Americo Application Packet Thank you for your interest in applying for the Americo Medicare Supplement plan! This application packet provides you with access to a printable copy of the Enrollment Form and the in addition to a link to the Choosing a Medigap Policy Guide. Should you decide to apply by mail/fax/email, the printable application needs to be reviewed and signed by an Agent before it can be submitted to Americo. You may upload, email, fax or mail it in to CDA Insurance: Fax: 1.541.284.2994 Email: cs@cda-insurance.com Secure File Upload: Click here Mail: CDA Insurance LLC PO Box 26540 Eugene, Oregon 97402 Other Important Information Download Medicare s Choosing a Medigap Policy Guide (.pdf) Download Policy Outline (.pdf) Download Application (.pdf) Our website: http://www.medicare-utah.net If you should have any questions on the application, please call us at 1.800.884.2343 or 1.541.434.9613.
This chart shows the benefits included in each of the standard Medicare Supplement plans. Every insurer must make available Plan A. Some plans may not be available in your state. See sections for details about ALL plans. Basic Benefits are: Hospitalization Part A coinsurance plus coverage for 365 additional days after Medicare Benefits end. Medical Expenses Part B coinsurance (generally 20% of Medicare approved amounts) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or copayments. First three pints of blood each year. Hospice Part A coinsurance Only Medicare Supplement Benefit Plans A, F, G, and N are offered by Americo Financial Life and Annuity Insurance Company. Basic including Part B A B C D F / F* G K L M N Basic including Part B Basic including Part B Skilled Nursing Facility Basic including Part B Skilled Nursing Facility Basic including Part B Skilled Nursing Facility Part A Deductible Part A Deductible Part A Part A Deductible Deductible Part B Deductible Part B Emergency Emergency Deductible Part B Excess Emergency Basic including Part B Skilled Nursing Facility Part A Deductible Part B Excess Emergency Hospitalization and preventative care paid at ; other Basic Benefits paid at 50% 50% Skilled Nursing Facility 50% Part A Deductible Out of Pocket limit $5,120; paid at after limit reached. Hospitalization and preventative care paid at ; other Basic Benefits paid at 75% 75% Skilled Nursing Facility 75% Part A Deductible Out of Pocket limit $2,560; paid at after limit reached. Basic including Part B Skilled Nursing Facility 50% Part A Deductible Emergency Basic including Part B, except up to $20 copayment for office visit, and up to $50 copayment for Emergency Room that don t result in inpatient admission. Skilled Nursing Facility Part A Deductible Emergency *Plan F also has an option called a high Deductible Plan F. This high Deductible plan pays the same benefits as Plan F after one has paid a calendar years $2,200 Deductible. Benefits from high Deductible Plan F will not begin until out-of-pocket expenses exceed $2,200. Out-of-pocket expenses for this Deductible are expenses that would have ordinarily been paid by the Policy. These expenses include the Medicare Deductibles for Part A and Part B, but do not include the plans separate foreign travel emergency Deductible. 1 of 13
Monthly Rates by Plan - Utah Zip Codes: All Zip Codes Non-Tobacco Rates Plan A Plan F Plan G Plan N Plan A Attained Age Tobacco Rates Plan F Plan G Plan N Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male 108.01 124.21 130.26 149.80 100.56 115.64 84.42 97.08 65 124.21 142.84 149.80 172.27 115.64 132.99 97.08 111.64 108.01 124.21 130.26 149.80 100.56 115.64 84.42 97.08 66 124.21 142.84 149.80 172.27 115.64 132.99 97.08 111.64 108.01 124.21 130.26 149.80 100.56 115.64 84.42 97.08 67 124.21 142.84 149.80 172.27 115.64 132.99 97.08 111.64 112.61 129.50 135.43 155.75 105.02 120.77 88.09 101.30 68 129.50 148.93 155.75 179.11 120.77 138.88 101.30 116.50 117.13 134.70 140.74 161.85 109.58 126.02 91.77 105.54 69 134.70 154.90 161.85 186.13 126.02 144.92 105.54 121.37 121.50 139.72 145.67 167.52 113.83 130.91 95.24 109.53 70 139.72 160.68 167.52 192.65 130.91 150.54 109.53 125.95 125.13 143.90 150.44 173.00 117.94 135.63 98.72 113.53 71 143.90 165.49 173.00 198.96 135.63 155.98 113.53 130.56 128.77 148.08 155.21 178.49 122.05 140.35 102.21 117.54 72 148.08 170.29 178.49 205.26 140.35 161.41 117.54 135.17 132.40 152.26 159.97 183.97 126.15 145.08 105.69 121.55 73 152.26 175.10 183.97 211.57 145.08 166.84 121.55 139.78 136.04 156.44 164.74 189.45 130.26 149.80 109.18 125.55 74 156.44 179.91 189.45 217.87 149.80 172.27 125.55 144.38 139.74 160.70 169.59 195.03 134.43 154.60 112.72 129.62 75 160.70 184.81 195.03 224.29 154.60 177.79 129.62 149.07 142.29 163.63 173.85 199.92 138.04 158.74 115.93 133.32 76 163.63 188.18 199.92 229.91 158.74 182.55 133.32 153.32 144.86 166.59 178.14 204.86 141.67 162.92 119.18 137.06 77 166.59 191.58 204.86 235.58 162.92 187.36 137.06 157.62 147.53 169.66 182.55 209.94 145.41 167.23 122.52 140.90 78 169.66 195.11 209.94 241.43 167.23 192.31 140.90 162.03 150.22 172.75 187.02 215.07 149.19 171.57 125.89 144.77 79 172.75 198.67 215.07 247.33 171.57 197.31 144.77 166.49 153.01 175.97 191.62 220.36 153.08 176.05 129.36 148.76 80 175.97 202.36 220.36 253.41 176.05 202.45 148.76 171.07 155.25 178.54 196.21 225.64 156.97 180.51 133.00 152.94 81 178.54 205.32 225.64 259.49 180.51 207.59 152.94 175.89 157.59 181.23 200.95 231.09 160.97 185.12 136.74 157.25 82 181.23 208.42 231.09 265.76 185.12 212.89 157.25 180.84 159.95 183.95 205.74 236.61 165.02 189.78 140.53 161.61 83 183.95 211.54 236.61 272.10 189.78 218.24 161.61 185.85 162.34 186.69 210.59 242.18 169.12 194.49 144.36 166.02 84 186.69 214.70 242.18 278.51 194.49 223.66 166.02 190.92 164.75 189.47 215.49 247.82 173.26 199.25 148.24 170.47 85 189.47 217.88 247.82 284.99 199.25 229.14 170.47 196.05 166.93 191.97 220.01 253.01 177.04 203.59 151.77 174.54 86 191.97 220.76 253.01 290.96 203.59 234.13 174.54 200.72 169.13 194.50 224.59 258.28 180.87 208.00 155.35 178.66 87 194.50 223.67 258.28 297.02 208.00 239.20 178.66 205.45 171.36 197.06 229.23 263.61 184.76 212.47 158.99 182.84 88 197.06 226.62 263.61 303.16 212.47 244.34 182.84 210.26 173.53 199.56 233.82 268.89 188.60 216.89 162.60 186.99 89 199.56 229.49 268.89 309.23 216.89 249.43 186.99 215.03 175.63 201.98 238.36 274.11 192.41 221.27 166.17 191.10 90 201.98 232.27 274.11 315.23 221.27 254.46 191.10 219.76 176.95 203.49 242.03 278.33 195.49 224.81 169.15 194.52 91 203.49 234.01 278.33 320.08 224.81 258.53 194.52 223.70 178.27 205.01 245.74 282.60 198.60 228.39 172.16 197.99 92 205.01 235.76 282.60 324.99 228.39 262.64 197.99 227.68 179.43 206.34 249.24 286.62 201.54 231.77 175.03 201.29 93 206.34 237.29 286.62 329.61 231.77 266.53 201.29 231.48 180.59 207.68 252.77 290.68 204.51 235.18 177.93 204.62 94 207.68 238.83 290.68 334.28 235.18 270.46 204.62 235.31 181.76 209.03 256.33 294.78 207.50 238.63 180.85 207.98 95 209.03 240.38 294.78 338.99 238.63 274.42 207.98 239.17 183.58 211.12 258.89 297.72 209.58 241.01 182.66 210.06 96 211.12 242.78 297.72 342.38 241.01 277.16 210.06 241.57 185.42 213.23 261.48 300.70 211.67 243.42 184.49 212.16 97 213.23 245.21 300.70 345.81 243.42 279.93 212.16 243.98 187.27 215.36 264.09 303.71 213.79 245.86 186.33 214.28 98 215.36 247.66 303.71 349.26 245.86 282.74 214.28 246.42 189.14 217.51 266.74 306.74 215.93 248.32 188.19 216.42 99 217.51 250.14 306.74 352.76 248.32 285.56 216.42 248.89 For Annual Premium mode, multiply monthly rates by 12. For Class 1 rates multiply by 1.15. AUT500-OC RATES Household Premium Discount of 10% may apply. See Household Premium Discount description. 2 of 13 Effective: 07/01/2017 RATES
Disclosures. Use this outline to compare benefits and premiums among policies. Premium Information. Americo Financial Life and Annuity Insurance Company can only raise your premium if we raise the premium for all policies like yours in the same geographic area of the state where you live. Until you are age 99, your premium may change each year. This change will only be made on the first renewal date that coincides with or follows each anniversary of the effective date. Schedules of rates may vary depending upon your effective date. Household Premium Discount. If you resided with at least one, but no more than three, other adults who are age 60 or older for the past year, you will be eligible for a household premium discount. The discounted premium will be priced 10% lower than the rates illustrated. Your policy's household premium discount will be removed if the other adult no longer resides with you (other than in the case of his or her death). 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 us. Right to Return Policy. If you find that you are not satisfied with your policy, you may return it to us at our Medicare Supplement Administrative Offices: PO Box 10812, Clearwater, FL 33757-8812. 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. The policy may not fully cover all of your medical costs. Neither we nor our agents are connected with Medicare. This outline 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. We may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded. No Health Review. No health review is required if you enroll within the first six months after you reach age 65 and enroll in Medicare Part B, or in other situations as required by law. PLEASE REFER TO YOUR POLICY FOR DETAILS. 3 of 13
Plan A Medicare Part A Hospital Services Per Benefit Period A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. Services Medicare Pays Plan A Pays You Pay Hospitalization Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,316 $1,316 Part A Deductible 61 st thru 90 th day All but $329 a day $329 a day 91 st day and after - While using 60 lifetime reserve days - Once lifetime reserve days are used Additional 365 days Beyond the additional 365 days 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 21 st thru 100 th days 101 st day and after Additional amounts Hospice Care You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but $658 a day All approved amounts All but $164.50 a day All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care. $658 a day of Medicare Eligible Expenses 3 pints ** Up to $164.50 a day Medicare copayment/coinsurance *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. Plan A 4 of 13
Plan A Medicare Part B Medical Services per Calendar Year Once you have been billed $183 of Medicare Eligible Expenses for covered services (which are noted with an asterisk), your Medicare Part B Deductible will have been met for the calendar year. Services Medicare Pays Plan A Pays You Pay Medical Expenses In or out of the hospital and outpatient hospital treatment, such as Physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare approved amounts* Generally Generally 20% Part B Excess Charges (above Medicare approved amounts) All costs Next $183 of Medicare approved amounts* All costs 20% Clinical Laboratory Services Tests for diagnostic services Parts A & B Services Medicare Pays Plan A Pays You Pay Home Health Care Medicare Eligible Services - Medically necessary skilled care services and medical supplies - Durable medical equipment. First $183 of Medicare approved amounts* - 20% Plan A 5 of 13
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 F Pays You Pay Hospitalization Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,316 $1,316 Part A Deductible 61 st thru 90 th day All but $329 a day $329 a day 91 st day and after - While using 60 lifetime reserve days - Once lifetime reserve days are used Additional 365 days Beyond the additional 365 days 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 21 st thru 100 th days 101 st day and after Additional amounts Hospice Care You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but $658 a day All approved amounts All but $164.50 a day All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care. $658 a day of Medicare Eligible Expenses Up to $164.50 a day 3 pints ** Medicare copayment/coinsurance **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. Plan F 6 of 13
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 Medicare Part B Deductible will have been met for the calendar year. Services Medicare Pays Plan F Pays You Pay Medical Expenses In or out of the hospital and outpatient hospital treatment, such as Physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare approved amounts* Generally Generally 20% Part B Excess Charges (above Medicare approved amounts) Next $183 of Medicare approved amounts* All costs $20% Clinical Laboratory Services Tests for Diagnostic services Parts A & B Services Medicare Pays Plan F Pays You Pay Home Health Care Medicare Eligible Services - Medically necessary skilled care services and medical supplies - Durable medical equipment. First $183 of Medicare approved amounts* - 20% Other Benefits Not Covered by Medicare Services Medicare Pays Plan F Pays You Pay Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA. First $250 each calendar year Remainder of charges to a lifetime maximum benefit of $50,000. $250 20% and amounts over the $50,000 lifetime maximum. Plan F 7 of 13
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 G Pays You Pay Hospitalization Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,316 $1,316 Part A Deductible 61 st thru 90 th day All but $329 a day $329 a day 91 st day and after - While using 60 lifetime reserve days - Once lifetime reserve days are used Additional 365 days Beyond the additional 365 days 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 21 st thru 100 days 101 st day and after Additional amounts Hospice Care You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but $658 a day All approved amounts All but $164.50 a day All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care. $658 a day of Medicare Eligible Expenses Up to $164.50 a day 3 pints ** Medicare copayment/coinsurance **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. Plan G 8 of 13
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 Medicare Part B Deductible will have been met for the calendar year. Services Medicare Pays Plan G Pays You Pay Medical Expenses In or out of the hospital and outpatient hospital treatment, such as Physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare approved amounts* Generally Generally 20% Part B Excess Charges (above Medicare approved amounts) Next $183 of Medicare approved amounts* All costs $20% Clinical Laboratory Services Tests for Diagnostic services Parts A & B Services Medicare Pays Plan G Pays You Pay Home Health Care Medicare Eligible Services - Medically necessary skilled care services and medical supplies - Durable medical equipment. First $183 of Medicare approved amounts* - 20% Plan G 9 of 13
Plan G Other Benefits Not Covered by Medicare Services Medicare Pays Plan G Pays You Pay Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA. First $250 each calendar year Remainder of Charges to a lifetime maximum benefit of $50,000. $250 20% and amounts over the $50,000 lifetime maximum. Plan G 10 of 13
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 N Pays You Pay Hospitalization Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,316 $1,316 Part A Deductible 61 st thru 90 th day All but $329 a day $329 a day 91 st day and after - While using 60 lifetime reserve days - Once lifetime reserve days are used Additional 365 days Beyond the additional 365 days 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 21 st thru 100 days 101 st day and after Additional amounts Hospice Care You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but $658 a day All approved amounts All but $164.50 a day All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care. $658 a day of Medicare Eligible Expenses Up to $164.50 a day 3 pints ** Medicare copayment/coinsurance **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. Plan N 11 of 13
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 Medicare Part B Deductible will have been met for the calendar year. Services Medicare Pays Plan N Pays You Pay Medical Expenses In or out of the hospital and outpatient hospital treatment, such as Physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare approved amounts* Generally 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) All costs Next $183 of Medicare approved amounts* All costs $20% Clinical Laboratory Services Tests for diagnostic services Parts A & B 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. Services Medicare Pays Plan N Pays You Pay Home Health Care Medicare Eligible Services - Medically necessary skilled care services and medical supplies - Durable medical equipment. First $183 of Medicare approved amounts - 20% Plan N 12 of 13
Plan N Other Benefits Not Covered by Medicare Services Medicare Pays Plan N Pays You Pay Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA. First $250 each calendar year Remainder of charges to a lifetime maximum benefit of $50,000. $250 20% and amounts over the $50,000 lifetime maximum. 13 of 13 Plan N