BCBSMA Medex Choice Sales Kit Book 05/01/2019 Approved by Angela 04/25/2019 10:38 AM

Medicare Supplement Plans

Coverage you need
From a name you can trust

Medex®´Choice 2019

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

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Dear Prospective Member,

Thank you for requesting information about Medex®´ Choice, a unique Medicare
supplement plan from Blue Cross Blue Shield of Massachusetts HMO Blue, a wholly
controlled subsidiary of Blue Cross and Blue Shield of Massachusetts. All of our Medex
plan options 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,
one that fits your needs and budget. We have enclosed the following materials to help you
get started:

• Learn about the value of Medex Choice from our Solutions to Medicare brochure
• Compare coverage options with a detailed overview of Medex Bronze, Medex

Choice, and Medex Core in the Outline of Coverage
• Enroll in Medex Choice using the enclosed application and self-addressed envelope

If you’re ready, you can enroll by telephone, mail, or fax:
• Telephone—Call us at 1-800-678-2265 (TTY: 711) Monday through Friday,
8:00 a.m. to 6:00 p.m. ET, for more information or to enroll
• 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,
Senior 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 1-800-200-4255 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para
1-800-200-4255 (TTY: 711).

188996M 99-0482-19 (08/18)

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.

In This Booklet

01 Plan Information

• Solution to Supplement Medicare
• Outline of Medicare Supplement Coverage
• Seminar Information
• GeoBlue Information

02 Disclosures

• Nondiscrimination Notice
• Translation Resources

03 Enrollment

• Enrollment Forms
• Business Reply Envelope



01

Plan
Information



Medex®´ Choice

Solution to
Supplement Medicare

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

With Medex Choice, you’ll get the
coverage you need—coverage that
goes beyond Original Medicare.

Medex Choice Sales: 1-800-678-2265 2

Table of Contents 2–4
2-3
Medex Choice
Medex Choice: How Does it Work? 4
An Introduction to Medex Choice
5–7
Medicare 5
What Is Original Medicare? 6
Why Do I Need to Supplement Medicare? 7
Medicare Coverage
8–13
Medicare and Medex Choice Together 8–11
Medicare Coverage Combined with Medex Choice
Medex Coverage - Wellness Programs 12
Medex Choice Advantages 13

Enrollment in Medex Choice 14–17
Am I Eligible for Medex Choice? 14
When Do I Enroll? 15
How Do I Enroll? 16
When Will My Coverage Begin? 17

Miscellaneous Information 18–21
How Referrals Work 18-19
Helpful Numbers
Premium Rates 20
21

1 www.bluecrossma.com/medicare

Medex Choice: How does it work?

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 with Medicare turn to
Blue Cross Blue Shield of Massachusetts. Medex Choice,1 a part
of our family of Medicare supplement plans, is designed to cover
these gaps in Medicare.

Medex Choice helps you save money by lowering your out-of-pocket expenses. Medex Choice
covers the gaps in your Medicare benefits by paying all, or part, of the costs you have to pay for
Medicare-covered services (like your Medicare deductible and co-insurance) and some other
services that are not covered by Medicare.

When you enroll in Original Medicare, you will be required to:
• Choose a primary care provider (PCP)
• Follow plan requirements—including referrals to specialists

Important Notes:

• Benefits received outside of the HMO Blue network are only covered by Original Medicare,

except in the case of emergency medical care and urgent care.

• If you choose your PCP from one of the Medex Choice Medical groups listed on the next

page, you will receive Medex Choice enhanced coverage.

• Medex Choice enhanced coverage includes coverage for 100% of your Medicare

Part A and Part B deductibles and for Medicare-covered admissions in a skilled nursing
facility, days 1 through 100.

• If you choose a non-Choice PCP, you will receive more limited coverage.

See pages 8-14 for more details.

1. Medex Choice is a Medicare supplement plan from Blue Cross Blue Shield of Massachusetts HMO Blue, a wholly
controlled subsidiary of Blue Cross and Blue Shield of Massachusetts.

Medex Choice Sales: 1-800-678-2265 2

Choice Primary www.bluecrossma.com/Medicare
Care Providers (PCPs)2
1-800-678-2265 (TTY: 711)
• Atrius Health3 Monday through Friday,
8:00 a.m. to 6:00 p.m. ET
• Baycare Health Partners
Visit www.bluecrossma.com/findadoctor
• Beth Israel Deaconess to choose your Choice PCP or, if you need help
Physician Organization choosing a PCP, call Blue Cross Blue Shield of
Massachusetts at 1-800-258-2226 (TTY: 711),
• Cooley Dickinson Physician Monday through Friday, 8:00 a.m. to 6:00 p.m. ET.
Hospital Organization
Please take a moment to review this easy-to-
• Mount Auburn Cambridge follow booklet. We’ll explain everything you
Independent Practice Association need to know about Medex Choice. If you have
any questions about coverage—or about our
• Partners®˝ HealthCare other Medex plans (Medex Bronze or Medex
Core)—call us toll-free at 1-800-678-2265 (TTY:
• Steward Health Care System®˝ 711). Our office hours are Monday through Friday,
8:00 a.m. to 6:00 p.m. ET. You can also visit our
• All HMO Blue primary care website at www.bluecrossma.com/medicare
providers in Berkshire County for more information.

2. Primary care providers (PCPs) are part of the Blue Cross Blue Shield of Massachusetts HMO Blue® provider
network. When you need specialized care, your PCP will work with you to identify the best doctor for your care
and provide a referral, most often to doctors and hospitals with whom they are affiliated in the HMO Blue®
provider Network. Please see page 18 to learn more about referrals.

3. Harvard Vanguard Medical Associates, Granite Medical Group and Dedham Medical Associates.

3 www.bluecrossma.com/medicare

An Introduction to Medex Choice

Medex Choice is a Medicare supplement plan offered by
Blue Cross Blue Shield of Massachusetts HMO Blue, a
wholly controlled subsidiary of Blue Cross and 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 Choice helps cover
health care expenses left over after Medicare has covered its
portion of costs.

+

Choose a Primary Care Receive Medex Choice Medex Choice Medical
Provider from the HMO Enhanced Coverage Groups, Specialists, and

Blue Network If you choose your PCP Hospitals
from one of the medical
When you enroll in Medex groups on page 3, you will Your Choice PCP will
Choice coverage, you will be be eligible to receive Medex usually refer you to a
required to choose a primary Choice enhanced coverage, provider affiliated with their
care provider from the HMO such as full coverage for Medex Choice medical
Blue network. The primary your Medicare Part A and group for needed specialist
care provider that you choose Part B deductibles and for or hospital care.
is referred to as your PCP. Medicare-covered admissions
in a skilled nursing facility.

Medex Choice 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.

But let’s begin by exploring how Medicare works and how you might benefit from our Medex
Choice supplemental plan.

Medex Choice policy will not restrict payment for covered services provided by non-HMO Blue network providers if
both of the following conditions exist: (a) The services are for symptoms requiring emergency care or are immediately
required for an unforeseen illness, injury, or condition; and (b) is it not reasonable to obtain services through HMO Blue
network providers.

Medex Choice Sales: 1-800-678-2265 4

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 Part A.
SERVICES COVERED:
Facility Care SERVICES COVERED:
• Inpatient hospital care Medical Expenses
• Skilled nursing facility care
• Hospice care • Doctors’ services
• Home health services
• Physical and speech therapy

• Diagnostic tests

• Ambulance trips

• Durable medical equipment

• Diabetic testing supplies

5 www.bluecrossma.com/medicare

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.

• 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 8 through 11 for coverage when Medicare is combined with Medex Choice.

Medex Choice Sales: 1-800-678-2265 6

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 the $682 per day co-insurance
$1,364 deductible All costs after 150 days

Days 61–90 each benefit period: 100% coverage after you pay $341 No cost
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

After day 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 trips • Diabetic testing supplies
• Diagnostic tests • Doctors’ services
• Durable medical equipment • Physical & speech therapy

Coverage begins after you pay the $185 calendar-year deductible $185 deductible

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

Prescription Drugs Most outpatient prescription costs

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

Routine Services and Preventive Care

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

7 www.bluecrossma.com/medicare

Medicare Coverage (Combined with Medex Choice)

Hospital 1–60 Medicare Medex Choice Medex Choice
Services Days (with Choice PCP) (with other PCP)
61–90 Days Coverage for Coverage for Medicare
60 days, after the $1,364 Full coverage of the daily co-insurance after
Lifetime deductible1 Medicare deductible you pay the $1,364 Part A
Reserve Coverage for 61–90 days, and co-insurance deductible
Days after $341 daily co-insurance
Coverage for an additional Full coverage for Full coverage for lifetime
Skilled 1–20 60 lifetime reserve lifetime reserve reserve co-insurance, then
Nursing Days days, after $682 daily co-insurance, then an an additional 365 days per
Facility 21–100 co-insurance additional 365 days per lifetime when Medicare
Days lifetime when Medicare benefits end
Full coverage for 20 days in a benefits end
101+ Medicare-participating facility Covered by Medicare
Days Coverage for days 21–100, Covered by Medicare
after $170.50 daily No coverage
Physician and Other co-insurance Full coverage for
Provider Services Medicare daily No coverage
Care in the Hospital No coverage after 100 co-insurance for days
Physician and Other days 21–100 Coverage of 20%
Provider Services co-insurance after you pay
Outpatient Department Visits, 80% coverage of approved $10 a day for days the $185 annual
Office Visits, and Patient services, after the $185 101–3652 at Part B deductible
Home Visits annual Part B deductible a Medicare- Coverage of 20%
participating facility co-insurance after you pay
80% coverage of approved the $185 annual Part B
services, after the $185 Full coverage of the deductible
annual Part B deductible Medicare deductible
and co-insurance

Full coverage of the
Medicare deductible
and co-insurance

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.
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. Choice coverage also includes $8 a day for days 1–365 at a non-Medicare-participating facility.

Medex Choice Sales: 1-800-678-2265 8

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

Other Part B Services Medicare Medex Choice Medex Choice
Ambulance Trips, Durable (with Choice PCP) (with other PCP)
Medical Equipment, Etc. 80% coverage of approved
services, after the $185 Full coverage of the Coverage of 20%
Inpatient annual Part B deductible Medicare deductible co-insurance, after you pay
Admissions and co-insurance the $185 annual Part B
in a General • Coverage for days 1–60 deductible
Hospital per benefit period, after • Full coverage
or Mental the $1,364 of the Medicare • Coverage for Medicare
Hospital inpatient deductible2 deductible and daily co-insurance after
Biologically co-insurance you pay the $1,364
Based • Coverage for days Part A deductible
Mental 61–90, after $341 daily • Full coverage of
Conditions1 co-insurance lifetime reserve • Full coverage of
days co-insurance lifetime reserve days
Outpatient • Coverage for an co-insurance
Visits additional 60 lifetime • Full coverage of up
reserve days, after $682 to 365 additional • Full coverage of up to
daily co-insurance hospital days in 365 additional hospital
your lifetime when days in your lifetime
• Coverage for mental Medicare benefits when Medicare benefits
hospital admissions is end3 end3
limited to 190 days
per lifetime • When covered • When covered by
by Medicare, Medicare, coverage of
Full benefits, less the full coverage of 20% co-insurance, after
Part B deductible and the Medicare you pay the $185 annual
co-insurance deductible and Part B deductible
co-insurance
• When not covered by
• When not covered Medicare, full Medex
by Medicare, full benefits with no visit
Medex benefits maximum
with no visit
maximum

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 consecutive days.

3. The 365 additional days per lifetime are a combination of days in a general hospital or a mental hospital.
9 www.bluecrossma.com/medicare

Medicare Coverage (Combined with Medex Choice)

Non- Inpatient Medicare Medex Choice Medex Choice
Biologically Admissions (with Choice PCP) (with other PCP)
Based in a General • Coverage for days 1–60
Mental Hospital per benefit period, after • Full coverage of the • Coverage for Medicare
Conditions the $1,364 inpatient Medicare deductible daily co-insurance after
Inpatient deductible1 and co-insurance you pay the $1,364
(includes drug Admissions Part A deductible
in a Mental • Coverage for days • Full coverage of
addiction and Hospital 61–90, after $341 daily lifetime reserve • Full coverage of
co-insurance days co-insurance lifetime reserve days
alcoholism) co-insurance
• Coverage for an additional • Full coverage of up
60 lifetime reserve to 365 additional • Full coverage of up to
days, after $682 daily hospital days in 365 additional hospital
co-insurance your lifetime when days in your lifetime
Medicare benefits when Medicare benefits
Same coverage as general end2 end2
hospital, but coverage
limited to 190 days per • Full coverage of the • Coverage for Medicare
lifetime Medicare deductible daily co-insurance after
and co-insurance you pay the $1,364 Part
A deductible
• Full coverage of
lifetime reserve days • Full coverage of
co-insurance lifetime reserve days
co-insurance
• When Medicare days
are used up, 60 • When Medicare days
days per calendar are used up, 60 days
year, less any days per calendar year, less
in a mental hospital any days in a mental
already covered by hospital already covered
Medicare or Medex by Medicare or Medex in
in that calendar year that calendar year

Full benefits, less the • When covered • When covered by
Part B deductible and by Medicare, full Medicare, coverage of
co-insurance coverage of Part 20% co-insurance, after
B deductible and you pay the $185 annual
Outpatient co-insurance with no Part B deductible
Visits visit maximum
• When not covered by
• When not covered by Medicare, full Medex
Medicare, full Medex benefits with no visit
benefits with no visit maximum
maximum

Medex Choice Sales: 1-800-678-2265 10

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

Medicare Medex Choice Medex Choice
(with Choice PCP) (with other PCP)
80% coverage of approved
services, after the $185 For blood glucose For blood glucose
annual Part B deductible monitoring equipment monitoring equipment
and supplies covered and supplies covered by
Diabetic Testing Supplies3 by Medicare: Medicare:

• Full coverage • Coverage for Medicare
of the Medicare co-insurance
deductible and
co-insurance For urine-testing materials
(not covered by Medicare):
For urine-testing
materials (not • 100% coverage of
covered by Medicare): allowed charges

• 100% coverage of
allowed charges

Medex Choice

Fitness Benefit N/A Medex members may receive up to $150 per
Weight Loss Benefit N/A calendar year in qualified health club membership
fees and exercise classes

Medex members may receive up to $150 per
calendar year when enrolled in a qualified
weight-loss program

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. The 365 additional days per lifetime are a combination of days in a general hospital or a mental hospital.
3. Medicare covers blood glucose materials for all diabetics, whether or not insulin-dependent.

Medicare does not cover urine-testing materials.
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.

11 www.bluecrossma.com/medicare

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 cardiovascular • One-time initiation or termination fees
and strength-training exercise equipment—
e.g., traditional health clubs, YMCAs, • Fees paid for gymnastics, tennis, pool-only
YWCAs, and community fitness centers. facilities, martial arts schools, instructional
dance studios, country clubs or social clubs,
• Fitness classes available at participating sports teams or leagues
Councils on Aging facilities.
• Personal trainer sessions
• Starting in 2019 - A fitness studio with
instructor-led group classes such as yoga, • Fitness equipment or clothing
Pilates, Zumba®´, kickboxing, indoor cycling/
spinning, and other exercise 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
and Weight Watchers At Work program.
• Food, supplements, books, scales, or
• Hospital based weight-loss programs. exercise equipment

• Starting in 2019 - Weight Watchers • Individual nutrition counseling sessions
online and other non-hospital programs (see your health plan coverage)
(in-person or online) that combine healthy
eating, exercise, and coaching sessions
with certified health professionals such
as nutritionists, registered dietitians, or
exercise physiologists.

Medex Choice Sales: 1-800-678-2265 12

Medex Choice Advantages

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

+

Claim Medicare Medex Choice
(pays first) (pays second)
(medical care)

Medex Choice has many advantages when you choose a Choice PCP
(see pages 2 and 3 for more information):

• Coverage for the Medicare Part A deductible

• Coverage for the Medicare Part B deductible

• Coverage for skilled nursing co-insurance for days 21 through 100

• Coverage for physician services co-insurance

• You can change your Medex coverage to another Medex plan at any time during the year.
Your coverage in the new plan will begin the first of the month following receipt of your
request to change plans.

With Medex Choice, you’ll also get:

• Up to $150 per calendar year in qualified health club membership fees and exercise
classes (Fitness Benefit), and up to $150 per calendar year when enrolled in a qualified
weight-loss program (Weight-Loss Benefit)

• The peace of mind of a Blue Cross Blue Shield ID card—the most recognized ID card in
health care today

13 www.bluecrossma.com/medicare

Am I Eligible for Medex Choice?

You are eligible for Medex Choice if you meet the
following requirements:
• Live in Massachusetts.
• Are enrolled (or will be enrolling) in both

Medicare Part A and Part B.
• May also be eligible if you are under 65 and have

a disability other than end-stage renal disease.

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.

Medex Choice Sales: 1-800-678-2265

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:
Within six months of your Medicare Part B effective date
Under 65 Within six months of your 65th birthday
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 the event

Approaching 65

Enrolling in both parts of Medicare

Over 65

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 www.bluecrossma.com/medicare

How Do I Enroll?

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



1. 2. Medex Choice requires

Decide if you want to be billed Enroll by phone, mail, or fax. applicants to select a primary
monthly or quarterly. You may find See below for details. In addition care provider (PCP) from the
the quarterly billing option more to your name and address, you
convenient if you plan to travel for will need to provide the Medicare HMO Blue Network. Please go
more than a few weeks at a time. number that appears on your to www.bluecrossma.com/
You must also decide if you want Medicare card. (If you don’t have findadoctor to choose your
your premium to be due on the your Medicare card, contact the
1st or 15th of each month. Social Security Administration Choice PCP and to obtain the
office).
PCP’s ID number. If you need

help choosing a PCP or finding
the PCP ID number, please call
1-800-258-2226 (TTY: 711),
Monday through Friday, 8:00

a.m. to 6:00 p.m. ET.

Please note that spouses need to fill out separate applications. 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 Choice, you can enroll by
telephone, by mail, or by fax:

• TELEPHONE: Call 1-800-678-2265, Monday through Friday, 8:00 a.m. to 6:00 p.m. ET.
• MAIL: Complete and return the enclosed enrollment form in the pre-addressed business reply envelope provided.
• FAX: You may also fax your completed enrollment form to us at 1-617-246-3633.

And that’s it! No need to send your premium payment with the application. You 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.

Medex Choice Sales: 1-800-678-2265 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 Choice 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 of your The first day of the month following the month your
Medicare Part B coverage or 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 www.bluecrossma.com/medicare

How Referrals Work

Your Choice primary care provider (PCP) will often refer
you to health care providers within their own groups and to
hospitals they know and trust.

This helps the doctors who care for you communicate better and give you more coordinated
health care. Although a friend or relative may recommend a particular doctor, your primary care
provider’s expert recommendation is based on what’s best for your specific medical condition.

What Is a Referral?

When you and your primary care provider determine that you need specialized care, your primary
care provider “refers” you to a provider within the HMO Blue provider Network. A referral is required
by your Medex Choice plan before the plan will cover certain services. If you do not have a referral
from your PCP before you get care from an HMO Blue specialist, your Medex Choice plan may
not provide coverage for your care. In this situation, you will still be covered for your Medicare
benefits. But, you may have to pay the costs that are not covered by Medicare (such as your
Medicare deductibles and coinsurance). It’s important that the referral comes from your primary
care provider—not only because your plan requires it, but also because your primary care provider
needs to be involved with the care you’re receiving so they can coordinate with you and your
specialist on an ongoing basis.

Why Do I Have to Check with My Primary Care Provider
Before Seeing a Specialist?

Your primary care provider knows your history and overall health, so they are best qualified
to help you decide if you should see a specialist. In order to better coordinate your care,
they may want to evaluate your needs before you see a specialist. Your primary care provider is
committed to making sure you get the right care, at the right time, in the right setting—including
when you need to see a specialist.

How Do I Request a Referral?

Contact your primary care provider to discuss your health situation. Together you can decide if
you need a specialist. If you do need a specialist, your primary care provider will help you choose
the most appropriate doctor for the care you need. Be sure to have this conversation before you
visit a specialist. If you do not have a referral from your PCP before you get care from a specialist,
your Medex Choice plan may not provide coverage for your care. In this situation, you still have the
right to receive your Medicare benefits. But, you may have to pay the costs that are not covered by
Medicare (such as your Medicare deductibles and co-insurance).

Medex Choice Sales: 1-800-678-2265 18

Where Will I Be Referred for Services and Specialties?

Your primary care provider relies on a trusted network that includes a wide range of specialists to
carry out your treatment plan. Primary care providers (PCPs) are part of the Blue Cross Blue Shield
of Massachusetts HMO Blue® provider network. When you need specialized care, your PCP will
work with you to identify the best doctor for your care and provide a referral, most often to doctors
and hospitals with whom they are affiliated in the HMO Blue® provider Network.

It’s very important to always discuss your clinical condition and concerns with your primary care
provider to determine if a specialist visit is needed and which doctor is best for you.

Are There Times When I Don’t Need a Referral?

Because your primary care provider coordinates your care, you should always let them know
when you seek treatment of any kind. There are certain instances, however, when you don’t need
a referral from your primary care provider and will still be covered by your plan. Some examples
include emergency medical care, covered annual gynecological exams, and required follow-up
services. If you do not have a required referral from your primary care provider before you get
care from a specialist, Medex Choice may not provide coverage for your care. You will still be
covered for your Medicare benefits, whether or not you have a referral from your PCP for the care.

Who Should I See if an Emergency Room Recommends Follow-Up Care
at Their Facility?

As the coordinator of your care, you should always contact your selected primary care provider
about your emergency room visit. He or she will determine the best follow-up care for you.

How Do I Know if My Health Plan Requires Referrals?

There are several ways to learn about your plan’s referral requirements:
• Visit Member Central at www.bluecrossma.com/membercentral
• Call Member Service at the number on the front of your Blue Cross ID card
It’s essential that you fully understand your plan’s referral requirements, because if you don’t get a
required referral prior to receiving non-emergency care, Medex Choice may not provide coverage
for your care.

Who Do I Call if I Have a Question About a Referral?

If you need information about whether a service is covered or requires a referral,
please call Member Service at the number on the front of your Blue Cross ID card or
visit www.bluecrossma.com/myblue.

19 www.bluecrossma.com/medicare

Helpful Numbers

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

Blue Cross Blue Shield of Massachusetts

Blue Cross Blue Shield of Massachusetts associates can answer questions regarding Medex
options, premium rates, applications, timing, enrollment, and other Medex-related issues.
Medex Sales: 1-800-678-2265 (TTY: 711)

Serving the Health Information Needs of Everyone (SHINE)

SHINE is an independent organization dedicated to helping you understand and compare all your
health plan options. Trained and certified counselors help you determine if you qualify for any sup-
plemental assistance programs. All services are free of charge.
1-800-AGE-INFO (1-800-243-4636)

Medicare

If you have questions regarding Medicare, or to order a Medicare & You handbook,
call 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048) or visit www.cms.gov.

24/7 Nurse Line: 1-888-247-BLUE (2583)

Not sure if you need to see a doctor? Medex members can call a registered nurse 24 hours
a day at the Blue Care Line for immediate assistance with health-related questions.

We think it’s important for you to know...

At the onset of an emergency medical condition that in your judgment requires immediate attention,
you should go to the nearest emergency room. For assistance, call your local emergency medical
service system by dialing 911, or your local emergency telephone number.

Medex Choice Sales: 1-800-678-2265 20

Premium Rates

2019 Rates Billed Monthly Billed Quarterly

Medex Choice $146.23 $436.68

Rates effective January 1, 2019 through December 31, 2019.

-15%First Year -10%Second Year -5%Third Year

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. Call 1-800-678-2265 to determine if you are
eligible for the discount.

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

21 www.bluecrossma.com/medicare

Blue Cross Blue Shield of Massachusetts Resources

www.bluecrossma.com/Medicare

Medicare Plan Sales: 1-800-678-2265 (TTY: 711)
Monday through Friday, 8:00 a.m. to 6:00 p.m. ET

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-200-4255 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis.
Ligue para 1-800-200-4255 (TTY: 711).

®, SM Registered Marks and Service Marks of the Blue Cross and Blue Shield Association.
®´, SM´ Registered Marks and Service 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. © 2018 Blue Cross and Blue Shield of Massachusetts, Inc.

188566 55-0829-19 (11/18)

Medex®´

Outline of Medicare
Supplement Coverage

Cover Page: Benefit Plans Medicare Supplement Core Through Choice

The chart on the following page shows the benefits included in each Medicare Supplement
Insurance plan. Every company must make available the “Core” plan. Companies may add
certain benefits to the standard benefits, if approved by the Commissioner. Look at each
company’s materials to find out which benefits, if any, the company has added to the standard
benefits for each plan it offers.

BASIC BENEFITS Included in all plans.
HOSPITALIZATION
Part A co-insurance coverage for the first 90 days per benefit period (not including the
MEDICAL EXPENSES Medicare Part A deductible) and the 60 Medicare lifetime reserve days, plus coverage
BLOOD for 365 additional days after Medicare benefits end. This shall include benefits for
biologically based mental disorders.

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

First three pints of blood each year.

For more www.bluecrossma.com/medicare
information:
1-800-678-2265 (TTY: 711)
Monday through Friday, 8:00 a.m. to 6:00 p.m.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association
1

Medicare Supplement Core Medicare Supplement 1 Medicare Supplement Choice
Medex Core Medex Bronze Medex Choice

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; for hospital; for other mental disorders: hospital, less Part A deductibles;

other mental disorders: stays in a stays in a licensed mental hospital for a for other mental disorders: stays

licensed mental hospital for at least minimum of 120 days per benefit period in a licensed mental hospital for

60 days per calendar year less days (at least 60 days per calendar year) less at least 60 days per calendar year

covered by Medicare or already days covered by Medicare or already less days covered by Medicare or

covered by plan in that calendar covered by plan in that calendar year for already covered by plan in that

year for the other mental disorders, the other mental disorders. calendar year for the other mental

less Part A deductibles. disorders, less Part A deductibles.

Skilled nursing co-insurance

Part A deductible

Part B deductible

Foreign travel
ADDITIONAL BENEFITS

Fitness program Fitness program Fitness program

Weight loss program Weight loss program Weight loss program
Foreign travel
Part A deductible—100% cover-
age when you select a Choice PCP

Part B deductible—100% coverage
when you select a Choice PCP

Skilled Nursing Facility—
Coverage for days 21–100 when
you select a Choice PCP

RATES
Effective 1/1/19

Billed monthly: $98.42 Billed monthly: $197.74 Billed monthly: $146.23

Billed quarterly: $294.45 Billed quarterly: $591.63 Billed quarterly: $436.68

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)

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

• Medicare Supplement Choice—Medex Choice
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, If you are replacing another health insurance
can only raise your premium if we raise policy, do NOT cancel it until you have
the premium for all policies like yours in actually received your new policy and are
Massachusetts, and if approved by the sure you want to keep it. If you cancel your
Commissioner of Insurance. If you choose to present policy and then decide that you do
pay your premium on a monthly or quarterly not want to keep your new policy, it may not
basis, upon your death, we will refund the be possible to get back the coverage of the
unearned portion of the premium paid. If you present policy.
choose to pay your premium on a monthly
or quarterly basis and you cancel your Notice
policy, we will refund the unearned portion
of the premium paid. In the case of death, This policy may not fully cover all of your
the unearned portion of the premium will be medical costs. Blue Cross Blue Shield
refunded on a pro-rata basis. of Massachusetts is not connected
with Medicare. This outline of coverage does
Disclosures not give all the details of Medicare coverage.
Contact your local Social Security office or
Use this outline to compare benefits and consult “Medicare & You” for more details.
premiums among policies.
Complete Answers
Read Your Policy Very Carefully Are Very Important

This is only an outline describing your policy’s When you fill out the application for the new
most important features. The policy is your policy, be sure to answer all the questions
insurance contract. You must read the policy truthfully and completely. The company may
itself to understand all of the rights and duties of cancel your policy and refuse to pay any claims
both yourself and your insurance company. if you leave out or falsify important information.
Review the application carefully before you
Right To Return Policy sign it. Be certain that all information has been
properly recorded.
If you find you are not satisfied with your
policy, you may return it to Blue Cross Blue
Shield of Massachusetts, Medex Member
Services, P.O. Box 9130, North Quincy, MA
02171-9130. If you send the policy back to us
within 30 days after you receive it, we will treat
the policy as if it had never been issued and
return all of your payments.

3

Massachusetts Medicare Supplement Insurance: Outline Of Coverage

Massachusetts Summary The Benefits-to-Premium Ratio
for Medex Bronze Is 93.9%.
The Commissioner of Insurance has set
standards for the sale of Medicare Supplement This means that during the anticipated life
Insurance policies. Such policies help you of your policy and others just like it, Blue
pay hospital and doctor bills, and some other Cross Blue Shield of Massachusetts expects
bills, that are not covered in full by Medicare. to pay out $93.90 in claims made by you
Please note that the benefits provided by and other policyholders for every $100 we
Medicare and this Medicare Supplement collect in premiums. The minimum loss ratio
Insurance policy may not cover all of the costs for Blue Cross Blue Shield of Massachusetts
associated with your treatment. It is important policies of this type is 90%. The minimum
that you become familiar with the benefits loss ratio for non-Blue Cross Blue Shield of
provided by Medicare and your Medicare Massachusetts policies of this type is 65%. A
Supplement Insurance policy. This policy higher ratio is to your advantage, as long as it
summary outlines the different coverages you allows the company reasonable return so that
have if, in addition to this policy, you are also the product remains available.
covered by Part A (hospital bills, mainly) and
Part B (doctors’ bills, mainly) of Medicare. The Benefits-to-Premium Ratio
for Medex Core Is 93.9%.
Under Massachusetts General Laws, c.
112, s. 2, no physician who agrees to treat This means that during the anticipated life
a Medicare beneficiary may charge to or of your policy and others just like it, Blue
collect from that beneficiary any amount in Cross Blue Shield of Massachusetts expects
excess of the reasonable charge for that to pay out $93.90 in claims made by you
service as determined by the United States and other policyholders for every $100 we
Secretary of Health and Human Services. collect in premiums. The minimum loss ratio
This prohibition is commonly referred to as for Blue Cross Blue Shield of Massachusetts
the “ban on balance billing.” A physician is policies of this type is 90%. The minimum
allowed to charge you or collect from your loss ratio for non-Blue Cross Blue Shield of
insurer a copayment or co-insurance for Massachusetts policies of this type is 65%. A
Medicare-covered services. However, if your higher ratio is to your advantage, as long as it
physician charges you or attempts to collect allows the company reasonable return so that
from you an amount, which together with the product remains available.
your copayment or co-insurance is greater
than the Medicare-approved amount, The Benefits-to-Premium Ratio
please contact the Board of Registration in for Medex Choice Is 93.9%.
Medicine at (781) 867-8200.
This means that during the anticipated life of
We cannot explain everything here. your policy and others just like it, Blue Cross
Massachusetts law requires that personal Blue Shield of Massachusetts expects to pay
insurance policies be written in easy-to-read out $93.90 in claims made by you and other
language. So, if you have questions about policyholders for every $100 we collect
your coverage that are not answered in this in premiums. The minimum loss ratio for Blue
brochure, read your policy. If you still have Cross Blue Shield of Massachusetts policies
questions, ask your agent or company. You of this type is 90%. A higher ratio is to your
may also wish to get a copy of “Medicare & advantage, as long as it allows the company
You”, a small book put out by Medicare that reasonable return so that the product
describes Medicare benefits. remains available.

4

Massachusetts Medicare Supplement Insurance: Outline Of Coverage

Complaints • Write or Fax: The preferred option is for
you to send your grievance in writing
If you have a complaint, call Medex Member to: Member Grievance Program, Blue
Service at 1-800-258-2226. If you are not Cross Blue Shield of Massachusetts, One
satisfied, you may write to The Massachusetts Enterprise Drive, Quincy, MA 02171-2126.
Division of Insurance, 1000 Washington Street, Or, you may fax your grievance to 1-617-
Suite 810, Boston, Massachusetts 02118-6200 246-3616. Blue Cross Blue Shield will let
or call (617) 521-7794 (Boston). you know that your request was received
by sending you a written confirmation
Grievance Program within 15 calendar days.

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

5

Medicare Supplement Core: Medex Core

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

Services Medicare Pays Plan Pays You Pay

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

61st through 90th day of a benefit period All but $341 a day $341 a day $0
91st day and after of a benefit period: All but $682 a day
– While using 60 lifetime reserve days $0 $682 a day $0
– Once lifetime reserve days are used: 100% of Medicare All Costs
eligible expenses
• Additional 365 days $0

• Beyond the additional 365 days $0 All but $1,364
$0
Licensed mental hospital stays
not covered by Medicare for biologically
based mental disorders

First 60 days of a benefit period

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

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

Services Medicare Pays Plan Pays You Pay
$0
Licensed mental hospital stays not covered by All but $1,364 $1,364
Medicare for other mental disorders (Part A deductible)

First 60 days per calendar year less days
covered by Medicare or plan in that calendar year

61st through 120th day of a benefit period $0 100% of Medicare $0
eligible expenses
Days after 60 days per calendar year less days $0
covered by Medicare or plan in that calendar year $0 All Costs

Skilled Nursing Facility Care*

(Participating with Medicare)
You must meet Medicare’s requirements,
including having been in a hospital for at least
three days and entered a Medicare-approved
facility within 30 days after having left the hospital

First 20 days of a benefit period All approved amounts $0 $0

21st through 100th day of a benefit period All but $170.50 $0 Up to $170.50
101st day and after of a benefit period a day $0 a day

$0 All Costs

Blood $0 Three pints $0
First three pints

Additional amounts 100% $0 $0

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

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

First $185 of Medicare-approved amounts**

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 $185 (Part B deductible)

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

Outpatient treatment for biologically based $0 100% of $0
expenses
mental disorders and other mental health disorders

(for services not covered by Medicare)

Blood

First 3 pints $0 All Costs $0

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

8

Medicare Supplement Core: Medex Core (continued)

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

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

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

Remainder of Medicare-approved amounts

Other Benefits—Not Covered By Medicare

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

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 and miscellaneous services and supplies,
and licensed mental hospital stays for biologically
based mental disorders or other mental disorders
prior to the 190-day Medicare lifetime maximum

First 60 days of a benefit period All but $1,364 $1,364 $0
61st through 90th day of a benefit period All but $341 a day (Part A deductible) $0

$341 a day

91st day and after of a benefit period:

– While using 60 lifetime reserve days All but $682 a day $682 a day $0

– Once lifetime reserve days are used:

• Additional 365 days $0 100% of Medicare $0
• Beyond the additional 365 days $0 eligible expenses All Costs

$0

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

First 60 days of a benefit period $0 100% of Medicare $0
61st through 90th day of a benefit period $0 eligible expenses $0
91st day and after of a benefit period:
100% of Medicare
eligible expenses

– While using 60 lifetime reserve days $0 100% of Medicare $0
– Once lifetime reserve days are used: eligible expenses
$0
• Additional 365 days $0 100% of Medicare $0
eligible expenses All Costs
• Beyond the additional 365 days
$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.

10

Medicare Supplement 1: Medex Bronze (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 that calendar year

Skilled Nursing Facility Care*
(Participating with Medicare)
You must meet Medicare’s requirements,
including having been in a hospital for at least three
days and entered a Medicare-approved facility within
30 days after having left the hospital

First 20 days of a benefit period All approved $0 $0
amounts
21st through 100th day of a benefit period Up to $170.50 $0
All but $170.50 a day
101st day through 365th day of a benefit period a day $10 a day Balance
Beyond the 365th day of a benefit period $0 $0 All Costs

$0

(Not participating with Medicare) $0 $8 a day Balance
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

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

First 3 pints $0 3 pints $0

Additional amounts 100% $0 $0

Hospice Care All but very Actual billed $0

Available as long as your doctor certifies limited charges up
you are terminally ill and you elect to
receive these services co-insurance for to the

outpatient drugs co-insurance amount

and inpatient respite

care

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

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

Services Medicare Pays Plan Pays You Pay

Medical expenses in or out of the hospital and
outpatient hospital treatment, such as physician’s
services, inpatient and outpatient medical and surgical

services and supplies, physical and speech therapy,

diagnostic tests, and durable medical equipment

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

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

Outpatient treatment for biologically based mental $0 100% of expenses $0
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 Supplement 1: Medex Bronze (continued)

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

Services Medicare Pays Plan Pays You Pay
Blood
First 3 pints $0 All Costs $0
Next $185 of Medicare-approved amounts**
$0 $185 $0
Remainder of Medicare-approved amounts
Clinical Laboratory Services (Part B deductible)

80% 20% $0

Blood tests for diagnostic services 100% $0 $0
Special Medical Formulas Mandated by Law $0
Covered by Medicare $185 $0
First $185 of Medicare-approved amounts** (Part B deductible)
$0
Remainder of Medicare-approved amounts 80% 20% Balance
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)

Services Medicare Pays Plan Pays You Pay

Home Health Care—Medicare-Approved Services

Medically necessary skilled care services 100% $0 $0
and medical supplies

Durable medical equipment

First $185 of Medicare-approved amounts** $0 $185 $0
Remainder of Medicare-approved amounts 80% (Part B deductible) $0

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.

Other Benefits—Not Covered By Medicare

Services Medicare Pays Plan Pays You Pay

Foreign Travel—Not Covered by Medicare Remainder of $0
Only the services listed above while traveling out- $0
side the United States charges (including

portion normally paid

by Medicare)

Outpatient Prescription Drugs—Not Covered $0 $0 All Costs
by Medicare $0
Fitness Program—Not Covered by Medicare $0 $150 per All charges
calendar year after $150
Weight Loss Program—Not Covered
by Medicare $150 per All charges
calendar year after $150

14

Medicare Supplement Choice: Medex Choice

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

Services Medicare Pays Plan Pays You Pay
With
Hospitalization* With With Choice With
Semiprivate room and board, general Choice Other PCP Other
hospital nursing and miscellaneous services PCP PCP PCP
and supplies, and licensed mental hospital $0
stays for biologically based mental disorders $0 $1,364
or other mental disorders prior to the $0 (Part A
190-day Medicare lifetime maximum $0 Deductible)
All Costs $0
First 60 days of a benefit period All but $1,364 $1,364 $0
$0 $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 $0
– While using 60 lifetime reserve days All but $682 a day $682 a day All Costs
– Once lifetime reserve days are used: $0
$0 100% of Medicare $1,364
• Additional 365 days eligible expenses $0 (Part A
All Costs Deductible)
• Beyond the additional 365 days $0 $0 $0
Licensed mental hospital stays
not covered by Medicare for biologically $0 100% of All but
based mental disorders Medicare $1,364
First 60 days of a benefit period eligible
expenses
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
$0 100% of Medicare
– Once lifetime reserve days are used: eligible expenses
• Additional 365 days
$0 100% of Medicare
• Beyond the additional 365 days eligible expenses

$0 $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. 15

Medicare Supplement Choice: Medex Choice (continued)

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

Services Medicare Pays Plan Pays You Pay
With Choice PCP
Licensed mental hospital stays not covered by With Choice PCP
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 All Costs
eligible expenses
Days after 120 days per benefit period (or 60 days $0 $0 With Other PCP
per calendar year) less days covered by Medicare
or plan in that calendar year With Other PCP $1,364
(Part A deductible)
Licensed mental hospital stays not covered
by Medicare for other mental disorders $0

First 60 days per calendar year less days $0 All but $1,364 All Costs
covered by Medicare or plan in that $0
calendar year 100% of Medicare
eligible expenses
61st day and after of a benefit period
$0
Days after 60 days per calendar year $0
less days covered by Medicare or plan
in that calendar year With With With With
Choice Other Choice Other
Skilled Nursing Facility Care* PCP PCP PCP PCP
(Participating with Medicare)
You must meet Medicare’s requirements, includ-
ing having been in a hospital for at least three
days and entered a Medicare-approved facility
within 30 days after having left the hospital

First 20 days of a benefit period All approved $0 $0 $0 $0
21st through 100th day of a benefit period amounts $0
$170.50 $0 Up to
101st day and after of a benefit period All but $170.50 per day Balance $170.50 a
a day day

$0 $10 a day $0 All Costs

Beyond the 365th day of a benefit period $0 $0 $0 All Costs 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 Supplement Choice: Medex Choice (continued)

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

Services Medicare Pays Plan Pays You Pay
With
(Not participating with Medicare) With With Choice With
You must meet Medicare’s requirements, includ- Choice Other PCP Other
ing having been in a hospital for at least three PCP PCP PCP
days and transferred to the facility within 30 days Balance
after having left the hospital $8 a day $0 All costs All Costs
All Costs
1st day through 365th day of a benefit period $0 $0

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

Blood

First three pints $0 Three pints

Additional amounts 100% $0 $0

Hospice Care All but very Actual billed $0

Available as long as your doctor certifies limited charges up to the

you are terminally ill and you elect to co-insurance for co-insurance amount

receive these services outpatient drugs

and inpatient

respite care

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 Choice: Medex Choice (continued)

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

Services Medicare Pays Plan Pays You Pay

Medical expenses in or out of the hospital With With With With
and outpatient hospital treatment, such as Choice Other Choice Other
physician’s services, inpatient and outpatient PCP PCP PCP PCP

medical and surgical services and supplies,

physical and speech therapy, diagnostic

tests, and durable medical equipment

First $185 of Medicare-approved amounts** $0 $185 $0 $0 $185 (Part B
Remainder of Medicare-approved amounts Generally 80% Generally 20% deductible)

$0 $0

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

First $185 of Medicare-approved amounts** $0 $185 $0 $0 $185 (Part B
Remainder of Medicare-approved amounts 80% deductible)

20% 20% $0 $0

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

Blood

First 3 pints $0 All Costs All Costs $0 $0
Next $185 of Medicare-approved amounts** $0
$185 $0 $0 $185 (Part B
Remainder of Medicare-approved amounts 80% deductible)
20% 20% $0 $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