Title

Outline of Coverage | UnitedHealthcare Insurance Company

Outline of Medicare Supplement Coverage Cover Page

Benefit Plans A, B, C, F, K, L, N, Select C, and Select F

See Outlines of Coverage sections for details about ALL plans

This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must

make Plan “A” available. Some plans may not be available in your state.

Basic Benefits:

• Hospitalization: Part A co-insurance plus coverage for 365 additional days after Medicare benefits end.

• Medical Expenses: Part B co-insurance (generally 20% of Medicare-approved expenses) or co-payments for

hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or

co-payments.

• Blood: First three pints of blood each year.

• Hospice: Part A coinsurance

·Medicare Select Plans C and F contain the same benefits as standardized Medicare Supplement Plans C and F,

except for restrictions on your use of hospitals.

Plan

A

Plan

B

Plan

C·

Plan

D

Plan

F*·

Plan

G

Basic,

Basic,

Basic,

Basic,

Basic,

Basic,

including including including including including including

100%

100%

100%

100%

100%

100%

Part B co- Part B co- Part B co- Part B co- Part B co- Part B coinsurance insurance insurance insurance insurance insurance

Skilled Skilled Skilled

Skilled

nursing nursing nursing nursing

facility co- facility co- facility co- facility coinsurance insurance insurance insurance

Part A

Part A

Part A

Part A

Part A

deductible deductible deductible deductible deductible

Part B

Part B

deductible

deductible

Part B

Part B

excess excess

(100%) (100%)

Foreign Foreign Foreign Foreign

travel

travel

travel

travel

emergency emergency emergency emergency

*Plan F also has an option called a high deductible Plan F.

This option is not currently offered by UnitedHealthcare

Insurance Company. This high deductible plan pays the

same benefits as Plan F after...