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United of Omaha Life Insurance Company A Mutual of Omaha Company The Facts About Your Plan Your United of Omaha Medicare supplement insurance policy helps pay some eligible expenses not paid for by Medicare Part A and Medicare Part B. There may be charges above what Medicare and United of Omaha pay. Medicare Part A Eligible Expenses for Hospital/ Skilled Nursing Facility Care include expenses for semiprivate room and board, general nursing, and miscellaneous services and supplies. Medicare Part B Eligible Expenses for Medical Services include expenses for physicians’ services, hospital outpatient services and supplies, physical and speech therapy, and ambulance service. “Medicare Eligible Expenses” means expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare. A Benefit Period begins the first full day you are hospitalized and ends when you have not been in a hospital or skilled nursing facility for 60 days in a row. Coinsurance is the portion of the eligible expense not paid by Medicare and paid by United of Omaha. As Medicare deductibles and coinsurance increase, your Medicare supplement benefits will automatically increase. Benefits are not paid for any expense paid by Medicare. Benefits are paid to you or to your hospital or doctor. You have 31 days from your renewal date to pay your premium. Your policy will stay in force during this 31-day grace period. Your policy is guaranteed renewable. Your policy cannot be canceled. It will be renewed as long as the premiums are paid on time and the information is correct on your application. You cannot be singled out for a rate increase, no matter how many times you receive benefits. Your premium changes: (a) each year on the renewal date coinciding with or following the anniversary of your Policy Date until you reach age 90; or (b) when the same premium change is made on all in-force Medicare supplement policies of the same form issued to persons of your classification in the same ZIP code. Your policy’s two-person household premium discount ends if the person you live with terminates his or her policy or moves to a different residence. 2009 Medicare Supplement Insurance Plans Medicare supplement insurance is underwritten by United of Omaha Life Insurance Company A Mutual of Omaha Company Mutual of Omaha Plaza Omaha, Nebraska 68175 mutualofomaha.com You are covered immediately. There is no waiting period for preexisting conditions. Benefits will be paid from the time your policy is in force. Your United of Omaha Medicare supplement insurance policy will not pay for: ■ any expense incurred before your Policy Date ■ s ervices for which no charge is made when there is no insurance ■ expense paid for by Medicare This is a brief description of your coverage. The outline of coverage must accompany this brochure. For complete information on benefits, exceptions, reductions and limitations, please read your outline of coverage and your policy. Neither United of Omaha Life Insurance Company nor its Medicare supplement insurance policies are connected with or endorsed by the U.S. government or the federal Medicare program. United of Omaha Life Insurance Company is licensed nationwide except in NY. This is a solicitation of insurance and an agent will contact you by telephone. Policy Form UM1 – Plan A Policy Form UM4 – Plan F Policy Form UM5 – Plan G UC6845_TN Tennessee Policy Forms UM1, UM4, UM5 Spontaneous. Fun. Fearless. Whether you’re six or sixty-something, playing keeps you youngat-heart. The difference now, of course, is that you have adult responsibilities, including making sound financial decisions. You’ll probably enjoy playing, however you define it, even more when you feel you’ve got your bases covered. A Medicare supplement insurance policy from United of Omaha Life Insurance Company can help you attain that secure feeling. A Mutual of Omaha company since 1926, United of Omaha Life Insurance Company offers a diversified portfolio of life insurance, fixed annuities and other insurance, including Medicare supplement policies. When you own a United of Omaha Medicare supplement, you get the reputation, stability and power of Mutual of Omaha and its affiliates, which have been providing quality products and services for 100 years. Add our friendly personal customer service and affordable premiums – including a discount for your eligible spouse or household resident – and you have the financial value and security you seek. We’ve got you covered. Go play! Choose the Medicare Supplement Plan That Meets Your Needs Your Medicare Supplement Benefits Medicare Medicare Medicare Services and Supplies Supplement Supplement Supplement Medicare Plan A Plan F Plan G Medicare Part A_ ______________________ Pays__________ Pays__________ Pays_ _________ Pays Hospital Coverage Deductible___________________________ Nothing ____________________ $1,068_ _______ $1,068 First 60 days___________________________ 100%_ _____________________________________ Coinsurance_ ________________________ All but_________$267__________ $267__________$267 61-90 days $267 a day a day a day a day Coinsurance_ ________________________ All but________ $534_ ________ $534__________$534 91-150 days (Lifetime Reserve) $534 a day a day a day a day Extended Hospital Coverage_____________ Nothing ______ Eligible_ ______ Eligible_______ Eligible (up to an additional 365 days Expenses Expenses Expenses in your lifetime) Benefit for Blood______________________ All but______ Three pints_____Three pints_ ___ Three pints three pints Skilled Nursing Facility Care First 20 days___________________________ 100%_ _____________________________________ Coinsurance_ ________________________ All but_____________________ Up to_________ Up to $133.50 $133.50 $133.50 21-100 days a day a day a day Medicare Part B Physician’s Services and Supplies Deductible___________________________ Nothing _____________________ $135____________ Coinsurance_ _________________________ 80%_________ 20%_________ 20%_ _________ 20% Excess Benefits____________________________________________________100%__________ 80% up to up to Medicare’s Medicare’s limit limit Benefit for Blood______________________ All but______ Three pints____ Three pints____ Three pints three pints Additional Benefits* 80% to 80% to lifetime max of lifetime max of Emergency Care Received__________________________________________ $50,000________$50,000 Outside the U.S. At-home Recovery Visits_________________________________________________________ $1,600 Medicare Part A Hospital Coverage Your Premium Your Premium Your Premium * Refer to the next page and your outline of coverage for more information. $ ___________ $ ___________ $ ___________ Deductible — Plans F and G pay the $1,068 inpatient hospital deductible for each benefit period. First 60 Days — After the Medicare Part A deductible, Medicare pays all eligible expenses for services from your first through 60th day of hospital confinement. Services include semiprivate room and board, general nursing, and miscellaneous hospital services and supplies. Coinsurance — Plans A, F and G pay $267 a day when you are hospitalized from the 61st through the 90th day. And, when you are in the hospital from the 91st day through the 150th day, you receive $534 a day for each Lifetime Reserve day used. Extended Hospital Coverage — When you are in the hospital longer than 150 days during a benefit period, and you have exhausted your 60 days of Medicare Lifetime Reserve, Plans A, F and G pay the Medicare Part A eligible expenses for hospitalization, paid at the Prospective Payment System (PPS) rate or other appropriate standard of payment, subject to a lifetime maximum benefit of an additional 365 days. Benefit for Blood — Medicare has one calendar-year deductible for blood that is the cost of the first three pints needed. Plans A, F and G pay this deductible. Skilled Nursing Facility Care First 20 Days — Medicare pays all eligible expenses. Coinsurance — Plans F and G pay up to $133.50 a day from the 21st through the 100th day during which you receive skilled nursing care. You must enter a Medicare-certified skilled nursing facility within 30 days of being hospitalized for at least three days. Medicare Part B Physician’s Services and Supplies Deductible — Plan F pays the $135 calendar-year deductible. Coinsurance — After the Medicare Part B deductible, Plans A, F and G pay 20% of eligible expenses for physician’s services, and supplies, physical and speech therapy, and ambulance service. For hospital outpatient services, the copayment amount will be paid under a prospective payment system. If this system is not used, then 20% of eligible expenses will be paid. Excess Benefits — Your bill for Medicare Part B services and supplies may exceed the Medicare eligible expense. When that occurs, Plan F pays 100% and Plan G pays 80% of excess charges up to the Medicare approved amount. Benefit for Blood — Medicare has one calendar-year deductible for blood that is the cost of the first three pints needed. Plans A, F and G pay this deductible. Additional Benefits Emergency Care Received Outside the U.S. — After you pay a $250 calendar-year deductible, Plans F and G pay you 80% of eligible expenses incurred during the first 60 days of a trip up to a lifetime maximum of $50,000. Benefits are payable for health care you need because of a covered injury or illness. At-home Recovery Visits — Plan G pays for seven visits a week, up to $40 a visit up to a maximum of $1,600 a year for assistance with activities of daily living. Benefits are payable for services necessary for your continuing recovery from an illness, injury or surgery. Spontaneous. Fun. Fearless. Whether you’re six or sixty-something, playing keeps you youngat-heart. The difference now, of course, is that you have adult responsibilities, including making sound financial decisions. You’ll probably enjoy playing, however you define it, even more when you feel you’ve got your bases covered. A Medicare supplement insurance policy from United of Omaha Life Insurance Company can help you attain that secure feeling. A Mutual of Omaha company since 1926, United of Omaha Life Insurance Company offers a diversified portfolio of life insurance, fixed annuities and other insurance, including Medicare supplement policies. When you own a United of Omaha Medicare supplement, you get the reputation, stability and power of Mutual of Omaha and its affiliates, which have been providing quality products and services for 100 years. Add our friendly personal customer service and affordable premiums – including a discount for your eligible spouse or household resident – and you have the financial value and security you seek. We’ve got you covered. Go play! Choose the Medicare Supplement Plan That Meets Your Needs Your Medicare Supplement Benefits Medicare Medicare Medicare Services and Supplies Supplement Supplement Supplement Medicare Plan A Plan F Plan G Medicare Part A Pays Pays Pays Pays Hospital Coverage Deductible___________________________ Nothing ____________________ $1,068_ _______ $1,068 First 60 days___________________________ 100%_ _____________________________________ Coinsurance_ ________________________ All but_________$267__________ $267__________$267 61-90 days $267 a day a day a day a day Coinsurance_ ________________________ All but________ $534_ ________ $534__________$534 91-150 days (Lifetime Reserve) $534 a day a day a day a day Extended Hospital Coverage_____________ Nothing ______ Eligible_ ______ Eligible_______ Eligible (up to an additional 365 days Expenses Expenses Expenses in your lifetime) Benefit for Blood______________________ All but______ Three pints_____Three pints_ ___ Three pints three pints Skilled Nursing Facility Care First 20 days___________________________ 100%_ _____________________________________ Coinsurance_ ________________________ All but_____________________ Up to_________ Up to $133.50 $133.50 $133.50 21-100 days a day a day a day Medicare Part B Physician’s Services and Supplies Deductible___________________________ Nothing _____________________ $135____________ Coinsurance_ _________________________ 80%_________ 20%_________ 20%_ _________ 20% Excess Benefits____________________________________________________100%__________ 80% up to up to Medicare’s Medicare’s limit limit Benefit for Blood______________________ All but______ Three pints____ Three pints____ Three pints three pints Additional Benefits* 80% to 80% to lifetime lifetime max of max of Emergency Care Received__________________________________________ $50,000________$50,000 Outside the U.S. At-home Recovery Visits_________________________________________________________ $1,600 Medicare Part A Hospital Coverage Your Premium Your Premium Your Premium * Refer to the next page and your outline of coverage for more information. $ ___________ $ ___________ $ ___________ Deductible — Plans F and G pay the $1,068 inpatient hospital deductible for each benefit period. First 60 Days — After the Medicare Part A deductible, Medicare pays all eligible expenses for services from your first through 60th day of hospital confinement. Services include semiprivate room and board, general nursing, and miscellaneous hospital services and supplies. Coinsurance — Plans A, F and G pay $267 a day when you are hospitalized from the 61st through the 90th day. And, when you are in the hospital from the 91st day through the 150th day, you receive $534 a day for each Lifetime Reserve day used. Extended Hospital Coverage — When you are in the hospital longer than 150 days during a benefit period, and you have exhausted your 60 days of Medicare Lifetime Reserve, Plans A, F and G pay the Medicare Part A eligible expenses for hospitalization, paid at the Prospective Payment System (PPS) rate or other appropriate standard of payment, subject to a lifetime maximum benefit of an additional 365 days. Benefit for Blood — Medicare has one calendar-year deductible for blood that is the cost of the first three pints needed. Plans A, F and G pay this deductible. Skilled Nursing Facility Care First 20 Days — Medicare pays all eligible expenses. Coinsurance — Plans F and G pay up to $133.50 a day from the 21st through the 100th day during which you receive skilled nursing care. You must enter a Medicare-certified skilled nursing facility within 30 days of being hospitalized for at least three days. Medicare Part B Physician’s Services and Supplies Deductible — Plan F pays the $135 calendar-year deductible. Coinsurance — After the Medicare Part B deductible, Plans A, F and G pay 20% of eligible expenses for physician’s services, and supplies, physical and speech therapy, and ambulance service. For hospital outpatient services, the copayment amount will be paid under a prospective payment system. If this system is not used, then 20% of eligible expenses will be paid. Excess Benefits — Your bill for Medicare Part B services and supplies may exceed the Medicare eligible expense. When that occurs, Plan F pays 100% and Plan G pays 80% of excess charges up to the Medicare approved amount. Benefit for Blood — Medicare has one calendar-year deductible for blood that is the cost of the first three pints needed. Plans A, F and G pay this deductible. Additional Benefits Emergency Care Received Outside the U.S. — After you pay a $250 calendar-year deductible, Plans F and G pay you 80% of eligible expenses incurred during the first 60 days of a trip up to a lifetime maximum of $50,000. Benefits are payable for health care you need because of a covered injury or illness. At-home Recovery Visits — Plan G pays for seven visits a week, up to $40 a visit up to a maximum of $1,600 a year for assistance with activities of daily living. Benefits are payable for services necessary for your continuing recovery from an illness, injury or surgery. Spontaneous. Fun. Fearless. Whether you’re six or sixty-something, playing keeps you youngat-heart. The difference now, of course, is that you have adult responsibilities, including making sound financial decisions. You’ll probably enjoy playing, however you define it, even more when you feel you’ve got your bases covered. A Medicare supplement insurance policy from United of Omaha Life Insurance Company can help you attain that secure feeling. A Mutual of Omaha company since 1926, United of Omaha Life Insurance Company offers a diversified portfolio of life insurance, fixed annuities and other insurance, including Medicare supplement policies. When you own a United of Omaha Medicare supplement, you get the reputation, stability and power of Mutual of Omaha and its affiliates, which have been providing quality products and services for 100 years. Add our friendly personal customer service and affordable premiums – including a discount for your eligible spouse or household resident – and you have the financial value and security you seek. We’ve got you covered. Go play! Choose the Medicare Supplement Plan That Meets Your Needs Your Medicare Supplement Benefits Medicare Medicare Medicare Services and Supplies Supplement Supplement Supplement Medicare Plan A Plan F Plan G Medicare Part A_ ______________________ Pays__________ Pays__________ Pays_ _________ Pays Hospital Coverage Deductible___________________________ Nothing ____________________ $1,068_ _______ $1,068 First 60 days___________________________ 100%_ _____________________________________ Coinsurance_ ________________________ All but_________$267__________ $267__________$267 61-90 days $267 a day a day a day a day Coinsurance_ ________________________ All but________ $534_ ________ $534__________$534 91-150 days (Lifetime Reserve) $534 a day a day a day a day Extended Hospital Coverage_____________ Nothing ______ Eligible_ ______ Eligible_______ Eligible (up to an additional 365 days Expenses Expenses Expenses in your lifetime) Benefit for Blood______________________ All but______ Three pints_____Three pints_ ___ Three pints three pints Skilled Nursing Facility Care First 20 days___________________________ 100%_ _____________________________________ Coinsurance_ ________________________ All but_____________________ Up to_________ Up to $133.50 $133.50 $133.50 21-100 days a day a day a day Medicare Part B Physician’s Services and Supplies Deductible___________________________ Nothing _____________________ $135____________ Coinsurance_ _________________________ 80%_________ 20%_________ 20%_ _________ 20% Excess Benefits____________________________________________________100%__________ 80% up to up to Medicare’s Medicare’s limit limit Benefit for Blood______________________ All but______ Three pints____ Three pints____ Three pints three pints Additional Benefits* 80% to 80% to lifetime max of lifetime max of Emergency Care Received__________________________________________ $50,000________$50,000 Outside the U.S. At-home Recovery Visits_________________________________________________________ $1,600 Medicare Part A Hospital Coverage Your Premium Your Premium Your Premium * Refer to the next page and your outline of coverage for more information. $ ___________ $ ___________ $ ___________ Deductible — Plans F and G pay the $1,068 inpatient hospital deductible for each benefit period. First 60 Days — After the Medicare Part A deductible, Medicare pays all eligible expenses for services from your first through 60th day of hospital confinement. Services include semiprivate room and board, general nursing, and miscellaneous hospital services and supplies. Coinsurance — Plans A, F and G pay $267 a day when you are hospitalized from the 61st through the 90th day. And, when you are in the hospital from the 91st day through the 150th day, you receive $534 a day for each Lifetime Reserve day used. Extended Hospital Coverage — When you are in the hospital longer than 150 days during a benefit period, and you have exhausted your 60 days of Medicare Lifetime Reserve, Plans A, F and G pay the Medicare Part A eligible expenses for hospitalization, paid at the Prospective Payment System (PPS) rate or other appropriate standard of payment, subject to a lifetime maximum benefit of an additional 365 days. Benefit for Blood — Medicare has one calendar-year deductible for blood that is the cost of the first three pints needed. Plans A, F and G pay this deductible. Skilled Nursing Facility Care First 20 Days — Medicare pays all eligible expenses. Coinsurance — Plans F and G pay up to $133.50 a day from the 21st through the 100th day during which you receive skilled nursing care. You must enter a Medicare-certified skilled nursing facility within 30 days of being hospitalized for at least three days. Medicare Part B Physician’s Services and Supplies Deductible — Plan F pays the $135 calendar-year deductible. Coinsurance — After the Medicare Part B deductible, Plans A, F and G pay 20% of eligible expenses for physician’s services, and supplies, physical and speech therapy, and ambulance service. For hospital outpatient services, the copayment amount will be paid under a prospective payment system. If this system is not used, then 20% of eligible expenses will be paid. Excess Benefits — Your bill for Medicare Part B services and supplies may exceed the Medicare eligible expense. When that occurs, Plan F pays 100% and Plan G pays 80% of excess charges up to the Medicare approved amount. Benefit for Blood — Medicare has one calendar-year deductible for blood that is the cost of the first three pints needed. Plans A, F and G pay this deductible. Additional Benefits Emergency Care Received Outside the U.S. — After you pay a $250 calendar-year deductible, Plans F and G pay you 80% of eligible expenses incurred during the first 60 days of a trip up to a lifetime maximum of $50,000. Benefits are payable for health care you need because of a covered injury or illness. At-home Recovery Visits — Plan G pays for seven visits a week, up to $40 a visit up to a maximum of $1,600 a year for assistance with activities of daily living. Benefits are payable for services necessary for your continuing recovery from an illness, injury or surgery. United of Omaha Life Insurance Company A Mutual of Omaha Company The Facts About Your Plan Your United of Omaha Medicare supplement insurance policy helps pay some eligible expenses not paid for by Medicare Part A and Medicare Part B. There may be charges above what Medicare and United of Omaha pay. Medicare Part A Eligible Expenses for Hospital/ Skilled Nursing Facility Care include expenses for semiprivate room and board, general nursing, and miscellaneous services and supplies. Medicare Part B Eligible Expenses for Medical Services include expenses for physicians’ services, hospital outpatient services and supplies, physical and speech therapy, and ambulance service. “Medicare Eligible Expenses” means expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare. A Benefit Period begins the first full day you are hospitalized and ends when you have not been in a hospital or skilled nursing facility for 60 days in a row. Coinsurance is the portion of the eligible expense not paid by Medicare and paid by United of Omaha. As Medicare deductibles and coinsurance increase, your Medicare supplement benefits will automatically increase. Benefits are not paid for any expense paid by Medicare. Benefits are paid to you or to your hospital or doctor. You have 31 days from your renewal date to pay your premium. Your policy will stay in force during this 31-day grace period. Your policy is guaranteed renewable. Your policy cannot be canceled. It will be renewed as long as the premiums are paid on time and the information is correct on your application. You cannot be singled out for a rate increase, no matter how many times you receive benefits. Your premium changes: (a) each year on the renewal date coinciding with or following the anniversary of your Policy Date until you reach age 90; or (b) when the same premium change is made on all in-force Medicare supplement policies of the same form issued to persons of your classification in the same ZIP code. Your policy’s two-person household premium discount ends if the person you live with terminates his or her policy or moves to a different residence. 2009 Medicare Supplement Insurance Plans Medicare supplement insurance is underwritten by United of Omaha Life Insurance Company A Mutual of Omaha Company Mutual of Omaha Plaza Omaha, Nebraska 68175 mutualofomaha.com You are covered immediately. There is no waiting period for preexisting conditions. Benefits will be paid from the time your policy is in force. Your United of Omaha Medicare supplement insurance policy will not pay for: ■ any expense incurred before your Policy Date ■ s ervices for which no charge is made when there is no insurance ■ expense paid for by Medicare This is a brief description of your coverage. The outline of coverage must accompany this brochure. For complete information on benefits, exceptions, reductions and limitations, please read your outline of coverage and your policy. Neither United of Omaha Life Insurance Company nor its Medicare supplement insurance policies are connected with or endorsed by the U.S. government or the federal Medicare program. United of Omaha Life Insurance Company is licensed nationwide except in NY. This is a solicitation of insurance and an agent will contact you by telephone. Policy Form UM1 – Plan A Policy Form UM4 – Plan F Policy Form UM5 – Plan G UC6845_TN Tennessee Policy Forms UM1, UM4, UM5 United of Omaha Life Insurance Company A Mutual of Omaha Company The Facts About Your Plan Your United of Omaha Medicare supplement insurance policy helps pay some eligible expenses not paid for by Medicare Part A and Medicare Part B. There may be charges above what Medicare and United of Omaha pay. Medicare Part A Eligible Expenses for Hospital/ Skilled Nursing Facility Care include expenses for semiprivate room and board, general nursing, and miscellaneous services and supplies. Medicare Part B Eligible Expenses for Medical Services include expenses for physicians’ services, hospital outpatient services and supplies, physical and speech therapy, and ambulance service. “Medicare Eligible Expenses” means expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare. A Benefit Period begins the first full day you are hospitalized and ends when you have not been in a hospital or skilled nursing facility for 60 days in a row. Coinsurance is the portion of the eligible expense not paid by Medicare and paid by United of Omaha. As Medicare deductibles and coinsurance increase, your Medicare supplement benefits will automatically increase. Benefits are not paid for any expense paid by Medicare. Benefits are paid to you or to your hospital or doctor. You have 31 days from your renewal date to pay your premium. Your policy will stay in force during this 31-day grace period. Your policy is guaranteed renewable. Your policy cannot be canceled. It will be renewed as long as the premiums are paid on time and the information is correct on your application. You cannot be singled out for a rate increase, no matter how many times you receive benefits. Your premium changes: (a) each year on the renewal date coinciding with or following the anniversary of your Policy Date until you reach age 90; or (b) when the same premium change is made on all in-force Medicare supplement policies of the same form issued to persons of your classification in the same ZIP code. Your policy’s two-person household premium discount ends if the person you live with terminates his or her policy or moves to a different residence. 2009 Medicare Supplement Insurance Plans Medicare supplement insurance is underwritten by United of Omaha Life Insurance Company A Mutual of Omaha Company Mutual of Omaha Plaza Omaha, Nebraska 68175 mutualofomaha.com You are covered immediately. There is no waiting period for preexisting conditions. Benefits will be paid from the time your policy is in force. Your United of Omaha Medicare supplement insurance policy will not pay for: ■ any expense incurred before your Policy Date ■ s ervices for which no charge is made when there is no insurance ■ expense paid for by Medicare This is a brief description of your coverage. The outline of coverage must accompany this brochure. For complete information on benefits, exceptions, reductions and limitations, please read your outline of coverage and your policy. Neither United of Omaha Life Insurance Company nor its Medicare supplement insurance policies are connected with or endorsed by the U.S. government or the federal Medicare program. United of Omaha Life Insurance Company is licensed nationwide except in NY. This is a solicitation of insurance and an agent will contact you by telephone. Policy Form UM1 – Plan A Policy Form UM4 – Plan F Policy Form UM5 – Plan G UC6845_TN Tennessee Policy Forms UM1, UM4, UM5