2025 DENTAL BLUE® 65 Coverage you need from a name you can trust Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. 2025 DENTAL BLUE® 65 Coverage you need from a name you can trust Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. March 2025 (2501610)
101 Huntington Avenue Suite 1300 Boston, MA 02199-7611 bluecrossma.org Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Dear prospective member, Thank you for your interest in our Dental Blue® 65 plans. Maintaining good oral health can contribute to your overall health. We designed these plans to supplement your Medicare coverage and keep your teeth in the best shape possible. Throughout this booklet, you can: See how Dental Blue 65 offers benefits to smile about Compare your coverage options Choose how to enroll at your convenience Benefits To Smile About All Dental Blue 65 plans cover 100% of preventive services and include an extensive network of dentists across the country. They also offer Enhanced Dental Benefits, which provide additional, specific support for members with qualifying conditions. If you have any questions, we’re here to help. Sincerely, Gloria A. Paradiso, Vice President, Government Sales Enclosures Contact us with questions or to enroll. By phone: 1-800-678-2265 (TTY: 711) Monday through Friday: 8:00 a.m. to 5:00 p.m. Online: bluecrossma.com/medicare By mail: Complete the enclosed enrollment form and return it in the self-addressed envelope. By fax: Complete the enclosed enrollment form and fax it 1-617-246-8506.
Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-678-2265 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-678-2265 (TTY: 711). ® Registered Marks of the Blue Cross and Blue Shield Association. © 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 002889300 99-0617-25 (9/24)
IN THIS BOOKLET 1 Plan information • Discover something to smile about • Outline of coverage 2 Disclosures • Nondiscrimination notice • Translation resources 3 Enrollment • Enrollment forms • Business reply envelope
Plan Information 01
Dental Blue® 65 DENTAL PLANS THAT WILL MAKE YOU SMILE Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
THESE BENEFITS ARE PRETTY BRILLIANT Maintaining a healthy grin can contribute to your overall health. So we designed a plan with the benefits to keep your teeth in the best shape possible. When you add one of our three Dental Blue 65 plans to your Medicare plan, you get: • Access to 93% of local dentists and over 520,000 provider locations nationwide • Coverage for routine cleanings and exams 3 times in a calendar year • 100% coverage for preventive services with no waiting period » All waiting periods waived, based on eligibility of having continuous prior dental coverage Enhanced Dental Benefits Our Dental Blue 65 plans include Enhanced Dental Benefits, a complete program that focuses on at-risk members with qualifying medical conditions. We offer additional, specific support, including full coverage for preventive and periodontal services* that have been connected to improved overall health. Can I use my current dentist? If you already have a dentist and you want to know if they participate with Blue Cross Blue Shield of Massachusetts, you may call the dentist, refer to the most current dental provider directory at bluecrossma.com/Medicare, or call Member Service toll-free at 1-888-741-4340, Monday through Friday from 8:00 a.m. to 6:00 p.m. ET (TTY: 711). *Available on plans that offer periodontal benefits; standard waiting periods apply.
YOUR 2025 DENTAL PLAN OPTIONS Dental Blue® 65 Preventive* $26.23/month No waiting period No annual deductible or calendar-year maximum Plan pays 100% of the following: • One complete initial oral exam, including dental history, and charting your teeth and supporting structures (gums, bones) to evaluate their condition • Full mouth X-rays (7 or more films), or panoramic X-ray with bitewing X-rays, once every 60 months. Additional bitewing X-rays once every 6 months • Periapical X-rays as needed • Periodic or routine oral exams 3 times in a calendar year • Emergency exams • Study models and casts used in planning treatment once every 60 months Dental Blue® 65 Basic* $40.94/month 6-month waiting period** $100 annual deductible and $1,250 calendar-year maximum Plan pays 100% of preventive services and 50% of the following basic services: • Silver or white fillings for each tooth surface every 12 months • Tooth extractions and biopsies • Periodontal scaling and root planing, once in each quadrant every 24 months • Periodontal surgery, once in each quadrant every 36 months • Periodontal maintenance, once every 3 months • Root canals • Repairs of partial or complete dentures, crowns, and bridges, once every 12 months • Adding teeth to existing denture • Rebase or reline of dentures, once every 36 months • Recementing of crowns, inlays, onlays, and fixed bridgework, once every 12 months • Bite adjustment, once every 24 months • Services to treat root sensitivity • General anesthesia when administered in conjunction with covered surgical services • Emergency dental treatment to relieve acute pain Dental Blue® 65 Premier* $76.60/month 6-month waiting period for basic services 12-month waiting period for major services $50 annual deductible and $1,500 calendar-year maximum Plan pays 100% of preventive services, 80% of basic services, and 50% of the following major services: • Complete or partial denture, including services to fabricate and adjust, once every 60 months for each arch • Fixed bridges, including services to fabricate, and adjust, once every 60 months per tooth • Dental implant placement (once per tooth every 60 months) • Replacement of dentures and bridges, but only when they are installed at least 60 months after the initial placement, and only if the existing appliance cannot be made serviceable • Temporary partial dentures to replace any of the 6 upper or lower front teeth, but only if they are installed immediately following the loss of teeth and during the period of healing • Crowns once every 60 months for each tooth • Metallic, porcelain, and white resin inlays, once every 60 months per tooth • Replacement of crowns and metallic, porcelain, and composite resin inlays/onlays once every 60 months for each tooth • Post and core or crown buildup once every 60 months per tooth *Covered services. Please see the Outline of Coverage at bluecrossma.com/dentalblue. ** You may be eligible to have all waiting periods waived to allow you to receive minor and major restorative services right away.
Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711). ® Registered Marks of the Blue Cross and Blue Shield Association. © 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 002887200 55-0530-25 (9/24) FOR MORE INFORMATION OR TO ENROLL: Blue Cross Blue Shield of Massachusetts 1-800-678-2265 (TTY: 711) Monday through Friday, 8:00 a.m. to 5:00 p.m. ET bluecrossma.com/Medicare
2025 OUTLINE OF COVERAGE Dental Blue® 65 Preventive Dental Blue® 65 Basic Dental Blue® 65 Premier Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Effective January 1, 2025
BENEFITS TO SMILE ABOUT Maintaining a healthy grin can contribute to your overall health. So we designed our plans to keep your teeth in the best shape possible. In this document, you’ll find a detailed description and summary of benefits for these plans from Blue Cross Blue Shield of Massachusetts: • Dental Blue 65 Preventive • Dental Blue 65 Basic • Dental Blue 65 Premier ELIGIBILITY REQUIREMENTS • Age 65 or older • Resident of Massachusetts Policy Number: DENT SR (1–1–2012) “Read your subscriber certificate carefully. This disclosure statement is a very brief summary of your dental plan. The plan itself sets forth the rights and obligations of both you and the insurance company. It is, therefore, important that you read your subscriber certificate carefully.”
1 Outline of Coverage THESE BENEFITS ARE PRETTY BRILLIANT With each of our Dental Blue 65 plans, you get: Extensive access Dental Blue 65 offers access to 93 percent of practicing dentists in Massachusetts and over 520,000 provider locations nationwide. Out-of-area dentists in our nationwide network are also available to our members. Comprehensive coverage All of our Dental Blue 65 plans include coverage for dental exams 3 times within a calendar year. Plus, our members get 100% coverage for preventive services with no waiting period. Enhanced Dental Benefits Members with qualifying medical conditions receive additional, specific support, including full coverage for preventive and periodontal services* that have been connected to improved overall health. Frequently Asked Questions Can I continue to use my dentist? If you already have a dentist and want to know if they participate in our network, you can call your dentist, refer to the most current dental provider directory, or call Member Service at the number on your Dental Blue 65 ID card. How can I find a new dentist? If you’d like help choosing a new dentist, call the Physician Selection Service at 1-800- 821-1388, or visit the online dental provider directory at bluecrossma.org. When does my coverage begin? Your coverage will be effective the first of the month following the month we receive your application. For example, if we received your application on March 15, your coverage would begin on April 1. An upgrade or downgrade to a Dental Blue 65 policy made by a member will be effective on the plan renewal date, January 1st, of each year. How do I file a claim? In-network dentists will send claims to us for you. Just show them your Dental Blue 65 ID card. The payment will be sent directly to your dentist. If you receive care from an out-of-network dentist, you may have to submit the claim yourself. If you file, send the Attending Dentist’s Statement form with the original itemized bills. Any benefit payment will be sent to you. You can get a copy of the Attending Dentist’s Statement from Member Service. Any claims that you file should be sent to: Blue Cross Blue Shield of Massachusetts, P.O. Box 986030, Boston, MA 02298. All member-submitted claims must be received within two years of the date of service. (Coverage is not available for non-network dentists in Massachusetts except for covered emergency services.) The Blue Cross Blue Shield Grievance Program is fully described in the subscriber certificate. *Available on plans that offer periodontal benefits. Standard waiting periods apply.
bluecrossma.com/medicare 2 Other Information Coordination of benefits (COB) applies to plan members who are covered by another plan for health care expenses. COB ensures that payments from all health care plans do not exceed the total charges billed for covered services. Your subscriber certificate has a subrogation clause. This does not affect the scope of benefits. This clause allows claim payments to be retracted when a member recovers payment for the same charges from a third party due to liability for injury. Go green with paperless billing We offer paperless billing for your dental premiums through eBill. You can view your statement and make payments online, or sign up for electronic funds transfer (EFT) and have your premium payments deducted directly from your bank account on each due date. When you receive an initial paper invoice, sign in to your MyBlue account or create a new one at bluecrossma.org to sign up for eBilling. DENTAL BLUE 65 PREVENTIVE Monthly premium January 1, 2025–December 31, 2025: $26.23 Services and benefits Your covered services include: • One complete initial oral exam, including dental history and charting of the teeth and supporting structures • Periodic or routine oral exams 3 times within a calendar year • Routine cleaning, scaling, and polishing of the teeth 3 times within a calendar year • Full mouth X-rays, 7 or more films, or panoramic X-ray with bitewing X-rays once every 60 months • Bitewing X-rays once every 6 months • Single-tooth X-rays as needed • Study models and casts used in planning treatment once every 60 months • Emergency exams Co-insurance, annual deductible, and annual maximum This dental plan provides full benefits based on the allowed charge for participating providers. There are no annual deductibles and no annual plan maximums. Waiting periods and pre-existing condition limitations Your dental services will be covered from your effective date of this dental plan without a waiting period or pre-existing condition restrictions. Exclusions and limitations Services limited by frequency include but are not limited to: • X-rays • Exams • Cleanings Please review your dental policy for a full list of limitations and exclusions.
3 Outline of Coverage DENTAL BLUE 65 BASIC Monthly premium January 1, 2025–December 31, 2025: $40.94 Services and benefits Your covered services include: 100% coverage for all services covered under Dental Blue 65 Preventive, plus 50% coverage for: Restorative services • Amalgam (silver) fillings (limited to one filling for each tooth surface in each 12 months) • Composite resin (tooth color) fillings on teeth (limited to one filling per tooth surface in each 12 months) • Pin retention for fillings Oral surgery • Tooth extractions, root removal, and biopsies Periodontics (gum and bone) • Periodontal scaling and root planning, once in each quadrant each 24 months • Periodontal surgery (soft-and hard-tissue surgeries), once in each quadrant each 36 months • Periodontal maintenance following active periodontal therapy, once each 3 months Endodontics (root and pulp) • Root canal therapy on permanent teeth, once per lifetime for each tooth • Retreatment root canal therapy on permanent teeth, once in a lifetime for each tooth • Other endodontic surgery intended to treat or remove the dental root Prosthetic maintenance • Repair of partial or complete dentures, crowns, and bridges, once each 12 months • Adding teeth to existing partial or complete dentures • Rebase or reline dentures, once each 36 months • Recementing of crowns, inlays, onlays, and fixed bridgework, once each 12 months Other covered services • Occlusal adjustment, once each 24 months • Services to treat root sensitivity • General anesthesia when administered in conjunction with covered surgical services • Emergency dental treatment to relieve acute pain • Emergency dental treatment to control a dental condition that requires immediate care to prevent permanent harm to the member Co-insurance, annual deductible, and annual maximum This dental plan provides: • 100% coverage for all preventive services • 50% coverage for services outlined in the plan’s Services and Benefits section • Coverage is based on the allowed charge for participating providers • There is a $100 annual deductible and $1,250 calendar-year maximum Waiting periods and pre-existing condition limitations Your dental services will be covered from your effective date of this dental plan without a waiting period or pre-existing condition restrictions for all preventive services. For services that fall outside of preventive, a six-month waiting period from the effective date is required. If you’ve had continuous prior dental coverage, you may be eligible to have all waiting periods waived to allow you to receive minor and major restorative services right away. Exclusions and limitations Certain services may be limited or excluded from this plan. These services may include: • Fillings on tooth surfaces where a sealant was applied within the prior 12 months • Replacement of a filling within 12 months of the date of prior restoration • A service, supply, procedure, or appliance to stabilize teeth when it is due to periodontal disease Please review your dental policy for a full list of limitations and exclusions.
bluecrossma.com/medicare 4 DENTAL BLUE 65 PREMIER Monthly premium January 1, 2025–December 31, 2025: $76.60 Services and benefits Your covered services include: • 100% coverage for all services covered under Dental Blue 65 Preventive • 80% coverage for all services covered under Dental Blue 65 Basic • 50% coverage for: » Prosthodontics (tooth replacement) » Complete or partial dentures, including services to fabricate, measure, fit, and adjust them once each 60 months for each arch » Fixed bridges, including services to fabricate, measure, fit, and adjust them once each 60 months per tooth » Replacement of dentures and bridges, but only when they are installed at least 60 months after the initial placement, and only if the existing appliance cannot be made serviceable » Temporary partial dentures to replace any of the six upper or lower front teeth, but only if they are installed immediately following the loss of teeth and during the period of healing Major restorative services (crowns, inlays, onlays) • Crowns once each 60 months for each tooth • Metallic, porcelain, and composite resin inlays and onlays once every 60 months per tooth • Single tooth dental endosteal implants to replace permanent teeth through second molars (once per tooth in 60 months) • Replacement of crowns once every 60 months for each tooth • Replacement of metallic, porcelain, and composite resin inlays and onlays once every 60 months • Post and core or crown build up once every 60 months per tooth Co-insurance, annual deductible, and annual maximum This dental plan provides: • 100% coverage for all preventive services • 80% coverage for minor restorative services, oral surgery, periodontics, endodontics, prosthetic maintenance, and other services originally covered by Dental Blue 65 Basic • 50% coverage for major restorative services, prosthodontics/tooth replacements, crowns, inlays, onlays, dental implants and other services outlined in the plan’s Services and Benefits section • Benefits are based on the allowed charge for participating providers • There is a $50 annual deductible and $1,500 calendar-year maximum Waiting periods and pre-existing condition limitations Your dental services will be covered from your effective date of this dental plan without a waiting period or pre-existing condition restrictions for all preventive services. For services that fall outside of preventive, a 6-month waiting period from the effective date is required for minor restorative services, and a 12-month waiting period from the effective date is required for major restorative services. If you’ve had continuous prior dental coverage, you may be eligible to have all waiting periods waived to allow you to receive minor and major restorative services right away. Exclusions and limitations Certain services may be limited or excluded from this plan. These services may include: • Fillings on tooth surfaces where a sealant was applied within the prior 12 months • Replacement of a filling within 12 months of the date of prior restoration • Duplicate dentures or bridges • Cast restorations, copings, or attachments for installing overdentures, including associated endodontic procedures such as root canals, precision attachments, or semiprecision attachments Please review your dental policy for a full list of limitations and exclusions.
5 Outline of Coverage RENEWAL AND PREMIUM CHANGES Continuing your dental coverage You have the right to continue this dental plan as long as: • You pay your premiums on time • You do not make a material misrepresentation to Blue Cross Blue Shield of Massachusetts • Blue Cross Blue Shield of Massachusetts continues to offer this coverage Right to change premium Your dental premium for this dental plan may change. Blue Cross Blue Shield of Massachusetts will send you a notice at least 60 days before a change is effective. The notice will describe the change and tell you when it is effective. These changes will apply to all dental plans of this type, not just your dental plan. Allowed charge Blue Cross Blue Shield of Massachusetts calculates payment of your benefits based on the allowed charge. The allowed charge that Blue Cross Blue Shield of Massachusetts uses depends on the type of dental provider that furnishes the covered service to you. Participating dentists For covered services furnished by dentists who have a written payment agreement to furnish dental services to members enrolled in a Dental Blue plan, Blue Cross Blue Shield of Massachusetts calculates your benefits based on the provisions of the participating dentist’s payment agreement and the participating dentist’s contracted rate that is in effect at the time a covered service is furnished. This contracted rate is referred to as the dentist’s allowed charge. In most cases, you do not have to pay the amount of the participating dentist’s actual charge that is in excess of the allowed charge. However, there are certain situations when you will have to pay the difference between the claim payment and the participating dentist’s actual charge. Non-participating dentists For covered services furnished by non-participating dentists, Blue Cross Blue Shield of Massachusetts calculates your benefits based on the usual and customary charge for covered services. The term “usual and customary” means the amount allowed (also referred to as the “allowed charge”) for a service in a geographic area based on the payment levels usually accepted by dentists in the area for the same or similar service. The usual and customary charge may sometimes be less than the dentist’s actual charge. If this is the case, you will be responsible for the amount of the dentist’s actual charge that is in excess of the usual and customary charge. Please see your certificate to determine what services are covered by non-participating dentists in Massachusetts. Blue Cross Blue Shield will provide dental benefits for covered services furnished by a non-participating dentist in Massachusetts when the covered services are emergency services and a participating dentist is not reasonably available. Notice of right to examine subscriber certificate for 10 days If you are a newly enrolled subscriber in this dental plan, you have 10 days from the date you received your subscriber certificate to review it. If you are not satisfied for any reason, you have the right to return the subscriber certificate within 10 days and have your premium refunded to you.
bluecrossma.com/medicare 6 Complaints If you have a complaint, please call Member Service at 1-800-258-2226. (TTY: 711) If you aren’t satisfied, you may call the Massachusetts Division of Insurance at 1-617-521-7777 (Boston) or 1-413-785-5526 (Springfield). Important Limitations and exclusions In the event of any inconsistency between this outline of coverage and the subscriber certificate, the terms of the subscriber certificate will govern. These pages summarize the benefits of your dental care plan. Your plan description and riders define the full terms and conditions. Should any questions arise concerning benefits, the plan description and riders will govern. For a complete list of limitations and exclusions, refer to your plan description and riders.
7 Outline of Coverage NONDISCRIMINATION NOTICE Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. Blue Cross Blue Shield of Massachusetts provides: • Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print or other formats). • Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact the Medicare Advantage Appeals and Grievance Manager. If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender, you can file a grievance with the Medicare Advantage Appeals and Grievance Manager by mail at P.O. Box 55007, Boston, MA 02205; phone at 1-800-200-4255 (TTY: 711) from April 1 through September 30, 8:00 a.m. to 8:00 p.m., Monday through Friday, or October 1 through March 31, 8:00 a.m. to 8:00 p.m., seven days a week; fax at 1-617-246-8506; or email at [email protected]. You can file a grievance in person, by mail, fax, email, or you can call 1-800-200-4255 (TTY: 711). If you need help filing a grievance, the Medicare Advantage Appeals and Grievance Manager 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 online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD). Complaint forms are available at hhs.gov.
NOTES
Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711). ® Registered Marks of the Blue Cross and Blue Shield Association. © 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 002916157 55-0166-25 (9/24) FOR MORE INFORMATION OR TO ENROLL: Medicare plan sales 1-800-678-2265 (TTY: 711), Monday through Friday, 8:00 a.m. to 5:00 p.m. ET. Questions? Call Member Service toll-free at 1-888-741-4340 (TTY: 711), Monday through Friday between 8:00 a.m. and 6:00 p.m. ET. bluecrossma.com/medicare
Disclosures 02
NONDISCRIMINATION NOTICE Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. Blue Cross Blue Shield of Massachusetts provides: • Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print or other formats). • Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call Member Service at the number on your ID card. If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Civil Rights Coordinator by mail at Civil Rights Coordinator, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126; phone at 1-800-472-2689 (TTY: 711); fax at 1-617-246-3616; or email at [email protected]. If you need help filing a grievance, the Civil Rights Coordinator 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 online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD/TTY). Complaint forms are available at hhs.gov. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. 001614756 55-2067 (9/22)
TRANSLATION RESOURCES Proficiency of Language Assistance Services Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Spanish/Español: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711). Portuguese/Português: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711). Chinese/简体中文: 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- 200-4255 (TTY: 711) 。 Haitian Creole/Kreyòl Ayisyen: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-200-4255 (TTY: 711). Vietnamese/Tiếng Việt: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-200-4255 (TTY: 711). Russian/Русский: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-200-4255 (TTY: 711). ةي ب: /Arabic ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-800-200-4255( 711: TTY ) رقم هاتف الصم والبكم Mon-Khmer, Cambodian/ខ្មែរ: ប្រយ័ត្ន៖ ប ើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា បោយ មិនគិតឈ្ន ួល គឺអាចមានសំរា ់ ំបរ ើអ្នក។ ចូ រ ទូរស័ព្ទ1-800-200-4255 (TTY: 711)។ French/Français: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-200-4255 (TTY: 711). Italian/Italiano: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-200-4255 (TTY: 711). Korean/한국어: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-200-4255 (TTY: 711)번으로 전화해 주십시오. Greek/Eλληνικά: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-200-4255 (TTY: 711). Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-200-4255 (TTY: 711). Hindi/ह िंदी: ध्यान दें: यदद आप ह िंदी बोलतेहैंतो आपकेदलए मुफ्त मेंभाषा सहायता सेवाएं उपलब्ध हैं। 1-800- 200-4255 (TTY: 711) पर कॉल करें ।
Gujarati/ગુજરાતી: સુચના: જો તમેગુજરાતી બોલતા હો, તો નન:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-800-200-4255 (TTY: 711). Tagalog/Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-200-4255 (TTY: 711). Japanese/日本語: 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- 800-200-4255 (TTY: 711）まで、お電話にてご連絡ください。 German/Deutsch: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-200-4255 (TTY: 711). Lao/ພາສາລາວ: ໂປດຊາບ: ຖ້າວ່ າ ທ່ ານເ ວ້ າພາສາ ລາວ, ການບໍ ິ ລການຊ່ ວຍເຫຼື ອດ້ ານພາສາ, ໂດຍບໍ ່ ເສັ ຽຄ່ າ , ແມ່ ນມີ ພ້ ອມໃຫ້ທ່ ານ. ໂທຣ 1-800-200-4255 (TTY: 711) Navajo/Diné Bizaad: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-200-4255 (TTY: 711.) ® Registered Marks of the Blue Cross and Blue Shield Association. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001615801 55-2066-23 (9/22) 있습니다. 1-800-200-4255 (TTY: 711)번으로 전화해 주십시오. Greek/Eλληνικά: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-200-4255 (TTY: 711). Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-200-4255 (TTY: 711). Hindi/ह िंदी: ध्यान दें: यदद आप ह िंदी बोलतेहैंतो आपकेदलए मुफ्त मेंभाषा सहायता सेवाएं उपलब्ध हैं। 1-800- 200-4255 (TTY: 711) पर कॉल करें ।
Enrollment 03
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Dental Blue® 65 APPLICATION FOR DENTAL BLUE 65 Directions • Please print clearly. • Carefully read and answer all questions. Incomplete applications won’t be accepted. Keep one copy of the application for yourself. • Don’t send money with this application. You’ll receive a bill when payment is due. You’ll also receive an invitation to sign up for our eBill option. • Please complete and return to: Blue Cross Blue Shield of Massachusetts Enrollment Department P.O. Box 55011 Boston, MA 02205 • Or, fax the application to 1-617-246-8506. • To enroll by phone, call 1-800-678-2265. You’re eligible to apply for a Dental Blue 65 plan if you meet all of the following requirements: • You’re a resident of Massachusetts and you actually live in Massachusetts. • You’re age 65 or older. Questions? Individuals experiencing homelessness • The dental premium rate and benefits are explained in the Outline of Coverage you received with this application. If you need more information or assistance, call us at 1-800-678-2265. • For all other questions, call Dental Blue 65 Member Service at 1-888-741-4340 (TTY: 711). • If you want to join a plan but have no permanent residence, a Post Office Box, an address of a shelter or clinic, or the address where you receive mail (e.g., Social Security checks) may be considered your permanent residence address.
Please answer all questions. I am applying for: Dental Blue® 65 Preventive ($26.23/month) Dental Blue® 65 Basic ($40.94/month) Dental Blue® 65 Premier ($76.60/month) Your Social Security number:* _________ - ________ - ______________ How often would you like to be billed? Monthly Quarterly Would you like your premium payment due on the 1st of the month or the 15th of the month? 1st of the month 15th of the month First name: Last name: Middle initial: Your gender: Male Female Non-binary Your complete date of birth: ( —— —— ————) M M D D Y Y Y Y Your telephone number: ( ) – Your permanent home address: Number and street City: State: ZIP Code: If you want your Dental Blue 65 bill sent to an address other than your home address, complete the following section. Your billing address only: Number and street City: State: ZIP Code: Your email address (optional): By providing your email, you are opting in to receiving your plan materials digitally. You can opt out at any time. Are you currently a Blue Cross Blue Shield of Massachusetts member? Yes No If yes, provide your Blue Cross Blue Shield identification number: The information here is complete and true. I understand that Blue Cross and Blue Shield will rely on this information to enroll me into a dental plan membership. I understand that I should read the subscriber certificate to understand my benefits and any restrictions that apply to my health care plan. I understand that Blue Cross and Blue Shield may obtain personal and medical information about me to carry out its business, and that it may use and disclose that information in accordance with law. I acknowledge that I may obtain further information about the collection, use, and disclosure of my information in “Our Commitment to Confidentiality,” Blue Cross and Blue Shield’s notice of privacy practices. Applicant’s signature: Date: Will this policy replace an active dental insurance policy? Yes No If yes, please complete the “Notice to Applicant” form and include it with this application. Please also indicate below if the policy will replace an existing policy with continuous, uninterrupted coverage for: 6 months of Basic Restorative benefits 12 months of Major Restorative benefits * Under the Affordable Care Act, we’re required to collect your Social Security number when you enroll in one of our plans.
Notice to Applicant If you intend to lapse or otherwise terminate your present policy and replace it with a policy to be issued by Blue Cross Blue Shield of Massachusetts, you must sign and return this form with your application. For your own information and protection, certain facts should be pointed out to you, which could affect your rights to coverage under the new policy. Health conditions, which you may presently have, may not be covered under the new policy. This could result in a claim for benefits being denied that have been payable under your present policy. Even though some of your present health conditions may be covered under the new policy, these conditions may be subject to certain waiting periods under the new policy before coverage is effective. Questions in the application for the new policy must be answered truthfully and completely; otherwise, the validity of the policy and the payment of any benefits thereunder may be voided. It may be to your advantage to secure the advice of your present carrier or its agent regarding the proposed replacement of your present policy. This is your right under the policy you have chosen. Applicant’s signature: Date:
Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-678-2265 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-678-2265 (TTY: 711). ® Registered Marks of the Blue Cross and Blue Shield Association. © 2025 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 003349550 Y0014_23205_C 55-0167-25 (2/25) FOR MORE INFORMATION OR HELP WITH ENROLLMENT Call 1-800-678-2265 (TTY: 711), Monday through Friday, 8:00 a.m. to 5:00 p.m. ET bluecrossma.com/medicare
Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-678-2265 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-678-2265 (TTY: 711). ® Registered Marks of the Blue Cross and Blue Shield Association. © 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 002886803 99-0656-25 (9/24) FOR MORE INFORMATION OR TO ENROLL: Medicare plan sales: 1-800-678-2265 (TTY: 711) 8:00 a.m. to 8:00 p.m. ET, Monday through Friday bluecrossma.com/Medicare 3-346