Medicare Supplement Coverage Options

Transcription

1 A Division of HealthNow New York Inc. An Independent Licensee of the BlueCross BlueShield Association Medicare Supplement Coverage Options Thank you for your interest in our Medicare Supplemental coverage options, also known as BlueShield of Northeastern New York Medicare Supplement (Medigap) plans. The Medicare Supplement Plans, when combined with payments made by Medicare, are designed to reduce your out-of-pocket costs for most Medicare-covered services. We offer five Medicare Supplemental policies you choose the benefit design that best meets your needs. Why Do I Need a Medicare Supplemental (Medigap) Policy? A Medicare Supplemental policy provides coverage for health care expenses that Medicare does not cover. These policies pay most, if not all, of the Original Medicare Plan coinsurance and outpatient copayment amounts. Some policies also cover the Original Medicare Plan deductibles. Please refer to the enclosed Outline of Medicare Supplemental Coverage Benefit Plans for details about the benefits of each plan. Your cost-sharing is nominal and with some plans, there is none at all. There is no need for you to get referrals and there are no networks. Plan members can receive medical care from any doctor, specialist, or hospital that participates with Medicare. How to Enroll Enrolling is simple. To enroll in a BlueShield of Northeastern New York Medicare Supplement (Medigap) plan, complete and return your application to us in the enclosed envelope. Do not include payment at this time. We will process your application and bill you at a later date. You will also promptly receive a policy and identification card. If you are not completely satisfied, return the policy and membership card within 30 days from the day you received the card. Any premium payments you have made will be refunded in full. In the event you have filed a claim within this 30-day period, you will be responsible for the cost of any services you received. Questions? Please call our Government Program Sales Department at if you have any questions. If you are a current member you may call our Customer Service Department at For more information about Medicare coverage and Medigap policies, you may want to review the Guide To Health Insurance For People With Medicare. You may obtain this guide from your local Social Security office, or from the Medicare web site at CG1D3F0385

2 BlueShield of Northeastern New York Mailing address: PO BOX 15013, Albany, New York Physical address: 40 Century Hill Drive, Latham, New York Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After February 1, 2017 This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make available Plans A & B and either C or F. Some plans may not be available in your state. The plans we sell are A, B, C, F and F*. BASIC BENEFITS: Hospitalization: Medical Expenses: Blood: Hospice: Part A coinsurance plus coverage for 365 additional days in your lifetime after Medicare benefits end. Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. First three pints of blood each year. Part A coinsurance A B C D F/F* G K L M N Basic, including coinsurance Basic, including coinsurance Part A Basic, including coinsurance Skilled Nursing Facility Part A Part B Foreign Travel Emergency Basic, including coinsurance Skilled Nursing Facility Part A Foreign Travel Emergency Basic, including coinsurance Skilled Nursing Facility Part A Part B Part B Excess (100%) Foreign Travel Emergency Basic, including coinsurance Skilled Nursing Facility Part A Part B Excess (100%) Foreign Travel Emergency Hospitalization and preventative care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility 50% Part A Out-of-Pocket Limit $5,120 paid at 100% after limit reached Hospitalization and preventative care paid at 100%; other basic benefits paid at 75% 75% Skilled Nursing Facility 75% Part A Out-of-Pocket Limit $2,560 paid at 100% after limit reached Basic, including coinsurance Skilled Nursing Facility Part A Foreign Travel Emergency Basic, including coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Part A Foreign Travel Emergency *Plan "F" also has an option called a high deductible Plan "F". This high deductible plan pays the same benefits as Plan "F" after one has paid a calendar year $2,200 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses are $2,200. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible. CG1D3F0385 Page 1 of 14

3 PREMIUM INFORMATION BlueShield of Northeastern New York can only raise your premium if we raise the premium for all policies like yours in this state. Service Area Albany, Colombia, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington counties PLAN TYPE MONTHLY PREMIUM QUARTERLY PREMIUM SEMI-ANNUAL PREMIUM ANNUAL PREMIUM Plan A $ $ $1, $2, Plan B $ $ $1, $3, Plan C $ $ $1, $3, Plan F $ $ $1, $3, Plan F* $ $ $ $1, Rates effective 02/01/2017 CG1D3F0385 Page 2 of 14

4 DISCLOSURES Use this outline to compare benefits and premiums among policies. This outline shows benefits and premiums of policies sold for effective dates on or after February 1, Policies sold for effective dates prior to February 1, 2017 have different benefits and premiums. READ YOUR POLICY VERY CAREFULLY This is only an outline describing your policy's most important 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 are not satisfied with your policy, you may return it to BlueShield of Northeastern New York, Attention: Marketing Department, PO Box 15013, Albany, New York 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. POLICY REPLACEMENT If you are 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 BlueShield of Northeastern New York, nor its agents are connected with Medicare. This Outline of Coverage does not give all the details of Medicare coverage. Contact your local Social Security office or consult "Medicare and You" for more details. COMPLETE ANSWERS ARE VERY IMPORTANT Review the application carefully before you sign it. Be certain that all information has been properly recorded. CG1D3F0385 Page 3 of 14

5 PLAN A MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD *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. HOSPITALIZATION* SERVICES MEDICARE PAYS PLAN A PAYS WITH PLAN A YOU PAY Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A deductible) 61 st thru 90 th day All but $329 a day $329 a day 91 st day and after: All but $658 a day $658 a day While using 60 Lifetime Reserve days Once Lifetime Reserve days are used: - Additional 365 days (lifetime) 100% of Medicareeligible expenses - Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* 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 21 st thru 100 th day All but $ a day Up to $ a day 101 st day and after All costs BLOOD (per calendar year) First three pints Three pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayments/coinsurance CG1D3F0385 Page 4 of 14

6 PLAN A MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN A PAYS WITH PLAN A YOU PAY 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 First $183 of Medicare-approved amounts* $183 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% Part B excess charges (Above Medicare-approved All costs amounts) BLOOD First three pints All costs Next $183 of Medicare-approved amounts* $183 (Part B deductible) CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% MEDICARE PARTS A & B HOME HEALTH CARE 100% MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $183 of Medicare-approved amounts* $183 (Part B deductible) CG1D3F0385 Page 5 of 14

7 PLAN B MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD *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. SERVICES MEDICARE PAYS PLAN B PAYS WITH PLAN B YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A deductible) 61 st thru 90 th day All but $329 a day $329 a day 91 st day and after: All but $658 a day $658 a day While using 60 Lifetime Reserve days Once Lifetime Reserve days are used: - Additional 365 days (lifetime) 100% of Medicareeligible expenses - Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* 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 21 st thru 100 th day All but $ a day Up to $ a day 101 st day and after All costs BLOOD (per calendar year) First three pints Three pints Additional amounts 100% HOSPICE CARE All but very limited Medicare You must meet Medicare s requirements, including a copayment/coinsurance for copayments/coinsurance doctor s certification of terminal illness outpatient drugs and inpatient respite care CG1D3F0385 Page 6 of 14

8 PLAN B MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN B PAYS WITH PLAN B YOU PAY 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 First $183 of Medicare-approved amounts* $183 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% Part B excess charges (Above Medicare-approved amounts) All costs BLOOD First three pints All costs Next $183 of Medicare-approved amounts* $183 (Part B deductible) CLINICAL LABORATORY SERVICES BLOOD TESTS FOR DIAGNOSTIC SERVICES 100% MEDICARE PARTS A & B HOME HEALTH CARE 100% MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $183 of Medicare-approved amounts* $183 (Part B deductible) CG1D3F0385 Page 7 of 14

9 PLAN C MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD *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. SERVICES MEDICARE PAYS PLAN C PAYS WITH PLAN C YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A deductible) 61 st thru 90 th day All but $329 a day $329 a day 91 st day and after: All but $658 a day $658 a day While using 60 Lifetime Reserve days Once Lifetime Reserve days are used: - Additional 365 days (lifetime) 100% of Medicare-eligible expenses - Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* 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 21 st thru 100 th day All but $ a day Up to $ a day 101 st day and after All costs BLOOD (per calendar year) First three pints Three pints Additional amounts 100% HOSPICE CARE All but very limited Medicare You must meet Medicare s requirements, including a copayment/coinsurance for copayments/coinsurance doctor s certification of terminal illness outpatient drugs and inpatient respite care CG1D3F0385 Page 8 of 14

10 PLAN C MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN C PAYS WITH PLAN C YOU PAY 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 First $183 of Medicare-approved amounts* $183 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% Part B excess charges (Above Medicare-approved amounts) All costs BLOOD First three pints All costs Next $183 of Medicare-approved amounts* $183 (Part B deductible) CLINICAL LABORATORY SERVICES TESTS FOR 100% DIAGNOSTIC SERVICES MEDICARE PARTS A & B HOME HEALTH CARE 100% MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $183 of Medicare-approved amounts* $183 (Part B deductible) OTHER BENEFITS NOT COVERED BY MEDICARE FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of charges 80% to a lifetime Maximum Benefit of $50,000 20% and amounts over the $50,000 lifetime maximum CG1D3F0385 Page 9 of 14

11 PLAN F MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD *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. SERVICES MEDICARE PAYS PLAN F PAYS WITH PLAN F YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A deductible) 61 st thru 90 th day All but $329 a day $329 a day 91 st day and after: All but $658 a day $658 a day While using 60 Lifetime Reserve days Once Lifetime Reserve days are used: - Additional 365 days (lifetime) 100% of Medicare-eligible expenses - Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* 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 21 st thru 100 th day All but $ a day Up to $ a day 101 st day and after All costs BLOOD (per calendar year) First three pints Three pints Additional amounts 100% HOSPICE CARE All but very limited Medicare You must meet Medicare s requirements, including a copayment/coinsurance for copayments/coinsurance doctor s certification of terminal illness outpatient drugs and inpatient respite care CG1D3F0385 Page 10 of 14

12 PLAN F MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN F PAYS WITH PLAN F YOU PAY 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 First $183 of Medicare-approved amounts* $183 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% Part B excess charges (Above Medicare-approved amounts) All costs BLOOD First three pints All costs Next $183 of Medicare-approved amounts* $183 (Part B deductible) CLINICAL LABORATORY SERVICES TESTS FOR 100% DIAGNOSTIC SERVICES MEDICARE PARTS A & B HOME HEALTH CARE 100% MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $183 of Medicare-approved amounts* $183 (Part B deductible) OTHER BENEFITS NOT COVERED BY MEDICARE FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of charges 80% to a lifetime Maximum Benefit of $50,000 20% and amounts over the $50,000 lifetime maximum CG1D3F0385 Page 11 of 14

13 HIGH DEDUCTIBLE PLAN F MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD *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. ** This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,200 deductible. Benefits from the high deductible F plan will not begin until out-of-pocket expenses are $2,200. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by this policy. This includes Medicare deductibles for Part A and Part B, but does not include the plan s separate foreign travel emergency deductible. SERVICES MEDICARE PAYS PLAN F+ PAYS WITH PLAN F+ YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,316 $1,316 (Part A deductible) 61 st thru 90 th day All but $329 a day $329 a day 91 st day and after: All but $658 a day $658 a day While using 60 Lifetime Reserve days Once Lifetime Reserve days are used: - Additional 365 days (lifetime) 100% of Medicare-eligible expenses - Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* 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 21 st thru 100 th day All but $ a day Up to $ a day 101 st day and after All costs BLOOD (per calendar year) First three pints Three pints Additional amounts 100% HOSPICE CARE All but very limited Medicare copayment/coinsurance for You must meet Medicare s requirements, including a copayments/coinsurance outpatient drugs and inpatient doctor s certification of terminal illness respite care CG1D3F0385 Page 12 of 14

14 HIGH DEDUCTIBLE PLAN F MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B will have been met for the calendar year. ** This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,200 deductible. Benefits from the high deductible F plan will not begin until out-of-pocket expenses are $2,200. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by this policy. This includes Medicare deductibles for Part A and Part B, but does not include the plan s separate foreign travel emergency deductible. SERVICES MEDICARE PAYS PLAN F+ PAYS WITH PLAN F+ YOU PAY 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 First $183 of Medicare-approved amounts* $183 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% Part B excess charges (Above Medicare-approved amounts) All costs BLOOD First three pints All costs Next $183 of Medicare-approved amounts* $183 (Part B deductible) CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% CG1D3F0385 Page 13 of 14

15 HIGH DEDUCTIBLE PLAN F MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B will have been met for the calendar year. ** This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,200 deductible. Benefits from the high deductible F plan will not begin until out-of-pocket expenses are $2,200. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by this policy. This includes Medicare deductibles for Part A and Part B, but does not include the plan s separate foreign travel emergency deductible. HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies MEDICARE PARTS A & B 100% Durable medical equipment First $183 of Medicare-approved amounts* $183 (Part B deductible) OTHER BENEFITS NOT COVERED BY MEDICARE FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of charges 80% to a lifetime Maximum Benefit of $50,000 20% and amounts over the $50,000 lifetime maximum CG1D3F0385 Page 14 of 14