OAKLAND COUNTY MEDICARE SUPPLEMENTAL PLAN OVERVIEW OF BENEFITS

The Oakland County Medicare Supplemental/Retiree Plan is designed to provide levels of benefits after Medicare makes a primary payment. Benefits that are payable are subject to the terms and conditions of the plan.

Medicare Services and Limits Trustmark Health Benefits Coverage and Limits After Medicare Deductible Met

Hospital-Inpatient

Facility 100% of Medicare approved amount

Physician 100%

Surgery 100% of Medicare approved amount Emergency Room

Illness/Accidental Injury

Urgent Care

100% of Medicare approved amount, subject to $100 co-pay (co-pay waived if admitted or accidental injury)

Not Covered; Medicare may pay 80%

Allergy Testing and Injections 100% of Medicare approved amount

Ambulance 100% of Medicare approved amount Anesthesia 100% of Medicare approved amount Blood 100% of Medicare approved amount Cardiac Rehabilitation 100% of Medicare approved amount Chemotherapy 100% of Medicare approved amount Chiropractic Care

Office Visits, Spinal Manipulation, and Adjustments

X-rays and Modalities (hot packs, massage therapy, etc.)

Not Covered; Medicare may pay 80%

Not Covered unless approved by Medicare

Consultations Inpatient

Outpatient

100% of Medicare approved amount

Not Covered; Medicare may pay 80% Dialysis 100% of Medicare approved amount

Home Health Care (Up to 100 visits per calendar year)

100% of Medicare approved amount For purposes of determining this benefit, a visit by each nurse or

therapist and a visit by a home health aide of up to 4 hours constitutes one visit.

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Medicare Services and Limits Trustmark Coverage and Limits Hospice

Inpatient (30 days per lifetime)

Outpatient ($5,000 per lifetime)

100% of Medicare approved amount

100% of Medicare approved amount

Laboratory Testing 100% of Medicare approved amount Medical Equipment and Supplies 100% of Medicare approved amount

Mental Disorders and/or Substance Abuse Expenses

Inpatient

Outpatient therapy (excluding office visit)

100% of Medicare approved amount

100% of Medicare approved amount

Occupational Therapy 100% of Medicare approved amount

Office Visits Not Covered; Medicare may pay 80% Orthotics 100% of Medicare approved amount Physical Therapy

100% of Medicare approved amount

Pregnancy Related Expenses - Mother 100% of Medicare approved amount

Prescription Drugs (Navitus) Retail

Tier I Tier II Tier III

Mail Order Tier I

Tier II Tier III

34-day or 90-day supply$5

$20 $40

90-day supply$5

$20 $40

Prosthetic Devices 100% of Medicare approved amount Radiation Therapy 100% of Medicare approved amount

Skilled Nursing Facility - Inpatient (100 days per benefit period)

100% of Medicare approved amount

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Medicare Services and Limits Trustmark Coverage and Limits Speech Therapy ($1,900 per calendar year; Medicare may extend to $3,700 depending on Medical necessity)

100% of Medicare approved amount

Transplants 100% of Medicare approved amount Weight Management (Excluding office visits and weight loss programs)

100% of Medicare approved amount

X-rays 100% of Medicare approved amount

Preventive Care as defined by PPACA (Patient Protection Affordability Care Act)

Physical Examination (One visit per calendar year) 100%

Immunizations (Including administration)

Influenza Pneumococcal Hepatitis B Zosters Chickenpox

100%

Mammography (Age 40 and over each year for breast cancer screening)

100%

Cervical Cancer or Cervical Dysplasia Screening (One per calendar year)

100%

Prostate Cancer Screening Prostate Specific Antigen Test (PSA)

Digital Rectal Exam

100%

Colorectal Cancer Screening (Age 50 and over)

100%

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/18 – 12/31/18 Oakland County: Medicare Supplemental Plan Coverage for: Individual | Plan Type: Supplemental

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The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, see www.mycoresource.com and/or call 1-248-858-7592. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-248-858-7592 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible? $0 See the Common Medical Events chart below for your costs for services this plan covers.

Are there services covered before you meet your deductible?

Yes. Medicare approved expenses. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

Not Applicable. This plan does not have an out-of-pocket limit on your expenses.

What is not included in the out-of-pocket limit?

Not Applicable. This plan does not have an out-of-pocket limit on your expenses.

Will you pay less if you use a network provider?

Not Applicable. This plan does not use a provider network. You can receive covered services from any provider.

Do you need a referral to see a specialist?

No. You can see the specialist you choose without a referral.

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2 of 5[* For more information about limitations and exceptions, see the plan or policy document at www.mycoresource.com.]

Common Medical Event

Services You May Need What You Will Pay Limitations, Exceptions, & Other Important

Information

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness Not covered None.

Specialist visit Not covered None.

Preventive care/screening/immunization No charge

You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

If you have a test Diagnostic test (x-ray, blood work) No charge None.

Imaging (CT/PET scans, MRIs) No charge None.

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.navitus.com.

Generic drugs $5.00

Retail: 34-day to 90-day supply.

Mail order: 90-day supply.

Preferred brand drugs $20.00

Non-preferred brand drugs $40.00

Specialty drugs Same as coverage levels listed above

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) No charge None.

Physician/surgeon fees No charge None.

If you need immediate medical attention

Emergency room care $100.00 co-pay Co-pay waived if admitted or for accidental injury.

Emergency medical transportation No charge None.

Urgent care Not covered None.

If you have a hospital stay Facility fee (e.g., hospital room) No charge None.

Physician/surgeon fees No charge None.

If you need mental health, behavioral health, or substance abuse services

Outpatient services No charge Excludes office visits.

Inpatient services No charge None.

If you are pregnant

Office visits Not covered None.

Childbirth/delivery professional services No charge None.

Childbirth/delivery facility services No charge None.

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3 of 5[* For more information about limitations and exceptions, see the plan or policy document at www.mycoresource.com.]

Common Medical Event

Services You May Need What You Will Pay Limitations, Exceptions, & Other Important

Information

If you need help recovering or have other special health needs

Home health care No charge

No charge for Medicare approved amount.

Maximum: 100 visits per calendar year. Each visit by a nurse or therapist equals one visit. Each visit up to four hours equals one visit.

Rehabilitation services No charge $1,900 for physical therapy and speech therapy services combined. $1,900 for occupational therapy services.

Habilitation services Not covered None.

Skilled nursing care No charge 100 days per benefit period.

Durable medical equipment No charge None.

Hospice services No charge

No charge for Medicare approved amount.

Maximum: 30 days per lifetime for inpatient.

Maximum: $5,000 per lifetime for outpatient.

If your child needs dental or eye care

Children’s eye exam Not covered More information about vision coverage is available at www.e-nva.com.

Children’s glasses Not covered None.

Children’s dental check-up Not covered More information about dental coverage is available at www.deltadental.com.

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Acupuncture

Chiropractic care (except for x-rays,adjustments/manipulations, and modalitieswhen approved by Medicare)

Cosmetic surgery

Dental care (Adult)

Hearing aides

Infertility treatment

Long-term care

Non-emergency care when traveling outside the U.S.

Non-Medicare approved services

Office visits, other than those required by law

Routine eye care (Adult)

Routine foot care (unless approved by Medicare)

Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Bariatric surgery Private-duty nursing

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4 of 5[* For more information about limitations and exceptions, see the plan or policy document at www.mycoresource.com.]

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the Retirement Unit of the Human Resources Department at 1-248-858-7592.

Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-248-858-7592.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-248-858-7592.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-248-858-7592.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-248-858-7592.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

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The plan would be responsible for the other costs of these EXAMPLE covered services.

Peg is Having a Baby (9 months of in-network pre-

natal care and a hospital delivery)

Mia’s Simple Fracture (in-network emergency room

visit and follow up care)

Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a well-controlled condition)

The plan’s overall deductible $0 Specialist Not Covered Hospital (facility) [coinsurance] 0% Other [coinsurance] 0%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $12,800

In this example, Peg would pay:

Cost Sharing

Deductibles $0

Copayments $20

Coinsurance $0

What isn’t covered

Limits or exclusions $258

The total Peg would pay is $278

The plan’s overall deductible $0 Specialist Not Covered Hospital (facility) [coinsurance] 0% Other [coinsurance] 0%

This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

Total Example Cost $7,400

In this example, Joe would pay:

Cost Sharing

Deductibles $0

Copayments $415

Coinsurance $0

What isn’t covered

Limits or exclusions $1,120

The total Joe would pay is $1,535

The plan’s overall deductible $0 Specialist Not Covered Hospital (facility) [coinsurance] 0% Other [coinsurance] 0%

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost $1,900

In this example, Mia would pay:

Cost Sharing

Deductibles $0

Copayments $0

Coinsurance $0

What isn’t covered

Limits or exclusions $293

The total Mia would pay is $293

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

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NONDISCRIMINATION AND ACCESSIBILITY REQUIREMENTS

Discrimination is Against the Law

Oakland County complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Oakland County does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Oakland County:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters Information written in other languages

If you need these services, contact Julie Fisher, the Civil Rights Coordinator.

If you believe that Oakland County has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Julie Fisher, Labor Relations Specialist, 2100 Pontiac Lake Road, Waterford Twp., MI 48328, (248) 858-0539, (TTY: 248-858-0530), Fisherj@oakgov.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Julie Fisher is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-999-0114 (TTY: 1-248-858-0530).

-248-1)رقم هاتف الصم والبكم: 0114-999-800-1ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 858-0530.)

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-999-0114（TTY：1-248-858-0530）

ܢ ܿ ܢ ܝܠ ܼ ܬܢ ܬ ܢ ܩܕ ܼܿ ܢ ܿ ܼܝ ܢ ܵ ܝܢ، ܝܬܨ

ܝܵ ܼ ܢ ܝܢ ܫܠ ܿܵ ܢ ܿ ܢ ܡܙܼ ܬܢ ܼܬ ܟ ܢܵ ܬ ܿ ܚܬܬ ܼܼܵܙ: ܿ ܢܵ ܠܿܫܢܝܢ ܿܘܢܬ ܢܼܡ ܵܩܐܝܠܬ 0114-999-800-1 ܵܿܒܡܢܢ

(TTY: 1-248-858-0530) ܐ ܹܢܢ ܵ ܵܝܬܪܬ ܡܢܬ ܵ ܚ

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-999-0114 (TTY: 1-248-858-0530).

KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-800-999-0114 (TTY: 1-248-858-0530).

https://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-999-0114 (TTY: 1-

248-858-0530)번으로 전화해 주십시오.

ল�য্ করনঃ যিদ আযিন বাাংলা, কথা বললত িাল রন, তালেল য নঃখরচায় ভাষা সোয়তা যিলরষবা উিল� আআছ। আ ফান করন ১ 1-800-999-0114 (TTY: 1-248-858-0530).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-999-0114 (TTY: 1-248-858-0530).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-999-0114 (TTY: 1-248-858-0530).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-999-0114 (TTY: 1-248-858-0530).

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-999-0114（TTY: 1-248-

858-0530）まで、お電話にてご連絡ください。

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-999-0114 (телетайп: 1-248-858-0530).

OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-800-999-0114 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-248-858-0530).

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-999-0114 (TTY: 1-248-858-0530).

Prescription Drug Coverage and Medicare

NOTICE OF CREDITABLE COVERAGE Important Notice from Oakland County

About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Oakland County and about your options under Medicare’s prescription drug coverage.

This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone withMedicare. You can get this coverage if you join a Medicare Prescription Drug Plan or joina Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage.All Medicare drug plans provide at least a standard level of coverage set by Medicare.Some plans may also offer more coverage for a higher monthly premium.

2. Oakland County has determined that the prescription drug coverage offered byOakland County is, on average for all plan participants, expected to pay out as much asstandard Medicare prescription drug coverage pays and is therefore consideredCreditable Coverage. Because your existing coverage is Creditable Coverage, you cankeep this coverage and not pay a higher premium (a penalty) if you later decide to join aMedicare drug plan.

WHEN CAN YOU JOIN A MEDICARE DRUG PLAN?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from November 15th through December 31st. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

WHAT HAPPENS TO YOUR CURRENT OAKLAND COUNTY COVERAGE IF YOU DECIDE TO JOIN A MEDICARE DRUG PLAN?

If you decide to join a Medicare drug plan, your current Oakland County coverage will be affected. Your current coverage through Oakland County pays for health expenses, in addition to prescription drugs, and you will no longer be eligible to receive all of your prescription drug benefits if you choose to enroll in a Medicare prescription drug plan. Therefore, if you enroll in a Medicare prescription drug plan, be aware that you may not be able to get your Oakland County coverage back later.

Medicare Drug Coverage Continued –

WHEN WILL YOU PAY A HIGHER PREMIUM (PENALTY) TO JOIN A MEDICARE DRUG PLAN?

You should also know that if you drop or lose your current coverage with Oakland County and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join.

For More Information about this Notice or Your Current Prescription Drug Coverage

Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Oakland County changes. You may also request a copy of this notice at any time.

For More Information about your Options Under Medicare Prescription Drug Coverage

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

• Visit www.medicare.gov

• Call your State Health Insurance Assistance Program (see the inside back cover of yourcopy of

the “Medicare & You” handbook for their telephone number) for personalized help

• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov , or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Date: November, 2017 Name of Entity/Sender: Oakland County

Contact—Position/Office: HR Retirement Unit Address: 2100 Pontiac Lake Rd, Waterford, MI 48328

Phone Number: 248-858-7592 Email: https://www.oakgov.com/hr/retirement

Coresource 2019 Overview of Benefits CoreSource Medicare sectionCoresource 2019 Overview of Benefits CoreSource Medicare section2018 Medicare Supplement_SBCcredible coverage letterPrescription Drug Coverage and Medicare Credible Coverage