PrimeTime Choices Medicare Supplement Insurance offered by AultCare Insurance Company
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Medicare Supplement plans sold with effective dates for coverage on or after January 1, 2020
Outline of Coverage High Deductible 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.

​
**This high deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,340 deductible.  Benefits from the high deductible plan G will not begin until out-of-pocket expenses are $2,340.  Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy.  This includes the Medicare deductibles for Part A and Part B, but does not include the Plan’s separate foreign travel emergency deductible.

Review All other Plans
Review Area 1 Rates
Review Area 2 Rates
Review Area 3 Rates
Services
Medicare Pays
After You Pay $2,340 Deductible,  Plan Pays
After You Pay
​$2,340 Deductible, Plan Pays
HOSPITALIZATION*
Semi-private room and board, general nursing & miscellaneous services and supplies
​
First 60 days

61st thru 90th day

91st day & after:
-while using 60 lifetime reserve days

Once lifetime reserve days are used:                                                               - additional 365 days
​
- beyond the additional 365 days                        
​




​All but $1,408


All but $352 a day
​

All but $704 a day





$0                          


$0





​​$1,408 (Part A deductible)

$352 a day
​

$704 a day

​


100% of Medicare-eligible expenses


​$0


​

$0


$0
​

$0





$0**                          



All costs
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

21st thru 100th day

101st day and after









All approved amounts              

​All but $176 a day

$0









​$0

Up to $176 a day

$0
​








​$0


$0

All costs
BLOOD

First 3 pints
​
Additional amounts


​$0

100%

​3 pints


$0

​$0


$0
HOSPICE CARE
​
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.

​All but very limited co-payment/coinsurance for outpatient drugs and inpatient respite care           

​Medicare              
co-payment/coinsurance
 
$0
**Notice:  When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as   provided by 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.
 

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
After You Pay $2,340 Deductible, Plan Pays
After You Pay
$2,340 Deductible, Plan 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 amounts*
 
Remainder of Medicare-approved amounts
​                        
​










​$0
                          


Generally 80%







​



​$0



​Generally 20%


​







​$198 (Unless Part B deductible has not been met)                         


$0
Part B Excess Charges  (above Medicare-approved amounts)
$0

​100%

$0
BLOOD

First 3 pints
​
Next $198 of Medicare-approved amounts*

Remainder of Medicare-approved amounts


​$0


$0
​


​80%
​All costs


$0
​


​20%
​$0


$198 (Unless Part B deductible has not been met)
​ 
​


​$0
CLINICAL LABORATORY            SERVICES - TESTS FOR DIAGNOSTIC SERVICES
 
100%         
$0 
$0

Parts A & B

Services
Medicare Pays
After You Pay $2,340 Deductible,
​Plan Pays
After You Pay $2,340 Deductible, Plan Pays
​HOME HEALTH CARE
MEDICARE-APPROVED SERVICES
​
Medically necessary skilled care services and medical supplies
Durable medical equipment
  
                             
- First $198 of Medicare-approved amounts*   
                                                  
- Remainder of Medicare-approved amounts
​


​100%



$0
​


​80%
​


​​$0



$0
​


​20%
​


​$0



$198 (Unless Part B deductible has been met)
​


​$0

Other Benefits - Not Covered by Medicare

Services
Medicare Pays
Plan 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
                                                  
- Remainder of charges
​


​




​
$0
​

​$0






​
​
$0
​
80% to a lifetime maximum benefit of $50,000

​






​
$250
​
20% and amounts over the $50,000 lifetime maximum
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Location

PrimeTime Choices
AultCare Insurance Company
Morrow House
2600 Sixth St SW
Canton, Ohio 44710
(330) 363-4031
(877) 863-1791

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