Two women in retirement walking outside for exercise

BENEFITS

Medicare Supplement

PROVIDER

The Hartford/Mercer
Group Number AGP 6003
(for residents of KS, MD, MT, NY & OR)
Group Number AGP 6040
(for residents of all other states)
Telephone 1-800-728-1378

Through a partnership with The Hartford and Mercer, a supplemental retiree health plan is available to eligible WoodmenLife retirees and their spouses who are also eligible for Medicare. The plan is a Medicare Supplement Plan F, which pays 100% of the Medicare-approved charges on almost all medical services after Medicare pays. This plan will only supplement claims for those enrolled in original Medicare. A schedule of all the benefits will be provided by Mercer.

Eligible dependents include:

  • Legally married spouse, according to federal law;

  • Married or unmarried children up to age 26, including stepchildren, legally adopted grandchildren, and children under court-appointed guardianship

  • Disabled children

PREMIUM CHART - MEDICARE SUPPLEMENT

Monthly Premiums

Retiree Years of Service

Retiree (Medicare-Eligible)

Spouse (Medicare-Eligible)

30 years and over

$100.58

$259.23

20 to 29 years

$180.16

$259.23

5 to 19 years

$259.23

$259.23

Please remember the total monthly retiree premium you pay is determined by adding the retiree, spouse and children premium amounts together, which may include Medicare premiums.

Services

Medicare Pays

Hartford Plan Pays

You Pay

Hospital Confinement Benefit1

Semi-private room and board, general nursing and miscellaneous services and supplies:

Semi-private room and board, general nursing and miscellaneous services and supplies:

All but $1,484

$1,484

$0

61st through 90th day

All but $371 per day

$371 per day

$0

91st through 150th day (60-day Lifetime Reserve Period)

All but $742 per day

$742 per day

$0

Once Lifetime Reserve days are used (or would have ended if used) additional 365 days of confinement per person per life-time

$0

100%

$0

Beyond the Additional 365 days

$0

$0

All costs

Skilled Nursing Facility Care


Semi-private room and board, skilled nursing and rehabilitative services, and other services and supplies. You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital:

First 20 days

All approved amounts

$0

$0

21st through 100th day

All but $185.50 per day

Up to $185.50 per day

$0

101st through 365th day

$0

$0

All costs

Hospice Care


Pain relief, symptom management and support services for terminally ill:

As long as Physician certifies the need

All costs, but limited to costs for outpatient drug and inpatient respite care

Co-insurance charges for inpatient respite care, drugs and biologicals approved by Medicare

All other charges

Blood Deductible


Hospital Confinement and Outpatient Medical Expenses when furnished by a hospital or skilled nursing facility during a covered stay:

First three pints

$0

$100

$0

Additional amounts

$100

$0

$0

Outpatient 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:

Medicare Part B Deductible
First $203 of Medicare-approved amounts

$0

$203

$0

Remainder of Medicare-approved amounts

Generally 80%

$20

$0

Part B Excess Charges cover the difference between the actual Medicare Part B charge as billed and the Medicare-approved Part B charge.

$0

100%

$0

Outpatient 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:

Medicare Part B Deductible
First $185 of Medicare-approved amounts

$0

$185

$0

Remainder of Medicare-approved amounts

Generally 80%

$20

$0

Part B Excess Charges cover the difference between the actual Medicare Part B charge as billed and the Medicare-approved Part B charge.

$0

100%

$0

PayPreventive Medical Care & Cancer Screenings2

Coverage for expenses incurred by a covered person for physical exams, preventive screening tests and services, cancer screenings, and any other tests or preventive measures determined to be appropriate by the attending Physician. Refer to your “Medicare and You” handbook for more information on Preventive services.

“Welcome to Medicare” Physical Exam-within first 12 months of Part B enrollment

$100

$0

$0

Annual Wellness Visit

100%

$0

$0

Vaccinations

100%

$0

$0

Preventive Care Cancer Screening Benefits

generally 100% for most preventative screenings

100%

$0

Foreign Travel Emergency


Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States:

First $250 each Calendar Year

$0

$0

$250 deductible

Remainder of charges

$0

80% of (to a lifetime maximum of $50,000)

20% of expenses incurred (to a lifetime maximum of $50,000, 100% thereafter)

ScriptSave® Benefit

Members of the WoodmenLife family are eligible for a prescription drug savings card. This discount, administered by ScriptSave®, provides you with discounts at participating pharmacies. To request a card or to inquire about this benefit, call ScriptSave® Cardholder Services at 1-800-700-3957. You can also enroll online by visiting scriptsave.com and referring to Group #394A.

Coordination of Benefits

You cannot use the WoodmenLife prescription drug savings card in conjunction with other prescription drug programs. If you reach your annual maximum benefit, ask your pharmacist which option will provide you with the greatest savings. (The ScriptSave® discount is NOT creditable coverage.)

Disclosures

Medicare amounts as of Jan. 1, 2019.

  1. 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.

  2. If any of the cancer screening tests are not covered by Medicare, the plan will pay the usual and customary charges incurred.

The summary of program benefits described herein is for illustrative purposes only. In case of differences or errors, the Group Policy governs.

Customer Service: 1-800-225-3108
Monday – Thursday 7:00 a.m. to 5:00 p.m.
Friday 7:00 a.m. to 12:00 p.m. (Central Time)

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Omaha, Nebraska

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