AARP Medicare Supplement Application - Colorado Health Agents

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Outline of Coverage | UnitedHealthcare Insurance Company Plan Benefit Tables: Plan L (continued) Medicare Part B: Medical Services per Calendar Year Service Medicare Pays Plan L Pays You Pay 4 Medical Expenses INCLUDES TREATMENT 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. Part B Excess Charges Above Medicare-approved amounts Parts A and B Preventive Benefits for Medicare Covered Services Remainder of Medicare-approved amounts Generally 75% or more of Medicareapproved amounts Remainder of Medicareapproved amounts First $147 of $0 $0 $147 amounts 5 deduct- Medicare-approved (Part B ible) 5 All costs above Medicareapproved amounts Generally 80% Generally 15% Generally 5% $0 $0 All Costs (and they do not count toward annual out-of-pocket limit of $2400) 4 Blood First 3 pints $0 75% 25% Next $147 of $0 $0 $147 Medicare-approved (Part B amounts 5 deductible) 5 Remainder of Medicare-approved Generally 80% Generally 15% Generally 5% amounts Clinical Laboratory Services Tests for diagnostic services 100% $0 $0 Service Medicare Pays Plan L Pays You Pay 4 Home Health Care Medicare-approved services Medically necessary skilled care services and medical supplies Notes 4 This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2400 per 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. 100% $0 $0 Continued on next page 5 Once you have been billed $147 of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year. ▲ 0000001 0000021 0042 0074 UMS1129 01 L
Outline of Coverage | UnitedHealthcare Insurance Company Plan Benefit Tables: Plan L (continued) Parts A and B Service Medicare Pays Plan L Pays You Pay 4 Durable medical equipment Medicare-approved services First $147 of Medicare-approved amounts 6 $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts 80% 15% 5% Notes 6 Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. BT30 1/13 0000001 0000022 0043 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 41: 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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