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BCBSMA 2020 Medex Core Sapphire Bronze SalesKit Book 11/01/2019 Approved by Angela Gagnon 10/22/2019 8:27 AM

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Published by it, 2019-10-18 11:41:29

BCBSMA 2020 Medex Core Sapphire Bronze SalesKit Book 11/01/2019 Approved by Angela Gagnon 10/22/2019 8:27 AM

BCBSMA 2020 Medex Core Sapphire Bronze SalesKit Book 11/01/2019 Approved by Angela Gagnon 10/22/2019 8:27 AM

Medicare Supplement Plans

Medex Core | Medex Sapphire | Medex Bronze

MEDEX®´ 2020

COVERAGE YOU NEED FROM A NAME YOU CAN TRUST

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

(11/01/19)



Dear Prospective Member:

Thank you for requesting information about Medex,®´ a family of Medicare supplement plans from
Blue Cross Blue Shield of Massachusetts. Our three plan options, Medex Core, Medex Sapphire
and Medex Bronze, are designed to fill the gaps in Original Medicare and add real value to your
health care coverage.

Our goal is to provide you with information that will help you choose the right plan for you
that fits your needs and budget. We have enclosed the following materials to help you get started:
• Learn about the value of Medex from our Freedom of Choice brochure
• Compare coverage options with a detailed overview of Medex Core, Medex Sapphire and

Medex Bronze
• Enroll in Medex using the enclosed application and self-addressed envelope

If you’re ready, you can enroll by telephone, online, by mail, or by fax:
• Telephone—Call us at 1-800-678-2265 (TTY: 711), 8:00 a.m. to 5:00 p.m. ET,

Monday through Friday.
• Online—Visit www.bluecrossma.com/medicare
• Mail—Complete and return the enclosed enrollment form in the self-addressed business

reply envelope provided
• Fax—You may also fax your completed enrollment form to us at 1-617-246-3633

Again, thank you for your interest in Blue Cross Blue Shield of Massachusetts.
We look forward to serving you.

Sincerely,

Gloria Paradiso,
Executive Director, Medicare Sales
Enclosures

101 Huntington Avenue, Suite 1300 | Boston, MA 02199-7611 | www.bluecrossma.com
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).

101 Huntington Avenue, Suite 1300 | Boston, MA 02199-7611 | www.bluecrossma.com

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks are the property of their

respective owners. © 2019 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of

198638M Massachusetts HMO Blue, Inc. 99-0483-20SB (08/19)

IN THIS BOOKLET

01 Plan Information
• Solutions to Supplement
Medicare
• Outline of Medicare
Supplement Coverage

02 Resources
• Seminar Information
• It Pays to Stay Blue
• Vision and Hearing
• GeoBlue International
Medical Coverage

03 Disclosures
• Nondiscrimination Notice
• Translation Resources

04 Enrollment
• Enrollment Forms
• Business Reply Envelope



01

Plan
Information



Medex®´ Core
Medex®´ Sapphire

Medex®´ Bronze

FREEDOM OF CHOICE
SOLUTIONS TO SUPPLEMENT MEDICARE

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

With Medex from Blue Cross Blue Shield
of Massachusetts, the choice is yours.
We’ve created plan options for our members
that allow you to choose what you need

from your health plan and more.

CONTENTS

Medex . . . . . . . . . . . . . . . . 1–2
The Freedom of Medex . . . . . . . . 1
An Introduction to Medex . . . . . . . 2

Medicare . . . . . . . . . . . . . . .4–6
What Is Original Medicare? . . . . . . 4
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 FREEDOM OF MEDEX

Many people who enroll in Original Medicare are surprised to learn
that it doesn’t provide the coverage they expect. After all, deductibles,
co-insurance, and gaps in health care coverage can amount to thousands
of dollars in expenses a year. That’s why so many Massachusetts residents
turn to Blue Cross Blue Shield of Massachusetts.

Medex, our family of Medicare supplement plans, is designed to add real value and flexibility
to your Medicare solution. Medex helps you save money by lowering your out-of-pocket
expenses. It also fills the gaps in Original Medicare coverage and gives you the power
to see any Medicare provider in the country without a referral.

With Medex, you’ll gain access to benefit features, including:

  The peace of mind
of a Blue Cross Blue Shield
The versatility Medex Core, Sapphire, of Massachusetts ID card—the
of worldwide coverage and Bronze members most recognized ID card
are entitled to a fitness benefit
($150 a year) and weight loss in health care today
benefit ($150 a year)

Please take a moment to review this easy-to-follow booklet.
We’ll explain everything you need to know about Medicare supplement plans

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

Our office hours are Monday through Friday,
8:00 a.m. to 5:00 p.m. ET. You can also visit our website
at www.bluecrossma.com/medicare for more information.

1 Medex Sales: 1-800-678-2265

AN INTRODUCTION TO MEDEX

Medex is a Medicare supplement plan offered by Blue Cross Blue Shield
of Massachusetts. It 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.

Medex offers you a choice of three plans with varying coverage levels and premiums,
making it easy to find a plan that meets your unique needs.

Part Keep + Medicare +
A&B Original Supplement
Medicare Insurance Medex Bronze
and add… Full Supplemental

Coverage
— or —
Medex Sapphire
Enhanced Supplemental
Coverage

--or--
Medex Core
Basic Supplemental
Coverage

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

www.bluecrossma.com/medicare 2

Important: If you haven’t enrolled in Medicare,
it is recommended that you contact
your local Social Security office

three months prior to your 65th birthday.

WHAT IS ORIGINAL MEDICARE?

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

Original Medicare has two parts:

 

Medicare Part A Medicare Part B

(Hospital insurance) pays for inpatient (Medical insurance) pays for outpatient
hospital expenses. hospital charges, doctor visits, and many
other medical services not covered by
Services covered: Part A.
Facility Care
Services covered:
• Inpatient hospital care Medical Expenses

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

www.bluecrossma.com/medicare 4

MEDICARE COVERAGE

(Without Supplemental Insurance)

Why Do I Need to Supplement Medicare?

Although Medicare pays a large portion of your medical expenses, you are responsible
for the remaining costs. Also, Medicare does not cover all medical services in all situations.

Here are some important things to know about Medicare:

• 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 are responsible for before Medicare begins
to pay, and they are 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 does not cover you outside the United States, even in the event
of an emergency. Please refer to the chart on page 6 for an illustration of Medicare
coverage that’s not supplemented with a Medex plan. The chart highlights Medicare’s
benefits, deductible and co-insurance costs, and some of the services Medicare does
not cover.

• Expenses that are not covered by Medicare are often referred to as “gaps.” Medicare
supplement (“Medigap”) plans, such as Medex, help to fill in these coverage gaps.
They help you pay Medicare’s deductible and co-insurance costs, and cover certain
services Medicare doesn’t.

Please refer to the charts on pages 7 through 14 for coverage when Medicare is combined
with a Medex plan.

5 Medex Sales: 1-800-678-2265

These Medicare benefits are effective January 1, 2019.
Medicare deductibles and co-insurances are subject to change each year.

Medicare Part A Your Cost

Inpatient Hospital Care $1,364 deductible
$341 per day co-insurance
Days 1–60 each benefit period: 100% coverage after you pay $682 per day co-insurance
the $1,364 deductible All costs after 150 days

Days 61–90 each benefit period: 100% coverage after you pay No cost
$341 per day co-insurance $170.50 per day co-insurance
All costs after 100 days
Days 91–150 (60 lifetime reserve days): 100% coverage after you pay
$682 per day co-insurance

Days 150+: no coverage

Skilled Nursing Facility Care

Days 1–20 each benefit period: 100% coverage

Days 21–100 each benefit period: 100% coverage after you pay
$170.50 per day co-insurance

No coverage after 100 days in a benefit period

Medicare Part B Your Cost

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

Coverage begins after you pay the $185 calendar-year deductible $185 deductible
20% co-insurance
Medicare covers 80% of the Medicare-approved amount; you pay 20%
co-insurance Most outpatient prescription costs
No cost when Medicare covers the
Prescription Drugs preventive service in full and provider
accepts assignment
Members may voluntarily purchase Medicare Part D, which covers All costs
prescription drugs (unless the drug is covered under Part B)

Routine Services and Preventive Care

100% coverage for specific Medicare preventive services.
A complete listing is found on the Medicare website,
www.medicare.gov

Travel Outside the United States

No coverage for medical costs incurred outside the U.S.

www.bluecrossma.com/medicare 6

MEDICARE COVERAGE

(Combined with a Medex Core Plan)

Days Medicare Medex Core
(Medicare Supplement Core)
Hospital 1–60 Coverage for 60 days, Coverage for Medicare daily
Services 61–90 after the $1,364 deductible1 co-insurance after you pay
Skilled Lifetime Coverage for 61–90 days, $1,364 Part A deductible
Nursing Reserve after $341 daily co-insurance Full coverage for lifetime reserve
Facility 1–20 co-insurance, then an additional
21–100 Coverage for an additional 365 days per lifetime when
101+ 60 lifetime reserve days, Medicare benefits end
after $682 daily co-insurance Covered by Medicare

Full coverage for 20 days in a No coverage
Medicare-participating facility
No coverage
Coverage for days 21–100, Coverage of 20% co-insurance,
after $170.50 daily co-insurance after you pay $185 annual
Part B deductible
No coverage after 100 days
Coverage of 20% co-insurance,
Physician and Other 80% coverage of approved after you pay $185 annual
Provider Services services, after the $185 annual Part B deductible
Care in the Hospital Part B deductible
Coverage of 20% co-insurance,
Physician and Other 80% coverage of approved after you pay $185 annual
Provider Services services, after the $185 annual Part B deductible
Outpatient Department Visits, Part B deductible
Office Visits, and Patient
Home Visits 80% coverage of approved
services, after the $185 annual
Other Part B Services Part B deductible
Ambulance Trips, Durable
Medical Equipment, Etc.

Note: Although the $185 calendar-year Medicare medical insurance (Part B) deductible appears more than once in this
benefit chart, only one $185 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 does not include all Medicare benefits. Please refer to the Medicare & You handbook published by the
Centers for Medicare and Medicaid Services for more information about Medicare benefits, or call 1-800-MEDICARE
(1-800-633-4227) (TTY: 1-877-486-2048). You can also visit www.cms.gov for more information.

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

7 Medex Sales: 1-800-678-2265

MEDICARE COVERAGE Medex Sapphire
(Medicare Supplement 1A)
(Combined with a Medex Sapphire Plan)
Full coverage of Medicare
Days Medicare deductible and co-insurance

Hospital 1–60 Coverage for 60 days, Full coverage for lifetime reserve
Services 61–90 after the $1,364 deductible1 co-insurance, then an additional
Skilled Lifetime 365 days per lifetime when
Nursing Reserve Coverage for 61–90 days, Medicare benefits end
Facility 1–20 after $341 daily co-insurance Covered by Medicare
21–100 Full coverage for Medicare daily
101+ Coverage for an additional co-insurance for days 21–100
60 lifetime reserve days, $10 a day for days 101–3652 at a
after $682 daily co-insurance Medicare-participating facility
Coverage of 20% co-insurance,
Full coverage for 20 days in a after you pay $185 annual
Medicare-participating facility Part B deductible

Coverage for days 21–100, Coverage of 20% co-insurance,
after $170.50 daily co-insurance after you pay $185 annual
Part B deductible
No coverage after 100 days
Coverage of 20% co-insurance,
Physician and Other 80% coverage of approved after you pay $185 annual
Provider Services services, after the $185 annual Part B deductible
Care in the Hospital Part B deductible
Continued
Physician and Other 80% coverage of approved
Provider Services services, after the $185 annual
Outpatient Department Visits, Part B deductible
Office Visits, and Patient
Home Visits

Other Part B Services 80% coverage of approved
Ambulance Trips, Durable services, after the $185 annual
Medical Equipment, Etc. Part B deductible

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

www.bluecrossma.com/medicare 8

MEDICARE COVERAGE Medex Bronze
(Medicare Supplement 1)
(Combined with a Medex Bronze Plan)
Full coverage of Medicare
Days Medicare deductible and co-insurance

Hospital 1–60 Coverage for 60 days, Full coverage for lifetime reserve
Services 61–90 after the $1,364 deductible1 co-insurance, then an additional
Skilled Lifetime 365 days per lifetime when
Nursing Reserve Coverage for 61–90 days, Medicare benefits end
Facility 1–20 after $341 daily co-insurance Covered by Medicare
21–100 Full coverage for Medicare daily
101+ Coverage for an additional co-insurance for days 21–100
60 lifetime reserve days, $10 a day for days 101–3652
after $682 daily co-insurance at a Medicare-participating facility
Full coverage of Medicare
Full coverage for 20 days in a deductible and co-insurance
Medicare-participating facility
Full coverage of Medicare
Coverage for days 21–100, deductible and co-insurance
after $170.50 daily co-insurance
Full coverage of Medicare
No coverage after 100 days deductible and co-insurance

Physician and Other 80% coverage of approved
Provider Services services, after the $185 annual
Care in the Hospital Part B deductible

Physician and Other 80% coverage of approved
Provider Services services, after the $185 annual
Outpatient Department Visits, Part B deductible
Office Visits, and Patient
Home Visits 80% coverage of approved
services, after the $185 annual
Other Part B Services Part B deductible
Ambulance Trips, Durable
Medical Equipment, Etc.

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

9 Medex Sales: 1-800-678-2265

These Medicare benefits are effective January 1, 2019.
Medicare deductibles and co-insurances are subject to change each year.

Medicare Medex Core, Medex Sapphire
& Medex Bronze
Inpatient • Coverage for days 1–60 per
Admissions in a benefit period, after the • Full coverage of the Medicare
General Hospital $1,364 inpatient deductible2 deductible3 and co-insurance
or Mental
Hospital • Coverage for days 61–90, • Full coverage of lifetime reserve
after $341 daily co-insurance days co-insurance
Biologically
Based Mental • Coverage for an additional • Full coverage of up to 365
Conditions1 60 lifetime reserve days, additional hospital days
after $682 daily co-insurance in your lifetime when
Medicare benefits end4
• Coverage for mental hospital
admissions is limited to • When covered by Medicare,
190 days per lifetime full coverage of Medicare
deductible5 and co-insurance
• Full benefits, less the with no visit maximum
Part B deductible and the
• When not covered by Medicare,
Part B co-insurance full Medex benefits with no
visit maximum
Outpatient Visits

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

www.bluecrossma.com/medicare 10

MEDICARE COVERAGE

(Combined with a Medex Plan)

Medicare Medex Core, Medex Sapphire
& Medex Bronze
Inpatient • Coverage for days 1–60 per
Admissions in a benefit period, after the • Full coverage of the Medicare
General Hospital $1,364 inpatient deductible1 deductible2 and co-insurance

• Coverage for days 61–90, • Full coverage of lifetime
after $341 daily co-insurance reserve days co-insurance

• Coverage for an additional 60 • Full coverage of up to 365
lifetime reserve days, after additional hospital days
$682 daily co-insurance in your lifetime when
Medicare benefits end3
• Coverage for mental hospital
admissions is limited to 190 • Full coverage of Medicare
days per lifetime deductible2 and co-insurance

Non-Biologically • Same coverage as general • Full coverage of lifetime reserve
Based Mental hospital, but coverage limited day co-insurance
Conditions
(includes drug to 190 days per lifetime • When Medicare days are used
addiction and up, 120 days per benefit period
alcoholism) Inpatient (at least 60 days per calendar
Admissions in a year), less any days in a mental
Mental Hospital hospital already covered by
Medicare or Medex in that
• Full benefits, less the Part B benefit period (or calendar year)
deductible and the Part B
• When covered by Medicare,
co-insurance full coverage of Part B deductible4
and co-insurance with no visit
Outpatient Visits maximum

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

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

11 Medex Sales: 1-800-678-2265

These Medicare benefits are effective January 1, 2019.
Medicare deductibles and co-insurances are subject to change each year.

Medicare Medex Core, Medex Sapphire
& Medex Bronze

Travel Outside the U.S. No Coverage Full Coverage (same as in U.S.)
Fitness Benefit
Weight Loss Benefit No Coverage Medex members may receive up to $150
per calendar year in qualified health club
Diabetic Testing Supplies1 membership fees and exercise classes

Diabetic Testing Supplies1 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

80% coverage of approved For blood glucose monitoring equipment
services, after $185 annual Part and supplies covered by Medicare:
B deductible
• Coverage for Medicare co-insurance

For urine-testing materials
(not covered by Medicare):

• 100% coverage of allowed charges

Medicare Medex Bronze

80% coverage of approved For blood glucose monitoring equipment
services, after $185 annual Part and supplies covered by Medicare:
B deductible
• Coverage for Medicare deductible
and co-insurance

For urine-testing materials
(not covered by Medicare):

• 100% coverage of allowed charges

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

www.bluecrossma.com/medicare 12

MEDEX COVERAGE WELLNESS PROGRAMS

Fitness Benefit

When a member is enrolled in a qualified health club or fitness facility, they can receive
up to $150 per calendar year toward club membership fees and exercise classes.

Qualifying programs include: Programs that DO NOT qualify:

• Health clubs with a variety of • One-time initiation or termination fees
cardiovascular and strength-training • Fees paid for gymnastics, tennis,
exercise equipment—e.g., traditional
health clubs, YMCAs, YWCAs, and pool-only facilities, martial arts schools,
community fitness centers. instructional dance studios, country clubs
or social clubs, sports teams or leagues
• Fitness studios with instructor-led group • Personal trainer sessions
classes such as yoga, Pilates, Zumba®´, • Fitness equipment or clothing
kickboxing, indoor cycling/spinning, and
other exercise programs.

• Fitness classes available at participating
Councils on Aging facilities.

Earn Up To $150 (per calendar year)

When a member is enrolled in a qualified fitness or weight-loss program.

(See details for qualifying programs)

Weight-Loss Benefit

When a member is enrolled in a qualified weight-loss program, they can receive
up to $150 per calendar year toward program fees.

Qualifying programs include: Programs that DO NOT qualify:

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

• Hospital based weight-loss programs

13 Medex Sales: 1-800-678-2265

HOW MEDEX WORKS

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

Medex plans have many advantages

• You can seek care from any • You can adjust your Medex coverage
Medicare physician or hospital at any time during the year. Your coverage
throughout the United States. in the new plan will begin the first of the
month following receipt of your request
• You don’t need to choose a PCP. to change plans*.
• You don’t need to get referrals for
• Your Blue Cross Blue Shield of
specialty care. Massachusetts ID card is recognized
• There are no copayments for around the world.

physician services.

Am I Eligible for Medex?

You don’t need to complete a health care screening to qualify for Medex coverage.

You are eligible for Medex if you meet the following requirements:

• You live in Massachusetts. • You may also be eligible if you are under
• You are enrolled (or will be enrolling) in age 65 and have a disability other than
end-stage renal disease (ESRD).
both Medicare Part A and Part B.

Medex Bronze shall, on or after January 1, 2020, only be offered to eligible persons who: (a) have attained
65 years of age before January 1, 2020; or (b) first became eligible for Medicare due to age, disability or
end-stage renal disease, 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 are not eligible to purchase Medex Bronze,
shall be eligible to purchase all other Direct Billed Medex plans that are currently offered.

Note: If you are 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 will not
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.

www.bluecrossma.com/medicare 14

WHEN DO I ENROLL?

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

Initial eligibility

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

If You Are: You May Apply for Medex:

Under 65 Within six months of your Medicare Part B
effective date
Enrolling in Medicare due to a disability
other than end-stage renal disease (ESRD) Within six months of your 65th birthday
Within six months of your Medicare Part B
Approaching 65 effective date

Enrolling in both parts of Medicare Within six months of the event

Retiring from an employer-sponsored health plan
and enrolled in Medicare Part B or enrolling in
Medicare Part B

Over or Under 65

Involuntarily losing an employer-sponsored
retiree health plan

Moving out of the service area of a Medicare health
maintenance organization (HMO)

Becoming a resident of Massachusetts

Medex Continuous Open Enrollment

You may apply for Medex coverage at any time. Your coverage will begin the first of the month
following the receipt of the application.

Please note: If you wish to switch from a Medicare Advantage plan to a Medex plan, call 1-800-MEDICARE
(1-800-633-4227) (TTY: 1-877-486-2048) to learn how to dis-enroll from your Medicare Advantage plan.

15 Medex Sales: 1-800-678-2265

HOW DO I ENROLL?

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

 

Choose a Medex plan. Decide if you want to be billed Enroll online, by phone,
The charts in this brochure let monthly or quarterly. You may by mail, or by fax. See below
you compare plan coverage find the quarterly billing option for details. In addition to your name
and determine which option more convenient if you plan and address, you will need to
best suits your unique needs. provide the Medicare number that
to travel for more than appears on your Medicare card.
a few weeks at a time. You must (If you don’t have your Medicare
card, contact the Social Security
also decide if you want your
premium due on the 1st Administration office).
or 15th of each month.

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

Enrolling Is Easy

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

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

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

www.bluecrossma.com/medicare 16

WHEN WILL MY COVERAGE BEGIN?

Effective Date of Your Coverage

If you do not yet have Medicare coverage, 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.

When Your Application Is Received Your Medex Coverage Will Begin

Before the effective date of your Medicare coverage The same day as your Medicare coverage

• If you enroll within the first six months • The first day of the month following the month
of your Medicare Part B coverage or your application is received

• If you enroll during continuous open enrollment

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

17 Medex Sales: 1-800-678-2265

PREMIUM RATES

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.
If you are eligible for this discount, you will receive a 15 percent discount
the first year of enrollment, a 10 percent discount during the second year
of enrollment, and a 5 percent discount during the third year of enrollment.
After the third year, there is no discounted premium rate. To determine
if you are eligible for the discount, call 1-800-678-2265.

15% 10% 5%

FIRST YEAR SECOND YEAR THIRD YEAR
SAVINGS SAVINGS SAVINGS

2020 Rates Billed Monthly Billed Quarterly
Medex Core $104.10 $311.34
Medex Sapphire $177.97 $532.26
Medex Bronze $209.21 $625.68

Rates effective January 1, 2020 through December 31, 2020.
Please note: If you obtained Medicare under the age of 65 due to disability, you are not eligible for the discount.

www.bluecrossma.com/medicare 18

HELPFUL NUMBERS

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

Blue Cross Blue Shield Medicare
of Massachusetts
If you have questions regarding
Blue Cross Blue Shield of Massachusetts Medicare, or to order a Medicare & You
associates can answer questions regarding handbook, call 1-800-MEDICARE
Medex options, premium rates, applications, (1-800-633-4227) (TTY: 1-877-486-2048)
timing, enrollment, and other Medex-related or visit www.cms.gov.
issues.
Medex Sales: 1-800-678-2265 TTY: 711 24/7 Nurse Line:
1-888-247-BLUE (2583)
Serving the Health Information
Needs of Everyone (SHINE) Not sure if you need to see a doctor?
Medex members can call a registered nurse
SHINE is an independent organization 24 hours a day at the Blue Care Line for
dedicated to helping you understand immediate assistance with health-related
and compare all your health plan options. questions.
Trained and certified counselors help
you determine if you qualify for any We think it’s important
supplemental assistance programs. for you to know...
All services are free of charge.
1-800-AGE-INFO (1-800-243-4636) 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.

19 Medex Sales: 1-800-678-2265

Index

Medicare Coverage (Combined with a Medex Core, Medex Sapphire, or Medex Bronze Plan) Refer to Pages 7, 8, 9

1. A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after
you have been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.

2. Medex Bronze and Medex Sapphire coverage also includes $8 a day for days 1–365 at a
non-Medicare-participating facility.

Refer to Page 10

1. Biologically based mental conditions are defined as: schizophrenia; schizoaffective disorder; major depressive
disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder;
delirium and dementia; affective disorders; eating disorders; substance abuse; post-traumatic stress disorder
(PTSD); autism; and any biologically based mental disorders that are scientifically recognized and approved by the
Massachusetts Department of Mental Health. Treatment for rape-related mental or emotional disorders is covered
to the same extent as biologically based conditions.

2. A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have
been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

3. Medex Core provides full coverage for Medicare daily co-insurance after you pay $1,364 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 $185 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 $1,364 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 $185 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 does not
cover urine-testing materials.

1-800-678-2265 (TTY: 711) Monday - Friday, 8:00 a.m. - 5:00 p.m.
For plan information and a personal consultation.

www.bluecrossma.com/medicare 20

RESOURCES

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

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.

© 2019 Blue Cross and Blue Shield of Massachusetts, Inc.

198562M 42-0430-20 (09/19)

Medex®´

OUTLINE OF MEDICARE
SUPPLEMENT COVERAGE

Cover Page: 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
Medical Expenses the Medicare Part A deductible) and the 60 Medicare lifetime reserve days, plus coverage
Blood for 365 additional days after Medicare benefits end. This shall include benefits for
biologically based mental disorders.

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

First three pints of blood each year.

For more information: www.bluecrossma.com/medicare 1
1-800-678-2265 (TTY: 711) Monday through Friday, 8:00 a.m. to 5:00 p.m.

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

Medicare Supplement Core Medicare Supplement 1 Medicare Supplement 1A
Medex Core Medex Bronze Medex Sapphire

Standard Benefits
Basic Benefits

Hospitalization Hospitalization Hospitalization
For biologically based mental For biologically based mental For biologically based mental
disorders, stays in a licensed mental disorders, stays in a licensed mental disorders, stays in a licensed mental
hospital, less Part A deductibles; hospital; for other mental disorders: hospital; for other mental disorders:
for other mental disorders: stays stays in a licensed mental hospital stays in a licensed mental hospital
in a licensed mental hospital for at for a minimum of 120 days per for a minimum of 120 days per
least 60 days per calendar year less benefit period (at least 60 days per benefit period (at least 60 days per
days covered by Medicare or already calendar year) less days covered by calendar year) less days covered by
covered by plan in that calendar year Medicare or already covered by plan Medicare or already covered by plan
for the other mental disorders, less in that calendar year for the other in that calendar year for the other
Part A deductibles. mental disorders. 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 1/1/20

Billed monthly: $104.10 Billed monthly: $209.21 Billed monthly: $177.97

Billed quarterly: $311.34 Billed quarterly: $625.68 Billed quarterly: $532.26

2

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 Policy Replacement

We, Blue Cross Blue Shield of Massachusetts, can only If you are replacing another health insurance policy,
raise your premium if we raise the premium for all do NOT cancel it until you have actually received your
policies like yours in Massachusetts, and if approved new policy and are sure you want to keep it. If you cancel
by the Commissioner of Insurance. If you choose to pay your present policy and then decide that you do not want
your premium on a monthly or quarterly basis, upon to keep your new policy, it may not be possible to get
your death, we will refund the unearned portion of the back the coverage of the present policy.
premium paid. If you choose to pay your premium on a
monthly or quarterly basis and you cancel your policy, If you newly enroll in a Medicare Supplement 1 plan
we will refund the unearned portion of the premium paid. and you became Medicare Eligible before January 1, 2020,
In the case of death, the unearned portion of the premium you will not be able to switch into the same company’s
will be refunded on a pro-rata basis. Medicare Supplement 1A plan until you have been
covered under the Medicare Supplement 1 plan for
Disclosures a period of at least 12 months.

Use this outline to compare benefits and premiums Notice
among policies.
This policy may not fully cover all of your medical costs.
Read Your Policy Very Carefully Blue Cross Blue Shield of Massachusetts is not connected
with Medicare. This outline of coverage does not give
This is only an outline describing your policy’s most all the details of Medicare coverage. Contact your local
important features. The policy is your insurance Social Security office or consult “Medicare & You” for
contract. You must read the policy itself to understand more details.
all of the rights and duties of both yourself and your
insurance company. Complete Answers Are Very Important

Right To Return Policy When you fill out the application for the new policy,
be sure to answer all the questions truthfully and
If you find you are not satisfied with your policy, you may completely. The company may cancel your policy and
return it to Blue Cross Blue Shield of Massachusetts, refuse to pay any claims if you leave out or falsify
Medex Member Services, P.O. Box 9130, North Quincy, important information.
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 Review the application carefully before you sign it.
had never been issued and return all of your payments. Be certain that all information has been properly recorded.

3

Massachusetts Medicare Supplement Insurance: Outline Of Coverage

Massachusetts Summary The Benefits-to-Premium Ratio
for Medex Bronze Is 94.0%.
The Commissioner of Insurance has set standards for
the sale of Medicare Supplement Insurance policies. This means that during the anticipated life of your
Such policies help you pay hospital and doctor bills, and policy and others just like it, Blue Cross Blue Shield of
some other bills, that are not covered in full by Medicare. Massachusetts expects to pay out $94.00 in claims made
Please note that the benefits provided by Medicare and this by you and other policyholders for every $100 we collect
Medicare Supplement Insurance policy may not cover all of in premiums. The minimum loss ratio for Blue Cross Blue
the costs associated with your treatment. It is important that Shield of Massachusetts policies of this type is 90%. The
you become familiar with the benefits provided by Medicare minimum loss ratio for non-Blue Cross Blue Shield of
and your Medicare Supplement Insurance policy. This policy Massachusetts policies of this type is 65%. A higher ratio
summary outlines the different coverages you have if, is to your advantage, as long as it allows the company
in addition to this policy, you are also covered by Part A reasonable return so that the product remains available.
(hospital bills, mainly) and Part B (doctors’ bills, mainly)
of Medicare. The Benefits-to-Premium Ratio
for Medex Core Is 94.0%.
Under Massachusetts General Laws, c. 112, s. 2, no
physician who agrees to treat a Medicare beneficiary may This means that during the anticipated life of your
charge to or collect from that beneficiary any amount policy and others just like it, Blue Cross Blue Shield of
in excess of the reasonable charge for that service as Massachusetts expects to pay out $94.00 in claims made
determined by the United States Secretary of Health and by you and other policyholders for every $100 we collect in
Human Services. This prohibition is commonly referred premiums. The minimum loss ratio for Blue Cross Blue
to as the “ban on balance billing.” A physician is allowed Shield of Massachusetts policies of this type is 90%.
to charge you or collect from your insurer a copayment The minimum loss ratio for non-Blue Cross Blue Shield
or co-insurance for Medicare-covered services. However, of Massachusetts policies of this type is 65%. A higher
if your physician charges you or attempts to collect from ratio is to your advantage, as long as it allows the company
you an amount, which together with your copayment reasonable return so that the product remains available.
or co-insurance is greater than the Medicare-approved
amount, please contact the Board of Registration in The Benefits-to-Premium Ratio
Medicine at (781) 876-8200. for Medex Sapphire Is 94.0%.

We cannot explain everything here. Massachusetts law This means that during the anticipated life of your
requires that personal insurance policies be written in policy and others just like it, Blue Cross Blue Shield of
easy-to-read language. So, if you have questions about Massachusetts expects to pay out $94.00 in claims made
your coverage that are not answered in this brochure, by you and other policyholders for every $100 we collect
read your policy. If you still have questions, ask your agent in premiums. The minimum loss ratio for Blue Cross Blue
or company. You may also wish to get a copy of “Medicare Shield of Massachusetts policies of this type is 90%.
& You”, a small book put out by Medicare that describes A higher ratio is to your advantage, as long as it allows
Medicare benefits. the company reasonable return so that the product
remains available.

4

Complaints Internal Formal Grievance Review

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

5

Medicare Supplement Core: Medex Core

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

Services Medicare Pays Plan Pays You Pay

Hospitalization* $1 ,364
Semiprivate room and board, general (Part A deductible)
hospital nursing and miscellaneous services $0
and supplies, and licensed mental hospital $0
stays for biologically based mental disorders $0
or other mental disorders prior to the All Costs
190-day Medicare lifetime maximum
$1,364
First 60 days of a benefit period All but $1,364 $0 (Part A deductible)
$0
61st through 90th day of a benefit period All but $341 a day $341 a day
91st day and after of a benefit period: $0
– While using 60 lifetime reserve days All but $682 a day $682 a day
– Once lifetime reserve days are used: $0
$0 100% of Medicare All Costs
• Additional 365 days eligible expenses

• Beyond the additional 365 days $0 $0
Licensed mental hospital stays
not covered by Medicare for biologically
based mental disorders

First 60 days of a benefit period $0 All but $1,364

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

The Deductible and Co-insurance amounts listed above reflect the 2019 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

6

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

Services Medicare Pays Plan Pays You Pay
$0
Licensed mental hospital stays All but $1,364 $1,364
not covered by Medicare for other mental disorders (Part A deductible)
100% of
First 60 days per calendar year less days Medicare $0
covered by Medicare or plan in that calendar year eligible expenses

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

Days after 60 days per calendar year less days $0 $0 All Costs
covered by Medicare or plan in that calendar year
Skilled Nursing Facility Care* All approved $0 $0
(Participating with Medicare) amounts
You must meet Medicare’s requirements, including All but $170.50 $0 Up to $170.50
having been in a hospital for at least a day a day
three days and entered a Medicare-approved $0
facility within 30 days after having left the hospital $0 All Costs
$0
First 20 days of a benefit period 100% Three pints $0
All but very limited $0 $0
21st through 100th day of a benefit period co-insurance for
outpatient drugs Actual billed $0
101st day and after of a benefit period and inpatient charges up to the
Blood respite care co-insurance
First three pints amount
Additional amounts

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

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

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

The Deductible and Co-insurance amounts listed above reflect the 2019 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

7

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 $185 (Part B
and outpatient hospital treatment, such as physician’s deductible)
services, inpatient and outpatient $0

medical and surgical services and supplies, $185 (Part B
deductible)
physical and speech therapy, diagnostic tests, $0
$0
and durable medical equipment
$0
First $185 of Medicare-approved amounts** $0 $0 $185 (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 $185 of Medicare-approved amounts** $0 $0

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

Blood

First three pints

Next $185 of Medicare-approved amounts** $0 $0

Remainder of Medicare-approved amounts 80% 20%

**Once you have been billed $185 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 2019 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

8

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

Services Medicare Pays Plan Pays You Pay

Clinical Laboratory Services 100% $0 $0
Blood tests for diagnostic services
Special Medical Formulas Mandated by Law $185
Covered by Medicare (Part B deductible)
$0
First $185 of Medicare-approved amounts** $0 $0 Balance

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

Medicare (Parts A & B)

Services Medicare Pays Plan Pays You Pay
100% $0
Home Health Care—Medicare-Approved Services $0
$0
Medically necessary skilled-care services 20% $185
and medical supplies (Part B deductible)
$0
Durable medical equipment

First $185 of Medicare-approved amounts** $0

Remainder of Medicare-approved amounts 80%

Other Benefits—Not Covered By Medicare Medicare Pays Plan Pays You Pay
$0 All Costs
Services $0
Outpatient Prescription Drugs— $0
Not Covered by Medicare Remainder of
Foreign Travel—Not Covered by Medicare charges (including All charges
portion normally paid after $150
Only the services listed above while traveling $0 by Medicare All charges
outside the United States $150 after $150
per calendar year
Fitness Program—Not Covered by Medicare $0 $150
per calendar year
Weight-Loss Program—Not Covered by Medicare $0

**Once you have been billed $185 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 2019 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

9

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 All but $1,364 $1,364 $0
and miscellaneous services and supplies, and licensed All but $341 a day (Part A deductible) $0
mental hospital stays for biologically based mental disorders All but $682 a day $341 a day $0
or other mental disorders prior to the 190-day Medicare $0 $0
lifetime maximum $0 $682 a day All Costs

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

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

91st day and after of a benefit period:

– While using 60 lifetime reserve days

– Once lifetime reserve days are used:

• Additional 365 days

• Beyond the additional 365 days

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

The Deductible and Co-insurance amounts listed above reflect the 2019 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

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 Medicare $0
eligible expenses $0
61st through 120th day of a benefit period $0
100% of Medicare
eligible expenses

Days after 120 days per benefit period (or 60 days per $0 $0 All Costs
calendar year) less days covered by Medicare or plan in
that calendar year All approved $0 $0
Skilled Nursing Facility Care* amounts
Participating with Medicare) All but $170.50 Up to $170.50 $0
You must meet Medicare’s requirements, including having a day a day Balance
been in a hospital for at least three days and entered a $0 $10 a day All Costs
Medicare-approved facility within 30 days after having left $0 $0
the hospital

First 20 days of a benefit period

21st through 100th day of a benefit period

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

(Not participating with Medicare)
You must meet Medicare’s requirements, including having

been in a hospital for at least three days and transferred to

the facility within 30 days after having left the hospital

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

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

The Deductible and Co-insurance amounts listed above reflect the 2019 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

11

Medicare Supplement 1: Medex Bronze (continued)

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

Services Medicare Pays Plan Pays You Pay

Blood $0 three pints $0
$0
First three pints 100% $0
$0
Additional amounts All but very limited Actual billed
co-insurance for charges up
Hospice Care outpatient drugs to the
Available as long as your doctor certifies and inpatient co-insurance
you are terminally ill and you elect to respite care amount
receive these services

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

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

Services Medicare Pays Plan Pays You Pay

Medical expenses in or out of the hospital and $0 $185 $0
outpatient hospital treatment, such as physician’s Generally 80% (Part B deductible) $0
services, inpatient and outpatient medical and surgical
services and supplies, physical and speech therapy, $0 Generally 20%
diagnostic tests, and durable medical equipment 80%
$0 $185 $0
First $185 of Medicare-approved amounts** (Part B deductible) $0

Remainder of Medicare-approved amounts 20%
Outpatient treatment for biologically based mental
disorders and other mental health disorders 100% of expenses $0
(for services covered by Medicare)

First $185 of Medicare-approved amounts**

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

**Once you have been billed $185 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 2019 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

12

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

Services Medicare Pays Plan Pays You Pay
Blood $0 All Costs $0
First three pints $0
$0
Next $185 of Medicare-approved amounts** $0 $185 $0
(Part B deductible)
$0
Remainder of Medicare-approved amounts 80% 20% $0
Clinical Laboratory Services 100% $0 Balance
Blood tests for diagnostic services
Special Medical Formulas Mandated by Law
Covered by Medicare

First $185 of Medicare-approved amounts** $0 $185
(Part B deductible)

Remainder of Medicare-approved amounts 80% 20%

Not covered by Medicare $0 All allowed charges

**Once you have been billed $185 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 2019 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

13

Medicare Supplement 1: Medex Bronze (continued)

Medicare (Parts A & B) Medicare Pays Plan Pays You Pay

Services 100% $0 $0
Home Health Care—Medicare-Approved Services
Medically necessary skilled care services $0 $185 $0
and medical supplies 80% (Part B deductible) $0
Durable medical equipment
20%
First $185 of Medicare-approved amounts**

Remainder of Medicare-approved amounts

**Once you have been billed $185 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 2019 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

Other Benefits—Not Covered By Medicare Medicare Pays Plan Pays You Pay

Services

Foreign Travel—Not Covered by Medicare

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

14

Medicare Supplement 1A: Medex Sapphire

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

Services Medicare Pays Plan Pays You Pay

Hospitalization* $1,364 $0
Semiprivate room and board, general hospital nursing (Part A deductible) $0
and miscellaneous services and supplies, and licensed $341 a day $0
mental hospital stays for biologically based mental disorders $682 a day $0
or other mental disorders prior to the 190-day Medicare 100% of Medicare All Costs
lifetime maximum eligible expenses
$0
First 60 days of a benefit period All but $1,364

61st through 90th day of a benefit period All but $341 a day
91st day and after of a benefit period: All but $682 a day
– While using 60 lifetime reserve days
– Once lifetime reserve days are used:

• Additional 365 days $0

• Beyond the additional 365 days $0

Licensed mental hospital stays not covered by Medicare
for biologically based mental disorders

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

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

$0 $0 All Costs

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

The Deductible and Co-insurance amounts listed above reflect the 2019 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

15

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 Medicare- $0
eligible expenses

61st through 120th day of a benefit period $0 100% of Medicare $0
eligible expenses

Days after 120 days per benefit period (or 60 days per $0 $0 All Costs
calendar year) less days covered by Medicare or plan in $0 $0
that calendar year All approved
amounts
Skilled Nursing Facility Care*
(Participating with Medicare)
You must meet Medicare’s requirements, including having
been in a hospital for at least three days and entered a
Medicare-approved facility within 30 days after having left
the hospital

First 20 days of a benefit period

21st through 100th day of a benefit period All but $170.50 Up to $170.50 a $0
a day day

101st day and after of a benefit period $0 $10 a day Balance

Beyond the 365th day of a benefit period $0 $0 All Costs

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

The Deductible and Co-insurance amounts listed above reflect the 2019 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

16

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

Services Medicare Pays Plan Pays You Pay

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

1st day through 365th day of a benefit period $0 $8 a day

Beyond the 365th day of a benefit period $0 $0

Blood

First three pints $0 Three pints

Additional amounts 100% $0

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

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

The Deductible and Co-insurance amounts listed above reflect the 2019 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

17

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 $185
hospital treatment, such as physician’s services, inpatient (Part B deductible)
and outpatient medical and surgical services and supplies,

physical and speech therapy, diagnostic tests, and durable

medical equipment

First $185 of Medicare-approved amounts** $0 $0

Remainder of Medicare-approved amounts Generally 80% Generally 20% $0
Outpatient treatment for biologically based mental
disorders and other mental health disorders $0 $0 $185
(for services covered by Medicare) (Part B deductible)

First $185 of Medicare-approved amounts**

Remainder of Medicare-approved amounts 80% 20% $0
Outpatient treatment for biologically based mental $0 $0
disorders and other mental health disorders 100%
(for services not covered by Medicare) $0 of expenses
Blood $0
All Costs $0
First three pints All Costs
$185
Next $185 of Medicare-approved amounts** $0 (Part B deductible)

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

**Once you have been billed $185 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 2019 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

18


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