Medicare Supplement Plans

Transcription

1 KPShealth plans P R O V I D E R N E T W O R K If you have questions about any of our Medicare Supplement plans or about the application process, please feel free to contact us at , or toll free at Frequently Asked Questions Can I buy a KPS Medicare Supplement plan if I am under age 65 or disabled? KPS does not offer Medicare Supplement plans for those under age 65, nor a plan for those on Medicare due to disability. What happens if I become eligible for Medicaid, but already have a Medicare Supplement contract? If you already have a Medicare Supplement plan and then become eligible for Medicaid, KPS must suspend coverage and waive the monthly premiums during the time you are eligible for Medicaid, not to exceed a period of 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If your Medicaid benefits end, and you notify KPS within 90 days of the date they end, KPS will reinstate an equivalent policy without a pre-existing condition waiting period. Can KPS Health Plans increase my monthly rate as I get older? No. KPS Health Plans can only raise your monthly rate if we raise the monthly rate for all contracts like yours in the state of Washington. Rate increases require approval by the state Office of the Insurance Commissioner. Generally, KPS Health Plans issues new rates effective January 1 of each year. What if my employer offers a continuation or conversion from my employer group plan? Many employers offer continuation or conversion as a retirement benefit, allowing retirees to continue the group coverage or convert to a retiree health plan. Make sure you compare the benefits offered by a retirement plan to the standardized Medicare Supplement plans before making a decision, as retirement plans may offer more comprehensive benefits. Can I be turned down for a Medicare Supplement plan with KPS? If you meet all of the eligibility requirements, you are enrolled in Medicare Parts A and B, and are applying within six months of your initial enrollment in Part B, you will not be declined for Medicare Supplement coverage with KPS Health Plans. (If applying outside of your initial enrollment period, a health statement may be required.) Corporate Office: PO Box 34803, Seattle, WA For more information, please call , or toll free, TTY number is info@kpshealthplans.com 133KPS Guide to Medicare Supplement Plans MSG0113-V2

2 We re Here for you At KPS we feel that you deserve a quality health plan that works for you, not one tailored for someone in another state. You deserve a plan backed by quality customer service and not from a call center in another state or country. We know your needs as we have been here for you and your neighbors for more than 65 years. Ask KPS Health Plans to place additional restrictions on our use or disclosure of your personal information for treatment, payment, health care operations or to persons you identify. We are not required to agree to these additional restrictions and will notify you about the reasons regarding this action. If we do agree to the additional restrictions, we will abide by our agreement (except in an emergency). Get a separate electronic or paper copy of this notice. Notice of Privacy Practices (cont.) If you are the primary subscriber with KPS Health Plans and other persons are covered by KPS Health Plans through you, we suggest that you share this information with each other to ensure that each of you is aware of our policy and your privacy rights. By law, you have the right to: See and get a copy of your personal information held by KPS Health Plans, except in certain limited situations. Make a reasonable request in writing to amend any of your personal information created by KPS Health Plans if you believe that it is wrong or if information is missing, and KPS Health Plan agrees. If KPS Health Plans disagrees, we will notify you why in writing. You may have a statement of your disagreement added to your personal information. Get a listing of those obtaining your personal information from KPS Health Plans in the past 6 years. The listing will not include information: 3 That was given to you or your personal representative or close family relative involved in your care or payment of such care, or 3 That you authorized KPS Health Plans to release, or 3 That was given out for law enforcement purposes, or 3 That was given out to pay for your health care claim or a disputed claim. Why KPS KPS was established in Bremerton, Washington in We are a Washington state nonprofit health care service contractor offering preferred provider organization (PPO) health plans, and providing Medicare Supplement health care coverage to seniors throughou state of Washington. You Need a Plan that Offers a Free Prescription Drug Discount Program KPS provides the MedImpact Preferred Price Program on all KPS Medicare Supplement Plans at no cost or obligation to you! * You Need Access to the Providers You Need to See! KPS offers complete access to any Medicare-approved provider with no referrals required! You may go to any provider (physician, specialist or hospital) that accepts Medicare. MyKPS.net KPS offers online service! View claims status, check eligibility or speak to member services it s all securely within your reach with one simple login. Enclosed is a comparison of benefits which includes each of our Medicare Supplement products Plan A (2010 Standardized), Plan F (2010 Standardized), Plan K and Plan N. Information on eligibility, enrollment, rates, contacts, application instructions, privacy practices, and disclosures are also provided. We want to make it simple, so we have provided everything you need to enroll, including an application, Automatic Premium Payment Form and a postage-paid, and self-addressed envelope. Please pay special attention to the application instructions that describe the other materials enclosed; and be sure to review the information on open enrollment and eligibility. This Guide to Medicare Supplement Plans is a summary of benefits. Please review this information carefully before selecting a plan, and keep it for your records. If you have questions about any of our Medicare Supplement plans or about the application process, please feel free to contact us at , or toll free at or visit us online at kpshealthplans.com. Either way, our knowledgeable staff will be happy to guide you through the process. *The Prescription Drug Discount Program is not a Part D Prescription Drug plan and may be discontinued at any time. For more information about exercising your rights set out in this notice, you may call KPS Health Plans Member Services department at (360) or toll free at (800) You can also reach KPS Health Plans privacy official for this purpose at (800) If you believe KPS Health Plans has violated your privacy rights set out in this notice, you may file a complaint with KPS Health Plans at the following address: KPS Health Plans Compliance Department PO Box 34803, Seattle, WA Filing a complaint will not affect your benefits under KPS Health Plans. You also may file a complaint with the Secretary of the Department of Health and Human Services. KPS Health Plans does have the right to change the way your personal information is used and given out. If KPS Health Plans makes any changes, you will get a new notice by mail within 60 days of the change, and that notice will become effective on the date the revised notice is issued. Please note: Telephone calls to and from KPS Health Plans may be recorded for quality assurance and training purposes.

3 Notice of Privacy Practices this notice describes how medical information about you may be used and disclosed and how you can get access to this information. please review it carefully. KPS Health Plans is committed to protecting the privacy of your personal and health information. Effective April 14, 2003 we were required by applicable federal and state law to maintain the privacy of your personal and health information. KPS Health Plans is also required to give you this notice to tell you how KPS may use and give out ( disclose ) your personal and health information held by KPS Health Plans. Personal and health information (referred to in this notice as personal information ) means any information that is identifiable to you as your personal information, including information regarding your health care and treatment, identifiable factors such as your name, age, and address; or financial information. We may collect personal information about you, or members covered by KPS Health Plans through you, from the following sources: Information we receive from you, including information you provide on applications or other forms, Information we receive from your health care providers or other companies, such as other health insurance companies, relating to your medical claims and billings, General information about the health care services you have received, such as the quality and availability of services. We restrict access to personal information about you to only those who need to know that information to provide treatment, payment or health care operations services to you. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your personal information. We do not disclose any personal information about our members or former members to anyone, except as permitted or required by law. However, KPS Health Plans will use and give out your personal health information: To you or someone who has the legal right to act for you (your personal representative) or a close family member who is involved in your care, or responsible for the payment of your services, To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected, To law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions, and Where required by law. KPS Health Plans has the right to use and give out your personal information to arrange for treatment, payment of, and health care operations services, including: Medical quality reviews. Accounting. Legal and risk management services. KPS Health Plans may use or give out your personal information for the following purposes under limited circumstances: For Government healthcare oversight activities (such as fraud and abuse investigations), To avoid a serious and imminent threat to the health or safety of you or the public. By law, KPS Health Plans must have your written permission (an authorization ) to use or give out your personal information for any purpose that is not set out in this notice. You may take back ( revoke ) your written permission at any time, except if KPS has already acted based on your permission. Request in writing that KPS Health Plans communicate with you in confidence about your personal information by alternative means or to an alternative location. If you advise us that disclosure of all or any part of your personal information could endanger you, we must comply with any reasonable request provided it specifies an alternative means or location. Overview KPS has provided Medicare Supplement plans for more than 30 years. We offer a choice of affordable plans; a discount program for prescription drugs*; friendly, knowledgeable customer service; and freedom to choose your own providers without a referral. Eligibility You are eligible to enroll in KPS s Medicare Supplement Plan A (2010 Standardized), Plan F (2010 Standardized), Plan K and Plan N if you are: Age 65 or older Enrolled in Medicare Part A and Part B A resident of the state of Washington Initial Enrollment Period During the first six-month period from the date you initially enroll in Medicare Part B (at age 65 or older), you cannot be denied coverage on any Medicare Supplement plan, regardless of your health. Plan A (2010 Standardized) A Medicare Supplement plan with a basic benefit structure that covers 20% of Medicare-approved amounts on Medicare Part B medical services. Plan F (2010 Standardized) A comprehensive Medicare Supplement plan that pays both Medicare Part A and Part B deductibles and 100% of the Part B excess charges. Plan K A Medicare Supplement plan with a basic benefit structure that covers half of the Part A deductible, and Part A coinsurance, while offering an out-of-pocket (OOP) limit. Plan N A comprehensive Medicare Supplement plan with basic benefits including the Part A deductible and Part B coinsurance except up to $20 office visit copay and $50 copay for Emergency Room. *The Prescription Drug Discount Program is not a Part D Prescription Drug plan and may be discontinued at any time.

4 Summary of Medicare Supplement Benefits What you pay on original Medicare Plan A (2010 Standardized) Plan pays You pay MEDICARE PART A HOSPITAL SERVICES PER BENEFIT PERIOD *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. **When your Part A hospital benefits are exhausted, KPS will pay whatever Medicare would have paid for an additional 365 days. During this time the hospital cannot bill you for the difference between its billed charges and the amount Medicare would pay. Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days (Part A deductible=$1,184) $1,184 $0 $1,184 61st through 90th day $296 a day $296 a day $0 91st day and after, while using 60 lifetime reserve days $592 a day $592 a day $0 91st day and after, once lifetime reserve days are used: 100% of Medicare 100% additional 365 days Eligible Expenses** $0** 91st day and after, once lifetime reserve days are used: beyond the additional 365 days All costs $0 All costs 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 $0 for approved amounts $0 $0 21st through 100th day $148 a day $0 Up to $148 a day 101st day and after 100% $0 All costs Blood First 3 pints 100% 3 pints $0 Additional amounts $0 $0 $0 Hospice Care Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited coinsurance for outpatient drugs and inpatient respite care Medicare Copayment/Coinsurance MEDICARE PART B MEDICAL SERVICES PER CALENDAR YEAR ***Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a triple asterisk***), your Part B deductible will have been met for the calendar year. 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 and durable medical equipment. First $147 of Medicare-approved amounts*** (Part B deductible=$147) $147 $0 $147 Remainder of Medicare-approved amounts 20% Generally 20% $0 Part B excess charges (above Medicare-approved amounts) All costs $0 All costs Blood First 3 pints All costs All costs $0 Next $147 of Medicare-approved amounts*** (Part B deductible=$147) $147 $0 $147 Remainder of Medicare-approved amounts 20% 20% $0 Clinical Laboratory Services Tests for diagnostic services $0 $0 $0 MEDICARE PARTS A & B Home Health Care Medicare-approved services Medically necessary skilled care services and medical supplies $0 $0 $0 Durable medical equipment: first $147 of Medicare-approved amounts*** (Part B deductible=$147) $147 $0 $147 Durable medical equipment: remainder of Medicare-approved amounts 20% 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE Foreign Travel Medically necessary emergency care services beginning during the first 60 days of each trip outside USA First $250 each calendar year $250 $0 $250 Remainder of charges All costs $0 All costs $0 Should the subscriber elect to make monthly payments in advance of the current monthly rate due date and the revised rate is to become effective at the beginning of a month for which the subscriber has already paid, the next billing will include a retroactive adjustment for the revised rate. KPS Health Plans can only raise your monthly rate if all KPS contracts like yours are raised in the state. Disclosures Disclosures Use this Guide to Medicare Supplement Plans to compare the benefits and monthly rates of the plans we offer. Read Your Contract Carefully This is only a summary describing your contract s most important features. You must read the contract itself to understand all of the rights and duties of both you and KPS Health Plans. Right to Return Contract If you find that you are not satisfied with your contract, you may return it to KPS Health Plans, PO Box 34803, Seattle, WA , Attn.: Marketing. If you send the contract back to us within 30 days after you receive it, we will treat the contract as if it had never been issued and return all of your payments. Contract Replacement If you are replacing another health insurance contract, do NOT cancel it until you have actually received your new contract and are sure you want to keep it. Plan A (2010 Standardized) F (2010 Standardized) Rates Monthly Rates Per Person Effective 1/1/2013 $125 $232 K $81 N $131 Notice The contract may not fully cover all your medical costs. Neither KPS Health Plans, nor its agents, are connected with Medicare. This guide does not give all the details of Medicare coverage. Contact your local Social Security office or consult the Medicare and You handbook for more details. Complete Answers are Very Important When you fill out the application for the new contract, be sure to answer truthfully and completely all questions about your medical and health history. KPS Health Plans may cancel your contract 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.

5 Application Instructions Application for Medicare Supplement Please complete the application and (if applicable) the health statement (see below), sign page five where indicated, and return to KPS Health Plans in the enclosed postage-paid, self-addressed envelope. Forms may also be located at medicare. Health Statement A health statement must be completed, unless you are: 65 years of age or older and applying within six (6) months of your first enrollment under Medicare Part B; or Transferring from another Medicare Supplement Plan A to the KPS Medicare Supplement Plan A (2010 Standardized); or Transferring from a Medicare Supplement plan other than Plan A to a KPS Medicare Supplement plan; or Transferring from more comprehensive coverage (e.g., employer group coverage) to a KPS Medicare Supplement plan. Replacement of Medicare Supplement Health Care Coverage KPS cannot sell you a Medicare Supplement plan if you intend to keep a previous plan that provides the same benefits. If you are replacing your Medicare Supplement Plan with this Medicare Supplement Plan, please complete and sign the enclosed replacement form for your records and return a completed/signed copy to KPS Health Plans. Guide to Health Insurance for People with Medicare This is produced by the Centers for Medicare and Medicaid Services (CMS). It contains helpful information for Medicare beneficiaries regarding the Medicare program and different coverage options. Automatic Premium Payment Form Return only if you wish to have your financial institution automatically deduct each month s payment from your account. Allow 4 to 6 weeks for the deduction to go into effect. MedImpact Preferred Price Program In a continuing effort to provide the greatest possible savings to our members, KPS Health Plans is pleased to offer the MedImpact Preferred Price Program on all KPS Medicare Supplement Plans at no cost or obligation to you.* *The Prescription Drug Discount Program is not a Part D Prescription Drug plan and may be discontinued at any time. Summary of Medicare Supplement Benefits What you pay on original Medicare Plan F (2010 Standardized) Plan pays You pay MEDICARE PART A HOSPITAL SERVICES PER BENEFIT PERIOD *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. **When your Part A hospital benefits are exhausted, KPS will pay whatever Medicare would have paid for an additional 365 days. During this time the hospital cannot bill you for the difference between its billed charges and the amount Medicare would pay. Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days (Part A deductible=$1,184) $1,184 $1,184 $0 61st through 90th day $296 a day $296 a day $0 91st day and after, while using 60 lifetime reserve days $592 a day $592 a day $0 91st day and after, once lifetime reserve days are used: 100% of Medicare 100% additional 365 days Eligible Expenses** $0** 91st day and after, once lifetime reserve days are used: beyond the additional 365 days All costs $0 All costs 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 $0 for approved amounts $0 $0 21st through 100th day $148 a day Up to $148 a day $0 101st day and after 100% $0 All costs Blood First 3 pints 100% 3 pints $0 Additional amounts $0 $0 $0 Hospice Care Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited coinsurance for outpatient drugs and inpatient respite care Medicare Copayment/Coinsurance MEDICARE PART B MEDICAL SERVICES PER CALENDAR YEAR ***Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a triple asterisk***), your Part B deductible will have been met for the calendar year. 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 and durable medical equipment. First $147 of Medicare-approved amounts*** (Part B deductible=$147) $147 $147 $0 Remainder of Medicare-approved amounts 20% Generally 20% $0 Part B excess charges (above Medicare-approved amounts) All costs 100% $0 Blood First 3 pints All costs All costs $0 Next $147 of Medicare-approved amounts*** (Part B deductible=$147) $147 $147 $0 Remainder of Medicare-approved amounts 20% 20% $0 Clinical Laboratory Services Tests for diagnostic services $0 $0 $0 MEDICARE PARTS A & B Home Health Care Medicare-approved services Medically necessary skilled care services and medical supplies $0 $0 $0 Durable medical equipment: first $147 of Medicare-approved amounts*** (Part B deductible=$147) $147 $147 $0 Durable medical equipment: remainder of Medicare-approved amounts 20% 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE Foreign Travel Medically necessary emergency care services beginning during the first 60 days of each trip outside USA First $250 each calendar year $250 $0 $250 80% to lifetime 20% + amounts over Remainder of charges All costs maximum of $50,000 $50,000 lifetime maximum $0

6 Summary of Medicare Supplement Benefits What you pay on original Medicare Plan K You pay Plan pays MEDICARE PART A HOSPITAL SERVICES PER BENEFIT PERIOD *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. **When your Part A hospital benefits are exhausted, KPS will pay whatever Medicare would have paid for an additional 365 days. During this time the hospital cannot bill you for the difference between its billed charges and the amount Medicare would pay. Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days (Part A deductible=$1,184) $1,184 $592 $592 61st through 90th day $296 a day $296 a day $0 91st day and after, while using 60 lifetime reserve days $592 a day $592 a day $0 91st day and after, once lifetime reserve days are used: 100% of Medicare 100% additional 365 days Eligible Expenses** $0** 91st day and after, once lifetime reserve days are used: beyond the additional 365 days All costs $0 All costs 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 $0 for approved amounts $0 $0 21st through 100th day $148 a day Up to $74 a day Up to $74 a day 101st day and after 100% $0 All costs Blood First 3 pints 100% 50% 50% Additional amounts $0 $0 $0 Hospice Care Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited 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 $147 of Medicare-approved amounts for covered services (which are noted with a triple asterisk***), your Part B deductible will have been met for the calendar year. 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 and durable medical equipment. First $147 of Medicare-approved amounts*** (Part B deductible=$147) $147 $0 $147 Remainder of Medicare-approved amounts 20% Generally 10% Generally 10% Part B excess charges (above Medicare-approved amounts) All costs $0 All costs Blood First 3 pints All costs 50% 50% Next $147 of Medicare-approved amounts*** (Part B deductible=$147) $147 $0 $147 Remainder of Medicare-approved amounts 20% Generally 10% Generally 10% Clinical Laboratory Services Tests for diagnostic services $0 $0 $0 MEDICARE PARTS A & B Home Health Care Medicare-approved services Medically necessary skilled care services and medical supplies $0 $0 $0 Durable medical equipment: first $147 of Medicare-approved amounts*** (Part B deductible=$147) $147 $0 $147 Durable medical equipment: remainder of Medicare-approved amounts 20% 10% 10% OTHER BENEFITS NOT COVERED BY MEDICARE Foreign Travel Medically necessary emergency care services beginning during the first 60 days of each trip outside USA First $250 each calendar year $250 $0 $250 Remainder of charges All costs $0 All costs Summary of Medicare Supplement Benefits What you pay on original Medicare Plan pays Plan N You pay MEDICARE PART A HOSPITAL SERVICES PER BENEFIT PERIOD *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. **When your Part A hospital benefits are exhausted, KPS will pay whatever Medicare would have paid for an additional 365 days. During this time the hospital cannot bill you for the difference between its billed charges and the amount Medicare would pay. Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days (Part A deductible=$1,184) $1,184 $1,184 $0 61st through 90th day $296 a day $296 a day $0 91st day and after, while using 60 lifetime reserve days $592 a day $592 a day $0 91st day and after, once lifetime reserve days are used: additional 365 days 91st day and after, once lifetime reserve days are used: beyond the additional 365 days 100% 100% of Medicare Eligible Expenses** $0** All costs $0 All costs 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 $0 for approved amounts $0 $0 21st through 100th day $148 a day Up to $148 a day $0 101st day and after 100% $0 All costs Blood First 3 pints 100% 100% $0 Additional amounts $0 $0 $0 Hospice Care Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited coinsurance for outpatient drugs and inpatient respite care Medicare Copayment/Coinsurance MEDICARE PART B MEDICAL SERVICES PER CALENDAR YEAR ***Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a triple asterisk***), your Part B deductible will have been met for the calendar year. 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 and durable medical equipment. First $147 of Medicare-approved amounts*** (Part B deductible=$147) Remainder of Medicare-approved amounts 20% $147 $0 $147 Balance, other than $20 per office visit and $50 per emergency room visit. Part B excess charges (above Medicare-approved amounts) All costs $0 All costs Blood First 3 pints All costs All costs $0 Next $147 of Medicare-approved amounts*** (Part B deductible=$147) $147 $0 $147 Remainder of Medicare-approved amounts 20% 20% $0 Clinical Laboratory Services Tests for diagnostic services $0 $0 $0 MEDICARE PARTS A & B Home Health Care Medicare-approved services Medically necessary skilled care services and medical supplies Durable medical equipment: first $147 of Medicare-approved amounts*** (Part B deductible=$147) Durable medical equipment: remainder of Medicare-approved amounts OTHER BENEFITS NOT COVERED BY MEDICARE $0 $0 $0 $147 $0 $147 20% 20% $0 $0 $20 per office visit and $50 per emergency room visit. Foreign Travel Medically necessary emergency care services beginning during the first 60 days of each trip outside USA First $250 each calendar year $250 $0 $250 80% to lifetime 20% + amounts over Remainder of charges All costs maximum of $50,000 $50,000 lifetime maximum

7 KPS HEALTH PLANS Outline of Medicare Supplement Coverage - Cover Page Benefit Plans A and F See Outlines of Coverage sections for details about ALL plans These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan "A". Some plans may not be available in your state. KPS Health Plans offers only Plans A, F, K and N, shaded below. Basic Benefits for Plans A through G 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 copayment for hospital outpatient services. Blood: First three pints of blood each year. Hospice: Part A coinsurance A B C D F F* G Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Skilled Nursing Facility Coinsurance 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 Part B Deductible Part B Deductible Part B Excess (100%) Part B Excess (100%) Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,110 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,110. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the contract. These expenses include the Medicare deductibles for Part A and Part B but do not include the plan s separate foreign travel emergency deductible. KPS Health Plans does not offer the high deductible Plan F. MSOC of 16 11/16/12

8 KPS HEALTH PLANS Outline of Medicare Supplement Coverage - Cover Page 2 K L M N Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER 50% of Skilled Nursing Facility Coinsurance 75% of Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance 50% Part A Deductible 75% Part A Deductible 50% Part A Deductible Part A Deductible Foreign Travel Emergency Foreign Travel Emergency Out-of pocket limit $4,800; paid at 100% after limit is reached. Out-of pocket limit $2,400; paid at 100% after limit is reached. MSOC of 16 11/16/12

9 EFFECTIVE 1/01/2013 MONTHLY RATES PER PERSON ARE AS FOLLOWS: KPS PLAN A (2010 Standardized): $ KPS PLAN F (2010 Standardized): $ KPS PLAN K $81 KPS PLAN N $131 Should the Subscriber elect to make monthly payments in advance of the current monthly rate due date and the revised rate is to become effective at the beginning of a month for which the Subscriber has already paid, the next billing will include a retroactive adjustment for the revised rate. MSOC of 16 11/16/12

10 PREMIUM INFORMATION We, KPS Health Plans, can only raise your monthly premium if we raise the premium for all contracts like yours in this state. DISCLOSURES Use this outline to compare benefits and premiums among contracts. READ YOUR CONTRACT VERY CAREFULLY This is only an outline describing your contract's most important features. The contract is your health care coverage contract. You must read the contract itself to understand all of the rights and duties of both you and KPS Health Plans. RIGHT TO RETURN CONTRACT If you find that you are not satisfied with your contract, you may return it to KPS Health Plans, P.O. Box 339, 400 Warren Avenue, Bremerton, Washington, 98337, Attn: Marketing. If you send the contract back to us within thirty days after you receive it, we will treat the contract as if it had never been issued and return all of your payments. CONTRACT REPLACEMENT If you are replacing another health insurance contract, do NOT cancel it until you have actually received your new contract and are sure you want to keep it. NOTICE This contract may not fully cover all of your medical costs. Neither KPS Health Plans nor its agents are 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 contract, be sure to answer truthfully and completely all questions about your medical and health history. KPS Health Plans may cancel your contract 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. MSOC of 16 11/16/12

11 PLAN A 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. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,184 $0 $1,184 (Part A Deductible) 61st thru 90th day All but $296 a day $296 a day $0 91st day and after: - While using 60 lifetime reserve days All but $592 a day $592 a day $0 Once lifetime reserve days are used: - Additional 365 days $0 100% of Medicare Eligible Expenses $0** - Beyond the Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but $148 a day $0 Up to $148 a day 101st day and after $0 $0 All Costs BLOOD First 3 pints $0 100% $0 Additional amounts 100% $0 $0 HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited coinsurance for outpatient drugs and inpatient respite care Medicare co-payment/ 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 contract 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. $0 MSOC of 16 11/16/12

12 PLAN A MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR * Once you have been billed $147 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. SERVICES MEDICARE PAYS PLAN 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 $147 of Medicare approved amounts* $0 $0 $147 (Part B Deductible) Remainder of Medicare approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare approved amounts) $0 $0 All Costs BLOOD First 3 pints $0 All Costs $0 Next $147 of Medicare approved amounts* $0 $0 $147 (Part B Deductible) Remainder of Medicare approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PLAN A PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES - Medically necessary skilled care services and medical supplies 100% $0 $0 - Durable medical equipment First $147 of Medicare approved amounts* $0 $0 $147 (Part B Deductible) Remainder of Medicare approved amounts 80% 20% $0 MSOC of 16 11/16/12

13 PLAN F 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. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days SERVICES MEDICARE PAYS PLAN PAYS YOU PAY All but $1,184 (Part A Deductible) $1,184 (Part A Deductible) 61st thru 90th day All but $296 a day $296 a day $0 91st day and after: - While using 60 lifetime reserve days All but $592 a day $592a day $0 Once lifetime reserve days are used: 100% of Medicare $0 - Additional 365 days Eligible Expenses $0*** - Beyond the Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicareapproved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but $148 a day Up to $148 a day $0 101st day and after $0 $0 All Costs BLOOD First 3 pints $0 100% $0 Additional amounts 100% $0 $0 HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited coinsurance for outpatient drugs and inpatient respite care Medicare co-payment/ 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 contract 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. $0 $0 MSOC of 16 11/16/12

14 PLAN F MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR * Once you have been billed $147 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. SERVICES MEDICARE PAYS PLAN 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 $147 of Medicare approved amounts* $0 $147 (Part B Deductible) $0 Remainder of Medicare approved Amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare approved amounts) $0 100% $0 BLOOD First 3 pints $0 All Costs $0 Next $147 of Medicare approved amounts* $0 $147 (Part B Deductible) $0 Remainder of Medicare approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PLAN F PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES - Medically necessary skilled care services and medical supplies 100% $0 $0 - Durable medical equipment First $147 of Medicare Approved Amounts* $0 $147 (Part B Deductible) $0 Remainder of Medicare Approved Amounts 80% 20% $0 OTHER BENEFITS - NOT COVERED BY MEDICARE FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of Charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum MSOC of 16 11/16/12

15 PLAN K * You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit each calendar year. The amounts that count toward your annual limit are noted with diamonds ( ) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare co-payment 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. PLAN K 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. HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days SERVICES MEDICARE PAYS PLAN PAYS YOU PAY All but $1,184 (Part A Deductible) $592 (50% of Part A Deductible) 61st thru 90th day All but $296 a day $296 a day $0 91st day and after: - While using 60 lifetime reserve days All but $578 a day $578 a day $0 Once lifetime reserve days are used: 100% of Medicare $0 - Additional 365 days Eligible Expenses $0*** - Beyond the Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY CARE** You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicareapproved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but $148 a day Up to $74 a day (50% of Part A coinsurance) $592 (50% of Part A deductible) Up to $74 a day (50% of Part A coinsurance) 101st day and after $0 $0 All Costs BLOOD First 3 pints $0 50% 50% Additional amounts 100% $0 $0 MSOC of 16 11/16/12

16 HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited coinsurance for outpatient drugs and inpatient respite care 50% Medicare copayment/coinsurance 50% of 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 contract 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. MSOC of 16 11/16/12

17 PLAN K MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR **** Once you have been billed $147 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. SERVICES MEDICARE PAYS PLAN 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 $147 of Medicare approved amounts**** $0 $0 $147 (Part B Deductible)**** Preventive Benefits for Medicare covered services Generally 80% or more of Medicare approved amounts Remainder of Medicare approved amounts All costs above Medicare approved amounts Remainder of Medicare approved Amounts Generally 80% Generally 10% Generally 10% Part B Excess Charges (Above Medicare approved amounts) $0 $0 All costs (and they do not count toward annual outof-pocket limit of $4,800)* BLOOD First 3 pints $0 50% 50% Next $147 of Medicare approved amounts**** $0 $0 $147 (Part B Deductible)**** Remainder of Medicare approved amounts Generally 80% Generally 10% Generally 10% CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 *This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $4,800 per year. However, this limit does NOT include charges from your provider t hat 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. MSOC of 16 11/16/12

18 PLAN F PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES - Medically necessary skilled care services and medical supplies 100% $0 $0 - Durable medical equipment First $147 of Medicare Approved Amounts***** $0 $0 $147 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 10% 10% ***** Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. MSOC of 16 11/16/12

19 PLAN N 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. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days SERVICES MEDICARE PAYS PLAN PAYS YOU PAY All but $1,184 (Part A Deductible) $1,184 (Part A Deductible) 61st thru 90th day All but $296 a day $296 a day $0 91st day and after: - While using 60 lifetime reserve days All but $592 a day $592 a day $0 Once lifetime reserve days are used: 100% of Medicare $0 - Additional 365 days Eligible Expenses $0** - Beyond the Additional 365 days $0 $0 All Costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicareapproved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but $148 a day Up to $148 a day $0 101st day and after $0 $0 All Costs BLOOD First 3 pints $0 100% $0 Additional amounts 100% $0 $0 HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited coinsurance for outpatient drugs and inpatient respite care Medicare co-payment/ 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 contract 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. $0 $0 MSOC of 16 11/16/12

20 PLAN N MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR * Once you have been billed $147 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. SERVICES MEDICARE PAYS PLAN 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 $147 of Medicare approved amounts* $0 $0 Remainder of Medicare approved Amounts Generally 80% Balance, other than $20 per office visit and $50 per emergency room visit. The copayment of $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. $147 (Part B Deductible) $20 per office visit and $50 per emergency room visit. The copayment of $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. Part B Excess Charges (Above Medicare approved amounts) $0 $0 All costs BLOOD First 3 pints $0 All Costs $0 Next $147 of Medicare approved amounts* $0 $0 $147 (Part B Deductible) Remainder of Medicare approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 MSOC of 16 11/16/12

21 PLAN N PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES - Medically necessary skilled care services and medical supplies 100% $0 $0 - Durable medical equipment First $147 of Medicare Approved Amounts* $0 $0 $147 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0 OTHER BENEFITS - NOT COVERED BY MEDICARE FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 80% to a lifetime 20% and amounts Remainder of Charges $0 maximum benefit of $50,000 over the $50,000 lifetime maximum MSOC of 16 11/16/12

22 CORPORATE OFFICE: 400 Warren Avenue Bremerton, Washington Mailing Address P.O. Box Seattle, WA (360) TTY - (800) info@kpshealthplans.com MSOC of 16 11/16/12