Happiness is... Protection from unexpected health care costs.

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1 Happiness is... Protection from unexpected health care costs. WPS Companion Help Fill the Gaps in with Wisconsin s Most Popular Supplement Plans Lower-premium cost-sharing options available! Effective March 1, 2015

2 IMPORTANT: If there s ever a discrepancy between the policy and this outline of coverage, the policy has final authity. To Be Eligible f WPS Companion, You: 1. Have to be a Wisconsin resident when you enroll. 2. Have to be enrolled in Part A & Part B by the date the WPS Companion plan starts. 3. Can t be covered by Medicaid. If you re eligible to apply, please read on. This brochure contains imptant infmation about policy benefits and limitations, and your rights and responsibilities under the plan. Why the WPS Companion? Payment Options and Renewal Terms... 7 Two Plans to Choose From... 8 What s Covered Standard Plan Cost-Sharing Plans How to Calculate Your Premium Standard Plan Rate Wksheet Standard Plan Premium Rates Cost-Sharing Plan Rate Wksheet...22 Cost-Sharing Plan Premium Rates Covered Preventive Care...25 Limitations & Exclusions...26 Grievance Procedures

3 WPS Health Insurance Outline of Supplement Coverage WPS MEDICARE COMPANION Supplement Insurance The Wisconsin Insurance Commissioner has set standards f supplement insurance. This policy meets these standards. It, along with, may not cover all of your medical costs. You should review carefully all policy limitations. F an explanation of these standards and other imptant infmation, see the Wisconsin Guide to Health Insurance f People with, given to you when you applied f this policy. Do not buy this policy if you did not get this guide. PREMIUM INFORMATION We can only raise your premium if: we raise the premium f all policies like yours in this state, you enter a new age categy, your residence changes such that you move to a new rating area, if there is a change in benefits. DISCLOSURES Use this outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY This is only an outline describing your policy s most imptant 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. Neither WPS Health Insurance n its agents are connected with the federal program. 3

4 alone is not enough. That s why there s Companion. is a valuable benefit, but it doesn t pay f everything. There are deductibles and coinsurance you have to pay befe pays its share. And though no one likes to say it, there is always a chance that a serious illness injury could exhaust your benefits. So what can you do to protect your health and retirement savings? That s where the WPS Companion comes in. Comprehensive coverage that helps fill the gaps in. Every WPS Companion policy begins with an excellent ce of benefits. Our Base Plans cover your 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. Companion pays f a variety of imptant services, including: Hospitalization, skilled nursing care, and home health care services Medical and surgical services and supplies Chiropractic services X-rays, mammograms, and lab tests Licensed ambulance services Physical, radiation, and speech therapy Equipment and certain supplies to treat diabetes Dialysis and kidney transplant services Durable medical equipment and prosthetics F a me detailed description of Companion benefits, see pages 9 11 (Standard Plan) and (Cost-Sharing Plans). Preventive benefits to help keep you healthy. We also help pay f preventive health services beyond standard coverage up to $1,000 annually f a routine vision hearing exam, and other preventive services not covered 100% by. 1 1 Does not apply to the Cost Share options. Flexibility to fit your needs. You can enhance the WPS Companion Standard Base Plan with up to five optional benefit riders, each available at an additional cost. Optional riders include: 50% Part A Deductible; 100% Part A Deductible Part B Deductible; Part B Copayment Coinsurance Rider Part B Excess Charges Additional Home Health Care Feign Travel Emergency Medical Care Please see page 17 f a description of the benefits provided by these riders. Freedom to choose your own docts and hospitals that accept anywhere in the U.S. With the WPS Companion, you can keep the same doct you ve been seeing f years. Or, you can select a new doct at any time. You have complete freedom to choose your health care providers. And if you move, your WPS Companion coverage moves with you anywhere in the U.S. Keeps pace with. Each time the Centers f & Medicaid Services (CMS) increases the deductibles, your WPS Companion benefits will adjust to cover the increase. You can feel secure in knowing your plan will always remain current with. 4

5 Save money with our household discount. WPS offers a 5% discount when you and a second household member are enrolled in a WPS supplement plan.* Guaranteed renewable f life. We promise that your WPS supplement policy will never be canceled because of your health. As long as you pay your premium on time, the WPS Companion is guaranteed renewable f life. No paperwk. No wries! With our automatic claims service, you don t have to wry about filing claims dealing with medical bills. That s because Part B sends your claims electronically right to WPS. We handle the claims and you enjoy the convenience of no paperwk. Online resources just point and click to find what you need. Visit the WPS website at to quickly and easily verify your benefits, eligibility, and claims status. You can request a replacement WPS ID card and Member Guide; and find infmation in our online health center about healthy eating, managing chronic conditions, patient safety, and me, including a special area devoted to seni health issues. Going the extra mile f members. When you call WPS, you reach people who care. Your questions are answered promptly and accurately by highly trained Member Services representatives suppted by state-of-the-art technology. You can be sure our representatives will go the extra mile to assist you. Maybe that s why outstanding member service has been our hallmark f me than 65 years. Highly Rated Prescription Drug Coverage Our WPS Rx (PDP) plans received the highest possible rating f prescription drug plans in the state f 2015: 5 out of 5 stars! 1 Our plans offer: Stable rates and simple copays Quality coverage f both brand-name and generic drugs Convenient service at me than 63,000 pharmacies nationwide Ask your agent how WPS Rx plans can help protect you against the high cost of prescription drugs. Wisconsin Physicians Service Insurance Cpation (WPS Health Insurance) is a -approved Part D spons. 1.gov, 10/2014. Plan perfmance star ratings are assessed each year and may change from one year to the next. S5753_27089_021_1410 CMS Accepted SilverSneakers Fitness Program and me. WPS Companion members receive FREE access to amenities such as treadmills, weights, heated pools and fitness classes that are included with a basic fitness center membership through the award-winning SilverSneakers Fitness Program. Your WPS ID card also entitles you to discounts on eye care, eyewear, and hearing aids accessible at maj retailers throughout Wisconsin and nationwide.** * Household: Two me individuals who reside together in the same dwelling. Dwelling is defined as a single home, condominium unit, apartment unit within an apartment complex. **Fitness program, vision and hearing discount programs are not part of the insurance policy and are offered at no additional charge. SilverSneakers is a registered trademark of Healthways, Inc. 5

6 How Open Enrollment Wks WPS offers an open-enrollment period during the six calendar months immediately following the month you enroll in Part B. You can submit your application f the WPS Companion up to three calendar months befe the open-enrollment period begins. If you apply during the open-enrollment period, you won t need to answer any health questions; simply complete and submit a policy enrollment application. Coverage begins the first of the month after we accept your application and premium, with an effective date you request up to three months in the future. What if you re currently enrolled in Part B? You have a six-month open-enrollment period beginning with the month of your 65th birthday. Do you have other coverage that s terminating changing? If you have other coverage that s terminating, you may be eligible f guaranteed acceptance of this policy. In this instance, you must apply within 63 days of receiving your final coverage termination notice within 63 days of the date your current coverage ends. If your employer retiree plan premium increased by me than 25%, you may be eligible f guaranteed acceptance of this policy. To learn if you qualify f guaranteed acceptance, please call your agent your WPS sales representative. We re proud that the Wisconsin Retired Educats Association (WREA), a nearly 14,000- member statewide ganization, has endsed the WPS Companion. The WREA trusts WPS to take care of its membership in retirement, and so can you. 6

7 Convenient Payment Options. Automatic premium payment. With our Automatic Cash Handling (ACH) service, you can have your bank automatically transfer the exact amount of your premium payment to WPS each time it s due. It s a safe and easy way to pay your premium. No checks to write. No envelopes to mail. Plus, you ll never have to wry that your coverage will be canceled because your payment was lost in the mail. You even have the choice of paying your premium monthly, quarterly, semiannually, annually! To take advantage of ACH, just fill out the Automatic Withdrawal Payment Authization section of your WPS Supplement Enrollment Application. Attach a voided check a savings deposit slip to your application. Your bank will electronically transfer the exact amount of your premium on the day of the month that s most convenient f you. 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, annually. Simply complete the Credit/Debit Card Authization section of your WPS Supplement Enrollment Application. Renewal Terms. F your WPS Companion 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 Cash Handling program, no bills are sent.) Your grace period f paying the premium is: 31 days after the premium due date when you pay quarterly, semiannually, annually 10 days after the premium due date when you pay monthly Your premium is subject to change at our option. Any change in your WPS Companion 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 pri to your requested termination date. Direct billing. This is the traditional method of paying premium. If you choose to pay through Direct Billing, WPS will mail subsequent premium notices to you accding to the payment schedule you select monthly, quarterly, semiannually, annually. One-year rate guarantee. The initial premium f Standard plans is guaranteed f the first 12 months that you have the policy unless your residence changes you move into a new rating area. 1 You can terminate your coverage at any time simply by writing to us pri to your requested termination date. The rates in this brochure reflect a discount f using Automatic Cash Handling, debit card, credit card, automated bank draft, annual billing by mail. Rates will be $5.00 higher per billing period f members who select direct billing on a monthly, quarterly, semiannual basis. 1 Does not apply to the Cost Share options. 7

8 Choose the Plan That s Right f You WPS Companion Standard Plan The most popular supplement in Wisconsin 1 helps cover a variety of costs not paid by. Members can select up to five riders (additional areas of coverage) 2 See page 17. WPS Companion Cost-Sharing Plans (25% and 50%) These plans offer me affdable coverage by trading higher out-of-pocket costs f lower monthly premiums. They typically pay 75% 50% of costs left over after pays its ption; out-of-pocket costs are limited by maximums set by the federal government. Members can add one rider f additional home health care. See page 22. Companion Plan Quick Comparison* Part A Part B Supplement Benefits Standard Companion 25% Cost- Sharing Plan 50% Cost- Sharing Plan Hospitalization Optional riders to pay Plan pays 75% of Plan pays 50% of 100% 50% of deductible deductible deductible Skilled Nursing Plan pays 100% of Plan pays 75% of Plan pays 50% of Facility Care copays/ copays/ copays/ coinsurance coinsurance coinsurance Hospice Care Plan pays 100% of Plan pays 75% of Plan pays 50% of copays/ copays/ copays/ coinsurance coinsurance coinsurance Blood (first three pints) Plan pays 100% of Plan pays 75% of Plan pays 50% of copays/ copays/ copays/ coinsurance coinsurance coinsurance Part B Deductible Optional rider Not available Not available Part B Optional rider Not available Not available Excess Charges Home Health Care Plan pays f 40 visits (up Plan pays f 40 Plan pays f 40 to 365 with optional rider) visits (up to 365 visits (up to 365 with optional rider) with optional rider) Feign Travel Optional rider Not available Not available Emergency Medical Care (up to plan limits) Out-of-Pocket Limits Value-Added Perks Including SilverSneakers Fitness Program, Discounts on Eye Care, Eyewear, and Hearing Aids** Additional Preventive Care Not available Not available (see p. 4) * IMPORTANT: This chart provides a basic overview. Limits may apply. Please see plan summaries on the following pages f details. If there is ever a discrepancy between the policy and this brochure, the policy has final authity. ** Fitness program, vision and hearing discount programs are not part of the insurance policy and are offered at no additional charge. SilverSneakers is a registered trademark of Healthways, Inc. 1 Based on enrollment data submitted to the National Association of Insurance Commissioners, Requires purchase of optional 100% Part A and B deductible riders and Part B excess charges rider. 8

9 Outline of Supplement Insurance Companion Standard Plan Supplement Part A Hospital Services Your 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 f 60 days in a row. SERVICES Hospitalization Semiprivate room and board, general nursing, and miscellaneous hospital services and supplies. Skilled Nursing Facility Care You must meet s requirements, including having been in a hospital f at least 3 days and entered a approved facility within 30 days after leaving the hospital. PER BENEFIT PERIOD when MEDICARE PAYS First 60 days All but the $1,260 deductible THIS POLICY PAYS Part A 100% Rider Part A 50% Rider **** $630 61st to 90th days All but $315 per day $315 a day 91st day and after while using 60 lifetime reserve days All but $630 per day $630 a day Once lifetime reserve days are used: Additional 365 days Beyond the additional 365 days First 20 days 100% of eligible expenses 3 100% All approved 21st through All but $ per Up to $ a day 100th day day 101st day and after 100% you pay $1,260 deductible The WPS Companion also provides benefits f certain skilled nursing care and services that don t qualify f benefits. We ll pay benefits at the maximum daily rate established f the State of Wisconsin Medical Assistance Program, up to an additional 30 days f each confinement. You may request a policy f me details. Inpatient Psychiatric Care Inpatient psychiatric care in a participating psychiatric hospital. Blood Hospice Care Available as long as your doct certifies you are terminally ill and you elect to receive these services. First 3 pints Additional 190 days per lifetime 100% All but very limited coinsurance f outpatient drugs and inpatient respite care An additional 175 days per lifetime First 3 pints copayment/ coinsurance Standard Plan Summary Expenses beyond 365 days per lifetime This outline of coverage does not give all the details of coverage. Contact your local Social Security office consult the & You handbook f me details. *** This is an optional rider. You may purchase this benefit by checking the box on the application and paying the premium. **** This optional rider may reduce your premium when you pay 50% of Part A deductible. 3 NOTICE: When your Part A hospital benefits are exhausted, the insurer stands in the place of and will pay whatever amount would have paid as provided in the policy s Ce Benefits. *** 9

10 Standard Plan Summary Outline of Supplement Insurance Companion Standard Plan (continued) Part B part b benefits Medical Expenses Eligible expense f physician s services, inpatient and outpatient medical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. PER CALENDAR Year First $147 of -approved 1 Remainder of -approved when MEDICARE PAYS THIS POLICY PAYS Optional Part B Deductible Rider** Generally 80% Generally 20% Optional Part B Copayment Coinsurance rider* Optional Part B Excess Charges Rider** you pay $147 Blood First 3 pints All costs Next $147 of -approved 1 Optional Part B $147 Deductible Rider** Remainder of 80% 20% -approved Clinical Labaty Services Tests f diagnostic services. 100% Home Health Care 100% of charges f visits considered medically necessary by 40 visits Optional Additional Home Health Care Rider** Charges exceeding eligible charges No me than $20 per office visit and $50 per emergency room visit All expenses beyond 40 visits per year All expenses beyond 365 visits per year The dollar benefits shown are based on the payable by f They will change in future years as benefits are changed. * This is an optional rider that may decrease your premium when you pay copayments f medical and emergency room visits. 1 Once you have been billed $147 of -approved f covered services, your Part B Deductible will have been met f the calendar year. 10

11 Feign Travel Emergency Medical Care Benefits Standard Plan Summary Services when MEDICARE PAYS THIS POLICY PAYS you pay Feign Travel Emergency Medical Care This benefit rider can be added at any time without answering medical questions. See page 17 f details. Optional Feign Travel Emergency Rider** All charges while traveling outside the U.S. $250 deductible and 20% of emergency medical charges that begin in the first 60 days of your trip up to the $50,000 lifetime maximum Other Wisconsin-Mandated Benefits 2 Services when MEDICARE PAYS THIS POLICY PAYS you pay Kidney Transplants Dialysis Treatments Kidney Disease Care Diabetic Equipment Certain Diabetic Supplies Diabetes Self-Management Education Programs Chiropractic Care Breast Reconstruction after a Mastectomy Hospital, Ambulaty Surgery Center, and Anesthesia Charges f Dental Care (limited to specific conditions and circumstances) 80% of -eligible charges (after Part B deductible) 20% of eligible charges (after Part B deductible) Optional Part B Excess Charges Rider** Charges exceeding 20% of the eligible charges (Plus $147 if you have not chosen the Part B Deductible Rider) Wisconsin-mandated benefits may apply f services denied by. Mandated benefits f kidney transplants, dialysis treatments, and kidney disease care are subject to a $30,000 maximum per calendar year. All other benefits are payable at 100% of usual, customary, and reasonable charges. See page 26 f me infmation. Preventive Health Care Benefits covers services that are medically necessary as well as -covered routine services (below). Services when MEDICARE PAYS THIS POLICY PAYS you pay Routine Eye Exams and Eye Refractions Routine Hearing Exams Other Preventive Services not covered 100% by Preventive Services (Preventive services rated A B by the U.S. Preventive Services Task Fce. Visit f complete list of covered services.) Other immunizations not covered by Up to $1,000 per calendar year 100% of the eligible charges (no Part B deductible) Optional Part B Excess Charges Rider** Up to $100 per calendar year Charges exceeding $1,000 per calendar year Charges exceeding -eligible charges Charges exceeding $100 per calendar year ** This is an optional rider. You may purchase this benefit by checking the box on the application and paying the premium. 2 These benefits are required under Wisconsin law and are payable under the policy when the services are not covered by. When services are covered by Part B, Companion benefits will also apply. 11

12 Outline of Supplement Coverage 25% Cost-Sharing Plan You will pay one quarter the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2,470 each calendar year. The that count toward your annual limit are noted with diamonds ( ) in the chart below. Once you reach the annual limit, the policy pays 100% of your copayment and coinsurance f the rest of the calendar year. However, the annual out-of-pocket limit does NOT include charges from your provider that exceed -approved (these are called Excess Charges ). You will be responsible f paying this difference in the amount charged by your provider and the amount paid by f the item service. Cost-Sharing Plan Part A Hospital Services Per Benefit Period services Hospitalization Semiprivate room and board, general nursing, and miscellaneous hospital services and supplies. Skilled Nursing Facility Care You must meet s requirements, including having been in a hospital f at least 3 days and entered a approved facility within 30 days after leaving the hospital. Inpatient Psychiatric Care Inpatient psychiatric care in a participating psychiatric hospital. PER benefit period when MEDICARE PAYS THIS POLICY PAYS First 60 days All but $1,260 $945 (75% of Part A deductible) you pay $315 (25% of Part A deductible) 61st to 90th day All but $315 per day $315 per day 91st day and after All but $630 per day $630 per day while using 60 lifetime reserve days Once lifetime 100% eligible reserve days are used: Additional 365 days expenses 1 Beyond the additional 365 days 100% First 20 days All approved 21st through All but $ Up to $ Up to $ th day per day per day per day 101st day and after All costs 190 days per lifetime 175 days per lifetime 25% Cost-Sharing Plan Summary 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 f 60 days in a row. Expenses beyond 365 days per lifetime Blood First 3 pints 75% 25% Additional 100% Hospice Care Available as long as your doct certifies you are terminally ill Generally, most -eligible expenses f 75% of copayments/ 25% of copayments/ and you elect to receive these services. outpatient drugs and coinsurance inpatient respite care coinsurance 1 NOTICE: When your Part A hospital benefits are exhausted, the insurer stands in the place of and will pay whatever amount would have paid as provided in the policy s Ce Benefits. 12

13 Outline of Supplement Coverage 25% Cost-Sharing Plan (continued) Cost-Sharing Plan Part B Benefits part b benefits Medical Expenses Eligible expense f physician s services, inpatient and outpatient medical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. PER calendar year First $147 of approved 2 Preventive Benefits f covered services when MEDICARE PAYS THIS POLICY PAYS you pay $147 (Part B Deductible) Generally 75% me of approved Remainder of -approved All costs above approved Remainder of Generally 80% Generally 15% Generally 5% approved Blood First 3 pints 75% 25% Clinical Labaty Services Tests f diagnostic services. Home Health Care Next $147 of -approved 2 Remainder of approved $147 (Part B Deductible) Generally 80% Generally 15% Generally 5% 100% 100% of charges f visits considered medically necessary by 25% Cost-Sharing Plan Summary 40 visits Optional Additional Home Health Care Rider* Beyond 40 visits per calendar year beyond 365 visits This outline of coverage does not give all the details of coverage. Contact your local Social Security Office consult & You f me details. The dollar benefits shown are based on the payable by f They will change in future years as benefits are changed. 2 Once you have been billed $147 of -approved f covered services (which are noted with an asterisk), your Part B Deductible will have been met f the calendar year. * This is an optional rider. You may purchase this benefit by checking the box on the application and paying the premium. 13

14 14 Outline of Supplement Coverage 50% Cost-Sharing Plan You will pay one half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $4,940 each calendar year. The that count toward your annual limit are noted with diamonds ( ) in the chart below. Once you reach the annual limit, the policy pays 100% of your copayment and coinsurance f the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed approved (these are called Excess Charges ). You will be responsible f paying this difference in the amount charged by your provider and the amount paid by f the item service. Cost-Sharing Plan Part A Hospital Services Per Benefit Period services Hospitalization Semiprivate room and board, general nursing, and miscellaneous hospital services and supplies. Skilled Nursing Facility Care You must meet s requirements, including having been in a hospital f at least 3 days and entered a approved facility within 30 days after leaving the hospital. Inpatient Psychiatric Care Inpatient psychiatric care in a participating psychiatric hospital. PER benefit period when MEDICARE PAYS First 60 days All but the $1,260 deductible THIS POLICY PAYS $630 (50% of Part A deductible) you pay $630 (50% of Part A deductible) 61st to 90th day All but $315 per day $315 per day 91st day and after All but $630 per day $630 per day while using 60 lifetime reserve days Once lifetime reserve 100% eligible days are used: Additional 365 days expenses 1 Beyond the additional 365 days 100% First 20 days All approved 21st through All but $ Up to $78.75 Up to $ th day per day per day per day 101st day and after All costs 190 days per lifetime 175 days per lifetime Blood First 3 pints 50% of coinsurance copayments Hospice Care Available as long as your doct certifies you are terminally ill and you elect to receive these services. 50% Cost-Sharing Plan Summary 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 f 60 days in a row. Expenses beyond 365 days per lifetime 50% of coinsurance copayments Additional 100% Generally, most 50% of 50% of eligible expenses f outpatient copayments/ copayments/ drugs and coinsurance coinsurance inpatient respite care 1 NOTICE: When your Part A hospital benefits are exhausted, the insurer stands in the place of and will pay whatever amount would have paid as provided in the policy s Ce Benefits.

15 50% Cost-Sharing Plan Summary Outline of Supplement Coverage 50% Cost-Sharing Plan (continued) Cost-Sharing Plan Part B Benefits part b benefits Medical Expenses Eligible expense f physician s services, inpatient and outpatient medical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. PER calendar year First $147 of -approved 2 Preventive Benefits f covered services Remainder of -approved when MEDICARE PAYS THIS POLICY PAYS This outline of coverage does not give all the details of coverage. Contact your local Social Security Office consult & You f me details. The dollar benefits shown are based on the payable by f They will change in future years as benefits are changed. you pay $147 (Part B Deductible) Generally 75% me of approved Remainder of -approved All costs above approved Generally 80% Generally 10% Generally 10% Blood First 3 pints 50% 50% Next $147 of -approved 2 $147 (Part B Deductible) Clinical Labaty Services Tests f diagnostic services. Home Health Care Remainder of -approved Generally 80% Generally 10% Generally 10% 100% 100% of charges f visits considered medically necessary by 40 visits Optional Additional Home Health Care Rider* Beyond 40 visits per calendar year beyond 365 visits 2 Once you have been billed $147 of -approved f covered services (which are noted with an asterisk), your Part B Deductible will have been met f the calendar year. * This is an optional rider. You may purchase this benefit by checking the box on the application and paying the premium. 15

16 How to Calculate Your Rates WPS Companion Standard Plan Follow the steps below (and use the Premium Calculation Wksheet at right) to choose your base coverage, add any optional benefit riders you desire, and calculate your rate crectly. Do not simply add up the numbers across every column of the chart. Sample rate chart: Current Age A B choose one base plan Companion Base Plan (1) Companion Base Plan (2) with Copayment Coinsurance Rider Supplement Standard Plan C OPTIONAL RIDERS ADD ANY OR ALL OF THE FOLLOWING RIDERS TO YOUR CHOSEN BASE PLAN Option 1: Part B Deductible (Available only with Base Plan 1) = $12.25 Option 2: Additional Home Health Care = $2.00 Option 3: Feign Travel = $1.50 Option 4: Part A Deductible Coverage (Choose 50% 100%) Option 5: Part B Excess Age 50% 100% Charges 65 $xxx.xx $xxx.xx 65 $xxx.xx $xxx.xx $xxx.xx 66 $xxx.xx $xxx.xx 66 $xxx.xx $xxx.xx $xxx.xx STEP 1: Choose a Base Plan. Determine whether you reside in Area 1 (pages 18 19) Area 2 (pages 20 21) based on your ZIP code. Decide whether you wish to pay your premium monthly (pages 18 and 20) annually (pages 19 and 21). Then choose either Base Plan 1 (see column marked A) OR Base Plan 2 (see column marked B) with Copayment Coinsurance Rider. STEP 2: Choose optional riders if desired. In the wld of supplements, a rider is any plan option that adds coverage to the basic plan. See the area labeled C in the sample rate chart above. STEP 3: Remember to calculate your 5% Household Discount* if both you and a second member of your household are enrolled in a current WPS supplement plan. To calculate, multiply your final rate by * A household is defined as two me individuals who reside together in the same dwelling. Dwelling is defined as a single home, condominium unit, apartment unit within an apartment complex. Questions? We re here to help! Please talk with your agent WPS salesperson if you have any questions if you would like assistance completing your Premium Calculation Wksheet. 16

17 Premium Calculation Wksheet WPS Companion Base Plan (1) $ WPS Companion Base Plan (2) plus Part B Copayment Coinsurance Rider If you select this coverage, after you pay the Part B deductible, you pay a $20 copayment f office visits and up to a $50 copayment f emergency room visits, pay the Part B Coinsurance, whichever is less. OPTIONAL BENEFITS FOR MEDICARE SUPPLEMENT POLICY Each of these riders may be purchased separately. $ $ $ $ $ Option 1: Part B Deductible If you select this coverage, we ll pay your Part B deductible of $147 each calendar year. This coverage can only be selected if you chose the WPS Companion Standard Base Plan 1. Option 2: Additional Home Health Care If you select this coverage, we ll pay benefits f an additional 325 home health care visits each calendar year, up to a total of 365 visits per year, including those covered by. Option 3: Feign Travel Emergency Rider If you select this coverage, we ll pay 80% of expenses associated with emergency medical care you receive outside the U.S. that begins in the first 60 days of a trip, after you satisfy a deductible of $250, up to a lifetime maximum benefit of $50,000. Option 4: 50% Part A Deductible If you select this coverage, we ll pay 50% of your Part A deductible of $1,260 during the first 60 days of a confinement. Part A Deductible If you select this coverage, we ll pay 100% of your Part A deductible of $1,260 during the first 60 days of a confinement. Option 5: Part B Excess Charges If you select this coverage, we ll pay the difference between what approves f payment and the amount charged by the provider, if your provider does not accept assignment. The difference shall be no me than the actual charge the limited charge allowed by, whichever is less. $ Total f Base Policy and Selected Optional Benefits In addition to this Outline of Coverage, WPS Health Insurance will send an annual notice to you 30 days pri to the effective date of changes which will describe these changes and the changes in your supplement coverage. See pages 12 through 16 f applicable discounts and additional infmation on calculating rates. 17

18 18 Monthly Premium Rates Standard Plan Effective March 1, 2015 AREA 1 (The Milwaukee area and southeastern Wisconsin) Rates f applicants living in Area 1, including the following ZIP codes: 530 : 02, 04, 05, 07, 08, 12, 17, 18, 21, 22, 24, 25, 27-30, 33, 37, 40, 41, 45, 46, 51-56, 58, 60, 64, 66-69, 71, 72, 74, 76, 77, 80, 86, 87, 89, 90, 92, : 01-13, 16-19, 22-24, 26, 27, 29-36, 39-46, 49-55, 58-75, 77, 79-83, 85-89, 92-94, and 534 : All ZIP codes, and all out-of-state ZIP codes OPTIONAL RIDERS choose one base plan ADD ANY OR ALL OF THE FOLLOWING RIDERS TO YOUR CHOSEN BASE PLAN Current Age Companion Base Plan (1) Companion Base Plan (2) with Copayment Coinsurance Rider Option 1: Part B Deductible (Available only with Base Plan 1) = $12.25 Option 2: Additional Home Health Care = $2.00 Option 3: Feign Travel = $1.50 Option 4: Part A Deductible Coverage (Choose 50% 100%) Option 5: Part B Excess Charges Age 50% 100% 65 $ $ $13.62 $27.78 $ $ $ $14.50 $29.55 $ $ $ $15.36 $31.33 $ $ $ $16.24 $33.12 $ $ $ $17.11 $34.88 $ $ $ $17.96 $36.67 $ $ $ $18.84 $38.46 $ $ $ $19.72 $40.24 $ $ $ $20.58 $42.00 $ $ $ $21.45 $43.78 $ $ $ $22.33 $45.55 $ $ $ $23.19 $47.34 $ $ $ $24.07 $49.10 $ $ $ $24.93 $50.89 $ $ $ $25.80 $52.66 $ $ $ $26.69 $54.45 $ $ $ $27.57 $56.23 $ $ $ $28.42 $58.00 $ $ $ $29.30 $59.77 $ $ $ $30.16 $61.56 $ $ $ $31.02 $63.35 $11.65 Under 65 $ $ Under 65 $31.02 $63.35 $11.65 f help calculating rates, see pages Rates include a discount f using one of our automated payment options (payment by debit card, credit card, automated bank draft, annual billing by mail). If you prefer to receive a bill in the mail on a monthly, quarterly, semiannual basis, the cost will be $5.00 higher f each bill. WPS offers a 5% household discount when both you and a second member of your household are enrolled in a current WPS supplement plan. To calculate, multiply your final rate by Note: These rates also apply if you move outside Wisconsin. If, in the future, you permanently relocate to another state, Area 1 rates will apply. If you relocate to another Wisconsin ZIP code, Area 1 2 rates will apply as appropriate.

19 Annual Premium Rates Standard Plan Effective March 1, 2015 AREA 1 (The Milwaukee area and southeastern Wisconsin) Rates f applicants living in Area 1, including the following ZIP codes: 530 : 02, 04, 05, 07, 08, 12, 17, 18, 21, 22, 24, 25, 27-30, 33, 37, 40, 41, 45, 46, 51-56, 58, 60, 64, 66-69, 71, 72, 74, 76, 77, 80, 86, 87, 89, 90, 92, : 01-13, 16-19, 22-24, 26, 27, 29-36, 39-46, 49-55, 58-75, 77, 79-83, 85-89, 92-94, and 534 : All ZIP codes, and all out-of-state ZIP codes OPTIONAL RIDERS choose one base plan ADD ANY OR ALL OF THE FOLLOWING RIDERS TO YOUR CHOSEN BASE PLAN Current Age Companion Base Plan (1) Companion Base Plan (2) with Copayment Coinsurance Rider Option 1: Part B Deductible (Available only with Base Plan 1) = $ Option 2: Additional Home Health Care = $24.00 Option 3: Feign Travel 4 = $18.00 Option 4: Part A Deductible Coverage (Choose 50% 100%) Age 50% 100% Option 5: Part B Excess Charges 65 $1, $1, $ $ $ $1, $1, $ $ $ $1, $1, $ $ $ $1, $1, $ $ $ $2, $1, $ $ $ $2, $1, $ $ $ $2, $1, $ $ $ $2, $1, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $3, $2, $ $ $ $3, $2, $ $ $ $3, $2, $ $ $ $3, $2, $ $ $ $3, $2, $ $ $ $3, $2, $ $ $ Under 65 $3, $3, Under 65 $ $ $ TO CALCULATE RATES: Quarterly: Divide annual rate by four Semiannually: Divide annual rate by two Rates include a discount f using one of our automated payment options (payment by debit card, credit card, automated bank draft, annual billing by mail). Note: These rates also apply if you move outside Wisconsin. If, in the future, you permanently relocate to another state, Area 1 rates will apply. If you relocate to another Wisconsin ZIP code, Area 1 2 rates will apply as appropriate. 4 The Feign Travel Emergency Medical Care rider can be added at any time in the future without answering medical questions. However, if you add this rider after your iginal effective date, a $25 administration fee will apply. 19

20 20 Monthly Premium Rates Standard Plan Effective March 1, 2015 AREA 2 (All other Wisconsin locations not included in Area 1) Rates f applicants living in Area 2, including the following ZIP codes: 530 : 01, 03, 06, 09-11, 13-16, 19, 20, 23, 26, 31, 32, 34-36, 38, 39, 42-44, 47-50, 57, 59, 61-63, 65, 70, 73, 75, 78, 79, 81-85, 88, 91, 93, 94, 98, : 14, 15, 20, 21, 25, 28, 37, 38, 47, 48, 56, 57, 76, 78, 84, 90, 91, thru 549 : All ZIP codes OPTIONAL RIDERS choose one base plan ADD ANY OR ALL OF THE FOLLOWING RIDERS TO YOUR CHOSEN BASE PLAN Current Age Companion Base Plan (1) Companion Base Plan (2) with Copayment Coinsurance Rider Option 1: Part B Deductible (Available only with Base Plan 1) = $12.25 Option 2: Additional Home Health Care = $2.00 Option 3: Feign Travel = $1.50 Option 4: Part A Deductible Coverage (Choose 50% 100%) Option 5: Part B Excess Charges Age 50% 100% 65 $ $ $12.38 $25.25 $ $ $ $13.18 $26.86 $ $ $ $13.96 $28.48 $ $ $ $14.76 $30.11 $ $ $ $15.55 $31.71 $ $ $ $16.33 $33.34 $ $ $ $17.13 $34.96 $ $ $ $17.93 $36.58 $ $ $ $18.71 $38.18 $ $ $ $19.50 $39.80 $ $ $ $20.30 $41.41 $ $ $ $21.08 $43.04 $ $ $ $21.88 $44.64 $ $ $ $22.66 $46.26 $ $ $ $23.45 $47.87 $ $ $ $24.26 $49.50 $ $ $ $25.06 $51.12 $ $ $ $25.84 $52.73 $ $ $ $26.64 $54.34 $ $ $ $27.42 $55.96 $ $ $ $28.20 $57.59 $10.59 Under 65 $ $ Under 65 $28.20 $57.59 $10.59 f help calculating rates, see pages Rates include a discount f using one of our automated payment options (payment by debit card, credit card, automated bank draft, annual billing by mail). If you prefer to receive a bill in the mail on a monthly, quarterly, semiannual basis, the cost will be $5.00 higher f each bill. WPS offers a 5% household discount when both you and a second member of your household are enrolled in a current WPS supplement plan. To calculate, multiply your final rate by Note: These rates also apply if you move outside Wisconsin. If, in the future, you permanently relocate to another state, Area 1 rates will apply. If you relocate to another Wisconsin ZIP code, Area 1 2 rates will apply as appropriate.

21 Annual Premium Rates Standard Plan Effective March 1, 2015 AREA 2 (All other Wisconsin locations not included in Area 1) Rates f applicants living in Area 2, including the following ZIP codes: 530 : 01, 03, 06, 09-11, 13-16, 19, 20, 23, 26, 31, 32, 34-36, 38, 39, 42-44, 47-50, 57, 59, 61-63, 65, 70, 73, 75, 78, 79, 81-85, 88, 91, 93, 94, 98, : 14, 15, 20, 21, 25, 28, 37, 38, 47, 48, 56, 57, 76, 78, 84, 90, 91, thru 549 : All ZIP codes OPTIONAL RIDERS choose one base plan ADD ANY OR ALL OF THE FOLLOWING RIDERS TO YOUR CHOSEN BASE PLAN Current Age Companion Base Plan (1) Companion Base Plan (2) with Copayment Coinsurance Rider Option 1: Part B Deductible (Available only with Base Plan 1) = $ Option 2: Additional Home Health Care = $24.00 Option 3: Feign Travel 4 = $18.00 Option 4: Part A Deductible Coverage (Choose 50% 100%) Option 5: Part B Excess Charges Age 50% 100% 65 $1, $1, $ $ $ $1, $1, $ $ $ $1, $1, $ $ $ $1, $1, $ $ $ $1, $1, $ $ $ $1, $1, $ $ $ $1, $1, $ $ $ $2, $1, $ $ $ $2, $1, $ $ $ $2, $1, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $2, $2, $ $ $ $3, $2, $ $ $ Under 65 $3, $2, Under 65 $ $ $ TO CALCULATE RATES: Quarterly: Divide annual rate by four Semiannually: Divide annual rate by two Rates include a discount f using one of our automated payment options (payment by debit card, credit card, automated bank draft, annual billing by mail). Note: These rates also apply if you move outside Wisconsin. If, in the future, you permanently relocate to another state, Area 1 rates will apply. If you relocate to another Wisconsin ZIP code, Area 1 2 rates will apply as appropriate. 4 The Feign Travel Emergency Medical Care rider can be added at any time in the future without answering medical questions. However, if you add this rider after your iginal effective date, a $25 administration fee will apply. 21

22 How to Calculate Your Rates Follow these steps (and use the Premium Calculation Wksheet below) to calculate your rate crectly. Do not simply add up the numbers across every column of the chart. Supplement Cost-Sharing Plans Sample rate chart: A B C STEP 1: Choose a Base Plan. choose one base plan OPTIONAL RIDER Determine whether you reside in Area 1 (page 23) Area 2 (page Add Home 24) based on your ZIP code. Decide Current 25% Cost- 50% Cost- Health Care Rider whether you wish to pay your Age Sharing Plan Sharing Plan if Desired premium monthly annually. Then choose either the 25% Cost $xxx.xx $xxx.xx $xxx.xx Sharing Plan (see column marked $xxx.xx $xxx.xx $xxx.xx A) OR the 50% Cost-Sharing Plan (see column marked B). STEP 2: Choose optional rider if so desired. In the wld of supplements, a rider is any plan option that adds coverage to the basic plan. Add the Home Health Care Rider if you would like coverage f additional home health care visits. See the area labeled C in the sample rate chart above. STEP 3: Remember to calculate your 5% Household Discount* if both you and a second member of your household are enrolled in a current WPS supplement plan. To calculate, multiply your final rate by Questions? We re here to help! Please talk with your agent WPS salesperson if you have any questions if you would like assistance completing your Premium Calculation Wksheet. *A household is defined as two me individuals who reside together in the same dwelling. Dwelling is defined as a single home, condominium unit, apartment unit within an apartment complex. Premium Calculation Wksheet $ Companion Cost-Sharing Base Plan 25% Cost-Sharing Plan 50% Cost-Sharing Plan OPTIONAL BENEFITS FOR MEDICARE SUPPLEMENT POLICY This rider may be purchased f additional coverage. $ Additional Home Health Care If you select this coverage, we ll pay benefits f an additional 325 home health care visits each calendar year, up to a total of 365 visits per year, including those covered by. $ Monthly Total f Cost-Sharing Policy and Selected Optional Benefit In addition to this Outline of Coverage, WPS Health Insurance will send an annual notice to you 30 days pri to the effective date of changes which will describe these changes and the changes in your supplement coverage. See page 16 f additional infmation on calculating rates. 22

23 Premium Rates Cost-Sharing Plans Effective March 1, 2015 (The Milwaukee area and Southeastern Wisconsin) Rates f applicants living in Area 1, including the following ZIP codes: 530 : 02, 04, 05, 07, 08, 12, 17, 18, 21, 22, 24, 25, 27-30, 33, 37, 40, 41, 45, 46, 51-56, 58, 60, 64, 66-69, 71, 72, 74, 76, 77, 80, 86, 87, 89, 90, 92, : 01-13, 16-19, 22-24, 26, 27, 29-36, 39-46, 49-55, 58-75, 77, 79-83, 85-89, 92-94, thru 534 : All ZIP codes AREA 1 Current Age 25% Cost- Sharing Plan 50% Cost- Sharing Plan Add Home Health Care Rider if Desired $99.06 $78.01 $ $ $87.32 $ $ $ $ $ $ $2.00 Under 65 $ $ $2.00 Current Age Monthly Premium choose one base plan Annual Premium choose one base plan 25% Cost- Sharing Plan 50% Cost- Sharing Plan OPTIONAL RIDER OPTIONAL RIDER Add Home Health Care Rider if Desired $1, $ $ $1, $1, $ $1, $1, $ $1, $1, $24.00 Under 65 $1, $1, $24.00 f help calculating rates, see the wksheet on page 22. Quarterly: Divide annual rate by four Semiannually: Divide annual rate by two Rates include a discount f using one of our automated payment options (payment by debit card, credit card, automated bank draft, annual billing by mail). If you prefer to receive a bill in the mail on a monthly, quarterly, semiannual basis, the cost will be $5.00 higher f each bill. Additional notes: These rates also apply if you move outside Wisconsin. If, in the future, you permanently relocate to another state, Area 1 rates will apply. If you relocate to another Wisconsin ZIP code, Area 1 2 rates will apply as appropriate. This brochure contains rates and plan infmation f coverage effective March 1, If you would like to enroll, please contact your agent WPS sales representative f the latest infmation. Household discount: WPS offers a 5% household discount when both you and a second member of your household (two me individuals who reside together in a single home, condominium unit, apartment unit within an apartment complex) are enrolled in a current WPS supplement plan. To calculate, multiply your final rate by

24 Premium Rates Cost-Sharing Plans Effective March 1, 2015 (All other Wisconsin locations not included in Area 1) Rates f applicants living in Area 2, including the following ZIP codes: 530 : 01, 03, 06, 09-11, 13-16, 19, 20, 23, 26, 31, 32, 34-36, 38, 39, 42-44, 47-50, 57, 59, 61-63, 65, 70, 73, 75, 78, 79, 81-85, 88, 91, 93, 94, 98, : 14, 15, 20, 21, 25, 28, 37, 38, 47, 48, 56, 57, 76, 78, 84, 90, 91, thru 549 : All ZIP codes AREA 2 Current Age 25% Cost- Sharing Plan 50% Cost- Sharing Plan Add Home Health Care Rider if Desired $90.05 $70.92 $ $ $79.38 $ $ $98.65 $ $ $ $2.00 Under 65 $ $ $2.00 Current Age Monthly Premium choose one base plan Annual Premium choose one base plan 25% Cost- Sharing Plan 50% Cost- Sharing Plan OPTIONAL RIDER OPTIONAL RIDER Add Home Health Care Rider if Desired $1, $ $ $1, $ $ $1, $1, $ $1, $1, $24.00 Under 65 $1, $1, $24.00 f help calculating rates, see the wksheet on page 22. Quarterly: Divide annual rate by four Semiannually: Divide annual rate by two Rates include a discount f using one of our automated payment options (payment by debit card, credit card, automated bank draft, annual billing by mail). If you prefer to receive a bill in the mail on a monthly, quarterly, semiannual basis, the cost will be $5.00 higher f each bill. Additional notes: These rates also apply if you move outside Wisconsin. If, in the future, you permanently relocate to another state, Area 1 rates will apply. If you relocate to another Wisconsin ZIP code, Area 1 2 rates will apply as appropriate. This brochure contains rates and plan infmation f coverage effective March 1, If you would like to enroll, please contact your agent WPS sales representative f the latest infmation. Household discount: WPS offers a 5% household discount when both you and a second member of your household (two me individuals who reside together in a single home, condominium unit, apartment unit within an apartment complex) are enrolled in a current WPS supplement plan. To calculate, multiply your final rate by

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