Attachment 13 - GIC Member Handbook Medicare Example.pdf

Medicare Extension Plan Member Handbook

For Medicare retirees

1082241MAMENWLP Rev. 09/25 Effective July 1, 2026

Series 2

Welcome Medicare Extension plan members

Effective July 1, 2026–June 30, 2027

Introduction

Wellpoint Medicare Extension Plan Member Handbook (2026–2027)4

You are covered under the Wellpoint Medicare Extension plan The Medicare Extension plan supplements your Medicare benefits by providing you with comprehensive coverage, which includes hospital stays, surgery, emergency care, preventive care, outpatient services, and other medically necessary treatment. The plan covers services from any care provider, but benefits can be different depending on the service, and on the provider you use.

Keep in mind:

• Benefits can differ based on the service and the care provider.

• Not all services are covered.

• Services are covered only when they’re needed to take care of your health (medically necessary).

Your benefits are provided through the GIC

The Group Insurance Commission (GIC) is the state agency responsible for benefits for employees and retirees of the state, certain municipalities, and other government entities. The GIC determines who is eligible for its plans. The plan is funded by the Commonwealth of Massachusetts and administered by Wellpoint. Wellpoint is not the fiduciary or the insurer of the Medicare Extension plan.

About your Medicare membership You must be enrolled in Medicare Part A and Part B to be eligible for the Medicare Extension plan.

If you let your Medicare coverage lapse, you will no longer be eligible for benefits under the Medicare Extension plan.

Do not enroll in a separate Medicare Part D plan. This plan includes Medicare Part D coverage.

If you enroll in another Part D plan, the Centers for Medicare and Medicaid Services (CMS) will disenroll you from your GIC coverage. If that happens, you’ll lose your GIC health, behavioral health, and prescription drug benefits.

Language interpretation/translation services are available If you need help with language interpretation or translation, call Member Services. A Wellpoint Health Guide will connect you with an interpreter to translate your conversation in real time. If you use a TTY machine, you can reach Wellpoint by calling 711.

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Si necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando al número de servicio al cliente que aparece al dorso de su tarjeta de identificación o en el folleto de inscripción.

Important terms to know Your member costs are lower when you use care providers that have an agreement with Medicare about what they charge for healthcare services.

Important! In this handbook, care providers who have an agreement with Medicare are called Preferred care providers.

What is a Preferred provider?

In this handbook, care providers who have an agreement with Medicare are called Preferred care providers.

For medical services

• Preferred care providers are doctors, hospitals, or other healthcare providers that participate or opt in to Medicare. They are also known as in-network or contracted providers, and you may see these terms used on wellpointmass.com.

• Nonpreferred care providers are those that do not participate or opt in to Medicare. They are also known as out-of-network or noncontracted providers. If you use a Nonpreferred medical care provider, your out-of-pocket costs may be higher than if you use a Preferred care provider. This may not apply to every service. Please check the benefit sections in this handbook for details.

• Balance billing is when a care provider bills you for the difference between what they charge and what your health plan allows (the allowed amount).

– In Massachusetts: Members cannot be balance billed for medical services.

– Outside Massachusetts: Members may be balance billed for medical services.

Table 1. Location of care cost differences

Location of care Care provider type Member cost difference

In or outside Massachusetts

Preferred care provider (providers who participate in Medicare)

Covered, no cost difference

In or outside Massachusetts

Nonpreferred care provider (providers who do not participate in Medicare)

Covered, but at a higher cost to the member http://wellpoint.com/mass

Wellpoint Medicare Extension Plan Member Handbook (2026–2027)6

For behavioral health services

• Preferred (or in-network or contracted) behavioral health care providers participate or opt in to Medicare. They are also known as in-network or contracted providers, and you may see these terms used on wellpointmass.com. Preferred behavioral health care providers won’t balance bill you.

• Nonpreferred (or out-of-network or noncontracted) behavioral health care providers are those that do not participate or opt in to Medicare. Your plan will pay the allowed amount for covered services, and a Nonpreferred behavioral health care provider may balance bill you for the rest.

• Balance billing is when a care provider bills you for the difference between what they charge and what your health plan allows (the allowed amount).

– In Massachusetts: Members cannot be balance billed for behavioral health services from Preferred facilities or Preferred care providers. Members cannot be balance billed for supplies from any Preferred supplier, or for emergency behavioral health care from any care provider.

– Outside Massachusetts: Members may be balance billed for behavioral health services from Nonpreferred behavioral health care providers.

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Important contacts

Medical and behavioral health care coverage

Wellpoint

Contact Wellpoint for questions about:

• Benefits for a medical service or procedure

• Benefits for mental health or substance use disorder services

• Status of a medical or behavioral health claim

• Finding a doctor, hospital, or other care provider

• Chapters 1–11 of this handbook

Wellpoint Member Services:

• Phone: 800-442-9300/TTY: 711 (toll-free) Monday through Thursday, 7:30 a.m.–6 p.m.;

Friday, 7:30 a.m.–5 p.m.

If you call after business hours, leave a message. Member Services will return your call the next business day.

• Email:

contact.ma@wellpoint.com

• Website:

wellpointmass.com

Prescription drug coverage

SilverScript

Contact SilverScript, an affiliate of CVS Caremark, for questions about:

• Benefits for a prescription drug

• Status of a prescription drug claim

• Where to get prescriptions filled

• Which drugs are covered

• Chapter 12 of this handbook

CVS Caremark Customer Service:

• Phone: 877-876-7214 (toll-free)

• Website:

gic.silverscript.com

For questions about enrollment, go to mass.gov/forms/contact-the-gic and fill out the GIC online contact form.

mailto:%20%20contact.ma%40wellpoint.com?subject= mailto:%20%20contact.ma%40wellpoint.com?subject= https://www.wellpoint.com/mass https://www.wellpoint.com/mass https://info.caremark.com/oe/gicsilverscript?r=826 https://info.caremark.com/oe/gicsilverscript?r=826 http://mass.gov/forms/contact-the-gic http://mass.gov/forms/contact-the-gic

Table of contents

Wellpoint Medicare Extension Plan Member Handbook (2026–2027)8

Table of Contents

– You are covered under the Wellpoint Medicare Extension plan

– About your Medicare membership

– Language interpretation/translation services are available

– Important terms to know

– Important contacts

Getting started

What to know to begin using your plan

• Chapter 1: Getting started with your plan

– About this handbook

– Do you have other health insurance?

– Your member ID card

– Preapproval for certain services

– Getting the most from your plan

• Chapter 2: Costs and billing

– The basics

– Member costs (out-of-pocket costs)

– How member costs work

– How the providers you choose affect your costs

– Copays

– Coinsurance

– Out-of-pocket (OOP) maximums

– Your rights and protections against surprise medical bills

• Chapter 3: Preapproval

– What is preapproval?

– Who handles preapproval reviews?

– Preapprovals for behavioral health services

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Your benefits and coverage

What to know about your coverage for medical and behavioral health services

• Chapter 4: Summary of covered services

• Chapter 5: Explanation of your coverage

– Your benefits for covered medical services

– Allergy shots

– Ambulance transportation

– Anesthesia

– Autism Spectrum Disorders (ASDs)

– Cardiac rehabilitation (rehab) programs

– Chemotherapy

– Chiropractic care

– Chronic pain management

– Circumcision

– Cleft lip and cleft palate

– Clinical trials (clinical research studies)

– Dental services

– Diabetes care

– Diabetic supplies and equipment

– Dialysis

– Doctor services (and services from other medical care providers)

– Durable medical equipment (DME)

– Early intervention programs

– Emergency care and urgent care

– Enteral and oral therapy

– Eye care

– Eyeglasses and contact lenses

– Family planning

– Fitness reimbursement

– Foot care (routine)

Wellpoint Medicare Extension Plan Member Handbook (2026–2027)10

– Gender affirmation services

– Gynecology exams

– Hearing aids

– Hearing exams

– High-tech imaging

– Home healthcare

– Home infusion therapy

– Hospice and end‑of‑life care

– Immunizations (vaccines)

– Infertility treatment

– Inpatient medical care (hospital admissions)

– Laboratory services (lab work) and radiology

– Long‑term care facilities

– Maternity services

– Medical care outside the U.S

– Medical services (not listed elsewhere)

– Neuropsychological (neuropsych) testing

– Occupational therapy

– Office visits

– Outpatient hospital services (if not listed elsewhere)

– Oxygen

– Palliative care

– Personal emergency response systems (PERS)

– Physical therapy

– Prescription drugs

– Preventive care

– Prosthetics and orthotics

– Pulmonary rehabilitation (rehab) programs

– Radiation therapy

– Rehabilitation (rehab) hospitals

– Retail health clinics

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– Skilled nursing facilities

– Sleep studies

– Speech therapy

– Surgery

– Tobacco cessation counseling

– Transplants

– Travel clinics

– Urgent care

– Virtual care (telehealth)

– Walk-in clinics

– Wigs

– Your benefits for covered behavioral health services

– Behavioral health services

– Applied Behavior Analysis

– Autism Spectrum Disorders (ASDs)

– Behavioral Health Help Line

– Community Behavioral Health Centers and Mobile Crisis Intervention

– Inpatient behavioral health care (hospital admissions)

– Medication-assisted treatment (MAT)

– Outpatient services

– Substance use assessment/referral

– Therapy (outpatient)

• Chapter 6: Covered preventive services

Using your plan

Details about your plan and coverage

• Chapter 7: Excluded and limited services

• Chapter 8: Your plan and coverage

– Types of care providers

– How to find care providers

– How Wellpoint reimburses care providers

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– How to submit a claim

– Deadlines for filing claims

– Recovery of overpaid claims

– Checking the claims for billing accuracy

– Claim reviews for fraud and other inappropriate activity

– Deadlines on bringing legal action

– Right of reimbursement (payment from a third party)

– Your privacy rights

– The review process

– About your appeal rights

• Chapter 9: Enrollment and membership

– Free or low-cost health coverage for children and families

– Information for disabled dependents

– Applying for coverage

– When coverage begins

– When coverage ends for enrollees

– When coverage ends for dependents

– Duplicate coverage

– Enrolling dependents after the new-hire period

– Continuing coverage when employment ends

– Notice of COBRA continuation coverage rights

– Converting to nongroup health coverage

– Coordination of benefits with other health plans

• Chapter 10: Other plan resources

– The Sydney Health app

– Behavioral health quality programs

– About the wellpointmass.com website

– Calling the 24-Hour Nurse Line

– How to ask for a claim review

– To get your medical information released

• Chapter 11: Plan definitions

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Prescription benefits

Your coverage for prescription drugs

• Chapter 12: Prescription benefits

– GIC’s pharmacy benefit and your pharmacy plan

– How to get started and use the plan

– Exclusions

– Definitions

– Clinical operations prior authorizations, exceptions, and appeals programs

– Review of adverse benefit determinations

– Confidentiality

Appendices

Notices and reference information

• Appendix A: GIC notices

– Notice of Group Insurance Commission Privacy Practices

– Important notice from the GIC about your prescription drug coverage and Medicare

– The Uniformed Services Employment and Reemployment Rights Act (USERRA)

• Appendix B: Mandates and required member notices

– Premium assistance under Medicaid and the Children’s Health Insurance Program

– Paperwork Reduction Act Statement

– Coverage for reconstructive breast surgery

– The Newborns’ and Mothers’ Health Protection Act

– Massachusetts state clinical trial definition

– Massachusetts state mandates

– Member rights and responsibilities (Carelon)

– Right of reimbursement (subrogation)

– We’re here for you — in many languages

Getting started What to know to begin using your plan

For questions about information in Chapters 1–3 of this handbook, please call Wellpoint Member Services at 800-442-9300.

Chapter 1: Getting started

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Chapter 1: Getting started with your plan

About this handbook This handbook looks at features and coverage for medical or general healthcare, behavioral health care, and prescription drugs.

• Medical services are administered by Wellpoint.

• Behavioral health services are administered by Wellpoint in partnership with Carelon behavioral health. These benefits cover services for mental health and substance use disorder.

• Prescription drugs are separately administered by SilverScript.

Important! This handbook is not a description of your Medicare benefits. For more information, visit medicare.gov/medicare-and-you for the Medicare & You handbook, or it’s also available from your local Social Security office.

A note about terms and definitions

You can find definitions for many terms used in this handbook in Chapter 11. Also keep in mind:

• In this handbook and other plan materials, we may refer to your Wellpoint health plan as the plan.

• We often use the abbreviation GIC for the Group Insurance Commission.

• If you have dependents covered under your plan, text that refers to you also applies to your dependents.

• Medical services (medical care) are services to treat medical (physical) conditions. Behavioral health services are services to treat mental health and substance use disorder conditions. When we’re talking about both types of services together, we usually call them healthcare services.

• Medical services from care providers in the state of Massachusetts are covered at the highest (Preferred) benefit level. (This does not apply to behavioral health services.)

https://www.medicare.gov/medicare-and-you https://www.medicare.gov/medicare-and-you

Wellpoint Medicare Extension Member Handbook (2026–2027)16

Symbols used in this handbook

Table 2. What the handbook symbols mean

Icon/treatment Meaning

Important! Important information — this may affect your benefits or costs.

No coverage, limited coverage, or benefit restriction — Chapter 7 includes a full list of plan exclusions and limitations.

May need preapproval review — this service may need review to determine if it is eligible for benefits. Check Chapter 3.

Use Medicare-participating or Preferred care providers and suppliers

— to get the best benefit, use a Medicare-participating care provider or supplier for this service or product. Find Medicare-participating providers at medicare.gov. If no Medicare-participating care providers are available, find Preferred care providers at wellpointmass.com.

Do you have other health insurance?

If you or one of your dependents has health coverage from a different insurer than Wellpoint, you may need to send us an Other Health Insurance (OHI) form. Wellpoint needs this information to coordinate your benefits with other plans. To learn more about how this works, turn to “Coordination of benefits with other health plans” in Chapter 9.

Find this and other forms at wellpointmass.com.

You don’t need to submit an OHI form if:

• You don’t have coverage under any other health plans

• You have other coverage but it’s from Medicare

• You’ve already submitted an OHI form and your information hasn’t changed

You do need to submit an OHI form if:

• You’re covered under another health plan that isn’t Medicare

• You haven’t submitted an OHI form before or you need to update your information https://www.medicare.gov/ https://www.medicare.gov/ https://www.wellpoint.com/mass

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Your member ID card Each member will get a Wellpoint member ID card. Your ID card lists key telephone numbers and information about your benefits.

• Order replacement ID cards through the member portal at wellpointmass.com.

• Access a digital member ID card in the Sydney® Health app. Go to sydneyhealth.com to download the app.

Your prescription drug card is separate. SilverScript will send it. Call SilverScript at 877-876-7214 if you have questions.

Preapproval for certain services We review certain services ahead of time to make sure they are safe and appropriate. This is called preapproval or preauthorization. Services that need preapproval from Wellpoint are marked with a caution icon . For those services to be covered, your care provider must notify Wellpoint in advance. For more about preapprovals, check Chapter 3.

Getting the most from your plan Your GIC plan gives you access to quality, cost-effective care. To get even more from your plan, follow these tips.

Keep costs down by using Preferred care providers

Use Medicare-participating care providers and suppliers for the best benefit. These providers have agreed to accept Medicare’s payment as payment in full for covered medical services and supplies.

Look for Medicare suppliers at medicare.gov.

Choose Preferred care providers and suppliers

If you can’t find a Medicare provider for the services, supplies, or equipment you need, choose a Preferred provider. These providers accept the plan’s payment as payment in full and won’t bill you for the rest. Find Preferred care providers at wellpointmass.com.

Important! Medical services from care providers in the state of Massachusetts are covered at the highest (Preferred) benefit level. (This does not apply to behavioral health services.)

https://www.wellpoint.com/mass https://www.sydneyhealth.com/ https://www.sydneyhealth.com/ https://www.sydneyhealth.com/ https://www.medicare.gov/

Wellpoint Medicare Extension Member Handbook (2026–2027)18

Know before you go

Learn the difference between preventive and diagnostic care. Preventive services don’t include treating health conditions you already have. If you have diagnostic services during a preventive visit with your doctor, you may owe member costs. Learn about your preventive benefits in Chapter 6.

Choose your urgent care center ahead of time. Urgent care centers (and ambulatory surgery centers) may bill as hospitals if they’re hospital owned. That can cost you more. If you aren’t sure, ask how they’ll bill your visit.

If you need care quickly and it isn’t a medical emergency, take advantage of walk-in clinics. You have a $10 copay at walk-in clinics, like urgent care centers and retail health clinics. At a hospital emergency room, your copay is $50.

A note about networks

In this handbook, we use the term “in network” for care providers and suppliers who accept your plan’s payment as payment in full for services, supplies, and equipment. This means they won’t bill you for anything above what your plan pays them.

In Massachusetts: You can see any care provider in Massachusetts for medical care, and they won’t bill you for anything above what your plan pays. This isn’t a formal network, but they accept your plan’s payment as payment in full.

Outside Massachusetts: Use in-network suppliers and care providers.

They won’t bill you for anything above your plan’s payment.

Getting care outside of Massachusetts

When you’re out of state, visit Preferred care providers. Make sure out-of-state dependents do too.

These care providers have agreed to accept Wellpoint’s payment as payment in full — they won’t bill you for the rest. Confirm care providers are in your plan’s network ahead of time. Care provider status can change at any time. Find Preferred care providers at wellpointmass.com.

Chapter 2: Costs and billing

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Chapter 2: Costs and billing

The basics Medical bills can be hard to understand. What was covered? Has insurance paid? How much do you owe? Here are a few things to know about your medical bills.

A single appointment can include many medical services

If you visit your doctor for a tetanus shot, for example, you’ll find a list of charges on the bill:

• The office visit with your doctor

• The service of administering the vaccine (giving you the injection)

• The material used in the injection (tetanus serum, in this case)

This is how medical billing works. Each part of a visit has a unique code, and medical bills list them separately.

Not all services are covered by insurance

Health insurance covers, or pays for, services you need to take care of your health. These are called medically necessary services. Other services aren’t covered by insurance. Most insurance plans have a list of services that are excluded (never covered). For example, cosmetic treatments aren’t covered because they aren’t medically necessary most of the time. You can find the list of excluded or limited services in Chapter 7.

How Medicare and Medicare Extension work together

You must be enrolled in Medicare Part A and Part B to be eligible for the Medicare Extension plan.

If you let your Medicare coverage lapse, you won’t be eligible for benefits under the Medicare Extension plan.

Do not enroll in a non-GIC Medicare Part D product. This plan includes Medicare Part D coverage.

If you enroll in another Part D product, the Centers for Medicare and Medicaid Services (CMS) will disenroll you from your GIC coverage and you’ll lose your GIC health, behavioral health, and prescription drug benefits.

Wellpoint Medicare Extension Plan Member Handbook (2026–2027)20

What the Medicare Extension plan covers

Medicare Extension covers all or part of the costs that Medicare does not pay for covered services.

For example, if Medicare pays 80% of a claim, the Medicare Extension plan will pay some or all of the remaining 20%. Medicare Part A provides benefits for hospital services, and Medicare Part B provides benefits for physician and some other care provider services. The Medicare Extension plan also covers the Medicare Part A inpatient deductible, the Part B deductible, and Part B coinsurance.

Medicare Extension covers some services that Medicare doesn’t cover, like immunizations and hearing aids.

How benefits are determined between Medicare and Medicare Extension

• Your plan only pays for services that are covered under Medicare or the Medicare Extension plan.

• The maximum amount that can be paid is the Medicare-approved amount, or Wellpoint’s allowed amount if the service isn’t covered by Medicare.

• We subtract any Medicare payments from the original amount of the claim, then apply Medicare Extension benefits to any remaining claim balance.

Allowed amounts and Medicare-approved amounts

Medicare sets an allowed cost for each covered service. Even if your doctor charges more, Medicare won’t pay more than the allowed cost. If Medicare covers 80% of a service, that means 80% of the allowed cost Medicare approved.

Wellpoint also sets an allowed amount for each service that it covers. For services covered by Medicare, Wellpoint’s allowed amount matches the Medicare-approved amount.

Important! 100% coverage means 100% of the allowed amount, not 100% of the bill.

Some care providers take the allowed amount as their full payment, and some don’t

Care providers and suppliers that have agreed to accept your plan’s allowed amount as payment in full are called Preferred providers. Nonpreferred care providers are those who haven’t agreed to your plan’s allowed amounts. They can bill you for the difference between what they charge and what your plan paid. This is called balance billing or surprise billing. In the pages ahead, you’ll find more information about surprise medical bills.

Who pays what?

In the example of the tetanus shot, your plan pays the allowed amount. You also may owe a fee, called a copay, at the doctor’s office. When you pay something toward your healthcare services, that’s known as cost sharing.

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Member costs (out-of-pocket costs) Costs you pay toward your medical bills are your member costs. They’re also called out-of-pocket costs, member share, or cost sharing.

Table 3. Types of member costs

Member cost Definition

Copay A fixed fee you pay for each visit, service, or prescription

Coinsurance A percentage of the cost of a service; for example, your plan pays 80%, and the other 20% is your coinsurance

There is a limit on member costs. An out-of-pocket maximum caps how much you’ll spend each plan year on the combination of copays and coinsurance.

How member costs work Medicare pays its portion of your claims first. Then, because you are in Wellpoint’s Medicare Extension plan, the rest of the claim balance is sent to Wellpoint. If you owe any member costs after a medical visit, we’ll send you an Explanation of Benefits (EOB). An EOB shows how the claim was paid and what costs you owe.

Here is how we pay claims:

1. Start with the allowed amount for the claim.

2. Subtract any member costs from the allowed amount. First the copay (if any), then the coinsurance amount (if any).

3. Wellpoint sends payment to your care provider.

4. The care provider bills you for the member costs we subtracted from their payment. (If you had any services that weren’t covered, the care provider’s bill may include those charges too.)

Wellpoint processes claims as they come in, so claims may not be paid in the same order you got the services.

Wellpoint Medicare Extension Plan Member Handbook (2026–2027)22

How the providers you choose affect your costs You may owe different amounts for the same services, depending on a provider’s payment arrangement with Medicare.

Medicare-enrolled providers are those that accept Medicare payments.

Medicare-participating providers are sometimes referred to as providers who accept “Medicare assignment,” because they allow Medicare to assign each service’s cost. These providers accept Medicare’s payment for covered services as payment in full.

Medicare-nonparticipating providers have not allowed Medicare to assign the costs of their services. They might charge more than the Medicare-approved amount, and you’re responsible for the additional cost.

Private contract providers don’t do any business with Medicare. Medicare doesn’t cover any services from these providers, so they’ll have you sign an Advance Beneficiary Notice of Noncoverage (ABN) contract to pay for the services yourself.

Important! If you visit a private contract provider for a Medicare-covered service, your Wellpoint Medicare Extension plan’s allowed amount is only 20% of what Medicare would have paid to an enrolled provider. Your benefit is then applied to that allowed amount. You must pay the rest of the cost yourself.

For more information about how Medicare pays providers, check the Medicare & You handbook and other Medicare publications, available at medicare.gov.

Table 3 illustrates how your benefits work for the three types of providers.

Table 4. How Medicare-provider arrangements affect benefits

Type of provider Claim amount

Allowed amount

Medicare pays

Wellpoint pays

You owe

Medicare-participating providers (accept Medicare assignment)

$150 $100 $80 $20 $0

Medicare-nonparticipating providers $150 $100 $80 $20 $501

Private contract providers (Medicare opt-out providers) $150 $100 $0 $202 $1303

1 The amount of the claim left over after Medicare and Wellpoint have paid.

2 Wellpoint pays only what it would have paid if you had used a participating provider.

3 The amount of the claim that neither Medicare nor Wellpoint paid.

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Choosing in-network care providers and suppliers

For certain services and supplies, you get the highest benefit when you use a provider or supplier that is contracted with or in network with your health plan. For the Wellpoint Medicare Extension plan, these are Medicare suppliers, Wellpoint-contracted suppliers, or both that provide one or more of the following services and supplies:

• Durable medical equipment (DME)

• Homehealth care

• Home infusion therapy (including enteral and oral therapy)

• Medical or diabetic supplies

• Orthotics, prostheses, and prosthetic devices

You get the highest benefit for these services when you use a Medicare supplier. Find Medicare suppliers at medicare.gov.

If there aren’t any Medicare suppliers for the service or supply, look for a supplier contracted or in network with Wellpoint.

In-network suppliers are covered at 100% of the allowed amount. For other suppliers, the plan covers 80% of the allowed amount, and you owe the remaining 20% coinsurance. This is true even when the item or service isn’t available from an in-network or contracted supplier. If you live outside Massachusetts, contracted suppliers won’t balance bill you for charges over the allowed amount, but other suppliers might.

Find in-network suppliers at wellpointmass.com. In this handbook, the checkmark lets you know when a service has a contracted supplier benefit.

Important! Non-contracted suppliers are covered at 80%, even if you are using the non-contracted supplier because the item isn’t available from a contracted supplier.

Copays What is a copay?

A copay is a member cost you owe at the time you get a service. For example, you pay a copay when you visit your doctor for a sore throat, when you have outpatient surgery, or when you’re admitted to a hospital. You have copays for some medical services and for some behavioral health services. Services that have copays include:

• Doctor visits, in person or through virtual care

• Urgent care centers and retail health clinic visits

• Routine eye exams https://www.medicare.gov/

Wellpoint Medicare Extension Plan Member Handbook (2026–2027)24

• Emergency room (ER) visits

• Behavioral health outpatient services

Which services have copays?

Care provider visits

You owe a copay for each in-person or virtual care visit (telehealth) with a care provider at a medical practice or clinic, including urgent care centers and retail clinics. The dollar amount of the copay depends on the type of facility you use and whether you visit a primary care provider (PCP) or a specialist.

• A PCP (primary care provider) can be a nurse practitioner, physician assistant, or physician whose specialty is family medicine, general medicine, pediatrics, geriatrics, or internal medicine.

• A specialist (specialty care provider) can be a nurse practitioner, physician assistant, or physician.

You owe the specialist copay whether you visit for primary care or specialty care services.

ER visits

You owe an ER copay each time you go. If you’re admitted to the hospital from the ER, the ER copay is waived.

Outpatient behavioral health services

You owe a per-visit copay for many outpatient services when you use behavioral health care providers contracted with Carelon (a Wellpoint-affiliated company). You don’t owe a copay to visit a Nonpreferred behavioral health care provider, but you’ll owe 20% coinsurance. Also, Nonpreferred care providers may bill you for charges that are over the allowed amount (balance billing).

Coinsurance Coinsurance is your share of the cost of a covered service when the service isn’t covered at 100%.

For example, if the plan pays 80% of the allowed amount for a service, you are responsible for paying the other 20%. Coinsurance applies to any balance left after Medicare processes your claim

— this applies to all member costs.

Out-of-pocket (OOP) maximums There is a limit on member costs toward covered services. An out-of-pocket (OOP) maximum caps how much you’ll spend each year on the combination of copays and coinsurance. Once you reach the OOP maximum, your plan pays 100% of the allowed amounts for services for the rest of the year.

Your Medicare Extension plan has three separate out-of-pocket maximums:

• A coinsurance OOP maximum for medical services

• An OOP maximum for services from in-network behavioral health care providers

• An OOP maximum for services from out-of-network behavioral health care providers

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Table 5. Your OOP maximums

Out-of-pocket maximum Amount

Coinsurance limit $500

OOP max with in-network behavioral health providers $1,000

OOP max with out-of-network behavioral health providers $3,000

These costs do not count toward your OOP maximums:

• Prescription drug costs.

• Premiums.

• Balance bills (charges over the plan’s allowed amounts). Check “Your rights and protections against surprise medical bills” for information about balance billing protection.

• Costs for healthcare services your plan doesn’t cover.

Questions?

Contact Member Services at 800-442-9300 for help finding a Preferred care provider, so you get the most from your Wellpoint plan.

Your rights and protections against surprise medical bills When you visit a doctor or other care provider, you may owe out-of-pocket costs like a copay, coinsurance, or deductible. If you visit a Nonpreferred care provider, you might owe more.

Nonpreferred doctors and facilities can bill you for the difference between their charges for a service and Wellpoint’s allowed amount. This is called balance billing. Balance bills from Nonpreferred care providers don’t count toward your out-of-pocket maximum.

Surprise billing is a balance bill you didn’t expect. This can happen when you can’t control who is involved in your care — like when you have an emergency or when you schedule a visit at a Preferred facility but you’re unexpectedly treated by a Nonpreferred doctor.

Wellpoint Medicare Extension Plan Member Handbook (2026–2027)26

Protections against surprise billing

You’re protected from receiving surprise bills — balance bills that you don’t expect — under some circumstances.

• Emergency services in Massachusetts and elsewhere: No care provider can balance bill for medical or behavioral health emergency services, by federal law. This applies to Preferred and Nonpreferred care providers.

• Medical services in Massachusetts: No medical care provider in Massachusetts can balance bill Wellpoint members, by state law.

• Medical services outside Massachusetts: No care provider can balance bill for services you have at a Wellpoint-contracted facility. Some care providers at these facilities may be Nonpreferred, but by federal law they can’t balance bill you.

• Behavioral health services in Massachusetts and elsewhere: Behavioral health care providers contracted with Carelon won’t balance bill you. Nonpreferred behavioral health care providers might, but federal laws against surprise billing apply to medical providers and behavioral health providers alike.

If you use a Nonpreferred care provider, you could be balance billed. The balance bill is your responsibility to pay, and it doesn’t count toward your out-of-pocket maximum. Always make sure a care provider is still Preferred before your visit because that status can change.

Important! You never have to give up your protection from balance billing, and you never have to get care from Nonpreferred doctors or facilities.

What to do if you get a surprise bill

If you get a balance bill from any of the following types of care providers and suppliers, contact Wellpoint Member Services at 800-442-9300. These providers aren’t allowed to balance bill Wellpoint members:

• Any care provider of emergency medical or emergency behavioral health care

• Any care provider at Preferred facilities

• Medical care providers in Massachusetts

• Preferred suppliers

• Preferred medical care providers outside of Massachusetts

• Preferred behavioral health care providers both in and outside of Massachusetts

Balance bills from other suppliers and care providers are your responsibility to pay. Since the plan doesn’t cover balance bills and they don’t count toward your out-of-pocket maximum, using from suppliers and Nonpreferred care providers can end up being very costly.

Chapter 3: Preapproval

Wellpoint Medicare Extension Plan Member Handbook (2026–2027) 27

Chapter 3: Preapproval

What is preapproval?

Your plan needs to approve some services ahead of time. This is called preapproval (or prior authorization). Once a service is preapproved, you can be sure it’s covered by your plan.

Benefits offered by Medicare and Wellpoint apply to services that are medically necessary. As the primary insurer, Medicare determines medically necessity for the services it covers. In most cases, Wellpoint does not separately review services covered by Medicare. Wellpoint may review services that aren’t covered by Medicare, or when you’ve hit your Medicare benefit limit for certain services.

In most cases, care providers know to send Wellpoint the information needed. There may be times when you’ll need to ask your care provider to contact Wellpoint about preapproval — for example, if you use a Nonpreferred care provider outside Massachusetts.

If you don’t get preapproval for a service that needs it, your plan may not cover it. If you need help with preapproval, Wellpoint Member Services can reach out to your care provider.

Other helpful information about preapproval

• Your care provider must contact Wellpoint for preapproval before the service takes place.

• You don’t need to get preapproval if you’re outside the continental United States (the continental U.S. includes all states except Alaska and Hawaii).

• In this handbook, the caution icon marks services that need preapproval.

• If you’re not sure whether a service needs preapproval, ask your doctor to check the lists on the next few pages or contact Wellpoint to find out.

Who handles preapproval reviews?

Depending on the service, preapproval reviews are handled by Wellpoint, Carelon Medical Benefits Management, or CarelonRx. If you have questions or need help with preapproval review, call Wellpoint Member Services at 800-442-9300.

Wellpoint Medicare Extension Plan Member Handbook (2026–2027)28

Table 6. Preapproval reviewers

Medical and behavioral health reviewers Services

Wellpoint

• 800-442-9300/TTY: 711 (toll-free)

• wellpoint.com/mass/providers/preapprovals

Behavioral health services and some medical services

Specialty pharmacy reviewers

SilverScript

• 800-237-2767 (toll-free)

• Check the “Prescription benefits” section for more information.

Preapprovals for medical services These are some of the types of medical services that need preapproval. This is a general list, and it could change. If you need help deciding if a service needs preapproval, contact Wellpoint Member Services at 800-442-9300.

Examples of medical services that need preapproval

• Durable medical equipment (DME)

• Enteral and oral therapy

• Home healthcare

• Inpatient admissions

• Surgeries such as organ transplants

Preapprovals for behavioral health services Care providers can contact Wellpoint 24 hours a day, seven days a week, for preapproval of behavioral health services. You don’t need preapproval for Medicare-covered services from a care provider who participates in Medicare. Otherwise, you or your care provider must get preapproval before the service will be covered. Below are behavioral health services that need preapproval.

https://www.wellpoint.com/mass/providers/preapprovals

Wellpoint Medicare Extension Plan Member Handbook (2026–2027) 29

Table 7. Inpatient services for mental health treatment (if not covered by Medicare)

Service With Preferred care providers

With Nonpreferred care providers

• Acute residential treatment

• Inpatient psychiatric services Needs preapproval Needs preapproval

• Community-based acute treatment

(CBAT)

• Transitional care units (TCUs)

• In Massachusetts:

Notify Wellpoint within 72 hours

• Outside Massachusetts:

Needs preapproval

• In Massachusetts:

N/A

• Outside Massachusetts:

Needs preapproval

What is a DPH-licensed provider?

The Massachusetts Department of Public Health (DPH) licenses healthcare facilities that meet quality and safety standards.

Table 8. Inpatient services for substance use disorders (if not covered by Medicare)

Service With Preferred care providers

With Nonpreferred care providers

• Acute residential withdrawal management (ASAM level 3.7 detox)*

• Clinical stabilization services (CSS) (ASAM level 3.5)

• Dual diagnosis acute treatment (DDAT) (ASAM level 3.5)

• Inpatient substance use disorder services, medically managed (ASAM level 4 detox)

• In Massachusetts:

Notify Wellpoint within 48 hours

• Outside Massachusetts:

Needs preapproval

• DPH-licensed care providers in Massachusetts:

Notify Wellpoint within 48 hours

• All other Nonpreferred care providers: Needs preapproval

Crisis stabilization units (CSUs) Preapproval needed for stays over 5 days

Preapproval needed for stays over 5 days

* ASAM stands for American Society of Addiction Medicine. These are levels of criteria based on a set of guidelines that help care providers evaluate a person’s needs and recommend the right level of treatment.

Wellpoint Medicare Extension Plan Member Handbook (2026–2027)30

Table 9. Outpatient services, including office services (if not covered by Medicare)

Service With Preferred care providers

With Nonpreferred care providers

• Acupuncture withdrawal management

• Community support programs (CSPs)

• Day treatment

N/A Needs preapproval

• Applied Behavior Analysis (ABA)

• Dialectical behavioral therapy (DBT)

• Family stabilization teams (FSTs)

• Partial hospitalization programs (PHPs) for mental health conditions

• Psychiatric visiting nurse services

• Transcranial magnetic stimulation (TMS)

Needs preapproval Needs preapproval

PHPs for substance use disorders (ASAM level 2.5)*

• In Massachusetts:

Notify Wellpoint within 48 hours

• Outside Massachusetts:

Needs preapproval

• DPH-licensed care providers in Massachusetts:

Notify Wellpoint within 48 hours

• All other Nonpreferred care providers: Needs preapproval

• Intensive outpatient programs (IOPs)

• Structured outpatient addiction programs (SOAPs)

• Notify Wellpoint within 48 hours

• DPH-licensed care providers in Massachusetts:

Notify Wellpoint within 48 hours

• All other Nonpreferred care providers: Needs preapproval

* ASAM stands for American Society of Addiction Medicine. These are levels of criteria based on a set of guidelines that help care providers evaluate a person’s needs and recommend the right level of treatment.

Your benefits and coverage What to know about your coverage for medical and behavioral health services

Benefits are administered by Wellpoint. For questions about any information in

Chapters 4–6 of this handbook, please call Wellpoint Member Services at 800-442-9300.

Chapter 4: Summary of covered services

Wellpoint Medicare Extension Plan Member Handbook (2026–2027)32

Chapter 4: Summary of covered services Important! Services are covered only when they’re needed to take care of your health (medically necessary). Your plan covers up to the allowed amount for a service.

Table 10. Summary of your costs for covered medical and behavioral health services

Service Member costs and benefit limits

Ambulances No member costs

Applied Behavior Analysis (ABA)

• Preferred care providers — $10 copay (no member costs first four visits)

• Nonpreferred care providers — 20% coinsurance for visits 1–15, 50% coinsurance for visits beyond 15

Bereavement counseling 20% coinsurance (your plan will pay up to $1,500 for a family in a calendar year)

Cardiac rehab programs No member costs

Chemotherapy No member costs

Chiropractic care No member costs (limited to 20 visits in a calendar year)

Diabetic supplies

• Preferred suppliers — no member costs (you also have a $100 copay for the emergency room visit)

• Nonpreferred — 20% coinsurance

Dialysis No member costs

Doctor visits $10 copay

Doctors — other services

• At an emergency room — no member costs

• For inpatient hospital care — no member costs

• For outpatient hospital care — $10 copay

Durable medical equipment (DME)

• Preferred suppliers — no member costs

• Nonpreferred — 20% coinsurance

Early intervention programs No member costs (limited to $5,200 for each child in a calendar year, with a lifetime limit of $15,600 for each child)

Emergency room visits $50 copay

Eye exams (routine) $10 copay (limited to one exam every 24 months)

Eyeglasses and contact lenses No member costs (limited to the first lenses within six months of eye injury or cataract surgery)

Wellpoint Medicare Extension Plan Member Handbook (2026–2027) 33

Important! Services are covered only when they’re needed to take care of your health (medically necessary). Your plan covers up to the allowed amount for a service.

Service Member costs and benefit limits

Family planning services No member costs

Fitness reimbursement Your plan will reimburse (pay back) up to $100 per member in a calendar year

Hearing aids

• Age 21 and younger — no member costs (your plan will pay up to $2,000 for each impaired ear every 24 months)

• Age 22 and older — no member costs (your plan will pay up to $1,700 for each impaired ear every 24 months)

Hearing exams $10 copay

High-tech imaging (like MRIs or CT scans)

• Outpatient hospital and non-hospital-owned facilities

— no member costs

Home healthcare

• Preferred suppliers — no member costs

• Nonpreferred suppliers — 20% coinsurance

Home infusion therapy

• Preferred suppliers — no member costs

• Nonpreferred suppliers — 20% coinsurance

Hospice care No member costs

Immunizations (vaccines) No member costs (but you may have costs for the office visit)

Inpatient behavioral health care

• Preferred — No member costs

• Nonpreferred — 20% coinsurance

Inpatient medical care

• At a hospital or rehab facility in a semiprivate room

— no member costs

• At a hospital or rehab facility in a medically necessary private room — you pay the dollar difference between a semiprivate room and a private room

Lab services No member costs

Medical services not listed elsewhere 20% coinsurance

Medication-assisted treatment (MAT) No member costs

Wellpoint Medicare Extension Plan Member Handbook (2026–2027)34

Important! Services are covered only when they’re needed to take care of your health (medically necessary). Your plan covers up to the allowed amount for a service.

Service Member costs and benefit limits

Medication management (outpatient)

Preferred — $5 copay (no member costs first four visits)

Nonpreferred — 20% coinsurance visits 1–15, then 50% coinsurance each visit after 15

Mobile Crisis Intervention (MCI) No member costs

Nutritional counseling No member costs

Occupational therapy

• If Medicare pays — no member costs

• If Medicare doesn’t pay — 20% coinsurance

Outpatient behavioral health office services

• Preferred care provider — $10 copay (no member costs first four visits)

• Nonpreferred care provider — deductible and 20% coinsurance

Outpatient behavioral health services not mentioned elsewhere

• Preferred — no member costs

• Nonpreferred — 20% coinsurance

Outpatient hospital services not listed elsewhere No member costs

Oxygen

• Preferred suppliers — no member costs

• Nonpreferred suppliers — 20% coinsurance

Personal Emergency Response Systems (PERS)

• Installation — 20% coinsurance (your plan will pay up to $50 in a calendar year)

• Rental — no member costs (your plan will pay up to $40 each month)

Physical therapy

Prescription drugs SilverScript administers your benefits for prescription drugs. Benefits are described in Chapter 12. Call SilverScript at 877-876-7214 for more information.

Preventive care No member costs. Check Table 13.

Prosthetics and orthotics

• Breast prosthetics — no member costs

• Other prosthetics and orthotics

– If Medicare pays — no member costs

– If Medicare doesn’t pay — 20% coinsurance

Wellpoint Medicare Extension Plan Member Handbook (2026–2027) 35

Important! Services are covered only when they’re needed to take care of your health (medically necessary). Your plan covers up to the allowed amount for a service.

Service Member costs and benefit limits

Radiation therapy No member costs

Radiology (like X-rays and ultrasounds)

• Emergency room — no member costs

• Inpatient hospital — no member costs

• Outpatient hospital and non-hospital-owned facilities

— no member costs

Retail health clinic visits $10 copay

Skilled nursing and long-term care facilities

• Days paid by Medicare — no member costs until plan benefit limit is reached

• Days not paid by Medicare — 20% coinsurance until plan benefit limit is reached (your plan will pay up to $13,400 each calendar year)

Speech therapy $20 copay

Substance use disorder assessment or referral No member costs

Surgery

• In Massachusetts — no member costs

• Outside Massachusetts

– Medicare participating — no member costs

– Medicare nonparticipating — 20% of the differences between the plan’s allowed amount and the provider’s charge

Therapy or counseling (outpatient)

• Preferred care provider — $10 copay (no member costs first four visits)

• Nonpreferred care provider — 20% coinsurance visits 1–15, 50% coinsurance after 15 visits

Tobacco cessation counseling No member costs

Transplants

• At a Medicare-certified transplant facility — no member costs

• At other hospitals — 20% coinsurance

Urgent care center visits $10 copay

Wellpoint Medicare Extension Plan Member Handbook (2026–2027)36

Important! Services are covered only when they’re needed to take care of your health (medically necessary). Your plan covers up to the allowed amount for a service.

Service Member costs and benefit limits

Virtual care (telehealth) $10 copay

Virtual care (telehealth) — behavioral health

• Preferred care provider — $10 copay…