UnitedHealthcare Insurance Company
OUTLINE OF COVERAGE
Benefit Plans A, B, C, F, G, K, L, N, Select G, Select N
Benefit Chart of Medicare Supplement Plans Sold on or after January 1, 2020
NOTICE TO BUYER: This policy may not cover all of the costs associated with medical care incurred by the
buyer during the period of coverage. The buyer is advised to review carefully all policy limitations.
Benefits
Plans Available to All Applicants
Medicare
first eligible
before 2020
only+
A
B D G
1
K L M N
C F
1
Medicare Part A coinsurance
and hospital coverage (up to
an additional 365 days after
Medicare benefits are used up)
Medicare Part B coinsurance
or Copayment
50%
75%
copays
apply
3
Blood (first three pints)
50% 75%
Part A hospice care
coinsurance or copayment
50% 75%
Skilled nursing facility
coinsurance
50% 75%
Medicare Part A deductible
50% 75% 50%
Medicare Part B deductible
Medicare Part B excess
charges
Foreign travel emergency
(up to plan limits)
Out-of-pocket limit in 2020
2
2
$5880
2
$2940
Note: A means 100% of this benefit is paid. +Only applicants first eligible for Medicare before
January 1, 2020 may purchase Plans C, F, and high deductible F. This chart shows the benefits included in
each of the standard Medicare supplement plans. Some plans may not be available. Every company must make
Plan “A” available.
1 -
Plans F and G also have a high deductible option which require first paying a plan deductible of $2340
before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the
rest of the calendar year. High deductible Plans F and G do not cover the separate Foreign travel emergency
deductible. High deductible Plan G does not cover the Medicare Part B deductible. However, high deductible
Plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.
-
2
Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-
pocket yearly limit.
-
3
Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and
up to a $50 co-payment for emergency room visits that do not result in an inpatient admission.
Medicare Select Plans G and N contain the same benefits as standardized Medicare Supplement Plans G
and N, except for restrictions on your use of hospitals.
OOCFL6 POV57 S 1/20
Hospitalization
Medical Expenses
Blood
Hospice
If you find that you are not satisfied with your coverage, you may return the certificate to:
never been issued and return all of your premium payments.
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security
Office or consult Medicare and You
and it is NOT
status application,” be sure to answer truthfully and completely all questions about your medical and health
application are correct and complete. The company may cancel your certificate and refuse to pay any claims if
To review “Open Enrollment”
BASIC BENEFITS
– Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
– Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for
outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or co-payments.
– First three pints of blood each year.
– Part A coinsurance.
PREMIUM INFORMATION
We, UnitedHealthcare Insurance Company, can only raise your premium if we raise the premium for all plans
like yours in the state of Florida
READ YOUR POLICY VERY CAREFULLY
This is only an outline describing your certificate’s most important features. The certificate is your insurance
contract. You must read the certificate itself to understand all of the rights and duties of both you and your
insurance company.
RIGHT TO RETURN THE CERTIFICATE
UnitedHealthcare
PO BOX 30607
Salt Lake City, UT 84130-0607
If you send the certificate back to us within 30 days after you receive it, we will treat the certificate as if it had
NOTICE
Neither UnitedHealthcare Insurance Company, nor its agents are connected with Medicare.
for more details. Use this outline to compare benefits and premiums
among policies.
POLICY REPLACEMENT
If you are replacing another health insurance policy, do NOT cancel it until you have actually received your
new certificate and are sure you want to keep it.
COMPLETE ANSWERS ARE VERY IMPORTANT
When you fill out the application for the new certificate an “Open Enrollment or Guaranteed Issue
history. The certificate is issued on the basis that the answers to all questions and all information shown in the
you make misstatements, you leave out or falsify important information. Review the application carefully before
you sign it. Be certain that all information has been properly recorded.
timeframes please go to the following link on the Medicare.gov website:
https://www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/when-can-i-buy-
medigap.html
OOCFL6 RD74 S
Grievance Procedure
UnitedHealthcare has established a formal procedure to respond to
method of evaluating and resolving complaints and griev
a
Complaint and Grievance Procedure -
customer complaints and grievances. UnitedHealthcare desires to provide a fair, accessible and responsive
action that it has taken was incorrect, corrective action will
complaint to the Department of Insurance in your state.
Complaints - If you have a complaint, you may call us at
PO BOX 740807, Atlanta, GA 30374-0807. We will ackno
respond to all complaints within a reasonable period of tim
-
ri
r
a
a
s
n
Grievances If you are dissatisfied with our handling of
any other reason, you may submit a formal grievance. G
"this is a grievance" to ensure that we understand the pu
the nature of the grievance and send it to: UnitedHealthc
will acknowledge in writing all grievances within 15 days
period of time. All grievances must be filed within 60 day
denial of benefits or other action giving rise to the grieva
ances. If UnitedHealthcare determines that any prior
be taken. You may, at any time, submit a written
1-800-523-5880 or write to us at UnitedHealthcare,
wledge all complaints within 15 days and will
e.
complaint or a claim denial, or are dissatisfied for
evances must be in writing and contain the words
pose of the communication. You must clearly state
re, PO BOX 740807, Atlanta, GA 30374-0807. We
nd respond to all grievances within a reasonable
or as soon as reasonably possible from the date of
ce.
OOCFL6 RD74 S
RP250FLGRS_OOCFL6_1020
Cover Page - Rates
Female Non-Tobacco Monthly Plan Rates for Florida - Area 1
AARP
®
Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Plans Available to All Applicants
Medicare first eligible
before 2020 only
2
Female Non-Tobacco Standard Rates
Age
1
Plan A Plan B Plan G Select G
3
Plan K Plan L Plan N Select N
3
Plan C
2
Plan F
2
50-64
$810.64 $954.61 $1,029.80 $952.56 $397.97 $663.41 $802.80 $742.60 $1,106.00 $1,112.44
65 $201.60 $244.20 $243.22 $224.99 $88.99 $169.89 $199.68 $184.70 $283.06 $284.75
66 $208.33 $252.36 $251.35 $232.50 $91.97 $175.57 $206.35 $190.87 $292.52 $294.27
67 $216.57 $262.33 $261.28 $241.69 $95.60 $182.50 $214.51 $198.42 $304.08 $305.90
68 $224.55 $272.00 $270.92 $250.60 $99.12 $189.23 $222.41 $205.73 $315.29 $317.17
69 $232.79 $281.98 $280.85 $259.79 $102.76 $196.17 $230.57 $213.27 $326.85 $328.80
70 $240.52 $291.35 $290.18 $268.42 $106.17 $202.69 $238.23 $220.36 $337.71 $339.73
71 $248.25 $300.71 $299.51 $277.06 $109.59 $209.21 $245.89 $227.45 $348.57 $350.65
72 $255.74 $309.78 $308.54 $285.41 $112.89 $215.52 $253.30 $234.30 $359.08 $361.22
73 $263.47 $319.15 $317.88 $294.04 $116.31 $222.03 $260.96 $241.39 $369.94 $372.15
74 $270.46 $327.61 $326.30 $301.84 $119.39 $227.92 $267.88 $247.79 $379.74 $382.02
75 $277.95 $336.68 $335.34 $310.19 $122.69 $234.23 $275.30 $254.65 $390.25 $392.59
76 $284.68 $344.84 $343.46 $317.71 $125.67 $239.91 $281.97 $260.82 $399.71 $402.10
77 $291.92 $353.60 $352.19 $325.78 $128.86 $246.00 $289.14 $267.45 $409.87 $412.32
78 $294.66 $356.93 $355.50 $328.85 $130.07 $248.32 $291.86 $269.96 $413.72 $416.20
79 $294.66 $356.93 $355.50 $328.85 $130.07 $248.32 $291.86 $269.96 $413.72 $416.20
80+ $322.11 $390.17 $388.62 $359.48 $142.19 $271.44 $319.04 $295.11 $452.26 $454.97
The rates above are for plan effective dates from January 2020 - May 2021 and may change.
OOCFL6 MRP0196 FLA 10-20
RP250FLGRS_OOCFL6_1020
Cover Page - Rates
Female Tobacco Monthly Plan Rates for Florida - Area 1
AARP
®
Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Plans Available to All Applicants
Medicare first eligible
before 2020 only
2
Female Tobacco Standard Rates
Age
1
Plan A Plan B Plan G Select G
3
Plan K Plan L Plan N Select N
3
Plan C
2
Plan F
2
50-64
$891.70 $1,050.07 $1,132.78 $1,047.81 $437.76 $729.75 $883.08 $816.86 $1,216.60 $1,223.68
65 $221.76 $268.62 $267.54 $247.48 $97.88 $186.87 $219.64 $203.17 $311.36 $313.22
66 $229.16 $277.59 $276.48 $255.75 $101.16 $193.12 $226.98 $209.95 $321.77 $323.69
67 $238.22 $288.56 $287.40 $265.85 $105.16 $200.75 $235.96 $218.26 $334.48 $336.49
68 $247.00 $299.20 $298.01 $275.66 $109.03 $208.15 $244.65 $226.30 $346.81 $348.88
69 $256.06 $310.17 $308.93 $285.76 $113.03 $215.78 $253.62 $234.59 $359.53 $361.68
70 $264.57 $320.48 $319.19 $295.26 $116.78 $222.95 $262.05 $242.39 $371.48 $373.70
71 $273.07 $330.78 $329.46 $304.76 $120.54 $230.13 $270.47 $250.19 $383.42 $385.71
72 $281.31 $340.75 $339.39 $313.95 $124.17 $237.07 $278.63 $257.73 $394.98 $397.34
73 $289.81 $351.06 $349.66 $323.44 $127.94 $244.23 $287.05 $265.52 $406.93 $409.36
74 $297.50 $360.37 $358.93 $332.02 $131.32 $250.71 $294.66 $272.56 $417.71 $420.22
75 $305.74 $370.34 $368.87 $341.20 $134.95 $257.65 $302.83 $280.11 $429.27 $431.84
76 $313.14 $379.32 $377.80 $349.48 $138.23 $263.90 $310.16 $286.90 $439.68 $442.31
77 $321.11 $388.96 $387.40 $358.35 $141.74 $270.60 $318.05 $294.19 $450.85 $453.55
78 $324.12 $392.62 $391.05 $361.73 $143.07 $273.15 $321.04 $296.95 $455.09 $457.82
79 $324.12 $392.62 $391.05 $361.73 $143.07 $273.15 $321.04 $296.95 $455.09 $457.82
80+ $354.32 $429.18 $427.48 $395.42 $156.40 $298.58 $350.94 $324.62 $497.48 $500.46
The rates above are for plan effective dates from January 2020 - May 2021 and may change.
OOCFL6 MRP0196 FLA 10-20
RP250FLGRS_OOCFL6_1020
Cover Page - Rates
Male Non-Tobacco Monthly Plan Rates for Florida - Area 1
AARP
®
Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Plans Available to All Applicants
Medicare first eligible
before 2020 only
2
Male Non-Tobacco Standard Rates
Age
1
Plan A Plan B Plan G Select G
3
Plan K Plan L Plan N Select N
3
Plan C
2
Plan F
2
50-64
$843.90 $993.77 $1,072.04 $991.64 $414.30 $690.63 $835.74 $773.06 $1,151.38 $1,158.08
65 $209.87 $254.22 $253.20 $234.22 $92.64 $176.86 $207.87 $192.28 $294.67 $296.43
66 $216.88 $262.71 $261.66 $242.04 $95.74 $182.77 $214.82 $198.70 $304.52 $306.34
67 $225.45 $273.09 $272.00 $251.61 $99.52 $189.99 $223.31 $206.56 $316.55 $318.44
68 $233.76 $283.16 $282.03 $260.88 $103.19 $197.00 $231.54 $214.17 $328.22 $330.18
69 $242.34 $293.54 $292.37 $270.45 $106.97 $204.22 $240.03 $222.02 $340.26 $342.29
70 $250.39 $303.30 $302.09 $279.44 $110.53 $211.00 $248.00 $229.40 $351.56 $353.66
71 $258.44 $313.05 $311.80 $288.42 $114.08 $217.79 $255.98 $236.78 $362.87 $365.04
72 $266.23 $322.49 $321.20 $297.12 $117.52 $224.36 $263.70 $243.92 $373.81 $376.04
73 $274.28 $332.24 $330.92 $306.10 $121.08 $231.14 $271.67 $251.29 $385.11 $387.42
74 $281.56 $341.05 $339.69 $314.22 $124.29 $237.27 $278.87 $257.96 $395.32 $397.69
75 $289.35 $350.49 $349.09 $322.92 $127.73 $243.84 $286.59 $265.09 $406.26 $408.70
76 $296.36 $358.99 $357.55 $330.74 $130.82 $249.75 $293.54 $271.52 $416.11 $418.60
77 $303.89 $368.11 $366.64 $339.15 $134.15 $256.10 $301.00 $278.42 $426.69 $429.24
78 $306.75 $371.57 $370.09 $342.34 $135.41 $258.50 $303.83 $281.04 $430.70 $433.28
79 $306.75 $371.57 $370.09 $342.34 $135.41 $258.50 $303.83 $281.04 $430.70 $433.28
80+ $335.32 $406.18 $404.56 $374.22 $148.02 $282.58 $332.13 $307.22 $470.81 $473.63
The rates above are for plan effective dates from January 2020 - May 2021 and may change.
OOCFL6 MRP0196 FLA 10-20
RP250FLGRS_OOCFL6_1020
Cover Page - Rates
Male Tobacco Monthly Plan Rates for Florida - Area 1
AARP
®
Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Plans Available to All Applicants
Medicare first eligible
before 2020 only
2
Male Tobacco Standard Rates
Age
1
Plan A Plan B Plan G Select G
3
Plan K Plan L Plan N Select N
3
Plan C
2
Plan F
2
50-64
$928.29 $1,093.14 $1,179.24 $1,090.80 $455.73 $759.69 $919.31 $850.36 $1,266.51 $1,273.88
65 $230.85 $279.64 $278.52 $257.64 $101.90 $194.54 $228.65 $211.50 $324.13 $326.07
66 $238.56 $288.98 $287.82 $266.24 $105.31 $201.04 $236.30 $218.57 $334.97 $336.97
67 $247.99 $300.39 $299.20 $276.77 $109.47 $208.98 $245.64 $227.21 $348.20 $350.28
68 $257.13 $311.47 $310.23 $286.96 $113.50 $216.70 $254.69 $235.58 $361.04 $363.19
69 $266.57 $322.89 $321.60 $297.49 $117.66 $224.64 $264.03 $244.22 $374.28 $376.51
70 $275.42 $333.63 $332.29 $307.38 $121.58 $232.10 $272.80 $252.34 $386.71 $389.02
71 $284.28 $344.35 $342.98 $317.26 $125.48 $239.56 $281.57 $260.45 $399.15 $401.54
72 $292.85 $354.73 $353.32 $326.83 $129.27 $246.79 $290.07 $268.31 $411.19 $413.64
73 $301.70 $365.46 $364.01 $336.71 $133.18 $254.25 $298.83 $276.41 $423.62 $426.16
74 $309.71 $375.15 $373.65 $345.64 $136.71 $260.99 $306.75 $283.75 $434.85 $437.45
75 $318.28 $385.53 $383.99 $355.21 $140.50 $268.22 $315.24 $291.59 $446.88 $449.57
76 $325.99 $394.88 $393.30 $363.81 $143.90 $274.72 $322.89 $298.67 $457.72 $460.46
77 $334.27 $404.92 $403.30 $373.06 $147.56 $281.71 $331.10 $306.26 $469.35 $472.16
78 $337.42 $408.72 $407.09 $376.57 $148.95 $284.35 $334.21 $309.14 $473.77 $476.60
79 $337.42 $408.72 $407.09 $376.57 $148.95 $284.35 $334.21 $309.14 $473.77 $476.60
80+ $368.85 $446.79 $445.01 $411.64 $162.82 $310.83 $365.34 $337.94 $517.89 $520.99
The rates above are for plan effective dates from January 2020 - May 2021 and may change.
OOCFL6 MRP0196 FLA 10-20
1 Your age as of your plan effective date. Your rate will always be based on your age on your effective date.
2 IMPORTANT: Only applicants first eligible for Medicare before January 1, 2020 may purchase Plans C and F.
Applicants first eligible for Medicare before 1/1/2020 have (a) a 65th birthday prior to 1/1/2020 or (b) a Medicare Part A effective date prior to 1/1/2020.
3 You must use a network hospital with Select Plans G and N.
RP250FLGRS_OOCFL6_1020
OOCFL6 MRP0196 FLA 10-20
0)
0
FLORIDA Area 1 ZIP Codes
The ZIP Codes Below Apply to Rates Included on the Page Headed “Cover Page – Rates
33002
33004
33008
33009
33010
33011
33012
33013
33014
33015
33016
33017
33018
33019
33020
33021
33022
33023
33024
33025
33026
33027
33028
33029
33030
33031
33032
33033
33034
33035
33039
33054
33055
33056
33060
33061
33062
33063
33064
33065
33066
33067
SA5074
33068
33069
33071
33072
33073
33074
33075
33076
33077
33081
33082
33083
33084
33090
33092
33093
33097
33101
33102
33106
33109
33111
33112
33114
33116
33119
33122
33124
33125
33126
33127
33128
33129
33130
33131
33132
33133
33134
33135
33136
33137
33138
FA (07-2
33139
33140
33141
33142
33143
33144
33145
33146
33147
33149
33150
33151
33152
33153
33154
33155
33156
33157
33158
33160
33161
33162
33163
33164
33165
33166
33167
33168
33169
33170
33172
33173
33174
33175
33176
33177
33178
33179
33180
33181
33182
33183
-20)
33184
33185
33186
33187
33188
33189
33190
33191
33192
33193
33194
33195
33196
33197
33198
33199
33206
33222
33231
33233
33234
33238
33239
33242
33243
33245
33247
33255
33256
33257
33261
33265
33266
33269
33280
33283
33296
33299
33301
33302
33303
33304
R
33305
33306
33307
33308
33309
33310
33311
33312
33313
33314
33315
33316
33317
33318
33319
33320
33321
33322
33323
33324
33325
33326
33327
33328
33329
33330
33331
33332
33334
33335
33336
33337
33338
33339
33340
33345
33346
33348
33349
33351
33355
33359
P250FL
33388
33394
33401
33402
33403
33404
33405
33406
33407
33408
33409
33410
33411
33412
33413
33414
33415
33416
33417
33418
33419
33420
33421
33422
33424
33425
33426
33427
33428
33429
33430
33431
33432
33433
33434
33435
33436
33437
33438
33441
33442
33443
GRS_OO
33444
33445
33446
33448
33449
33454
33458
33459
33460
33461
33462
33463
33464
33465
33466
33467
33468
33469
33470
33472
33473
33474
33476
33477
33478
33480
33481
33482
33483
33484
33486
33487
33488
33493
33496
33497
33498
33499
CFL6_102
Page 1 of 1
RP250FLGRS_OOCFL6_1020
Cover Page - Rates
Female Non-Tobacco Monthly Plan Rates for Florida - Area 2
AARP
®
Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Plans Available to All Applicants
Medicare first eligible
before 2020 only
2
Female Non-Tobacco Standard Rates
Age
1
Plan A Plan B Plan G Select G
3
Plan K Plan L Plan N Select N
3
Plan C
2
Plan F
2
50-64
$570.69 $672.05 $724.98 $670.60 $280.17 $467.04 $565.17 $522.79 $778.63 $783.16
65 $141.93 $171.92 $171.23 $158.39 $62.65 $119.60 $140.57 $130.03 $199.27 $200.46
66 $146.67 $177.66 $176.95 $163.68 $64.74 $123.60 $145.27 $134.37 $205.93 $207.16
67 $152.46 $184.68 $183.94 $170.15 $67.30 $128.48 $151.01 $139.68 $214.07 $215.35
68 $158.08 $191.49 $190.73 $176.42 $69.78 $133.22 $156.58 $144.83 $221.96 $223.29
69 $163.88 $198.51 $197.72 $182.89 $72.34 $138.10 $162.32 $150.14 $230.10 $231.48
70 $169.33 $205.11 $204.29 $188.97 $74.75 $142.69 $167.71 $155.13 $237.75 $239.17
71 $174.77 $211.70 $210.86 $195.05 $77.15 $147.28 $173.11 $160.12 $245.39 $246.86
72 $180.04 $218.09 $217.22 $200.93 $79.48 $151.72 $178.33 $164.95 $252.79 $254.30
73 $185.49 $224.68 $223.78 $207.00 $81.88 $156.31 $183.72 $169.94 $260.43 $261.99
74 $190.40 $230.64 $229.72 $212.49 $84.05 $160.46 $188.59 $174.44 $267.34 $268.94
75 $195.67 $237.02 $236.08 $218.37 $86.38 $164.90 $193.81 $179.27 $274.74 $276.38
76 $200.42 $242.77 $241.80 $223.67 $88.47 $168.89 $198.51 $183.62 $281.40 $283.08
77 $205.51 $248.94 $247.94 $229.35 $90.72 $173.19 $203.55 $188.28 $288.55 $290.28
78 $207.44 $251.28 $250.27 $231.51 $91.57 $174.81 $205.47 $190.05 $291.26 $293.01
79 $207.44 $251.28 $250.27 $231.51 $91.57 $174.81 $205.47 $190.05 $291.26 $293.01
80+ $226.76 $274.68 $273.59 $253.07 $100.10 $191.10 $224.60 $207.76 $318.39 $320.30
The rates above are for plan effective dates from January 2020 - May 2021 and may change.
OOCFL6 MRP0196 FLB 10-20
RP250FLGRS_OOCFL6_1020
Cover Page - Rates
Female Tobacco Monthly Plan Rates for Florida - Area 2
AARP
®
Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Plans Available to All Applicants
Medicare first eligible
before 2020 only
2
Female Tobacco Standard Rates
Age
1
Plan A Plan B Plan G Select G
3
Plan K Plan L Plan N Select N
3
Plan C
2
Plan F
2
50-64
$627.75 $739.25 $797.47 $737.66 $308.18 $513.74 $621.68 $575.06 $856.49 $861.47
65 $156.12 $189.11 $188.35 $174.22 $68.91 $131.56 $154.62 $143.03 $219.19 $220.50
66 $161.33 $195.42 $194.64 $180.04 $71.21 $135.96 $159.79 $147.80 $226.52 $227.87
67 $167.70 $203.14 $202.33 $187.16 $74.03 $141.32 $166.11 $153.64 $235.47 $236.88
68 $173.88 $210.63 $209.80 $194.06 $76.75 $146.54 $172.23 $159.31 $244.15 $245.61
69 $180.26 $218.36 $217.49 $201.17 $79.57 $151.91 $178.55 $165.15 $253.11 $254.62
70 $186.26 $225.62 $224.71 $207.86 $82.22 $156.95 $184.48 $170.64 $261.52 $263.08
71 $192.24 $232.87 $231.94 $214.55 $84.86 $162.00 $190.42 $176.13 $269.92 $271.54
72 $198.04 $239.89 $238.94 $221.02 $87.42 $166.89 $196.16 $181.44 $278.06 $279.73
73 $204.03 $247.14 $246.15 $227.70 $90.06 $171.94 $202.09 $186.93 $286.47 $288.18
74 $209.44 $253.70 $252.69 $233.73 $92.45 $176.50 $207.44 $191.88 $294.07 $295.83
75 $215.23 $260.72 $259.68 $240.20 $95.01 $181.39 $213.19 $197.19 $302.21 $304.01
76 $220.46 $267.04 $265.98 $246.03 $97.31 $185.77 $218.36 $201.98 $309.54 $311.38
77 $226.06 $273.83 $272.73 $252.28 $99.79 $190.50 $223.90 $207.10 $317.40 $319.30
78 $228.18 $276.40 $275.29 $254.66 $100.72 $192.29 $226.01 $209.05 $320.38 $322.31
79 $228.18 $276.40 $275.29 $254.66 $100.72 $192.29 $226.01 $209.05 $320.38 $322.31
80+ $249.43 $302.14 $300.94 $278.37 $110.11 $210.21 $247.06 $228.53 $350.22 $352.33
The rates above are for plan effective dates from January 2020 - May 2021 and may change.
OOCFL6 MRP0196 FLB 10-20
RP250FLGRS_OOCFL6_1020
Cover Page - Rates
Male Non-Tobacco Monthly Plan Rates for Florida - Area 2
AARP
®
Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Plans Available to All Applicants
Medicare first eligible
before 2020 only
2
Male Non-Tobacco Standard Rates
Age
1
Plan A Plan B Plan G Select G
3
Plan K Plan L Plan N Select N
3
Plan C
2
Plan F
2
50-64
$594.10 $699.62 $754.72 $698.12 $291.67 $486.20 $588.36 $544.24 $810.57 $815.29
65 $147.75 $178.97 $178.25 $164.89 $65.22 $124.51 $146.34 $135.36 $207.45 $208.69
66 $152.68 $184.95 $184.21 $170.40 $67.40 $128.67 $151.23 $139.89 $214.38 $215.66
67 $158.72 $192.26 $191.49 $177.13 $70.06 $133.75 $157.21 $145.41 $222.85 $224.19
68 $164.57 $199.35 $198.55 $183.66 $72.65 $138.69 $163.00 $150.78 $231.07 $232.45
69 $170.60 $206.66 $205.83 $190.40 $75.31 $143.77 $168.98 $156.30 $239.54 $240.97
70 $176.27 $213.52 $212.67 $196.72 $77.81 $148.55 $174.59 $161.50 $247.50 $248.98
71 $181.94 $220.39 $219.51 $203.05 $80.31 $153.32 $180.21 $166.69 $255.46 $256.99
72 $187.43 $227.03 $226.13 $209.17 $82.74 $157.95 $185.64 $171.72 $263.16 $264.73
73 $193.10 $233.90 $232.97 $215.50 $85.24 $162.72 $191.26 $176.91 $271.12 $272.74
74 $198.22 $240.10 $239.14 $221.21 $87.50 $167.04 $196.33 $181.60 $278.31 $279.97
75 $203.70 $246.75 $245.76 $227.33 $89.92 $171.66 $201.76 $186.63 $286.01 $287.72
76 $208.64 $252.73 $251.72 $232.84 $92.10 $175.82 $206.65 $191.15 $292.94 $294.69
77 $213.94 $259.15 $258.12 $238.76 $94.44 $180.29 $211.90 $196.01 $300.39 $302.18
78 $215.95 $261.59 $260.54 $241.01 $95.33 $181.99 $213.90 $197.85 $303.21 $305.03
79 $215.95 $261.59 $260.54 $241.01 $95.33 $181.99 $213.90 $197.85 $303.21 $305.03
80+ $236.07 $285.95 $284.81 $263.45 $104.21 $198.94 $233.82 $216.28 $331.45 $333.44
The rates above are for plan effective dates from January 2020 - May 2021 and may change.
OOCFL6 MRP0196 FLB 10-20
RP250FLGRS_OOCFL6_1020
Cover Page - Rates
Male Tobacco Monthly Plan Rates for Florida - Area 2
AARP
®
Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Plans Available to All Applicants
Medicare first eligible
before 2020 only
2
Male Tobacco Standard Rates
Age
1
Plan A Plan B Plan G Select G
3
Plan K Plan L Plan N Select N
3
Plan C
2
Plan F
2
50-64
$653.51 $769.58 $830.19 $767.93 $320.83 $534.82 $647.19 $598.66 $891.62 $896.81
65 $162.52 $196.86 $196.07 $181.37 $71.74 $136.96 $160.97 $148.89 $228.19 $229.55
66 $167.94 $203.44 $202.63 $187.44 $74.14 $141.53 $166.35 $153.87 $235.81 $237.22
67 $174.59 $211.48 $210.63 $194.84 $77.06 $147.12 $172.93 $159.95 $245.13 $246.60
68 $181.02 $219.28 $218.40 $202.02 $79.91 $152.55 $179.30 $165.85 $254.17 $255.69
69 $187.66 $227.32 $226.41 $209.44 $82.84 $158.14 $185.87 $171.93 $263.49 $265.06
70 $193.89 $234.87 $233.93 $216.39 $85.59 $163.40 $192.04 $177.65 $272.25 $273.87
71 $200.13 $242.42 $241.46 $223.35 $88.34 $168.65 $198.23 $183.35 $281.00 $282.68
72 $206.17 $249.73 $248.74 $230.08 $91.01 $173.74 $204.20 $188.89 $289.47 $291.20
73 $212.41 $257.29 $256.26 $237.05 $93.76 $178.99 $210.38 $194.60 $298.23 $300.01
74 $218.04 $264.11 $263.05 $243.33 $96.25 $183.74 $215.96 $199.76 $306.14 $307.96
75 $224.07 $271.42 $270.33 $250.06 $98.91 $188.82 $221.93 $205.29 $314.61 $316.49
76 $229.50 $278.00 $276.89 $256.12 $101.31 $193.40 $227.31 $210.26 $322.23 $324.15
77 $235.33 $285.06 $283.93 $262.63 $103.88 $198.31 $233.09 $215.61 $330.42 $332.39
78 $237.54 $287.74 $286.59 $265.11 $104.86 $200.18 $235.29 $217.63 $333.53 $335.53
79 $237.54 $287.74 $286.59 $265.11 $104.86 $200.18 $235.29 $217.63 $333.53 $335.53
80+ $259.67 $314.54 $313.29 $289.79 $114.63 $218.83 $257.20 $237.90 $364.59 $366.78
The rates above are for plan effective dates from January 2020 - May 2021 and may change.
OOCFL6 MRP0196 FLB 10-20
1 Your age as of your plan effective date. Your rate will always be based on your age on your effective date.
2 IMPORTANT: Only applicants first eligible for Medicare before January 1, 2020 may purchase Plans C and F.
Applicants first eligible for Medicare before 1/1/2020 have (a) a 65th birthday prior to 1/1/2020 or (b) a Medicare Part A effective date prior to 1/1/2020.
3 You must use a network hospital with Select Plans G and N.
RP250FLGRS_OOCFL6_1020
OOCFL6 MRP0196 FLB 10-20
0)
0
FLORIDA Area 2 ZIP Codes
The ZIP Codes Below Apply to Rates Included on the Page Headed “Cover Page – Rates
32003
32004
32006
32009
32011
32030
32033
32034
32035
32041
32043
32046
32050
32065
32067
32068
32073
32079
32080
32081
32082
32084
32085
32086
32092
32095
32097
32099
32145
32160
32201
32202
32203
32204
32205
32206
32207
32208
32209
32210
32211
32212
SA5074
32214
32216
32217
32218
32219
32220
32221
32222
32223
32224
32225
32226
32227
32228
32229
32231
32232
32233
32234
32235
32236
32237
32238
32239
32240
32241
32244
32245
32246
32247
32250
32254
32255
32256
32257
32258
32259
32260
32266
32277
32401
32402
FB (07-2
32403
32404
32405
32406
32407
32408
32409
32410
32411
32412
32413
32417
32422
32425
32427
32428
32433
32434
32435
32437
32438
32439
32444
32452
32455
32456
32457
32459
32461
32462
32463
32464
32465
32466
32501
32502
32503
32504
32505
32506
32507
32508
-20)
32509
32511
32512
32513
32514
32516
32520
32521
32522
32523
32524
32526
32530
32531
32533
32534
32535
32536
32537
32538
32539
32540
32541
32542
32544
32547
32548
32549
32550
32559
32560
32561
32562
32563
32564
32565
32566
32567
32568
32569
32570
32571
R
32572
32577
32578
32579
32580
32583
32588
32591
32656
32701
32703
32704
32707
32708
32709
32710
32712
32714
32715
32716
32718
32719
32730
32732
32733
32745
32746
32747
32750
32751
32752
32754
32762
32765
32766
32768
32771
32772
32773
32775
32777
32779
P250FL
32780
32781
32783
32789
32790
32791
32792
32793
32794
32795
32796
32798
32799
32801
32802
32803
32804
32805
32806
32807
32808
32809
32810
32811
32812
32814
32815
32816
32817
32818
32819
32820
32821
32822
32824
32825
32826
32827
32828
32829
32830
32831
GRS_OO
32832
32833
32834
32835
32836
32837
32839
32853
32854
32855
32856
32857
32858
32859
32860
32861
32862
32867
32868
32869
32872
32877
32878
32885
32886
32887
32891
32896
32897
32898
32899
32901
32902
32903
32904
32905
32906
32907
32908
32909
32910
32911
CFL6_102
32912
32919
32920
32922
32923
32924
32925
32926
32927
32931
32932
32934
32935
32936
32937
32940
32941
32948
32949
32950
32951
32952
32953
32954
32955
32956
32957
32958
32959
32960
32961
32962
32963
32964
32965
32966
32967
32968
32969
32970
32971
32976
32978
33001
33036
33037
33040
33041
33042
33043
33045
33050
33051
33052
33070
33440
33455
33471
33475
33503
33508
33509
33510
33511
33523
33524
33525
33526
33527
33530
33534
33537
33539
33540
33541
33542
33543
33544
33545
33547
33548
33549
33550
33556
33558
33559
33563
33564
33565
33566
33567
33568
33569
33570
33571
33572
33573
33574
33575
33576
33578
33579
33583
33584
33586
33587
33592
33593
33594
33595
33596
33598
33601
33602
33603
33604
33605
33606
33607
33608
33609
33610
33611
33612
33613
33614
33615
33616
33617
33618
33619
33620
33621
33622
33623
33624
33625
33626
33629
33630
33631
33633
33634
33635
33637
33647
33646
33650
33655
33660
33661
33662
33663
33664
33672
33673
33674
33675
33677
33679
33680
33681
33682
33684
33685
33686
33687
33688
Pag
33689
33694
33701
33702
33703
33704
33705
33706
33707
33708
33709
33710
33711
33712
33713
33714
33715
33716
33729
33730
33731
33732
33733
33734
33736
33738
33740
33741
33742
33743
33744
33747
33755
33756
33757
33758
33759
33760
33761
33762
33763
33764
e 1 of 2
FLORIDA Area 2 ZIP Codes
The ZIP Codes Below Apply to Rates Included on the Page Headed “Cover Page – Rates
33765
33766
33767
33769
33770
33771
33772
33773
33774
33775
33776
33777
33778
33779
33780
33781
33782
33784
33785
33786
33825
33826
33834
33848
33852
33857
33862
33865
33870
33871
33872
33873
33875
33876
33890
33900
33901
33902
33903
33904
33905
33906
33907
33908
33909
33910
33911
33912
33913
33914
33915
33916
33917
33918
33919
33920
33921
33922
33924
33927
33928
33929
33930
33931
33932
33935
33936
33938
33944
33945
33946
33947
33948
33949
33950
33951
33952
33953
33954
33955
33956
33957
33960
33965
33966
33967
33970
33971
33972
33973
33974
33975
33976
33980
33981
33982
33983
33990
33991
33993
33994
34101
34102
34103
34104
34105
34106
34107
34108
34109
34110
34112
34113
34114
34116
34117
34119
34120
34133
34134
34135
34136
34137
34138
34139
34140
34141
34142
34143
34145
34146
34201
34202
34203
34204
34205
34206
34207
34208
34209
34210
34211
34212
34215
34216
34217
34218
34219
34220
34221
34222
34223
34224
34228
34229
34230
34231
34232
34233
34234
34235
34236
34237
34238
34239
34240
34241
34242
34243
34249
34250
34251
34260
34264
34265
34266
34267
34268
34269
34270
34272
34274
34275
34276
34277
34280
34281
34282
34284
34285
34286
34287
34288
34289
34290
34291
34292
34293
34295
34601
34602
34603
34604
34605
34606
34607
34608
34609
34610
34611
34613
34614
34636
34637
34638
34639
34652
34653
34654
34655
34656
34660
34661
34667
34668
34669
34673
34674
34677
34679
34680
34681
34682
34683
34684
34685
34688
34689
34690
34691
34692
34695
34697
34698
34734
34739
34740
34741
34742
34743
34744
34745
34746
34747
34758
34760
34761
34769
34770
34771
34772
34773
34777
34778
34786
34787
34945
34946
34947
34948
34949
34950
34951
34952
34953
34954
34956
34957
34958
34972
34973
34974
34979
34981
34982
34983
34984
34985
34986
34987
34988
34990
34991
34992
34994
34995
34996
34997
The following ZIP code is no longer recognized by the U.S. Post Office: 34278
Page 2 of 2
RP250FLGRS_OOCFL6_1020
RP250FLGRS_OOCFL6_1020
Cover Page - Rates
Female Non-Tobacco Monthly Plan Rates for Florida - Area 3
AARP
®
Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Plans Available to All Applicants
Medicare first eligible
before 2020 only
2
Female Non-Tobacco Standard Rates
Age
1
Plan A Plan B Plan G Select G
3
Plan K Plan L Plan N Select N
3
Plan C
2
Plan F
2
50-64
$538.26 $633.86 $683.78 $632.50 $264.25 $440.51 $533.06 $493.08 $734.39 $738.66
65 $133.86 $162.15 $161.50 $149.39 $59.09 $112.81 $132.59 $122.64 $187.95 $189.07
66 $138.33 $167.57 $166.90 $154.38 $61.07 $116.58 $137.02 $126.74 $194.23 $195.39
67 $143.80 $174.19 $173.49 $160.48 $63.48 $121.18 $142.43 $131.75 $201.91 $203.11
68 $149.10 $180.61 $179.89 $166.40 $65.82 $125.65 $147.68 $136.60 $209.35 $210.60
69 $154.57 $187.23 $186.48 $172.50 $68.23 $130.26 $153.10 $141.61 $217.03 $218.32
70 $159.71 $193.45 $192.68 $178.23 $70.50 $134.59 $158.18 $146.32 $224.24 $225.58
71 $164.84 $199.67 $198.88 $183.96 $72.77 $138.91 $163.27 $151.02 $231.45 $232.83
72 $169.81 $205.69 $204.87 $189.51 $74.96 $143.10 $168.19 $155.58 $238.43 $239.85
73 $174.95 $211.92 $211.07 $195.24 $77.23 $147.43 $173.28 $160.28 $245.64 $247.11
74 $179.59 $217.53 $216.67 $200.42 $79.28 $151.34 $177.88 $164.53 $252.15 $253.66
75 $184.56 $223.56 $222.66 $205.97 $81.47 $155.53 $182.80 $169.09 $259.13 $260.68
76 $189.03 $228.97 $228.06 $210.96 $83.44 $159.30 $187.23 $173.18 $265.41 $267.00
77 $193.83 $234.79 $233.86 $216.32 $85.56 $163.35 $191.99 $177.59 $272.15 $273.78
78 $195.66 $237.00 $236.05 $218.35 $86.37 $164.88 $193.79 $179.26 $274.71 $276.36
79 $195.66 $237.00 $236.05 $218.35 $86.37 $164.88 $193.79 $179.26 $274.71 $276.36
80+ $213.88 $259.08 $258.04 $238.69 $94.41 $180.24 $211.84 $195.95 $300.30 $302.10
The rates above are for plan effective dates from January 2020 - May 2021 and may change.
OOCFL6 MRP0196 FLC 10-20
RP250FLGRS_OOCFL6_1020
Cover Page - Rates
Female Tobacco Monthly Plan Rates for Florida - Area 3
AARP
®
Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Plans Available to All Applicants
Medicare first eligible
before 2020 only
2
Female Tobacco Standard Rates
Age
1
Plan A Plan B Plan G Select G
3
Plan K Plan L Plan N Select N
3
Plan C
2
Plan F
2
50-64
$592.08 $697.24 $752.15 $695.75 $290.67 $484.56 $586.36 $542.38 $807.82 $812.52
65 $147.24 $178.36 $177.65 $164.32 $64.99 $124.09 $145.84 $134.90 $206.74 $207.97
66 $152.16 $184.32 $183.59 $169.81 $67.17 $128.23 $150.72 $139.41 $213.65 $214.92
67 $158.18 $191.60 $190.83 $176.52 $69.82 $133.29 $156.67 $144.92 $222.10 $223.42
68 $164.01 $198.67 $197.87 $183.04 $72.40 $138.21 $162.44 $150.26 $230.28 $231.66
69 $170.02 $205.95 $205.12 $189.75 $75.05 $143.28 $168.41 $155.77 $238.73 $240.15
70 $175.68 $212.79 $211.94 $196.05 $77.55 $148.04 $173.99 $160.95 $246.66 $248.13
71 $181.32 $219.63 $218.76 $202.35 $80.04 $152.80 $179.59 $166.12 $254.59 $256.11
72 $186.79 $226.25 $225.35 $208.46 $82.45 $157.41 $185.00 $171.13 $262.27 $263.83
73 $192.44 $233.11 $232.17 $214.76 $84.95 $162.17 $190.60 $176.30 $270.20 $271.82
74 $197.54 $239.28 $238.33 $220.46 $87.20 $166.47 $195.66 $180.98 $277.36 $279.02
75 $203.01 $245.91 $244.92 $226.56 $89.61 $171.08 $201.08 $185.99 $285.04 $286.74
76 $207.93 $251.86 $250.86 $232.05 $91.78 $175.23 $205.95 $190.49 $291.95 $293.70
77 $213.21 $258.26 $257.24 $237.95 $94.11 $179.68 $211.18 $195.34 $299.36 $301.15
78 $215.22 $260.70 $259.65 $240.18 $95.00 $181.36 $213.16 $197.18 $302.18 $303.99
79 $215.22 $260.70 $259.65 $240.18 $95.00 $181.36 $213.16 $197.18 $302.18 $303.99
80+ $235.26 $284.98 $283.84 $262.55 $103.85 $198.26 $233.02 $215.54 $330.33 $332.31
The rates above are for plan effective dates from January 2020 - May 2021 and may change.
OOCFL6 MRP0196 FLC 10-20
RP250FLGRS_OOCFL6_1020
Cover Page - Rates
Male Non-Tobacco Monthly Plan Rates for Florida - Area 3
AARP
®
Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Plans Available to All Applicants
Medicare first eligible
before 2020 only
2
Male Non-Tobacco Standard Rates
Age
1
Plan A Plan B Plan G Select G
3
Plan K Plan L Plan N Select N
3
Plan C
2
Plan F
2
50-64
$560.35 $659.87 $711.84 $658.45 $275.09 $458.58 $554.93 $513.31 $764.51 $768.96
65 $139.35 $168.80 $168.13 $155.52 $61.51 $117.43 $138.03 $127.67 $195.66 $196.83
66 $144.01 $174.44 $173.74 $160.72 $63.57 $121.36 $142.64 $131.94 $202.20 $203.41
67 $149.70 $181.33 $180.61 $167.07 $66.08 $126.15 $148.27 $137.15 $210.19 $211.45
68 $155.22 $188.02 $187.27 $173.23 $68.52 $130.81 $153.74 $142.21 $217.94 $219.24
69 $160.91 $194.91 $194.14 $179.58 $71.03 $135.60 $159.38 $147.42 $225.93 $227.28
70 $166.26 $201.39 $200.59 $185.55 $73.39 $140.11 $164.67 $152.32 $233.44 $234.83
71 $171.60 $207.87 $207.04 $191.51 $75.75 $144.61 $169.97 $157.22 $240.94 $242.38
72 $176.78 $214.13 $213.28 $197.29 $78.04 $148.97 $175.09 $161.96 $248.21 $249.69
73 $182.12 $220.61 $219.73 $203.25 $80.40 $153.48 $180.39 $166.86 $255.71 $257.24
74 $186.95 $226.46 $225.56 $208.64 $82.53 $157.55 $185.17 $171.28 $262.49 $264.07
75 $192.13 $232.73 $231.80 $214.42 $84.81 $161.91 $190.30 $176.02 $269.76 $271.37
76 $196.78 $238.37 $237.42 $219.61 $86.87 $165.83 $194.91 $180.29 $276.30 $277.95
77 $201.79 $244.43 $243.45 $225.20 $89.07 $170.05 $199.86 $184.87 $283.32 $285.02
78 $203.68 $246.72 $245.74 $227.31 $89.91 $171.65 $201.74 $186.61 $285.98 $287.69
79 $203.68 $246.72 $245.74 $227.31 $89.91 $171.65 $201.74 $186.61 $285.98 $287.69
80+ $222.65 $269.70 $268.63 $248.48 $98.29 $187.63 $220.53 $203.99 $312.62 $314.49
The rates above are for plan effective dates from January 2020 - May 2021 and may change.
OOCFL6 MRP0196 FLC 10-20
RP250FLGRS_OOCFL6_1020
Cover Page - Rates
Male Tobacco Monthly Plan Rates for Florida - Area 3
AARP
®
Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Plans Available to All Applicants
Medicare first eligible
before 2020 only
2
Male Tobacco Standard Rates
Age
1
Plan A Plan B Plan G Select G
3
Plan K Plan L Plan N Select N
3
Plan C
2
Plan F
2
50-64
$616.38 $725.85 $783.02 $724.29 $302.59 $504.43 $610.42 $564.64 $840.96 $845.85
65 $153.28 $185.68 $184.94 $171.07 $67.66 $129.17 $151.83 $140.43 $215.22 $216.51
66 $158.41 $191.88 $191.11 $176.79 $69.92 $133.49 $156.90 $145.13 $222.42 $223.75
67 $164.67 $199.46 $198.67 $183.77 $72.68 $138.76 $163.09 $150.86 $231.20 $232.59
68 $170.74 $206.82 $205.99 $190.55 $75.37 $143.89 $169.11 $156.43 $239.73 $241.16
69 $177.00 $214.40 $213.55 $197.53 $78.13 $149.16 $175.31 $162.16 $248.52 $250.00
70 $182.88 $221.52 $220.64 $204.10 $80.72 $154.12 $181.13 $167.55 $256.78 $258.31
71 $188.76 $228.65 $227.74 $210.66 $83.32 $159.07 $186.96 $172.94 $265.03 $266.61
72 $194.45 $235.54 $234.60 $217.01 $85.84 $163.86 $192.59 $178.15 $273.03 $274.65
73 $200.33 $242.67 $241.70 $223.57 $88.44 $168.82 $198.42 $183.54 $281.28 $282.96
74 $205.64 $249.10 $248.11 $229.50 $90.78 $173.30 $203.68 $188.40 $288.73 $290.47
75 $211.34 $256.00 $254.98 $235.86 $93.29 $178.10 $209.33 $193.62 $296.73 $298.50
76 $216.45 $262.20 $261.16 $241.57 $95.55 $182.41 $214.40 $198.31 $303.93 $305.74
77 $221.96 $268.87 $267.79 $247.72 $97.97 $187.05 $219.84 $203.35 $311.65 $313.52
78 $224.04 $271.39 $270.31 $250.04 $98.90 $188.81 $221.91 $205.27 $314.57 $316.45
79 $224.04 $271.39 $270.31 $250.04 $98.90 $188.81 $221.91 $205.27 $314.57 $316.45
80+ $244.91 $296.67 $295.49 $273.32 $108.11 $206.39 $242.58 $224.38 $343.88 $345.93
The rates above are for plan effective dates from January 2020 - May 2021 and may change.
OOCFL6 MRP0196 FLC 10-20
1 Your age as of your plan effective date. Your rate will always be based on your age on your effective date.
2 IMPORTANT: Only applicants first eligible for Medicare before January 1, 2020 may purchase Plans C and F.
Applicants first eligible for Medicare before 1/1/2020 have (a) a 65th birthday prior to 1/1/2020 or (b) a Medicare Part A effective date prior to 1/1/2020.
3 You must use a network hospital with Select Plans G and N.
RP250FLGRS_OOCFL6_1020
OOCFL6 MRP0196 FLC 10-20
20)
0
FLORIDA Area 3 ZIP Codes
The ZIP Codes Below Apply to Rates Included on the Page Headed “Cover Page – Rates
32007
32008
32013
32024
32025
32026
32038
32040
32042
32044
32052
32053
32054
32055
32056
32058
32059
32060
32061
32062
32063
32064
32066
32071
32072
32083
32087
32091
32094
32096
32102
32105
32110
32111
32112
32113
32114
32115
32116
32117
32118
32119
SA5074
32120
32121
32122
32123
32124
32125
32126
32127
32128
32129
32130
32131
32132
32133
32134
32135
32136
32137
32138
32139
32140
32141
32142
32143
32147
32148
32149
32157
32158
32159
32162
32163
32164
32168
32169
32170
32173
32174
32175
32176
32177
32178
FC (07-
32179
32180
32181
32182
32183
32185
32187
32189
32190
32192
32193
32195
32198
32301
32302
32303
32304
32305
32306
32307
32308
32309
32310
32311
32312
32313
32314
32315
32316
32317
32318
32320
32321
32322
32323
32324
32326
32327
32328
32329
32330
32331
-20)
32332
32333
32334
32335
32336
32337
32340
32341
32343
32344
32345
32346
32347
32348
32350
32351
32352
32353
32355
32356
32357
32358
32359
32360
32361
32362
32395
32399
32420
32421
32423
32424
32426
32430
32431
32432
32440
32442
32443
32445
32446
32447
R
32448
32449
32460
32601
32602
32603
32604
32605
32606
32607
32608
32609
32610
32611
32612
32614
32615
32616
32617
32618
32619
32621
32622
32625
32626
32627
32628
32631
32633
32634
32635
32639
32640
32641
32643
32644
32648
32653
32654
32655
32658
32662
P250FL
32663
32664
32666
32667
32668
32669
32680
32681
32683
32686
32692
32693
32694
32696
32697
32702
32706
32713
32720
32721
32722
32723
32724
32725
32726
32727
32728
32735
32736
32738
32739
32744
32753
32756
32757
32759
32763
32764
32767
32774
32776
32778
GRS_OO
32784
33513
33514
33521
33538
33585
33597
33801
33802
33803
33804
33805
33806
33807
33809
33810
33811
33812
33813
33815
33820
33823
33827
33830
33831
33835
33836
33837
33838
33839
33840
33841
33843
33844
33845
33846
33847
33849
33850
33851
33853
33854
CFL6_102
33855
33856
33858
33859
33860
33863
33867
33868
33877
33880
33881
33882
33883
33884
33885
33888
33896
33897
33898
34420
34421
34423
34428
34429
34430
34431
34432
34433
34434
34436
34441
34442
34445
34446
34447
34448
34449
34450
34451
34452
34453
34460
34461
34464
34465
34470
34471
34472
34473
34474
34475
34476
34477
34478
34479
34480
34481
34482
34483
34484
34487
34488
34489
34491
34492
34498
34705
34711
34712
34713
34714
34715
34729
34731
34736
34737
34748
34749
34753
34755
34756
34759
34762
34785
34788
34789
34797
Page 1 of 1
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 Pays You Pay
HOSPITALIZATION*
Semiprivate room and board,
general nursing and
miscellaneous services and
supplies
First 60 days All but $1,408 $0 $1,408 (Part A
Deductible)
st th
61 thru 90 day All but $352 a day $352 a day $0
st
91 day and after:
– While using 60 lifetime All but $704 a day $704 a day $0
reserve days
– Once lifetime reserve
days are used:
Additional 365 days $0 100% of Medicare $0**
e ligible e xpense s
Beyond the additional $0 $0 All costs
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
All approved amounts $0 $0
First 20 days
st th
21 thru 100 day All but $176.00 a day $0 Up to $176.00 a day
st
101 day and after $0 $0 All costs
BLOOD
First 3 p ints $0 3 pints $0
Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicares All but very limited Medicare copayment/ $0
requirements, including a copayment/ coinsurance
doctor’s certification of coinsurance for
terminal illness. outpatient drugs and
inpatient respite care.
**NOTICE: When yo ur 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.
OOCFL6 BT178 1/20
Plan A
MEDICARE (PART B) – MEDICAL SERVICES PER CALENDAR YEAR
* Once you have been billed $198 of Medicare Approved amounts for covered services (whic h are noted
with an asterisk), your Part B Deductible will have been met for the calendar year.
Services Medicare Pays Plan 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 $198 of Medicare Ap proved $0 $0 $198 (Part B
amounts* Deductible)
Remainder of Medicare Approved Generally 80% Generally 20% $0
amounts
PART B EXCESS CHARGES
(Above Medicare Approved $0 $0 All costs
amounts)
BLOOD
First 3 p ints $0 All costs $0
Next $198 of Medicare Approved $0 $0 $198 (Part B
amounts* Deductible)
Remainder of Medicare Approved 80% 20% $0
amounts
CLINICAL LABORATORY
SERVICES
Tests For Diagnostic Services 100% $0 $0
PARTS A & B
HOME HEALTH CARE
MEDICARE APPROVED
SERVICES
Medically necessary skilled 100% $0 $0
care services and medical
supplies
Durable medical equipment:
$0 $198 (Part B
First $198 of Medicare $0
Deductible)
Approved amounts*
Remainder of Medicare 80% 20% $0
Approv ed amounts
OOCFL6 BT178 1/20
Plan B
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
HOSPITALIZATION*
Medicare Pays Plan Pays You Pay
Semiprivate room and board,
general nursing and
miscellaneous services and
supplies
First 60 days
All but $1,408 $1,408 (Part A $0
Deductible)
st th
61 thru 90 day All but $352 a day $352 a day $0
st
91 day and after:
While using 60 lifetime All but $704 a day $704 a day $0
reserve days
Once lifetime reserve
days are used:
Additional 365 days $0 100% of Medicare $0**
eligible expenses
Beyond the additional
$0 $0 All costs
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
All approved amounts $0 $0
st th
21 thru 100 day All but $176.00 a day $0 Up to $176.00 a
day
st
101 day and after $0 $0 All costs
BLOOD
First 3 pints
$0 3 pints $0
Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s
All but very limited Medicare copayment/ $0
requirements, including a
copayment/coinsurance coinsurance
doctor’s certification of
for outpatient drugs and
terminal illness.
inpatient respite care.
** 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.
OOCFL6 BT179 1/20
Plan B
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
* Once you have been billed $198 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.
Services Medicare Pays Plan 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 $198 of Medicare Approved
$0 $0 $198
amounts*
(Part B
Deductible)
Remainder of Medicare Approved Generally 80% Generally 20% $0
amounts
PART B EXCESS CHARGES
(Above Medicare-approved amounts)
$0 $0 All costs
BLOOD
First 3 pints
$0 All costs $0
Next $198 of Medicare Approved $0 $0 $198
amounts* (Part B
Deductible)
Remainder of Medicare Approved 80% 20% $0
amounts
CLINICAL LABORATORY
SERVICES –
Tests For Diagnostic Services
100% $0 $0
PARTS A & B
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
Medically necessary skilled care
100% $0 $0
services and medical supplies
– Durable medical equipment:
First $198 of Medicare Approved
$0 $0 $198
amounts*
(Part B
Deductible)
Remainder of Medicare Approved
80% 20% $0
amounts
OOCFL6 BT179 1/20
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.
Services Medicare Pays Plan Pays You Pay
HOSPITALIZATION*
Semiprivate room and board,
general nursing and miscellaneous
services and supplies
First 60 days
All but $1,408 $1,408 (Part A Deductible) $0
st th
61 thru 90 day All but $352 a day $352 a day $0
st
91 day and after:
While using 60 lifetime reserve All but $704 a day $704 a day $0
days
Once lifetime reserve days are
used:
Additional 365 days $0 100% of Medicare e ligible $0**
e xpenses
Beyond the additional 365 $0 $0 All costs
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
All approved amounts $0 $0
st th
21 thru 100 day All but $176.00 a day Up to $176.00 a day $0
st
101 day and after $0 $0 All costs
BLOOD
First 3 p ints $0 3 pints $0
Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicares All but very limited Medicare copayment/ $0
requirements, including a doctor’s copayment/ coinsurance
certification of terminal illness. coinsurance for outpatient
drugs and
inpatient respite care.
**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.
+Only applicants first eligible for Medicare before January 1, 2020 may purchase Plans C, F, and high
deductible F.
OOCFL6 BT180 1/20
Plan C+
MEDICARE (PART B) – MEDICAL SERVICES PER CALENDAR YEAR
* Once you have been billed $198 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.
Services Medicare Pays Plan Pays You Pay
MEDICAL EXPENSES -
IN OR OUT OF THE HOSPITAL AND
OUTPATIENT HOSPITAL
TREATMENT, such as Physicians
services, inpatient and outpatient
medical and surgical services and
supplies, physical and speech
therapy, diagnostic tests, durable
medical equipment
First $198 of Medicare Approved $0 $198 (Part B $0
amounts* Deductible)
Remainder of Medicare Approved Generally 80% Generally 20% $0
amounts
PART B EXCESS CHARGES
(Above Medicare -approved amounts) $0 $0 All costs
BLOOD
First 3 p ints $0 All costs $0
Next $198 of Medicare A pproved $0 $198 (Part B $0
amounts* Deductible)
Remainder of Med icare Approved 80% 20% $0
amounts
CLINICAL LABORATORY
SERVICES–
Tests For Diagnostic Services 100% $0 $0
PARTS A & B
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
Medically necessary skilled care 100% $0 $0
services and medical supplies
– Durable medical equipment:
First $198 of Medicare Approved
$0 $198 (Part B Deductible) $0
amounts*
Remainder of Medicare
80% 20% $0
Approved amounts
+Only applicants first eligible for Medicare before January 1, 2020 may purchase Plans C, F, and high
deductible F.
OOCFL6 BT180 1/ 20
Plan C+
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 $250 each calendar year $0 $0 $250
Remainder of Charges $0 80% to a lifetime 20% and
maximum benefit of amounts over
$50,000 the $50,000
lifetime
maximum
+Only applicants first eligible for Medicare before January 1, 2020 may purchase Plans C, F, and high
deductible F.
OOCFL6 BT180 1/20
**
M ed
in ed
o
+
O
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.
NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of
edicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provid
the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance bas
n any difference between its billed charges and the amount Medicare would have paid.
Only applicants first eligible for Medicare before January 1, 2020 may purchase Plans C, F, and high
deductible F.
OCFL6 BT181 1/20
Services
HOSPITALIZATION*
Medicare Pa
ys Plan Pays
You Pay
Semiprivate room and board,
general nursing and
miscellaneous services and
supplies
First 60 days All but $1,408 $1,408 (Part A Deductible) $0
st th
61 thru 90 day All but $352 a day $352 a day $0
st
91 day and after:
– While using 60 lifetime All but $704 a day $704 a day $0
reserve days
– Once lifetime reserve days
are used:
Additional 365 days $0 100% of Medicare eligible $0**
expenses
Beyond the additional 365
$0 $0 All costs
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
All approved amounts $0 $0
First 20 days
st th
21 thru 100 day All but $176.00 a day Up to $176.00 a day $0
st
101 day and after $0 $0 All costs
BLOOD
First 3 pints
$0 3 pints $0
Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s
All but very limited Medicare copayment/ $0
requirements, including a doctor’s
copayment/ coinsurance
certification of terminal illness.
coinsurance for outpatient
drugs and
inpatient respite care.
Plan F+
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
* Once you have been billed $198 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.
Services Medicare Pays Plan 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 $198 of Medicare Approved $0 $198 (Part B $0
amounts* Deductible)
Remainder of Medicare Approved Generally 80% Generally 20% $0
amounts
PART B EXCESS CHARGES
(Above Medicare-approved amounts)
$0 100% $0
BLOOD
First 3 pints
$0 All costs $0
Next $198 of Medicare Approved $0 $198 (Part B $0
amounts* Deductible)
Remainder of Medicare Approved 80% 20% $0
amounts
CLINICAL LABORATORY
SERVICES –
Tests For Diagnostic Services
100% $0 $0
PARTS A & B
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
– Medically necessary skilled care
100% $0 $0
services and medical supplies
– Durable medical equipment:
First $198 of Medicare Approved
$0 $198 (Part B $0
amounts*
Deductible)
Remainder of Medicare Approved
80% 20% $0
amounts
+Only applicants first eligible for Medicare before January 1, 2020 may purchase Plans C, F, and high
deductible F.
OOCFL6 BT181 1/20
Plan F+
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 $250 each calendar year
$0 $0 $250
Remainder of Charges $0 80% to a lifetime 20% and amounts
maximum benefit over the $50,000
of $50,000 lifetime maximum
+Only applicants first eligible for Medicare before January 1, 2020 may purchase Plans C, F, and high
deductible F.
OOCFL6 BT181 1/20
**
M ed
in ed
o
O
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.
NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of
edicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provid
the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance bas
n any difference between its billed charges and the amount Medicare would have paid.
OCFL6 BT182 1/20
Services
HOSPITALIZATION*
Medicare Pa
ys Plan Pays
You Pay
Semiprivate room and board,
general nursing and
miscellaneous services and
supplies
First 60 days All but $1,408 $1,408 (Part A Deductible) $0
st th
61 thru 90 day All but $352 a day $352 a day $0
st
91 day and after:
– While using 60 lifetime All but $704 a day $704 a day $0
reserve days
– Once lifetime reserve days
are used:
Additional 365 days $0 100% of Medicare eligible $0**
expenses
Beyond the additional 365
$0 $0 All costs
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
All approved amounts $0 $0
First 20 days
st th
21 thru 100 day All but $176.00 a day Up to $176.00 a day $0
st
101 day and after $0 $0 All costs
BLOOD
First 3 pints
$0 3 pints $0
Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s
All but very limited Medicare copayment/ $0
requirements, including a doctor’s
copayment/ coinsurance
certification of terminal illness.
coinsurance for outpatient
drugs and
inpatient respite care.
Plan G
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
* Once you have been billed $198 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.
Services Medicare Pays Plan 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 $198 of Medicare Approved $0 $0 $198 (Unless Part
amounts* B Deductible has
been met)
Remainder of Medicare Approved Generally 80% Generally 20% $0
amounts
PART B EXCESS CHARGES
(Above Medicare-approved amounts)
$0 100% $0
BLOOD
First 3 pints
$0 All costs $0
Next $198 of Medicare Approved $0 $0 $198 (Unless Part
amounts* B Deductible has
been met)
Remainder of Medicare Approved 80% 20% $0
amounts
CLINICAL LABORATORY
SERVICES –
Tests For Diagnostic Services
100% $0 $0
PARTS A & B
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
– Medically necessary skilled care
100% $0 $0
services and medical supplies
Durable medical equipment:
First $198 of Medicare Approved
$0 $0 $198 (Unless Part
amounts*
B Deductible has
been met)
Remainder of Medicare Approved
80% 20% $0
amounts
OOCFL6
BT182 1/20
Plan G
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 $250 each calendar year
$0 $0 $250
Remainder of Charges $0 80% to a lifetime 20% and amounts
maximum benefit over the $50,000
of $50,000 lifetime maximum
OOCFL6 BT182 1/20
Medicare Select - 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.
** Provider restrictions apply.
Services Medicare Pays Medicare Select
Plan G Pays
You Pay
HOSPITALIZATION* in a
Participating Hospital**
Semiprivate room and
board, general nursing
and miscellaneous
services and supplies
First 60 days All but $1,408 $1,408 (Part A Deductible) $0
61
st
thru 90
th
day
91
st
day and after:
All but $352 a day
$352 a day
$0
– While using 60
lifetime reserve days
– Once lifetime reserve
days are used:
All but $704 a day
$704 a day
$0
Additional 365
days
$0
100% of Medicare eligible
expenses
$0***
Beyond the
additional 365 days
$0 $0 All costs
SKILLED NURSING
FACILITY CARE*
You must meet Medicare’s
requirements, including
having been in a hospital
for atleast 3 days and
entered a Medicare
Approved facility within 30
days after leaving the
hospital
First 20 days All approved amounts $0 $0
21
st
thru 100
th
day All but $176.00 a day Up to $176.00 a day $0
101
st
day and after $0 $0 All costs
BLOOD
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
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
$0
***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.
OOCFL6 BT186 1/20
Medicare Select - Plan G
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
* Once you have been billed $198 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.
Services Medicare Pays Medicare Select You Pay
Plan G Pays
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 $198 of Medicare $0 $0 $198 (Unless Part B
Approved amounts* Deductible has been
met)
Remainder of Medicare Generally 80% Generally 20% $0
Approved amounts
PART B EXCESS CHARGES
(Above Medicare Approved
amounts) $0 100% $0
BLOOD
First 3 pints $0 All costs $0
Next $198 of Medicare $0 $0 $198 (Unless Part B
Approved amounts* Deductible has been
met)
Remainder of Medicare 80% 20% $0
Approved amounts
CLINICAL LABORATORY
SERVICES
Tests For Diagnostic Services 100% $0 $0
PARTS A & B
HOME HEALTH CARE -
MEDICARE APPROVED
SERVICES
– Medically necessary 100% $0 $0
skilled care services
and medical supplies
Durable medical
equipment:
First $198 of Medicare $0 $0 $198 (Unless Part B
Approved amounts* Deductible has been
met)
Remainder of Medicare 80% 20% $0
Approved amounts
OOCFL6 BT186 1/20
Medicare Select - Plan G
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
OTHER BENEFITS – NOT COVERED BY MEDICARE
Services
Medicare Pays Medicare Select
Plan G Pays
You Pay
FOREIGN TRAVEL – NOT
COVERED BY MEDICARE
Medically necessary
emergency care services
beginning during the first 60
days of each trip outside the
USA.
First $250 each calendar year $0 $0 $250
Remainder of Charges $0 80% to a lifetime maximum
benefit of $50,000
20% and amounts
over the $50,000
lifetime maximum
OOCFL6 BT186 1/20
Plan K
* You will pay half of the cost-sharing of some covered services until you reach the annual out-of-pocket limit
of $5880 each calendar year. The amounts that count toward your annual limit are noted with diamonds ()
in the chart below. 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.
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 Pays You Pay*
HOSPITALIZATION**
Semiprivate room and board, general
nursing and miscellaneous services
and supplies
First 60 days All but $1,408 $704 (50% of Part A $704 (50% of Part A
Deductible) Deductible)
st th
61 thru 90 day All but $352 a day $352 a day $0
st
91 day and after:
While using 60 lifetime reserve All but $704 a day $704 a day $0
days
Once lifetime reserve days are
used:
Additional 365 days (lifetime) $0 100% of Medicare $0***
Eligible Expenses
Beyond the additional 365
$0 $0 All costs
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
All approved amounts $0 $0
st th
21 thru 100 day All but $176.00 a day Up to $88.00 a day $88.00 a day
st
101 day and after $0 $0 All costs
BLOOD
First 3 Pints $0 50% 50%
Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s All but very limited 50% of copayment/ 50% of
requirements, including a doctor’s copayment/ coinsurance copayment/
certification of terminal illness. coinsurance for coinsurance
outpatient drugs and
inpatient respite care.
*** 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.
OOCFL6 BT183 1/20
Plan K
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
**** Once you have been billed $198 of Medicare Approved amounts for covered services
(which are noted with asterisks), your Part B Deductible will have been met for the calendar year.
Services Medicare Pays Plan 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 $198 of Medicare $0 $0 $198 (Part B
Approved Amounts**** Deductible)****
Preventive Benefits for Generally 80% or Remainder of Medicare All costs above
Medicare Covered Services more of Medicare Approved amounts Medicare Approved
Approved amounts amounts
Remainder of Medicare Generally 80% Generally 10% Generally 10%
Approved Amounts
PART B EXCESS CHARGES
(Above Medicare Approved $0 $0 All costs (and they do
Amounts) not count toward
annual out-of-pocket
limit of $5880)*
BLOOD
First 3 Pints $0 50% 50%
Next $198 of Medicare $0 $0 $198 (Part B
Approved Amounts**** Deductible)****
Remainder of Medicare Generally 80% Generally 10% Generally 10%
Approved Amounts
CLINICAL LABORATORY
SERVICES
Tests For Diagnostic Services 100% $0 $0
* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $5880 per
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.
PARTS A & B
HOME HEALTH CARE
MEDICARE APPROVED
SERVICES
- Medically necessary skilled 100% $0 $0
care services and medical
supplies
- Durable medical equipment:
First $198 of Medicare $0 $0 $198 (Part B
Approved Amounts***** Deductible)
Remainder of Medicare 80% 10% 10%
Approved Amounts
***** Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People
with Medicare.
OOCFL6 BT183 1/20
Plan L
* You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-
pocket limit of $2940 each calendar year. The amounts that count toward your annual limit are noted with
diamonds () in the chart below. Once you reach the annual limit, the plan pays 100% of your 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.
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 Pays You Pay*
HOSPITALIZATION**
Semiprivate room and board,
general nursing and
miscellaneous services and
supplies
First 60 days All but $1,408 $1,056 (75% of Part A $352 (25% of Part A
Deductible) Deductible)
st th
61 thru 90 day All but $352 a day $352 a day $0
st
91 day and after:
While using 60 lifetime All but $704 a day $704 a day $0
reserve days
Once lifetime reserve days
are used:
Additional 365 days $0 100% of Medicare $0***
(lifetime) Eligible Expenses
Beyond the additional $0 $0 All costs
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
All approved amounts $0 $0
First 20 days
st th
21 thru 100 day All but $176.00 a day Up to $132.00 a day $44.00 a day
st
101 day and after $0 $0 All costs
BLOOD
First 3 Pints $0 75% 25%
Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s All but very limited 75% of copayment/ 25% of
requirements, including a copayment/ coinsurance copayment/
doctor’s certification of terminal coinsurance for coinsurance
illness. outpatient drugs and
inpatient respite care.
*** 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.
OOCFL6 BT184 1/20
Plan L
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
**** Once you have been billed $198 of Medicare Approved amounts for covered services
(which are noted with asterisks), your Part B Deductible will have been met for the calendar year.
Services Medicare Pays Plan 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 $198 of Medicare $0 $0 $198 (Part B
Approved Amounts**** Deductible)****
Preventive Benefits for Generally 80% or Remainder of Medicare All costs above
Medicare Covered Services more of Medicare Approved amounts Medicare Approved
Approved amounts amounts
Remainder of Medicare Generally 80% Generally 15% Generally 5%
Approved Amounts
PART B EXCESS CHARGES
(Above Medicare Approved $0 $0 All costs (and they
Amounts) do not count toward
annual out-of-pocket
limit of $2940)*
BLOOD
First 3 Pints $0 75% 25%
Next $198 of Medicare $0 $0 $198 (Part B
Approved Amounts**** Deductible)****
Remainder of Medicare Generally 80% Generally 15% Generally 5%
Approved Amounts
CLINICAL LABORATORY
SERVICES –
Tests For Diagnostic Services 100% $0 $0
* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2940 per
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.
PARTS A & B
HOME HEALTH CARE
MEDICARE APPROVED
SERVICES
- Medically necessary skilled 100% $0 $0
care services and medical
supplies
- Durable medical equipment:
First $198 of Medicare $0 $0 $198 (Part B
Approved Amounts***** Deductible)
Remainder of Medicare 80% 15% 5%
Approved Amounts
***** Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People
with Medicare.
OOCFL6 BT184 1/20
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 Pays You Pay
HOSPITALIZATION*
Semiprivate room and board,
general nursing and
miscellaneous services and
supplies
First 60 days
All but $1,408 $1,408 (Part A Deductible) $0
st th
61 thru 90 day All but $352 a day $352 a day $0
st
91 day and after:
– While using 60 lifetime All but $704 a day $704 a day $0
reserve days
– Once lifetime reserve days
are used:
Additional 365 days $0 100% of Medicare eligible $0**
expenses
Beyond the additional 365
$0 $0 All costs
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
All approved amounts $0 $0
First 20 days
st th
21 thru 100 day All but $176.00 a day Up to $176.00 a day $0
st
101 day and after $0 $0 All costs
BLOOD
First 3 pints
$0 3 pints $0
Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s
All but very limited Medicare copayment/ $0
requirements, including a doctor’s
copayment/ coinsurance
certification of terminal illness.
coinsurance for outpatient
drugs and
inpatient respite care.
**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.
OOCFL6 BT185 1/20
m
ent
ed
Plan N
Services Medicare Pays Plan Pays You Pay
MEDICAL EXPENSES – IN OR OUT
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
* Once you have been billed $198 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.
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 $198 of Medicare Approved $0 $0 $198 (Part B
amounts* Deductible)
Remainder of Medicare Approved Generally 80% Balance other than up to Up to $20 per office
amounts $20 per office visit and up visit and up to $50
to $50 per emergency per emergency roo
room visit. The co- visit. The co-paym
payment of up to $50 is of up to $50 is waiv
waived if the insured is if the insured is
admitted to any hospital admitted to any
and the emergency visit is hospital and the
covered as a Medicare emergency visit is
Part A expense. covered as a
Medicare Part A
expense.
PART B EXCESS CHARGES
(Above Medicare-approved amounts) $0 $0 All Costs
BLOOD
First 3 pints $0 All costs $0
Next $198 of Medicare Approved $0 $0 $198 (Part B
amounts* Deductible)
Remainder of Medicare Approved 80% 20% $0
amounts
CLINICAL LABORATORY
SERVICES –
Tests For Diagnostic Services 100% $0 $0
PARTS A & B
HOME HEALTH CARE
MEDICARE APPROVED SERVICES
– Medically necessary skilled care 100% $0 $0
services and medical supplies
Durable medical equipment:
First $198 of Medicare Approved $0 $0 $198 (Part B
amounts* Deductible)
Remainder of Medicare Approved 80% 20% $0
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 $250 each calendar year $0 $0 $250
Remainder of Charges $0 80% to a lifetime 20% and amounts
maximum benefit of over the $50,000
$50,000 lifetime maximum
OOCFL6 BT185 1/20
Medicare Select - 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.
** Provider restrictions apply.
Services Medicare Pays Medicare Select You Pay
Plan N Pays
HOSPITALIZATION* in a
Participating Hospital**
Semiprivate room and
board, general nursing
and miscellaneous
services and supplies
First 60 days
All but $1,408 $1,408 (Part A Deductible) $0
st th
61 thru 90 day All but $352 a day $352 a day $0
st
91 day and after:
– While using 60 All but $704 a day $704 a day $0
lifetime reserve days
– Once lifetime reserve
days are used:
Additional 365 $0 100% of Medicare eligible $0***
days expenses
Beyond the $0 $0 All costs
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
All approved amounts $0 $0
st th
21 thru 100 day All but $176.00 a day Up to $176.00 a day $0
st
101 day and after $0 $0 All costs
BLOOD
First 3 pints
$0 3 pints $0
Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s
All but very limited Medicare copayment/ $0
requirements, including a
copayment/coinsurance for coinsurance
doctor’s certification of
outpatient drugs and
terminal illness.
inpatient respite care.
***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.
OOCFL6 BT187 1/20
Medicare Select - Plan N
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
* Once you have been billed $198 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.
Services Medicare Pays Medicare Select You Pay
Plan N Pays
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 $198 of Medicare Approved $0 $0 $198 (Part B
amounts* Deductible)
Remainder of Medicare-approved Generally 80% Balance other than up Up to $20 per
amounts to $20 per office visit office visit and
and up to $50 per up to $50 per
emergency room visit. emergency room
The co-payment of up visit. The co-
to $50 is waived if the payment of up to
insured is admitted to $50 is waived if
any hospital and the the insured is
emergency visit is admitted to any
covered as a Medicare hospital and the
Part A expense. emergency visit
is covered as a
Medicare Part A
expense.
PART B EXCESS CHARGES
(Above Medicare-approved $0 $0 All costs
amounts)
BLOOD
First 3 pints $0 All costs $0
Next $198 of Medicare Approved $0 $0 $198 (Part B
amounts* Deductible)
Remainder of Medicare-approved 80% 20% $0
amounts
CLINICAL LABORATORY
SERVICES
Tests For Diagnostic Services 100% $0 $0
OOCFL6 BT187 1/20
Medicare Select - Plan N
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
* Once you have been billed $198 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.
PARTS A & B
Services Medicare Pays Medicare Select You Pay
Plan N Pays
HOME HEALTH CARE -
MEDICARE APPROVED
SERVICES
– Medically necessary skilled care 100% $0 $0
services and medical supplies
Durable medical equipment:
First $198 of Medicare $0 $0 $198 (Part B
Approved amounts* Deductible)
Remainder of Medicare 80% 20% $0
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 $250 each calendar year $0 $0 $250
Remainder of Charges $0 80% to a lifetime 20% and
maximum benefit of amounts over
$50,000 the $50,000
lifetime
maximum
OOCFL6 BT187 1/20
Your Guide
To AARP Medicare Select and Medicare Supplement Insurance Plans
To help you choose the AARP Medicare Select or AARP Medicare Supplement Insurance Plan, insured by UnitedHealthcare Insurance
Company, to best meet your needs and budget, be sure to look at the information shown in this Guide and the other documents that
show the expenses that Medicare pays, the benefits each Plan pays and the costs you will have to pay yourself. Also, be sure to review
the Monthly Premium information. Please use the documents that show the specific benefits and rates of each plan which allow you
to compare the AARP Medicare Select and AARP Medicare Supplement Plans with other Medicare supplement plans. Benefits and
cost vary depending upon the Plan selected.
Eligibility to Apply
______________________________________________________
To be eligible to apply, you must be an AARP member or spouse of a member, age 50 or older, enrolled in both Part A and Part B of
Medicare, and not duplicating any Medicare supplement coverage.
Guaranteed Acceptance
__________________________________________________
n Your acceptance in any plan for which you’re eligible to enroll is guaranteed during your Medicare Supplement Open Enrollment
Period which lasts for 6 months beginning with the first day of the month in which you are both age 65 or older and enrolled in
Medicare Part B. Also, there is a 2-month open enrollment period after the loss of group health insurance coverage*.
n If you are age 50-64 and are eligible for Medicare due to disability or End-Stage Renal Disease, your acceptance in any plan is
guaranteed during your Medicare supplement open enrollment period which is the first 6 months you are enrolled in Medicare Part
B, unless you are entitled to one of the following Guaranteed Issue situations.
n Also, you may be eligible for Guaranteed Issue of a Medicare supplement plan if you lost or terminated other health coverage under
one of the following circumstances. You must provide a copy of the termination notice or letter you received from your prior plan
or employer and your Application Form must be received no more than 63 days after the termination date of your prior coverage.
GU25097FL (01-20)
Continued…
Plans Available Without Underwriting For Applicants Entitled to Guaranteed Issue
Questions? Call UnitedHealthcare Insurance Company at 1-800-523-5800.
Guaranteed Issue Situations:
For Applicants Age 50-64 who are eligible for Medicare by
reason of disability or End-Stage Renal Disease with:
Notice, letter or other documentation
from prior insurer must include items
below.
Also, please answer the questions
on the Application Form in the “Is
your acceptance guaranteed” and
“Your past and current coverage”
sections.
A Medicare Part A Effective
Date PRIOR to 1/1/2020.
A Medicare Part A Effective
Date on or AFTER 1/1/2020.
For Applicants Age 65 and over with:
A 65th birthday PRIOR to
1/1/2020.
OR
A Medicare Part A Effective
Date PRIOR to 1/1/2020.
A 65th birthday AND
Medicare Part A Effective
Date on or AFTER 1/1/2020.
1. Applicant loses, learns they
have lost, or drops employer
coverage, or the employer plan
no longer provides benefits at
least equal to those of Medicare
Supplement Plan A*.
A, B, C, F, K, L, N or, if available
in your area, Medicare Select N
A, B, G, K, L, N or, if available in
your area, Medicare Select G or
Medicare Select N
• Applicant’s name.
Plan Type – confirmation that it’s
employer coverage being lost.
• Coverage termination date.
2. Applicant is enrolled in a
Medicare Advantage (MA), other
Medicare managed care, Program
of All-Inclusive Care for the
Elderly (PACE) or Medicare Select
plan and:
The plan stops coverage in the
area, or
The plan sends notice it will
stop coverage, or
Applicant moves out of the
service area
A, B, C, F, K, L, N or, if available
in your area, Medicare Select N
A, B, G, K, L, N or, if available in
your area, Medicare Select G or
Medicare Select N
• Applicant’s name.
Plan Type – confirmation that it’s a
Medicare Advantage, other Medicare
managed care, Program of All-Inclusive
Care for the Elderly (PACE) or Medicare
Select plan being lost.
Coverage termination date and one of
the termination reasons shown in the
first column.
Marie A. Pero, Licensed Agent
Agent License ID #W128591
3. Applicant is enrolled in an MA,
other Medicare managed care,
PACE or Medicare supplement
(including Select) and the plan:
Violates the insurance contract
(for example, by failing to
provide necessary medical
care), or
Was misrepresented in
marketing to the individual
A, B, C, F, K, L, N or, if available
in your area, Medicare Select N
A, B, G, K, L, N or, if available in
your area, Medicare Select G
or Medicare Select N
• Applicant’s name.
Plan Type – confirmation that it’s a
Medicare Advantage, other Medicare
managed care, Program of All-Inclusive
Care for the Elderly (PACE) or Medicare
Supplement (including Select) being
replaced.
• Coverage termination date.
• Termination reason.
4. Applicant is enrolled in a
Medicare supplement plan
(including Select) that is
involuntarily terminated (for
example, company bankruptcy).
A, B, C, F, K, L, N or, if available
in your area, Medicare Select N
A, B, G, K, L, N or, if available in
your area, Medicare Select G or
Medicare Select N
• Applicant’s name.
Plan Type – confirmation that it’s a
Medicare supplement plan being lost.
• Insurer name.
Reason for involuntary termination.
If available, documentation of
bankruptcy of insurer.
Coverage termination date.
5. Applicant dropped Medicare
supplement coverage to enroll
for the first time in an MA, other
Medicare managed care, PACE,
or Select plan, and dropped that
plan within two years.
- If the previous plan you
had was an AARP Medicare
Supplement Plan, then you
may apply for Plans A, B, C, F,
K, L, N or, if available in your
area, Medicare Select N. Also,
you can apply for Plan G or, if
available in your area, Medicare
Select G without having to
answer health questions only if
Plan G or Medicare Select G was
the Plan you previously had.
- If the previous Medicare
Supplement Plan** you had was
with another insurer, then you
can only apply for Plans A, B, C,
F, K, L, N or, if available in your
area, Medicare Select N.
A, B, G, K, L, N or, if available in
your area, Medicare Select G or
Medicare Select N
• See information at the top of this
chart.
6. On first enrolling in Medicare
Part A at age 65***, applicant
enrolled in an MA or PACE plan at
the same time, and dropped that
plan within two years.
***NOTE: The MA or PACE plan
effective date must be equal to
the Medicare Part A effective
date for this qualifying event to
apply.
A, B, C, F, G, K, L, N or, if
available in your area, Medicare
Select G or Medicare Select N
A, B, G, K, L, N or, if available in
your area, Medicare Select G or
Medicare Select N
• See information at the top of this
chart.
*Also, there is a 2-month open enrollment period after the loss of group health insurance coverage. Applicants with a 65th birthday or a
Medicare Part A Effective Date prior to 1/1/2020 may apply for Plans A, B, C, F, G, K, L, N or, if available in your area, Medicare Select G or
Medicare Select N. Applicants with a 65th birthday and a Medicare Part A Effective Date on or after 1/1/2020 may apply for Plans A, B,
G, K, L, N or, if available in your area, Medicare Select G or Medicare Select N. Proof of loss of the group health insurance coverage must
be submitted with the Application Form.
**Prior Plan can also be a Medicare Select or High Deductible version of the Plan being applied for.
If you have any questions on your guaranteed right to insurance, you may wish to contact the administrator of your prior health
insurance plan or your local state department on aging.
Additional Information
Exclusions
____________________________________________________________
n Benefits provided under Medicare.
n Care not meeting Medicare’s standards.
n Injury or sickness payable by Workers’ Compensation or similar laws.
n Stays or treatment provided by a government-owned or -operated hospital or facility unless payment of charges is required by law.
n Stays, care, or visits for which no charge would be made to you in the absence of insurance.
n Care or services provided by a non-participating hospital, except in the event of a medical emergency, or if the services are not
available from any participating hospital in the service area.
n Any stay which begins, or medical expenses you incur, during the first 3 months after your effective date will not be considered
if due to a pre-existing condition. A pre-existing condition is a condition for which medical advice was given or treatment was
recommended by or received from a physician within 3 months prior to your plan’s effective date.
The following individuals are entitled to a waiver of this pre-existing condition exclusion:
1. Individuals who are replacing prior creditable coverage within 63 days after termination; or
2. Individuals who are turning age 65 and whose application form is received within six (6) months after they turn 65 AND are
enrolled in Medicare Part B; or
3. Individuals who are entitled to Guaranteed Issue; or
4. Individuals who have been covered under other health insurance coverage within the last 63 days and have enrolled in Medicare
Part B within the last 6 months.
Other exclusions may apply; however, in no event will your plan contain coverage limitations or exclusions for the Medicare Eligible
Expenses that are more restrictive than those of Medicare. Benefits and exclusions paid by your plan will automatically change
when Medicare’s requirements change.
Medicare Select Disclosure Statement
Please read this information carefully. The following information is provided in order to make a full and fair disclosure to you of the
provisions, restrictions, and limitations of the AARP Medicare Select Plan.
Medicare Select Provider Restrictions
______________________________________
In order for benefits to be payable under this insurance plan, you must use one of the select hospitals located throughout
the United States, unless:
(1) there is a Medical Emergency; (2) covered services are not available from any select hospital in the Service Area; or (3) covered
services are received from a Medicare-approved non-select hospital more than 100 miles from your Primary Residence.
In the case of (3) above, the following benefits may be payable subject to the terms and conditions of this plan:
- 75% of the Part A Medicare Inpatient Hospital Deductible amount per Benefit Period;
- 75% of the Part A Medicare Eligible Expenses not paid by Medicare; and
- 75% of the Part B Medicare Eligible Expenses for outpatient hospital services not paid by Medicare.
Only certain hospitals are network providers under this policy. Check with your physician to determine if he or she has
admitting privileges at the Network Hospital. If he or she does not, you may be required to use another physician at the
time of hospitalization or you will be required to pay for all expenses.
Right to Replace Your Medicare Select Plan
_________________________________
You have the right to replace your AARP Medicare Select Plan with any other AARP Medicare Supplement Plan, insured by
UnitedHealthcare Insurance Company, that has the same or lesser benefits as your current insurance and which does not require the
use of participating providers, without providing evidence of insurability.
Quality Assurance
______________________________________________________
Participating providers are required to maintain a quality assurance program conforming with nationally recognized quality of care
standards.
For Your Protection, Please Be Aware of the Following:
You Cannot Be Singled Out for Cancellation
_________________________________
Your AARP Medicare Select or Medicare Supplement Plan cannot be canceled because of your age, your health, or the number of
claims you make. Your AARP Medicare Select or Medicare Supplement Plan may be canceled due to nonpayment of premium or
material misrepresentation. If your group policy terminates and is not replaced by another group policy providing the same type of
coverage, you may convert your AARP Medicare Select Plan or AARP Medicare Supplement Plan to an individual Medicare supplement
policy issued by UnitedHealthcare Insurance Company. Of course, you may cancel your AARP Medicare Select Plan or AARP Medicare
Supplement Plan any time you wish. Any premium for days after the date of cancellation or death will be refunded.
The AARP Insurance Trust
_______________________________________________
AARP established the AARP Insurance Plan, a trust, to hold the master group insurance policies. The AARP Medicare Select and
AARP Medicare Supplement Plans are insured by UnitedHealthcare Insurance Company, not by AARP or its affiliates. Please contact
UnitedHealthcare Insurance Company if you have questions about your policy, including any limitations and exclusions.
Premiums are collected from you by the Trust. These premiums are paid to the insurance company for your insurance coverage, a
percentage is used to pay expenses, benefitting the insureds, and incurred by the Trust in connection with the insurance programs. At
the direction of UnitedHealthcare Insurance Company, a portion of the premium is paid as a royalty to AARP and used for the general
purposes of AARP. Income earned from the investment of premiums while on deposit with the Trust is paid to AARP and used for the
general purposes of AARP.
Participants are issued certificates of insurance by UnitedHealthcare Insurance Company under the master group insurance policy. The
benefits of participating in an insurance program carrying the AARP name are solely the right to receive the insurance coverage and
ancillary services provided by the program.
General Information
By enrolling, you are agreeing to the release of Medicare claim information to UnitedHealthcare Insurance Company so your AARP
Medicare Select or Medicare Supplement Plan claims may be processed automatically.
AARP and its affiliates are not insurers. AARP does not employ or endorse agents, brokers or producers.
You must be an AARP member to enroll in an AARP Medicare Select or Medicare Supplement Plan.
The Policy Form No. GRP79171 GPS-1 (G-36000-4) is issued in the District of Columbia to the Trustees of the AARP Insurance Plan.
AARP Medicare Select and Medicare Supplement Plans have been developed in line with federal standards. However, these plans
are not connected with, or endorsed by, the U.S. Government or the federal Medicare program.
This is a solicitation of insurance. An agent may contact you.
These materials describe the AARP Medicare Select and AARP Medicare Supplement Plans available in your state, but is not a contract,
policy, or insurance certificate. Please read your Certificate of Insurance, upon receipt, for plan benefits, definitions, exclusions, and
limitations.
Questions? Call UnitedHealthcare Insurance Company at 1-800-523-5800.
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