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  • Home Medicare Shop for Plans Cigna Medicare Supplement (Medigap) Insurance Plans Medicare Supplement State Disclosures

    Medicare Supplement State Disclosures

    Look up the important features of your Medicare Supplement policy by state.

    General Disclosures

    This website is designed as a marketing aid and is not to be construed as a contract for insurance. It provides a brief description of the important features of the policy. Full terms and conditions of coverage are defined by and governed by an issued Medicare Supplement policy.

    American Retirement Life Insurance Company

    Medicare Supplement Policy Form Series:

    • Plan A: AR-MSD-AA-A-GN, AR-MSD-IA-A-GN, AR-MSD-CR-A-GN
    • Plan F: AR-MSD-AA-F-GN, AR-MSD-IA-F-GN; AR-MSD-CR-F-GN
    • Plan G: AR-MSD-AA-G-GN, AR-MSD-IA-G-GN, AR-MSD-CR-G-GN
    • Plan N: AR-MSD-AA-N-GN, AR-MSD-IA-N-GN, AR-MSD-CR-N-GN

    Address:
    American Retirement Life Insurance Company
    PO Box 5700
    Scranton, PA 18505-5700

    Arkansas

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare eligible expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible (not applicable in Plan F);

    (2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare eligible expense except as provided previously in this policy;

    (6) any deductible, coinsurance or co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy;

    (7) confinement that begins or expenses incurred while your policy is not in force; or

    (8) Pre-existing Conditions: We will not pay for any expenses incurred for care or treatment of a pre-existing condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior creditable coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If you had less than six (6) months prior creditable coverage, the Pre-existing Conditions limitation will be reduced by the aggregate amount of creditable coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied. A pre-existing condition is a condition for which medical advice was given or treatment was recommended by or received from a physician within six (6) months prior to the policy effective date.

    Cigna Health And Life Insurance Company

    Medicare Supplement Policy Form Series:

    • Plan A: CHLIC-MS-AA-A-GN, CHLIC-MS-IA-A-GN, CHLIC-MS-CR-A-GN
    • Plan F: CHLIC-MS-AA-F-GN, CHLIC-MS-IA-F-GN, CHLIC-MS-CR-F-GN
    • Plan High Deductible F (HDF): CHLIC-MS-AA-HDF-GN, CHLIC-MS-IA-HDF-GN, CHLIC-MS-CR-HDF-GN
    • Plan G: CHLIC-MS-AA-G-GN, CHLIC-MS-IA-G-GN, CHLIC-MS-CR-G-GN
    • Plan N: CHLIC-MS-AA-N-GN, CHLIC-MS-IA-N-GN, CHLIC-MS-CR-N-GN

    Address:
    Cigna Health and Life Insurance Company
    PO Box 5700
    Scranton, PA 18505-5700

    Delaware, Iowa, Maine, Nebraska, and Virginia

    Exclusions and Limitations

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible (not applicable in Plans F & HDF);

    (2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare eligible expense except as provided previously in this policy;

    (6) any deductible, coinsurance or co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Pre-existing Conditions: We will not pay for any expenses incurred for care or treatment of a pre-existing condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior creditable coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If you had less than six (6) months prior creditable coverage, the pre-existing conditions limitation will be reduced by the aggregate amount of creditable coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied. A pre-existing condition is a condition for which medical advice was given or treatment was recommended by or received from a Physician within six (6) months prior to the policy effective date.

    California

    Medicare Supplement Policy Forms: Plan A: CHLIC-MS-AA-A-CA; Plan F: CHLIC-MS-AA-F-CA; Plan HDF: CHLIC-MS-AA-HDF-CA; Plan G: CHLIC-MS-AA-G-CA; Plan N: CHLIC-MS-AA-N-CA

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare eligible expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible (not applicable in Plans F and HDF);

    (2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medi-Cal or Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare eligible expense except as provided previously in this policy;

    (6) any deductible, coinsurance or co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Pre-existing Conditions: These policies will not pay for any expenses incurred for care or treatment of a Pre-existing Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior creditable coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If you had less than six (6) months prior creditable coverage, the pre-existing conditions limitation will be reduced by the aggregate amount of creditable coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied. A pre-existing condition is a condition for which medical advice was given or treatment was recommended by or received from a Physician within six (6) months prior to the policy effective date.

    Idaho

    Medicare Supplement Policy Form Series: Plan A: CHLIC-MS-CR-A.v2-ID; Plan F: CHLIC-MS-CR-F.v2-ID; Plan High Deductible F (HDF): CHLIC-MS-CR-HDF.v2-ID; Plan G: CHLIC-MS-CR-G.v2-ID and Plan N: CHLIC-MS-CR-N.v2-ID

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible; (Not Applicable in Plans F & HDF)

    (2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare; or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare eligible expense except as provided previously in this policy;

    (6) any deductible, coinsurance or co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Pre-existing Conditions: We will not pay for any expenses incurred for care or treatment of a pre- existing condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior creditable coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If you had less than six (6) months prior creditable coverage, the pre-existing conditions limitation will be reduced by the aggregate amount of creditable coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied. A pre-existing condition is a condition for which medical advice was given or treatment was recommended by or received from a Physician within six (6) months before the effective date of coverage.

    Minnesota

    Medicare Supplement Policy and Rider Form Numbers: Basic Medicare Supplement Policy: CHLIC-MS-BASIC-MN; Extended Basic Medicare Supplement Policy: CHLIC-MS-EXTENDED-MN; Medicare Supplement Policy with $20 and $50 Copayment Medicare Part B Coverage: CHLIC-MS-COPAYMENT-MN; High Deductible Coverage Medicare Supplement Policy: CHLIC-MS-HIGHD-MN; Medicare Part A Deductible Rider: CHLIC-MS-PTAD-MN; Medicare Part B Deductible Rider: CHLIC-MS-PTBD-MN; Medicare Part B Excess Charge: CHLIC-MS-PTBEXC-MN; Preventive Medical Care Benefit Rider: CHLIC-MS-PC-MN.

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1a) Basic Medicare Supplement Policy: The Medicare Part A & Part B Deductibles. The Part B deductible has limited availability for individuals eligible for coverage prior to January 1, 2020.
    (b) Medicare Supplement Policy with $20 and $50 Copayment Medicare Part B Coverage: the Medicare Part B Deductible;
    (c) High Deductible Coverage Medicare Supplement Policy: the Medicare Part B Deductible.

    (2) Any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) Any services that are not medically necessary as determined by Medicare;

    (4) Any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid);

    (5) Any type of expense not a Medicare Eligible Expense except as provided previously in this policy; or

    (6) Any Deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy;

    (7) Expense resulting from a Pre-existing Condition is not covered unless it is incurred 6 months or more after the Coverage Effective Date. The Pre-Existing Condition limitation does not apply to individuals seeking coverage during their guaranteed enrollment period. A Pre-existing Condition is one: (a) for which medical advice was given or treatment was recommended by or received from a Physician within 90 days or less before Your Coverage Effective Date; and (b) which would not have caused Us to deny issuing Your policy had it been named on Your application.
    This provision does not apply if, as of the date of application, You had a Continuous Period of Creditable Coverage or had prior coverage under a Medicare Supplement policy for at least six (6) months. If, as of the date of application, You had less than six (6) months prior Creditable Coverage, the Pre-existing Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied. This provision does not apply if You applied for and were issued this policy under guaranteed issue status.

    Missouri

    Medicare Supplement Policy Forms: Plan A: CHLIC-MS-IA-A-MO; Plan F: CHLIC-MS-IA-F-MO; Plan HDF: CHLIC-MS-IA-HDF-MO; Plan G: CHLIC-MS-IA-G-MO; Plan N: CHLIC-MS-IA-N-MO

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible (not applicable in Plans F & HDF);

    (2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare eligible expense except as provided previously in this policy;

    (6) any deductible, coinsurance or co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Pre-existing Conditions: We will not pay for any expenses incurred for care or treatment of a pre-existing condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior creditable coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If you had less than six (6) months prior creditable coverage, the pre-existing conditions limitation will be reduced by the aggregate amount of creditable coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied. A pre-existing condition is a condition for which medical advice was given or treatment was recommended by or received from a Physician within six (6) months prior to the policy effective date.

    Montana

    Medicare Supplement Policy Forms: Plan A: CHLIC-MS-AA-A-MT; Plan F: CHLIC-MS-AA-F-MT; Plan HDF: CHLIC-MS-AA-HDF-MT; Plan G: CHLIC-MS-AA-G-MT; Plan N: CHLIC-MS-AA-N-MT

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    New Hampshire

    Medicare Supplement Policy Forms: Plan A: CHLIC-MS-IA-A-NH; Plan F: CHLIC-MS-IA-F-NH; Plan HDF: CHLIC-MS-IA-HDF-NH; Plan G: CHLIC-MS-IA-G-NH; Plan N: CHLIC-MS-IA-N-NH

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible (not applicable in Plan F);

    (2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Pre-existing Conditions: We will not pay for any expenses incurred for care or treatment of a Pre-existing Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Pre-existing Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    New Jersey

    Medicare Supplement Policy Forms: Plan A: CHLIC-MS-AA-A-NJ; Plan C: CHLIC-MS-AA-C-NJ; Plan F: CHLIC-MS-AA-F-NJ; Plan High Deductible F (HDF): CHLIC-MS-AA-HDF-NJ; Plan G: CHLIC-MS-AA-G-NJ; Plan N: CHLIC-MS-AA-N-NJ.

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible (not applicable in Plans F and HDF);

    (2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare eligible expense except as provided previously in this policy;

    (6) any deductible, coinsurance or co-payment not covered by Medicare, unless such coverage is listed as an additional benefit in this policy; or

    (7) Pre-existing Conditions: We will not pay for any expenses incurred for care or treatment of a pre-existing condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior creditable coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If you had less than six (6) months prior creditable coverage, the pre-existing conditions limitation will be reduced by the aggregate amount of creditable coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied. A pre-existing condition is a condition for which medical advice was given or treatment was recommended by or received from a Physician within six (6) months prior to the policy effective date.

    New Mexico

    Medicare Supplement Policy Forms: Plan A: CHLIC-MS-AA-A-NM; Plan F: CHLIC-MS-AA-F-NM; Plan HDF: CHLIC-MS-AA-HDF-NM; Plan G: CHLIC-MS-AA-G-NM; Plan N: CHLIC-MS-AA-N-NM

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible (not applicable in Plans F & HDF);

    (2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare eligible expense except as provided previously in this policy;

    (6) any deductible, coinsurance or co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Pre-existing Conditions: We will not pay for any expenses incurred for care or treatment of a pre-existing condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior creditable coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If you had less than six (6) months prior creditable coverage, the pre-existing conditions limitation will be reduced by the aggregate amount of creditable coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied. A pre-existing condition is a condition for which medical advice was given or treatment was recommended by or received from a Physician within six (6) months prior to the policy effective date.

    North Dakota

    Medicare Supplement Policy Forms: Plan A: CHLIC-MS-AA-A-ND, CHLIC-MS-AO-A-ND; Plan F: CHLIC-MS-AA-F-ND, CHLIC-MS-AO-F-ND; Plan HDF: CHLIC-MS-AA-HDF-ND, CHLIC-MS-AO-HDF-ND; Plan G: CHLIC-MS-AA-G-ND, CHLIC-MS-AO-G-ND; Plan N: CHLIC-MS-AA-N-ND, CHLIC-MS-AO-N-ND

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Rhode Island

    Medicare Supplement Policy Forms: Plan A: CHLIC-MS-AA-A-RI; Plan F: CHLIC-MS-AA-F-RI; Plan High Deductible F (HDF): CHLIC-MS-AA-HDF-RI; Plan G: CHLIC-MS-AA-G-RI; and Plan N: CHLIC-MS-AA-N-RI.

    Exclusions and Limitations:

    The benefits of a policy will not duplicate any benefits paid by Medicare. The combined benefits of a policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. A policy will not pay benefits for the following:

    (1) the Medicare Part B deductible (not applicable for Plans F and C);

    (2) any expense which you are not legally obligated to pay or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid) or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in the policy;

    (6) any deductible, coinsurance, or copayment not covered by Medicare, unless such coverage is listed as a benefit in the policy; or

    (7) Pre-Existing Conditions: We will not pay for any expenses incurred for care or treatment of a Pre-Existing Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued a policy under guaranteed issue status; if on the date of application for a policy you had at least six (6) months of prior Creditable Coverage; or if the policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for a policy. If you had less than six (6) months prior Creditable Coverage, the Pre-Existing Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If the policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Vermont

    Medicare Supplement Policy Forms: Plan A: CHLIC-MS-CR-A-VT; Plan F: CHLIC-MS-CR-F-VT; Plan HDF: CHLIC-MS-CR-HDF-VT; Plan G: CHLIC-MS-CR-G-VT; Plan N: CHLIC-MS-CR-N-VT

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare eligible expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible (not applicable in Plans F and HDF);

    (2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare eligible expense except as provided previously in this policy;

    (6) any deductible, coinsurance or co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy;

    (7) Pre-existing Conditions: These policies will not pay for any expenses incurred for care or treatment of a Pre-existing Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior creditable coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If you had less than six (6) months prior creditable coverage, the pre-existing conditions limitation will be reduced by the aggregate amount of creditable coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied. A pre-existing condition is a condition for which medical advice was given or treatment was recommended by or received from a Physician within six (6) months prior to the policy effective date.

    Washington

    Medicare Supplement Policy Forms: Plan A: CHLIC-MS-CR-A-WA, CHLIC-MS-CR-AO-A-WA; Plan F: CHLIC-MS-CR-F-WA, CHLIC-MS-CR-AO-F-WA; Plan HDF: CHLIC-MS-CR-HDF-WA, CHLIC-MS-CR-AO-HDF-WA; Plan G: CHLIC-MS-CR-G-WA, CHLIC-MS-CR-AO-G-WA; Plan N: CHLIC-MS-CR-N-WA, CHLIC-MS-CR-AO-N-WA

    Exclusions and Limitations:
    The benefits of a policy will not duplicate any benefits paid by Medicare. The combined benefits of a policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. A policy will not pay benefits for the following:

    (1) the Medicare Part B deductible (not applicable for Plans F and C);

    (2) any expense which you are not legally obligated to pay or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid) or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in the policy;

    (6) any deductible, coinsurance, or copayment not covered by Medicare, unless such coverage is listed as a benefit in the policy; or

    (7) Pre-Existing Conditions: We will not pay for any expenses incurred for care or treatment of a Pre-Existing Condition for the first three (3) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued a policy under guaranteed issue status; if on the date of application for a policy you had at least three (3) months of prior Creditable Coverage; or if the policy is replacing another Medicare Supplement policy and a three (3) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for a policy. If you had less than three (3) months prior Creditable Coverage, the Pre-Existing Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If the policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    West Virginia

    Medicare Supplement Policy Forms: Plan A: CHLIC-MS-AA-A.v2-WV; Plan F: CHLIC-MS-AA-F.v2-WV; Plan HDF: CHLIC-MS-AA-HDF.v2-WV; Plan G: CHLIC-MS-AA-G.v2-WV; Plan N: CHLIC-MS-AA-N.v2-WV

    Exclusions and Limitations:

    The benefits of a policy will not duplicate any benefits paid by Medicare. The combined benefits of a policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. A policy will not pay benefits for the following:

    (1) the Medicare Part B deductible (not applicable for Plans F and C);

    (2) any expense which you are not legally obligated to pay or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid) or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in the policy;

    (6) any deductible, coinsurance, or copayment not covered by Medicare, unless such coverage is listed as a benefit in the policy; or

    (7) Pre-Existing Conditions: We will not pay for any expenses incurred for care or treatment of a Pre-Existing Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued a policy under guaranteed issue status; if on the date of application for a policy you had at least six (6) months of prior Creditable Coverage; or if the policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for a policy. If you had less than six (6) months prior Creditable Coverage, the Pre-Existing Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If the policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Wyoming

    Medicare Supplement Policy Forms: Plan A: CHLIC-MS-AA-A.v2-WY; Plan F: CHLIC-MS-AA-F.v2-WY; Plan G: CHLIC-MS-AA-G.v2-WY; Plan High Deductible G: CHLIC-MS-AA-HDG-WY; Plan N: CHLIC-MS-AA-N.v2-WY

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first ninety (90) days from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least ninety (90) days of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a ninety (90) day waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

    If You had less than ninety (90) days prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Cigna Insurance Company

    Medicare Supplement Policy Form Series:

    • Plan A: CIC-MS-AA-A-GN
    • Plan F: CIC-MS-AA-F-GN
    • Plan G: CIC-MS-AA-G-GN
    • Plan HDG: CIC-MS-AA-HDG-GN
    • Plan N: CIC-MS-AA-N-GN

    Address:
    Cigna Insurance Company
    PO Box 5700
    Scranton, PA 18505-5700

    Colorado

    Medicare Supplement Policy Forms: Plan A: CIC-MS-AA-A.v2-CO; Plan F: CIC-MS-AA-F.v2-CO; Plan G: CIC-MS-AA-G.v2-CO; Plan HDG: CIC-MS-AA-HDG.v2-CO; Plan N: CIC-MS-AA-N.v2-CO

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

    If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Indiana

    Medicare Supplement Policy Forms: Plan A: CIC-MS-AA-A.v2-IN; Plan F: CIC-MS-AA-F.v2-IN; Plan G: CIC-MS-AA-G.v2-IN; Plan HDG: CIC-MS-AA-HDG.v2-IN; Plan N: CIC-MS-AA-N.v2-IN

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

    If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Pennsylvania

    Medicare Supplement Policy Forms: Plan A: CIC-MS-AA-A-PA, CIC-MS-AO-A-PA; Plan B: CIC-MS-AA-B-PA, CIC-MS-AO-B-PA; Plan F: CIC-MS-AA-F-PA, CIC-MS-AO-F-PA; Plan G: CIC-MS-AA-G-PA, CIC-MS-AO-G-PA; Plan HDG: CIC-MS-AA-HDG-PA, CIC-MS-AO-HDG-PA; Plan N: CIC-MS-AA-N-PA, CIC-MS-AO-N-PA

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Pre-existing Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied.  Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

    If you had less than six (6) months prior Creditable Coverage, the Pre-existing Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Texas

    Medicare Supplement Policy Forms: Plan A: CIC-MS-AA-A-TX; Plan F: CIC-MS-AA-F-TX; Plan G: CIC-MS-AA-G-TX; Plan HDG: CIC-MS-AA-HDG-TX; Plan N: CIC-MS-AA-N-TX

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

    If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied. Please see form entitled Medicare Supplement Supplementary Application to determine qualification for guaranteed issue status.

    Cigna National Health Insurance Company

    Address:
    Cigna National Health Insurance Company
    PO Box 5700
    Scranton, PA 18505-5700

    Medicare Supplement Policy Form Series:

    • CNHIC-MS-AA-A-GN
    • CNHIC-MS-AA-F-GN
    • CNHIC-MS-AA-G-GN
    • CNHIC-MS-AA-HDG-GN
    • CNHIC-MS-AA-N-GN

    Alabama, Arizona, Georgia, Kentucky, Louisiana, Maryland, Mississippi, Nevada, North Carolina, South Dakota, Utah

    Exclusions and Limitations

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following: 

    (1) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (2) any services that are not medically necessary as determined by Medicare;

    (3) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (4) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (5) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    6) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Connecticut

    Medicare Supplement Policy Forms: Plan A: CNHIC-MS-CR-A-CT; Plan F: CNHIC-MS-CR-F-CT; Plan G: CNHIC-MS-CR-G-CT; Plan High Deductible G: CNHIC-MS-CR-HDG-CT; Plan N: CNHIC-MS-CR-N-CT

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

    If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Florida

    Medicare Supplement Policy Forms: Plan A: CNHIC-MS-IA-A-FL; Plan F: CNHIC-MS-IA-F-FL; Plan HDG: CNHIC-MS-IA-HDG-FL; Plan G: CNHIC-MS-IA-G-FL; Plan N: CNHIC-MS-IA-N-FL

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

    If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Renewal and Premium Payment Provisions: This policy may be kept in force during Your lifetime by paying the premiums on time. We cannot cancel or refuse to renew this policy for any reason other than nonpayment of premium or material misrepresentation in the application for insurance.

    Renewal: All renewal premiums must be paid in consecutive terms. They shall be paid by modes currently offered by Us. Renewal premiums are payable to Us. Premiums must be paid on or before the date due or before the end of the grace period. If this policy should lapse, the payment of a premium will reinstate this policy only as provided in the reinstatement provision in this section.

    Cancellation: You may cancel this policy at any time by notifying Us. Your cancellation will be effective upon receipt of Your notice or on such later date as may be specified in such notice. In the event of cancellation, We will return promptly the unearned portion of any premium paid by You. We will determine the amount of the refund, if any, by prorating the last modal premium paid from the date of the cancellation until the next modal premium due date. Cancellation will be without prejudice to any claim originating prior to the effective date of cancellation.

    Illinois

    Medicare Supplement Policy Forms: Plan A: CNHIC-MS-AA-A-IL; Plan F: CNHIC-MS-AA-F-IL; Plan G: CNHIC-MS-AA-G-IL; Plan High Deductible G: CNHIC-MS-AA-HDG-IL; Plan N: CNHIC-MS-AA-N-IL

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

    If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Kansas

    Medicare Supplement Policy Forms: Plan A: CNHIC-MS-AA-A-KS, CNHIC-MS-AO-A-KS; Plan F: CNHIC-MS-AA-F-KS, CNHIC-MS-AO-F-KS; Plan G: CNHIC-MS-AA-G-KS, CNHIC-MS-AO-G-KS; Plan N: CNHIC-MS-AA-N-KS, CNHIC-MS-AO-N-KS

    Exclusions and Limitations:
    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (2) any services that are not medically necessary as determined by Medicare;

    (3) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (4) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (5) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (6) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Michigan

    Medicare Supplement Policy Forms: Plan A: CNHIC-MS-AA-A-MI; Plan F: CNHIC-MS-AA-F-MI; Plan G: CNHIC-MS-AA-G-MI; Plan N: CNHIC-MS-AA-N-MI

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (2) any services that are not medically necessary as determined by Medicare;

    (3) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (4) any type of expense not a Medicare eligible expense except as provided previously in this policy;

    (5) any deductible, coinsurance or co-payment not covered by Medicare, unless such coverage is listed as an additional benefit in this policy; or

    (6) Pre-existing Conditions: We will not pay for any expenses incurred for care or treatment of a Pre-existing Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Pre-existing Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Ohio

    Medicare Supplement Policy Forms: Plan A: CNHIC-MS-AA-A-OH; Plan F: CNHIC-MS-AA-F-OH; Plan G: CNHIC-MS-AA-G-OH; Plan High Deductible G: CNHIC-MS-AA-HDG-OH; Plan N: CNHIC-MS-AA-N-OH

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

    If you had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Oklahoma

    Medicare Supplement Policy Forms: Plan A: CNHIC-MS-AA-A-OK; Plan F: CNHIC-MS-AA-F-OK; Plan G: CNHIC-MS-AA-G-OK; Plan High Deductible G: CNHIC-MS-AA-HDG-OK; Plan N: CNHIC-MS-AA-N-OK

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    1) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    2) any services that are not medically necessary as determined by Medicare;

    3) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    4) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    5) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    6) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    South Carolina

    Medicare Supplement Policy Forms: Plan A: CNHIC-MS-AA-A-SC; Plan F: CNHIC-MS-AA-F-SC; Plan G: CNHIC-MS-AA-G-SC; Plan N: CNHIC-MS-AA-N-SC

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible (not applicable for Plan F);

    (2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Pre-existing Conditions: We will not pay for any expenses incurred for care or treatment of a Pre-existing Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Pre-existing Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Tennessee

    Medicare Supplement Policy Forms: Plan A: CNHIC-MS-AA-A-TN; Plan F: CNHIC-MS-AA-F-TN; Plan G: CNHIC-MS-AA-G-TN; Plan N: CNHIC-MS-AA-N-TN

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. With the exception of the Medicare Part B Excess Charges Benefit, the combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which You are not legally obligated to pay and no other services or organization has a legal obligation to provide or pay for;

    (3)  any services that are not medically necessary as determined by Medicare;

    (4)  any portion of any expense for which payment is made by Medicare; or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (5)  any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6)  any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy;

    (7)  or Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Wisconsin

    Medicare Supplement Policy Form Series: CNHIC-MS-BASIC-WI, CNHIC-MS-AHC-WI, CNHIC-MS-FTV-WI, CNHIC-MS-PBCO-WI, CNHIC-MS-PBEX-WI, CNHIC-MS-PTAD-WI, CNHIC-MS-PTBD-WI

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) Skilled Nursing Facility Care costs beyond what is covered by Medicare and the Wisconsin mandated thirty (30) day skilled nursing benefit;

    (2) Home Health Care visits beyond the number of visits covered by Medicare and the Wisconsin mandated forty (40) visits in a twelve (12) month period;

    (3) Physician charges above Medicare's approved charge, unless the Optional Medicare Part B Excess Charges Rider is purchased;

    (4) Outpatient prescription drugs;

    (5) most care received outside the USA, unless the Optional Foreign Travel Emergency Rider is purchased;

    (6) dental care (except anesthesia charges for dental care provided in a hospital or ambulatory surgery center), dentures, checkups, routine immunizations, cosmetic surgery, routine foot care, examinations for and the cost of eyeglasses or hearing aids, unless eligible by Medicare;

    (7) any expense incurred in excess of the Usual and Customary Charge or not medically necessary as determined by Us for all required Wisconsin mandated benefits;

    (8) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (9) any services that are not medically necessary as determined by Medicare;

    (10) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (11) any type of expense not a Medicare Eligible Expense except as provided previously in this policy; and

    (12) We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy.

    If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Loyal American Life Insurance Company

    Medicare Supplement Policy Form Series:

    • Plan A: LY-MSD-AA-A-GN, LY-MSD-IA-A-GN, LY-MSD-CR-A-GN
    • Plan F: LY-MSD-AA-F-GN, LY-MSD-IA-F-GN, LY-MSD-CR-F-GN
    • Plan G: LY-MSD-AA-G-GN, LY-MSD-IA-G-GN, LY-MSD-CR-G-GN
    • Plan N: LY-MSD-AA-N-GN, LY-MSD-IA-N-GN, LY-MSD-CR-N-GN

    Address:
    Loyal American Life Insurance Company
    PO Box 5700
    Scranton, PA 18505-5700

    Alaska, District of Columbia and Hawaii

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare eligible expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible (not applicable in Plan F);

    (2) any expense which you are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if you were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare eligible expense except as provided previously in this policy;

    (6) any deductible, coinsurance or co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy;

    (7) confinement that begins or expenses incurred while your policy is not in force; or

    (8) Pre-existing Conditions:  These policies will not pay for any expenses incurred for care or treatment of a Pre-existing Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if you applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy you had at least six (6) months of prior creditable coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied.  Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If you had less than six (6) months prior creditable coverage, the pre-existing conditions limitation will be reduced by the aggregate amount of creditable coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied. A pre-existing condition is a condition for which medical advice was given or treatment was recommended by or received from a Physician within six (6) months prior to the policy effective date.

    Notice for persons eligible for Medicare because of disability:

    In the following states, all Medicare Supplement plans are available to persons eligible for Medicare because of disability: California, Colorado, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Kansas, Kentucky, Louisiana, Maine, Minnesota, Mississippi, Missouri, Montana, New Hampshire, Oregon, Pennsylvania, South Dakota, Tennessee, Vermont, and Wisconsin.

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  • Medicare Advantage and Medicare Part D Policy Disclaimers

    Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group. The Cigna Healthcare names, logos, and marks, including THE CIGNA GROUP and CIGNA HEALTHCARE are owned by The Cigna Group Intellectual Property, Inc. Subsidiaries of The Cigna Group contract with Medicare to offer Medicare Advantage HMO and PPO plans and Part D Prescription Drug Plans (PDP) in select states, and with select State Medicaid programs. Enrollment in a Cigna Healthcare product depends on contract renewal.

    To file a marketing complaint, contact Cigna Healthcare or call 1-800-MEDICARE (), 24 hours a day, 365 days a year, TTY . Please include the agent/broker name if possible.

    Medicare Supplement Policy Disclaimers

    Medicare Supplement website content not approved for use in: Oregon.

    AN OUTLINE OF COVERAGE IS AVAILABLE UPON REQUEST. We'll provide an outline of coverage to all persons at the time the application is presented.

    Our company and agents are not connected with or endorsed by the U.S. Government or the federal Medicare program. This is a solicitation for insurance. An insurance agent may contact you. Premium and benefits vary by plan selected. Plan availability varies by state. Medicare Supplement policies are underwritten by American Retirement Life Insurance Company, Cigna Health and Life Insurance Company, Cigna Insurance Company, Cigna National Health Insurance Company or Loyal American Life Insurance Company. Each insurer has sole responsibility for its own products.

    The following Medicare Supplement Plans are available to persons eligible for Medicare due to disability: Plan A in Arkansas, Connecticut, Indiana, Maryland, Oklahoma, Rhode Island, Texas, and Virginia; Plans A, F, and G in North Carolina; and Plans C and D in New Jersey for individuals aged 50-64. Medicare Supplement policies contain exclusions, limitations, and terms under which the policies may be continued in force or discontinued. For costs and complete details of coverage, contact the company.

    This website is designed as a marketing aid and is not to be construed as a contract for insurance. It provides a brief description of the important features of the policy. Please refer to the policy for the full terms and conditions of coverage.

    In Kentucky, Plans A, F, G, HDG, N are available under Cigna National Health Insurance Company, Plans A, F, G, HDF, N are available under Cigna Health and Life Insurance Company and Plans A, B, C, D, F, G, N are available under Loyal American Life Insurance Company.

    Kansas Disclosures, Exclusions and Limitations

    Medicare Supplement Policy Forms: Plan A: CNHIC-MS-AA-A-KS, CNHIC-MS-AO-A-KS; Plan F: CNHIC-MS-AA-F-KS, CNHIC-MS-AO-F-KS; Plan G: CNHIC-MS-AA-G-KS, CNHIC-MS-AO-G-KS; Plan N: CNHIC-MS-AA-N-KS, CNHIC-MS-AO-N-KS

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Selecting these links will take you away from Cigna.com to another website, which may be a non-Cigna Healthcare website.

    Y0036_24_1037312_M | Page last updated 03/28/2024

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