BCBSMA Medex Core Sapphire Bronze SalesBook 2002 (V4_012022_0493) Approved by Angela Gagnon 01/21/2022 1:33 PM

Medex®´ 2022

MEDICARE
SUPPLEMENT
PLANS

Medex®´ Core
Medex®´ Sapphire
Medex®´ Bronze
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.
2022 (V3_120321_9324)



101 Huntington Avenue
Suite 1300
Boston, MA 02199-7611
bluecrossma.org

Dear Prospective Member:
Thank you for your interest in our Medex®´ plans.
Original Medicare doesn’t cover everything. Our plan options, Medex Core, Medex Sapphire,
and Medex Bronze, are designed to fill the gaps. We want you to get the coverage that best
fits your needs, so please see the enclosed guide to find out which plan is right for you.

  

See How Medex Can Compare Your Choose How to Enroll
Bring You Peace of Mind Coverage Options at Your Convenience

Why Choose Blue?

Quality, service, and trust. That’s why more people in Massachusetts choose
our Medicare plans over any other option.1
If you have any questions, we’re here to help.

Sincerely,

Gloria Paradiso, Online: bluecrossma.com/medicare
Executive Director, Medicare Sales
Enclosures By mail: Complete the enclosed enrollment form and mail
in the self-addressed envelope.
Ready to Enroll?
By fax: Complete the enclosed enrollment form and fax
By phone: 1-800-678-2265 (TTY: 711) to 1-617-246-8506.
Monday through Friday,
8:00 a.m. to 5:00 p.m. ET.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee
of the Blue Cross and Blue Shield Association.

1. Represents Medicare Advantage and Medicare Supplemental Individual
and Group plan membership based on data from CMS (cms.gov)
and the Massachusetts Department of Insurance (mass.gov).

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.
®´ Registered Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross

and Blue Shield of Massachusetts HMO Blue, Inc. © 2021 Blue Cross and Blue Shield
of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000894892 99-0483-22 (9/21)

IN THIS BOOKLET

Plan Information
• Solutions to

Supplement Medicare
• Outline of Medicare

Supplement Coverage

Resources
• Seminar Information
• It Pays to Stay Blue
• Vision and Hearing
• GeoBlue® International

Medical Coverage

Disclosures
• Nondiscrimination Notice
• Translation Resources

Enrollment
• Enrollment Forms
• Business Reply Envelope



01

Plan
Information



Medex®´ Core,
Medex®´ Sapphire,
and Medex®´ Bronze
Plans for 2022

FILLING THE
GAPS IN YOUR
MEDICARE PLAN

Our Medex®´ plans are
designed to complement
your Original Medicare
coverage.

Blue Cross Blue Shield of Massachusetts
is an Independent Licensee of the Blue Cross
and Blue Shield Association.

The Choice Is Yours

With Medex from Blue Cross
Blue Shield of Massachusetts,
you have the freedom to pick what
you need from your health plan.

CONTENTS Medicare and Medex Together . . . 7–14
Medicare Coverage Combined
Medex . . . . . . . . . . . . . . . . . . . . 1–2 with a Medex Plan . . . . . . . . . . . 7–12
The Freedom of Medex . . . . . . . . . . 1 Medex Coverage
An Introduction to Medex. . . . . . . . . 2 Wellness Programs . . . . . . . . . . . . .13
How Medex Works . . . . . . . . . . . . .14
Medicare . . . . . . . . . . . . . . . . . 4–6
What Is Original Medicare? . . . . . . . . 3 Enrollment in Medex . . . . . . . . . .14–17
Why Do I Need Am I Eligible for Medex? . . . . . . . . . .14
to Supplement Medicare? . . . . . . . . 5 When Do I Enroll? . . . . . . . . . . . . . .15
Medicare Coverage . . . . . . . . . . . . 6 How Do I Enroll? . . . . . . . . . . . . . . 16
When Will My Coverage Begin? . . . . .17

Miscellaneous Information . . . . . 18–19
Premium Rates . . . . . . . . . . . . . . .18
Helpful Numbers . . . . . . . . . . . . . 19

THE FREEDOM OF MEDEX

Original Medicare doesn’t cover everything. That’s where we come in.

Our Medex plans complement your coverage by lowering out-of-pocket costs, filling in
the gaps in Original Medicare, and giving you the power to see any Medicare provider
in the country without a referral.

With Medex, you can enjoy:

  PEACE OF MIND

WORLDWIDE COVERAGE HEALTHY BENEFITS Enjoy the security of having
a Blue Cross Blue Shield
Explore comfortably knowing Medex Core, Sapphire, of Massachusetts ID
that Medex includes coverage and Bronze members are
for urgent or emergency care eligible for a $150 fitness card—the most recognized
when traveling internationally. ID card in health care today.
reimbursement and
a $150 weight-loss
benefit each year.



Please read this booklet to learn everything you need
to know about Medicare supplement plans and Medex.

If you think Medex is right for you, or if you have any questions,
call us toll-free at 1-800-678-2265 (TTY: 711),

Monday through Friday, 8:00 a.m. to 5:00 p.m. ET,
or visit bluecrossma.com/medicare for more information.

1 Medex Sales: 1-800-678-2265

AN INTRODUCTION TO MEDEX

Medex, our Medicare supplement plan, can be added to Medicare Part A and Part B coverage
to fill “gaps” in your Medicare coverage.
As a supplemental insurance plan, Medex helps cover health care expenses left over after
Medicare has covered its portion of costs.

Three Plans to Choose From

+

Medex Bronze

Full Supplemental

Parts Keep  Medicare Coverage
A+B Original Supplement
Medicare Insurance — or —
and add…
Medex Sapphire
Enhanced Supplemental

Coverage

— or —

Medex Core

Basic Supplemental
Coverage

Depending on which option you choose, Medex may cover some or virtually all
of Medicare cost-sharing amounts, or “gaps,” as well as some services not covered
by Medicare. You’ll learn more about Medicare cost-sharing amounts in the next
few pages.
We’ll also help you determine which Medex plan is right for you by discussing
what each plan covers and comparing costs.

bluecrossma.com/medicare 2

WHAT IS ORIGINAL MEDICARE?

Original Medicare is a federally funded health insurance plan. It’s designed
for people age 65 or older and some disabled people under age 65.

ORIGINAL MEDICARE HAS TWO PARTS:

 

MEDICARE PART A MEDICARE PART B

(HOSPITAL INSURANCE) (MEDICAL INSURANCE)
pays for inpatient hospital expenses.
pays for outpatient hospital charges,
doctor visits, and many other medical

services not covered by Part A.

Services Covered: Services Covered:

Facility Care Medical Expenses

• Inpatient hospital care • Hospice care • Doctors’ services • Ambulance trips
• Skilled nursing • Home health services • Physical and • Durable medical equipment
• Diabetic testing supplies
facility care speech therapy
• Diagnostic tests

3 Medex Sales: 1-800-678-2265

Important: If you haven’t
enrolled in Medicare, contact
your local Social Security
office three months prior
to your 65th birthday.

bluecrossma.com/medicare 4

WHY DO I NEED TO SUPPLEMENT MEDICARE?

Although Medicare pays a large portion of your medical expenses, you’re responsible
for the remaining costs. Also, Medicare doesn’t cover all medical services in all situations.
Expenses that aren’t covered by Medicare are often referred to as “gaps.” Medicare supplement
(“Medigap”) plans, like Medex, help to fill in these coverage gaps, such as:
• You may have to pay deductible and co-insurance costs. When Medicare covers

a service, you often must pay for a portion of the cost. Your portion is referred to as a
deductible or co-insurance. Deductibles are the amount you’re responsible for before
Medicare begins to pay, and they’re subject to change from year to year. After your
deductible is paid, you may need to pay an additional amount—usually 20 percent
of the cost for the service, called co-insurance.
• In most cases, Medicare doesn’t cover you outside the United States, even in the event
of an emergency. Please refer to the chart on page 6 for an illustration of Medicare coverage
that’s not supplemented with a Medex plan. The chart highlights Medicare’s benefits,
deductible, and co-insurance costs, and some of the services Medicare doesn’t cover.
Please refer to the charts on pages 7 through 14 for coverage when Medicare is combined
with a Medex plan.

The Medicare benefits included in the charts on the following
pages are effective January 1, 2022.

Medicare deductibles and co-insurances
are subject to change each year.

5 Medex Sales: 1-800-678-2265

Medicare Coverage

(Without Supplemental Insurance)

Medicare Part A Your Cost

Inpatient Hospital Care $1,556 deductible
$389 per day co-insurance
Days 1–60 each benefit period: 100% coverage after you pay $778 per day co-insurance
the $1,556 deductible All costs after 150 days
Days 61–90 each benefit period: 100% coverage after you pay
$389 per day co-insurance No cost
Days 91–150 (60 lifetime reserve days): 100% coverage after you pay $194.50 per day co-insurance
$778 per day co-insurance All costs after 100 days

Days 150+: no coverage

Skilled Nursing Facility Care

Days 1–20 each benefit period: 100% coverage

Days 21–100 each benefit period: 100% coverage after you pay
$194.50 per day co-insurance

No coverage after 100 days in a benefit period

Medicare Part B Your Cost

Medical Expenses • Ambulance • Doctors’ services
• Diagnostic tests • Durable medical equipment
• Diabetic testing supplies • Physical and speech therapy

Coverage begins after you pay the $233 calendar-year deductible $233 deductible

Medicare covers 80% of the Medicare-approved amount; you pay 20% co-insurance
20% co-insurance

Prescription Drugs Most outpatient prescription costs

Members may voluntarily purchase Medicare Part D, which covers
prescription drugs (unless the drug is covered under Part B)

Routine Services and Preventive Care No cost when Medicare covers the
100% coverage for specific Medicare preventive services. preventive service in full and provider
A complete list is found on the Medicare website, medicare.gov accepts assignment

Travel Outside the United States All costs
No coverage for medical costs incurred outside the United States

bluecrossma.com/medicare 6

MEDICARE COVERAGE

(Combined with a Medex Core Plan)

Days Medicare Medex Core
1–60 (Medicare Supplement Core)
Coverage for 60 days, Coverage for Medicare daily
Hospital 61–90 after the $1,556 deductible1 co-insurance after you pay
Services Coverage for 61–90 days, $1,556 Part A deductible
Lifetime after $389 daily co-insurance
Reserve Coverage for an additional 60 Full coverage for lifetime reserve co-
lifetime reserve days, after $778 insurance, then an additional 365 days
Skilled 1–20 daily co-insurance per lifetime when Medicare benefits end
Nursing 21–100 Full coverage for 20 days in a Covered by Medicare
Facility 101+ Medicare-participating facility
Coverage for days 21–100, No coverage
Physician and Other after $194.50 daily co-insurance
Provider Services No coverage after 100 days No coverage
Care in the Hospital
80% coverage of approved services, Coverage of 20% co-insurance, after you
Physician and Other after the $233 annual Part B deductible pay $233 annual Part B deductible
Provider Services
80% coverage of approved services, Coverage of 20% co-insurance, after you
Outpatient Department Visits, after the $233 annual Part B deductible pay $233 annual Part B deductible
Office Visits, and Patient
Home Visits 80% coverage of approved services, Coverage of 20% co-insurance, after you
after the $233 annual Part B deductible pay $233 annual Part B deductible
Other Part B Services,
Ambulance Trips, Durable
Medical Equipment, Etc.

Note: Although the $233 calendar-year Medicare medical insurance (Part B) deductible appears more than once
in this benefit chart, only one $233 deductible is applicable in a calendar year. The Medex policy defines the terms
and conditions of all the Medex plans in greater detail. Should any questions arise concerning benefits, the Medex
policy will govern.

This chart doesn’t include all Medicare benefits. Please refer to the Medicare & You handbook published by the
Centers for Medicare and Medicaid Services for more information about Medicare benefits, or call 1-800-MEDICARE
(1-800-633-4227) (TTY: 1-877-486-2048). You can also visit cms.gov for more information.

Refer to the Index on page 20 for an explanation of the footnotes above.

7 Medex Sales: 1-800-678-2265

MEDICARE COVERAGE

(Combined with a Medex Sapphire Plan)

Days Medicare Medex Sapphire
(Medicare Supplement 1A)
Hospital 1–60 Coverage for 60 days,
Services after the $1,556 deductible1 Full coverage of Medicare
61–90 and co-insurance deductible insurance

Lifetime Coverage for 61–90 days, Full coverage for lifetime reserve
Reserve after $389 daily co-insurance co-insurance, then an additional 365 days
per lifetime when Medicare benefits end
Skilled 1–20 Coverage for an additional 60
Nursing 21–100 lifetime reserve days, after $778 daily Covered by Medicare
Facility 101+ co-insurance
Full coverage for Medicare daily
Physician and Other Full coverage for 20 days in a co-insurance for days 21–100
Provider Services Medicare-participating facility $10 a day for days 101–3652 at a
Care in the Hospital Medicare-participating facility
Coverage for days 21–100,
Physician and Other after $194.50 daily co-insurance Coverage of 20% co-insurance, after
Provider Services you pay $233 annual Part B deductible
Outpatient Department Visits, No coverage after 100 days
Office Visits, and Patient Coverage of 20% co-insurance, after
Home Visits 80% coverage of approved services, you pay $233 annual Part B deductible
after the $233 annual Part B deductible
Other Part B Services, Coverage of 20% co-insurance, after you
Ambulance Trips, Durable 80% coverage of approved services, pay $233 annual Part B deductible
Medical Equipment, Etc. after the $233 annual Part B deductible
Continued
80% coverage of approved services,
after the $233 annual Part B deductible

Refer to the Index on page 20 for an explanation of the footnotes above.

bluecrossma.com/medicare 8

MEDICARE COVERAGE

(Combined with a Medex Bronze Plan)

Days Medicare Medex Bronze
1–60 (Medicare Supplement 1)
Coverage for 60 days,
Hospital 61–90 after the $1,556 deductible1 Full coverage of Medicare deductible
Services and co-insurance
Lifetime Coverage for 61–90 days,
Reserve after $389 daily co-insurance

Coverage for an additional Full coverage for lifetime reserve
60 lifetime reserve days, co-insurance, then an additional 365 days
after $778 daily co-insurance per lifetime when Medicare benefits end

1–20 Full coverage for 20 days in a Medicare- Covered by Medicare
21–100 participating facility
101+
Skilled Coverage for days 21–100, Full coverage for Medicare daily
Nursing after $194.50 daily co-insurance co-insurance for days 21–100
Facility

No coverage after 100 days $10 a day for days 101–3652
at a Medicare-participating facility

Physician and Other 80% coverage of approved Full coverage of Medicare deductible
Provider Services services, after the $233 annual and co-insurance
Care in the Hospital Part B deductible

Physician and Other 80% coverage of approved Full coverage of Medicare deductible
Provider Services services, after the $233 annual and co-insurance
Outpatient Department Visits, Part B deductible
Office Visits, and Patient
Home Visits 80% coverage of approved Full coverage of Medicare deductible
services, after the $233 annual and co-insurance
Other Part B Services, Part B deductible
Ambulance Trips, Durable
Medical Equipment, Etc.

Refer to the Index on page 20 for an explanation of the footnotes above.

9 Medex Sales: 1-800-678-2265

These Medicare benefits are effective January 1, 2022.
Medicare deductibles and co-insurances are subject to change
each year.

Medicare Medex Core, Medex Sapphire
& Medex Bronze

Biologically Inpatient • Coverage for days 1–60 per benefit • Full coverage of the Medicare
Based Mental Admissions in a period, after the $1,556 inpatient deductible3 and co-insurance
Conditions1 General Hospital deductible2
or Mental • Full coverage of lifetime reserve
Hospital • Coverage for days 61–90, after $389 days co-insurance
daily co-insurance
• Full coverage of up to 365 additional
• Coverage for an additional 60 lifetime hospital days in your lifetime when
reserve days, after $778 daily Medicare benefits end4
co-insurance

• Coverage for mental hospital
admissions is limited to 190 days
per lifetime

Outpatient Visits • Full benefits, less the Part B • When covered by Medicare, full
deductible and the Part B co- coverage of Medicare deductible5 and
insurance co-insurance with no visit maximum

• When not covered by Medicare, full
Medex benefits with no visit maximum

Refer to the Index on page 20 for an explanation of the footnotes above.

bluecrossma.com/medicare 10

MEDICARE COVERAGE

(Combined with a Medex Plan)

Medicare Medex Core, Medex Sapphire
& Medex Bronze
Non-Biologically Inpatient • Coverage for days 1–60 per benefit • Full coverage of the Medicare
Based Mental Admissions in a period, after the $1,556 inpatient
Conditions General Hospital deductible1 deductible2 and co-insurance
(includes drug • Full coverage of lifetime reserve
addiction and Inpatient • Coverage for days 61–90,
alcoholism) Admissions in a after $389 daily co-insurance days co-insurance
Mental Hospital • Full coverage of up to 365 additional
• Coverage for an additional 60
lifetime reserve days, after $778 hospital days in your lifetime when
daily co-insurance Medicare benefits end3

• Coverage for mental hospital • Full coverage of Medicare deductible2
admissions is limited to 190 days and co-insurance
per lifetime
• Full coverage of lifetime reserve
• Same coverage as general hospital, day co-insurance
but coverage limited to 190 days
per lifetime • When Medicare days are used up,
120 days per benefit period (at least
Outpatient Visits • Full benefits, less the Part B 60 days per calendar year), less any
deductible and the Part B days in a mental hospital already
co-insurance covered by Medicare or Medex in that
benefit period (or calendar year)

• When covered by Medicare, full
coverage of Part B deductible4 and
co-insurance with no visit maximum

• When not covered by Medicare,
full Medex benefits with no visit
maximum

Refer to the Index on page 20 for an explanation of the footnotes above.

11 Medex Sales: 1-800-678-2265

These Medicare benefits are effective January 1, 2022.
Medicare deductibles and co-insurances are subject to change
each year.

Medicare Medex Core, Medex Sapphire
& Medex Bronze

Travel Outside No coverage Full coverage (same as in United States)
the United States

Fitness Benefit No coverage Medex members may receive up to $150
per calendar year in qualified health club
membership fees and exercise classes

Weight-loss Benefit No coverage Medex members may receive up to $150
per calendar year when enrolled in a qualified
weight-loss program

Medicare Medex Core and Medex Sapphire

Diabetic Testing Supplies1 80% coverage of approved For blood glucose monitoring equipment
services, after $233 annual and supplies covered by Medicare:
Part B deductible • Coverage for Medicare co-insurance

For urine-testing materials
(not covered by Medicare):
• 100% coverage of allowed charges

Medicare Medex Bronze

Diabetic Testing Supplies1 80% coverage of approved For blood glucose monitoring equipment
services, after $233 annual Part and supplies covered by Medicare:
B deductible • Coverage for Medicare deductible

and co-insurance

For urine-testing materials
(not covered by Medicare):
• 100% coverage of allowed charges

Refer to the Index on page 20 for an explanation of the footnotes above.

bluecrossma.com/medicare 12

MEDEX COVERAGE WELLNESS PROGRAMS

Fitness Reimbursement

With Medex, you can receive up to $150 per calendar year when you enroll
in a qualified health club or fitness facility.

Qualified for Reimbursement: Not Qualified for Reimbursement:

• Health clubs with a variety of cardiovascular • One-time initiation or termination fees
and strength-training exercise equipment— • Fees paid for gymnastics, tennis,
e.g., traditional health clubs, YMCAs, YWCAs,
and community fitness centers pool-only facilities, martial arts schools,
instructional dance studios, country clubs
• Fitness studios with instructor-led group or social clubs, sports teams or leagues
classes such as yoga, Pilates, Zumba®´´ • Personal trainer sessions
kickboxing, indoor cycling/spinning, • Fitness equipment or clothing
and other exercise programs
Note: Referenced scenarios may be considered
• Virtual/on-line fitness memberships, taxable income.
subscriptions, programs, or classes that
provide cardiovascular and strength-
training using a digital platform.

• Fitness classes available at participating
Councils on Aging facilities

Weight-Loss Reimbursement

With Medex, you can receive up to $150 per calendar year when you enroll
in a qualified weight-loss program.

Qualified for Reimbursement: Not Qualified for Reimbursement:

• Traditional WW (formerly knows as Weight • One-time initiation or termination fees
Watchers®´´) meetings, WW At Work, WW • Food, supplements, books, scales,
online, and other non-hospital programs
(in-person or online) that combine healthy or exercise equipment
eating, exercise, and coaching sessions • Individual nutrition counseling sessions
with certified health professionals such
as nutritionists, registered dietitians, (see your health plan coverage)
or exercise physiologists

• Hospital based weight-loss programs

13 Medex Sales: 1-800-678-2265

HOW MEDEX WORKS

With Medex, you show two cards when you receive medical care:
your Medicare card and your Medex card. Medicare pays first.

Medex plans have many advantages • You can adjust your Medex coverage
at any time during the year. Your coverage
• You can get care from any in the new plan will begin the first of the
Medicare physician or hospital month following receipt of your request
throughout the United States. to change plans.*

• You don’t need to choose • Your Blue Cross Blue Shield of
a primary care provider (PCP). Massachusetts ID card is recognized
around the world.
• You don’t need to get referrals
for specialty care.

• There are no copayments for
physician services.

Am I Eligible for Medex?

You’re eligible for Medex if you meet the following requirements:

• You live in Massachusetts. • You may also be eligible if you’re
• You’re enrolled (or will be enrolling) in under age 65 and have a disability.

Medicare Parts A and Part B.

Medex Bronze shall, on or after January 1, 2020, only be offered to
eligible persons who: (a) have attained 65 years of age before January 1,
2020; or (b) first became eligible for Medicare due to age, disability before

January 1, 2020. Those who are otherwise eligible for Medicare Part A
and Part B and who are enrolled in Medicare Part B, but who aren’t eligible

to purchase Medex Bronze, shall be eligible to purchase all other
Direct Billed Medex plans that are currently offered.

Note: If you’re already covered by both Medicare and Medicaid, you may not need the additional coverage that Medex
would provide. For more information, contact the Massachusetts Executive Office of Elder Affairs insurance counseling
program at 1-800-882-2003.

*If you newly enroll in a Medex Bronze plan and you became Medicare Eligible before January 1, 2020, you won’t be able to
switch into Medex Sapphire until you have been covered under the Medex Bronze plan for a period of at least 12 months.

bluecrossma.com/medicare 14

WHEN DO I ENROLL?

You can apply for Medex during initial eligibility or continuous Open Enrollment,
and in special situations.

Initial eligibility

You’re considered “initially eligible” if one of the situations in the chart below applies to you.

If You’re: You May Apply for Medex:
Under 65

Enrolling in Medicare due to a disability Within six months of your Medicare Part B
effective date

Approaching 65

Enrolling in both parts of Medicare Within six months of your 65th birthday

Retiring from an employer-sponsored health plan Within six months of your Medicare Part B
and enrolled in Medicare Part B or enrolling in Medicare effective date
Part B

Over or Under 65

Involuntarily losing an employer-sponsored
retiree health plan

Moving out of the service area of a Medicare health Within six months of the event
maintenance organization (HMO)

Becoming a resident of Massachusetts

Medex Continuous Open Enrollment

You may apply for Medex coverage at any time. Your coverage will begin the first of the
month following the receipt of the application.
Please note: If you wish to switch from a Medicare Advantage plan to a Medex plan,
call 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048) to learn how to dis-enroll
from your Medicare Advantage plan.

15 Medex Sales: 1-800-678-2265

HOW DO I ENROLL?

If you want to enroll in Medex, just follow these easy steps:

 

CHOOSE A PLAN SET UP PAYMENT ENROLL AT YOUR
CONVENIENCE
Find the right Medex plan Customize your payment
for you by reviewing the plan: choose between Enroll online, by phone,
charts in this brochure, monthly or quarterly by mail, or by fax. You’ll need
comparing coverage details, billing, and having your
and determining which premium due on the 1st to provide the Medicare
or 15th of each month. number that appears
option best suits on your Medicare card.
your unique needs. See below for details.*

*If you don’t have your Medicare card, contact the Social Security Administration office.

Please note: that spouses need to enroll separately. If you receive your health benefits through a group contract (such as a
former employer), please follow that group’s enrollment procedures. Make sure that you keep a copy for your records.

Enrolling Is Easy
If you’re ready to enroll in Medex, you can enroll by telephone, online, by mail, or by fax:

Phone: Call 1-800-678-2265, Mail: Complete and return the enclosed
Monday through Friday, 8:00 a.m. to 5:00 p.m. ET. enrollment form in the pre-addressed business
reply envelope provided.
Online: Visit our website, bluecrossma.com/medicare,
and click Enroll, then Online. Fax: You may also fax your completed
enrollment form to us at 1-617-246-3633.

And that’s it! No need to send your premium payment with the application. You’ll receive a bill after your application
has been processed. If you have any questions about enrolling, please call us at 1-800-678-2265.

bluecrossma.com/medicare 16

WHEN WILL MY COVERAGE BEGIN?

If you don’t have Medicare coverage yet, the effective date of your Medex coverage
is determined by the effective date of your Medicare Part B coverage.
If you already have Medicare coverage, your effective date is determined by the date
we receive your application.

If Your Application Is Received: Your Medex Coverage Will Begin

• Before the effective date of your Medicare coverage • The same day as your Medicare coverage
• Within the first six months of your Medicare Part B • The first day of the month following the month

coverage, or your application is received
• During continuous open enrollment

Please Note: If you haven’t enrolled in Medicare, contact your local Social Security
Administration office three months prior to your 65th birthday.

17 Medex Sales: 1-800-678-2265

SAVE ON YOUR PREMIUMS

When you turn 65 and become initially eligible for Medicare, you may qualify
for a discounted Direct Pay Medex premium rate for up to three years.

15% 10% 5%

FIRST-YEAR SECOND-YEAR THIRD-YEAR
SAVINGS SAVINGS SAVINGS

To determine if you’re eligible for the discount, call 1-800-678-2265.

2022 Rates Billed Monthly Billed Quarterly
Medex Core $113.58 $340.35
Medex Sapphire $190.55 $570.96
Medex Bronze $226.29 $678.06

Rates effective January 1, 2022 through December 31, 2022.

Please note: If you obtained Medicare under the age of 65 due to disability, you’re not
eligible for the discount.

bluecrossma.com/medicare 18

WE’RE HERE TO HELP

We understand that health care can be confusing, particularly when combining
plans like Medicare and Medex. The resources provided below can help you
determine who to call to get the information you need.

Blue Cross Blue Shield Medicare
of Massachusetts
If you have questions regarding Medicare,
Blue Cross Blue Shield of Massachusetts or to order a Medicare & You handbook,
associates can answer questions regarding call 1-800-MEDICARE (1-800-633-4227)
Medex options, premium rates, applications, (TTY: 1-877-486-2048) or visit cms.gov.
timing, enrollment, and other Medex-related
issues. 24/7 Nurse Line:
Medex Sales: 1-800-678-2265 TTY: 711 1-888-247-BLUE (2583)

Serving the Health Information Not sure if you need to see a doctor?
Needs of Everyone (SHINE) Medex members can call a registered nurse 24
hours a day at the Nurse Line for immediate
SHINE is an independent organization assistance with health-related questions.
dedicated to helping you understand
and compare all your health plan options. We think it’s important
Trained and certified counselors help for you to know...
you determine if you qualify for any
supplemental assistance programs. At the onset of an emergency medical
All services are free of charge. condition that in your judgment requires
1-800-AGE-INFO (1-800-243-4636) immediate attention, you should go to the
nearest emergency room. For assistance,
call your local emergency medical service
system by dialing 911, or your local emergency
telephone number.

19 Medex Sales: 1-800-678-2265

INDEX

Medicare Coverage (Combined with a Medex Core, Medex Sapphire, or Medex Bronze Plan) Refer to Pages 7, 8, 9
1. A benefit period begins on the first day you receive services 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 consecutive days.
2. Medex Bronze and Medex Sapphire coverage also includes $8 a day for days 1–365 at a

non-Medicare-participating facility.

Refer to Page 10
1. Biologically based mental conditions are defined as: schizophrenia; schizoaffective disorder; major depressive disorder;

bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder; delirium
and dementia; affective disorders; eating disorders; substance abuse; post-traumatic stress disorder (PTSD); autism;
and any biologically based mental disorders that are scientifically recognized and approved by the Massachusetts
Department of Mental Health. Treatment for rape-related mental or emotional disorders is covered to the same extent
as biologically based conditions.
2. A benefit period begins on the first day you receive services 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.
3. Medex Core provides full coverage for Medicare daily co-insurance after you pay $1,556 Part A deductible,
and mental hospital coverage is limited to 60 days per calendar year.
4. Both days in a general hospital and days in a mental hospital count toward the 365 additional days per lifetime.
5. When covered by Medicare, Medex Core and Medex Sapphire provide full coverage of Medicare 20% co-insurance,
after you pay $233 annual Part B deductible, with no visit maximum.

Medicare Coverage (Combined with a Medex Plan) Refer to Page 11
1. A benefit period begins on the first day you receive services 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.
2. Medex Core provides full coverage for Medicare daily co-insurance after you pay $1,556 Part A deductible,

and mental hospital coverage is limited to 60 days per calendar year.
3. Both days in a general hospital and days in a mental hospital count toward the 365 additional days per lifetime.
4. When covered by Medicare, Medex Core and Medex Sapphire provide full coverage of Medicare 20% co-insurance,

after you pay $233 annual Part B deductible, with no visit maximum.

Refer to Page 12
1. Medicare covers blood glucose materials for all diabetics, whether or not insulin-dependent. Medicare doesn’t

cover urine-testing materials.

For plan information and a personal consultation,
call us at 1-800-678-2265 (TTY: 711)

Monday through Friday, 8:00 a.m. to 5:00 p.m. ET.

bluecrossma.com/medicare 20

 Medicare Plan Sales:

RESOURCES 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 doesn’t 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.
®´ Registered Marks of Blue Cross and Blue Shield of Massachusetts, Inc.,

and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

®´´ Registered Marks are the property of their respective owners.
© 2021 Blue Cross and Blue Shield of Massachusetts, Inc.,

or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

001037851 42-0430-22 V2 (12/21)

Medex®´

OUTLINE OF MEDICARE
SUPPLEMENT COVERAGE

Benefit Plans Medicare Supplement Core
Through Supplement 1A

Medicare Supplement Insurance can be sold in only standard plans. This chart shows the benefits
included in each plan. Every company must make available the “Core” plan. For persons who became
Medicare Eligible prior to January 1, 2020, companies which make Medicare Supplement 1A plans
available are to also make Medicare Supplement 1 plans available. For persons who became
Medicare Eligible after January 1, 2020, companies may make Medicare Supplement 1A plans
available, but they are not permitted to make Medicare Supplement 1 plans available. Companies
may add certain benefits to the standard benefits, if approved by the Commissioner. Look at each
company’s materials to find out what benefits, if any, the company has added to the standard
benefits for each plan it offers.

Basic Benefits Included in all plans.
Hospitalization
Part A co-insurance coverage for the first 90 days per benefit period (not including the
Medical Expenses Medicare Part A deductible) and the 60 Medicare lifetime reserve days, plus coverage
Blood for 365 additional days after Medicare benefits end. This shall include benefits for
biologically based mental disorders.

Part B co-insurance (generally 20% of Medicare-approved expenses) or, in the case
of hospital outpatient department services under a prospective payment system, applicable
copayments. This shall also include benefits for biologically based mental disorders.

First three pints of blood each year.

For more information: bluecrossma.com/medicare
1-800-678-2265 (TTY: 711) Monday through Friday,

8:00 a.m. to 5:00 p.m.

Independent Licensee of the Blue Cross and Blue Shield Association.

Medicare Supplement Core Medicare Supplement 1 Medicare Supplement 1A
Medex®´ Core Medex®´ Bronze Medex®´ Sapphire
Standard Benefits
Basic Benefits Hospitalization Hospitalization
For biologically based mental For biologically based mental
Hospitalization disorders, stays in a licensed mental disorders, stays in a licensed mental
For biologically based mental hospital; for other mental disorders: hospital; for other mental disorders:
disorders, stays in a licensed mental stays in a licensed mental hospital stays in a licensed mental hospital
hospital, less Part A deductibles; for a minimum of 120 days per for a minimum of 120 days per
for other mental disorders: stays benefit period (at least 60 days per benefit period (at least 60 days per
in a licensed mental hospital for at calendar year) less days covered by calendar year) less days covered by
least 60 days per calendar year less Medicare or already covered by plan Medicare or already covered by plan
days covered by Medicare or already in that calendar year for the other in that calendar year for the other
covered by plan in that calendar year mental disorders. mental disorders.
for the other mental disorders, less Skilled nursing co-insurance Skilled nursing co-insurance
Part A deductibles. Part A deductible Part A deductible
Part B deductible Foreign travel
Additional Benefits Foreign travel
Fitness program Fitness program
Fitness program Weight-loss program
Weight-loss program Weight-loss program
Billed monthly: $190.55
Foreign travel Billed monthly: $226.29 Billed quarterly: $570.96
Rates: Effective 1/1/22 Billed quarterly: $678.06
Billed monthly: $113.58

Billed quarterly: $340.35

1 2022 Medicare Plan Updates

Massachusetts Medicare Supplement Insurance: Outline Of Coverage

Blue Cross and Blue Shield Policy Category: Medicare
of Massachusetts, Inc. Supplement Insurance

• Medicare Supplement Core—Medex Core (ME 11 DB) “NOTICE TO BUYER: This policy may not cover all of the
• Medicare Supplement 1—Medex Bronze (ME 2 DB) costs associated with medical care incurred by the buyer
• Medicare Supplement 1A —Medex Sapphire during the period of coverage. The buyer is advised to review
carefully all policy limitations.”
(ME 2ADED DB)
Policy Replacement
Premium Information
If you are replacing another health insurance
We, Blue Cross Blue Shield of Massachusetts, policy, do NOT cancel it until you have actually
can only raise your premium if we raise the received your new policy and are sure you
premium for all policies like yours in want to keep it. If you cancel your present
Massachusetts, and if approved by the policy and then decide that you do not want to
Commissioner of Insurance. If you choose to keep your new policy, it may not be possible
pay your premium on a monthly or quarterly to get back the coverage of the present policy.
basis, upon your death, we will refund the
unearned portion of the premium paid. If you If you newly enroll in a Medicare Supplement 1
choose to pay your premium on a monthly plan and you became Medicare Eligible
or quarterly basis and you cancel your before January 1, 2020, you will not be able
policy, we will refund the unearned portion to switch into the same company’s Medicare
of the premium paid. In the case of death, Supplement 1A plan until you have been
the unearned portion of the premium will be covered under the Medicare Supplement 1
refunded on a pro-rata basis. plan for a period of at least 12 months.

Disclosures Notice

Use this outline to compare benefits and This policy may not fully cover all of your
premiums among policies. medical costs. Blue Cross Blue Shield
of Massachusetts is not connected
Read Your Policy Very Carefully with Medicare. This outline of coverage does
not give all the details of Medicare coverage.
This is only an outline describing your policy’s Contact your local Social Security office or
most important features. The policy is your consult Medicare & You for more details.
insurance contract. You must read the policy
itself to understand all of the rights and duties Complete Answers Are Very Important
of both yourself and your insurance company.
When you fill out the application for the new
Right To Return Policy policy, be sure to answer all the questions
truthfully and completely. The company may
If you find you are not satisfied with your policy, cancel your policy and refuse to pay any
you may return it to Blue Cross Blue Shield of claims if you leave out or falsify important
Massachusetts, Medex Member Services, P.O. information.
Box 9130, North Quincy, MA 02171-9130. If you
send the policy back to us within 30 days Review the application carefully before you
after you receive it, we will treat the policy sign it. Be certain that all information has been
as if it had never been issued and return properly recorded.
all of your payments.

Blue Cross Blue Shield of Massachusetts 2

Massachusetts Medicare Supplement Insurance: Outline Of Coverage

Massachusetts Summary The Benefits-to-Premium Ratio
for Medex Bronze Is 93.7%
The Commissioner of Insurance has set
standards for the sale of Medicare Supplement This means that during the anticipated life of
Insurance policies. Such policies help you pay your policy and others just like it, Blue Cross
hospital and doctor bills, and some other bills, Blue Shield of Massachusetts expects to pay
that are not covered in full by Medicare. Please out $93.70 in claims made by you and other
note that the benefits provided by Medicare policyholders for every $100 we collect in
and this Medicare Supplement Insurance policy premiums. The minimum loss ratio for Blue
may not cover all of the costs associated Cross Blue Shield of Massachusetts policies
with your treatment. It is important that you of this type is 90%. The minimum loss ratio for
become familiar with the benefits provided non-Blue Cross Blue Shield of Massachusetts
by Medicare and your Medicare Supplement policies of this type is 65%. A higher ratio
Insurance policy. This policy summary outlines is to your advantage, as long as it allows
the different coverages you have if, in addition the company reasonable return so that the
to this policy, you are also covered by Part A product remains available.
(hospital bills, mainly) and Part B (doctors’ bills,
mainly) of Medicare. The Benefits-to-Premium Ratio
for Medex Core Is 93.7%
Under Massachusetts General Laws, c. 112, s. 2,
no physician who agrees to treat a Medicare This means that during the anticipated life of
beneficiary may charge to or collect from your policy and others just like it, Blue Cross
that beneficiary any amount in excess of Blue Shield of Massachusetts expects to pay
the reasonable charge for that service as out $93.70 in claims made by you and other
determined by the United States Secretary of policyholders for every $100 we collect in
Health and Human Services. This prohibition premiums. The minimum loss ratio for
is commonly referred to as the “ban on balance Blue Cross Blue Shield of Massachusetts
billing.” A physician is allowed to charge you policies of this type is 90%. The minimum
or collect from your insurer a copayment or loss ratio for non-Blue Cross Blue Shield of
co-insurance for Medicare-covered services. Massachusetts policies of this type is 65%.
However, if your physician charges you or A higher ratio is to your advantage, as long
attempts to collect from you an amount, which as it allows the company reasonable return so
together with your copayment or co-insurance that the product remains available.
is greater than the Medicare-approved amount,
please contact the Board of Registration in The Benefits-to-Premium Ratio
Medicine at (781) 876-8200. for Medex Sapphire Is 93.7%
We cannot explain everything here.
Massachusetts law requires that personal This means that during the anticipated life of
insurance policies be written in easy-to-read your policy and others just like it, Blue Cross
language. So, if you have questions about Blue Shield of Massachusetts expects to pay
your coverage that are not answered in this out $93.70 in claims made by you and other
brochure, read your policy. If you still have policyholders for every $100 we collect in
questions, ask your agent or company. You premiums. The minimum loss ratio for
may also wish to get a copy of Medicare & Blue Cross Blue Shield of Massachusetts
You, a small book put out by Medicare that policies of this type is 90%. A higher ratio
describes Medicare benefits. is to your advantage, as long as it allows
the company reasonable return so that the
product remains available.

3 2022 Medicare Plan Updates

Complaints Internal Formal Grievance Review

If you have a complaint, call Medex Member How to Request a Grievance Review: To
Service at 1-800-258-2226. If you are not request a formal review from the Blue Cross
satisfied, you may write to The Massachusetts Blue Shield of Massachusetts internal Member
Division of Insurance, 1000 Washington Street, Grievance Program, you (or your authorized
Suite 810, Boston, Massachusetts 02118-6200 representative) have three options.
or call 1-617-521-7794 (Boston).
• Write or Fax: The preferred option is for you
Grievance Program to send your grievance in writing to: Member
Grievance Program, Blue Cross Blue Shield
As a Medex member, you have the right of Massachusetts, One Enterprise Drive,
to a review when you disagree with a Quincy, MA 02171-2126. Or, you may fax
decision made by Blue Cross Blue Shield of your grievance to 1-617-246-3616. Blue
Massachusetts to deny payment for services Cross Blue Shield will let you know that
that may be eligible for benefits under your request was received by sending you a
Medex or if you have a complaint about the written confirmation within 15 calendar days.
care or service that you received from
Blue Cross Blue Shield of Massachusetts or • Email: Or, you may send your grievance
from a provider. to the Blue Cross Blue Shield Member
Grievance Program at grievances@
Medex Inquiries or Claim Problems bcbsma.com. Blue Cross Blue Shield of
Massachusetts will let you know that your
Most Medex problems or concerns can be request was received by sending you a
handled with just one phone call. For help confirmation immediately by email.
to resolve a Medex problem or concern, you
should first call the Blue Cross • Telephone: Or, you may call the Blue Cross
Blue Shield of Massachusetts customer Blue Shield of Massachusetts Member
service office at 1-800-258-2226, Monday Grievance Program at 1-800-472-2689.
through Friday, 8:00 a.m. to 6:00 p.m. ET. When your request is made by phone,
The TTY toll-free number is 711. A customer Blue Cross Blue Shield of Massachusetts will
service representative will work with you. They send you a written account of the grievance
will help you understand your Medex coverage. within 48 hours of your phone call.
Or, they will work with you to resolve your
Medex problem or concern. They will do this Once your request is received, Blue Cross
as quickly as possible. If after speaking with Blue Shield of Massachusetts will research the
a Blue Cross Blue Shield of Massachusetts case in detail. They will ask for more information
customer service representative, you still if it is needed. Blue Cross Blue Shield of
disagree with a decision that is given to Massachusetts will let you know in writing
you, you may request a review through the of the decision or the outcome of the review.
Blue Cross Blue Shield of Massachusetts
internal formal grievance program. Note: Medicare has its own policies and procedures for
handling appeals and grievances. If you do not agree with a
decision by Medicare on the amount that Medicare has paid
on a claim or whether the services you received are covered
by Medicare, you have the right to appeal the decision.
The steps you should take to appeal the decision are
explained in your Medicare handbook. You may also look on
the Medicare website at medicare.gov for more detailed
information about the Medicare appeals process.

Blue Cross Blue Shield of Massachusetts 4

MEDICARE SUPPLEMENT CORE: MEDEX CORE

Medicare (Part A)—Hospital Services—Per Benefit Period

Services Medicare Pays Plan Pays You Pay

Hospitalization* $1,556
Semiprivate room and board, general hospital nursing (Part A deductible)
and miscellaneous services and supplies, and licensed $0
mental hospital stays for biologically based mental $0
disorders or other mental disorders prior to the $0
190-day Medicare lifetime maximum All costs

First 60 days of a benefit period All but $1,556 $0 $1,556
All but $389 a day $389 a day (Part A deductible)
61st through 90th day of a benefit period $0
91st day and after of a benefit period: All but $778 a day $778 a day
• While using 60 lifetime reserve days $0
• Once lifetime reserve days are used: $0 100% of Medicare
eligible expenses $0
• Additional 365 days All costs
$0 $0
• Beyond the additional 365 days
Licensed mental hospital stays $0 All but $1,556
not covered by Medicare for biologically
based mental disorders $0 100% of Medicare
eligible expenses
First 60 days of a benefit period
$0 100% of Medicare
61st through 90th day of a benefit period eligible expenses

91st day and after of a benefit period: $0 100% of Medicare
eligible expenses
• While using 60 lifetime reserve days
$0 $0
• Once lifetime reserve days are used:

• Additional 365 days

• Beyond the additional 365 days

*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.

The deductible and co-insurance amounts listed above reflect the 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

5 2022 Medicare Plan Updates

Medicare (Part A)—Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay
Licensed mental hospital stays
not covered by Medicare for other mental disorders $0 All but $1,556 $1,556
First 60 days per calendar year less days (Part A deductible)
covered by Medicare or plan in that calendar year
$0 100% of Medicare $0
61st through 120th day of a benefit period eligible expenses

Days after 60 days per calendar year less days $0 $0 All costs
covered by Medicare or plan in that calendar year
Skilled Nursing Facility Care* All approved $0 $0
(Participating with Medicare) amounts
You must meet Medicare’s requirements, including $0 Up to $194.50
having been in a hospital for at least three days and All but $194.50 $0 a day
entered a Medicare-approved facility within 30 days a day All costs
after having left the hospital
$0
First 20 days of a benefit period
$0 Three pints $0
21st through 100th day of a benefit period $0
100% $0
101st day and after of a benefit period $0
Blood All but very limited Actual billed
First three pints co-insurance for charges up to the
Additional amounts outpatient drugs co-insurance
and inpatient amount
Hospice Care respite care
Available as long as your doctor certifies
you are terminally ill and you elect to
receive these services

*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.

NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will
pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the Policy’s “Core Benefits.”
During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges
and the amount Medicare would have paid.

The deductible and co-insurance amounts listed above reflect the 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

Blue Cross Blue Shield of Massachusetts 6

Medicare Supplement Core: Medex Core (continued)

Medicare (Part B)—Medical Services—Per Calendar Year

Services Medicare Pays Plan Pays 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,
and durable medical equipment

First $233 of Medicare-approved amounts** $0 $0 $233 (Part B
deductible)

Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Outpatient treatment for biologically based
mental disorders and other mental health disorders
(for services covered by Medicare)

First $233 of Medicare-approved amounts** $0 $0 $233 (Part B
deductible)

Remainder of Medicare-approved amounts 80% 20% $0

Outpatient treatment for biologically based $0 100% of expenses $0
mental disorders and other mental health disorders
(for services not covered by Medicare)

Blood

First three pints $0 All costs $0

Next $233 of Medicare-approved amounts** $0 $0 $233 (Part B
deductible)

Remainder of Medicare-approved amounts 80% 20% $0

**Once you have been billed $233 of Medicare-approved amounts for covered services (which are noted with a double asterisk),
your Part B deductible will have been met for the calendar year.

The deductible and co-insurance amounts listed above reflect the 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

7 2022 Medicare Plan Updates

Medicare (Part B)—Medical Services—Per Calendar Year (continued)

Services Medicare Pays Plan Pays You Pay
Clinical Laboratory Services $0
Blood tests for diagnostic services 100% $0
Special Medical Formulas Mandated by Law
Covered by Medicare $0 $0 $233
(Part B deductible)
First $233 of Medicare-approved amounts**
80% 20% $0
Remainder of Medicare-approved amounts
Not covered by Medicare $0 All allowed charges Balance

Medicare (Parts A & B)

Services Medicare Pays Plan Pays You Pay

Home Health Care—Medicare-Approved Services 100% $0 $0

Medically necessary skilled-care services $233
and medical supplies (Part B deductible)
$0
Durable medical equipment

First $233 of Medicare-approved amounts** $0 $0

Remainder of Medicare-approved amounts 80% 20%

Other Benefits—Not Covered By Medicare

Services Medicare Pays Plan Pays You Pay
Outpatient Prescription Drugs— $0 $0 All costs
Not Covered by Medicare
Foreign Travel—Not Covered by Medicare Remainder of $0

Only the services listed above while traveling outside $0 charges (including All charges
the United States portion normally after $150
All charges
Fitness Program—Not Covered by Medicare paid by Medicare after $150

Weight-Loss Program—Not Covered by Medicare $0 $150
per calendar year

$0 $150
per calendar year

**Once you have been billed $233 of Medicare-approved amounts for covered services (which are noted with a double asterisk),
your Part B deductible will have been met for the calendar year.

The deductible and co-insurance amounts listed above reflect the 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

Blue Cross Blue Shield of Massachusetts 8

Medicare Supplement 1: Medex Bronze

Medicare (Part A)—Hospital Services—Per Benefit Period

Services Medicare Pays Plan Pays You Pay
Hospitalization*
Semiprivate room and board, general hospital nursing and All but $1,556 $1,556 $0
miscellaneous services and supplies, and licensed mental All but $389 a day (Part A deductible) $0
hospital stays for biologically based mental disorders
or other mental disorders prior to the 190-day Medicare $389 a day
lifetime maximum
All but $778 a day $778 a day $0
First 60 days of a benefit period
$0 100% of Medicare $0
61st through 90th day of a benefit period eligible expenses
91st day and after of a benefit period:
• While using 60 lifetime reserve days $0 $0 All costs
• Once lifetime reserve days are used:
$0 100% of Medicare $0
• Additional 365 days eligible expenses

• Beyond the additional 365 days $0 100% of Medicare $0
Licensed mental hospital stays eligible expenses
for biologically based mental disorders not covered
by Medicare $0 100% of Medicare $0
eligible expenses
First 60 days of a benefit period
$0 100% of Medicare $0
61st through 90th day of a benefit period eligible expenses

91st day and after of a benefit period: $0 $0 All costs

• While using 60 lifetime reserve days

• Once lifetime reserve days are used:

• Additional 365 days

• Beyond the additional 365 days

*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.

The deductible and co-insurance amounts listed above reflect the 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

9 2022 Medicare Plan Updates

Medicare (Part A)—Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay

Licensed mental hospital stays not covered $0 100% of Medicare $0
by Medicare for other mental disorders eligible expenses $0
First 120 days per benefit period (at least 60 days per All costs
calendar year) less days covered by Medicare or plan in $0 100% of Medicare
that calendar year eligible expenses $0
$0
First 60 days of a benefit period $0 $0 Balance
All costs
61st through 120th day of a benefit period All approved $0
amounts
Days after 120 days per benefit period (or 60 days per Up to $194.50
calendar year) less days covered by Medicare or plan in that All but $194.50 a day
calendar year a day $10 a day
$0
Skilled Nursing Facility Care* $0
Participating with Medicare)
You must meet Medicare’s requirements, including having $0
been in a hospital for at least three days and entered a
Medicare-approved facility within 30 days after having left the
hospital

First 20 days of a benefit period

21st through 100th day of a benefit period

101st day through 365th day of a benefit period
Beyond the 365th day of a benefit period

(Not participating with Medicare)

You must meet Medicare’s requirements, including having
been in a hospital for at least three days and transferred to the
facility within 30 days after having left the hospital

1st day through 365th day of a benefit period $0 $8 a day Balance
Beyond the 365th day of a benefit period $0 $0 All costs

*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.

The deductible and do-insurance amounts listed above reflect the 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

Blue Cross Blue Shield of Massachusetts 10

Medicare Supplement 1: Medex Bronze (continued)

Medicare (Part A)—Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay
$0
Blood $0 three pints $0

First three pints 100% $0 $0

Additional amounts All but very limited Actual billed
co-insurance for charges up
Hospice Care outpatient drugs to the
Available as long as your doctor certifies and inpatient co-insurance
you are terminally ill and you elect to respite care amount
receive these services

NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will
pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the Policy’s “Core Benefits.”
During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges
and the amount Medicare would have paid.

Medicare (Part B)—Medical Services—Per Calendar Year

Services Medicare Pays Plan Pays You Pay
Medical expenses in or out of the hospital and
outpatient hospital treatment, such as physician’s services, $0 $233 $0
inpatient and outpatient medical and surgical services and Generally 80% (Part B deductible) $0
supplies, physical and speech therapy, diagnostic tests, and Generally 20%
durable medical equipment $0 $0
80% $233 $0
First $233 of Medicare-approved amounts** $0 (Part B deductible) $0
20%
Remainder of Medicare-approved amounts 100% of expenses
Outpatient treatment for biologically based mental disorders
and other mental health disorders
(for services covered by Medicare)

First $233 of Medicare-approved amounts**

Remainder of Medicare-approved amounts
Outpatient treatment for biologically based mental disorders
and other mental health disorders
(for services not covered by Medicare)

**Once you have been billed $233 of Medicare-approved amounts for covered services (which are noted with a double
asterisk), your Part B deductible will have been met for the calendar year.

The deductible and co-insurance amounts listed above reflect the 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

11 2022 Medicare Plan Updates

Medicare (Part B)—Medical Services—Per Calendar Year (continued)

Services Medicare Pays Plan Pays You Pay
Blood
First three pints $0 All costs $0

Next $233 of Medicare-approved amounts** $0 $233 $0
(Part B deductible)
Remainder of Medicare-approved amounts
Clinical Laboratory Services 80% 20% $0
Blood tests for diagnostic services
Special Medical Formulas Mandated by Law 100% $0 $0
Covered by Medicare
$0 $233 $0
First $233 of Medicare-approved amounts** (Part B deductible)

Remainder of Medicare-approved amounts 80% 20% $0
Not covered by Medicare
$0 All allowed charges Balance

**Once you have been billed $233 of Medicare-approved amounts for covered services (which are noted with a double
asterisk), your Part B deductible will have been met for the calendar year.

The deductible and co-insurance amounts listed above reflect the 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

Blue Cross Blue Shield of Massachusetts 12

Medicare Supplement 1: Medex Bronze (continued)

Medicare (Parts A & B)

Services Medicare Pays Plan Pays You Pay
Home Health Care—Medicare-Approved Services
Medically necessary skilled care services 100% $0 $0
and medical supplies
Durable medical equipment $0 $233 $0
80% (Part B deductible) $0
First $233 of Medicare-approved amounts**
20%
Remainder of Medicare-approved amounts

**Once you have been billed $233 of Medicare-approved amounts for covered services (which are noted with a double asterisk),
your Part B deductible will have been met for the calendar year.

The deductible and co-insurance amounts listed above reflect the 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

Other Benefits—Not Covered By Medicare

Services Medicare Pays Plan Pays You Pay

Foreign Travel—Not Covered by Medicare

Only the services listed above while traveling $0 Remainder of $0
outside the United States charges (including
$0 portion normally
Outpatient Prescription Drugs—Not Covered $0 paid by Medicare)
by Medicare $0
$0 All costs
Fitness Program—Not Covered by Medicare
Weight-Loss Program—Not Covered $150 per All charges
by Medicare calendar year after $150

$150 per All charges
calendar year after $150

13 2022 Medicare Plan Updates

Medicare Supplement 1A: Medex Sapphire

Medicare (Part A)—Hospital Services—Per Benefit Period

Services Medicare Pays Plan Pays You Pay
Hospitalization*
Semiprivate room and board, general hospital nursing All but $1,556 $1,556 $0
and miscellaneous services and supplies, and licensed All but $389 a day (Part A deductible) $0
mental hospital stays for biologically based mental disorders
or other mental disorders prior to the 190-day Medicare $389 a day
lifetime maximum
All but $778 a day $778 a day $0
First 60 days of a benefit period
$0 100% of Medicare $0
61st through 90th day of a benefit period eligible expenses

91st day and after of a benefit period: $0 $0 All costs

• While using 60 lifetime reserve days
• Once lifetime reserve days are used:

• Additional 365 days

• Beyond the additional 365 days
Licensed mental hospital stays not covered by Medicare for
biologically based mental disorders

First 60 days of a benefit period $0 100% of Medicare $0
eligible expenses

61st through 90th day of a benefit period $0 100% of Medicare $0
91st day and after of a benefit period: eligible expenses
• While using 60 lifetime reserve days
• Once lifetime reserve days are used: $0 100% of Medicare $0
• Additional 365 days eligible expenses
• Beyond the additional 365 days
$0 100% of Medicare $0
eligible expenses

$0 $0 All costs

*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.

The deductible and co-insurance amounts listed above reflect the 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

Blue Cross Blue Shield of Massachusetts 14

Medicare Supplement 1A: Medex Sapphire (continued)

Medicare (Part A)—Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay
$0
Licensed mental hospital stays not covered by 100% of Medicare $0
Medicare for other mental disorders eligible expenses $0
100% of Medicare All costs
First 120 days per benefit period (at least 60 days eligible expenses
per calendar year) less days covered by Medicare or $0 $0
plan in that calendar year $0
$0
First 60 days of a benefit period

61st through 120th day of a benefit period $0

Days after 120 days per benefit period (or 60 days per $0
calendar year) less days covered by Medicare or plan
in that calendar year All approved
amounts
Skilled Nursing Facility Care*
(Participating with Medicare)
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 having left the hospital

First 20 days of a benefit period

21st through 100th day of a benefit period All but $194.50 Up to $194.50
a day a day

101st day and after of a benefit period $0 $10 a day Balance
Beyond the 365th day of a benefit period $0 $0 All costs

*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.

The deductible and co-insurance amounts listed above reflect the 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

15 2022 Medicare Plan Updates

Medicare (Part A)—Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay

(Not participating with Medicare) You must meet $0 $8 a day Balance
Medicare’s requirements, including having been in a $0 $0 All costs
hospital for at least three days and transferred to the $0
facility within 30 days after having left the hospital $0 Three pints $0

1st day through 365th day of a benefit period 100% $0 $0

Beyond the 365th day of a benefit period All but very limited Actual billed
co-insurance for charges up to the
Blood outpatient drugs co-insurance
and inpatient amount
First three pints respite care

Additional amounts

Hospice Care
Available as long as your doctor certifies
you are terminally ill and you elect to
receive these services

NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will
pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the Policy’s “Core Benefits.”
During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges
and the amount Medicare would have paid.

The deductible and co-insurance amounts listed above reflect the 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

Blue Cross Blue Shield of Massachusetts 16

Medicare Supplement 1A: Medex Sapphire (continued)

Medicare (Part B)—Medical Services—Per Calendar Year

Services Medicare Pays Plan Pays You Pay

Medical expenses in or out of the hospital and $233
outpatient hospital treatment, such as physician’s (Part B deductible)
services, inpatient and outpatient medical and surgical $0
services and supplies, physical and speech therapy,
diagnostic tests, and durable medical equipment $233
(Part B deductible)
First $233 of Medicare-approved amounts** $0 $0 $0
$0
Remainder of Medicare-approved amounts Generally 80% Generally 20%
$0
Outpatient treatment for biologically based mental $233
disorders and other mental health disorders (Part B deductible)
(for services covered by Medicare) $0

First $233 of Medicare-approved amounts** $0 $0

Remainder of Medicare-approved amounts 80% 20%
Outpatient treatment for biologically based mental $0 100%
disorders and other mental health disorders of expenses
(for services not covered by Medicare) $0
Blood All costs

First three pints

Next $233 of Medicare-approved amounts** $0 $0
Remainder of Medicare-approved amounts 80% 20%

**Once you have been billed $233 of Medicare-approved amounts for covered services (which are noted with a double
asterisk), your Part B deductible will have been met for the calendar year.

The deductible and co-insurance amounts listed above reflect the 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

17 2022 Medicare Plan Updates