WPS MEDICARE COMPANION

Transcription

1 WPS MEDICARE COMPANION Medicare supplement plan that provides relief from unexpected health care costs Rates effective January 1, 2017 Outline of Medicare Supplement Coverage Benefit Plans A, C, F, G, K, L, and N for Michigan Residents Current as of October 1, 2016 This request for information is insurance related and if you respond you may be contacted in an attempt to sell you insurance. Not connected with or endorsed by the United States government or the federal Medicare Program.

2 WPS Health Insurance Outline of Medicare Supplement Coverage 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. We are currently offering Medicare supplement Plans A, C, F, G, K, L, and N. Basic Benefits Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or copayments. Blood: First three pints of blood each year. Hospice: Part A coinsurance. A B C D F* G K L M N Basic, and Part B coinsurance Basic, and Part B coinsurance Basic, and Part B coinsurance Basic, and Part B coinsurance Basic, and Part B coinsurance Basic, and Part B coinsurance Hospitalization and preventive care paid at ; other basic benefits paid at 50% Hospitalization and preventive care paid at ; other basic benefits paid at 75% Basic, and Part B coinsurance Basic and part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance 50% Skilled Nursing Facility Coinsurance 75% Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible 50% Part A Deductible 75% Part A Deductible 50% Part A Deductible Part A Deductible 2 wpsmedicaresolutions.com Part B Deductible Foreign Travel Emergency Foreign Travel Emergency Part B Deductible Part B Excess () Foreign Travel Emergency Part B Excess () Foreign Travel Emergency Out-of-pocket limit $4,960; generally paid at after limit reached Out-of-pocket limit $2,480; generally paid at after limit reached Foreign Travel Emergency Foreign Travel Emergency *Plan F also has an option called a high deductible Plan F. This option is not currently offered by WPS.

3 Contents WPS Health Insurance Outline of Medicare Supplement Coverage...2 Important information and disclosures...3 Medicare alone is not enough...4 WPS Health Insurance delivers the coverage you need...5 Plans A, C, F, G, and N...6 Plans K and L...7 Renewal terms and convenient payment options...8 General information...9 Plan A Plans C and F Plans G and N Plans K and L Monthly premium rates Medicare preventive care and screening services...25 IMPORTANT: If there s ever a discrepancy between the policy and this outline of coverage, the policy has final authority. Important information and disclosures Premium information Outside of the rate guarantee period we can only raise your premium if we raise the premium for all policies like yours in this state or you enter a new age category. During your initial first-year rate guarantee period, your rate will not change unless your residence changes such that you move to a new rating area, or significant changes to state and/or federal health insurance mandates require WPS to change your benefits. Read your policy very carefully This is only an outline describing your policy s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. Right to return policy If you find that you re not satisfied with your policy, you may return it to: WPS Health Insurance, P.O. Box 8190, Madison, WI If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments directly to you. Policy replacement If you re replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. Notice This policy may not fully cover all of your medical costs. WPS Health Insurance and its agents are not connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security office or consult Medicare and You for more details. Complete answers are very important When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. We may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded. Disclosures Use this outline to compare benefits and premiums among policies, certificates, and contracts. WPS Medicare Companion 3

4 Medicare alone is not enough That s why there are WPS Medicare supplement plans. Medicare covers a lot of health care expenses, but it doesn t pay for all of them. There are deductibles and coinsurance you have to pay before Medicare pays its share. And there s always a chance that a serious illness or injury could exhaust some of your Medicare benefits. So what can you do to get the health care you need and to help protect your retirement savings? Sign up for a WPS Medicare supplement plan. Enjoy dependable protection from a local Midwestern not-for-profit health insurer Founded in Wisconsin in 1946, WPS Health Insurance has helped people with their health care bills for more than 70 years. We ve been serving people on Medicare since Medicare began. When you choose WPS, our years of experience and expertise are on your side. Serving members in several Midwestern states, we keep our business close to home so we re local wherever we go. Our members enjoy: Outstanding coverage and stable rates Freedom to choose your own doctors Prompt, friendly service based right next door in Wisconsin Call for more information. Named one of the World s Most Ethical Companies seven years in a row 1 Ethics and integrity are at the core of our values, and it shows in everything we do. That s why in 2016, the international Ethisphere Institute named WPS one of the World s Most Ethical Companies for the seventh year in a row. We re eager to put our good values to work for you. To learn more about the World s Most Ethical Companies designation, please visit ethisphere.com/wme World s Most Ethical Companies, Ethisphere Institute, worldsmostethicalcompanies.ethisphere.com/honorees/. 4 wpsmedicaresolutions.com

5 WPS Health Insurance delivers the coverage you need, plus peace of mind Every WPS Health Insurance Medicare supplement plan gives you coverage to help pay for what Medicare doesn t. Protect your retirement savings and rest easy knowing that you re covered! Get your Medicare supplement from WPS and enjoy the peace of mind that comes with: You can keep your plan as long as you pay your premium We promise that your WPS Medicare supplement policy will never be canceled because of your health. As long as you pay your premium on time, your WPS Medicare supplement is guaranteed renewable for life. Comprehensive coverage that helps fill the gaps in Medicare Every WPS Medicare supplement policy begins with an excellent core of benefits. You choose which plan you want: A, C, F, G, K, L, or N. See more detailed descriptions of WPS Medicare supplement plans on pages Freedom to choose your own doctors and hospitals that accept Medicare anywhere in the U.S. With a WPS Medicare supplement, you can keep the same doctor you ve been seeing for years. You can also select a new doctor at any time. You have complete freedom to choose your health care providers. And if you move, your WPS Medicare supplement coverage moves with you anywhere in the U.S. Coverage that keeps pace with Medicare Each time the Centers for Medicare & Medicaid Services (CMS) increases the Medicare deductibles, your WPS Medicare supplement benefits adjust to cover the increase. You can feel secure in knowing your plan will always remain current with Medicare. Our household discount can save you money WPS offers a 7% discount when you and a second household 1 member are enrolled in a WPS Medicare supplement plan. To calculate, multiply your final rate by Less paperwork, fewer worries! With our automatic claims service, you don t have to worry about filing claims or dealing with medical bills. That s because Medicare sends your claims electronically right to WPS. We handle the claims and you enjoy the convenience of almost no paperwork. Online resources just point and click to find what you need Visit the WPS website at wpsic.com to verify your benefits, eligibility, and claims status. You can request a replacement WPS ID card and Member Guide. You ll also find information in our online health center about healthy eating, managing chronic conditions, patient safety, and more, including a special area devoted to senior health issues. Going the extra mile for members When you call WPS, you reach people who care. Your questions are answered promptly and accurately by our highly trained Member Support team. We ll go the extra mile to assist you. Outstanding member service has been our hallmark for more than 70 years. 1 Household: Two or more individuals who reside together in the same dwelling. Dwelling is defined as a single home, condominium unit, or apartment unit within an apartment complex. WPS Medicare Companion 5

6 Plans A, C, F, G, and N: Comprehensive coverage These plans cover your Medicare Part A (Hospitalization) and Part B (Medical) coinsurance costs you would otherwise have to pay out of your own pocket. But that s just the beginning. WPS Medicare supplement plans pay for a variety of important services, including: Hospitalization, skilled nursing care, and home health care services Medical and surgical services and supplies X-rays, mammograms, and lab tests Licensed ambulance services Physical, radiation, and speech therapy Equipment and certain supplies to treat diabetes Beware of lowball plans! You ve probably seen some Medicare supplements with really low premiums. Don t fall for these lowball plans! A low rate right now can quickly evolve into a sky-high rate in subsequent years. Premiums that look too good to be true usually are. When you choose a WPS Medicare supplement plan, you can be confident that the rate you get is set by a company with a history of stable rates that don t jump dramatically from year to year. It s like your parents told you you get what you pay for. Top-quality coverage from WPS helps protect your health and your finances and that safety net is truly a relief. 6 wpsmedicaresolutions.com Silver&Fit program 1,2 These plans also offer extra features that you won t get from WPS Medicare Plans K or L. WPS Medicare Plans A, C, F, G, and N provide FREE access to fitness facilities, home fitness kits, a resource library, fitness challenges, and more through the Silver&Fit program. Take advantage of standard amenities, such as cardiovascular exercise equipment (e.g., treadmills, exercise bicycles), strength or resistance training equipment, and use of locker room and shower facilities. Facilities may include, but are not limited to, swimming pools, recreation centers, and dance, Pilates, or yoga studios. The Silver&Fit program also provides, through its ChooseHealthy Affinity program 3, discounts for members to see participating acupuncturists, chiropractors, dietitians, and massage therapists, as well as discounts on food supplements, herbs and botanicals, sports nutrition, and more through an online store! Please see the ChooseHealthy flyer included in your information kit for details. Vision discount and hearing services 2 Your WPS ID card also entitles you to discounts on eye exams, lenses, frames, and laser vision correction at participating providers locations. You re also eligible to receive free hearing screenings, discounts on hearing aids, and free office services (including retests, cleanings and adjustments) for the lifetime of your hearing aids. 1 The Silver&Fit program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a federally registered trademark of ASH. 2 Fitness program, vision, and hearing discount programs are not part of the insurance policy and are offered at no additional charge. 3 ChooseHealthy is a product of American Specialty Health Administrators, Inc., an affiliate of ASH Group and a subsidiary of American Specialty Health Incorporated.

7 Cost-sharing Plans K and L: Choose your share of the pie WPS Medicare Plans K and L offer two different designs: a 25% cost-sharing plan and a 50% costsharing plan. The percentages reflect how much of your covered medical expenses you pay after Medicare pays its share. And if you hit your limit for out-of-pocket expenses, WPS pays everything beyond that for all Medicare-approved benefits. 50% cost-sharing plan: Plan K If you want a low, low premium, you can select the 50% cost-sharing plan. For this plan, Medicare Part B pays its 80% following the deductible for your covered medical expenses. Then, you split the remainder of the bill evenly with WPS. This means that you pay about 10 cents of every dollar of your total covered health care bill, and WPS picks up the other 10. For Part A, WPS pays half of the deductible. After the deductible, the hospital charges are generally covered at. If you reach $4,960 in annual out-of-pocket costs on Medicare-approved services, WPS will generally cover of additional Medicare-approved costs thereafter until the end of the year. 25% cost-sharing plan: Plan L If you choose the 25% cost-sharing plan, Medicare Part B pays its 80% following the deductible, and you split the remainder of the bill with WPS: WPS pays three-fourths and you pay one-fourth. If you do the math, you ll see that this requires you to pay only about five cents of every dollar on your total covered medical bill. For Part A, WPS pays 75% of the deductible. After the deductible, the hospital charges are generally covered at. If you reach $2,480 in annual out-of-pocket costs on Medicareapproved services, WPS will generally cover of additional Medicare-approved costs thereafter until the end of the year. Medicare Part B Example Plan K (50% cost-sharing plan) WPS 10% Medicare 80% Patient 10% Plan L (25% cost-sharing plan) Medicare 80% WPS 15% Patient 5% WPS Medicare Companion 7

8 Renewal terms For your WPS Medicare supplement coverage to continue, we must receive your premium as required by the policy. We ll only send one bill to notify you when your premium is due. (If you re paying through our automatic premium withdrawal program, no bills are sent.) Your premium is subject to change at our option. Any change in your WPS Medicare supplement premium will apply to all policyholders with identical policies who live in the same ZIP code and who are the same age as you. You can terminate your coverage at any time by writing to us prior to your requested termination date. Convenient payment options Automatic premium withdrawal With our automatic premium withdrawal service, your premium is automatically withdrawn from your checking or savings account each time it s due. It s safe and easy to set up. No checks to write. No envelopes to mail. Plus, you ll never have to worry that your coverage will be canceled because your payment was lost in the mail or your credit card expired. And best of all, you receive a 2% discount off your premium when you choose this option! Credit/debit card payment If you choose to pay by credit/debit card, your initial premium amount will be charged to your card once your application has been approved. You can also pay your premium monthly, quarterly, semiannually, or annually. Direct billing If you choose to pay through direct billing, WPS will mail subsequent premium notices to you according to the payment schedule you select monthly, quarterly, semiannually, or annually. 8 wpsmedicaresolutions.com

9 General information This outline of coverage provides only a general description of WPS Medicare supplement benefits. You can find a more detailed description of WPS Medicare supplement coverage in the policy. The policy will be issued to you upon approval for coverage under the WPS Medicare supplement plan. Coverage is subject to all terms and conditions of the policy. We ve added the subject headings in this outline of coverage for easier reading and quick reference. These headings aren t part of the description of coverage and aren t to be used in determining applicable limitations and exclusions. This outline of coverage doesn t give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare & You for more details. To receive a copy of this handbook, call Have questions? Call for more information. WPS Medicare Companion 9 9

10 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. PLAN A Services Medicare Pays Plan A Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,288 $1,288 (Part A 61st to 90th day All but $322 a day $322 a day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days All but $644 a day $644 a day of Medicare eligible expenses ** SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts 21st to 100th day All but $161 a day Up to $161 a day 101st day and after BLOOD First 3 pints Additional amounts HOSPICE CARE You must meet Medicare's requirements, Including a doctor's certification of terminal illness. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare Copayment/ Coinsurance 10 wpsmedicaresolutions.com **Notice: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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.

11 MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $166 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. PLAN A Services Medicare Pays Plan A Pays You Pay 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 $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts Generally 80% Generally 20% PART B EXCESS CHARGES (Above Medicare-approved amounts) BLOOD First 3 pints Next $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services $166(Part B Medicare Parts A & B HOME HEALTH CARE (Medicare-approved services) Medically necessary skilled care services and medical supplies Durable medical equipment First $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts 80% 20% WPS Medicare Companion 11

12 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. PLANS C & F Services Medicare Pays Plan C Pays You Pay Plan F Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days 61st to 90th day All but $1,288 All but $322 a day $1,288 (Part A $322 a day $1,288 (Part A $322 a day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days All but $644 a day $644a day of Medicare eligible expenses ** $644 a day of Medicare eligible expenses ** SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital. First 20 days All approved amounts 21st to 100th day All but$161a day Up to $161 a day Up to $161 a day 101st day and after BLOOD First 3 pints Additional amounts HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness All but very limited Copayment/ Coinsurance for outpatient drugs and inpatient respite care Medicare Copayment/ Coinsurance Medicare Copayment/ Coinsurance 12 wpsmedicaresolutions.com **Notice: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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.

13 MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $166 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. PLANS C & F Services Medicare Pays Plan C Pays You Pay Plan F Pays You Pay 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 $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts Generally 80% Generally 20% Generally 20% PART B EXCESS CHARGES (Above Medicare-approved amounts) BLOOD First 3 pints Next $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services Medicare Parts A & B HOME HEALTH CARE (Medicare-approved services) Medically necessary skilled care services and medical supplies 20% Durable medical equipment First $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts 80% 20% 20% WPS Medicare Companion 13

14 MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR PLANS C & F Other Benefits Not Covered by Medicare Services Medicare pays Plan C Pays You Pay Plan F 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 $250 $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 14 wpsmedicaresolutions.com

15 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. PLANS G & N Services Medicare Pays Plan G Pays You Pay Plan N Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days 61st to 90th day All but $1,288 All but $322 a day $1,288 (Part A $322 a day $1,288 (Part A $322 a day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days All but $644 a day $644 a day of Medicare eligible expenses ** $644 a day of Medicare eligible expenses ** SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st to 100th day All but $161 a day Up to $161 a day Up to $161 a day 101st day and after BLOOD First 3 pints Additional amounts HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare Copayment/ Coinsurance Medicare Copayment/ Coinsurance **Notice: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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. WPS Medicare Companion 15

16 MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $166 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. PLANS G & N Services Medicare Pays Plan G Pays You Pay Plan N Pays You Pay 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 $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts Generally 80% Generally 20% Balance, other than up to $20 per office visit and up to $50per emergency room visit. The copayment of up to $50 is waived if you are admitted to any hospital & the emergency visit is covered as a Medicare Part A expense. Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if you are admitted to any hospital & the emergency visit is covered as a Medicare Part A expense. PART B EXCESS CHARGES (Above Medicare-approved amounts) BLOOD First 3 pints Next $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts 80% 20% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services 16 wpsmedicaresolutions.com

17 MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $166 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. PLANS G & N Medicare Parts A & B Services Medicare Pays Plan G Pays You Pay Plan N Pays You Pay HOME HEALTH CARE (Medicare-approved services) Medically necessary skilled care services and medical supplies Durable medical equipment First $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts 80% 20% 20% Other Benefits Not Covered by Medicare Services Medicare Pays Plan G Pays You Pay Plan N 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 80% to a lifetime maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum 80%to a lifetime maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum WPS Medicare Companion 17

18 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. PLANS K & L Services Medicare Pays Plan K Pays You Pay Plan L Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days 61st to 90th day All but $1,288 All but $322 a day $644 (50% of Part A $322 a day $644 (50% of Part A $966 (75% of Part A $322 a day $322 (25% of Part A 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicareapproved facility within 30 days after leaving the hospital First 20 days All but $644 a day $644 a day of Medicare eligible expenses ** $644 a day $ of Medicare eligible expenses ** All approved amounts 21st to 100th day 101st day and after BLOOD First 3 pints Additional amounts All but $161 a day Up to $80.50a day Up to $80.50 a day Up to $ a day Up to $40.25 a day 50% 50% 75% 25% With Plan L you will pay ¼ of the cost sharing of some covered services until you reach the annual out-of-pocket limit of $2,480 each calendar year. With Plan K you will pay ½ the cost sharing of some covered services until you reach the annual out-of-pocket limit of $4,960 each calendar year. The amounts that count toward your annual limit are noted with diamonds ( ) in the chart above. Once you reach the annual limit, the plan generally pays of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called Excess Charges ) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. **Notice: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the 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. 18 wpsmedicaresolutions.com

19 MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD Services Medicare Pays Plan K Pays You Pay Plan L Pays You Pay HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care 50% of Medicare Copayment/ Coinsurance 50% of Medicare Copayment/ Coinsurance MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $166 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. 75% of Medicare Copayment/ Coinsurance PLANS K & L 25% of Medicare Copayment/ Coinsurance Services Medicare Pays Plan K Pays You Pay Plan L Pays You Pay 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 $166 of Medicare-approved amounts* Preventive benefits for Medicarecovered services Remainder of Medicare-approved amounts PART B EXCESS CHARGES (Above Medicare-approved amounts) Generally 75% of Medicareapproved amounts Generally 80% Remainder of Medicareapproved amounts Generally 10% All costs above Medicareapproved amounts Generally 10% (and they do not count toward annual out-of-pocket limit of $4,960) Remainder of Medicareapproved amounts Generally 15% All costs above Medicareapproved amounts Generally 5% (and they do not count toward annual out-of-pocket limit of $2,480)** With Plan L you will pay ¼ of the cost sharing of some covered services until you reach the annual out-of-pocket limit of $2,480 each calendar year. With Plan K you will pay ½ the cost sharing of some covered services until you reach the annual out-of-pocket limit of $4,960 each calendar year. The amounts that count toward your annual limit are noted with diamonds ( ) in the chart above. Once you reach the annual limit, the plan generally pays of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called Excess Charges ) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. **This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2,480 for Plan L and $4,960 for Plan K, per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called Excess Charges ) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. WPS Medicare Companion 19

20 MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $166 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. PLANS K & L Services Medicare Pays Plan K Pays You Pay Plan L Pays You Pay BLOOD First 3 pints Next $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts Generally 80% 50% Generally 10% 50% Generally 10% 75% Generally 15% CLINICAL LABORATORY SERVICES Tests for diagnostic services 25% Generally 5% Medicare Parts A & B HOME HEALTH CARE (Medicare-approved services) Medically necessary skilled care services and medical supplies Durable medical equipment First $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts 80% 10% 10% 15% 5% With Plan L you will pay ¼ of the cost sharing of some covered services until you reach the annual out-of-pocket limit of $2,480 each calendar year. With Plan K you will pay ½ the cost sharing of some covered services until you reach the annual out-of-pocket limit of $4,960 each calendar year. The amounts that count toward your annual limit are noted with diamonds ( ) in the chart above. Once you reach the annual limit, the plan generally pays of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called Excess Charges ) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. 20 wpsmedicaresolutions.com

21 Monthly Premium Rates Effective January 1, 2017 ZIP Codes: 480xx 485xx and individuals that move out of state. AGE PLAN A PLAN C PLAN F PLAN G PLAN N Under 65 $ $ N/A N/A N/A 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ MALE ZIP Codes: 486xx 499xx AGE PLAN A PLAN C PLAN F PLAN G PLAN N Under 65 $ $ N/A N/A N/A 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ The rates shown above are based on attained ages. To calculate annual, semi-annual, or quarterly premiums, multiply the monthly premium amount by 12, 6, and 3, respectively. Members who pay by automatic premium withdrawal pay a premium that is 2% less than those who pay by credit/debit card or by monthly direct bill. We offer a 7% discount if two members of the same household enroll in a WPS Medicare supplement plan. To calculate, multiply your final rate by If a member requests to pay via check, monthly, quarterly, semi-annual, and annual payment options are available. WPS Medicare Companion 21

22 Monthly Premium Rates Effective January 1, 2017 ZIP Codes: 480xx 485xx and individuals that move out of state. AGE PLAN A PLAN C PLAN F PLAN G PLAN N Under 65 $ $ N/A N/A N/A 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ FEMALE ZIP Codes: 486xx 499xx AGE PLAN A PLAN C PLAN F PLAN G PLAN N Under 65 $ $ N/A N/A N/A 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ The rates shown above are based on attained ages. To calculate annual, semi-annual, or quarterly premiums, multiply the monthly premium amount by 12, 6, and 3, respectively. Members who pay by automatic premium withdrawal pay a premium that is 2% less than those who pay by credit/debit card or by monthly direct bill. We offer a 7% discount if two members of the same household enroll in a WPS Medicare supplement plan. To calculate, multiply your final rate by If a member requests to pay via check, monthly, quarterly, semi-annual, and annual payment options are available. 22 wpsmedicaresolutions.com

23 Monthly Premium Rates Effective January 1, 2017 ZIP Codes: 480xx 485xx and individuals that move out of state. AGE PLAN K PLAN L Under 65 N/A N/A 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ MALE ZIP Codes: 486xx 499xx AGE PLAN K PLAN L Under 65 N/A N/A 65 $91.48 $ $94.23 $ $97.07 $ $99.97 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ The rates shown above are based on attained ages. To calculate annual, semi-annual, or quarterly premiums, multiply the monthly premium amount by 12, 6, and 3, respectively. Members who pay by automatic premium withdrawal pay a premium that is 2% less than those who pay by credit/debit card or by monthly direct bill. We offer a 7% discount if two members of the same household enroll in a WPS Medicare supplement plan. To calculate, multiply your final rate by If a member requests to pay via check, monthly, quarterly, semi-annual, and annual payment options are available. WPS Medicare Companion 23

24 Monthly Premium Rates Effective January 1, 2017 FEMALE ZIP Codes: 480xx 485xx and individuals that move out of state. AGE PLAN K PLAN L Under 65 N/A N/A 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ ZIP Codes: 486xx 499xx AGE PLAN K PLAN L Under 65 N/A N/A 65 $79.94 $ $82.32 $ $84.81 $ $87.36 $ $89.99 $ $92.67 $ $95.92 $ $99.76 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ The rates shown above are based on attained ages. To calculate annual, semi-annual, or quarterly premiums, multiply the monthly premium amount by 12, 6, and 3, respectively. Members who pay by automatic premium withdrawal pay a premium that is 2% less than those who pay by credit/debit card or by monthly direct bill. We offer a 7% discount if two members of the same household enroll in a WPS Medicare supplement plan. To calculate, multiply your final rate by If a member requests to pay via check, monthly, quarterly, semi-annual, and annual payment options are available. 24 wpsmedicaresolutions.com

25 Medicare preventive care and screening services Medicare covers a number of preventive and screening services under Part B. The benefits under Medicare may be subject to certain age, health risk, or frequency requirements. Many of these services have no deductible or copayment. However, some services require that you pay a deductible, a copayment, or coinsurance. Your WPS Medicare supplement will help with the remaining costs associated with some of these services, such as: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests HIV screening Mammograms (screening) Medical nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings Sexually transmitted infections screening & counseling Shots: Flu shots Hepatitis B shots Pneumococcal shots Tobacco use cessation counseling Yearly "Wellness" visit All WPS Medicare supplement plans cover of the Medicare Part B preventive services that carry a copayment or coinsurance. Some services may be subject to the Part B calendaryear deductible. In addition, your health care provider may not accept Medicare assignment. WPS Medicare Companion 25

26 Notes: 26 wpsmedicaresolutions.com

27 Notes: WPS Medicare Companion 27

28 Find out more about WPS Medicare Companion supplement plan! Contact your local agent or call WPS today at Wisconsin Physicians Service Insurance Corporation. All rights reserved