIC-OC-2020-PA 6 7/27/20


2,127.73 177.24 2,403.66 200.23 3,107.43 258.85 2,490.84 207.49 1,711.08 142.53 65 2,361.78 196.74 2,668.07 222.25 3,449.25 287.32 2,764.84 230.31 1,899.30 158.212,127.73 177.24 2,403.66 200.23 3,107.43 258.85 2,490.84 207.49 1,762.31 146.80 66 2,361.78 196.74 2,668.07 222.25 3,449.25 287.32 2,764.84 230.31 1,956.16 162.952,127.73 177.24 2,403.66 200.23 3,107.43 258.85 2,490.84 207.49 1,815.07 151.20 67 2,361.78 196.74 2,668.07 222.25 3,449.25 287.32 2,764.84 230.31 2,014.73 167.832,127.73 177.24 2,403.66 200.23 3,107.43 258.85 2,490.84 207.49 1,869.41 155.72 68 2,361.78 196.74 2,668.07 222.25 3,449.25 287.32 2,764.84 230.31 2,075.05 172.852,191.43 182.55 2,475.63 206.22 3,190.10 265.74 2,565.42 213.70 1,925.38 160.38 69 2,432.49 202.63 2,747.95 228.90 3,541.01 294.97 2,847.61 237.21 2,137.18 178.032,257.04 188.01 2,549.75 212.39 3,275.24 272.83 2,642.23 220.10 1,983.03 165.19 70 2,505.31 208.69 2,830.22 235.76 3,635.52 302.84 2,932.87 244.31 2,201.16 183.362,324.61 193.64 2,626.09 218.75 3,362.93 280.13 2,721.33 226.69 2,042.40 170.13 71 2,580.32 214.94 2,914.96 242.82 3,732.85 310.95 3,020.68 251.62 2,267.06 188.852,394.21 199.44 2,704.71 225.30 3,453.25 287.66 2,802.81 233.47 2,103.55 175.23 72 2,657.58 221.38 3,002.23 250.09 3,833.10 319.30 3,111.12 259.16 2,334.94 194.502,465.89 205.41 2,785.69 232.05 3,546.27 295.40 2,886.72 240.46 2,166.53 180.47 73 2,737.14 228.00 3,092.11 257.57 3,936.36 327.90 3,204.26 266.91 2,404.84 200.322,539.72 211.56 2,869.09 239.00 3,642.07 303.38 2,973.15 247.66 2,231.39 185.87 74 2,819.09 234.83 3,184.69 265.28 4,042.70 336.76 3,300.20 274.91 2,476.84 206.322,615.76 217.89 2,954.99 246.15 3,740.75 311.60 3,062.16 255.08 2,298.20 191.44 75 2,903.49 241.86 3,280.04 273.23 4,152.23 345.88 3,399.00 283.14 2,551.00 212.502,694.07 224.42 3,043.46 253.52 3,842.38 320.07 3,153.84 262.72 2,367.00 197.17 76 2,990.42 249.10 3,378.24 281.41 4,265.04 355.28 3,500.77 291.61 2,627.38 218.862,774.73 231.14 3,134.58 261.11 3,947.05 328.79 3,248.27 270.58 2,437.87 203.07 77 3,079.95 256.56 3,479.38 289.83 4,381.22 364.96 3,605.58 300.34 2,706.04 225.412,857.81 238.06 3,228.43 268.93 4,054.85 337.77 3,345.52 278.68 2,510.86 209.15 78 3,172.16 264.24 3,583.55 298.51 4,500.89 374.92 3,713.53 309.34 2,787.05 232.162,943.37 245.18 3,325.08 276.98 4,165.89 347.02 3,445.68 287.03 2,586.03 215.42 79 3,267.14 272.15 3,690.84 307.45 4,624.13 385.19 3,824.71 318.60 2,870.50 239.113,031.49 252.52 3,424.63 285.27 4,280.24 356.54 3,548.84 295.62 2,663.46 221.87 80 3,364.95 280.30 3,801.34 316.65 4,751.07 395.76 3,939.22 328.14 2,956.44 246.273,122.25 260.08 3,527.17 293.81 4,398.03 366.36 3,655.09 304.47 2,743.20 228.51 81 3,465.70 288.69 3,915.15 326.13 4,881.81 406.65 4,057.15 337.96 3,044.95 253.643,215.73 267.87 3,632.77 302.61 4,519.33 376.46 3,764.52 313.58 2,825.33 235.35 82 3,569.46 297.34 4,032.37 335.90 5,016.46 417.87 4,178.62 348.08 3,136.12 261.243,312.01 275.89 3,741.53 311.67 4,644.27 386.87 3,877.23 322.97 2,909.92 242.40 83 3,676.33 306.24 4,153.10 345.95 5,155.14 429.42 4,303.73 358.50 3,230.01 269.063,411.17 284.15 3,853.55 321.00 4,772.95 397.59 3,993.31 332.64 2,997.04 249.65 84 3,786.39 315.41 4,277.44 356.31 5,297.98 441.32 4,432.58 369.23 3,326.71 277.123,513.29 292.66 3,968.92 330.61 4,905.48 408.63 4,112.87 342.60 3,086.77 257.13 85 3,899.76 324.85 4,405.50 366.98 5,445.09 453.58 4,565.29 380.29 3,426.31 285.413,618.48 301.42 4,087.75 340.51 5,041.98 420.00 4,236.01 352.86 3,179.19 264.83 86 4,016.51 334.58 4,537.40 377.97 5,596.60 466.20 4,701.97 391.67 3,528.90 293.963,664.35 305.24 4,139.57 344.83 5,101.51 424.96 4,289.71 357.33 3,219.49 268.18 87 4,067.43 338.82 4,594.92 382.76 5,662.68 471.70 4,761.58 396.64 3,573.63 297.683,710.22 309.06 4,191.39 349.14 5,161.04 429.91 4,343.41 361.81 3,259.79 271.54 88 4,118.35 343.06 4,652.44 387.55 5,728.75 477.21 4,821.19 401.60 3,618.37 301.413,756.10 312.88 4,243.21 353.46 5,220.57 434.87 4,397.11 366.28 3,300.10 274.90 89 4,169.27 347.30 4,709.97 392.34 5,794.83 482.71 4,880.79 406.57 3,663.11 305.143,801.97 316.70 4,295.03 357.78 5,280.10 439.83 4,450.81 370.75 3,340.40 278.26 90 4,220.19 351.54 4,767.49 397.13 5,860.91 488.21 4,940.40 411.54 3,707.84 308.863,838.48 319.75 4,336.28 361.21 5,327.48 443.78 4,493.56 374.31 3,372.48 280.93 91 4,260.71 354.92 4,813.27 400.95 5,913.50 492.59 4,987.85 415.49 3,743.45 311.833,874.99 322.79 4,377.53 364.65 5,374.86 447.73 4,536.30 377.87 3,404.56 283.60 92 4,301.24 358.29 4,859.06 404.76 5,966.10 496.98 5,035.29 419.44 3,779.06 314.803,911.51 325.83 4,418.78 368.08 5,422.24 451.67 4,579.04 381.43 3,436.64 286.27 93 4,341.77 361.67 4,904.84 408.57 6,018.69 501.36 5,082.74 423.39 3,814.67 317.763,948.02 328.87 4,460.02 371.52 5,469.63 455.62 4,621.79 384.99 3,468.72 288.94 94 4,382.30 365.05 4,950.63 412.39 6,071.29 505.74 5,130.18 427.34 3,850.28 320.733,984.53 331.91 4,501.27 374.96 5,517.01 459.57 4,664.53 388.56 3,500.80 291.62 95 4,422.83 368.42 4,996.41 416.20 6,123.88 510.12 5,177.63 431.30 3,885.89 323.693,984.53 331.91 4,501.27 374.96 5,517.01 459.57 4,664.53 388.56 3,500.80 291.62 96 4,422.83 368.42 4,996.41 416.20 6,123.88 510.12 5,177.63 431.30 3,885.89 323.693,984.53 331.91 4,501.27 374.96 5,517.01 459.57 4,664.53 388.56 3,500.80 291.62 97 4,422.83 368.42 4,996.41 416.20 6,123.88 510.12 5,177.63 431.30 3,885.89 323.693,984.53 331.91 4,501.27 374.96 5,517.01 459.57 4,664.53 388.56 3,500.80 291.62 98 4,422.83 368.42 4,996.41 416.20 6,123.88 510.12 5,177.63 431.30 3,885.89 323.693,984.53 331.91 4,501.27 374.96 5,517.01 459.57 4,664.53 388.56 3,500.80 291.62 99 4,422.83 368.42 4,996.41 416.20 6,123.88 510.12 5,177.63 431.30 3,885.89 323.69




Plan NAttained Age

Plan A Plan B Plan F Plan GPlan A Plan B Plan F Plan G Plan N

STANDARD III ANNUAL & MONTHLY BANK DRAFT RATES

FEMALE RATES MALE RATES



CNHIC-OC-2020-PA 7 7/27/20





PENNSYLVANIA - POLICY FORM SERIES CNHIC-MS-AAAttained Age Rates -- Effective 7/27/2020 -- Area II (150-154, 156)





CNHIC-OC-2020-PA 8 7/27/20





PENNSYLVANIA - POLICY FORM SERIES CNHIC-MS-AA


MEDICARE SUPPLEMENT

FEMALE RATESPlan F Plan A

Attained Age Rates -- Effective 7/27/2020 -- Area II (150-154, 156)

Attained AgePlan G Plan N Plan F


Plan G Plan NPlan BMALE RATES

Plan B


Plan A

CNHIC-OC-2020-PA 9 7/27/20


2,018.40 168.13 2,280.16 189.94 2,947.76 245.55 2,362.86 196.83 1,623.16 135.21 65 2,240.42 186.63 2,530.97 210.83 3,272.01 272.56 2,622.77 218.48 1,801.71 150.082,018.40 168.13 2,280.16 189.94 2,947.76 245.55 2,362.86 196.83 1,671.76 139.26 66 2,240.42 186.63 2,530.97 210.83 3,272.01 272.56 2,622.77 218.48 1,855.65 154.582,018.40 168.13 2,280.16 189.94 2,947.76 245.55 2,362.86 196.83 1,721.81 143.43 67 2,240.42 186.63 2,530.97 210.83 3,272.01 272.56 2,622.77 218.48 1,911.21 159.202,018.40 168.13 2,280.16 189.94 2,947.76 245.55 2,362.86 196.83 1,773.36 147.72 68 2,240.42 186.63 2,530.97 210.83 3,272.01 272.56 2,622.77 218.48 1,968.43 163.972,078.83 173.17 2,348.42 195.62 3,026.18 252.08 2,433.60 202.72 1,826.45 152.14 69 2,307.50 192.21 2,606.75 217.14 3,359.06 279.81 2,701.29 225.02 2,027.36 168.882,141.07 178.35 2,418.73 201.48 3,106.95 258.81 2,506.46 208.79 1,881.13 156.70 70 2,376.58 197.97 2,684.79 223.64 3,448.71 287.28 2,782.17 231.75 2,088.06 173.942,205.17 183.69 2,491.15 207.51 3,190.13 265.74 2,581.50 215.04 1,937.45 161.39 71 2,447.74 203.90 2,765.18 230.34 3,541.05 294.97 2,865.47 238.69 2,150.57 179.142,271.19 189.19 2,565.73 213.73 3,275.81 272.87 2,658.79 221.48 1,995.46 166.22 72 2,521.02 210.00 2,847.96 237.24 3,636.15 302.89 2,951.26 245.84 2,214.96 184.512,339.19 194.85 2,642.55 220.12 3,364.05 280.23 2,738.39 228.11 2,055.20 171.20 73 2,596.50 216.29 2,933.23 244.34 3,734.09 311.05 3,039.62 253.20 2,281.28 190.032,409.22 200.69 2,721.67 226.71 3,454.93 287.80 2,820.38 234.94 2,116.73 176.32 74 2,674.24 222.76 3,021.05 251.65 3,834.97 319.45 3,130.62 260.78 2,349.58 195.722,481.35 206.70 2,803.15 233.50 3,548.54 295.59 2,904.82 241.97 2,180.11 181.60 75 2,754.30 229.43 3,111.50 259.19 3,938.88 328.11 3,224.35 268.59 2,419.92 201.582,555.64 212.89 2,887.08 240.49 3,644.94 303.62 2,991.79 249.22 2,245.38 187.04 76 2,836.76 236.30 3,204.65 266.95 4,045.89 337.02 3,320.88 276.63 2,492.37 207.612,632.16 219.26 2,973.51 247.69 3,744.24 311.89 3,081.36 256.68 2,312.61 192.64 77 2,921.69 243.38 3,300.60 274.94 4,156.10 346.20 3,420.31 284.91 2,566.99 213.832,710.96 225.82 3,062.54 255.11 3,846.50 320.41 3,173.61 264.36 2,381.84 198.41 78 3,009.17 250.66 3,399.42 283.17 4,269.62 355.66 3,522.71 293.44 2,643.85 220.232,792.13 232.58 3,154.23 262.75 3,951.83 329.19 3,268.63 272.28 2,453.15 204.35 79 3,099.26 258.17 3,501.19 291.65 4,386.53 365.40 3,628.18 302.23 2,723.00 226.832,875.72 239.55 3,248.66 270.61 4,060.31 338.22 3,366.49 280.43 2,526.60 210.47 80 3,192.05 265.90 3,606.02 300.38 4,506.94 375.43 3,736.81 311.28 2,804.53 233.622,961.82 246.72 3,345.93 278.72 4,172.04 347.53 3,467.28 288.82 2,602.25 216.77 81 3,287.62 273.86 3,713.98 309.37 4,630.96 385.76 3,848.68 320.60 2,888.49 240.613,050.49 254.11 3,446.10 287.06 4,287.11 357.12 3,571.09 297.47 2,680.16 223.26 82 3,386.05 282.06 3,825.17 318.64 4,758.70 396.40 3,963.91 330.19 2,974.97 247.823,141.82 261.71 3,549.28 295.65 4,405.63 366.99 3,678.01 306.38 2,760.40 229.94 83 3,487.42 290.50 3,939.70 328.18 4,890.25 407.36 4,082.59 340.08 3,064.04 255.233,235.89 269.55 3,655.54 304.51 4,527.70 377.16 3,788.12 315.55 2,843.04 236.83 84 3,591.84 299.20 4,057.65 338.00 5,025.75 418.64 4,204.82 350.26 3,155.78 262.883,332.77 277.62 3,764.99 313.62 4,653.42 387.63 3,901.54 325.00 2,928.16 243.92 85 3,699.37 308.16 4,179.13 348.12 5,165.30 430.27 4,330.71 360.75 3,250.26 270.753,432.55 285.93 3,877.71 323.01 4,782.91 398.42 4,018.35 334.73 3,015.83 251.22 86 3,810.13 317.38 4,304.25 358.54 5,309.03 442.24 4,460.37 371.55 3,347.57 278.853,476.07 289.56 3,926.87 327.11 4,839.38 403.12 4,069.29 338.97 3,054.06 254.40 87 3,858.43 321.41 4,358.82 363.09 5,371.71 447.46 4,516.91 376.26 3,390.01 282.393,519.58 293.18 3,976.02 331.20 4,895.85 407.82 4,120.23 343.22 3,092.29 257.59 88 3,906.73 325.43 4,413.39 367.64 5,434.39 452.68 4,573.46 380.97 3,432.45 285.923,563.10 296.81 4,025.18 335.30 4,952.32 412.53 4,171.17 347.46 3,130.53 260.77 89 3,955.04 329.45 4,467.95 372.18 5,497.07 457.91 4,630.00 385.68 3,474.88 289.463,606.61 300.43 4,074.34 339.39 5,008.79 417.23 4,222.11 351.70 3,168.76 263.96 90 4,003.34 333.48 4,522.52 376.73 5,559.75 463.13 4,686.55 390.39 3,517.32 292.993,641.25 303.32 4,113.47 342.65 5,053.74 420.98 4,262.66 355.08 3,199.19 266.49 91 4,041.78 336.68 4,565.95 380.34 5,609.65 467.28 4,731.55 394.14 3,551.10 295.813,675.88 306.20 4,152.60 345.91 5,098.68 424.72 4,303.21 358.46 3,229.62 269.03 92 4,080.23 339.88 4,609.38 383.96 5,659.54 471.44 4,776.56 397.89 3,584.88 298.623,710.52 309.09 4,191.73 349.17 5,143.63 428.46 4,343.76 361.83 3,260.05 271.56 93 4,118.68 343.09 4,652.81 387.58 5,709.43 475.60 4,821.57 401.64 3,618.66 301.433,745.16 311.97 4,230.85 352.43 5,188.58 432.21 4,384.30 365.21 3,290.48 274.10 94 4,157.12 346.29 4,696.25 391.20 5,759.32 479.75 4,866.58 405.39 3,652.44 304.253,779.79 314.86 4,269.98 355.69 5,233.53 435.95 4,424.85 368.59 3,320.91 276.63 95 4,195.57 349.49 4,739.68 394.82 5,809.21 483.91 4,911.58 409.14 3,686.22 307.063,779.79 314.86 4,269.98 355.69 5,233.53 435.95 4,424.85 368.59 3,320.91 276.63 96 4,195.57 349.49 4,739.68 394.82 5,809.21 483.91 4,911.58 409.14 3,686.22 307.063,779.79 314.86 4,269.98 355.69 5,233.53 435.95 4,424.85 368.59 3,320.91 276.63 97 4,195.57 349.49 4,739.68 394.82 5,809.21 483.91 4,911.58 409.14 3,686.22 307.063,779.79 314.86 4,269.98 355.69 5,233.53 435.95 4,424.85 368.59 3,320.91 276.63 98 4,195.57 349.49 4,739.68 394.82 5,809.21 483.91 4,911.58 409.14 3,686.22 307.063,779.79 314.86 4,269.98 355.69 5,233.53 435.95 4,424.85 368.59 3,320.91 276.63 99 4,195.57 349.49 4,739.68 394.82 5,809.21 483.91 4,911.58 409.14 3,686.22 307.06





STANDARD II ANNUAL & MONTHLY BANK DRAFT RATES




CNHIC-OC-2020-PA 10 7/27/20


2,220.24 184.95 2,508.17 208.93 3,242.53 270.10 2,599.14 216.51 1,785.48 148.73 65 2,464.46 205.29 2,784.07 231.91 3,599.21 299.81 2,885.05 240.32 1,981.88 165.092,220.24 184.95 2,508.17 208.93 3,242.53 270.10 2,599.14 216.51 1,838.93 153.18 66 2,464.46 205.29 2,784.07 231.91 3,599.21 299.81 2,885.05 240.32 2,041.21 170.032,220.24 184.95 2,508.17 208.93 3,242.53 270.10 2,599.14 216.51 1,893.99 157.77 67 2,464.46 205.29 2,784.07 231.91 3,599.21 299.81 2,885.05 240.32 2,102.33 175.122,220.24 184.95 2,508.17 208.93 3,242.53 270.10 2,599.14 216.51 1,950.69 162.49 68 2,464.46 205.29 2,784.07 231.91 3,599.21 299.81 2,885.05 240.32 2,165.27 180.372,286.71 190.48 2,583.27 215.19 3,328.80 277.29 2,676.96 222.99 2,009.10 167.36 69 2,538.25 211.44 2,867.42 238.86 3,694.96 307.79 2,971.42 247.52 2,230.10 185.772,355.17 196.19 2,660.61 221.63 3,417.64 284.69 2,757.11 229.67 2,069.25 172.37 70 2,614.24 217.77 2,953.27 246.01 3,793.58 316.01 3,060.39 254.93 2,296.86 191.332,425.68 202.06 2,740.26 228.26 3,509.14 292.31 2,839.65 236.54 2,131.20 177.53 71 2,692.51 224.29 3,041.69 253.37 3,895.15 324.47 3,152.01 262.56 2,365.63 197.062,498.31 208.11 2,822.31 235.10 3,603.39 300.16 2,924.67 243.62 2,195.01 182.84 72 2,773.12 231.00 3,132.76 260.96 3,999.76 333.18 3,246.38 270.42 2,436.46 202.962,573.11 214.34 2,906.80 242.14 3,700.45 308.25 3,012.23 250.92 2,260.72 188.32 73 2,856.15 237.92 3,226.55 268.77 4,107.50 342.16 3,343.58 278.52 2,509.40 209.032,650.14 220.76 2,993.83 249.39 3,800.43 316.58 3,102.42 258.43 2,328.41 193.96 74 2,941.66 245.04 3,323.15 276.82 4,218.47 351.40 3,443.68 286.86 2,584.53 215.292,729.49 227.37 3,083.47 256.85 3,903.39 325.15 3,195.30 266.17 2,398.12 199.76 75 3,029.73 252.38 3,422.65 285.11 4,332.76 360.92 3,546.78 295.45 2,661.91 221.742,811.21 234.17 3,175.78 264.54 4,009.44 333.99 3,290.97 274.14 2,469.92 205.74 76 3,120.44 259.93 3,525.12 293.64 4,450.48 370.72 3,652.97 304.29 2,741.61 228.382,895.37 241.18 3,270.86 272.46 4,118.66 343.08 3,389.50 282.35 2,543.87 211.90 77 3,213.86 267.71 3,630.66 302.43 4,571.71 380.82 3,762.34 313.40 2,823.69 235.212,982.06 248.41 3,368.79 280.62 4,231.15 352.45 3,490.98 290.80 2,620.03 218.25 78 3,310.08 275.73 3,739.36 311.49 4,696.58 391.23 3,874.98 322.79 2,908.23 242.263,071.34 255.84 3,469.65 289.02 4,347.01 362.11 3,595.49 299.50 2,698.47 224.78 79 3,409.19 283.99 3,851.31 320.81 4,825.18 401.94 3,991.00 332.45 2,995.30 249.513,163.29 263.50 3,573.53 297.68 4,466.34 372.05 3,703.14 308.47 2,779.26 231.51 80 3,511.26 292.49 3,966.62 330.42 4,957.64 412.97 4,110.49 342.40 3,084.98 256.983,258.00 271.39 3,680.52 306.59 4,589.24 382.28 3,814.01 317.71 2,862.47 238.44 81 3,616.38 301.24 4,085.38 340.31 5,094.06 424.34 4,233.55 352.65 3,177.34 264.673,355.54 279.52 3,790.71 315.77 4,715.82 392.83 3,928.20 327.22 2,948.17 245.58 82 3,724.65 310.26 4,207.69 350.50 5,234.57 436.04 4,360.30 363.21 3,272.47 272.603,456.01 287.89 3,904.20 325.22 4,846.20 403.69 4,045.81 337.02 3,036.44 252.94 83 3,836.17 319.55 4,333.67 360.99 5,379.28 448.09 4,490.85 374.09 3,370.45 280.763,559.48 296.50 4,021.09 334.96 4,980.47 414.87 4,166.94 347.11 3,127.35 260.51 84 3,951.02 329.12 4,463.41 371.80 5,528.32 460.51 4,625.30 385.29 3,471.35 289.163,666.05 305.38 4,141.48 344.99 5,118.76 426.39 4,291.69 357.50 3,220.98 268.31 85 4,069.31 338.97 4,597.05 382.93 5,681.83 473.30 4,763.78 396.82 3,575.29 297.823,775.81 314.52 4,265.48 355.31 5,261.20 438.26 4,420.18 368.20 3,317.41 276.34 86 4,191.14 349.12 4,734.68 394.40 5,839.93 486.47 4,906.40 408.70 3,682.33 306.743,823.67 318.51 4,319.55 359.82 5,323.32 443.43 4,476.22 372.87 3,359.47 279.84 87 4,244.28 353.55 4,794.70 399.40 5,908.88 492.21 4,968.60 413.88 3,729.01 310.633,871.54 322.50 4,373.63 364.32 5,385.43 448.61 4,532.26 377.54 3,401.52 283.35 88 4,297.41 357.97 4,854.72 404.40 5,977.83 497.95 5,030.80 419.07 3,775.69 314.523,919.41 326.49 4,427.70 368.83 5,447.55 453.78 4,588.29 382.20 3,443.58 286.85 89 4,350.54 362.40 4,914.75 409.40 6,046.78 503.70 5,093.00 424.25 3,822.37 318.403,967.27 330.47 4,481.77 373.33 5,509.67 458.96 4,644.33 386.87 3,485.63 290.35 90 4,403.67 366.83 4,974.77 414.40 6,115.73 509.44 5,155.20 429.43 3,869.05 322.294,005.37 333.65 4,524.82 376.92 5,559.11 463.07 4,688.93 390.59 3,519.11 293.14 91 4,445.96 370.35 5,022.55 418.38 6,170.61 514.01 5,204.71 433.55 3,906.21 325.394,043.47 336.82 4,567.86 380.50 5,608.55 467.19 4,733.53 394.30 3,552.58 295.93 92 4,488.25 373.87 5,070.32 422.36 6,225.49 518.58 5,254.22 437.68 3,943.37 328.484,081.57 339.99 4,610.90 384.09 5,657.99 471.31 4,778.13 398.02 3,586.06 298.72 93 4,530.54 377.39 5,118.10 426.34 6,280.37 523.16 5,303.73 441.80 3,980.52 331.584,119.67 343.17 4,653.94 387.67 5,707.44 475.43 4,822.73 401.73 3,619.53 301.51 94 4,572.84 380.92 5,165.87 430.32 6,335.25 527.73 5,353.24 445.92 4,017.68 334.674,157.77 346.34 4,696.98 391.26 5,756.88 479.55 4,867.34 405.45 3,653.01 304.30 95 4,615.13 384.44 5,213.65 434.30 6,390.13 532.30 5,402.74 450.05 4,054.84 337.774,157.77 346.34 4,696.98 391.26 5,756.88 479.55 4,867.34 405.45 3,653.01 304.30 96 4,615.13 384.44 5,213.65 434.30 6,390.13 532.30 5,402.74 450.05 4,054.84 337.774,157.77 346.34 4,696.98 391.26 5,756.88 479.55 4,867.34 405.45 3,653.01 304.30 97 4,615.13 384.44 5,213.65 434.30 6,390.13 532.30 5,402.74 450.05 4,054.84 337.774,157.77 346.34 4,696.98 391.26 5,756.88 479.55 4,867.34 405.45 3,653.01 304.30 98 4,615.13 384.44 5,213.65 434.30 6,390.13 532.30 5,402.74 450.05 4,054.84 337.774,157.77 346.34 4,696.98 391.26 5,756.88 479.55 4,867.34 405.45 3,653.01 304.30 99 4,615.13 384.44 5,213.65 434.30 6,390.13 532.30 5,402.74 450.05 4,054.84 337.77




Plan G Plan NPlan NAttained Age

Plan A Plan B Plan FPlan A Plan B Plan F Plan G





CNHIC-OC-2020-PA 11 7/27/20





PENNSYLVANIA - POLICY FORM SERIES CNHIC-MS-AAAttained Age Rates -- Effective 7/27/2020 -- Area III (189-194)





CNHIC-OC-2020-PA 12 7/27/20





PENNSYLVANIA - POLICY FORM SERIES CNHIC-MS-AA


MEDICARE SUPPLEMENT

Attained Age Rates -- Effective 7/27/2020 -- Area III (189-194)

FEMALE RATESPlan A Plan B Plan F

MALE RATES

Attained AgePlan G Plan NPlan A Plan B Plan F Plan G

Applicants who reside with legal spouse (including civil union/domestic partner) apply a 6% discount to the rates above (multiply rates above by 0.94)If both insureds have a Medicare Supplement policy with Cigna then add an additional 9% discount (multiply rates above by 0.85)

Plan N

CNHIC-OC-2020-PA 13 7/27/20


2,312.75 192.65 2,612.68 217.64 3,377.64 281.36 2,707.44 225.53 1,859.87 154.93 65 2,567.15 213.84 2,900.07 241.58 3,749.18 312.31 3,005.26 250.34 2,064.46 171.972,312.75 192.65 2,612.68 217.64 3,377.64 281.36 2,707.44 225.53 1,915.55 159.57 66 2,567.15 213.84 2,900.07 241.58 3,749.18 312.31 3,005.26 250.34 2,126.27 177.122,312.75 192.65 2,612.68 217.64 3,377.64 281.36 2,707.44 225.53 1,972.90 164.34 67 2,567.15 213.84 2,900.07 241.58 3,749.18 312.31 3,005.26 250.34 2,189.92 182.422,312.75 192.65 2,612.68 217.64 3,377.64 281.36 2,707.44 225.53 2,031.97 169.26 68 2,567.15 213.84 2,900.07 241.58 3,749.18 312.31 3,005.26 250.34 2,255.49 187.882,381.99 198.42 2,690.90 224.15 3,467.50 288.84 2,788.50 232.28 2,092.81 174.33 69 2,644.01 220.25 2,986.90 248.81 3,848.92 320.62 3,095.23 257.83 2,323.02 193.512,453.30 204.36 2,771.47 230.86 3,560.04 296.55 2,871.98 239.24 2,155.47 179.55 70 2,723.17 226.84 3,076.33 256.26 3,951.65 329.17 3,187.90 265.55 2,392.57 199.302,526.75 210.48 2,854.44 237.77 3,655.36 304.49 2,957.97 246.40 2,220.00 184.93 71 2,804.70 233.63 3,168.43 263.93 4,057.45 337.99 3,283.35 273.50 2,464.20 205.272,602.40 216.78 2,939.90 244.89 3,753.53 312.67 3,046.53 253.78 2,286.46 190.46 72 2,888.67 240.63 3,263.29 271.83 4,166.42 347.06 3,381.65 281.69 2,537.98 211.412,680.32 223.27 3,027.92 252.23 3,854.64 321.09 3,137.74 261.37 2,354.92 196.16 73 2,975.15 247.83 3,360.99 279.97 4,278.65 356.41 3,482.89 290.12 2,613.96 217.742,760.57 229.96 3,118.57 259.78 3,958.78 329.77 3,231.68 269.20 2,425.43 202.04 74 3,064.23 255.25 3,461.62 288.35 4,394.24 366.04 3,587.17 298.81 2,692.22 224.262,843.22 236.84 3,211.94 267.55 4,066.03 338.70 3,328.44 277.26 2,498.04 208.09 75 3,155.97 262.89 3,565.26 296.99 4,513.30 375.96 3,694.57 307.76 2,772.83 230.982,928.34 243.93 3,308.11 275.57 4,176.50 347.90 3,428.09 285.56 2,572.83 214.32 76 3,250.46 270.76 3,672.00 305.88 4,635.91 386.17 3,805.18 316.97 2,855.84 237.893,016.01 251.23 3,407.15 283.82 4,290.27 357.38 3,530.73 294.11 2,649.86 220.73 77 3,347.77 278.87 3,781.94 315.04 4,762.20 396.69 3,919.10 326.46 2,941.34 245.013,106.31 258.76 3,509.16 292.31 4,407.45 367.14 3,636.43 302.91 2,729.20 227.34 78 3,448.00 287.22 3,895.17 324.47 4,892.27 407.53 4,036.44 336.24 3,029.41 252.353,199.31 266.50 3,614.22 301.06 4,528.14 377.19 3,745.31 311.98 2,810.91 234.15 79 3,551.24 295.82 4,011.78 334.18 5,026.23 418.69 4,157.29 346.30 3,120.11 259.903,295.10 274.48 3,722.43 310.08 4,652.44 387.55 3,857.44 321.32 2,895.06 241.16 80 3,657.56 304.67 4,131.89 344.19 5,164.21 430.18 4,281.76 356.67 3,213.52 267.693,393.75 282.70 3,833.88 319.36 4,780.46 398.21 3,972.93 330.94 2,981.74 248.38 81 3,767.06 313.80 4,255.60 354.49 5,306.31 442.02 4,409.95 367.35 3,309.73 275.703,495.36 291.16 3,948.66 328.92 4,912.32 409.20 4,091.87 340.85 3,071.01 255.82 82 3,879.85 323.19 4,383.01 365.10 5,452.67 454.21 4,541.98 378.35 3,408.82 283.953,600.01 299.88 4,066.88 338.77 5,048.12 420.51 4,214.38 351.06 3,162.96 263.47 83 3,996.01 332.87 4,514.24 376.04 5,603.41 466.76 4,677.97 389.67 3,510.88 292.463,707.79 308.86 4,188.64 348.91 5,187.99 432.16 4,340.56 361.57 3,257.65 271.36 84 4,115.65 342.83 4,649.39 387.29 5,758.67 479.70 4,818.02 401.34 3,615.99 301.213,818.80 318.11 4,314.05 359.36 5,332.05 444.16 4,470.51 372.39 3,355.19 279.49 85 4,238.87 353.10 4,788.59 398.89 5,918.57 493.02 4,962.27 413.36 3,724.26 310.233,933.13 327.63 4,443.21 370.12 5,480.42 456.52 4,604.36 383.54 3,455.64 287.85 86 4,365.78 363.67 4,931.96 410.83 6,083.26 506.74 5,110.84 425.73 3,835.76 319.523,982.99 331.78 4,499.53 374.81 5,545.12 461.91 4,662.73 388.41 3,499.45 291.50 87 4,421.12 368.28 4,994.48 416.04 6,155.08 512.72 5,175.63 431.13 3,884.38 323.574,032.85 335.94 4,555.86 379.50 5,609.83 467.30 4,721.10 393.27 3,543.25 295.15 88 4,476.47 372.89 5,057.01 421.25 6,226.91 518.70 5,240.42 436.53 3,933.01 327.624,082.71 340.09 4,612.19 384.20 5,674.53 472.69 4,779.47 398.13 3,587.06 298.80 89 4,531.81 377.50 5,119.53 426.46 6,298.73 524.68 5,305.21 441.92 3,981.64 331.674,132.58 344.24 4,668.52 388.89 5,739.24 478.08 4,837.84 402.99 3,630.87 302.45 90 4,587.16 382.11 5,182.05 431.66 6,370.55 530.67 5,370.00 447.32 4,030.26 335.724,172.26 347.55 4,713.35 392.62 5,790.74 482.37 4,884.30 406.86 3,665.74 305.36 91 4,631.21 385.78 5,231.82 435.81 6,427.72 535.43 5,421.57 451.62 4,068.97 338.954,211.95 350.86 4,758.18 396.36 5,842.24 486.66 4,930.76 410.73 3,700.61 308.26 92 4,675.26 389.45 5,281.58 439.96 6,484.89 540.19 5,473.14 455.91 4,107.67 342.174,251.64 354.16 4,803.02 400.09 5,893.74 490.95 4,977.22 414.60 3,735.48 311.17 93 4,719.32 393.12 5,331.35 444.10 6,542.06 544.95 5,524.72 460.21 4,146.38 345.394,291.32 357.47 4,847.85 403.83 5,945.25 495.24 5,023.68 418.47 3,770.35 314.07 94 4,763.37 396.79 5,381.12 448.25 6,599.22 549.72 5,576.29 464.50 4,185.08 348.624,331.01 360.77 4,892.69 407.56 5,996.75 499.53 5,070.14 422.34 3,805.21 316.97 95 4,807.42 400.46 5,430.88 452.39 6,656.39 554.48 5,627.86 468.80 4,223.79 351.844,331.01 360.77 4,892.69 407.56 5,996.75 499.53 5,070.14 422.34 3,805.21 316.97 96 4,807.42 400.46 5,430.88 452.39 6,656.39 554.48 5,627.86 468.80 4,223.79 351.844,331.01 360.77 4,892.69 407.56 5,996.75 499.53 5,070.14 422.34 3,805.21 316.97 97 4,807.42 400.46 5,430.88 452.39 6,656.39 554.48 5,627.86 468.80 4,223.79 351.844,331.01 360.77 4,892.69 407.56 5,996.75 499.53 5,070.14 422.34 3,805.21 316.97 98 4,807.42 400.46 5,430.88 452.39 6,656.39 554.48 5,627.86 468.80 4,223.79 351.844,331.01 360.77 4,892.69 407.56 5,996.75 499.53 5,070.14 422.34 3,805.21 316.97 99 4,807.42 400.46 5,430.88 452.39 6,656.39 554.48 5,627.86 468.80 4,223.79 351.84




PENNSYLVANIA - POLICY FORM SERIES CNHIC-MS-AAAttained Age Rates -- Effective 7/27/2020 -- Area III (189-194)STANDARD II ANNUAL & MONTHLY BANK DRAFT RATES

FEMALE RATES MALE RATESPlan F Plan N

Attained AgePlan A Plan BPlan A Plan B


Plan F Plan G Plan N


Plan G

CNHIC-OC-2020-PA 14 7/27/20


2,544.02 211.92 2,873.95 239.40 3,715.40 309.49 2,978.18 248.08 2,045.86 170.42 65 2,823.86 235.23 3,190.08 265.73 4,124.10 343.54 3,305.78 275.37 2,270.90 189.172,544.02 211.92 2,873.95 239.40 3,715.40 309.49 2,978.18 248.08 2,107.11 175.52 66 2,823.86 235.23 3,190.08 265.73 4,124.10 343.54 3,305.78 275.37 2,338.89 194.832,544.02 211.92 2,873.95 239.40 3,715.40 309.49 2,978.18 248.08 2,170.20 180.78 67 2,823.86 235.23 3,190.08 265.73 4,124.10 343.54 3,305.78 275.37 2,408.92 200.662,544.02 211.92 2,873.95 239.40 3,715.40 309.49 2,978.18 248.08 2,235.17 186.19 68 2,823.86 235.23 3,190.08 265.73 4,124.10 343.54 3,305.78 275.37 2,481.04 206.672,620.19 218.26 2,959.99 246.57 3,814.25 317.73 3,067.35 255.51 2,302.09 191.76 69 2,908.41 242.27 3,285.59 273.69 4,233.81 352.68 3,404.76 283.62 2,555.32 212.862,698.63 224.80 3,048.61 253.95 3,916.05 326.21 3,159.18 263.16 2,371.01 197.51 70 2,995.48 249.52 3,383.96 281.88 4,346.81 362.09 3,506.69 292.11 2,631.82 219.232,779.43 231.53 3,139.89 261.55 4,020.90 334.94 3,253.77 271.04 2,442.00 203.42 71 3,085.17 256.99 3,485.27 290.32 4,463.19 371.78 3,611.68 300.85 2,710.62 225.792,862.64 238.46 3,233.89 269.38 4,128.88 343.94 3,351.18 279.15 2,515.11 209.51 72 3,177.54 264.69 3,589.62 299.02 4,583.06 381.77 3,719.81 309.86 2,791.77 232.552,948.35 245.60 3,330.71 277.45 4,240.10 353.20 3,451.52 287.51 2,590.41 215.78 73 3,272.67 272.61 3,697.09 307.97 4,706.52 392.05 3,831.18 319.14 2,875.36 239.523,036.62 252.95 3,430.43 285.76 4,354.65 362.74 3,554.85 296.12 2,667.97 222.24 74 3,370.65 280.78 3,807.78 317.19 4,833.67 402.64 3,945.89 328.69 2,961.44 246.693,127.54 260.52 3,533.14 294.31 4,472.63 372.57 3,661.28 304.98 2,747.85 228.90 75 3,471.57 289.18 3,921.78 326.68 4,964.62 413.55 4,064.02 338.53 3,050.11 254.073,221.17 268.32 3,638.92 303.12 4,594.15 382.69 3,770.90 314.12 2,830.11 235.75 76 3,575.50 297.84 4,039.20 336.47 5,099.50 424.79 4,185.70 348.67 3,141.43 261.683,317.61 276.36 3,747.86 312.20 4,719.30 393.12 3,883.80 323.52 2,914.85 242.81 77 3,682.55 306.76 4,160.13 346.54 5,238.42 436.36 4,311.02 359.11 3,235.48 269.523,416.94 284.63 3,860.07 321.54 4,848.20 403.85 4,000.08 333.21 3,002.12 250.08 78 3,792.81 315.94 4,284.68 356.91 5,381.50 448.28 4,440.08 369.86 3,332.35 277.583,519.24 293.15 3,975.64 331.17 4,980.95 414.91 4,119.84 343.18 3,092.00 257.56 79 3,906.36 325.40 4,412.96 367.60 5,528.86 460.55 4,573.02 380.93 3,432.12 285.903,624.61 301.93 4,094.67 341.09 5,117.68 426.30 4,243.18 353.46 3,184.57 265.27 80 4,023.31 335.14 4,545.08 378.61 5,680.63 473.20 4,709.93 392.34 3,534.87 294.453,733.13 310.97 4,217.26 351.30 5,258.51 438.03 4,370.22 364.04 3,279.91 273.22 81 4,143.77 345.18 4,681.16 389.94 5,836.94 486.22 4,850.94 404.08 3,640.70 303.273,844.89 320.28 4,343.53 361.82 5,403.55 450.12 4,501.06 374.94 3,378.11 281.40 82 4,267.83 355.51 4,821.31 401.62 5,997.94 499.63 4,996.18 416.18 3,749.70 312.353,960.01 329.87 4,473.57 372.65 5,552.93 462.56 4,635.82 386.16 3,479.25 289.82 83 4,395.61 366.15 4,965.66 413.64 6,163.76 513.44 5,145.76 428.64 3,861.97 321.704,078.57 339.74 4,607.50 383.81 5,706.79 475.38 4,774.62 397.73 3,583.42 298.50 84 4,527.21 377.12 5,114.33 426.02 6,334.54 527.67 5,299.82 441.48 3,977.59 331.334,200.68 349.92 4,745.45 395.30 5,865.25 488.58 4,917.56 409.63 3,690.70 307.44 85 4,662.75 388.41 5,267.45 438.78 6,510.43 542.32 5,458.50 454.69 4,096.68 341.254,326.44 360.39 4,887.53 407.13 6,028.46 502.17 5,064.79 421.90 3,801.20 316.64 86 4,802.35 400.04 5,425.15 451.92 6,691.59 557.41 5,621.92 468.31 4,219.33 351.474,381.29 364.96 4,949.49 412.29 6,099.63 508.10 5,129.00 427.25 3,849.39 320.65 87 4,863.23 405.11 5,493.93 457.64 6,770.59 563.99 5,693.19 474.24 4,272.82 355.934,436.14 369.53 5,011.45 417.45 6,170.81 514.03 5,193.21 432.59 3,897.58 324.67 88 4,924.11 410.18 5,562.71 463.37 6,849.60 570.57 5,764.46 480.18 4,326.31 360.384,490.99 374.10 5,073.41 422.61 6,241.98 519.96 5,257.42 437.94 3,945.77 328.68 89 4,984.99 415.25 5,631.48 469.10 6,928.60 577.15 5,835.73 486.12 4,379.80 364.844,545.83 378.67 5,135.37 427.78 6,313.16 525.89 5,321.62 443.29 3,993.96 332.70 90 5,045.87 420.32 5,700.26 474.83 7,007.61 583.73 5,907.00 492.05 4,433.29 369.294,589.49 382.30 5,184.68 431.88 6,369.81 530.61 5,372.73 447.55 4,032.31 335.89 91 5,094.33 424.36 5,755.00 479.39 7,070.49 588.97 5,963.73 496.78 4,475.87 372.844,633.15 385.94 5,234.00 435.99 6,426.47 535.32 5,423.84 451.81 4,070.67 339.09 92 5,142.79 428.39 5,809.74 483.95 7,133.38 594.21 6,020.46 501.50 4,518.44 376.394,676.80 389.58 5,283.32 440.10 6,483.12 540.04 5,474.94 456.06 4,109.02 342.28 93 5,191.25 432.43 5,864.49 488.51 7,196.26 599.45 6,077.19 506.23 4,561.02 379.934,720.46 393.21 5,332.64 444.21 6,539.77 544.76 5,526.05 460.32 4,147.38 345.48 94 5,239.71 436.47 5,919.23 493.07 7,259.15 604.69 6,133.92 510.96 4,603.59 383.484,764.11 396.85 5,381.96 448.32 6,596.42 549.48 5,577.16 464.58 4,185.74 348.67 95 5,288.17 440.50 5,973.97 497.63 7,322.03 609.93 6,190.64 515.68 4,646.17 387.034,764.11 396.85 5,381.96 448.32 6,596.42 549.48 5,577.16 464.58 4,185.74 348.67 96 5,288.17 440.50 5,973.97 497.63 7,322.03 609.93 6,190.64 515.68 4,646.17 387.034,764.11 396.85 5,381.96 448.32 6,596.42 549.48 5,577.16 464.58 4,185.74 348.67 97 5,288.17 440.50 5,973.97 497.63 7,322.03 609.93 6,190.64 515.68 4,646.17 387.034,764.11 396.85 5,381.96 448.32 6,596.42 549.48 5,577.16 464.58 4,185.74 348.67 98 5,288.17 440.50 5,973.97 497.63 7,322.03 609.93 6,190.64 515.68 4,646.17 387.034,764.11 396.85 5,381.96 448.32 6,596.42 549.48 5,577.16 464.58 4,185.74 348.67 99 5,288.17 440.50 5,973.97 497.63 7,322.03 609.93 6,190.64 515.68 4,646.17 387.03




Plan F Plan G Plan N


Plan G Plan NAttained Age

Plan A Plan BPlan A Plan B Plan F



PENNSYLVANIA - POLICY FORM SERIES CNHIC-MS-AAAttained Age Rates -- Effective 7/27/2020 -- Area III (189-194)


CNHIC-OC-2020-PA 15 7/27/20

PREMIUM INFORMATION Your premium will increase each year because of the increase in your attained age. We, Cigna National Health Insurance Company, can also raise your premium if (a) we change the rates or discounts which apply to all policies of this form issued by us and in force in the state where your policy was issued; or (b) coverage under Medicare changes. We will send you a written notice at least thirty (30) days in advance when we change the premium rates or discounts for all policies of this form issued by us and in force in the state where your policy was issued.

DISCLOSURES Use this Outline to compare benefits and premiums 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 Cigna National Health Insurance Company.

30-DAY RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to Cigna National Health Insurance Company, PO Box 5700, Scranton, PA 18505-5700. If you send the policy back to us within thirty (30) days after you receive it, we will treat the policy as if it had never been issued and return all of your premiums.

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 fully cover all of your medical costs. Neither Cigna National Health Insurance Company nor its agents are connected with Medicare. This Outline of Coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult the Medicare and You for more details.

EXCLUSIONS AND LIMITATIONS The benefits of a policy will not duplicate any benefits paid by Medicare. The combined benefits of a policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. A policy will not pay benefits for the following: 1. the Medicare Part B deductible (not applicable for Plans F and C); 2. any expense which you are not legally obligated to pay or services for which no charge is normally made in the absence of insurance; 3. any services that are not medically necessary as determined by Medicare; 4. any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid) or for which payment

would have been made by Medicare if you were enrolled in Parts A and B of Medicare; 5. any type of expense not a Medicare Eligible Expense except as provided previously in the policy; 6. any deductible, coinsurance, or copayment not covered by Medicare, unless such coverage is listed as a benefit in the policy; or 7. Pre-Existing Conditions: We will not pay for any expenses incurred for care or treatment of a Pre-Existing Condition for the first six (6) months from

the effective date of coverage. This exclusion does not apply if you applied for and were issued a policy under guaranteed issue status; if on the date of application for a policy you had at least six (6) months of prior Creditable Coverage; or if the policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for a policy.

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If you had less than six (6) months prior Creditable Coverage, the Pre-Existing Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If the policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. We 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. RENEWABILITY The policy is guaranteed renewable for life. PREMIUM DISCOUNT Affiliate means an insurance company that is under common ownership or control with Cigna National Health Insurance Company and that is a member of the same insurance holding company system. Household is defined as a condominium unit, a single-family home, or an apartment unit within an apartment complex. Assisted Living facilities, Group Homes, Adult Day Care facilities and Nursing Homes, or any other health residential facility are not included in the definition of “Household.” You may be eligible for the following: 1. Household Premium Discount: A discount when you reside in a Household with your legal spouse (including civil union partner/domestic partner).

We may request additional documentation to determine eligibility. 2. Multi-Product Discount: A discount when you and another member of your Household enrolls or is enrolled in a Medicare Supplement policy

provided by or through an Affiliate of Cigna National Health Insurance Company. The discount will be removed if the other adult or Medicare Supplement policyholder whose policy status entitles you to the discount no longer resides in the Household or no longer has a Medicare Supplement policy through Cigna National Health Insurance Company or an Affiliate of Cigna National Health Insurance Company. If the other adult or the other Medicare Supplement policyholder becomes deceased, your discount will still apply. The addition or removal of the discount will occur on the billing cycle following the date we learn your eligibility has changed.

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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 A PAYS YOU PAY HOSPITALIZATION* Semi-private room and board, general nursing, and miscellaneous services and supplies First 60 days 61st through 90th day 91st day and after: – while using 60 lifetime reserve days – once lifetime reserve days are used, additional 365 days – beyond the additional 365 days

All but $1,408 All but $352 per day All but $704 per day $0 $0

$0 $352 per day $704 per day 100% of Medicare eligible expenses $0

$1,408 (Part A deductible) $0 $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 entering a Medicare-approved facility within 30 days after leaving the hospital First 20 days 21st through 100th day 101st day and after

All approved amounts All but $176 per day $0

$0 $0 $0

$0 Up to $176 per day All costs

BLOOD First 3 pints Additional amounts

$0 100%

3 pints $0

$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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PLAN A MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

*Once you have been billed $198 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 A 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 $198 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 Generally 80%

$0 Generally 20%

$198 (Part B deductible) $0

PART B EXCESS CHARGES (above Medicare-approved amounts)

$0

$0

All costs

BLOOD First 3 pints Next $198 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 $0 80%

All costs $0 20%

$0 $198 (Part B deductible) $0

CLINICAL LABORATORY SERVICES Tests for diagnostic services

100%

$0

$0

PARTS A & B

SERVICES MEDICARE PAYS PLAN A PAYS YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically-necessary skilled care services and medical supplies Durable medical equipment First $198 of Medicare-approved amounts* Remainder of Medicare-approved amounts

100% $0 80%

$0 $0 20%


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


SERVICES MEDICARE PAYS PLAN A PAYS YOU PAY HOSPITALIZATION* Semi-private room and board, general nursing, and miscellaneous services and supplies First 60 days 61st through 90th day 91st day and after: – while using 60 lifetime reserve days – once lifetime reserve days are used, additional 365 days – beyond the additional 365 days


$1,408 (Part A deductible) $352 per day $704 per day 100% of Medicare eligible expenses $0

$0 $0 $0 $0** All costs



$0 $0 $0

$0 Up to $176 per day All costs


$0 100%

3 pints $0

$0 $0





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


SERVICES MEDICARE PAYS PLAN A 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 $198 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 Generally 80%

$0 Generally 20%



$0

$0

All costs


$0 $0 80%

All costs $0 20%



100%

$0

$0

PARTS A & B

SERVICES MEDICARE PAYS PLAN A PAYS YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically-necessary skilled care services and medical supplies Durable medical equipment First $198 of Medicare-approved amounts* Remainder of Medicare-approved amounts

100% $0 80%

$0 $0 20%


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


SERVICES MEDICARE PAYS PLAN F PAYS YOU PAY HOSPITALIZATION* Semi-private room and board, general nursing, and miscellaneous services and supplies First 60 days 61st through 90th day 91st day and after: – while using 60 lifetime reserve days – once lifetime reserve days are used, additional 365 days – beyond the additional 365 days



$0 $0 $0 $0** All costs



$0 Up to $176 per day $0

$0 $0 All costs


$0 100%

3 pints $0

$0 $0





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


SERVICES MEDICARE PAYS PLAN F 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 $198 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 Generally 80%

$198 (Part B deductible) Generally 20%

$0 $0


$0

100%

$0


$0 $0 80%

All costs $198 (Part B deductible) 20%

$0 $0 $0


100%

$0

$0

PARTS A & B

SERVICES MEDICARE PAYS PLAN F PAYS YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically-necessary skilled care services and medical supplies Durable medical equipment First $198 of Medicare-approved amounts* Remainder of Medicare-approved amounts

100% $0 80%

$0 $198 (Part B deductible) 20%

$0 $0 $0

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PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR (cont’d.)

OTHER BENEFITS – NOT COVERED BY MEDICARE

SERVICES MEDICARE PAYS PLAN F 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 Remainder of charges

$0 $0

$0 80% to a lifetime maximum benefit of $50,000

$250 20% and amounts over the $50,000 lifetime maximum

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


SERVICES MEDICARE PAYS PLAN G PAYS YOU PAY HOSPITALIZATION* Semi-private room and board, general nursing, and miscellaneous services and supplies First 60 days 61st through 90th day 91st day and after: – while using 60 lifetime reserve days – once lifetime reserve days are used, additional 365 days – beyond the additional 365 days



$0 $0 $0 $0** All costs




$0 $0 All costs


$0 100%

3 pints $0

$0 $0





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


SERVICES MEDICARE PAYS PLAN G 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 $198 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 Generally 80%

$0 Generally 20%



$0

100%

$0


$0 $0 80%

All costs $0 20%



100%

$0

$0

PARTS A & B

SERVICES MEDICARE PAYS PLAN G PAYS YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically-necessary skilled care services and medical supplies Durable medical equipment First $198 of Medicare-approved amounts* Remainder of Medicare-approved amounts

100% $0 80%

$0 $0 20%


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PLAN G MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR (cont’d.)


SERVICES MEDICARE PAYS PLAN G 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 Remainder of charges

$0 $0



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


SERVICES MEDICARE PAYS PLAN N PAYS YOU PAY HOSPITALIZATION* Semi-private room and board, general nursing, and miscellaneous services and supplies First 60 days 61st through 90th day 91st day and after: – while using 60 lifetime reserve days – once lifetime reserve days are used, additional 365 days – beyond the additional 365 days



$0 $0 $0 $0** All costs




$0 $0 All costs


$0 100%

3 pints $0

$0 $0





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


SERVICES MEDICARE PAYS PLAN N 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 $198 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 Generally 80%

$0 Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the Insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

$198 (Part B deductible) 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.


$0

$0

All costs


$0 $0 80%

All costs $0 20%



100%

$0

$0

PARTS A & B

SERVICES MEDICARE PAYS PLAN N PAYS YOU PAY

HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically-necessary skilled care services and medical supplies Durable medical equipment First $198 of Medicare-approved amounts* Remainder of Medicare-approved amounts

100% $0 80%

$0 $0 20%


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PLAN N MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR (cont’d.)


SERVICES MEDICARE PAYS PLAN N 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 Remainder of charges

$0 $0



CNHIC-OC-2020-PA 30 7/27/20

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