Outline of Coverage - Aetna · Outline of Coverage ... 73 1,723 1,960 2,499 1,000 1,961 1,654 73 1,914 2,178 2,777 1,111 2,179 1,838 74 1,784 ... 91 3,002 3,415

Outline of CoverageMedicare Supplement Insurance

Underwritten by

Aetna Health and Life Insurance Company

Administrative Office800 Crescent Centre Dr.Suite 200Franklin, TN 37067800 264.4000aetnaseniorproducts.com

Aetna Health and Life Insurance Company

Rates Effective:

BENEFIT PLANS A, B, F, HIGH DEDUCTIBLE F, G, N

Louisiana

AHLMS03846LA © 2018 Aetna Inc. 08/2018 A

AHLM

S038

46LA

1

0

8/20

18 A

AEN

TA H

EALT

H A

ND

LIF

E IN

SUR

ANC

E C

OM

PAN

Y

OU

TLIN

E O

F M

EDIC

ARE

SUPP

LEM

ENT

CO

VER

AGE

CO

VER

PAG

E 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

supp

lem

ent p

lans

. Eve

ry c

ompa

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

paym

ents

for h

ospi

tal o

utpa

tient

ser

vice

s. P

lans

K,

L, a

nd N

requ

ire in

sure

ds to

pay

a p

ortio

n of

coi

nsur

ance

or c

opay

men

ts

Bloo

d: F

irst t

hree

pin

ts o

f blo

od e

ach

year

.

Hos

pice

-Par

t A c

oins

uran

ce

A B

C

D

F/

F*

G

K

L M

N

Ba

sic,

in

clud

ing

100%

Par

t B

coin

sura

nce

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

240;

pa

id a

t 100

%

afte

r lim

it re

ache

d

Out

-of-p

ocke

t lim

it $2

620;

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 $22

40

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 $

2240

. O

ut-o

f-poc

ket e

xpen

ses

for t

his

dedu

ctib

le a

re

expe

nses

that

wou

ld o

rdin

arily

be

paid

by

the p

olic

y. T

hese e

xpenses inclu

de the M

edic

are

deductible

s f

or

Part

A a

nd P

art

B, but do n

ot in

clu

de the p

lan’s

se

para

te fo

reig

n tra

vel e

mer

genc

y de

duct

ible

.

AHLMS03846LA 08/2018 A 07/2017 C 2

Attained Preferred Attained Standard

Age Plan A Plan B Plan F Plan HF Plan G Plan N Age Plan A Plan B Plan F Plan HF Plan G Plan N

Under 65 3,587 4,078 5,201 2,081 4,084 3,444 Under 65 3,985 4,530 5,778 2,312 4,538 3,826

65 1,481 1,683 2,148 859 1,686 1,420 65 1,645 1,871 2,387 953 1,873 1,579

66 1,481 1,683 2,148 859 1,686 1,420 66 1,645 1,871 2,387 953 1,873 1,579

67 1,481 1,683 2,148 859 1,686 1,420 67 1,645 1,871 2,387 953 1,873 1,579

68 1,499 1,705 2,174 869 1,707 1,438 68 1,667 1,895 2,415 966 1,896 1,598

69 1,531 1,742 2,220 889 1,743 1,469 69 1,702 1,935 2,466 987 1,938 1,633

70 1,571 1,788 2,279 912 1,789 1,509 70 1,745 1,987 2,534 1,013 1,988 1,677

71 1,619 1,841 2,348 939 1,842 1,553 71 1,798 2,046 2,608 1,044 2,047 1,726

72 1,669 1,899 2,420 969 1,900 1,602 72 1,854 2,110 2,690 1,076 2,112 1,780

73 1,723 1,960 2,499 1,000 1,961 1,654 73 1,914 2,178 2,777 1,111 2,179 1,838

74 1,784 2,029 2,588 1,035 2,032 1,712 74 1,981 2,254 2,874 1,149 2,258 1,901

75 1,849 2,104 2,682 1,073 2,105 1,776 75 2,055 2,337 2,980 1,192 2,339 1,974

76 1,914 2,176 2,775 1,111 2,179 1,837 76 2,127 2,419 3,084 1,235 2,421 2,041

77 1,979 2,251 2,869 1,147 2,252 1,899 77 2,198 2,501 3,188 1,275 2,503 2,110

78 2,042 2,325 2,962 1,186 2,326 1,961 78 2,270 2,583 3,292 1,317 2,584 2,179

79 2,110 2,401 3,060 1,224 2,402 2,025 79 2,345 2,666 3,400 1,360 2,669 2,250

80 2,176 2,474 3,157 1,263 2,477 2,089 80 2,419 2,750 3,506 1,404 2,753 2,321

81 2,245 2,553 3,255 1,302 2,554 2,156 81 2,494 2,837 3,617 1,446 2,839 2,394

82 2,314 2,633 3,357 1,343 2,634 2,221 82 2,572 2,926 3,729 1,491 2,927 2,468

83 2,387 2,714 3,461 1,384 2,715 2,291 83 2,652 3,016 3,845 1,539 3,017 2,545

84 2,460 2,797 3,567 1,427 2,799 2,361 84 2,734 3,108 3,963 1,585 3,111 2,624

85 2,545 2,895 3,691 1,477 2,897 2,442 85 2,828 3,216 4,101 1,641 3,220 2,713

86 2,619 2,977 3,796 1,518 2,980 2,513 86 2,909 3,308 4,218 1,687 3,310 2,792

87 2,691 3,061 3,904 1,562 3,064 2,583 87 2,990 3,402 4,337 1,735 3,404 2,870

88 2,767 3,148 4,013 1,605 3,150 2,656 88 3,075 3,497 4,460 1,784 3,500 2,952

89 2,844 3,234 4,124 1,650 3,238 2,730 89 3,161 3,594 4,582 1,833 3,598 3,033

90 2,923 3,324 4,238 1,696 3,327 2,806 90 3,248 3,693 4,710 1,885 3,696 3,117

91 3,002 3,415 4,354 1,742 3,417 2,881 91 3,335 3,794 4,838 1,935 3,796 3,200

92 3,083 3,506 4,471 1,788 3,510 2,958 92 3,425 3,897 4,968 1,987 3,900 3,287

93 3,166 3,600 4,590 1,837 3,603 3,038 93 3,518 4,000 5,101 2,041 4,004 3,376

94 3,248 3,695 4,711 1,885 3,698 3,118 94 3,608 4,106 5,234 2,094 4,109 3,465

95 3,333 3,791 4,834 1,934 3,795 3,199 95 3,704 4,213 5,372 2,149 4,217 3,554

96 3,420 3,891 4,959 1,984 3,893 3,282 96 3,800 4,323 5,510 2,205 4,325 3,647

97 3,506 3,989 5,086 2,034 3,991 3,366 97 3,897 4,432 5,651 2,260 4,435 3,740

98 3,597 4,091 5,215 2,086 4,093 3,451 98 3,996 4,546 5,795 2,318 4,549 3,835

99+ 3,686 4,193 5,344 2,138 4,195 3,537 99+ 4,094 4,658 5,938 2,375 4,661 3,929

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.

Rates Effective 8/1/2018

Female Rates

Aetna Health and Life Insurance CompanyAnnual Premiums

For Use in ZIP Codes: 700-701, 704, 707-708

AHLMS03846LA 08/2018 A 07/2017 C 3



Under 65 4,125 4,692 5,982 2,393 4,696 3,960 Under 65 4,583 5,210 6,645 2,657 5,218 4,400

65 1,703 1,935 2,470 987 1,940 1,633 65 1,891 2,150 2,744 1,098 2,154 1,816

66 1,703 1,935 2,470 987 1,940 1,633 66 1,891 2,150 2,744 1,098 2,154 1,816

67 1,703 1,935 2,470 987 1,940 1,633 67 1,891 2,150 2,744 1,098 2,154 1,816

68 1,725 1,961 2,500 1,000 1,962 1,654 68 1,917 2,179 2,777 1,111 2,181 1,838

69 1,761 2,003 2,553 1,022 2,005 1,690 69 1,956 2,225 2,837 1,135 2,228 1,878

70 1,807 2,056 2,621 1,049 2,058 1,735 70 2,007 2,285 2,914 1,165 2,286 1,929

71 1,861 2,117 2,700 1,080 2,118 1,787 71 2,068 2,353 3,001 1,200 2,354 1,984

72 1,920 2,184 2,784 1,113 2,185 1,842 72 2,132 2,428 3,093 1,237 2,429 2,047

73 1,981 2,254 2,874 1,149 2,255 1,901 73 2,201 2,504 3,194 1,277 2,506 2,114

74 2,052 2,334 2,976 1,191 2,336 1,970 74 2,278 2,593 3,305 1,322 2,597 2,188

75 2,127 2,419 3,084 1,235 2,420 2,042 75 2,363 2,688 3,428 1,371 2,690 2,270

76 2,201 2,503 3,191 1,277 2,506 2,112 76 2,446 2,783 3,548 1,419 2,785 2,348

77 2,276 2,589 3,300 1,320 2,590 2,184 77 2,527 2,877 3,665 1,465 2,878 2,428

78 2,349 2,673 3,407 1,362 2,675 2,255 78 2,610 2,971 3,786 1,514 2,972 2,506

79 2,428 2,761 3,519 1,409 2,762 2,328 79 2,697 3,066 3,910 1,565 3,069 2,588

80 2,503 2,846 3,630 1,453 2,848 2,402 80 2,783 3,163 4,033 1,614 3,166 2,669

81 2,581 2,936 3,742 1,496 2,937 2,479 81 2,868 3,261 4,160 1,663 3,265 2,754

82 2,661 3,029 3,861 1,544 3,030 2,554 82 2,958 3,364 4,288 1,714 3,366 2,838

83 2,744 3,122 3,980 1,592 3,123 2,634 83 3,051 3,469 4,422 1,769 3,470 2,927

84 2,828 3,217 4,101 1,641 3,220 2,714 84 3,144 3,573 4,558 1,823 3,578 3,017

85 2,927 3,329 4,245 1,699 3,332 2,808 85 3,252 3,698 4,716 1,887 3,704 3,119

86 3,011 3,424 4,365 1,745 3,428 2,890 86 3,346 3,803 4,850 1,941 3,808 3,211

87 3,095 3,520 4,489 1,796 3,523 2,971 87 3,439 3,911 4,987 1,996 3,915 3,301

88 3,181 3,621 4,614 1,846 3,624 3,055 88 3,537 4,021 5,128 2,052 4,026 3,394

89 3,271 3,719 4,743 1,898 3,723 3,139 89 3,634 4,133 5,270 2,108 4,137 3,488

90 3,362 3,822 4,874 1,950 3,825 3,226 90 3,736 4,248 5,417 2,167 4,251 3,584

91 3,451 3,927 5,006 2,003 3,929 3,313 91 3,835 4,363 5,562 2,225 4,365 3,680

92 3,545 4,033 5,142 2,056 4,036 3,403 92 3,938 4,481 5,713 2,285 4,485 3,781

93 3,640 4,141 5,279 2,112 4,143 3,493 93 4,045 4,600 5,867 2,348 4,604 3,882

94 3,736 4,249 5,418 2,167 4,253 3,585 94 4,150 4,721 6,019 2,408 4,724 3,985

95 3,834 4,360 5,559 2,224 4,364 3,679 95 4,258 4,845 6,178 2,472 4,849 4,088

96 3,933 4,474 5,703 2,282 4,476 3,773 96 4,371 4,972 6,336 2,536 4,974 4,194

97 4,033 4,587 5,849 2,339 4,590 3,871 97 4,481 5,097 6,499 2,599 5,099 4,301

98 4,136 4,705 5,997 2,399 4,707 3,969 98 4,596 5,227 6,664 2,665 5,231 4,411

99+ 4,238 4,821 6,147 2,459 4,825 4,067 99+ 4,709 5,357 6,829 2,731 5,360 4,519








Male Rates


For Use in ZIP Codes: 700-701, 704, 707-708

AHLMS03846LA 08/2018 A 07/2017 C 4



Under 65 2,781 3,161 4,032 1,613 3,166 2,670 Under 65 3,089 3,512 4,479 1,792 3,518 2,966

65 1,148 1,305 1,665 666 1,307 1,101 65 1,275 1,450 1,850 739 1,452 1,224

66 1,148 1,305 1,665 666 1,307 1,101 66 1,275 1,450 1,850 739 1,452 1,224

67 1,148 1,305 1,665 666 1,307 1,101 67 1,275 1,450 1,850 739 1,452 1,224

68 1,162 1,322 1,685 674 1,323 1,115 68 1,292 1,469 1,872 749 1,470 1,239

69 1,187 1,350 1,721 689 1,351 1,139 69 1,319 1,500 1,912 765 1,502 1,266

70 1,218 1,386 1,767 707 1,387 1,170 70 1,353 1,540 1,964 785 1,541 1,300

71 1,255 1,427 1,820 728 1,428 1,204 71 1,394 1,586 2,022 809 1,587 1,338

72 1,294 1,472 1,876 751 1,473 1,242 72 1,437 1,636 2,085 834 1,637 1,380

73 1,336 1,519 1,937 775 1,520 1,282 73 1,484 1,688 2,153 861 1,689 1,425

74 1,383 1,573 2,006 802 1,575 1,327 74 1,536 1,747 2,228 891 1,750 1,474

75 1,433 1,631 2,079 832 1,632 1,377 75 1,593 1,812 2,310 924 1,813 1,530

76 1,484 1,687 2,151 861 1,689 1,424 76 1,649 1,875 2,391 957 1,877 1,582

77 1,534 1,745 2,224 889 1,746 1,472 77 1,704 1,939 2,471 988 1,940 1,636

78 1,583 1,802 2,296 919 1,803 1,520 78 1,760 2,002 2,552 1,021 2,003 1,689

79 1,636 1,861 2,372 949 1,862 1,570 79 1,818 2,067 2,636 1,054 2,069 1,744

80 1,687 1,918 2,447 979 1,920 1,619 80 1,875 2,132 2,718 1,088 2,134 1,799

81 1,740 1,979 2,523 1,009 1,980 1,671 81 1,933 2,199 2,804 1,121 2,201 1,856

82 1,794 2,041 2,602 1,041 2,042 1,722 82 1,994 2,268 2,891 1,156 2,269 1,913

83 1,850 2,104 2,683 1,073 2,105 1,776 83 2,056 2,338 2,981 1,193 2,339 1,973

84 1,907 2,168 2,765 1,106 2,170 1,830 84 2,119 2,409 3,072 1,229 2,412 2,034

85 1,973 2,244 2,861 1,145 2,246 1,893 85 2,192 2,493 3,179 1,272 2,496 2,103

86 2,030 2,308 2,943 1,177 2,310 1,948 86 2,255 2,564 3,270 1,308 2,566 2,164

87 2,086 2,373 3,026 1,211 2,375 2,002 87 2,318 2,637 3,362 1,345 2,639 2,225

88 2,145 2,440 3,111 1,244 2,442 2,059 88 2,384 2,711 3,457 1,383 2,713 2,288

89 2,205 2,507 3,197 1,279 2,510 2,116 89 2,450 2,786 3,552 1,421 2,789 2,351

90 2,266 2,577 3,285 1,315 2,579 2,175 90 2,518 2,863 3,651 1,461 2,865 2,416

91 2,327 2,647 3,375 1,350 2,649 2,233 91 2,585 2,941 3,750 1,500 2,943 2,481

92 2,390 2,718 3,466 1,386 2,721 2,293 92 2,655 3,021 3,851 1,540 3,023 2,548

93 2,454 2,791 3,558 1,424 2,793 2,355 93 2,727 3,101 3,954 1,582 3,104 2,617

94 2,518 2,864 3,652 1,461 2,867 2,417 94 2,797 3,183 4,057 1,623 3,185 2,686

95 2,584 2,939 3,747 1,499 2,942 2,480 95 2,871 3,266 4,164 1,666 3,269 2,755

96 2,651 3,016 3,844 1,538 3,018 2,544 96 2,946 3,351 4,271 1,709 3,353 2,827

97 2,718 3,092 3,943 1,577 3,094 2,609 97 3,021 3,436 4,381 1,752 3,438 2,899

98 2,788 3,171 4,043 1,617 3,173 2,675 98 3,098 3,524 4,492 1,797 3,526 2,973

99+ 2,857 3,250 4,143 1,657 3,252 2,742 99+ 3,174 3,611 4,603 1,841 3,613 3,046








Female Rates


For Use in: Rest of State

AHLMS03846LA 08/2018 A 07/2017 C 5



Under 65 3,198 3,637 4,637 1,855 3,640 3,070 Under 65 3,553 4,039 5,151 2,060 4,045 3,411

65 1,320 1,500 1,915 765 1,504 1,266 65 1,466 1,667 2,127 851 1,670 1,408

66 1,320 1,500 1,915 765 1,504 1,266 66 1,466 1,667 2,127 851 1,670 1,408

67 1,320 1,500 1,915 765 1,504 1,266 67 1,466 1,667 2,127 851 1,670 1,408

68 1,337 1,520 1,938 775 1,521 1,282 68 1,486 1,689 2,153 861 1,691 1,425

69 1,365 1,553 1,979 792 1,554 1,310 69 1,516 1,725 2,199 880 1,727 1,456

70 1,401 1,594 2,032 813 1,595 1,345 70 1,556 1,771 2,259 903 1,772 1,495

71 1,443 1,641 2,093 837 1,642 1,385 71 1,603 1,824 2,326 930 1,825 1,538

72 1,488 1,693 2,158 863 1,694 1,428 72 1,653 1,882 2,398 959 1,883 1,587

73 1,536 1,747 2,228 891 1,748 1,474 73 1,706 1,941 2,476 990 1,943 1,639

74 1,591 1,809 2,307 923 1,811 1,527 74 1,766 2,010 2,562 1,025 2,013 1,696

75 1,649 1,875 2,391 957 1,876 1,583 75 1,832 2,084 2,657 1,063 2,085 1,760

76 1,706 1,940 2,474 990 1,943 1,637 76 1,896 2,157 2,750 1,100 2,159 1,820

77 1,764 2,007 2,558 1,023 2,008 1,693 77 1,959 2,230 2,841 1,136 2,231 1,882

78 1,821 2,072 2,641 1,056 2,074 1,748 78 2,023 2,303 2,935 1,174 2,304 1,943

79 1,882 2,140 2,728 1,092 2,141 1,805 79 2,091 2,377 3,031 1,213 2,379 2,006

80 1,940 2,206 2,814 1,126 2,208 1,862 80 2,157 2,452 3,126 1,251 2,454 2,069

81 2,001 2,276 2,901 1,160 2,277 1,922 81 2,223 2,528 3,225 1,289 2,531 2,135

82 2,063 2,348 2,993 1,197 2,349 1,980 82 2,293 2,608 3,324 1,329 2,609 2,200

83 2,127 2,420 3,085 1,234 2,421 2,042 83 2,365 2,689 3,428 1,371 2,690 2,269

84 2,192 2,494 3,179 1,272 2,496 2,104 84 2,437 2,770 3,533 1,413 2,774 2,339

85 2,269 2,581 3,291 1,317 2,583 2,177 85 2,521 2,867 3,656 1,463 2,871 2,418

86 2,334 2,654 3,384 1,353 2,657 2,240 86 2,594 2,948 3,760 1,505 2,952 2,489

87 2,399 2,729 3,480 1,392 2,731 2,303 87 2,666 3,032 3,866 1,547 3,035 2,559

88 2,466 2,807 3,577 1,431 2,809 2,368 88 2,742 3,117 3,975 1,591 3,121 2,631

89 2,536 2,883 3,677 1,471 2,886 2,433 89 2,817 3,204 4,085 1,634 3,207 2,704

90 2,606 2,963 3,778 1,512 2,965 2,501 90 2,896 3,293 4,199 1,680 3,295 2,778

91 2,675 3,044 3,881 1,553 3,046 2,568 91 2,973 3,382 4,312 1,725 3,384 2,853

92 2,748 3,126 3,986 1,594 3,129 2,638 92 3,053 3,474 4,429 1,771 3,477 2,931

93 2,822 3,210 4,092 1,637 3,212 2,708 93 3,136 3,566 4,548 1,820 3,569 3,009

94 2,896 3,294 4,200 1,680 3,297 2,779 94 3,217 3,660 4,666 1,867 3,662 3,089

95 2,972 3,380 4,309 1,724 3,383 2,852 95 3,301 3,756 4,789 1,916 3,759 3,169

96 3,049 3,468 4,421 1,769 3,470 2,925 96 3,388 3,854 4,912 1,966 3,856 3,251

97 3,126 3,556 4,534 1,813 3,558 3,001 97 3,474 3,951 5,038 2,015 3,953 3,334

98 3,206 3,647 4,649 1,860 3,649 3,077 98 3,563 4,052 5,166 2,066 4,055 3,419

99+ 3,285 3,737 4,765 1,906 3,740 3,153 99+ 3,650 4,153 5,294 2,117 4,155 3,503








Male Rates


For Use in: Rest of State

AHLMS03846LA 08/2018 A 6

PREMIUM INFORMATION

Aetna Health and Life Insurance Company can only raise your premium if we raise the premium for all policies like yours in this state. Premiums for this policy will increase due to the increase in your age. Upon attainment of an age requiring a rate increase, the renewal premium for the policy will be the renewal premium then in effect for your attained age. Other policies may be provided with Issue Age rating and do not increase with age. You should compare Issue Age with Attained Age policies.

Premiums payable other than 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 Aetna Health and Life Insurance Company 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 Aetna Health and Life Insurance Company 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; and (c) be 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 Aetna Health and Life Insurance Company, 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 Aetna Health and Life Insurance Company nor its agents are connected with Medicare.

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare & You for more details.

COMPLETE ANSWERS ARE VERY IMPORTANT

When you fill out the application for the new policy, be sure to answer truthfully and completely any questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

THE FOLLOWING CHARTS DESCRIBE PLANS A, B, F, HIGH DEDUCTIBLE F, G and N OFFERED BY AENTA HEALTH AND LIFE INSURANCE COMPANY.

AHLMS03846LA 08/2018 A 7

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 $1340 $0 $1340 (Part A Deductible)

61st thru 90th day All but $335 a day $335 a day $0 91st day and after While using 60 lifetime reserve days All but $670 a day $670 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 $167.50 a day $0 Up to $167.50 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.

AHLMS03846LA 08/2018 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.


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*


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 $183 of Medicare Approved amounts*


Remainder of Medicare Approved amounts 80% 20% $0

AHLMS03846LA 08/2018 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.


PLAN PAYS

YOU PAY


First 60 days All but $1340 $1340 (Part A Deductible)

$0



$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 $167.50 a day

$0 Up to $167.50 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

**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.

AHLMS03846LA 08/2018 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.


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 $183 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



100% $0 $0

Durable medical equipment First $183 of Medicare Approved amounts*



AHLMS03846LA 08/2018 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.


PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $167.50 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


AHLMS03846LA 08/2018 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.


PLAN PAYS

YOU PAY



$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


PARTS A & B


PLAN PAYS

YOU PAY



100% $0 $0



$0


AHLMS03846LA 08/2018 A 13

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

AHLMS03846LA 08/2018 A 14

High Deductible 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. ***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2240 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2240. 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 $2240

DEDUCTIBLE*** PLAN PAYS

IN ADDITION TO $2240

DEDUCTIBLE*** YOU PAY



$0



$0**




$0 $0


Up to $167.50 a day

$0

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

AHLMS03846LA 08/2018 A 15

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



$0


AHLMS03846LA 08/2018 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 $2240 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2240. 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 $2240







$0



$0


AHLMS03846LA 08/2018 A 17

HIGH DEDUCTIBLE PLAN F

PARTS A & B

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2240






100% $0 $0



$0



SERVICES

MEDICARE PAYS

AFTER YOU PAY $2240

DEDUCTIBLE** PLAN PAYS


DEDUCTIBLE** YOU PAY





AHLMS03846LA 08/2018 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.


PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $167.50 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


AHLMS03846LA 08/2018 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.


PLAN PAYS

YOU PAY







PARTS A & B


PLAN PAYS

YOU PAY


Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $183 of Medicare Approved amounts*



AHLMS03846LA 08/2018 A 20

PLAN G



PLAN PAYS

YOU PAY





AHLMS03846LA 08/2018 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.


PLAN PAYS

YOU PAY



$0



$0**




$0 $0


Up to $167.50 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


AHLMS03846LA 08/2018 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.


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 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.

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*



AHLMS03846LA 08/2018 A 23

PLAN N

PARTS A & B


PLAN PAYS

YOU PAY


Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $183 of Medicare Approved amounts*





PLAN PAYS

YOU PAY


First $250 each calendar year $0 $0 $250

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


Documents

Outline of Coverage - Aetna · Outline of Coverage ... 73 1,723 1,960 2,499 1,000 1,961 1,654 73 1,914 2,178 2,777 1,111 2,179 1,838 74 1,784 ... 91 3,002 3,415