Blue Cross Blue Shield of Massachusetts 18 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 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 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 **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 complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex, sexual orientation, or gender identity. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-258-2226 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-258-2226 (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. 001660211 32-3000-23 (10/22) BLUE CROSS BLUE SHIELD RESOURCES Medicare Plan Sales: 1-800-678-2265 Member Service: 1-800-258-2226 (TTY: 711) Monday through Friday, 8:00 a.m. to 5:00 p.m. ET. bluecrossma.com/medicare
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JOIN US AND LEARN MORE ABOUT MEDICARE The best plan is the kind you understand. Join one of our upcoming Medicare seminars to learn more about your options and get answers to your questions. Topics include: Medicare Advantage (HMO and PPO) Original Medicare and Medex®´ (Medicare Supplement) Prescription Drug Plans (PDP) Dental Blue® 65 GeoBlue® Travel Insurance UPCOMING SEMINARS To view the full list of upcoming seminars including in-person and online options and to sign up, scan the QR code, or visit bluecrossma.com/seminar. Seminar Type Date Time Location Medicare Advantage (HMO & PPO) Tuesday, June 20, 2023 2:00 p.m. - 3:00 p.m. Online Medicare Plan Options* Wednesday, June 21, 2023 10:00 a.m. - 12:00 p.m. Marriott 8A Centennial Drive, Peabody Dental Blue® 65 Thursday, June 22, 2023 9:30 a.m. - 10:00 a.m. Online Medicare Plan Options* Thursday, June 22, 2023 10:00 a.m. - 12:00 p.m. Beechwood Hotel 363 Plantation Street, Worcester GeoBlue® Travel Insurance Thursday, June 22, 2023 10:30 a.m. - 11:00 a.m Online Original Medicare & Medex®´ (Medicare Supplement) Friday, June 23, 2023 9:30 a.m. - 10:15 a.m. Online Prescription Drug Plans (PDP) Friday, June 23, 2023 10:30 a.m. - 11:15 a.m. Online Medicare Advantage (HMO & PPO) Monday, June 26, 2023 2:00 p.m. - 3:00 p.m. Online Medicare Plan Options* Tuesday, June 27, 2023 10:00 a.m. - 12:00 p.m. Holiday Inn 55 Ariadne Road, Dedham Original Medicare & Medex®´ (Medicare Supplement) Tuesday, June 27, 2023 2:00 p.m. - 2:45 p.m. Online Prescription Drug Plans (PDP) Tuesday, June 27, 2023 3:00 p.m. - 3:45 p.m. Online Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal. Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx plans. The joint enterprise is a Medicare-approved Part D sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal. ® 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. © 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 002145451 Y0014_22171_M 99-0645-23 (5/23) Not seeing a date that works for you? There are plenty more to choose from. Check out our full list of events at bluecrossma.com/seminar, or scan the QR Code. NEED HELP SIGNING UP? For assistance signing up for a seminar, or for accommodations for persons with special needs, call 1-800-262-BLUE (2583) (TTY: 711) 7:00 a.m. – 12:00 midnight, seven days a week (excluding holidays). Seminar Type Date Time Location Medicare Advantage (HMO & PPO) Thursday, June 29, 2023 4:00 p.m. - 5:00 p.m. Online Original Medicare & Medex (Medicare Supplement) Friday, June 30, 2023 9:30 a.m. - 10:15 a.m. Online Prescription Drug Plans (PDP) Friday, June 30, 2023 10:30 a.m. - 11:15 a.m. Online Dental Blue 65 Thursday, July 6, 2023 4:00 p.m. - 4:30 p.m. Online GeoBlue Travel Insurance Thursday, July 6, 2023 5:00 p.m. - 5:30 p.m. Online Original Medicare & Medex (Medicare Supplement) Monday, July 10, 2023 1:00 p.m. - 1:45 p.m. Online Prescription Drug Plans (PDP) Monday, July 10, 2023 2:00 p.m. - 2:45 p.m. Online Medicare Plan Options* Tuesday, July 11, 2023 10:00 a.m. - 12:00 p.m. La Quinta Inn & Suites by Wyndham 100 Congress Street, Springfield Medicare Advantage (HMO & PPO) Wednesday, July 12, 2023 3:00 p.m. - 4:00 p.m. Online Medicare Plan Options* Thursday, July 13, 2023 10:00 a.m. - 12:00 p.m. Clarion Hotel 700 Myles Standish Blvd., Taunton Original Medicare & Medex (Medicare Supplement) Monday, July 17, 2023 2:00 p.m. - 2:45 p.m. Online Medicare Plan Options* Tuesday, July 18, 2023 10:00 a.m. - 12:00 p.m. Marriott One Burlington Mall Road, Burlington *A Blue Cross Blue Shield of Massachusetts representative will present Medicare HMO, PPO, PDP, and Medicare Supplement plan options and benefits. They can answer your questions and assist with enrollment when you’re ready. Visit the website below to view the agenda.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Medex®´ Core, Medex®´ Sapphire, Medex®´ Bronze IT PAYS TO STAY BLUE If you’re 65 or older and eligible for Medicare for the first time, sticking with us could qualify you for these savings on your premium when you enroll in Medex®´: 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. How These Savings Work Plan Full Rate* First Year: 15% Discount* Second Year: 10% Discount* Third Year: 5% Discount* Medex Core $116.82 $99.30 $105.14 $110.98 Medex Sapphire $192.63 $163.74 $173.37 $183.00 Medex Bronze $229.51 $195.08 $206.56 $218.03 *Rates effective January 1, 2023 to December 31, 2023 Benefits for a Healthier You • MyBlue—Tap into all of your plan’s benefits, all in one place. Sign up at bluecrossma.org, or download the MyBlue app. • Fitness and Weight-Loss Reimbursements— Medex members are eligible for up to $150 a year for each reimbursement. • Vision and Hearing—Easily add a vision and hearing benefit to your Medex plan by calling us at the number below. • Dental Blue® 65—Complement your plan with dental benefits to smile about. Call us to learn more. • eBilling—Conveniently pay your bills online.
Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-258-2226 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-258-2226 (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. 001616451 99-0290-23 (9/22) Learn More For more information, visit bluecrossma.com/medicare, or 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, Medex®´ Bronze VISION AND HEARING BENEFITS If you have a direct-billed Medex Core, Medex Sapphire, or Medex Bronze plan, take a look at these benefits. They’ll help cover your vision and hearing expenses, while limiting your out-of-pocket costs. 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 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. ®´´ Registered Marks are the property of their respective owners. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001615420 55-000405190-23 (10/22) FOR MORE INFORMATION, OR TO ENROLL: ÷ Medicare Plan Sales: 1-800-678-2265 (TTY: 711) 8:00 a.m. to 5:00 p.m. ET, Monday through Friday bluecrossma.com/Medicare
1. No coverage is provided for amounts more than $150 per calendar year; orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; medical and/or surgical treatment of the eye, eyes, or supporting structures; any eye or vision examination, or any corrective eyewear required by a policyholder as a condition of employment; safety eyewear services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state, or subdivisions thereof; Plano (non-prescription) lenses and/or contact lenses; non-prescription sunglasses; two pair of glasses in lieu of bifocals; services rendered after the date an insured person ceases to be covered under the policy, except when vision materials ordered before coverage ended are delivered, and the services rendered to the insured person are within 31 days from the date of such order; services or materials provided by any other group benefit plan providing vision care; lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next benefit frequency when vision materials would next become available. 2. No coverage is provided for hearing aids that are not purchased from a TruHearing supplier; hearing aids that are not TruHearing-branded hearing aids; ear molds; hearing aid accessories; additional costs for optional hearing aid rechargeability; costs associated with loss and damage warranty claims; and replacement hearing aid batteries beyond the set number of batteries that are provided by TruHearing at the time of the hearing aid purchase. COMPLETE YOUR COVERAGE Glasses and hearing aids aren’t covered by Medicare. That’s why our Medex®´ Vision and Hearing benefit plan offers the coverage you’re missing. Plus, from January 1, 2023 to December 31, 2023, it’s just $2.66 per month. This amount will be added to your direct-billed Medex premium. With the Medex Vision and Hearing plan, you’ll get the following benefits: Vision Care Benefits • Routine vision exams: Covers one routine vision exam per calendar year to determine if you need corrective lenses. You pay nothing when seen by an EyeMed®´´ network provider. • Eyeglasses or contact lenses: Covers up to $1501 per calendar year for one set of frames and prescription lenses or contact lenses (in place of eyeglasses), from any licensed vision care supplier. If you choose to purchase eyeglasses or contact lenses from an EyeMed supplier, you may be eligible to receive additional discounts from the supplier for your vision supplies. This $150 benefit payment includes costs for measurement, fitting, and adjustments. What if the licensed vision care provider isn’t an EyeMed provider? When your exam is furnished by a provider that is not an EyeMed provider, the provider may ask you to pay all charges. In this case, you’ll have to send a claim to EyeMed for repayment of up to $50 for a covered exam. What if the vision care supplier isn’t an EyeMed supplier? When you purchase eyeglasses or contact lenses from a supplier that isn’t an EyeMed supplier, the supplier may ask you to pay all charges. If this happens, you’ll have to send a claim to EyeMed for repayment of up to $150 for covered eyeglasses or contact lenses. Complete the claim form and send it with your original itemized bill(s). If you need a claim form, call EyeMed Member Service at 1-866-525-5126, Monday through Saturday 7 a.m. to 11 p.m. ET and Sundays 8:00 a.m. to 11 p.m. ET. Hearing Care Benefits • Routine hearing exams: Covers one routine hearing exam per calendar year, when the exam is furnished by a TruHearing®´´ network provider. You pay nothing when seen by a TruHearing network provider. • Hearing aids: Coverage for one hearing aid per hearing impaired ear per calendar year, when furnished by a TruHearing supplier. You pay $699 or $999 for each covered TruHearing hearing aid.2 What if the licensed hearing care provider isn’t an TruHearing provider? No coverage is provided for routine hearing exams furnished by providers that aren’t TruHearing providers. What if the hearing care supplier isn’t an TruHearing supplier? No coverage is provided for hearing aids that aren’t purchased from a TruHearing supplier and hearing aids that aren’t TruHearing-branded hearing aids. If you have additional benefit questions, call TruHearing Member Service at 1-844-813-8129, Monday through Friday, 6:00 a.m. to 7:00 p.m. ET. HOW TO GET REIMBURSED It’s easy to get reimbursed for vision and hearing care services. BUY YOUR GLASSES, CONTACTS, OR HEARING AID(S) Your provider may ask you to pay all charges at the time of your purchase or at a later date. FILE A CLAIM WITH BLUE CROSS BLUE SHIELD OF MASSACHUSETTS Complete a claim form and send it in with your original, itemized bill(s) for repayment. How do I apply? The easiest way to enroll is by phone. Phone: 1-800-678-2265 (TTY: 711) Monday through Friday, 8:00 a.m. to 5:00 p.m. ET Enroll by mail or fax: Complete the application for Direct-Billed Medex. Mail to: Blue Cross Blue Shield of Massachusetts One Enterprise Drive Quincy, MA 02171-1753 Or fax to:1-617-246-3633.
1. No coverage is provided for amounts more than $150 per calendar year; orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; medical and/or surgical treatment of the eye, eyes, or supporting structures; any eye or vision examination, or any corrective eyewear required by a policyholder as a condition of employment; safety eyewear services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state, or subdivisions thereof; Plano (non-prescription) lenses and/or contact lenses; non-prescription sunglasses; two pair of glasses in lieu of bifocals; services rendered after the date an insured person ceases to be covered under the policy, except when vision materials ordered before coverage ended are delivered, and the services rendered to the insured person are within 31 days from the date of such order; services or materials provided by any other group benefit plan providing vision care; lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next benefit frequency when vision materials would next become available. 2. No coverage is provided for hearing aids that are not purchased from a TruHearing supplier; hearing aids that are not TruHearing-branded hearing aids; ear molds; hearing aid accessories; additional costs for optional hearing aid rechargeability; costs associated with loss and damage warranty claims; and replacement hearing aid batteries beyond the set number of batteries that are provided by TruHearing at the time of the hearing aid purchase. COMPLETE YOUR COVERAGE Glasses and hearing aids aren’t covered by Medicare. That’s why our Medex®´ Vision and Hearing benefit plan offers the coverage you’re missing. Plus, from January 1, 2023 to December 31, 2023, it’s just $2.66 per month. This amount will be added to your direct-billed Medex premium. With the Medex Vision and Hearing plan, you’ll get the following benefits: Vision Care Benefits • Routine vision exams: Covers one routine vision exam per calendar year to determine if you need corrective lenses. You pay nothing when seen by an EyeMed®´´ network provider. • Eyeglasses or contact lenses: Covers up to $1501 per calendar year for one set of frames and prescription lenses or contact lenses (in place of eyeglasses), from any licensed vision care supplier. If you choose to purchase eyeglasses or contact lenses from an EyeMed supplier, you may be eligible to receive additional discounts from the supplier for your vision supplies. This $150 benefit payment includes costs for measurement, fitting, and adjustments. What if the licensed vision care provider isn’t an EyeMed provider? When your exam is furnished by a provider that is not an EyeMed provider, the provider may ask you to pay all charges. In this case, you’ll have to send a claim to EyeMed for repayment of up to $50 for a covered exam. What if the vision care supplier isn’t an EyeMed supplier? When you purchase eyeglasses or contact lenses from a supplier that isn’t an EyeMed supplier, the supplier may ask you to pay all charges. If this happens, you’ll have to send a claim to EyeMed for repayment of up to $150 for covered eyeglasses or contact lenses. Complete the claim form and send it with your original itemized bill(s). If you need a claim form, call EyeMed Member Service at 1-866-525-5126, Monday through Saturday 7 a.m. to 11 p.m. ET and Sundays 8:00 a.m. to 11 p.m. ET. Hearing Care Benefits • Routine hearing exams: Covers one routine hearing exam per calendar year, when the exam is furnished by a TruHearing®´´ network provider. You pay nothing when seen by a TruHearing network provider. • Hearing aids: Coverage for one hearing aid per hearing impaired ear per calendar year, when furnished by a TruHearing supplier. You pay $699 or $999 for each covered TruHearing hearing aid.2 What if the licensed hearing care provider isn’t an TruHearing provider? No coverage is provided for routine hearing exams furnished by providers that aren’t TruHearing providers. What if the hearing care supplier isn’t an TruHearing supplier? No coverage is provided for hearing aids that aren’t purchased from a TruHearing supplier and hearing aids that aren’t TruHearing-branded hearing aids. If you have additional benefit questions, call TruHearing Member Service at 1-844-813-8129, Monday through Friday, 6:00 a.m. to 7:00 p.m. ET. HOW TO GET REIMBURSED It’s easy to get reimbursed for vision and hearing care services. BUY YOUR GLASSES, CONTACTS, OR HEARING AID(S) Your provider may ask you to pay all charges at the time of your purchase or at a later date. FILE A CLAIM WITH BLUE CROSS BLUE SHIELD OF MASSACHUSETTS Complete a claim form and send it in with your original, itemized bill(s) for repayment. How do I apply? The easiest way to enroll is by phone. Phone: 1-800-678-2265 (TTY: 711) Monday through Friday, 8:00 a.m. to 5:00 p.m. ET Enroll by mail or fax: Complete the application for Direct-Billed Medex. Mail to: Blue Cross Blue Shield of Massachusetts One Enterprise Drive Quincy, MA 02171-1753 Or fax to:1-617-246-3633.
Medex®´ Core, Medex®´ Sapphire, Medex®´ Bronze VISION AND HEARING BENEFITS If you have a direct-billed Medex Core, Medex Sapphire, or Medex Bronze plan, take a look at these benefits. They’ll help cover your vision and hearing expenses, while limiting your out-of-pocket costs. 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 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. ®´´ Registered Marks are the property of their respective owners. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001615420 55-000405190-23 (10/22) FOR MORE INFORMATION, OR TO ENROLL: ÷ Medicare Plan Sales: 1-800-678-2265 (TTY: 711) 8:00 a.m. to 5:00 p.m. ET, Monday through Friday bluecrossma.com/Medicare
BCBSMA Call Center 888-366-3212 Why should I choose a GeoBlue Plan? All GeoBlue products comprehensive benefits, unrivaled technology and unsurpassed protection. What short-term plan options are available? Single-trip plans up to 182 days in length GeoBlue Voyager - Up to $1,000,000 medical/$500,000 evacuation • Choice of medical limits and deductibles • Coverage of COVID-19 testing and treatment, at no additional cost, for everyone 95 years or younger • Pre-existing condition coverage option • Two levels of coverage: Essential and Choice • Primary U.S. health plan required for Choice option • Groups of 5 or more travelers may be enrolled as a group Multi-trip plans for unlimited trips that are a maximum 70 days in length GeoBlue Trekker - Up to $250,000 medical/$500,000 evacuation • Choice of medical limits • Pre-existing conditions covered • 364 day plan (70 days max. per trip) • Two levels of coverage are available: Essential and Choice • Primary U.S. health plan required for both Choice and Essential options What long-term plan options are available? Global living plans for assignments or trips lasting 6 months or longer. Coverage of COVID-19 testing and treatment, at no additional cost. GeoBlue Xplorer - Primary health insurance for global living. Unlimited medical maximum, evacuation, preventive care, pre-existing conditions covered with creditable coverage and more • Premier: Worldwide coverage, including the U.S. • Essential: Worldwide coverage, excluding the U.S., offers 50% savings • Essential w/ Basic U.S. Benefits: Worldwide coverage, excluding the U.S., except for accident and sickness coverage during 3 visits to the U.S. per year, each trip lasting up to 21 days GeoBlue Navigator - A customized version of GeoBlue Xplorer geared for the needs of career missionaries, yacht crew members, students and faculty GeoBlue is the trade name of Worldwide Insurance Services, LLC (Worldwide Services Insurance Agency, LLC in California and New York), an independent licensee of the Blue Cross and Blue Shield Association. GeoBlue is the administrator of coverage provided under insurance policies issued by 4 Ever Life International Limited, Bermuda, an independent licensee of the Blue Cross Blue Shield Association. Offered through the Global Citizens Association, Washington, D.C. What is GeoBlue? GeoBlue is a provider of health insurance for short-term and frequent leisure, study, mission, marine and business travel. Other questions? 4ELI-GBHPSPOT0620
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186095_Medicare Booklet Section Divider - Disclosures_06-11-18_AC.indd 2 6/12/18 10:05 AM
NONDISCRIMINATION NOTICE Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. Blue Cross Blue Shield of Massachusetts provides: • Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print or other formats). • Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call Member Service at the number on your ID card. If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Civil Rights Coordinator by mail at Civil Rights Coordinator, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126; phone at 1-800-472-2689 (TTY: 711); fax at 1-617-246-3616; or email at [email protected]. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD/TTY). Complaint forms are available at hhs.gov. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. 001614756 55-2067 (9/22)
TRANSLATION RESOURCES Proficiency of Language Assistance Services Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Spanish/Español: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711). Portuguese/Português: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711). Chinese/简体中文: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800- 200-4255 (TTY: 711) 。 Haitian Creole/Kreyòl Ayisyen: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-200-4255 (TTY: 711). Vietnamese/Tiếng Việt: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-200-4255 (TTY: 711). Russian/Русский: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-200-4255 (TTY: 711). ةي ب: /Arabic ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-800-200-4255( 711: TTY ) رقم هاتف الصم والبكم Mon-Khmer, Cambodian/ខ្មែរ: ប្រយ័ត្ន៖ ប ើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា បោយ មិនគិតឈ្ន ួល គឺអាចមានសំរា ់ ំបរ ើអ្នក។ ចូ រ ទូរស័ព្ទ1-800-200-4255 (TTY: 711)។ French/Français: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-200-4255 (TTY: 711). Italian/Italiano: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-200-4255 (TTY: 711). Korean/국어: 주의: 국어를 사용시는 경우, 언어 지원 서비스를 무료로 이용실 수 있습니다. 1-800-200-4255 (TTY: 711)번으로 전 주십시오. Greek/Eλληνικά: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-200-4255 (TTY: 711). Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-200-4255 (TTY: 711). Hindi/ह िंदी: ध्यान दें: यदद आप ह िंदी बोलतेहैंतो आपकेदलए मुफ्त मेंभाषा सहायता सेवाएं उपलब्ध हैं। 1-800- 200-4255 (TTY: 711) पर कॉल करें ।
Gujarati/ગુજરાતી: સુચના: જો તમેગુજરાતી બોલતા હો, તો નન:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-800-200-4255 (TTY: 711). Tagalog/Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-200-4255 (TTY: 711). Japanese/日本語: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1- 800-200-4255 (TTY: 711）まで、お電話にてご連絡ください。 German/Deutsch: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-200-4255 (TTY: 711). Lao/ພາສາລາວ: ໂປດຊາບ: ຖ້າວ່ າ ທ່ ານເ ວ້ າພາສາ ລາວ, ການບໍ ິ ລການຊ່ ວຍເຫຼື ອດ້ ານພາສາ, ໂດຍບໍ ່ ເສັ ຽຄ່ າ , ແມ່ ນມີ ພ້ ອມໃຫ້ທ່ ານ. ໂທຣ 1-800-200-4255 (TTY: 711) Navajo/Diné Bizaad: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-200-4255 (TTY: 711.) ® Registered Marks of the Blue Cross and Blue Shield Association. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001615801 55-2066-23 (9/22) Spanish/Español: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711). Portuguese/Português: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711). Chinese/简体中文: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800- 200-4255 (TTY: 711) 。 Haitian Creole/Kreyòl Ayisyen: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-200-4255 (TTY: 711). Vietnamese/Tiếng Việt: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-200-4255 (TTY: 711). Russian/Русский: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-200-4255 (TTY: 711). ةي ب: /Arabic ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-800-200-4255( 711: TTY ) رقم هاتف الصم والبكم Mon-Khmer, Cambodian/ខ្មែរ: ប្រយ័ត្ន៖ ប ើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា បោយ មិនគិតឈ្ន ួល គឺអាចមានសំរា ់ ំបរ ើអ្នក។ ចូ រ ទូរស័ព្ទ1-800-200-4255 (TTY: 711)។ French/Français: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-200-4255 (TTY: 711). Italian/Italiano: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-200-4255 (TTY: 711). Korean/국어: 주의: 국어를 사용시는 경우, 언어 지원 서비스를 무료로 이용실 수 있습니다. 1-800-200-4255 (TTY: 711)번으로 전 주십시오. Greek/Eλληνικά: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-200-4255 (TTY: 711). Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-200-4255 (TTY: 711). Hindi/ह िंदी: ध्यान दें: यदद आप ह िंदी बोलतेहैंतो आपकेदलए मुफ्त मेंभाषा सहायता सेवाएं उपलब्ध हैं। 1-800- 200-4255 (TTY: 711) पर कॉल करें ।
Enrollment 04 186098_Medicare Booklet Section Divider - Enrollment_06-12-18_AC.indd 1 6/12/18 10:23 AM
186098_Medicare Booklet Section Divider - Enrollment_06-12-18_AC.indd 2 6/12/18 10:23 AM
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Medex®´ Core, Medex®´ Sapphire, Medex®´ Bronze APPLICATION FOR DIRECT BILLED MEDEX®´ Directions • Please print clearly. • Carefully read and answer all questions. Incomplete applications will not be accepted. Please keep a copy of the application for your records. • Send us your application after you receive your red, white, and blue Medicare card. • Don’t send money with this application. You’ll receive a bill when payment is due. • Please complete and return to: Blue Cross Blue Shield of Massachusetts Enrollment Department P.O. Box 55011 Boston, MA 02205 • Or, fax the application to 1-617-246-3633. • To enroll by phone, call 1-800-678-2265. • Medex premium rates and benefits are explained in the booklet you received with this application. If you need more information or assistance, call us at 1-800-678-2265. • For all other questions, call: Medex Member Service: 1-800-258-2226 (TTY: 711) You’re eligible to apply for a Medex plan if you meet all of the following requirements: • You’re a resident of Massachusetts and you actually live in Massachusetts. • You’re eligible for Medicare Part A and Medicare Part B and enrolled in Medicare Part B. • If you’re under age 65, you qualify for Medicare coverage because of disability. Notes: 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 or disability before January 1, 2020. Those who are otherwise eligible for Medicare Part A and 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. If you’re covered by Medicaid, you may or may not be eligible to enroll in Direct Billed Medex. See paragraph (g) of the “Important Information” section of this application form.
Important Information Please read the below section, then answer questions 1 through 5. • You don’t need more than one Medicare supplemental insurance policy. • If you newly enroll in a Medicare Supplement 1 plan, you’re not permitted to switch within the same company into a Medicare Supplement 1A plan until you have been covered by the company’s Medicare Supplement 1 plan for at least 12 months. • If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverage. • You may be eligible for Medicaid benefits and may not need a Medicare supplemental insurance policy. • The benefits and premiums under your Medicare supplemental insurance policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you’re no longer entitled to Medicaid, your policy will be reinstituted if requested within 90 days of losing Medicaid eligibility. » If the Medicare supplemental insurance policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy won’t have outpatient prescription drug coverage, as you’ll be enrolled in the most comparable plan without outpatient prescription drug coverage. • If you’re eligible for, and have enrolled in a Medicare supplemental insurance policy by reason of disability and you later become covered by an employer or unionbased group health plan, the benefits and premiums under your Medicare supplemental insurance policy can be suspended, if requested, while you’re covered under the employer or union-based group health plan. If you suspend your Medicare supplemental insurance policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplemental insurance policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. » If the Medicare supplemental insurance policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy won’t have outpatient prescription drug coverage, as you’ll be enrolled in the most comparable plan without outpatient prescription drug coverage. • Counseling services are available in Massachusetts to provide advice concerning your purchase of Medicare supplemental Insurance policy and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB). You may call the Massachusetts Executive Office of Elder Affairs insurance counseling program at 1-800-243-4636 (TTY: 1-800-872-0166), or write to that office at the following address for more information: One Ashburton Place, 5th Floor, Boston, MA 02108. If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplemental insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplemental plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS. To the best of your knowledge, [Mark Yes or No below with an “X”] 1. (a) Did you turn age 65 in the last six months? Yes No (b) Did you enroll in Medicare Part B in the last six months? Yes No (c) If Yes, what is the effective date?_______________ 2. Are you covered for medical assistance through the state Medicaid program? [NOTE TO APPLICANT: If you’re participating in a “Spend-Down Program” and haven’t met your “Share of Cost,” please answer NO to this question.] Yes No If Yes, (a) Will Medicaid pay your premiums for this Medicare supplemental policy? Yes No (b) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium? Yes No Please answer all questions. Check the Medex plan of your choice: Medex Core (Medicare Supplement Core) Medex Sapphire (Medicare Supplement 1A) Medex Bronze (Medicare Supplement 1) Medex Core with Vision and Hearing Benefit Medex Sapphire with Vision and Hearing Benefit Medex Bronze with Vision and Hearing Benefit Your Social Security Number: ________ - _______ - _____________ How often would you like to be billed? Monthly Quarterly Would you like your premium payment due on the 1st of the month or the 15th of the month? 1st of the month 15th of the month First Name Last Name Middle Initial Your gender: Male Female Non-Binary Your complete date of birth: ( ——/——/————) M M D D YYYY Your telephone number: ( ) – Your permanent home address: Number and Street City: State: ZIP Code: If you want your Medex bill sent to an address other than your home address, complete the following section. Your billing address only: Number and Street City: State: ZIP Code: Medicare Insurance Information Please copy information from your red, white, and blue Medicare card in the spaces below. Medicare Number: Medicare Part A (Hospital Insurance) Effective Date: Medicare Part B (Medical Insurance) Effective Date: If you’re under age 65, what is your disability that qualifies you for Medicare coverage? Are you currently a Blue Cross Blue Shield of Massachusetts member? Yes No If Yes, give your Blue Cross Blue Shield identification number:
Important Information Please read the below section, then answer questions 1 through 5. • You don’t need more than one Medicare supplemental insurance policy. • If you newly enroll in a Medicare Supplement 1 plan, you’re not permitted to switch within the same company into a Medicare Supplement 1A plan until you have been covered by the company’s Medicare Supplement 1 plan for at least 12 months. • If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverage. • You may be eligible for Medicaid benefits and may not need a Medicare supplemental insurance policy. • The benefits and premiums under your Medicare supplemental insurance policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you’re no longer entitled to Medicaid, your policy will be reinstituted if requested within 90 days of losing Medicaid eligibility. » If the Medicare supplemental insurance policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy won’t have outpatient prescription drug coverage, as you’ll be enrolled in the most comparable plan without outpatient prescription drug coverage. • If you’re eligible for, and have enrolled in a Medicare supplemental insurance policy by reason of disability and you later become covered by an employer or unionbased group health plan, the benefits and premiums under your Medicare supplemental insurance policy can be suspended, if requested, while you’re covered under the employer or union-based group health plan. If you suspend your Medicare supplemental insurance policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplemental insurance policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. » If the Medicare supplemental insurance policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy won’t have outpatient prescription drug coverage, as you’ll be enrolled in the most comparable plan without outpatient prescription drug coverage. • Counseling services are available in Massachusetts to provide advice concerning your purchase of Medicare supplemental Insurance policy and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB). You may call the Massachusetts Executive Office of Elder Affairs insurance counseling program at 1-800-243-4636 (TTY: 1-800-872-0166), or write to that office at the following address for more information: One Ashburton Place, 5th Floor, Boston, MA 02108. If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplemental insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplemental plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS. To the best of your knowledge, [Mark Yes or No below with an “X”] 1. (a) Did you turn age 65 in the last six months? Yes No (b) Did you enroll in Medicare Part B in the last six months? Yes No (c) If Yes, what is the effective date?_______________ 2. Are you covered for medical assistance through the state Medicaid program? [NOTE TO APPLICANT: If you’re participating in a “Spend-Down Program” and haven’t met your “Share of Cost,” please answer NO to this question.] Yes No If Yes, (a) Will Medicaid pay your premiums for this Medicare supplemental policy? Yes No (b) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium? Yes No Please answer all questions. Check the Medex plan of your choice: Medex Core (Medicare Supplement Core) Medex Sapphire (Medicare Supplement 1A) Medex Bronze (Medicare Supplement 1) Medex Core with Vision and Hearing Benefit Medex Sapphire with Vision and Hearing Benefit Medex Bronze with Vision and Hearing Benefit Your Social Security Number: ________ - _______ - _____________ How often would you like to be billed? Monthly Quarterly Would you like your premium payment due on the 1st of the month or the 15th of the month? 1st of the month 15th of the month First Name Last Name Middle Initial Your gender: Male Female Non-Binary Your complete date of birth: ( ——/——/————) M M D D YYYY Your telephone number: ( ) – Your permanent home address: Number and Street City: State: ZIP Code: If you want your Medex bill sent to an address other than your home address, complete the following section. Your billing address only: Number and Street City: State: ZIP Code: Medicare Insurance Information Please copy information from your red, white, and blue Medicare card in the spaces below. Medicare Number: Medicare Part A (Hospital Insurance) Effective Date: Medicare Part B (Medical Insurance) Effective Date: If you’re under age 65, what is your disability that qualifies you for Medicare coverage? Are you currently a Blue Cross Blue Shield of Massachusetts member? Yes No If Yes, give your Blue Cross Blue Shield identification number:
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. 001615585 55-0936-23 (9/22) 3. (a) If you had coverage from any Medicare plan other than original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates below. If you’re still covered under this plan, leave “End” blank. Start __/__/__ End __/__/__ (b) If you’re still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplemental policy? Yes No (c) Was this your first time in this type of Medicare plan? Yes No (d) Did you drop a Medicare supplemental policy to enroll in the Medicare plan? Yes No 4. (a) Do you have another Medicare supplemental policy in force? Yes No (b) If so, with what company, and what plan do you have? (c) If so, do you intend to replace your current Medicare supplemental policy with this policy? Yes No 5. Have you had coverage under any other health insurance within the past 63 days? Yes No (For example, an employer, union, or individual plan) (a) If so, with what company and what kind of policy? (b) What are your dates of coverage under the other policy? Start ___/___/___ End ___/___/___ (If you’re still covered under the other policy, leave “End” blank.) I certify that the statements made and answers given are complete and true. I have read and carefully considered all of the “Important Information” on this form. I also certify that I received the “Outline of Medicare Supplement Coverage.” I understand that no health care provider, or private or government agency may sponsor, purchase, or contribute to the cost of this Medex plan. For the purpose of processing this application, for 30 months from the date this authorization is signed, and if I enroll in coverage, for as long as I am covered, I understand that all of my health care providers, other insurance companies, or my employer are authorized to release all of my medical records and other information to Blue Cross and Blue Shield of Massachusetts representatives for the purpose of determining my coverage and administering my benefits. I or my authorized representative is entitled to receive a copy of this authorization form. I understand that the benefits for which I am eligible are those described in the applicable Medex´ Subscriber Certificate. I understand that Medex benefits and premium rates are subject to change as allowed by state law. I understand that enrollment in this plan is contingent upon payment of premium. Applicant’s Signature: Date:
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Medex®´ Core, Medex®´ Sapphire, Medex®´ Bronze APPLICATION FOR DIRECT BILLED MEDEX®´ Directions • Please print clearly. • Carefully read and answer all questions. Incomplete applications will not be accepted. Please keep a copy of the application for your records. • Send us your application after you receive your red, white, and blue Medicare card. • Don’t send money with this application. You’ll receive a bill when payment is due. • Please complete and return to: Blue Cross Blue Shield of Massachusetts Enrollment Department P.O. Box 55011 Boston, MA 02205 • Or, fax the application to 1-617-246-3633. • To enroll by phone, call 1-800-678-2265. • Medex premium rates and benefits are explained in the booklet you received with this application. If you need more information or assistance, call us at 1-800-678-2265. • For all other questions, call: Medex Member Service: 1-800-258-2226 (TTY: 711) You’re eligible to apply for a Medex plan if you meet all of the following requirements: • You’re a resident of Massachusetts and you actually live in Massachusetts. • You’re eligible for Medicare Part A and Medicare Part B and enrolled in Medicare Part B. • If you’re under age 65, you qualify for Medicare coverage because of disability. Notes: 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 or disability before January 1, 2020. Those who are otherwise eligible for Medicare Part A and 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. If you’re covered by Medicaid, you may or may not be eligible to enroll in Direct Billed Medex. See paragraph (g) of the “Important Information” section of this application form.
Important Information Please read the below section, then answer questions 1 through 5. • You don’t need more than one Medicare supplemental insurance policy. • If you newly enroll in a Medicare Supplement 1 plan, you’re not permitted to switch within the same company into a Medicare Supplement 1A plan until you have been covered by the company’s Medicare Supplement 1 plan for at least 12 months. • If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverage. • You may be eligible for Medicaid benefits and may not need a Medicare supplemental insurance policy. • The benefits and premiums under your Medicare supplemental insurance policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you’re no longer entitled to Medicaid, your policy will be reinstituted if requested within 90 days of losing Medicaid eligibility. » If the Medicare supplemental insurance policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy won’t have outpatient prescription drug coverage, as you’ll be enrolled in the most comparable plan without outpatient prescription drug coverage. • If you’re eligible for, and have enrolled in a Medicare supplemental insurance policy by reason of disability and you later become covered by an employer or unionbased group health plan, the benefits and premiums under your Medicare supplemental insurance policy can be suspended, if requested, while you’re covered under the employer or union-based group health plan. If you suspend your Medicare supplemental insurance policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplemental insurance policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. » If the Medicare supplemental insurance policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy won’t have outpatient prescription drug coverage, as you’ll be enrolled in the most comparable plan without outpatient prescription drug coverage. • Counseling services are available in Massachusetts to provide advice concerning your purchase of Medicare supplemental Insurance policy and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB). You may call the Massachusetts Executive Office of Elder Affairs insurance counseling program at 1-800-243-4636 (TTY: 1-800-872-0166), or write to that office at the following address for more information: One Ashburton Place, 5th Floor, Boston, MA 02108. If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplemental insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplemental plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS. To the best of your knowledge, [Mark Yes or No below with an “X”] 1. (a) Did you turn age 65 in the last six months? Yes No (b) Did you enroll in Medicare Part B in the last six months? Yes No (c) If Yes, what is the effective date?_______________ 2. Are you covered for medical assistance through the state Medicaid program? [NOTE TO APPLICANT: If you’re participating in a “Spend-Down Program” and haven’t met your “Share of Cost,” please answer NO to this question.] Yes No If Yes, (a) Will Medicaid pay your premiums for this Medicare supplemental policy? Yes No (b) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium? Yes No Please answer all questions. Check the Medex plan of your choice: Medex Core (Medicare Supplement Core) Medex Sapphire (Medicare Supplement 1A) Medex Bronze (Medicare Supplement 1) Medex Core with Vision and Hearing Benefit Medex Sapphire with Vision and Hearing Benefit Medex Bronze with Vision and Hearing Benefit Your Social Security Number: ________ - _______ - _____________ How often would you like to be billed? Monthly Quarterly Would you like your premium payment due on the 1st of the month or the 15th of the month? 1st of the month 15th of the month First Name Last Name Middle Initial Your gender: Male Female Non-Binary Your complete date of birth: ( ——/——/————) M M D D YYYY Your telephone number: ( ) – Your permanent home address: Number and Street City: State: ZIP Code: If you want your Medex bill sent to an address other than your home address, complete the following section. Your billing address only: Number and Street City: State: ZIP Code: Medicare Insurance Information Please copy information from your red, white, and blue Medicare card in the spaces below. Medicare Number: Medicare Part A (Hospital Insurance) Effective Date: Medicare Part B (Medical Insurance) Effective Date: If you’re under age 65, what is your disability that qualifies you for Medicare coverage? Are you currently a Blue Cross Blue Shield of Massachusetts member? Yes No If Yes, give your Blue Cross Blue Shield identification number:
Important Information Please read the below section, then answer questions 1 through 5. • You don’t need more than one Medicare supplemental insurance policy. • If you newly enroll in a Medicare Supplement 1 plan, you’re not permitted to switch within the same company into a Medicare Supplement 1A plan until you have been covered by the company’s Medicare Supplement 1 plan for at least 12 months. • If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverage. • You may be eligible for Medicaid benefits and may not need a Medicare supplemental insurance policy. • The benefits and premiums under your Medicare supplemental insurance policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you’re no longer entitled to Medicaid, your policy will be reinstituted if requested within 90 days of losing Medicaid eligibility. » If the Medicare supplemental insurance policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy won’t have outpatient prescription drug coverage, as you’ll be enrolled in the most comparable plan without outpatient prescription drug coverage. • If you’re eligible for, and have enrolled in a Medicare supplemental insurance policy by reason of disability and you later become covered by an employer or unionbased group health plan, the benefits and premiums under your Medicare supplemental insurance policy can be suspended, if requested, while you’re covered under the employer or union-based group health plan. If you suspend your Medicare supplemental insurance policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplemental insurance policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. » If the Medicare supplemental insurance policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy won’t have outpatient prescription drug coverage, as you’ll be enrolled in the most comparable plan without outpatient prescription drug coverage. • Counseling services are available in Massachusetts to provide advice concerning your purchase of Medicare supplemental Insurance policy and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB). You may call the Massachusetts Executive Office of Elder Affairs insurance counseling program at 1-800-243-4636 (TTY: 1-800-872-0166), or write to that office at the following address for more information: One Ashburton Place, 5th Floor, Boston, MA 02108. If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplemental insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplemental plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS. To the best of your knowledge, [Mark Yes or No below with an “X”] 1. (a) Did you turn age 65 in the last six months? Yes No (b) Did you enroll in Medicare Part B in the last six months? Yes No (c) If Yes, what is the effective date?_______________ 2. Are you covered for medical assistance through the state Medicaid program? [NOTE TO APPLICANT: If you’re participating in a “Spend-Down Program” and haven’t met your “Share of Cost,” please answer NO to this question.] Yes No If Yes, (a) Will Medicaid pay your premiums for this Medicare supplemental policy? Yes No (b) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium? Yes No Please answer all questions. Check the Medex plan of your choice: Medex Core (Medicare Supplement Core) Medex Sapphire (Medicare Supplement 1A) Medex Bronze (Medicare Supplement 1) Medex Core with Vision and Hearing Benefit Medex Sapphire with Vision and Hearing Benefit Medex Bronze with Vision and Hearing Benefit Your Social Security Number: ________ - _______ - _____________ How often would you like to be billed? Monthly Quarterly Would you like your premium payment due on the 1st of the month or the 15th of the month? 1st of the month 15th of the month First Name Last Name Middle Initial Your gender: Male Female Non-Binary Your complete date of birth: ( ——/——/————) M M D D YYYY Your telephone number: ( ) – Your permanent home address: Number and Street City: State: ZIP Code: If you want your Medex bill sent to an address other than your home address, complete the following section. Your billing address only: Number and Street City: State: ZIP Code: Medicare Insurance Information Please copy information from your red, white, and blue Medicare card in the spaces below. Medicare Number: Medicare Part A (Hospital Insurance) Effective Date: Medicare Part B (Medical Insurance) Effective Date: If you’re under age 65, what is your disability that qualifies you for Medicare coverage? Are you currently a Blue Cross Blue Shield of Massachusetts member? Yes No If Yes, give your Blue Cross Blue Shield identification number:
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. 001615585 55-0936-23 (9/22) 3. (a) If you had coverage from any Medicare plan other than original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates below. If you’re still covered under this plan, leave “End” blank. Start __/__/__ End __/__/__ (b) If you’re still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplemental policy? Yes No (c) Was this your first time in this type of Medicare plan? Yes No (d) Did you drop a Medicare supplemental policy to enroll in the Medicare plan? Yes No 4. (a) Do you have another Medicare supplemental policy in force? Yes No (b) If so, with what company, and what plan do you have? (c) If so, do you intend to replace your current Medicare supplemental policy with this policy? Yes No 5. Have you had coverage under any other health insurance within the past 63 days? Yes No (For example, an employer, union, or individual plan) (a) If so, with what company and what kind of policy? (b) What are your dates of coverage under the other policy? Start ___/___/___ End ___/___/___ (If you’re still covered under the other policy, leave “End” blank.) I certify that the statements made and answers given are complete and true. I have read and carefully considered all of the “Important Information” on this form. I also certify that I received the “Outline of Medicare Supplement Coverage.” I understand that no health care provider, or private or government agency may sponsor, purchase, or contribute to the cost of this Medex plan. For the purpose of processing this application, for 30 months from the date this authorization is signed, and if I enroll in coverage, for as long as I am covered, I understand that all of my health care providers, other insurance companies, or my employer are authorized to release all of my medical records and other information to Blue Cross and Blue Shield of Massachusetts representatives for the purpose of determining my coverage and administering my benefits. I or my authorized representative is entitled to receive a copy of this authorization form. I understand that the benefits for which I am eligible are those described in the applicable Medex´ Subscriber Certificate. I understand that Medex benefits and premium rates are subject to change as allowed by state law. I understand that enrollment in this plan is contingent upon payment of premium. Applicant’s Signature: Date:
Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-678-2265 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-678-2265 (TTY: 711). ® Registered Marks of the Blue Cross and Blue Shield Association. ®´ 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. 001605108 99-0680-23 (9/22) FOR MORE INFORMATION, OR TO ENROLL: Medicare Plan Sales: 1-800-678-2265 (TTY: 711) 8:00 a.m. to 5:00 p.m. ET, Monday through Friday bluecrossma.com/Medicare