Outline of Coverage | UnitedHealthcare Insurance Company

Plan Benefit Tables: Plan N
Medicare Part A: Hospital Services per Benefit Period1 Service Hospitalization1 First 60 days Semiprivate room and board, general nursing and miscellaneous Days 61–90 services and supplies. Medicare Pays All but $1,184 All but $296 per day Plan N Pays $1,184 (Part A deductible) $296 per day $592 per day You Pay $0 $0 $0

Days 91 and later All but $592 per day while using 60 lifetime reserve days After lifetime reserve $0 days are used, an additional 365 days Beyond the additional $0 365 days Skilled Nursing Facility Care1 You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicareapproved facility within 30 days after leaving the hospital. Blood First 20 days Days 21–100 Days 101 and later

100% of Medicare eligible expenses $0

$02

All costs $0 $0 All costs

All approved amounts $0 All but $148 per day $0 Up to $148 per day $0

First 3 pints Additional amounts

$0 100%

3 pints $0

$0 $0 $0

Hospice Care Available as long as you meet Medicare’s requirements, your doctor certifies you are terminally ill and you elect to receive these services.

All but very limited Medicare co-payment/ co-payment/ co-insurance for co-insurance outpatient drugs and inpatient respite care

Continued on next page Notes 1 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.

2 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 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.

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physical and speech therapy. The co-payment of up to $50 is waived if you are admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. The copayment of up to $50 is waived if you are admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. durable medical equipment. inpatient and outpatient medical and surgical services and supplies. Part B Excess Charges Above Medicare-approved amounts Blood First 3 pints Next $147 of Medicare-approved amounts3 Remainder of Medicare-approved amounts Tests for diagnostic services $0 $0 $0 $0 All costs $0 80% 20% Clinical Laboratory Services Parts A and B Service Home Health Care Medicare-approved services 100% $0 $0 Medicare Pays Medically necessary 100% skilled care services and medical supplies Plan N Pays $0 You Pay $0 ▲ Continued on next page Notes 3 Once you have been billed $147 of Medicareapproved amounts for covered services.Outline of Coverage | UnitedHealthcare Insurance Company Plan Benefit Tables: Plan N (continued) Medicare Part B: Medical Services per Calendar Year Service Medical Expenses INCLUDES TREATMENT IN OR OUT OF THE HOSPITAL. First $147 of Medicare-approved amounts3 Remainder of Medicare-approved amounts Medicare Pays $0 Plan N Pays $0 You Pay $147 (Part B deductible) Up to $20 per office visit and up to $50 per emergency room visit. All costs $0 $147 (Part B deductible) $0 Generally 80% Balance. such as: physician’s services. . AND OUTPATIENT HOSPITAL TREATMENT. your Part B deductible will have been met for the calendar year. diagnostic tests. other than up to $20 per office visit and up to $50 per emergency room visit.

First $250 each calendar year Remainder of charges $0 $0 $250 Medicare Pays $0 Plan N Pays $0 You Pay $147 (Part B deductible) $0 80% 20% $0 80% to a lifetime maximum benefit of $50. continued Service Durable Medical Equipment Medicare-approved services First $147 of Medicare-approved amounts3 Remainder of Medicare-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.Outline of Coverage | UnitedHealthcare Insurance Company Plan Benefit Tables: Plan N (continued) Parts A and B.000 20% and amounts over the $50.000 lifetime maximum BT31 1/13 .

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