HealthPartners Medicare Supplement Outline of Coverage and Disclosure of Information HEALTHPARTNERS BASIC MEDICARE SUPPLEMENT PLAN Use this document to get to know the HealthPartners Basic Medicare Supplement plan. It outlines what the plan covers and what you pay for those services. This booklet doesn't list everything the plan covers, or every limitation or exclusion. For a full list of covered services contact us for a copy of the policy. For more information about the plan, call Medicare Sales at 952-883-5601 or 800-247-7015. If you re a current member and have questions, call us at 952-967-7877 or 833-256-7044. From Oct. 1 through March 31, we take calls from 8 a.m. to 8 p.m. CT seven days a week. You ll speak with a representative. From April 1 to Sept. 30, call us 8 a.m. to 8 p.m. Monday through Friday to speak with a representative. On Saturdays, Sundays and Federal holidays, you can leave a message and we ll get back to you within one business day. TTY users can call 711. HealthPartners is required to disclose the following information to you. The Commissioner of Commerce of the state of Minnesota has established two categories of Medicare Supplement insurance and minimum standards for each, with the Extended Basic Medicare Supplement being the most comprehensive and the Basic Medicare Supplement being the least comprehensive. NOTICE: THESE POLICIES DO NOT COVER ALL MEDICAL EXPENSES BEYOND THOSE COVERED BY MEDICARE. THESE POLICIES DO NOT COVER ALL SKILLED NURSING HOME CARE EXPENSES AND DOES NOT COVER CUSTODIAL OR RESIDENTIAL NURSING CARE. READ YOUR POLICY CAREFULLY TO DETERMINE WHICH NURSING HOME FACILITIES AND EXPENSES ARE COVERED BY YOUR POLICY. Supp_111959 IR 9/2018 Outline of Coverage_Basic
Plan options HealthPartners offers Basic and Extended Basic policies in all 87 counties in Minnesota. Minnesota law also permits the purchase of additional riders with the Basic policy. Below is an overview of the plans and premiums effective Jan. 1, 2019 Dec. 31, 2019. Basic Benefits included in Medicare Supplement policies Inpatient Hospital Care: Covers the Medicare Part A coinsurance Medical Costs: Covers the Medicare Part B coinsurance (generally 20% of the Medicare-approved payment amount) Blood: Covers the first three pints of blood each year under Medicare Parts A and B Hospice: Covers Part A coinsurance Home Health Care and Medical Supplies: Covers Medicare Part A or B cost sharing The check marks mean the benefit is covered 100%. Medicare Supplement Benefits Extended * Basic Benefits Part A Skilled Nursing Facility Coinsurance Part A Inpatient Hospital Deductible Optional benefit rider Part B Deductible Optional benefit rider Part B Excess Charges Optional benefit rider Preventive Care (Not Covered by Medicare) Optional benefit rider Coverage While in a Foreign Country 80% Emergencies only 80% Additional Benefits (Not Covered by Medicare) 80% 80% or 100%; refer to State-mandated benefits policy for more information *100% after you spend $1,000 of out-of-pocket costs for a calendar year. Premium information 80% or 100%; refer to policy for more information Monthly rate Standard Rate Tobacco Rate Basic plan $163.95 $190.45 Optional benefit riders Rider 1: Part A Inpatient Hospital Deductible $36.30 $42.20 Rider 2: Part B Deductible $16.25 $16.25 Rider 3: Part B Excess Charges $1.00 $1.20 Rider 4: Preventive Care $2.50 $2.90 Total $220 $253 Extended Monthly rate Standard Rate Extended Basic plan $263.02 Total $263.02
HealthPartners Basic Medicare Supplement Plan The following summarizes the HealthPartners Basic Medicare Supplement coverage and the coverage under Original Medicare. It s not to be read or considered as a contract. Original Medicare Covers Inpatient hospital services 60 days of hospital inpatient care at 100% after your Medicare Part A deductible. Days 61-90 and your 60 day lifetime reserve days at 100% after a daily Part A coinsurance amount PLAN PAYS 100% of the Medicare Part A daily coinsurance for days 61-90 per benefit period 100% of the Medicare-eligible services covered in full after Medicare benefits are exhausted Medicare Part A deductible if optional rider is YOU PAY Medicare Part A deductible unless optional rider is Skilled nursing care The first 20 days at 100% 100% of the Medicare Part A Days 21-100 at 100% after Part A daily coinsurance amount per benefit period daily coinsurance through the 100 th day of per benefit period NO COVERAGE after the 100 th day per benefit period Hospice and Respite care All but very limited 100% of the Medicare Nothing copayment/coinsurance for copayments and coinsurance for outpatient drugs and inpatient all Part A Medicare-eligible respite care expenses Home health care 100% of Medicare eligible Covered in full by Medicare Nothing expenses Medical services, outpatient services, durable medical equipment and supplies 80% of Medicare s approved 20% of Medicare s approved charges after annual Part B charge deductible Part B deducible if optional rider is Remaining balances on Part B excess charges if optional rider is 80% for additional benefits not covered by Medicare All charges after the 100 th day per benefit period You must get care from a Medicare-certified hospice Part B deductible unless optional rider is All remaining balances on Part B excess charges unless optional rider is 20% for additional benefits not covered by Medicare
Original Medicare Covers Emergency care 80% of Medicare approved charges after annual Part B deductible Not covered outside the U.S. Foreign medical services Not covered, except under limited circumstances Preventive services (screening exams) 100% of Medicare-covered services and screenings such as colorectal screening exams, screening mammograms, pap smears and pelvic exams, prostate cancer screening exam, Welcome to Medicare visit, and Annual Wellness Visit PLAN PAYS 20% of Medicare s approved charges Part B deductible if optional rider is Optional coverage for remaining balances on non-assigned claims 80% of medically necessary services and supplies for medical emergencies when traveling outside the U.S. If optional rider is, 100% of non-medicare covered preventive services, up to a benefit limit of $120 per year Services may include annual routine physical exam, routine eye exam, and routine hearing exam YOU PAY Part B deductible and any remaining charges unless optional riders are 20% and any remaining charges above the allowed amount All charges not covered by Medicare unless optional preventive rider is selected. Any remaining charges above the benefit limit
Rules and disclosures about HealthPartners Medicare Supplement plans READ YOUR POLICY OR CERTIFICATE VERY CAREFULLY This outline of coverage is a summary of the policy issued or applied for and the policy should be consulted to determine governing contractual provisions. Additionally, it does not give all the details of Medicare coverage. Contact your local Social Security office or consult the Medicare & You handbook (sent by Medicare) for more details. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. Carefully read your policy that you receive with your new member materials. LOSS RATIO This policy provides an anticipated loss ratio of 77.3%. This means that, on the average, policyholders may expect that $77.30 of every $100 in premium will be returned as benefits to the policyholders over the life of the contract. PREMIUMS AND RENEWABILITY HealthPartners guarantees to renew this policy as long as the premium is paid on or before the due date or within the grace period. This policy will not be cancelled or non-renewed on the grounds of the deterioration of your health. never been issued and return all of your payments within ten days. POLICY OR CERTIFICATE REPLACEMENT If you are replacing another health insurance policy or certificate, do NOT cancel it until you have actually received your new policy or certificate and are sure you want to keep it. Notice: The policy may not fully cover all your medical costs. Neither HealthPartners nor its agents are connected with Medicare. COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new policy or certificate, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy or certificate and refuse to pay any claims if you leave out or falsify important medical information. If you are eligible for guaranteed issue, (including the six (6)-month openenrollment window following your Part B effective date) you may not need to provide health history information. EXCLUSIONS Certain services are excluded from coverage. Please refer to the policy for more information. MEDICARE COST-SHARING AMOUNTS Benefits under this policy that are designed to cover cost-sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible and coinsurance percentage factors. RIGHT TO RETURN POLICY OR CERTIFICATE If you find that you are not satisfied with your policy or certificate for any reason, you may return it to: HealthPartners Riverview Membership Accounting MS 21103R P.O. Box 9463 Minneapolis, MN 55440-9643 If you send the policy back to us within 30 days after you receive it, we will treat the contract as if it has