MediGap Plans A, C, F, & N

Transcription

1 MediGap Plans A, C, F, & N & MedSelect Plans C & N 2015 OUTLINE OF MEDICARE SUPPLEMENT COVERAGE

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3 BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD FOR EFFECTIVE DATES ON OR AFTER JANUARY 1, 2015 This chart shows the benefits included in each of the standard Medicare supplement plans that are offered by Paramount Insurance Company. The below benefits and premiums are effective on or after January 1, Basic Benefits: Hospitalization Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plan N require insureds to pay a portion of Part B coinsurance or copayments. Blood First three pints of blood each year. Hospice Part A coinsurance. Basic, including 100% Part B coinsurance A C C* F N N* Basic, including 100% Part B coinsurance Skilled nursing facility coinsurance Basic, including 100% Part B coinsurance Skilled nursing facility coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility coinsurance Part A deductible Part A deductible Part A deductible Part B deductible Part B deductible Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency * Medicare Select Plans C & N contain the same benefits as standardized Medicare Supplement Plans C & N, except for restrictions on your use of hospitals.

4 MEDICARE SUPPLEMENT PREMIUM INFORMATION THESE RATES ARE EFFECTIVE 01/01/2015 Paramount determines premiums for its Medicare supplement policies based upon attained age within fiveyear age bands. This means your premium will increase automatically as you get older, specifically, the January following the birthday on which you reached the new five-year age band. Your premium may also change if premiums for these policies change. Note: Medicare Select Plan C and Select Plan N are available in the following counties: Defiance, Fulton, Hancock, Henry, Lucas, Ottawa, Seneca, Williams and Wood. The Medicare Select Plans C & N rates listed below are applicable to these counties only. If you choose to pay directly by check, you will be billed monthly for the applicable premium listed below. If you choose to pay your premium through our automated bank deduction program, premiums will be withdrawn from your bank monthly. To find the amount of premium you will pay, find your year of birth in the first column, then choose the plan in which you are interested from one of the next six columns. Your Year of Birth MediGap Plan A MediGap Plan C MediGap Plan F MediGap Plan N MedSelect Plan C MedSelect Plan N $120 $172 $181 $141 $155 $ $144 $205 $217 $168 $186 $ $169 $241 $254 $198 $218 $ $199 $284 $299 $232 $256 $ and before $214 $305 $322 $250 $276 $227 2

5 MediGap Our MediGap product features: No designated network. You can see any Medicare-contracted provider in the USA. Must live in Ohio to enroll. It is transportable for when you vacation or move outside of Ohio. Does not include a drug card (Part D coverage). 3

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7 Paramount Insurance Company 1901 Indian Wood Circle Maumee, Ohio or MEDIGAP SUPPLEMENT COVERAGE BENEFIT PLANS A, C, F, & N PREMIUM INFORMATION We, Paramount Insurance Company, can only raise your premium if we raise the premium for all policies like yours in this state. Paramount determines premiums for its Medicare supplement policies based upon attained age within five-year age bands. This means your premium will increase automatically as you get older, specifically, the January following the birthday on which you reached the new five-year age band. DISCLOSURES Use this outline to compare benefits and premiums among policies. This outline shows benefits and premiums of policies sold for effective dates on or after January 1, Policies sold for effective dates prior to January 1, 2015, have different benefits and premiums. Plans E, H, I, and J are no longer available for sale. READ YOUR POLICY 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 Paramount Insurance Company at our address listed above. 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 of 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 This policy may not fully cover all of your medical costs. Neither Paramount 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 all 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. 5

8 MEDIGAP 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. HOSPITALIZATION* Services Medicare Pays Plan A Pays You Pay Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A Days All but $315 a day $315 a day Day 91 and after: While using 60 lifetime reserve days All but $630 a day $630 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicareeligible expenses Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital. First 20 days Days All approved amounts All but $ a day ** Up to $ a day Day 101 and after All costs BLOOD First three pints 3 pints Additional amounts 100% 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 ** 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. 6

9 MEDIGAP PLAN A MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $147 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. MEDICAL EXPENSES Services Medicare Pays Plan A Pays You Pay 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, and durable medical equipment. First $147 of Medicare-approved amounts* $147 (Part B Remainder of Medicare-approved amounts Generally 80% Generally 20% Part B Excess Charges (above Medicare-approved amounts) BLOOD All costs First three pints All costs Next $147 of Medicare-approved amounts* $147 (Part B Remainder of Medicare-approved amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services HOME HEALTH CARE Medicare-approved services Medically necessary skilled care services and medical supplies Durable medical equipment: First $147 of Medicare-approved amounts* 100% PARTS A & B 100% $147 (Part B Remainder of Medicare-approved amounts 80% 20% 7

10 MEDIGAP PLAN C 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. HOSPITALIZATION* Services Medicare Pays Plan C Pays You Pay Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A Days All but $315 a day $315 a day Day 91 and after: While using 60 lifetime reserve days All but $630 a day $630 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicareeligible expenses Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital. First 20 days Days All approved amounts All but $ a day ** 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. ** Up to $ a day Day 101 and after All costs BLOOD First three pints 3 pints Additional amounts 100% 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 8

11 MEDIGAP PLAN C MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $147 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. MEDICAL EXPENSES Services Medicare Pays Plan C Pays You Pay 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, and durable medical equipment. First $147 of Medicare-approved amounts* $147 (Part B Remainder of Medicare-approved amounts Generally 80% Generally 20% Part B Excess Charges (above Medicare-approved amounts) BLOOD All costs First three pints All costs Next $147 of Medicare-approved amounts* $147 (Part B Remainder of Medicare-approved amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services HOME HEALTH CARE Medicare-approved services Medically necessary skilled care services and medical supplies Durable medical equipment: First $147 of Medicare-approved amounts* 100% PARTS A & B 100% $147 (Part B Remainder of Medicare-approved amounts 80% 20% FOREIGN TRAVEL Not covered by Medicare Medical emergency care services beginning during the first 60 days of each trip outside of the USA. First $250 each calendar year OTHER BENEFITS NOT COVERED BY MEDICARE $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 9

12 MEDIGAP 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. HOSPITALIZATION* Services Medicare Pays Plan F Pays You Pay Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A Days All but $315 a day $315 a day Day 91 and after: While using 60 lifetime reserve days All but $630 a day $630 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicareeligible expenses Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital. First 20 days Days All approved amounts All but $ a day ** 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. ** Up to $ a day Day 101 and after All costs BLOOD First three pints 3 pints Additional amounts 100% 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 10

13 MEDIGAP PLAN F MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $147 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. MEDICAL EXPENSES Services Medicare Pays Plan F Pays You Pay 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, and durable medical equipment. First $147 of Medicare-approved amounts* $147 (Part B Remainder of Medicare-approved amounts Generally 80% Generally 20% Part B Excess Charges (above Medicare-approved amounts) BLOOD 100% First three pints All costs Next $147 of Medicare-approved amounts* $147 (Part B Remainder of Medicare-approved amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services HOME HEALTH CARE Medicare-approved services Medically necessary skilled care services and medical supplies Durable medical equipment: First $147 of Medicare-approved amounts* 100% PARTS A & B 100% $147 (Part B Remainder of Medicare-approved amounts 80% 20% FOREIGN TRAVEL Not covered by Medicare Medical emergency care services beginning during the first 60 days of each trip outside of the USA. First $250 each calendar year OTHER BENEFITS NOT COVERED BY MEDICARE $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 11

14 MEDIGAP 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. HOSPITALIZATION* Services Medicare Pays Plan N Pays You Pay Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A Days All but $315 a day $315 a day Day 91 and after: While using 60 lifetime reserve days All but $630 a day $630 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicareeligible expenses Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital. First 20 days Days All approved amounts All but $ a day ** 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. ** Up to $ a day Day 101 and after All costs BLOOD First three pints 3 pints Additional amounts 100% 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 12

15 MEDIGAP PLAN N MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $147 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. MEDICAL EXPENSES Services Medicare Pays Plan N Pays You Pay 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, and durable medical equipment. First $147 of Medicare-approved amounts* $147 (Part B 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. Part B Excess Charges (above Medicare-approved amounts) BLOOD All costs First three pints All costs 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. Next $147 of Medicare-approved amounts* $147 (Part B Remainder of Medicare-approved amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services 100% 13

16 HOME HEALTH CARE Medicare-approved services PARTS A & B Services Medicare Pays Plan N Pays You Pay Medically necessary skilled care services and medical supplies Durable medical equipment: First $147 of Medicare-approved amounts* 100% $147 (Part B Remainder of Medicare-approved amounts 80% 20% FOREIGN TRAVEL Not covered by Medicare Medical emergency care services beginning during the first 60 days of each trip outside of the USA. First $250 each calendar year MEDIGAP PLAN N OTHER BENEFITS NOT COVERED BY MEDICARE $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 14

17 MedSelect Our MedSelect product features: Allow use of any Medicare-contracted provider (physician, lab, radiology, skilled nursing facility). You must use a select list of hospitals. Must reside in one of the following counties: Defiance Fulton Hancock Henry Lucas Ottawa Wood Does not include a drug card (Part D). 15

18 MEDICARE SELECT PLANS C & N DISCLOSURES MEDICARE SELECT NETWORK HOSPITAL RESTRICTIONS Except as specified below, Part A and Part B (hospital or facility) benefits will not be paid for services provided at a hospital which is not a network hospital, and Part B (hospital or facility) benefits for outpatient surgery will only be provided if performed at a doctor s office, network hospital or outpatient surgery clinic which is owned, operated or has a written agreement with a network hospital to provide services. Full benefits of your coverage will be paid when: 1. Services are provided in the following places: a physician s office, another office setting (other than an outpatient surgery clinic) or a skilled nursing facility. 2. The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury or a condition, and it is not reasonable to obtain such services through the network hospital. 3. Required services are not available at a network hospital in your service area. The Part A and Part B deductible amounts, copayment amounts and coinsurance amounts are determined by Medicare. Network Hospitals A network hospital is one that has a written agreement with Paramount and has been designated by Paramount to provide hospital services insured under this policy. You may use any network hospital which is listed in the Network Hospital Directory. This directory is updated periodically. Paramount does not advise the purchase of a Medicare Select policy if you live more than 30 minutes from a network hospital unless the network hospital is the closest hospital to you. In addition, your physician(s) must have admitting privileges at a network hospital, or should be willing to refer you to a physician who does, in the event that you require hospitalization. Non-Network Hospital Admission Procedures Prior to admission to a non-network hospital, you, either directly or through your physician, should contact Paramount s Member Services department. The Member Services department will confirm whether the required services are available from a network hospital and, if not available, will assist you in locating a hospital that provides the necessary service. 16

19 RIGHT TO REPLACE YOUR MEDICARE SELECT PLAN You have the right to replace this Medicare Select supplemental insurance coverage with any other Medicare supplement plan offered by Paramount Insurance Company having the same or lesser benefits as your current coverage and which does not require the use of participating providers without providing evidence of insurability. If Paramount should discontinue the Medicare Select plan policy issued to you, you will be offered the opportunity to purchase the Paramount Medicare supplement policies in effect at the time of discontinuation without evidence of insurability. QUALITY ASSURANCE Paramount s quality improvement (QI) program provides a formal ongoing process by which Paramount and its participating providers utilize measurable indicators to monitor and evaluate the quality of clinical and administrative services provided to Paramount members. The program addresses both general medical and behavioral health care and services and the degree to which they are coordinated. It defines and facilitates a systematic approach to identify and pursue opportunities to improve services and to resolve identified problems. The quality improvement program is reviewed, updated and approved by the medical advisory council and the board of directors on an annual basis and by applicable regulatory bodies, as required. FILING A COMPLAINT OR GRIEVANCE If you have a complaint or grievance, please contact the Member Services department at or toll-free at (TTY ). You may also mail a written complaint or grievance to Paramount, Attention: Complaint/Appeals Department,1901 Indian Wood Circle, Maumee, OH, Paramount will document the substance of the complaint or grievance and research all relevant issues including aspects of clinical care involved. 17

20 PARAMOUNT SELECT PLANS C & N NETWORK HOSPITALS OUTPATIENT SURGICAL CENTERS NAME ProMedica Bay Park Hospital ProMedica Defiance Regional Hospital ProMedica Flower Hospital ProMedica Fostoria Community Hospital ADDRESS 2801 Bay Park Drive Oregon, OH Ralston Ave. Defiance, OH Harroun Road Sylvania, OH Van Buren St. Fostoria, OH PHONE DESCRIPTION & NUMBER HOURS OF OPERATION bed community hospital serving primarily Lucas, Ottawa and Wood counties. 24 hours a day, seven days a week bed community hospital serving primarily Defiance, Henry, Paulding, and Putnam counties. 24 hours a day, seven days a week bed hospital specializing in the areas of oncology and mental health services and primarily serving Fulton, Lenawee, Lucas, and Wood counties. 24 hours a day, seven days a week bed critical access hospital serving primarily Hancock, Seneca and Wood counties. Fulton County Health Center 725 Shoop Ave. Wauseon, OH Henry County Hospital SR 424 Napoleon, OH ProMedica Memorial Hospital 715 S. Taft Ave. Fremont, OH hours a day, seven days a week bed community hospital serving primarily Fulton and Williams counties. 24 hours a day, seven days a week bed community hospital serving primarily Henry and Wood counties. 24 hours a day, seven days a week bed hospital serving Sandusky county. Parkway Surgery Center 3500 Executive Pkwy. Toledo, OH hours a day, seven days a week Freestanding center with three operating suites available. Services are rendered 7 a.m. 4 p.m., Monday Friday. 18

21 NAME ProMedica St. Luke s Hospital ProMedica Toledo Hospital Toledo Clinic Outpatient Surgery Center ProMedica Wildwood Orthopaedic and Spine Hospital, A Division of ProMedica Toledo Hospital ProMedica Wildwood Surgical Center ADDRESS 5901 Monclova Road Maumee, OH N. Cove Blvd. Toledo, OH Secor Road Toledo, OH N. Reynolds Road Toledo, OH N. Reynolds Road, #190 Toledo, OH PHONE DESCRIPTION & NUMBER HOURS OF OPERATION bed community-based hospital serving primarily Lucas and Wood counties. 24 hours a day, seven days a week bed hospital/tertiary center with the following specialties: cardiac services, Level III neonatal services, Level I emergency services and serving primarily Defiance, Fulton, Henry, Lucas, Monroe, Sandusky, Seneca, and Wood counties. 24 hours a day, seven days a week Freestanding center with six operating suites available. Services are rendered 7:30 a.m. 3:30 p.m., Monday Friday The region s first dedicated orthopaedic hospital, with 36 patient rooms and six operating rooms. 24 hours a day, seven days a week Freestanding center with six operating suites available. Services are rendered 7:30 a.m. 6 p.m., Monday Friday. 19

22 MEDSELECT PLAN C MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD MedSelect Plan C contains the same benefits as standardized Medicare Supplement Plan C, except for restrictions on your hospital use. * 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. HOSPITALIZATION* Services Medicare Pays Plan C Pays You Pay Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A Days All but $315 a day $315 a day Day 91 and after: While using 60 lifetime reserve days All but $630 a day $630 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicareeligible expenses Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital. First 20 days Days All approved amounts All but $ a day ** 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. ** Up to $ a day Day 101 and after All costs BLOOD First three pints 3 pints Additional amounts 100% 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 20

23 MEDSELECT PLAN C MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR MedSelect Plan C contains the same benefits as standardized Medicare Supplement Plan C, except for restrictions on your hospital use. *Once you have been billed $147 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. MEDICAL EXPENSES Services Medicare Pays Plan C Pays You Pay 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, and durable medical equipment. First $147 of Medicare-approved amounts* $147 (Part B Remainder of Medicare-approved amounts Generally 80% Generally 20% Part B Excess Charges (above Medicare-approved amounts) BLOOD All costs First three pints All costs Next $147 of Medicare-approved amounts* $147 (Part B Remainder of Medicare-approved amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services HOME HEALTH CARE Medicare-approved services Medically necessary skilled care services and medical supplies Durable medical equipment: First $147 of Medicare-approved amounts* 100% PARTS A & B 100% $147 (Part B Remainder of Medicare-approved amounts 80% 20% FOREIGN TRAVEL Not covered by Medicare Medical emergency care services beginning during the first 60 days of each trip outside of the USA. First $250 each calendar year OTHER BENEFITS NOT COVERED BY MEDICARE $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum

24 22 MEDSELECT PLAN N MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD MedSelect Plan N contains the same benefits as standardized Medicare Supplement Plan N, except for restrictions on your hospital use. * 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. HOSPITALIZATION* Services Medicare Pays Plan N Pays You Pay Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A Days All but $315 a day $315 a day Day 91 and after: While using 60 lifetime reserve days All but $630 a day $630 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicareeligible expenses Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital. First 20 days Days All approved amounts All but $ a day ** 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. ** Up to $ a day Day 101 and after All costs BLOOD First three pints 3 pints Additional amounts 100% 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

25 MEDSELECT PLAN N MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR MedSelect Plan N contains the same benefits as standardized Medicare Supplement Plan N, except for restrictions on your hospital use. *Once you have been billed $147 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. MEDICAL EXPENSES Services Medicare Pays Plan N Pays You Pay 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, and durable medical equipment. First $147 of Medicare-approved amounts* $147 (Part B 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. Part B Excess Charges (above Medicare-approved amounts) BLOOD All costs First three pints All costs 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. Next $147 of Medicare-approved amounts* $147 (Part B Remainder of Medicare-approved amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services 100% 23

26 HOME HEALTH CARE Medicare-approved services PARTS A & B Services Medicare Pays Plan N Pays You Pay Medically necessary skilled care services and medical supplies Durable medical equipment: First $147 of Medicare-approved amounts* 100% $147 (Part B Remainder of Medicare-approved amounts 80% 20% FOREIGN TRAVEL Not covered by Medicare Medical emergency care services beginning during the first 60 days of each trip outside of the USA. First $250 each calendar year MEDSELECT PLAN N OTHER BENEFITS NOT COVERED BY MEDICARE $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 24

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28 2014 Paramount Insurance Company