Fill and Sign the Transportation Contract Nysed Fillable Form Tc

Spontaneous. Fun. Fearless. United World Life Insurance Company A Mutual of Omaha Company The Facts About Your Plan Your United World 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 World pay. If you receive Medicare benefits because of a disability, you may apply for a Medicare supplement insurance policy regardless of your age. 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 World. 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 the 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; and (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 geographic area of your state. 2010 Medicare Supplement Insurance Plans Whether you’re six or sixtysomething, playing keeps you young-at-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. You are covered immediately. There is no waiting period for preexisting conditions. Benefits will be paid from the time your policy is in force. A Medicare supplement insurance policy from United World Life Insurance Company can help you attain that secure feeling. Your United World Medicare supplement insurance policy will not pay for: A Mutual of Omaha company since 1983, United World Life Insurance Company offers specialty life insurance and Medicare supplement plans. When you own a United World Medicare supplement, you get the reputation, stability and power of Mutual of Omaha and its affiliates, which have been providing quality products and services since 1909. ■ any expense incurred before your Policy Date ■ hospital or skilled nursing facility confinement incurred during a Medicare Part A benefit period that begins while this policy is not in force ■ expense paid for by Medicare ■ services for non-Medicare eligible expenses ■ services for which no charge is made when there is no insurance ■ loss or expense that is payable under any other Medicare supplement insurance policy or certificate Add our friendly personal customer service and affordable premiums and you have the financial value and security you seek. This is a brief description of your coverage. The outline of coverage must accompany this brochure. For complete information on benefits, exceptions, limitations and reductions, please read your outline of coverage and your policy. We’ve got you covered. Go play! This is a solicitation of insurance and an insurance agent will contact you by telephone. Medicare supplement insurance is underwritten by Neither United World 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 World Life Insurance Company is licensed nationwide except in CT and NY. United World Life Insurance Company WC7167_CO Colorado Policy Form WM1 – Plan A Policy Form WM2 – Plan B Policy Form WM8 – Plan C Policy Form WM12 – Plan D Policy Form WM3 – Plan F Policy Form WM4 – Plan G A Mutual of Omaha Company Mutual of Omaha Plaza Omaha, NE 68175 mutualofomaha.com Your Medicare Supplement Benefits Choose the Medicare Supplement Plan That Meets Your Needs Services and Supplies Medicare Part A Hospital Coverage Deductible First 60 days Coinsurance 61-90 days Coinsurance 91-150 days (Lifetime Reserve) Extended Hospital Coverage (up to an additional 365 days in your lifetime) Benefit for Blood Skilled Nursing Facility Care First 20 days Coinsurance 21-100 days Medicare Part B Physician’s Services and Supplies Deductible Coinsurance Excess Benefits Benefit for Blood Medicare Pays Nothing 100% All but $275 a day All but $550 a day Nothing All but three pints Medicare Supplement Plan A Pays Medicare Supplement Plan B Pays Medicare Supplement Plan C Pays Medicare Supplement Plan D Pays Medicare Supplement Plan F Pays Medicare Supplement Plan G Pays $1,100 $1,100 $1,100 $1,100 $1,100 $275 a day $275 a day $275 a day $275 a day $275 a day $275 a day $550 a day $550 a day $550 a day $550 a day $550 a day $550 a day Eligible Expenses Eligible Expenses Eligible Expenses Eligible Expenses Eligible Expenses Eligible Expenses Three pints Three pints Three pints Three pints Three pints Three pints 100% All but $137.50 a day Nothing 80% All but three pints Additional Benefits* Emergency Care Received Outside the U.S. 20% Three pints 20% Three pints $155 20% Up to $137.50 a day 20% Up to $137.50 a day $155 20% 100% up to Medicare’s limit Three pints Up to $137.50 a day 20% 80% up to Medicare’s limit Three pints Three pints Three pints 80% to lifetime max of $50,000 $1,600 80% to lifetime max of $50,000 80% to lifetime max of $50,000 $1,600 Nothing Your Premium * Refer to the next page and your outline of coverage for more information. 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, B, C, D, F and G pay $275 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 $550 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, B, C, D, F and G pay the Medicare Part A eligible expenses for hospitalization, paid at the Diagnostic Related Group (DRG) day outlier per diem or other appropriate standard of payment, subject to a lifetime maximum benefit of an additional 365 days. Benefit for Blood – Medicare has one calendaryear deductible for blood that is the cost of the first three pints needed. Plans A, B, C, D, F and G pay this deductible. 80% to lifetime max of $50,000 Nothing At-home Recovery Visits Up to $137.50 a day Medicare Part A Hospital Coverage Medicare Part B Physician’s Services and Supplies Deductible – Plans B, C, D, F and G pay the $1,100 Your Premium Your Premium Your Premium Your Premium Your Premium $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ Skilled Nursing Facility Care First 20 Days – Medicare pays all eligible expenses. Coinsurance – Plans C, D, F and G pay up to $137.50 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. Deductible – Plans C and F pay the $155 calendaryear deductible. Coinsurance – After the Medicare Part B deductible, Plans A, B, C, D, 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 the difference, up to the charge limitation established by Medicare. Benefit for Blood – Medicare has one calendaryear deductible for blood that is the cost of the first three pints needed. Plans A, B, C, D, F and G pay this deductible. Additional Benefits Emergency Care Received Outside the U.S. – After you pay a $250 calendar-year deductible, Plans C, D, 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 – Plans D and G pay 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. Your Medicare Supplement Benefits Choose the Medicare Supplement Plan That Meets Your Needs Services and Supplies Medicare Part A Hospital Coverage Deductible First 60 days Coinsurance 61-90 days Coinsurance 91-150 days (Lifetime Reserve) Extended Hospital Coverage (up to an additional 365 days in your lifetime) Benefit for Blood Skilled Nursing Facility Care First 20 days Coinsurance 21-100 days Medicare Part B Physician’s Services and Supplies Deductible Coinsurance Excess Benefits Benefit for Blood Medicare Pays Nothing 100% All but $275 a day All but $550 a day Nothing All but three pints Medicare Supplement Plan A Pays Medicare Supplement Plan B Pays Medicare Supplement Plan C Pays Medicare Supplement Plan D Pays Medicare Supplement Plan F Pays Medicare Supplement Plan G Pays $1,100 $1,100 $1,100 $1,100 $1,100 $275 a day $275 a day $275 a day $275 a day $275 a day $275 a day $550 a day $550 a day $550 a day $550 a day $550 a day $550 a day Eligible Expenses Eligible Expenses Eligible Expenses Eligible Expenses Eligible Expenses Eligible Expenses Three pints Three pints Three pints Three pints Three pints Three pints 100% All but $137.50 a day Nothing 80% All but three pints Additional Benefits* Emergency Care Received Outside the U.S. 20% Three pints 20% Three pints $155 20% Up to $137.50 a day 20% Up to $137.50 a day $155 20% 100% up to Medicare’s limit Three pints Up to $137.50 a day 20% 80% up to Medicare’s limit Three pints Three pints Three pints 80% to lifetime max of $50,000 $1,600 80% to lifetime max of $50,000 80% to lifetime max of $50,000 $1,600 Nothing Your Premium * Refer to the next page and your outline of coverage for more information. 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, B, C, D, F and G pay $275 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 $550 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, B, C, D, F and G pay the Medicare Part A eligible expenses for hospitalization, paid at the Diagnostic Related Group (DRG) day outlier per diem or other appropriate standard of payment, subject to a lifetime maximum benefit of an additional 365 days. Benefit for Blood – Medicare has one calendaryear deductible for blood that is the cost of the first three pints needed. Plans A, B, C, D, F and G pay this deductible. 80% to lifetime max of $50,000 Nothing At-home Recovery Visits Up to $137.50 a day Medicare Part A Hospital Coverage Medicare Part B Physician’s Services and Supplies Deductible – Plans B, C, D, F and G pay the $1,100 Your Premium Your Premium Your Premium Your Premium Your Premium $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ Skilled Nursing Facility Care First 20 Days – Medicare pays all eligible expenses. Coinsurance – Plans C, D, F and G pay up to $137.50 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. Deductible – Plans C and F pay the $155 calendaryear deductible. Coinsurance – After the Medicare Part B deductible, Plans A, B, C, D, 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 the difference, up to the charge limitation established by Medicare. Benefit for Blood – Medicare has one calendaryear deductible for blood that is the cost of the first three pints needed. Plans A, B, C, D, F and G pay this deductible. Additional Benefits Emergency Care Received Outside the U.S. – After you pay a $250 calendar-year deductible, Plans C, D, 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 – Plans D and G pay 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. United World Life Insurance Company A Mutual of Omaha Company The Facts About Your Plan Your United World 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 World pay. If you receive Medicare benefits because of a disability, you may apply for a Medicare supplement insurance policy regardless of your age. 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 World. 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 the 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; and (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 geographic area of your state. 2010 Medicare Supplement Insurance Plans Whether you’re six or sixtysomething, playing keeps you young-at-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. You are covered immediately. There is no waiting period for preexisting conditions. Benefits will be paid from the time your policy is in force. A Medicare supplement insurance policy from United World Life Insurance Company can help you attain that secure feeling. Your United World Medicare supplement insurance policy will not pay for: A Mutual of Omaha company since 1983, United World Life Insurance Company offers specialty life insurance and Medicare supplement plans. When you own a United World Medicare supplement, you get the reputation, stability and power of Mutual of Omaha and its affiliates, which have been providing quality products and services since 1909. ■ any expense incurred before your Policy Date ■ hospital or skilled nursing facility confinement incurred during a Medicare Part A benefit period that begins while this policy is not in force ■ expense paid for by Medicare ■ services for non-Medicare eligible expenses ■ services for which no charge is made when there is no insurance ■ loss or expense that is payable under any other Medicare supplement insurance policy or certificate Add our friendly personal customer service and affordable premiums and you have the financial value and security you seek. This is a brief description of your coverage. The outline of coverage must accompany this brochure. For complete information on benefits, exceptions, limitations and reductions, please read your outline of coverage and your policy. We’ve got you covered. Go play! This is a solicitation of insurance and an insurance agent will contact you by telephone. Medicare supplement insurance is underwritten by Neither United World 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 World Life Insurance Company is licensed nationwide except in CT and NY. United World Life Insurance Company WC7167_CO Colorado Policy Form WM1 – Plan A Policy Form WM2 – Plan B Policy Form WM8 – Plan C Policy Form WM12 – Plan D Policy Form WM3 – Plan F Policy Form WM4 – Plan G A Mutual of Omaha Company Mutual of Omaha Plaza Omaha, NE 68175 mutualofomaha.com