AARP Medicare Supplement Application - Colorado Health Agents

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Outline of Coverage | UnitedHealthcare Insurance Company Plan Benefit Tables: Plan N (continued) Medicare Part B: Medical Services per Calendar Year Service Medicare Pays Plan N Pays You Pay 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. Parts A and B Service Medicare Pays Plan N Pays You Pay Notes 3 Once you have been billed $147 of Medicareapproved amounts for covered services, your Part B deductible will have been met for the calendar year. First $147 of $0 $0 $147 amounts 3 deductible) Medicare-approved (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 co-payment of up to $50 is waived if you are 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 you are admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. Part B Excess Charges $0 $0 All costs Above Medicare-approved amounts Blood First 3 pints $0 All costs $0 Next $147 of Medicare-approved amounts 3 $0 $0 $147 (Part B deductible) Remainder of 80% 20% $0 Medicare-approved amounts Clinical Laboratory Services Tests for diagnostic services 100% $0 $0 Home Health Care Medicare-approved services Medically necessary skilled care services and medical supplies 100% $0 $0 Continued on next page ▲ 0000001 0000023 0046 0074 UMS1129 01 L
Outline of Coverage | UnitedHealthcare Insurance Company Plan Benefit Tables: Plan N (continued) Parts A and B, continued Service Medicare Pays Plan N Pays You Pay Durable Medical Equipment Medicare-approved services Remainder of Medicare-approved amounts Other Benefits not covered by Medicare Foreign Travel NOT COVERED BY MEDICARE - Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA. First $147 of $0 $0 $147 amounts 3 deductible) Medicare-approved (Part B First $250 each calendar year Remainder of charges 80% 20% $0 $0 $0 $250 $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum BT31 1/13 0000001 0000024 0047 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 45: 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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