MEDICARE SUPPLEMENT PLANS Medex®´ Core, Medex®´ Sapphire, Medex®´ Bronze Get the coverage you need and the peace of mind you deserve. Medex®´ 2023 Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. PRESCRIPTION DRUG PLANS (PDP) Blue MedicareRx Value Plus Blue MedicareRx Premier Coverage You Need From a Name You Can Trust Blue MedicareRx (PDP) 2023 Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. June 2023 (2303421)
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 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 Bring You Peace of Mind Compare Your Coverage Options Choose How to Enroll 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 A. Paradiso, Vice President, Government Sales Enclosures Ready to Enroll? By phone: 1-800-678-2265 (TTY: 711) Monday through Friday, 8:00 a.m. to 5:00 p.m. ET. Online: bluecrossma.com/medicare By mail: Complete the enclosed enrollment form and mail in the self-addressed envelope. By fax: Complete the enclosed enrollment form and fax to 1-617-246-8506.
1. Represents Medicare Advantage and Medicare Supplemental Individual and Group plan membership based on data from Centers for Medicare & Medicaid Services (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. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001612426 99-000894892-23 (9/22)
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
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Medex®´ Core, Medex®´ Sapphire and Medex®´ Bronze Plans for 2023 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. 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. © 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001660265 42-0430-23 (3/23) FOR MORE INFORMATION: Medicare Plan Sales: 1-800-678-2265 (TTY: 711) Monday through Friday, 8:00 a.m. to 5:00 p.m. ET. bluecrossma.com/medicare
CONTENTS Medex . . . . . . . . . . . . . . . . . . . . 1–2 The Freedom of Medex . . . . . . . . . . 1 An Introduction to Medex. . . . . . . . . 2 Medicare . . . . . . . . . . . . . . . . . 4–6 What Is Original Medicare? . . . . . . . . 3 Why Do I Need to Supplement Medicare? . . . . . . . . 5 Medicare Coverage . . . . . . . . . . . . 6 Medicare and Medex Together . . . 7–14 Medicare Coverage Combined with a Medex Plan . . . . . . . . . . . 7–12 Medex Coverage Wellness Programs . . . . . . . . . . . . .13 How Medex Works . . . . . . . . . . . . .14 Enrollment in Medex . . . . . . . . . .14–17 Am I Eligible for Medex? . . . . . . . . . .14 When Do I Enroll? . . . . . . . . . . . . . .15 How Do I Enroll?. . . . . . . . . . . . . . 16 When Will My Coverage Begin? . . . . .17 Miscellaneous Information . . . . . 18–19 Premium Rates . . . . . . . . . . . . . . .18 Helpful Numbers . . . . . . . . . . . . . 19 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 Medex . . . . . . . . . . . . . . . . . . . . 1–2 The Freedom of Medex . . . . . . . . . . 1 An Introduction to Medex. . . . . . . . . 2 Medicare . . . . . . . . . . . . . . . . . 4–6 What Is Original Medicare? . . . . . . . . 3 Why Do I Need to Supplement Medicare? . . . . . . . . 5 Medicare Coverage . . . . . . . . . . . . 6 Medicare and Medex Together . . . 7–14 Medicare Coverage Combined with a Medex Plan . . . . . . . . . . . 7–12 Medex Coverage Wellness Programs . . . . . . . . . . . . .13 How Medex Works . . . . . . . . . . . . .14 Enrollment in Medex . . . . . . . . . .14–17 Am I Eligible for Medex? . . . . . . . . . .14 When Do I Enroll? . . . . . . . . . . . . . .15 How Do I Enroll?. . . . . . . . . . . . . . 16 When Will My Coverage Begin? . . . . .17 Miscellaneous Information . . . . . 18–19 Premium Rates . . . . . . . . . . . . . . .18 Helpful Numbers . . . . . . . . . . . . . 19 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.
1 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 2 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: WORLDWIDE COVERAGE Explore comfortably knowing that Medex includes coverage for urgent or emergency care when traveling internationally. HEALTHY BENEFITS Medex Core, Sapphire, and Bronze members are eligible for a $150 fitness reimbursement and a $150 weight-loss benefit each year. PEACE OF MIND Enjoy the security of having a Blue Cross Blue Shield of Massachusetts ID card—the most recognized ID card in health care today. 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 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. 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 explaining what each plan covers and comparing costs. Medex Bronze Full Supplemental Coverage — or — Medex Sapphire Enhanced Supplemental Coverage — or — Medex Core Basic Supplemental Coverage Parts A + B Keep Original Medicare and add… Medicare Supplement Insurance +
1 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 2 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: WORLDWIDE COVERAGE Explore comfortably knowing that Medex includes coverage for urgent or emergency care when traveling internationally. HEALTHY BENEFITS Medex Core, Sapphire, and Bronze members are eligible for a $150 fitness reimbursement and a $150 weight-loss benefit each year. PEACE OF MIND Enjoy the security of having a Blue Cross Blue Shield of Massachusetts ID card—the most recognized ID card in health care today. 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 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. 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 explaining what each plan covers and comparing costs. Medex Bronze Full Supplemental Coverage — or — Medex Sapphire Enhanced Supplemental Coverage — or — Medex Core Basic Supplemental Coverage Parts A + B Keep Original Medicare and add… Medicare Supplement Insurance +
3 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 4 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 (HOSPITAL INSURANCE) pays for inpatient hospital expenses. MEDICARE PART B (MEDICAL INSURANCE) 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 • Skilled nursing facility care • Hospice care • Home health services • Doctors’ services • Physical and speech therapy • Diagnostic tests • Ambulance trips • Durable medical equipment • Diabetic testing supplies Important: If you haven’t enrolled in Medicare, contact your local Social Security office three months prior to your 65th birthday.
3 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 4 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 (HOSPITAL INSURANCE) pays for inpatient hospital expenses. MEDICARE PART B (MEDICAL INSURANCE) 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 • Skilled nursing facility care • Hospice care • Home health services • Doctors’ services • Physical and speech therapy • Diagnostic tests • Ambulance trips • Durable medical equipment • Diabetic testing supplies Important: If you haven’t enrolled in Medicare, contact your local Social Security office three months prior to your 65th birthday.
5 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 6 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. 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. 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, 2023. Medicare deductibles and co-insurances are subject to change each year. MEDICARE COVERAGE (Without Supplemental Insurance) Medicare Part A Your Cost Inpatient Hospital Care Days 1–60 each benefit period: 100% coverage after you pay the $1,600 deductible $1,600 deductible Days 61–90 each benefit period: 100% coverage after you pay $400 per day co-insurance $400 per day co-insurance Days 91–150 (60 lifetime reserve days): 100% coverage after you pay $800 per day co-insurance $800 per day co-insurance Days 150+: no coverage All costs after 150 days Skilled Nursing Facility Care Days 1–20 each benefit period: 100% coverage No cost Days 21–100 each benefit period: 100% coverage after you pay $200 per day co-insurance $200 per day co-insurance No coverage after 100 days in a benefit period All costs after 100 days Medicare Part B Your Cost Medical Expenses • Ambulance • Diagnostic tests • Diabetic testing supplies • Doctors’ services • Durable medical equipment • Physical and speech therapy Coverage begins after you pay the $226 calendar-year deductible $226 deductible Medicare covers 80% of the Medicare-approved amount; you pay 20% co-insurance 20% co-insurance Prescription Drugs Members may voluntarily purchase Medicare Part D, which covers prescription drugs (unless the drug is covered under Part B) Most outpatient prescription costs Routine Services and Preventive Care 100% coverage for specific Medicare preventive services. A complete list is found on the Medicare website, medicare.gov No cost when Medicare covers the preventive service in full and provider accepts assignment Travel Outside the United States No coverage for medical costs incurred outside the United States All costs
5 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 6 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. 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. 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, 2023. Medicare deductibles and co-insurances are subject to change each year. MEDICARE COVERAGE (Without Supplemental Insurance) Medicare Part A Your Cost Inpatient Hospital Care Days 1–60 each benefit period: 100% coverage after you pay the $1,600 deductible $1,600 deductible Days 61–90 each benefit period: 100% coverage after you pay $400 per day co-insurance $400 per day co-insurance Days 91–150 (60 lifetime reserve days): 100% coverage after you pay $800 per day co-insurance $800 per day co-insurance Days 150+: no coverage All costs after 150 days Skilled Nursing Facility Care Days 1–20 each benefit period: 100% coverage No cost Days 21–100 each benefit period: 100% coverage after you pay $200 per day co-insurance $200 per day co-insurance No coverage after 100 days in a benefit period All costs after 100 days Medicare Part B Your Cost Medical Expenses • Ambulance • Diagnostic tests • Diabetic testing supplies • Doctors’ services • Durable medical equipment • Physical and speech therapy Coverage begins after you pay the $226 calendar-year deductible $226 deductible Medicare covers 80% of the Medicare-approved amount; you pay 20% co-insurance 20% co-insurance Prescription Drugs Members may voluntarily purchase Medicare Part D, which covers prescription drugs (unless the drug is covered under Part B) Most outpatient prescription costs Routine Services and Preventive Care 100% coverage for specific Medicare preventive services. A complete list is found on the Medicare website, medicare.gov No cost when Medicare covers the preventive service in full and provider accepts assignment Travel Outside the United States No coverage for medical costs incurred outside the United States All costs
7 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 8 MEDICARE COVERAGE (Combined with a Medex Sapphire Plan) Days Medicare Medex Sapphire (Medicare Supplement 1A) Hospital Services 1–60 Coverage for 60 days, after the $1,600 deductible1 and co-insurance Full coverage of Medicare deductible and co-insurance 61–90 Coverage for 61–90 days, after $400 daily co-insurance Lifetime Reserve Coverage for an additional 60 lifetime reserve days, after $800 daily co-insurance Full coverage for lifetime reserve co-insurance, then an additional 365 days per lifetime when Medicare benefits end Skilled Nursing Facility 1–20 Full coverage for 20 days in a Medicare-participating facility Covered by Medicare 21–100 Coverage for days 21–100, after $200 daily co-insurance Full coverage for Medicare daily co-insurance for days 21–100 101+ No coverage after 100 days $10 a day for days 101–3652 at a Medicare-participating facility Physician and Other Provider Services Care in the Hospital 80% coverage of approved services, after the $226 annual Part B deductible Coverage of 20% co-insurance, after you pay $226 annual Part B deductible Physician and Other Provider Services Outpatient Department Visits, Office Visits, and Patient Home Visits 80% coverage of approved services, after the $226 annual Part B deductible Coverage of 20% co-insurance, after you pay $226 annual Part B deductible Other Part B Services, Ambulance Trips, Durable Medical Equipment, Etc. 80% coverage of approved services, after the $226 annual Part B deductible Coverage of 20% co-insurance, after you pay $226 annual Part B deductible Continued Refer to the Index on page 20 for an explanation of the footnotes above. MEDICARE COVERAGE (Combined with a Medex Core Plan) Days Medicare Medex Core (Medicare Supplement Core) Hospital Services 1–60 Coverage for 60 days, after the $1,600 deductible1 Coverage for Medicare daily co-insurance after you pay $1,600 Part A deductible 61–90 Coverage for 61–90 days, after $400 daily co-insurance Lifetime Reserve Coverage for an additional 60 lifetime reserve days, after $800 daily co-insurance Full coverage for lifetime reserve coinsurance, then an additional 365 days per lifetime when Medicare benefits end Skilled Nursing Facility 1–20 Full coverage for 20 days in a Medicare-participating facility Covered by Medicare 21–100 Coverage for days 21–100, after $200 daily co-insurance No coverage 101+ No coverage after 100 days No coverage Physician and Other Provider Services Care in the Hospital 80% coverage of approved services, after the $226 annual Part B deductible Coverage of 20% co-insurance, after you pay $226 annual Part B deductible Physician and Other Provider Services Outpatient Department Visits, Office Visits, and Patient Home Visits 80% coverage of approved services, after the $226 annual Part B deductible Coverage of 20% co-insurance, after you pay $226 annual Part B deductible Other Part B Services, Ambulance Trips, Durable Medical Equipment, Etc. 80% coverage of approved services, after the $226 annual Part B deductible Coverage of 20% co-insurance, after you pay $226 annual Part B deductible Note: Although the $226 calendar-year Medicare medical insurance (Part B) deductible appears more than once in this benefit chart, only one $226 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 & 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 bluecrossma.com/medicare 8 MEDICARE COVERAGE (Combined with a Medex Sapphire Plan) Days Medicare Medex Sapphire (Medicare Supplement 1A) Hospital Services 1–60 Coverage for 60 days, after the $1,600 deductible1 and co-insurance Full coverage of Medicare deductible and co-insurance 61–90 Coverage for 61–90 days, after $400 daily co-insurance Lifetime Reserve Coverage for an additional 60 lifetime reserve days, after $800 daily co-insurance Full coverage for lifetime reserve co-insurance, then an additional 365 days per lifetime when Medicare benefits end Skilled Nursing Facility 1–20 Full coverage for 20 days in a Medicare-participating facility Covered by Medicare 21–100 Coverage for days 21–100, after $200 daily co-insurance Full coverage for Medicare daily co-insurance for days 21–100 101+ No coverage after 100 days $10 a day for days 101–3652 at a Medicare-participating facility Physician and Other Provider Services Care in the Hospital 80% coverage of approved services, after the $226 annual Part B deductible Coverage of 20% co-insurance, after you pay $226 annual Part B deductible Physician and Other Provider Services Outpatient Department Visits, Office Visits, and Patient Home Visits 80% coverage of approved services, after the $226 annual Part B deductible Coverage of 20% co-insurance, after you pay $226 annual Part B deductible Other Part B Services, Ambulance Trips, Durable Medical Equipment, Etc. 80% coverage of approved services, after the $226 annual Part B deductible Coverage of 20% co-insurance, after you pay $226 annual Part B deductible Continued Refer to the Index on page 20 for an explanation of the footnotes above. MEDICARE COVERAGE (Combined with a Medex Core Plan) Days Medicare Medex Core (Medicare Supplement Core) Hospital Services 1–60 Coverage for 60 days, after the $1,600 deductible1 Coverage for Medicare daily co-insurance after you pay $1,600 Part A deductible 61–90 Coverage for 61–90 days, after $400 daily co-insurance Lifetime Reserve Coverage for an additional 60 lifetime reserve days, after $800 daily co-insurance Full coverage for lifetime reserve coinsurance, then an additional 365 days per lifetime when Medicare benefits end Skilled Nursing Facility 1–20 Full coverage for 20 days in a Medicare-participating facility Covered by Medicare 21–100 Coverage for days 21–100, after $200 daily co-insurance No coverage 101+ No coverage after 100 days No coverage Physician and Other Provider Services Care in the Hospital 80% coverage of approved services, after the $226 annual Part B deductible Coverage of 20% co-insurance, after you pay $226 annual Part B deductible Physician and Other Provider Services Outpatient Department Visits, Office Visits, and Patient Home Visits 80% coverage of approved services, after the $226 annual Part B deductible Coverage of 20% co-insurance, after you pay $226 annual Part B deductible Other Part B Services, Ambulance Trips, Durable Medical Equipment, Etc. 80% coverage of approved services, after the $226 annual Part B deductible Coverage of 20% co-insurance, after you pay $226 annual Part B deductible Note: Although the $226 calendar-year Medicare medical insurance (Part B) deductible appears more than once in this benefit chart, only one $226 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 & 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.
9 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 10 These Medicare benefits are effective January 1, 2023. Medicare deductibles and co-insurances are subject to change each year. Medicare Medex Core, Medex Sapphire & Medex Bronze Biologically Based Mental Conditions1 Inpatient Admissions in a General Hospital or Mental Hospital • Coverage for days 1–60 per benefit period, after the $1,600 inpatient deductible2 • Coverage for days 61–90, after $400 daily co-insurance • Coverage for an additional 60 lifetime reserve days, after $800 daily co-insurance • Coverage for mental hospital admissions is limited to 190 days per lifetime • Full coverage of the Medicare deductible3 and co-insurance • Full coverage of lifetime reserve days co-insurance • Full coverage of up to 365 additional hospital days in your lifetime when Medicare benefits end4 Outpatient Visits • Full benefits, less the Part B deductible and the Part B coinsurance • When covered by Medicare, full coverage of Medicare deductible5 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. MEDICARE COVERAGE (Combined with a Medex Bronze Plan) Days Medicare Medex Bronze (Medicare Supplement 1) Hospital Services 1–60 Coverage for 60 days, after the $1,600 deductible1 Full coverage of Medicare deductible and co-insurance 61–90 Coverage for 61–90 days, after $400 daily co-insurance Lifetime Reserve Coverage for an additional 60 lifetime reserve days, after $800 daily co-insurance Full coverage for lifetime reserve co-insurance, then an additional 365 days per lifetime when Medicare benefits end Skilled Nursing Facility 1–20 Full coverage for 20 days in a Medicareparticipating facility Covered by Medicare 21–100 Coverage for days 21–100, after $200 daily co-insurance Full coverage for Medicare daily co-insurance for days 21–100 101+ No coverage after 100 days $10 a day for days 101–3652 at a Medicare-participating facility Physician and Other Provider Services Care in the Hospital 80% coverage of approved services, after the $226 annual Part B deductible Full coverage of Medicare deductible and co-insurance Physician and Other Provider Services Outpatient Department Visits, Office Visits, and Patient Home Visits 80% coverage of approved services, after the $226 annual Part B deductible Full coverage of Medicare deductible and co-insurance Other Part B Services, Ambulance Trips, Durable Medical Equipment, Etc. 80% coverage of approved services, after the $226 annual Part B deductible Full coverage of Medicare deductible and co-insurance Refer to the Index on page 20 for an explanation of the footnotes above.
9 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 10 These Medicare benefits are effective January 1, 2023. Medicare deductibles and co-insurances are subject to change each year. Medicare Medex Core, Medex Sapphire & Medex Bronze Biologically Based Mental Conditions1 Inpatient Admissions in a General Hospital or Mental Hospital • Coverage for days 1–60 per benefit period, after the $1,600 inpatient deductible2 • Coverage for days 61–90, after $400 daily co-insurance • Coverage for an additional 60 lifetime reserve days, after $800 daily co-insurance • Coverage for mental hospital admissions is limited to 190 days per lifetime • Full coverage of the Medicare deductible3 and co-insurance • Full coverage of lifetime reserve days co-insurance • Full coverage of up to 365 additional hospital days in your lifetime when Medicare benefits end4 Outpatient Visits • Full benefits, less the Part B deductible and the Part B coinsurance • When covered by Medicare, full coverage of Medicare deductible5 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. MEDICARE COVERAGE (Combined with a Medex Bronze Plan) Days Medicare Medex Bronze (Medicare Supplement 1) Hospital Services 1–60 Coverage for 60 days, after the $1,600 deductible1 Full coverage of Medicare deductible and co-insurance 61–90 Coverage for 61–90 days, after $400 daily co-insurance Lifetime Reserve Coverage for an additional 60 lifetime reserve days, after $800 daily co-insurance Full coverage for lifetime reserve co-insurance, then an additional 365 days per lifetime when Medicare benefits end Skilled Nursing Facility 1–20 Full coverage for 20 days in a Medicareparticipating facility Covered by Medicare 21–100 Coverage for days 21–100, after $200 daily co-insurance Full coverage for Medicare daily co-insurance for days 21–100 101+ No coverage after 100 days $10 a day for days 101–3652 at a Medicare-participating facility Physician and Other Provider Services Care in the Hospital 80% coverage of approved services, after the $226 annual Part B deductible Full coverage of Medicare deductible and co-insurance Physician and Other Provider Services Outpatient Department Visits, Office Visits, and Patient Home Visits 80% coverage of approved services, after the $226 annual Part B deductible Full coverage of Medicare deductible and co-insurance Other Part B Services, Ambulance Trips, Durable Medical Equipment, Etc. 80% coverage of approved services, after the $226 annual Part B deductible Full coverage of Medicare deductible and co-insurance Refer to the Index on page 20 for an explanation of the footnotes above.
11 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 12 MEDICARE COVERAGE (Combined with a Medex Plan) Medicare Medex Core, Medex Sapphire & Medex Bronze Non-Biologically Based Mental Conditions (includes drug addiction and alcoholism) Inpatient Admissions in a General Hospital • Coverage for days 1–60 per benefit period, after the $1,600 inpatient deductible1 • Coverage for days 61–90, after $400 daily co-insurance • Coverage for an additional 60 lifetime reserve days, after $800 daily co-insurance • Coverage for mental hospital admissions is limited to 190 days per lifetime • Full coverage of the Medicare deductible2 and co-insurance • Full coverage of lifetime reserve days co-insurance • Full coverage of up to 365 additional hospital days in your lifetime when Medicare benefits end3 Inpatient Admissions in a Mental Hospital • Same coverage as general hospital, but coverage limited to 190 days per lifetime • Full coverage of Medicare deductible2 and co-insurance • Full coverage of lifetime reserve day co-insurance • When Medicare days are used up, 120 days per benefit period (at least 60 days per calendar year), less any days in a mental hospital already covered by Medicare or Medex in that benefit period (or calendar year) Outpatient Visits • Full benefits, less the Part B deductible and the Part B co-insurance • 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. These Medicare benefits are effective January 1, 2023. Medicare deductibles and co-insurances are subject to change each year. Medicare Medex Core, Medex Sapphire & Medex Bronze Travel Outside the United States No coverage Full coverage (same as in 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 services, after $226 annual Part B deductible For blood glucose monitoring equipment and supplies covered by Medicare: • 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 services, after $226 annual Part B deductible For blood glucose monitoring equipment and supplies covered by Medicare: • 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.
11 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 12 MEDICARE COVERAGE (Combined with a Medex Plan) Medicare Medex Core, Medex Sapphire & Medex Bronze Non-Biologically Based Mental Conditions (includes drug addiction and alcoholism) Inpatient Admissions in a General Hospital • Coverage for days 1–60 per benefit period, after the $1,600 inpatient deductible1 • Coverage for days 61–90, after $400 daily co-insurance • Coverage for an additional 60 lifetime reserve days, after $800 daily co-insurance • Coverage for mental hospital admissions is limited to 190 days per lifetime • Full coverage of the Medicare deductible2 and co-insurance • Full coverage of lifetime reserve days co-insurance • Full coverage of up to 365 additional hospital days in your lifetime when Medicare benefits end3 Inpatient Admissions in a Mental Hospital • Same coverage as general hospital, but coverage limited to 190 days per lifetime • Full coverage of Medicare deductible2 and co-insurance • Full coverage of lifetime reserve day co-insurance • When Medicare days are used up, 120 days per benefit period (at least 60 days per calendar year), less any days in a mental hospital already covered by Medicare or Medex in that benefit period (or calendar year) Outpatient Visits • Full benefits, less the Part B deductible and the Part B co-insurance • 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. These Medicare benefits are effective January 1, 2023. Medicare deductibles and co-insurances are subject to change each year. Medicare Medex Core, Medex Sapphire & Medex Bronze Travel Outside the United States No coverage Full coverage (same as in 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 services, after $226 annual Part B deductible For blood glucose monitoring equipment and supplies covered by Medicare: • 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 services, after $226 annual Part B deductible For blood glucose monitoring equipment and supplies covered by Medicare: • 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.
13 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 14 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: • Health clubs with a variety of cardiovascular and strength-training exercise equipment— e.g., traditional health clubs, YMCAs, YWCAs, and community fitness centers • Fitness studios with instructor-led group classes such as yoga, Pilates, Zumba®´´ kickboxing, indoor cycling/spinning, and other exercise programs • Pool-only facility memberships, fitness classes, and aqua therapy at facilities with pools • Virtual/on-line fitness memberships, subscriptions, programs, or classes that provide cardiovascular and strengthtraining using a digital platform. • Fitness classes available at participating Councils on Aging facilities Not Qualified for Reimbursement: • One-time initiation or termination fees • Fees paid for gymnastics, tennis, martial arts schools, instructional dance studios, country clubs or social clubs, sports teams or leagues • Personal trainer sessions • Fitness equipment or clothing Note: Referenced scenarios may be considered taxable income. 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: • Traditional WW (formerly known as Weight Watchers®´´) meetings, WW At Work, WW online, and other non-hospital programs (in-person or online) that combine healthy eating, exercise, and coaching sessions with certified health professionals such as nutritionists, registered dietitians, or exercise physiologists • Hospital based weight-loss programs Not Qualified for Reimbursement: • One-time initiation or termination fees • Food, supplements, books, scales, or exercise equipment • Individual nutrition counseling sessions (see your health plan coverage) 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 get care from any Medicare physician or hospital throughout the United States. • You don’t need to choose a primary care provider (PCP). • You don’t need to get referrals for specialty care. • There are no copayments for physician services. • You can adjust your Medex coverage at any time during the year. Your coverage in the new plan will begin the first of the month following receipt of your request to change plans.* • Your Blue Cross Blue Shield of Massachusetts ID card is recognized around the world. Am I Eligible for Medex? You’re eligible for Medex if you meet the following requirements: • You live in Massachusetts. • You’re enrolled (or will be enrolling) in Medicare Part A and Part B. • You may also be eligible if you’re under age 65 and have a disability. 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.
13 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 14 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: • Health clubs with a variety of cardiovascular and strength-training exercise equipment— e.g., traditional health clubs, YMCAs, YWCAs, and community fitness centers • Fitness studios with instructor-led group classes such as yoga, Pilates, Zumba®´´ kickboxing, indoor cycling/spinning, and other exercise programs • Pool-only facility memberships, fitness classes, and aqua therapy at facilities with pools • Virtual/on-line fitness memberships, subscriptions, programs, or classes that provide cardiovascular and strengthtraining using a digital platform. • Fitness classes available at participating Councils on Aging facilities Not Qualified for Reimbursement: • One-time initiation or termination fees • Fees paid for gymnastics, tennis, martial arts schools, instructional dance studios, country clubs or social clubs, sports teams or leagues • Personal trainer sessions • Fitness equipment or clothing Note: Referenced scenarios may be considered taxable income. 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: • Traditional WW (formerly known as Weight Watchers®´´) meetings, WW At Work, WW online, and other non-hospital programs (in-person or online) that combine healthy eating, exercise, and coaching sessions with certified health professionals such as nutritionists, registered dietitians, or exercise physiologists • Hospital based weight-loss programs Not Qualified for Reimbursement: • One-time initiation or termination fees • Food, supplements, books, scales, or exercise equipment • Individual nutrition counseling sessions (see your health plan coverage) 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 get care from any Medicare physician or hospital throughout the United States. • You don’t need to choose a primary care provider (PCP). • You don’t need to get referrals for specialty care. • There are no copayments for physician services. • You can adjust your Medex coverage at any time during the year. Your coverage in the new plan will begin the first of the month following receipt of your request to change plans.* • Your Blue Cross Blue Shield of Massachusetts ID card is recognized around the world. Am I Eligible for Medex? You’re eligible for Medex if you meet the following requirements: • You live in Massachusetts. • You’re enrolled (or will be enrolling) in Medicare Part A and Part B. • You may also be eligible if you’re under age 65 and have a disability. 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.
15 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 16 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 and enrolled in Medicare Part B or enrolling in Medicare Part B Within six months of your Medicare Part B effective date 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. 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. HOW DO I ENROLL? If you want to enroll in Medex, just follow these easy steps: CHOOSE A PLAN Find the right Medex plan for you by reviewing the charts in this brochure, comparing coverage details, and determining which option best suits your unique needs. SET UP PAYMENT Customize your payment plan: choose between monthly or quarterly billing, and having your premium due on the 1st or 15th of each month. ENROLL AT YOUR CONVENIENCE Enroll online, by phone, by mail, or by fax. You’ll need to provide the Medicare number that appears on your Medicare card. See below for details.* *If you don’t have your Medicare card, contact the Social Security Administration office. Note: Spouses need to enroll separately. If you receive your health benefits through a group contract (such as a former employer), 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, Monday through Friday, 8:00 a.m. to 5:00 p.m. ET. Online: Visit our website, bluecrossma.com/medicare, and click Enroll, then Online. Mail: Complete and return the enclosed enrollment form in the pre-addressed business reply envelope provided. 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, call us at 1-800-678-2265.
15 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 16 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 and enrolled in Medicare Part B or enrolling in Medicare Part B Within six months of your Medicare Part B effective date 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. 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. HOW DO I ENROLL? If you want to enroll in Medex, just follow these easy steps: CHOOSE A PLAN Find the right Medex plan for you by reviewing the charts in this brochure, comparing coverage details, and determining which option best suits your unique needs. SET UP PAYMENT Customize your payment plan: choose between monthly or quarterly billing, and having your premium due on the 1st or 15th of each month. ENROLL AT YOUR CONVENIENCE Enroll online, by phone, by mail, or by fax. You’ll need to provide the Medicare number that appears on your Medicare card. See below for details.* *If you don’t have your Medicare card, contact the Social Security Administration office. Note: Spouses need to enroll separately. If you receive your health benefits through a group contract (such as a former employer), 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, Monday through Friday, 8:00 a.m. to 5:00 p.m. ET. Online: Visit our website, bluecrossma.com/medicare, and click Enroll, then Online. Mail: Complete and return the enclosed enrollment form in the pre-addressed business reply envelope provided. 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, call us at 1-800-678-2265.
17 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 18 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 • Within the first six months of your Medicare Part B coverage, or • During continuous open enrollment • The same day as your Medicare coverage • The first day of the month following the month your application is received Note: If you haven’t enrolled in Medicare, contact your local Social Security Administration office three months prior to your 65th birthday. 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% FIRST-YEAR SAVINGS 10% SECOND-YEAR SAVINGS 5% THIRD-YEAR SAVINGS To determine if you’re eligible for the discount, call 1-800-678-2265. 2023 Rates Billed Monthly Billed Quarterly Medex Core $116.82 $349.77 Medex Sapphire $192.63 $576.78 Medex Bronze $229.51 $687.21 Rates effective January 1, 2023 through December 31, 2023. Note: If you obtained Medicare under the age of 65 due to disability, you’re not eligible for the discount.
17 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 18 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 • Within the first six months of your Medicare Part B coverage, or • During continuous open enrollment • The same day as your Medicare coverage • The first day of the month following the month your application is received Note: If you haven’t enrolled in Medicare, contact your local Social Security Administration office three months prior to your 65th birthday. 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% FIRST-YEAR SAVINGS 10% SECOND-YEAR SAVINGS 5% THIRD-YEAR SAVINGS To determine if you’re eligible for the discount, call 1-800-678-2265. 2023 Rates Billed Monthly Billed Quarterly Medex Core $116.82 $349.77 Medex Sapphire $192.63 $576.78 Medex Bronze $229.51 $687.21 Rates effective January 1, 2023 through December 31, 2023. Note: If you obtained Medicare under the age of 65 due to disability, you’re not eligible for the discount.
19 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 20 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 of Massachusetts Blue Cross Blue Shield of Massachusetts associates can answer questions regarding Medex options, premium rates, applications, timing, enrollment, and other Medex-related issues. Medex Sales: 1-800-678-2265 TTY: 711 Serving the Health Information Needs of Everyone (SHINE) SHINE is an independent organization dedicated to helping you understand and compare all your health plan options. Trained and certified counselors help you determine if you qualify for any supplemental assistance programs. All services are free of charge. 1-800-AGE-INFO (1-800-243-4636) Medicare If you have questions regarding Medicare, or to order a Medicare & You handbook, call 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048) or visit cms.gov. 24/7 Nurse Line: 1-888-247-BLUE (2583) Not sure if you need to see a doctor? Medex members can call a registered nurse 24 hours a day at the Nurse Line for immediate assistance with health-related questions. We think it’s important for you to know... At the onset of an emergency medical condition that in your judgment requires 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. 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 $1,600 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 $226 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 $1,600 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 $226 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.
19 Medex Sales: 1-800-678-2265 bluecrossma.com/medicare 20 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 of Massachusetts Blue Cross Blue Shield of Massachusetts associates can answer questions regarding Medex options, premium rates, applications, timing, enrollment, and other Medex-related issues. Medex Sales: 1-800-678-2265 TTY: 711 Serving the Health Information Needs of Everyone (SHINE) SHINE is an independent organization dedicated to helping you understand and compare all your health plan options. Trained and certified counselors help you determine if you qualify for any supplemental assistance programs. All services are free of charge. 1-800-AGE-INFO (1-800-243-4636) Medicare If you have questions regarding Medicare, or to order a Medicare & You handbook, call 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048) or visit cms.gov. 24/7 Nurse Line: 1-888-247-BLUE (2583) Not sure if you need to see a doctor? Medex members can call a registered nurse 24 hours a day at the Nurse Line for immediate assistance with health-related questions. We think it’s important for you to know... At the onset of an emergency medical condition that in your judgment requires 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. 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 $1,600 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 $226 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 $1,600 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 $226 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.
Medex®´ Core, Medex®´ Sapphire and Medex®´ Bronze Plans for 2023 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. 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. © 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001660265 42-0430-23 (3/23) FOR MORE INFORMATION: Medicare Plan Sales: 1-800-678-2265 (TTY: 711) Monday through Friday, 8:00 a.m. to 5:00 p.m. ET. bluecrossma.com/medicare
Independent Licensee of the Blue Cross and Blue Shield Association. 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 Medicare Part A deductible) and the 60 Medicare lifetime reserve days, plus coverage for 365 additional days after Medicare benefits end. This shall include benefits for biologically based mental disorders. Medical Expenses 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. Blood 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.
Medicare Supplement Core Medex®´ Core Medicare Supplement 1 Medex®´ Bronze Medicare Supplement 1A Medex®´ Sapphire Standard Benefits Basic Benefits Hospitalization For biologically based mental disorders, stays in a licensed mental hospital, less Part A deductibles; for other mental disorders: stays in a licensed mental hospital for at least 60 days per calendar year less days covered by Medicare or already covered by plan in that calendar year for the other mental disorders, less Part A deductibles. Hospitalization For biologically based mental disorders, stays in a licensed mental hospital; for other mental disorders: stays in a licensed mental hospital for a minimum of 120 days per benefit period (at least 60 days per calendar year) less days covered by Medicare or already covered by plan in that calendar year for the other mental disorders. Hospitalization For biologically based mental disorders, stays in a licensed mental hospital; for other mental disorders: stays in a licensed mental hospital for a minimum of 120 days per benefit period (at least 60 days per calendar year) less days covered by Medicare or already covered by plan in that calendar year for the other mental disorders. Skilled nursing co-insurance Skilled nursing co-insurance Part A deductible Part A deductible Part B deductible Foreign travel Foreign travel Additional Benefits Fitness program Fitness program Fitness program Weight-loss program Weight-loss program Weight-loss program Foreign travel Rates: Effective 1/1/23 Billed monthly: $116.82 Billed monthly: $229.51 Billed monthly: $192.63 Billed quarterly: $349.77 Billed quarterly: $687.21 Billed quarterly: $576.78 1 2023 Medicare Plan Updates
Massachusetts Medicare Supplement Insurance: Outline Of Coverage Blue Cross and Blue Shield of Massachusetts, Inc. • Medicare Supplement Core—Medex Core (ME 11 DB) • Medicare Supplement 1—Medex Bronze (ME 2 DB) • Medicare Supplement 1A —Medex Sapphire (ME 2ADED DB) Policy Category: Medicare Supplement Insurance “NOTICE TO BUYER: This policy may not cover all of the costs associated with medical care incurred by the buyer during the period of coverage. The buyer is advised to review carefully all policy limitations.” Premium Information We, Blue Cross Blue Shield of Massachusetts, can only raise your premium if we raise the premium for all policies like yours in Massachusetts, and if approved by the Commissioner of Insurance. If you choose to pay your premium on a monthly or quarterly basis, upon your death, we will refund the unearned portion of the premium paid. If you choose to pay your premium on a monthly or quarterly basis and you cancel your policy, we will refund the unearned portion of the premium paid. In the case of death, the unearned portion of the premium will be refunded on a pro-rata basis. Disclosures Use this outline to compare benefits and premiums among policies. Read Your Policy Very Carefully This is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both yourself and your insurance company. Right to Return Policy If you find you are not satisfied with your policy, you may return it to Blue Cross Blue Shield of Massachusetts, Medex Member Services, P.O. Box 9130, North Quincy, MA 02171-9130. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments. Policy Replacement If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. If you cancel your present policy and then decide that you do not want to keep your new policy, it may not be possible to get back the coverage of the present policy. If you newly enroll in a Medicare Supplement 1 plan and you became Medicare Eligible before January 1, 2020, you will not be able to switch into the same company’s Medicare Supplement 1A plan until you have been covered under the Medicare Supplement 1 plan for a period of at least 12 months. Notice This policy may not fully cover all of your medical costs. Blue Cross Blue Shield of Massachusetts is not connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security office or consult Medicare & You for more details. Complete Answers Are Very Important When you fill out the application for the new policy, be sure to answer all the questions truthfully and completely. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important information. Review the application carefully before you sign it. Be certain that all information has been properly recorded. Blue Cross Blue Shield of Massachusetts 2
3 2023 Medicare Plan Updates Massachusetts Medicare Supplement Insurance: Outline Of Coverage Massachusetts Summary The Commissioner of Insurance has set standards for the sale of Medicare Supplement Insurance policies. Such policies help you pay hospital and doctor bills, and some other bills, that are not covered in full by Medicare. Please note that the benefits provided by Medicare and this Medicare Supplement Insurance policy may not cover all of the costs associated with your treatment. It is important that you become familiar with the benefits provided by Medicare and your Medicare Supplement Insurance policy. This policy summary outlines the different coverages you have if, in addition to this policy, you are also covered by Part A (hospital bills, mainly) and Part B (doctors’ bills, mainly) of Medicare. Under Massachusetts General Laws, c. 112, s. 2, no physician who agrees to treat a Medicare beneficiary may charge to or collect from that beneficiary any amount in excess of the reasonable charge for that service as determined by the United States Secretary of Health and Human Services. This prohibition is commonly referred to as the “ban on balance billing.” A physician is allowed to charge you or collect from your insurer a copayment or co-insurance for Medicare-covered services. However, if your physician charges you or attempts to collect from you an amount, which together with your copayment or co-insurance is greater than the Medicare-approved amount, please contact the Board of Registration in Medicine at 1-781-876-8200. We cannot explain everything here. Massachusetts law requires that personal insurance policies be written in easy-to-read language. So, if you have questions about your coverage that are not answered in this brochure, read your policy. If you still have questions, ask your agent or company. You may also wish to get a copy of Medicare & You, a small book put out by Medicare that describes Medicare benefits. The Benefits-to-Premium Ratio for Medex Bronze Is 93.7% This means that during the anticipated life of your policy and others just like it, Blue Cross Blue Shield of Massachusetts expects to pay out $93.70 in claims made by you and other policyholders for every $100 we collect in premiums. The minimum loss ratio for Blue Cross Blue Shield of Massachusetts policies of this type is 90%. The minimum loss ratio for non-Blue Cross Blue Shield of Massachusetts policies of this type is 65%. A higher ratio is to your advantage, as long as it allows the company reasonable return so that the product remains available. The Benefits-to-Premium Ratio for Medex Core Is 93.7% This means that during the anticipated life of your policy and others just like it, Blue Cross Blue Shield of Massachusetts expects to pay out $93.70 in claims made by you and other policyholders for every $100 we collect in premiums. The minimum loss ratio for Blue Cross Blue Shield of Massachusetts policies of this type is 90%. The minimum loss ratio for non-Blue Cross Blue Shield of Massachusetts policies of this type is 65%. A higher ratio is to your advantage, as long as it allows the company reasonable return so that the product remains available. The Benefits-to-Premium Ratio for Medex Sapphire Is 93.7% This means that during the anticipated life of your policy and others just like it, Blue Cross Blue Shield of Massachusetts expects to pay out $93.70 in claims made by you and other policyholders for every $100 we collect in premiums. The minimum loss ratio for Blue Cross Blue Shield of Massachusetts policies of this type is 90%. A higher ratio is to your advantage, as long as it allows the company reasonable return so that the product remains available.
Blue Cross Blue Shield of Massachusetts 4 Complaints If you have a complaint, call Medex Member Service at 1-800-258-2226. If you are not satisfied, you may write to The Massachusetts Division of Insurance, 1000 Washington Street, Suite 810, Boston, Massachusetts 02118-6200 or call 1-617-521-7794 (Boston). Grievance Program As a Medex member, you have the right to a review when you disagree with a decision made by Blue Cross Blue Shield of Massachusetts to deny payment for services that may be eligible for benefits under Medex or if you have a complaint about the care or service that you received from Blue Cross Blue Shield of Massachusetts or from a provider. Medex Inquiries or Claim Problems Most Medex problems or concerns can be handled with just one phone call. For help to resolve a Medex problem or concern, you should first call the Blue Cross Blue Shield of Massachusetts customer service office at 1-800-258-2226, Monday through Friday, 8:00 a.m. to 6:00 p.m. ET. The TTY toll-free number is 711. A customer service representative will work with you. They will help you understand your Medex coverage. Or, they will work with you to resolve your Medex problem or concern. They will do this as quickly as possible. If after speaking with a Blue Cross Blue Shield of Massachusetts customer service representative, you still disagree with a decision that is given to you, you may request a review through the Blue Cross Blue Shield of Massachusetts internal formal grievance program. Internal Formal Grievance Review How to Request a Grievance Review: To request a formal review from the Blue Cross Blue Shield of Massachusetts internal Member Grievance Program, you (or your authorized representative) have three options. • Write or Fax: The preferred option is for you to send your grievance in writing to: Member Grievance Program, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126. Or, you may fax your grievance to 1-617-246-3616. Blue Cross Blue Shield will let you know that your request was received by sending you a written confirmation within 15 calendar days. • Email: Or, you may send your grievance to the Blue Cross Blue Shield Member Grievance Program at grievances@ bcbsma.com. Blue Cross Blue Shield of Massachusetts will let you know that your request was received by sending you a confirmation immediately by email. • Telephone: Or, you may call the Blue Cross Blue Shield of Massachusetts Member Grievance Program at 1-800-472-2689. When your request is made by phone, Blue Cross Blue Shield of Massachusetts will send you a written account of the grievance within 48 hours of your phone call. Once your request is received, Blue Cross Blue Shield of Massachusetts will research the case in detail. They will ask for more information if it is needed. Blue Cross Blue Shield of Massachusetts will let you know in writing of the decision or the outcome of the review. 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.
5 2023 Medicare Plan Updates MEDICARE SUPPLEMENT CORE: MEDEX CORE Medicare (Part A)—Hospital Services—Per Benefit Period Services Medicare Pays Plan Pays You Pay Hospitalization* Semiprivate room and board, general hospital nursing and miscellaneous services and supplies, and licensed mental hospital stays for biologically based mental disorders or other mental disorders prior to the 190-day Medicare lifetime maximum First 60 days of a benefit period All but $1,600 $0 $1,600 (Part A deductible) 61st through 90th day of a benefit period All but $400 a day $400 a day $0 91st day and after of a benefit period: • While using 60 lifetime reserve days All but $800 a day $800 a day $0 • Once lifetime reserve days are used: • Additional 365 days $0 100% of Medicareeligible expenses $0 • Beyond the additional 365 days $0 $0 All costs Licensed mental hospital stays not covered by Medicare for biologically based mental disorders First 60 days of a benefit period $0 All but $1,600 $1,600 (Part A deductible) 61st through 90th day of a benefit period $0 100% of Medicareeligible expenses $0 91st day and after of a benefit period: • While using 60 lifetime reserve days $0 100% of Medicareeligible expenses $0 • Once lifetime reserve days are used: • Additional 365 days $0 100% of Medicareeligible expenses $0 • Beyond the additional 365 days $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 2023 Medicare deductible and co-insurance amounts. These amounts are subject to change each year.
Blue Cross Blue Shield of Massachusetts 6 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 First 60 days per calendar year less days covered by Medicare or plan in that calendar year $0 All but $1,600 $1,600 (Part A deductible) 61st through 120th day of a benefit period $0 100% of Medicareeligible expenses $0 Days after 60 days per calendar year less days covered by Medicare or plan in that calendar year $0 $0 All costs 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 All approved amounts $0 $0 21st through 100th day of a benefit period All but $200 a day $0 Up to $200 a day 101st day and after of a benefit period $0 $0 All costs Blood First three pints $0 Three pints $0 Additional amounts 100% $0 $0 Hospice Care Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited co-insurance for outpatient drugs and inpatient respite care Actual billed charges up to the co-insurance amount $0 *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 2023 Medicare deductible and co-insurance amounts. These amounts are subject to change each year.
7 2023 Medicare Plan Updates 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 $226 of Medicare-approved amounts** $0 $0 $226 (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 $226 of Medicare-approved amounts** $0 $0 $226 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 Outpatient treatment for biologically based mental disorders and other mental health disorders (for services not covered by Medicare) $0 100% of expenses $0 Blood First three pints $0 All costs $0 Next $226 of Medicare-approved amounts** $0 $0 $226 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 **Once you have been billed $226 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 2023 Medicare deductible and co-insurance amounts. These amounts are subject to change each year.
Blue Cross Blue Shield of Massachusetts 8 Medicare (Part B)—Medical Services—Per Calendar Year (continued) Services Medicare Pays Plan Pays You Pay Clinical Laboratory Services Blood tests for diagnostic services 100% $0 $0 Special Medical Formulas Mandated by Law Covered by Medicare First $226 of Medicare-approved amounts** $0 $0 $226 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 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 Medically necessary skilled-care services and medical supplies 100% $0 $0 Durable medical equipment First $226 of Medicare-approved amounts** $0 $0 $226 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 Other Benefits—Not Covered by Medicare Services Medicare Pays Plan Pays You Pay Outpatient Prescription Drugs— Not Covered by Medicare $0 $0 All costs Foreign Travel—Not Covered by Medicare Only the services listed above while traveling outside the United States $0 Remainder of charges (including portion normally paid by Medicare $0 Fitness Program—Not Covered by Medicare $0 $150 per calendar year All charges after $150 Weight-Loss Program—Not Covered by Medicare $0 $150 per calendar year All charges after $150 **Once you have been billed $226 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 2023 Medicare deductible and co-insurance amounts. These amounts are subject to change each year.
9 2023 Medicare Plan Updates 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 miscellaneous services and supplies, and licensed mental hospital stays for biologically based mental disorders or other mental disorders prior to the 190-day Medicare lifetime maximum First 60 days of a benefit period All but $1,600 $1,600 (Part A deductible) $0 61st through 90th day of a benefit period All but $400 a day $400 a day $0 91st day and after of a benefit period: • While using 60 lifetime reserve days All but $800 a day $800 a day $0 • Once lifetime reserve days are used: • Additional 365 days $0 100% of Medicareeligible expenses $0 • Beyond the additional 365 days $0 $0 All costs Licensed mental hospital stays for biologically based mental disorders not covered by Medicare First 60 days of a benefit period $0 100% of Medicareeligible expenses $0 61st through 90th day of a benefit period $0 100% of Medicareeligible expenses $0 91st day and after of a benefit period: • While using 60 lifetime reserve days $0 100% of Medicareeligible expenses $0 • Once lifetime reserve days are used: • Additional 365 days $0 100% of Medicareeligible expenses $0 • Beyond the additional 365 days $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 2023 Medicare deductible and co-insurance amounts. These amounts are subject to change each year.
Blue Cross Blue Shield of Massachusetts 10 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 First 120 days per benefit period (at least 60 days per calendar year) less days covered by Medicare or plan in that calendar year First 60 days of a benefit period $0 100% of Medicareeligible expenses $0 61st through 120th day of a benefit period $0 100% of Medicareeligible expenses $0 Days after 120 days per benefit period (or 60 days per calendar year) less days covered by Medicare or plan in that calendar year $0 $0 All costs 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 All approved amounts $0 $0 21st through 100th day of a benefit period All but $200 a day Up to $200 a day $0 101st day through 365th day of a benefit period $0 $10 a day Balance Beyond the 365th day of a benefit period $0 $0 All costs (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 2023 Medicare deductible and co-insurance amounts. These amounts are subject to change each year.
11 2023 Medicare Plan Updates Medicare Supplement 1: Medex Bronze (continued) Medicare (Part A)—Hospital Services—Per Benefit Period (continued) Services Medicare Pays Plan Pays You Pay Blood First three pints $0 three pints $0 Additional amounts 100% $0 $0 Hospice Care Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited co-insurance for outpatient drugs and inpatient respite care Actual billed charges up to the co-insurance amount $0 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, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment First $226 of Medicare-approved amounts** $0 $226 (Part B deductible) $0 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 $226 of Medicare-approved amounts** $0 $226 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 Outpatient treatment for biologically based mental disorders and other mental health disorders (for services not covered by Medicare) $0 100% of expenses $0 **Once you have been billed $226 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 2023 Medicare deductible and co-insurance amounts. These amounts are subject to change each year.
Blue Cross Blue Shield of Massachusetts 12 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 $226 of Medicare-approved amounts** $0 $226 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 Clinical Laboratory Services Blood tests for diagnostic services 100% $0 $0 Special Medical Formulas Mandated by Law Covered by Medicare First $226 of Medicare-approved amounts** $0 $226 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 Not covered by Medicare $0 All allowed charges Balance **Once you have been billed $226 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 2023 Medicare deductible and co-insurance amounts. These amounts are subject to change each year.
13 2023 Medicare Plan Updates 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 and medical supplies 100% $0 $0 Durable medical equipment First $226 of Medicare-approved amounts** $0 $226 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 **Once you have been billed $226 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 2023 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 outside the United States $0 Remainder of charges (including portion normally paid by Medicare) $0 Outpatient Prescription Drugs—Not Covered by Medicare $0 $0 All costs Fitness Program—Not Covered by Medicare $0 $150 per calendar year All charges after $150 Weight-Loss Program—Not Covered by Medicare $0 $150 per calendar year All charges after $150
Blue Cross Blue Shield of Massachusetts 14 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 and miscellaneous services and supplies, and licensed mental hospital stays for biologically based mental disorders or other mental disorders prior to the 190-day Medicare lifetime maximum First 60 days of a benefit period All but $1,600 $1,600 (Part A deductible) $0 61st through 90th day of a benefit period All but $400 a day $400 a day $0 91st day and after of a benefit period: • While using 60 lifetime reserve days All but $800 a day $800 a day $0 • Once lifetime reserve days are used: • Additional 365 days $0 100% of Medicare eligible expenses $0 • Beyond the additional 365 days $0 $0 All costs Licensed mental hospital stays not covered by Medicare for biologically based mental disorders First 60 days of a benefit period $0 100% of Medicareeligible expenses $0 61st through 90th day of a benefit period $0 100% of Medicareeligible expenses $0 91st day and after of a benefit period: • While using 60 lifetime reserve days $0 100% of Medicareeligible expenses $0 • Once lifetime reserve days are used: • Additional 365 days $0 100% of Medicareeligible expenses $0 • Beyond the additional 365 days $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 2023 Medicare deductible and co-insurance amounts. These amounts are subject to change each year.
15 2023 Medicare Plan Updates Medicare Supplement 1A: Medex Sapphire (continued) 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 First 120 days per benefit period (at least 60 days per calendar year) less days covered by Medicare or plan in that calendar year First 60 days of a benefit period $0 100% of Medicareeligible expenses $0 61st through 120th day of a benefit period $0 100% of Medicareeligible expenses $0 Days after 120 days per benefit period (or 60 days per calendar year) less days covered by Medicare or plan in that calendar year $0 $0 All costs 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 All approved amounts $0 $0 21st through 100th day of a benefit period All but $200 a day Up to $200 a day $0 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 2023 Medicare deductible and co-insurance amounts. These amounts are subject to change each year.
Blue Cross Blue Shield of Massachusetts 16 Medicare (Part A)—Hospital Services—Per Benefit Period (continued) Services Medicare Pays Plan Pays You Pay (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 Blood First three pints $0 Three pints $0 Additional amounts 100% $0 $0 Hospice Care Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited co-insurance for outpatient drugs and inpatient respite care Actual billed charges up to the co-insurance amount $0 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 2023 Medicare deductible and co-insurance amounts. These amounts are subject to change each year.
17 2023 Medicare Plan Updates 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 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 $226 of Medicare-approved amounts** $0 $0 $226 (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 $226 of Medicare-approved amounts** $0 $0 $226 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 Outpatient treatment for biologically based mental disorders and other mental health disorders (for services not covered by Medicare) $0 100% of expenses $0 Blood First three pints $0 All costs $0 Next $226 of Medicare-approved amounts** $0 $0 $226 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 **Once you have been billed $226 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 2023 Medicare deductible and co-insurance amounts. These amounts are subject to change each year.