65Plus Plan Documents

Get forms for different scenarios, like enrolling for ACH withdrawal or downloading our handy checklist. There are also benefit documents and required notices for your own reference. Click the “+” to access forms.

The benefits of the Health Tradition 65Plus automatically update to reflect changes in Medicare deductibles and coinsurance. The most recent updates are:
You are eligible to enroll in Health Tradition 65Plus if:
  • Age 65 and older, or disabled
  • Enrolled in Medicare Parts A and B
  • A Wisconsin resident and live within Health Tradition Health Plan’s service area at least 245 days each year

For complete instructions on enrollment, please visit our Enrollment page.
Download and complete the Health Tradition 65Plus application.
Save yourself the trouble of mailing checks for your 65Plus premium payments. Complete the Bank Authorization to Withdraw Funds form to have payments automatically deducted from either your checking or savings account. *Please note, for checking accounts, attach a voided check. For savings accounts, please attach a letter from your bank including the routing number and savings account number. Monthly automatic bank withdrawals are made on the 5th of the month. Download and print the Bank Authorization to Withdraw Funds form and mail to Health Tradition Health Plan.
A member may terminate their 65Plus coverage by sending a written request to Health Tradition Health Plan.  Health Tradition will not accept verbal requests to cancel coverage. Enrollment into another Medicare Supplement or Medicare Advantage plan does not automatically cancel your coverage with 65Plus. Print, complete and mail the form to Health Tradition Health Plan. 65Plus Cancellation of Coverage
Use this checklist to prepare for your transition to Medicare coverage. View and download the checklist here.
If you have questions or complaints about any aspect of Health Tradition 65Plus you may try and resolve the problem on an informal basis. Members may try and resolve the problem by directly contacting our Customer Service team at 877-823-1823 (toll-free) for assistance. If the complaint cannot be resolved informally, you or an authorized representative have a right to appeal the Plan’s decision by filing a formal written Grievance. You or your authorized representative may submit a Grievance along with copies of any supporting documents to Health Tradition Health Plan.
To have someone act on your behalf to inquire about claims or referrals, resolve issues for you, make changes to your account or file a complaint, you must send Health Tradition a signed document that authorizes that person as your representative. You must indicate the information that can be discussed with the representative as well as those that cannot. You can also limit the types of information and the time frames for the authorization. Print, complete, and mail the form to Health Tradition Health Plan. Authorization for Disclosure of Information You have the right to revoke an Authorization for Disclosure of Information at any time. Print, complete, and mail this form to Health Tradition Health Plan: Print, complete and mail the form to Health Tradition Health Plan. Revocation of Authorization for Disclosure of Information
This disclosure notice applies to 65Plus members with a Group #: MMDSLA, QMDSL, 65+Bab. This notice is about your current 65Plus prescription drug coverage and Medicare. Your current 65Plus benefit plan pays 80% of charges for outpatient prescription drugs, after you have paid the $6,250 deductible in a calendar year. Outpatient prescription drugs must be received at a participating pharmacy in order to apply the out-of-pocket cost toward the $6,250 deductible. Health Tradition Health Plan has determined that the prescription drug coverage offered by 65Plus is, on average for all plan participants, not expected to pay out as much as standard Medicare prescription drug coverage (Part D) pays. Therefore, it is considered Non-Creditable Coverage. Learn more: Non-Creditable Drug Coverage Notice
Download the glossary prepared by Centers for Medicare & Medicaid Services (CMS). It explains concepts and terms used in your plan documents.
Get familiar with your handbook for an overview of your 65Plus policy. The handbook does not provide full details of your plan benefits. Please refer to your 65Plus Policy for more details about your covered benefits, exclusions and limitations. View or download your 65Plus Member Handbook now.
The Outline of Coverage and the Medicare Select Policy work together to describe covered services provided by 65Plus. This is an outline of your policy’s most important features. View or download the 65Plus Outline of Coverage.
This Wisconsin Guide to Health Insurance for People with Medicare gives an overview of the Medicare program and the health and prescription drug insurance available to those on Medicare in Wisconsin. Click here to view it.