AARP Medicare Supplement Application - Colorado Health Agents

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0000001 0000020 0040 0074 UMS1129 01 L
Outline of Coverage | UnitedHealthcare Insurance Company Plan Benefit Tables: Plan L Medicare Part A: Hospital Services per Benefit Period 1 Service Medicare Pays Plan L Pays You Pay 3 Hospitalization 1 Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,184 $888 (75% of Part A deductible) Days 61–90 All but $296 per day $296 per day $0 Days 91 and later while using 60 lifetime reserve days After lifetime reserve days are used, an additional 365 days Beyond the additional 365 days All but $592 per day $592 per day $0 $0 100% of Medicare eligible expenses $296 (25% of Part A deductible) $0 2 $0 $0 All costs Skilled Nursing Facility Care 1 You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 Days 21–100 All but $148 per day Up to $111 per day Up to $37 per day Days 101 and later $0 $0 All costs Blood First 3 pints $0 75% 25% Hospice Care Available as long as you meet Medicare’s requirements, your doctor certifies you are terminally ill and you elect to receive these services. Additional amounts 100% $0 $0 All but very limited co-payment/ co-insurance for outpatient drugs and inpatient respite care 75% of co-payment/ co-insurance 25% of Medicare co-payment/ coinsurance Notes 1 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. 2 NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in 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. Continued on next page 3 You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-ofpocket limit of $2400 each calendar year. The amounts that count toward your annual limit are noted with diamonds () in the chart above. Once you reach the annual limit, the plan pays 100% of the Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. ▲ BT30 1/13 0000001 0000021 0041 0074 UMS1129 01 L
Page 1 and 2: Colorado AARP Medicare Supplement I
Page 3 and 4: Instructions Page Please Read Befor
Page 5 and 6: Hello, Thank you for your interest
Page 7 and 8: Your Plans and Rates AARP ® Medica
Page 9 and 10: Cover Page - Rates for Colorado - A
Page 25 and 26: Outline of Coverage | UnitedHealthc
Page 27 and 28: Your Guide to AARP Medicare Supplem
Page 39: Outline of Coverage | UnitedHealthc
Page 51 and 52: Your Exclusive Member Services. Get
Page 53 and 54: Enrollment Checklist In the followi
Page 55 and 56: Application Form AARP ® Medicare S
Page 57 and 58: 5 Answer these health questions to
Page 59 and 60: 7 Tell us about your past and curre
Page 61 and 62: 8 Authorization and Verification of
Page 63 and 64: AARP membership offers so much for
Page 65 and 66: Save $24 a year with the Electronic
Page 67 and 68: Save $24 a year with the Electronic
Page 69 and 70: NOTICE TO APPLICANT REGARDING REPLA
Page 71 and 72: 0000001 0000036 0071 0074 UMS1129 0
Page 73 and 74: Thank You for Applying for an AARP

AARP Medicare Supplement Application - Colorado Health Agents

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