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Outline of CoverageMedicare Supplement Insurance
Underwritten by
American Continental Insurance Company
800 Crescent Centre Dr. Suite 200
Franklin, TN 37067800 264.4000
aetnaseniorproducts.com
An Aetna Company
Rates Effective:
BENEFIT PLANS A, B, F, HIGH DEDUCTIBLE F, G, N
ALABAMA
ACIMS01063AL ©2017 Aetna Inc. 06/2017 A
ACIM
S010
63A
L
06/
2017
A
AMER
ICAN
CO
NTI
NEN
TAL
INSU
RAN
CE
CO
MPA
NY
OU
TLIN
E O
F M
EDIC
ARE
SUPP
LEM
ENT
CO
VER
AGE
CO
VER
PAG
E: P
age
1 of
2
BEN
EFIT
PLA
NS
AVAI
LAB
LE: A
, B, F
, HIG
H D
EDU
CTI
BLE
F, G
, N
Thes
e ch
arts
sho
w th
e be
nefit
s in
clud
ed in
eac
h of
the
stan
dard
Med
icar
e su
pple
men
t pla
ns. E
very
co
mp
an
y m
ust m
ake
ava
ilable
Pla
n “
A”
Som
e pl
ans
may
not
be
avai
labl
e in
you
r sta
te.
See
Out
lines
of C
over
age
sect
ions
for d
etai
ls a
bout
ALL
pla
ns
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
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Hos
pita
lizat
ion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basi
c be
nefit
s pa
id a
t 50%
Hos
pita
lizat
ion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basi
c be
nefit
s pa
id a
t 75%
Basi
c,
incl
udin
g 10
0% P
art B
co
insu
ranc
e
Basi
c, in
clud
ing
100%
Par
t B
coin
sura
nce,
exc
ept
up to
$20
co
paym
ent f
or o
ffice
vi
sit,
and
up to
$50
co
paym
ent f
or E
R
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
50%
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
75%
Ski
lled
Nur
sing
Fac
ility
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Skille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Pa
rt A
Ded
uctib
le
Part
A D
educ
tible
Pa
rt A
Ded
uctib
le
Part
A D
educ
tible
Pa
rt A
Ded
uctib
le
50%
Par
t A
Ded
uctib
le
75%
Par
t A
Ded
uctib
le
50%
Par
t A
Ded
uctib
le
Part
A D
educ
tible
Part
B D
educ
tible
Part
B D
educ
tible
Part
B Ex
cess
(1
00%
)
Part
B Ex
cess
(1
00%
)
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Fore
ign
Trav
el
Emer
genc
y
Out
-of-p
ocke
t lim
it $5
120;
pa
id a
t 100
%
afte
r lim
it re
ache
d
Out
-of-p
ocke
t lim
it $2
560;
pa
id a
t 100
%
afte
r lim
it re
ache
d
*Pla
n F
also
has
an
optio
n ca
lled
a hi
gh d
educ
tible
pla
n F.
Thi
s hi
gh d
educ
tible
pla
n pa
ys th
e sa
me
bene
fits
as P
lan
F af
ter o
ne h
as p
aid
a ca
lend
ar y
ear $
2200
de
duct
ible
. Be
nefit
s fro
m h
igh
dedu
ctib
le p
lan
F w
ill no
t be
gin
until
out
-of-p
ocke
t ex
pens
es e
xcee
d $2
200.
O
ut-o
f-poc
ket
expe
nses
for
thi
s de
duct
ible
are
ex
pens
es th
at w
ould
ord
inar
ily b
e pa
id b
y th
e po
licy.
The
se e
xpen
ses
incl
ude
the
Med
icar
e de
duct
ible
s fo
r Pa
rt A
and
Part
B, b
ut
do n
ot
inclu
de t
he p
lan’s
se
para
te fo
reig
n tra
vel e
mer
genc
y de
duct
ible
.
ACIM
S010
63A
L 06
/201
7 A
2
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n H
FP
lan
GP
lan
NA
geP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
65
1,30
0
1,63
7
1,95
6
683
1,49
8
1,14
0
65
1,44
5
1,82
0
2,17
5
759
1,66
6
1,26
6
66
1,31
3
1,65
6
1,97
6
691
1,51
4
1,15
2
66
1,45
7
1,84
0
2,19
7
765
1,68
3
1,27
8
67
1,32
6
1,67
3
1,99
6
697
1,53
0
1,16
2
67
1,47
4
1,85
9
2,21
8
774
1,70
0
1,29
3
68
1,38
2
1,74
1
2,07
9
727
1,59
3
1,21
3
68
1,53
6
1,93
5
2,31
0
806
1,77
1
1,34
6
69
1,44
5
1,82
0
2,16
0
755
1,66
6
1,26
5
69
1,60
4
2,02
1
2,40
1
840
1,85
1
1,40
8
70
1,50
2
1,89
5
2,24
1
783
1,73
3
1,31
7
70
1,66
6
2,10
2
2,49
1
869
1,92
5
1,46
3
71
1,55
8
1,96
4
2,31
7
809
1,79
8
1,36
7
71
1,73
3
2,18
2
2,57
6
899
1,99
9
1,51
8
72
1,61
2
2,03
4
2,39
2
835
1,86
0
1,41
4
72
1,79
1
2,25
6
2,65
7
927
2,06
7
1,57
2
73
1,66
3
2,09
6
2,45
5
857
1,91
9
1,45
8
73
1,85
0
2,32
9
2,73
0
953
2,13
3
1,62
2
74
1,71
0
2,15
7
2,51
8
879
1,97
4
1,49
9
74
1,90
3
2,39
8
2,79
8
978
2,19
5
1,66
7
75
1,75
5
2,21
3
2,57
6
899
2,02
4
1,53
9
75
1,94
8
2,45
8
2,86
2
1,00
1
2,24
9
1,70
9
76
1,79
4
2,26
1
2,62
6
920
2,07
1
1,57
5
76
1,99
5
2,51
4
2,91
6
1,01
7
2,30
0
1,74
9
77
1,83
8
2,31
1
2,67
0
933
2,11
4
1,61
0
77
2,03
8
2,56
7
2,96
6
1,03
6
2,35
2
1,78
8
78
1,86
7
2,35
7
2,71
1
947
2,15
7
1,63
9
78
2,07
8
2,61
7
3,01
1
1,05
3
2,39
7
1,82
2
79
1,90
3
2,39
8
2,74
9
961
2,19
5
1,66
6
79
2,11
5
2,66
5
3,05
3
1,06
8
2,43
8
1,85
2
80
1,93
3
2,43
6
2,78
3
974
2,22
9
1,69
6
80
2,14
7
2,70
7
3,09
4
1,08
0
2,47
6
1,88
4
81
1,96
2
2,46
9
2,82
0
986
2,26
1
1,71
9
81
2,17
9
2,74
5
3,13
4
1,09
4
2,51
3
1,91
1
82
1,98
7
2,50
3
2,85
5
1,00
0
2,29
1
1,74
2
82
2,20
8
2,78
4
3,17
3
1,10
9
2,54
7
1,93
5
83
2,01
3
2,53
7
2,89
0
1,01
1
2,32
2
1,76
5
83
2,23
9
2,81
8
3,21
0
1,12
2
2,57
9
1,96
0
84
2,03
7
2,56
6
2,92
3
1,02
0
2,35
0
1,78
8
84
2,26
5
2,85
4
3,25
0
1,13
4
2,61
1
1,98
5
85
2,06
0
2,59
8
2,95
6
1,03
4
2,37
7
1,80
8
85
2,29
0
2,88
5
3,28
7
1,14
9
2,64
3
2,00
9
86
2,08
5
2,62
8
2,98
6
1,04
4
2,40
5
1,82
8
86
2,31
5
2,92
0
3,32
0
1,16
0
2,67
1
2,03
1
87
2,10
5
2,65
5
3,01
8
1,05
5
2,42
9
1,84
7
87
2,34
3
2,95
1
3,35
2
1,17
1
2,70
1
2,05
3
88
2,12
7
2,68
3
3,04
5
1,06
6
2,45
5
1,86
6
88
2,36
4
2,97
9
3,38
3
1,18
1
2,72
7
2,07
2
89
2,14
7
2,70
7
3,07
0
1,07
2
2,47
6
1,88
4
89
2,38
5
3,00
6
3,41
3
1,19
3
2,75
3
2,09
3
902,
166
2,
731
3,
099
1,
082
2,
497
1,
901
902,
408
3,
032
3,
440
1,
201
2,
778
2,
113
912,
183
2,
755
3,
119
1,
089
2,
521
1,
916
912,
430
3,
058
3,
463
1,
211
2,
799
2,
127
922,
201
2,
773
3,
140
1,
096
2,
538
1,
930
922,
445
3,
082
3,
491
1,
221
2,
820
2,
146
932,
217
2,
794
3,
162
1,
106
2,
556
1,
944
932,
462
3,
105
3,
511
1,
229
2,
840
2,
160
942,
231
2,
810
3,
175
1,
109
2,
574
1,
955
942,
478
3,
123
3,
531
1,
234
2,
860
2,
175
952,
246
2,
827
3,
193
1,
115
2,
589
1,
968
952,
494
3,
144
3,
549
1,
241
2,
874
2,
188
962,
255
2,
843
3,
209
1,
122
2,
603
1,
979
962,
505
3,
161
3,
566
1,
246
2,
892
2,
199
972,
271
2,
860
3,
228
1,
128
2,
620
1,
991
972,
524
3,
176
3,
585
1,
253
2,
910
2,
212
982,
283
2,
877
3,
245
1,
134
2,
633
2,
002
982,
538
3,
197
3,
604
1,
260
2,
925
2,
225
99
2,29
8
2,89
4
3,25
9
1,13
8
2,64
8
2,01
5
99
2,55
5
3,21
5
3,62
1
1,26
5
2,94
6
2,23
8
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.52
00Q
uar
terl
y:0.
2650
Mo
nth
ly:
0.08
33
The
ab
ove
rat
es
do
no
t in
clu
de
th
e $
20 a
pp
lica
tio
n f
ee
.
To c
alcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ual
pre
miu
m x
mo
dal
fac
tor
= m
od
al p
rem
ium
(ro
un
d t
o n
ear
est
wh
ole
ce
nt)
M
od
al p
rem
ium
x .9
5 =
dis
cou
nte
d p
rem
ium
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d, u
se P
refe
rre
d r
ate
s.
Rat
es E
ffec
tive
6/1
/20
17
For
Use
in
ZIP
Co
des
: 3
50
-35
2, 3
55
Am
eri
can
Co
nti
ne
nta
l In
sura
nce
Co
mp
any
An
nu
al A
ttai
ned
Age
Pre
miu
ms
Fem
ale
Rat
es
ACIM
S010
63A
L 06
/201
7 A
3
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n H
FP
lan
GP
lan
NA
geP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
65
1,49
6
1,88
5
2,25
0
786
1,72
3
1,31
0
65
1,66
1
2,09
3
2,50
0
874
1,91
3
1,45
5
66
1,51
0
1,90
3
2,27
4
795
1,74
2
1,32
5
66
1,67
7
2,11
6
2,52
6
881
1,93
6
1,47
1
67
1,52
7
1,92
3
2,29
3
802
1,75
9
1,33
8
67
1,69
6
2,13
7
2,55
2
893
1,95
4
1,48
6
68
1,58
9
2,00
2
2,39
2
835
1,83
2
1,39
4
68
1,76
6
2,22
4
2,65
7
927
2,03
6
1,54
9
69
1,66
1
2,09
3
2,48
4
868
1,91
5
1,45
6
69
1,84
4
2,32
6
2,76
2
964
2,12
8
1,61
9
70
1,72
7
2,17
7
2,57
6
900
1,99
1
1,51
4
70
1,91
9
2,41
9
2,86
2
1,00
1
2,21
3
1,68
3
71
1,79
2
2,25
6
2,66
6
931
2,06
7
1,57
2
71
1,99
3
2,51
1
2,96
2
1,03
5
2,29
7
1,74
6
72
1,85
5
2,33
7
2,74
9
961
2,13
9
1,62
6
72
2,06
0
2,59
8
3,05
3
1,06
8
2,37
6
1,80
8
73
1,91
3
2,40
9
2,82
2
986
2,20
8
1,67
8
73
2,12
6
2,67
9
3,13
6
1,09
5
2,45
3
1,86
5
74
1,96
9
2,48
1
2,89
8
1,01
3
2,27
0
1,72
7
74
2,18
6
2,75
8
3,21
8
1,12
5
2,52
3
1,91
8
75
2,01
9
2,54
1
2,96
2
1,03
5
2,32
8
1,76
9
75
2,24
3
2,82
5
3,29
2
1,15
1
2,58
7
1,96
7
76
2,06
4
2,60
1
3,01
8
1,05
5
2,38
1
1,81
0
76
2,29
5
2,89
0
3,35
3
1,17
3
2,64
6
2,01
2
77
2,10
7
2,65
8
3,07
0
1,07
2
2,43
4
1,84
9
77
2,34
5
2,95
3
3,41
3
1,19
3
2,70
2
2,05
4
78
2,15
0
2,71
0
3,11
6
1,08
9
2,47
8
1,88
6
78
2,38
7
3,00
9
3,46
2
1,21
0
2,75
4
2,09
5
79
2,18
6
2,75
8
3,16
4
1,10
6
2,52
3
1,91
8
79
2,43
1
3,06
1
3,51
2
1,22
9
2,80
2
2,13
0
80
2,22
3
2,80
0
3,20
0
1,11
9
2,56
3
1,94
8
80
2,46
9
3,11
1
3,55
7
1,24
4
2,84
7
2,16
5
81
2,25
3
2,84
0
3,24
5
1,13
4
2,60
1
1,97
7
81
2,50
4
3,15
7
3,60
5
1,26
0
2,89
0
2,19
7
82
2,28
4
2,87
8
3,28
7
1,14
9
2,63
4
2,00
3
82
2,53
8
3,19
9
3,64
9
1,27
5
2,92
8
2,22
6
83
2,31
3
2,91
9
3,32
5
1,16
0
2,66
8
2,03
0
83
2,57
3
3,23
9
3,69
5
1,29
0
2,96
6
2,25
5
84
2,34
3
2,95
2
3,36
1
1,17
6
2,70
2
2,05
4
84
2,60
3
3,28
0
3,73
7
1,30
4
3,00
3
2,28
4
85
2,37
1
2,98
6
3,40
0
1,18
8
2,73
3
2,08
0
85
2,63
4
3,31
9
3,77
8
1,32
0
3,03
8
2,30
8
86
2,39
8
3,02
2
3,43
4
1,20
1
2,76
5
2,10
1
86
2,66
5
3,35
7
3,81
8
1,33
2
3,07
1
2,33
5
87
2,42
2
3,05
1
3,47
1
1,21
2
2,79
4
2,12
3
87
2,69
0
3,39
2
3,85
6
1,34
6
3,10
4
2,35
9
88
2,44
7
3,08
3
3,50
1
1,22
4
2,82
1
2,14
7
88
2,72
0
3,42
5
3,89
0
1,35
9
3,13
6
2,38
5
89
2,46
9
3,11
2
3,53
1
1,23
4
2,84
8
2,16
7
89
2,74
5
3,45
9
3,92
4
1,37
1
3,16
5
2,40
7
902,
493
3,
140
3,
561
1,
244
2,
873
2,
185
902,
767
3,
487
3,
956
1,
382
3,
193
2,
428
912,
513
3,
166
3,
586
1,
253
2,
899
2,
202
912,
794
3,
519
3,
987
1,
393
3,
219
2,
450
922,
532
3,
190
3,
612
1,
261
2,
919
2,
220
922,
813
3,
544
4,
013
1,
402
3,
245
2,
466
932,
550
3,
211
3,
634
1,
269
2,
939
2,
235
932,
833
3,
568
4,
038
1,
410
3,
268
2,
484
942,
565
3,
234
3,
657
1,
276
2,
959
2,
250
942,
851
3,
592
4,
059
1,
419
3,
288
2,
499
952,
581
3,
251
3,
674
1,
284
2,
978
2,
264
952,
868
3,
615
4,
080
1,
426
3,
308
2,
515
962,
597
3,
270
3,
693
1,
289
2,
993
2,
275
962,
884
3,
634
4,
102
1,
433
3,
327
2,
528
972,
611
3,
289
3,
710
1,
297
3,
012
2,
290
972,
902
3,
655
4,
120
1,
440
3,
347
2,
543
982,
628
3,
308
3,
726
1,
302
3,
029
2,
303
982,
920
3,
677
4,
144
1,
447
3,
366
2,
559
99
2,64
2
3,32
9
3,74
9
1,30
9
3,04
7
2,31
6
99
2,93
6
3,69
8
4,16
5
1,45
5
3,38
6
2,57
3
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.52
00Q
uar
terl
y:0.
2650
Mo
nth
ly:
0.08
33
The
ab
ove
rat
es
do
no
t in
clu
de
th
e $
20 a
pp
lica
tio
n f
ee
.
To c
alcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ual
pre
miu
m x
mo
dal
fac
tor
= m
od
al p
rem
ium
(ro
un
d t
o n
ear
est
wh
ole
ce
nt)
M
od
al p
rem
ium
x .9
5 =
dis
cou
nte
d p
rem
ium
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d, u
se P
refe
rre
d r
ate
s.
Rat
es E
ffec
tive
6/1
/20
17
Am
eri
can
Co
nti
ne
nta
l In
sura
nce
Co
mp
any
An
nu
al A
ttai
ned
Age
Pre
miu
ms
For
Use
in
ZIP
Co
des
: 3
50
-35
2, 3
55
Mal
e R
ates
ACIM
S010
63A
L
06/2
017
A
4
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n H
FP
lan
GP
lan
NA
geP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
65
1,17
6
1,48
1
1,77
0
618
1,35
6
1,03
2
65
1,30
7
1,64
6
1,96
7
687
1,50
8
1,14
6
66
1,18
8
1,49
8
1,78
8
625
1,37
0
1,04
2
66
1,31
9
1,66
4
1,98
7
693
1,52
3
1,15
6
67
1,20
0
1,51
3
1,80
6
631
1,38
4
1,05
2
67
1,33
4
1,68
2
2,00
6
700
1,53
8
1,16
9
68
1,25
0
1,57
5
1,88
1
657
1,44
1
1,09
7
68
1,39
0
1,75
1
2,09
0
730
1,60
3
1,21
8
69
1,30
7
1,64
6
1,95
4
683
1,50
8
1,14
5
69
1,45
2
1,82
9
2,17
3
760
1,67
5
1,27
4
70
1,35
9
1,71
5
2,02
7
709
1,56
8
1,19
1
70
1,50
8
1,90
2
2,25
3
787
1,74
1
1,32
3
71
1,41
0
1,77
7
2,09
7
732
1,62
6
1,23
7
71
1,56
8
1,97
4
2,33
0
813
1,80
9
1,37
4
72
1,45
8
1,84
0
2,16
4
755
1,68
2
1,28
0
72
1,62
1
2,04
2
2,40
4
839
1,87
1
1,42
2
73
1,50
5
1,89
6
2,22
1
775
1,73
7
1,32
0
73
1,67
4
2,10
7
2,47
0
863
1,92
9
1,46
8
74
1,54
8
1,95
1
2,27
8
795
1,78
6
1,35
7
74
1,72
1
2,17
0
2,53
2
884
1,98
6
1,50
9
75
1,58
7
2,00
3
2,33
0
813
1,83
2
1,39
3
75
1,76
2
2,22
4
2,59
0
905
2,03
5
1,54
7
76
1,62
4
2,04
5
2,37
6
832
1,87
3
1,42
5
76
1,80
5
2,27
4
2,63
8
921
2,08
1
1,58
3
77
1,66
3
2,09
1
2,41
6
845
1,91
2
1,45
6
77
1,84
4
2,32
3
2,68
4
938
2,12
8
1,61
8
78
1,68
9
2,13
3
2,45
3
857
1,95
1
1,48
3
78
1,88
0
2,36
7
2,72
5
953
2,16
9
1,64
8
79
1,72
1
2,17
0
2,48
7
869
1,98
6
1,50
8
79
1,91
3
2,41
1
2,76
3
966
2,20
6
1,67
6
80
1,74
9
2,20
4
2,51
8
882
2,01
7
1,53
4
80
1,94
3
2,44
9
2,80
0
978
2,24
0
1,70
4
81
1,77
6
2,23
3
2,55
2
892
2,04
5
1,55
5
81
1,97
1
2,48
3
2,83
6
990
2,27
3
1,72
9
82
1,79
7
2,26
5
2,58
3
904
2,07
3
1,57
6
82
1,99
8
2,51
8
2,87
1
1,00
3
2,30
5
1,75
1
83
1,82
1
2,29
5
2,61
4
915
2,10
0
1,59
7
83
2,02
5
2,55
0
2,90
4
1,01
6
2,33
3
1,77
4
84
1,84
3
2,32
2
2,64
5
922
2,12
6
1,61
8
84
2,04
9
2,58
2
2,94
0
1,02
6
2,36
3
1,79
6
85
1,86
4
2,35
0
2,67
4
936
2,15
1
1,63
6
85
2,07
2
2,61
1
2,97
4
1,03
9
2,39
1
1,81
7
86
1,88
7
2,37
8
2,70
2
944
2,17
6
1,65
4
86
2,09
5
2,64
2
3,00
4
1,05
0
2,41
7
1,83
7
87
1,90
5
2,40
3
2,73
0
955
2,19
7
1,67
1
87
2,11
9
2,67
0
3,03
2
1,05
9
2,44
3
1,85
7
88
1,92
5
2,42
7
2,75
5
964
2,22
1
1,68
8
88
2,13
8
2,69
5
3,06
1
1,06
9
2,46
7
1,87
4
89
1,94
3
2,44
9
2,77
8
970
2,24
0
1,70
4
89
2,15
7
2,72
0
3,08
8
1,07
9
2,49
1
1,89
3
901,
960
2,
471
2,
803
97
9
2,
259
1,
720
902,
178
2,
744
3,
112
1,
087
2,
514
1,
911
911,
975
2,
493
2,
822
98
5
2,
281
1,
734
912,
198
2,
766
3,
133
1,
095
2,
533
1,
925
921,
991
2,
509
2,
841
99
2
2,
296
1,
746
922,
213
2,
788
3,
159
1,
105
2,
552
1,
942
932,
005
2,
528
2,
860
1,
000
2,
312
1,
758
932,
228
2,
809
3,
177
1,
112
2,
570
1,
954
942,
019
2,
542
2,
873
1,
003
2,
328
1,
769
942,
242
2,
825
3,
195
1,
116
2,
588
1,
967
952,
032
2,
557
2,
889
1,
009
2,
343
1,
780
952,
256
2,
844
3,
211
1,
123
2,
600
1,
980
962,
041
2,
573
2,
903
1,
016
2,
355
1,
791
962,
267
2,
860
3,
226
1,
128
2,
616
1,
989
972,
055
2,
588
2,
920
1,
020
2,
370
1,
801
972,
284
2,
874
3,
243
1,
133
2,
632
2,
002
982,
065
2,
603
2,
936
1,
026
2,
383
1,
812
982,
296
2,
893
3,
260
1,
140
2,
647
2,
013
99
2,08
0
2,61
8
2,94
9
1,03
0
2,39
6
1,82
3
99
2,31
1
2,90
9
3,27
7
1,14
5
2,66
6
2,02
4
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.52
00Q
uar
terl
y:0.
2650
Mo
nth
ly:
0.08
33
The
ab
ove
rat
es
do
no
t in
clu
de
th
e $
20 a
pp
lica
tio
n f
ee
.
To c
alcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ual
pre
miu
m x
mo
dal
fac
tor
= m
od
al p
rem
ium
(ro
un
d t
o n
ear
est
wh
ole
ce
nt)
M
od
al p
rem
ium
x .9
5 =
dis
cou
nte
d p
rem
ium
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d, u
se P
refe
rre
d r
ate
s.
Rat
es E
ffec
tive
6/1
/20
17
Fem
ale
Rat
es
Am
eri
can
Co
nti
ne
nta
l In
sura
nce
Co
mp
any
An
nu
al A
ttai
ned
Age
Pre
miu
ms
For
Use
in
ZIP
Co
des
: R
est
of
Stat
e
ACIM
S010
63A
L
06/2
017
A
5
Att
ain
ed
Pre
ferr
ed
Att
ain
ed
Stan
dar
d
Age
Pla
n A
Pla
n B
Pla
n F
Pla
n H
FP
lan
GP
lan
NA
geP
lan
AP
lan
BP
lan
FP
lan
HF
Pla
n G
Pla
n N
65
1,35
4
1,70
5
2,03
6
712
1,55
9
1,18
6
65
1,50
3
1,89
3
2,26
2
790
1,73
1
1,31
7
66
1,36
6
1,72
1
2,05
8
719
1,57
6
1,19
9
66
1,51
7
1,91
4
2,28
6
797
1,75
2
1,33
1
67
1,38
1
1,73
9
2,07
5
726
1,59
1
1,21
0
67
1,53
4
1,93
3
2,30
9
808
1,76
8
1,34
4
68
1,43
7
1,81
2
2,16
4
755
1,65
8
1,26
2
68
1,59
8
2,01
2
2,40
4
839
1,84
2
1,40
1
69
1,50
3
1,89
3
2,24
8
786
1,73
3
1,31
8
69
1,66
8
2,10
4
2,49
9
872
1,92
6
1,46
5
70
1,56
3
1,96
9
2,33
0
814
1,80
1
1,37
0
70
1,73
7
2,18
9
2,59
0
905
2,00
3
1,52
3
71
1,62
2
2,04
2
2,41
2
843
1,87
1
1,42
2
71
1,80
3
2,27
1
2,68
0
937
2,07
9
1,58
0
72
1,67
9
2,11
5
2,48
7
869
1,93
5
1,47
2
72
1,86
4
2,35
0
2,76
3
966
2,15
0
1,63
6
73
1,73
1
2,17
9
2,55
4
892
1,99
8
1,51
8
73
1,92
4
2,42
3
2,83
8
991
2,21
9
1,68
7
74
1,78
1
2,24
5
2,62
2
917
2,05
4
1,56
3
74
1,97
8
2,49
6
2,91
2
1,01
7
2,28
3
1,73
6
75
1,82
7
2,29
9
2,68
0
937
2,10
6
1,60
1
75
2,02
9
2,55
6
2,97
8
1,04
1
2,34
1
1,77
9
76
1,86
8
2,35
3
2,73
0
955
2,15
5
1,63
8
76
2,07
7
2,61
4
3,03
3
1,06
1
2,39
4
1,82
0
77
1,90
7
2,40
4
2,77
8
970
2,20
2
1,67
3
77
2,12
1
2,67
1
3,08
8
1,07
9
2,44
4
1,85
8
78
1,94
6
2,45
2
2,82
0
985
2,24
2
1,70
6
78
2,15
9
2,72
3
3,13
2
1,09
4
2,49
2
1,89
5
79
1,97
8
2,49
6
2,86
2
1,00
0
2,28
3
1,73
6
79
2,19
9
2,76
9
3,17
8
1,11
2
2,53
6
1,92
8
80
2,01
1
2,53
4
2,89
6
1,01
3
2,31
9
1,76
2
80
2,23
3
2,81
5
3,21
9
1,12
6
2,57
5
1,95
9
81
2,03
9
2,57
0
2,93
6
1,02
6
2,35
3
1,78
9
81
2,26
6
2,85
7
3,26
1
1,14
0
2,61
4
1,98
7
82
2,06
6
2,60
4
2,97
4
1,03
9
2,38
4
1,81
3
82
2,29
6
2,89
5
3,30
1
1,15
3
2,65
0
2,01
4
83
2,09
3
2,64
1
3,00
9
1,05
0
2,41
4
1,83
6
83
2,32
8
2,93
1
3,34
3
1,16
8
2,68
4
2,04
1
84
2,11
9
2,67
0
3,04
1
1,06
4
2,44
4
1,85
8
84
2,35
5
2,96
8
3,38
1
1,18
0
2,71
7
2,06
6
85
2,14
5
2,70
2
3,07
6
1,07
4
2,47
3
1,88
2
85
2,38
4
3,00
3
3,41
8
1,19
4
2,74
8
2,08
8
86
2,17
0
2,73
4
3,10
7
1,08
7
2,50
1
1,90
1
86
2,41
1
3,03
7
3,45
4
1,20
6
2,77
9
2,11
3
87
2,19
2
2,76
1
3,14
1
1,09
6
2,52
8
1,92
1
87
2,43
4
3,06
9
3,48
8
1,21
8
2,80
8
2,13
5
88
2,21
4
2,78
9
3,16
7
1,10
8
2,55
3
1,94
3
88
2,46
1
3,09
9
3,52
0
1,22
9
2,83
8
2,15
7
89
2,23
3
2,81
6
3,19
5
1,11
6
2,57
6
1,96
1
89
2,48
3
3,12
9
3,55
0
1,24
1
2,86
3
2,17
7
902,
255
2,
841
3,
221
1,
126
2,
599
1,
977
902,
503
3,
155
3,
580
1,
250
2,
889
2,
196
912,
273
2,
864
3,
244
1,
133
2,
623
1,
992
912,
528
3,
183
3,
607
1,
261
2,
913
2,
216
922,
290
2,
886
3,
268
1,
141
2,
641
2,
008
922,
545
3,
206
3,
631
1,
268
2,
936
2,
232
932,
308
2,
905
3,
288
1,
149
2,
659
2,
023
932,
563
3,
228
3,
654
1,
276
2,
956
2,
248
942,
321
2,
926
3,
309
1,
154
2,
677
2,
036
942,
579
3,
250
3,
673
1,
283
2,
974
2,
261
952,
335
2,
941
3,
324
1,
162
2,
694
2,
048
952,
594
3,
271
3,
692
1,
290
2,
993
2,
275
962,
349
2,
958
3,
341
1,
167
2,
708
2,
059
962,
610
3,
288
3,
712
1,
297
3,
011
2,
288
972,
363
2,
975
3,
356
1,
173
2,
726
2,
072
972,
626
3,
307
3,
728
1,
302
3,
029
2,
301
982,
378
2,
993
3,
372
1,
178
2,
741
2,
083
982,
642
3,
327
3,
750
1,
309
3,
046
2,
315
99
2,39
0
3,01
2
3,39
2
1,18
5
2,75
7
2,09
6
99
2,65
6
3,34
6
3,76
9
1,31
7
3,06
4
2,32
8
Mo
dal
Fac
tors
:Se
mi-
An
nu
al:
0.52
00Q
uar
terl
y:0.
2650
Mo
nth
ly:
0.08
33
The
ab
ove
rat
es
do
no
t in
clu
de
th
e $
20 a
pp
lica
tio
n f
ee
.
To c
alcu
late
a H
ou
seh
old
dis
cou
nt:
A
nn
ual
pre
miu
m x
mo
dal
fac
tor
= m
od
al p
rem
ium
(ro
un
d t
o n
ear
est
wh
ole
ce
nt)
M
od
al p
rem
ium
x .9
5 =
dis
cou
nte
d p
rem
ium
If a
pp
lyin
g d
uri
ng
Op
en
En
roll
me
nt
or
Gu
aran
tee
d Is
sue
Pe
rio
d, u
se P
refe
rre
d r
ate
s.
Rat
es E
ffec
tive
6/1
/20
17
Mal
e R
ates
Am
eri
can
Co
nti
ne
nta
l In
sura
nce
Co
mp
any
An
nu
al A
ttai
ned
Age
Pre
miu
ms
For
Use
in
ZIP
Co
des
: R
est
of
Stat
e
ACIM
S010
63A
L
0
6/20
17 A
6
PREM
IUM
INFO
RM
ATI
ON
Am
eric
an C
ontin
enta
l Ins
uran
ce C
ompa
ny c
an o
nly
rais
e yo
ur
prem
ium
if w
e ra
ise
the
prem
ium
for a
ll po
licie
s lik
e yo
urs
in th
is
stat
e. P
rem
ium
s fo
r th
is p
olic
y w
ill in
crea
se d
ue to
the
incr
ease
in
yo
ur
age.
U
pon
atta
inm
ent
of
an
age
requ
iring
a
rate
in
crea
se, t
he re
new
al p
rem
ium
for t
he p
olic
y w
ill be
the
rene
wal
pr
emiu
m th
en in
effe
ct fo
r you
r atta
ined
age
. Oth
er p
olic
ies
may
be
pro
vide
d w
ith Is
sue
Age
ratin
g an
d do
not
incr
ease
with
age
. Yo
u sh
ould
com
pare
Issu
e A
ge w
ith A
ttain
ed A
ge p
olic
ies.
P
rem
ium
s pa
yabl
e ot
her
than
an
nual
ly
will
be
de
term
ined
ac
cord
ing
to th
e fo
llow
ing
fact
ors:
S
emi-a
nnua
l: 0.
5200
Qua
rterly
: 0.2
650
Mon
thly
EFT
: 0.0
833.
DIS
CLO
SUR
ES
Use
th
is
outli
ne
to c
ompa
re
bene
fits
and
prem
ium
am
ong
polic
ies.
H
OU
SEH
OLD
DIS
CO
UN
T
In o
rder
to
be e
ligib
le f
or t
he H
ouse
hold
dis
coun
t un
der
an
Am
eric
an
Con
tinen
tal
Insu
ranc
e C
ompa
ny
Med
icar
e su
pple
men
t pl
an,
you
mus
t ap
ply
for
a M
edic
are
supp
lem
ent
plan
at t
he s
ame
time
as a
noth
er M
edic
are
elig
ible
adu
lt or
the
othe
r M
edic
are
elig
ible
adu
lt m
ust
curre
ntly
be
cove
red
by a
n A
mer
ican
C
ontin
enta
l In
sura
nce
Com
pany
M
edic
are
supp
lem
ent
polic
y. T
he M
edic
are
elig
ible
adu
lt m
ust
be e
ither
(a
) yo
ur s
pous
e; (
b) b
e so
meo
ne w
ith w
hom
you
are
in a
civ
il un
ion
partn
ersh
ip; o
r (c)
be
a pe
rman
ent r
esid
ent i
n yo
ur h
ome.
Th
e ho
useh
old
disc
ount
will
onl
y be
app
licab
le i
f a
polic
y fo
r ea
ch a
pplic
ant i
s is
sued
. The
dis
coun
ted
rate
will
be 5
per
cent
lo
wer
than
the
indi
vidu
al ra
tes.
REA
D Y
OU
R P
OLI
CY
VER
Y C
AR
EFU
LLY
This
is o
nly
an o
utlin
e de
scrib
ing y
ou
r p
olic
y’s
mo
st
imp
ort
an
t fe
atur
es.
The
polic
y is
you
r in
sura
nce
cont
ract
. Yo
u m
ust
read
th
e po
licy
itsel
f to
unde
rsta
nd a
ll of
the
right
s an
d du
ties
of b
oth
you
and
your
insu
ranc
e co
mpa
ny.
RIG
HT
TO R
ETU
RN
PO
LIC
Y
If yo
u fin
d th
at y
ou a
re n
ot s
atis
fied
with
you
r po
licy,
you
may
re
turn
it to
Am
eric
an C
ontin
enta
l Ins
uran
ce C
ompa
ny, P
.O. B
ox
1477
0, L
exin
gton
, KY
4051
2-47
70. I
f yo
u se
nd th
e po
licy
back
to
us
with
in 3
0 da
ys a
fter
you
rece
ive
it, w
e w
ill tr
eat t
he p
olic
y as
if it
had
nev
er b
een
issu
ed a
nd re
turn
all
your
pay
men
ts.
PO
LIC
Y R
EPLA
CEM
ENT
If yo
u ar
e re
plac
ing
anot
her
heal
th i
nsur
ance
pol
icy,
do
NO
T ca
ncel
it u
ntil
you
have
act
ually
rec
eive
d yo
ur n
ew p
olic
y an
d ar
e su
re y
ou w
ant t
o ke
ep it
. NO
TIC
E
The
polic
y m
ay n
ot c
over
all
of y
our m
edic
al c
osts
.
Nei
ther
A
mer
ican
C
ontin
enta
l In
sura
nce
Com
pany
no
r its
ag
ents
are
con
nect
ed w
ith M
edic
are.
This
out
line
of c
over
age
does
not
giv
e al
l the
det
ails
of M
edic
are
cove
rage
. C
onta
ct y
our
loca
l So
cial
Sec
urity
Offi
ce o
r co
nsul
t M
ed
icare
& Y
ou fo
r mor
e de
tails
.
CO
MPL
ETE
AN
SWER
S A
RE
VER
Y IM
POR
TAN
T
Whe
n yo
u fil
l out
the
appl
icat
ion
for
the
new
pol
icy,
be
sure
to
answ
er
truth
fully
an
d co
mpl
etel
y an
y qu
estio
ns
abou
t yo
ur
med
ical
and
hea
lth h
isto
ry.
The
com
pany
may
can
cel
your
po
licy
and
refu
se t
o pa
y an
y cl
aim
s if
you
leav
e ou
t or
fal
sify
im
porta
nt m
edic
al in
form
atio
n.
Rev
iew
the
app
licat
ion
care
fully
bef
ore
you
sign
it.
Be
certa
in
that
all
info
rmat
ion
has
been
pro
perly
reco
rded
.
THE
FOLL
OW
ING
CH
AR
TS D
ESC
RIB
E PL
AN
S A
, B, F
, HIG
H
DED
UC
TIB
LE
F,
G
and
N
OFF
ERED
B
Y A
MER
ICA
N
CO
NTI
NEN
TAL
INSU
RA
NC
E C
OM
PAN
Y.
ACIMS01063AL 06/2017 A 7
PLAN A MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1316 $0 $1316 (Part A Deductible)
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts $0 $0 21st thru 100th day All but $164.50 a day $0 Up to $164.50 a
day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
ACIMS01063AL 06/2017 A 8
PLAN A MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
PARTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment
First $183 of Medicare Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
ACIMS01063AL 06/2017 A 9
PLAN B MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day
$0 Up to $164.50 a day
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
ACIMS01063AL 06/2017 A 10
PLAN B MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
* Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES –
TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
PARTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment First $183 of Medicare Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
ACIMS01063AL 06/2017 A 11
PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day
Up to $164.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
ACIMS01063AL 06/2017 A 12
PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-Approved amounts*
$0 $183 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*
$0 $183 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
PARTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment First $183 of Medicare Approved amounts*
$0 $183 (Part B Deductible)
$0
Remainder of Medicare Approved amounts 80% 20% $0
ACIMS01063AL 06/2017 A 13
PLAN F OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime
maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
ACIMS01063AL 06/2017 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 $2200 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses are $2200. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.
SERVICES MEDICARE
PAYS AFTER YOU PAY
$2200 DEDUCTIBLE***
PLAN PAYS
IN ADDITION TO $2200
DEDUCTIBLE*** YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day
Up to $164.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0
ACIMS01063AL 06/2017 A 15
HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
ACIMS01063AL 06/2017 A 16
HIGH DEDUCTIBLE PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. ***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2200 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses are $2200. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.
SERVICES MEDICARE
PAYS AFTER YOU PAY
$2200 DEDUCTIBLE***
PLAN PAYS
IN ADDITION TO $2200
DEDUCTIBLE*** YOU PAY
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-Approved amounts*
$0 $183 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*
$0 $183 (Part B Deductible)
$0
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
ACIMS01063AL 06/2017 A 17
HIGH DEDUCTIBLE PLAN F
PARTS A & B
SERVICES MEDICARE
PAYS AFTER YOU PAY
$2200 DEDUCTIBLE***
PLAN PAYS
IN ADDITION TO $2200
DEDUCTIBLE*** YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment First $183 of Medicare Approved amounts*
$0 $183 (Part B Deductible)
$0
Remainder of Medicare Approved amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE
PAYS AFTER YOU PAY
$2200 DEDUCTIBLE**
PLAN PAYS
IN ADDITION TO $2200
DEDUCTIBLE** YOU PAY
FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime
maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
ACIMS01063AL 06/2017 A 18
PLAN G MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day
Up to $164.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness services
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
ACIMS01063AL 06/2017 A 19
PLAN G MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-Approved amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare-Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
PARTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $183 of Medicare Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
ACIMS01063AL 06/2017 A 20
PLAN G
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime
maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
ACIMS01063AL 06/2017 A 21
PLAN N MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1316 $1316 (Part A Deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0 91st day and after While using 60 lifetime reserve days All but $658 a day $658 a day $0 Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare Eligible Expenses
$0**
Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE*
You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day
Up to $164.50 a day
$0
101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness services
All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/ coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
ACIMS01063AL 06/2017 A 22
PLAN N MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts
Generally 80%
Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The 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*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
ACIMS01063AL 06/2017 A 23
PLAN N
PARTS A & B
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
HOME HEALTH CARE – MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $183 of Medicare Approved amounts*
$0 $0 $183 (Part B Deductible)
Remainder of Medicare Approved amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS
PLAN PAYS
YOU PAY
FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum