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1 More value Thank you for considering KPS KPS Health Plans 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 throughout the entire state of Washington. KPS has provided Medicare Supplement plans for more than thirty 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. 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. *The Prescription Drug Discount Program is not a Part D Prescription Drug plan and may be discontinued at any time. 15-KPS-1266

2 Statewide Provider Coverage Our job is to aid, not interfere in your relationship with your doctor. As a Preferred Provider Organization (PPO), we give you the freedom to self-refer to specialists. And by using a combination of the KPS and First Choice provider networks, you can be assured that you are covered wherever you may live, work or travel in Washington state. KPS Network First Choice Health Healthy Employees. Healthy Companies. There are more than 47,000 preferred providers in Washington state. You are covered worldwide for urgent and emergent care.

3 Benefits for Medicare Supplement Plans Plan A (2010 Standardized) You Pay Monthly Premium $135 Deductible(s) Part A Deductible: $1,260/benefit period Part B Deductible: $147/calendar year Doctor and Hospital Choice You may go to any doctor, specialist or hospital that accepts Medicare. Preventive Services $0 Outpatient Doctor Office Visits Part B Deductible: $147; $0 Diagnostic Tests, X-rays, Lab Services and Radiology Services Medicare does not cover most supplemental routine screening tests, like checking your cholesterol. Diagnostic Tests and X-Rays: Part B Deductible: $147; $0 Lab Services: $0 copay; Must be medically necessary for diagnosis/treatment. Outpatient Surgery Part B Deductible: $147; $0 Ambulance Part B Deductible: $147; $0 Emergency Room Physician s services: Part B Deductible: $147; $0 Facility Services: Specified copayment. Copay cannot exceed Part A deductible for each service provided by the hospital. Copay waived if admitted with 3 days of ER visit. Inpatient Hospital Care Includes 60 lifetime reserve days Part A Deductible: $1,260 Days 61-90: $0; Days : $0; Additional 365 days: $0 Skilled Nursing Facility Subject to prior 3-day Inpatient admit Days 1-20: $0; Days : $157.50/day; Days 101+: 100% Home Health Care $0 Hospice $0 Durable Medical Equipment Part B Deductible: $147; $0 Vision Exam: $0 Vision Hardware: $0 for one pair of eyeglasses or contact Vision Services lenses after cataract surgery. Supplemental routine eye exams and eyeglasses (lenses and frames) are not covered. Foreign Travel, emergency Not Covered Wellness/Education Services *Good For You!; Global Fit 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. *Good For You!, a value-added program, and the Global Fit Program, a separate discount program, are not part of your Medicare Supplement plan and may be discontinued at any time.

4 Benefits for Medicare Supplement Plans Plan F (2010 Standardized) You Pay Monthly Premium $251 Deductible(s) $0; $0 Doctor and Hospital Choice You may go to any doctor, specialist or hospital that accepts Medicare. Preventive Services $0 Outpatient Doctor Office Visits $0; $0 Diagnostic Tests, X-rays, Lab Services and Radiology Services Medicare does not cover most supplemental routine screening tests, like checking your cholesterol. Diagnostic Tests and X-Rays: $0; $0 Lab Services: $0 copay; Must be medically necessary for diagnosis/treatment. Outpatient Surgery $0; $0 Ambulance $0; $0 Emergency Room Inpatient Hospital Care Includes 60 lifetime reserve days Physician s services: $0; $0 Facility Services: $0 $0 Days 61-90: $0; Days : $0; Additional 365 days: $0 Skilled Nursing Facility Subject to prior 3-day Inpatient admit Days 1-20: $0; Days : $0; Days 101+: 100% Home Health Care $0 Hospice $0 Durable Medical Equipment $0; $0 Vision Services Foreign Travel, emergency Wellness/Education Services Vision Exam: $0 Vision Hardware: $0 for one pair of eyeglasses or contact lenses after cataract surgery. Supplemental routine eye exams and eyeglasses (lenses and frames) are not covered. First $250 ; 20% Coinsurance; $50,000 Lifetime Maximum Good For You!; Global Fit 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. *Good For You!, a value-added program, and the Global Fit Program, a separate discount program, are not part of your Medicare Supplement plan and may be discontinued at any time.

5 Benefits for Medicare Supplement Plans Plan K You Pay Monthly Premium $87 Deductible(s) 50% of Part A Deductible: $630/benefit period Part B Deductible: $147/calendar year Doctor and Hospital Choice You may go to any doctor, specialist or hospital that accepts Medicare. Preventive Services $0 Outpatient Doctor Office Visits Diagnostic Tests, X-rays, Lab Services and Radiology Services Medicare does not cover most supplemental routine screening tests, like checking your cholesterol. Outpatient Surgery Ambulance Emergency Room Inpatient Hospital Care Includes 60 lifetime reserve days Skilled Nursing Facility Subject to prior 3-day Inpatient admit Part B Deductible: $147; 10% Coinsurance Diagnostic Tests and X-Rays: Part B Deductible: $147; 10% Coinsurance Lab Services: $0 copay; Must be medically necessary for diagnosis/treatment. Part B Deductible: $147; 10% Coinsurance Part B Deductible: $147; 10% Coinsurance Physician s services: Part B Deductible: $147; 10% Coinsurance Facility Services: Specified copayment. Copay cannot exceed Part A deductible for each service provided by the hospital. Copay waived if admitted with 3 days of ER visit. 50% of Part A Deductible: $630 Days 61-90: $0; Days : $0; Additional 365 days: $0 Days 1-20: $0; Days : $78.75/day; Days 101+: 100% Home Health Care $0 You pay 50% of the patient part of the cost for Hospice outpatient drugs and inpatient respite care. You must get care from a Medicare-certified hospice. Durable Medical Equipment Part B Deductible: $147; 10% Coinsurance Vision Services Foreign Travel, emergency Wellness/Education Services Vision Exam: 10% Vision Hardware: $0 for one pair of eyeglasses or contact lenses after cataract surgery.supplemental routine eye exams and eyeglasses (lenses and frames) are not covered. Not Covered *Good For You!; Global Fit 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. *Good For You!, a value-added program, and the Global Fit Program, a separate discount program, are not part of your Medicare Supplement plan and may be discontinued at any time.

6 Benefits for Medicare Supplement Plans Plan N You Pay Monthly Premium $141 Deductible(s) Doctor and Hospital Choice $0 Part B Deductible: $147/calendar year You may go to any doctor, specialist or hospital that accepts Medicare. Preventive Services $0 Outpatient Doctor Office Visits Diagnostic Tests, X-rays, Lab Services and Radiology Services Medicare does not cover most supplemental routine screening tests, like checking your cholesterol. $0; $20 copay Diagnostic Tests and X-Rays: Part B Deductible: $147; $0 Lab Services: $0 copay; Must be medically necessary for diagnosis/treatment. Outpatient Surgery Part B Deductible: $147; $0 Ambulance Part B Deductible: $147; $0 Physician s services: Part B Deductible: $147; $20 Copay Emergency Room Facility Services: $50 Copay Inpatient Hospital Care Includes 60 lifetime reserve days $0 Days 61-90: $0; Days : $0; Additional 365 days: $0 Skilled Nursing Facility Subject to prior 3-day Inpatient Days 1-20: $0; Days : $0; Days 101+: 100% admit Home Health Care $0 Hospice $0 Durable Medical Equipment $0; $0 Vision Services Foreign Travel, emergency Vision Exam: $0 Vision Hardware: $0 for one pair of eyeglasses or contact lenses after cataract surgery. Supplemental routine eye exams and eyeglasses (lenses and frames) are not covered. First $250 ; 20% Coinsurance; $50,000 Lifetime Maximum Wellness/Education Services Good For You!; Global Fit 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. *Good For You!, a value-added program, and the Global Fit Program, a separate discount program, are not part of your Medicare Supplement plan and may be discontinued at any time.

7 GlobalFit Health and Fitness Program KPS offers members the GlobalFit health and fitness discount program. The program is for all members and their dependents offering a network of health clubs to choose from, as well as exercise videos and equipment you can use at home. The NutriSystem weight loss program is also available. See Globalfit or call for more information. KPS Good For You! Wellness Program Feel your best and equip yourself with tools to learn important facts about your health and health care. KPS offers an extensive interactive online program called Good For You! as part of the MyKPS package at no additional cost. This exciting program supports you and your family through activities and resources to learn the personal connection between health and outcomes. MyKPS is your gateway to Good For You!, and your 24/7 secure online customer service portal. Through MyKPS.net, you can: View plan information Check claim status Track pharmacy charges Request a new ID card Contact Customer Service Locate a provider or pharmacy Much, much more *Good For You!, a value-added program, and the Global Fit Program, a separate discount program, are not part of your Medicare Supplement plan and may be discontinued at any time.

8 Enroll Online Enroll Online Get a quote and enroll online Automatic Payment Plan You can choose to have your funds transferred electronically with the Automatic Premium Payment Form (PDF). If you choose this option, your monthly premium will be deducted from your bank account. Enrollment Checklist KPS has a choice of affordable plans. To enroll in one of these plans, please follow the instructions below. Important: Please fill out and mail back the enclosed forms in a self-addressed stamped envelope. Required Required If applicable Optional Application A copy of your Red, White and Blue Medicare card Notice of Replacement of Coverage Authorized agreement for automatic premium payment form Return all of the appropriate forms in self-addressed stamped envelope, and mail it to: KPS Health Plans PO Box 34803, Seattle, WA Questions? Please call the KPS sales staff: or TTY WA Relay at or 711. Hours are Monday Friday, 8 a.m. 5 p.m.

9 Here are some of the most common Medicare terms. Understanding these will help you pick the plan that s right for you. Benefit period The way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you re admitted as an inpatient in a hospital or skilled nursing facility. The benefit period ends when you haven t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. (Note: when 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. Coinsurance An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%). Copayment An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor s visit, hospital outpatient visit, or prescription. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor s visit or prescription. Deductible The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay. Lifetime reserve days In Original Medicare, these are additional days that Medicare will pay for when you re in a hospital for more than 90 days. You have a total of 60 reserve days that can be used during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance. Medically necessary Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine. Medicare-approved amount In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you re responsible for the difference. Premium The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage. Preventive services Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include Pap tests, flu shots, and screening mammograms.) Skilled nursing facility (SNF) care Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

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