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Spontaneous. Fun. Fearless. Mutual of Omaha Insurance Company The Facts About Your Plan Your Mutual 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 Mutual of Omaha pay. During the first six months your policy is in force, your benefits will not pay for any illness or injury for which medical advice was given or treatment was recommended by or received from a physician within six (6) months before your Policy Date. 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. 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. However, if creditable coverage was continuous to a date not more than 63 days prior to the effective date of your current coverage, preexisting conditions are covered immediately. This would include situations where you are replacing another Medicare supplement, Medicare SELECT or Medicare Advantage policy with this one. 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 Mutual 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 the application. You cannot be singled out for a rate increase, no matter how many times you receive benefits. Your premium changes when the same premium change is made on all in-force Medicare supplement policies of the same form issued to persons of your classification (subject to approval by the New York State Insurance Department). 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 Mutual of Omaha Insurance Company can help you attain that secure feeling. Your Mutual of Omaha Medicare supplement insurance policy will not pay for: You can be confident that your Medicare supplement benefits will be paid as promised because Mutual of Omaha Insurance Company has been serving people like you since Medicare began more than 40 years ago. And, we’re committed to continue providing Medicare supplement benefits amid an ever-changing political and economic environment. ■ any expense incurred before your Policy Date ■ services for which no charge is made when there is no insurance ■ that portion of expense paid for by Medicare ■ that portion of any expense payable under mandatory automobile No Fault insurance policies This policy meets the minimum standards for Medicare supplement policies as defined by the New York States Insurance Department. The expected benefit ratio for the policy is 65%. This ratio is the portion of future premiums which the Company expects to return as benefits, when averaged over all people with the policy. Add our friendly personal customer service and competitive premiums – and you have the financial value and security you seek. IMPORTANT NOTICE—A CONSUMER’S GUIDE TO HEALTH INSURANCE FOR PEOPLE ELIGIBLE FOR MEDICARE MAY BE OBTAINED FROM YOUR LOCAL SOCIAL SECURITY OFFICE OR FROM MUTUAL OF OMAHA. We’ve got you covered. Go play! 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. Medicare supplement insurance is underwritten by Mutual of Omaha Insurance Company This is a solicitation of insurance and an insurance agent will contact you by telephone. Neither Mutual of Omaha Insurance Company nor its Medicare supplement insurance policies are connected with or endorsed by the U.S. government or the federal Medicare program. Mutual of Omaha Insurance Company is licensed nationwide. Mutual of Omaha Plaza Omaha, NE 68175 mutualofomaha.com MC34168_NY New York Policy Form M201-17336-Plan A Policy Form M203-17338-Plan B Policy Form M250-17611-Plan F Policy Form M374-20779-Plan G Rider 0LM8M 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 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 F Pays Medicare Supplement Plan G Pays $1,100 $1,100 $1,100 $275 a day $275 a day $275 a day $275 a day $550 a day $550 a day $550 a day $550 a day Eligible Expenses Eligible Expenses Eligible Expenses Eligible Expenses Three pints Three pints Three pints Three pints 100% All but $137.50 a day Up to $137.50 a day Up to $137.50 a day Medicare Part B Physician’s Services and Supplies Deductible Coinsurance Excess Benefits Benefit for Blood Nothing 80% Nothing All but three pints Additional Benefits* Emergency Care Received Outside the U.S. Three pints 20% Three pints Nothing At-home Recovery Visits 20% $155 20% 100% up to Medicare’s limit Three pints Nothing Medicare Part A Hospital Coverage Medicare Part B Physician’s Services and Supplies Deductible – Plans B, F and G pay the $1,100 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, 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, F and G pay the Medicare Part A eligible expenses for hospitalization, 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, F and G pay this deductible. Skilled Nursing Facility Care 20% 80% up to Medicare’s limit Three pints 80% to lifetime max of $50,000 80% to lifetime max of $50,000 $1,600 Your Premium * Refer to the next page and your outline of coverage for more information. Your Medicare Supplement Benefits Your Premium Your Premium Your Premium $ __________ $ __________ $ __________ $ __________ First 20 Days – Medicare pays all eligible expenses. Coinsurance – Plans 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 – Plan F pays the $155 calendar-year deductible. Coinsurance – After the Medicare Part B deductible, Plans A, B, 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, 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. 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 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 F Pays Medicare Supplement Plan G Pays $1,100 $1,100 $1,100 $275 a day $275 a day $275 a day $275 a day $550 a day $550 a day $550 a day $550 a day Eligible Expenses Eligible Expenses Eligible Expenses Eligible Expenses Three pints Three pints Three pints Three pints 100% All but $137.50 a day Up to $137.50 a day Up to $137.50 a day Medicare Part B Physician’s Services and Supplies Deductible Coinsurance Excess Benefits Benefit for Blood Nothing 80% Nothing All but three pints Additional Benefits* Emergency Care Received Outside the U.S. Three pints 20% Three pints Nothing At-home Recovery Visits 20% $155 20% 100% up to Medicare’s limit Three pints Nothing Medicare Part A Hospital Coverage Medicare Part B Physician’s Services and Supplies Deductible – Plans B, F and G pay the $1,100 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, 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, F and G pay the Medicare Part A eligible expenses for hospitalization, 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, F and G pay this deductible. Skilled Nursing Facility Care 20% 80% up to Medicare’s limit Three pints 80% to lifetime max of $50,000 80% to lifetime max of $50,000 $1,600 Your Premium * Refer to the next page and your outline of coverage for more information. Your Medicare Supplement Benefits Your Premium Your Premium Your Premium $ __________ $ __________ $ __________ $ __________ First 20 Days – Medicare pays all eligible expenses. Coinsurance – Plans 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 – Plan F pays the $155 calendar-year deductible. Coinsurance – After the Medicare Part B deductible, Plans A, B, 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, 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. Mutual of Omaha Insurance Company The Facts About Your Plan Your Mutual 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 Mutual of Omaha pay. During the first six months your policy is in force, your benefits will not pay for any illness or injury for which medical advice was given or treatment was recommended by or received from a physician within six (6) months before your Policy Date. 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. 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. However, if creditable coverage was continuous to a date not more than 63 days prior to the effective date of your current coverage, preexisting conditions are covered immediately. This would include situations where you are replacing another Medicare supplement, Medicare SELECT or Medicare Advantage policy with this one. 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 Mutual 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 the application. You cannot be singled out for a rate increase, no matter how many times you receive benefits. Your premium changes when the same premium change is made on all in-force Medicare supplement policies of the same form issued to persons of your classification (subject to approval by the New York State Insurance Department). 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 Mutual of Omaha Insurance Company can help you attain that secure feeling. Your Mutual of Omaha Medicare supplement insurance policy will not pay for: You can be confident that your Medicare supplement benefits will be paid as promised because Mutual of Omaha Insurance Company has been serving people like you since Medicare began more than 40 years ago. And, we’re committed to continue providing Medicare supplement benefits amid an ever-changing political and economic environment. ■ any expense incurred before your Policy Date ■ services for which no charge is made when there is no insurance ■ that portion of expense paid for by Medicare ■ that portion of any expense payable under mandatory automobile No Fault insurance policies This policy meets the minimum standards for Medicare supplement policies as defined by the New York States Insurance Department. The expected benefit ratio for the policy is 65%. This ratio is the portion of future premiums which the Company expects to return as benefits, when averaged over all people with the policy. Add our friendly personal customer service and competitive premiums – and you have the financial value and security you seek. IMPORTANT NOTICE—A CONSUMER’S GUIDE TO HEALTH INSURANCE FOR PEOPLE ELIGIBLE FOR MEDICARE MAY BE OBTAINED FROM YOUR LOCAL SOCIAL SECURITY OFFICE OR FROM MUTUAL OF OMAHA. We’ve got you covered. Go play! 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. Medicare supplement insurance is underwritten by Mutual of Omaha Insurance Company This is a solicitation of insurance and an insurance agent will contact you by telephone. Neither Mutual of Omaha Insurance Company nor its Medicare supplement insurance policies are connected with or endorsed by the U.S. government or the federal Medicare program. Mutual of Omaha Insurance Company is licensed nationwide. Mutual of Omaha Plaza Omaha, NE 68175 mutualofomaha.com MC34168_NY New York Policy Form M201-17336-Plan A Policy Form M203-17338-Plan B Policy Form M250-17611-Plan F Policy Form M374-20779-Plan G Rider 0LM8M