Supplemental Coverage Option 2 + 1

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Supplemental Coverage

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Supplemental Coverage Option 2+1 1

Here‘s how our Supplemental

coverage works:

Step 1

As your primary coverage, Medicare pays your health costs first.

Step 2

As your secondary coverage, Blue Cross then pays your Medicare deductible and coinsurance or set copayment if the service is a Supplemental benefit.

Supplemental coverage gives

you total health protection

Our Blues Supplemental coverage fills

in many of the Medicare “gaps” —

like deductible, coinsurance and

copayment amounts that you pay

each year. This means lower

out-of-pocket costs and more

money in your pocket.

Here are three important tips to

remember:

Always give your Medicare and Blue Cross Blue

•

Shield ID cards to your health care provider. This ensures that both Medicare and Blue Cross Blue Shield review your claims for payment. Don’t destroy or misplace your

• Medicare

Summary Notice – Part B or Notice of Utilization because if you need to file for

Supplemental coverage payment, you must send them to Blue Cross Blue Shield of Michigan. Always include your Blue Cross Blue Shield

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Medicare Part A Hospital Services — Per Benefit Period

Medicare Part B Medical Services — Per Calendar Year

Skilled Nursing Facility Care

You must meet Medicare requirements, including having been in a hospital for at least three consecutive days and having entered a Medicare-approved facility within 30 days of discharge from the hospital

Medicare Pays Supplemental Coverage Pays You Pay

Days 1–20 Medicare-approved amount $0 – covered in full by Medicare $0

Days 21–100 Medicare-approved amount less Part A daily coinsurance

Medicare Part A daily coinsurance

$0

Days 101 and after $0 – not covered by Medicare $0 – not covered by Supplemental coverage

All costs

Home and Office Visits

Medicare-approved amount less Part B deductible and coinsurance

$0 – not covered by Supplemental coverage

Medicare Part B deductible and coinsurance

Outpatient Mental Health Care

Medicare-approved amount less Medicare Part B deductible and $0

Hospitalization

Semiprivate room and board, general nursing care and miscellaneous services and supplies

Days 1–60 Medicare-approved amount less Part A deductible

Medicare Part A deductible $0

Days 61–90 Medicare-approved amount less Part A daily coinsurance

$0

Lifetime reserve days (60 days)

Medicare-approved amount less Part A daily coinsurance. Because lifetime reserve days are not renewed, Medicare will not pay once all 60 days are used.

$0

Additional days $0 – not covered by Medicare Blue Cross-approved amount up to an additional 275 days

$0 until you use all additional 275 days, then you pay all costs

Hospice Care

Supportive services needed for care and pain relief for terminally ill patients provided by a Medicare-participating hospice program when the patient elects this type of care

Medicare-approved amount less small copayment for outpatient drugs and less small coinsurance for inpatient respite care

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Medical Expenses

Inpatient 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 $131 of Medicare-approved amounts for covered services†

$0 – applied to Medicare Part B deductible

Medicare Part B deductible $0

Covered services after Part B deductible is met

Medicare-approved amount less Part B coinsurance

Medicare Part B coinsurance $0 except for outpatient medical visits, consultations, injections, and some chiropractic services

Clinical Laboratory Services

Laboratory and pathology tests used in the diagnosis and treatment of illness or injury

Medicare-approved amount $0 – covered in full by Medicare $0

Home Health Care

Medically necessary home health visits when you are under a physician’s care and homebound; also includes aide services, therapy, medical social services and medical supplies when criteria are met

Medically approved home health services

Medicare-approved amount $0 – covered in full by Medicare $0

Durable medical equipment

Medicare Part B coinsurance $0

Blood

Pints 1–3 after Medicare deductible is met

Note: Three-pint blood deductible is not applicable when services are received in Michigan

$0 – not covered by Medicare

Note: If the 3-pint deductible has been met under Part A, it need not be met again for Part B

Medicare blood deductible $0

Additional pints after Medicare deductible is met

Medicare Part B coinsurance $0

Foreign Travel

$0 – not covered by Medicare Covered hospital services for up to 30 days and covered physician services up to Blue Cross-approved amount

All costs for non-covered services

Medicare Part B Medical Services — Per Calendar Year

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Medicare Part A&B Services

† Once you have paid $131 of Medicare-approved amounts for covered services, your Medicare Part B deductible is met for the calendar year. Note: You may be responsible for additional amounts if your doctor does not accept Medicare’s assignment.

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Here’s an example to help you understand

How Supplemental coverage works with Medicare

Example

Pat has outpatient surgery which is subject to the Medicare Part B deductible and a 20 percent

coinsurance. (We’ve used a 20 percent coinsurance for illustration purposes. The Medicare coinsurance amount varies according to the service.) The total cost for the surgery is $550. Pat has not met the Medicare Part B $131 deductible.

*If your doctor does not accept Medicare’s assignment, you may be responsible for additional amounts. To limit your out-of-pocket costs, be sure to discuss Medicare participation and assignment — as well as fees — with your doctor before you receive services.

Medicare Supplemental Coverage Pat

Approves $400 and applies the first $131 of the Medicare-approved amount to Pat’s Part B deductible:

$400 –131 $269

Medicare then pays 80 percent of the $269:

$269 x 80% $215.20

…leaving a coinsurance balance: $269.00

–215.20 $ 53.80

Note: Pat’s doctor accepts Medicare’s assignment*; therefore, Pat is not responsible for the difference between the doctor’s charge ($550) and the Medicare-approved amount ($400).

Covers Pat’s Medicare Part B deductible and coinsurance: $131.00

+ 53.80 $184.80

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Here are answers to frequently asked questions about Medicare and

Blue Cross Blue Shield Supplemental coverage.

What does it mean when a doctor accepts

assignment?

This is a Medicare term that refers to doctors, medical suppliers and other health care providers who agree to accept the Medicare-approved amount as full payment for covered services.

If my doctor submits my claim to Medicare, is he or she required to accept the Medicare-approved amount as payment in full?

No. Although doctors are required to file your claim with Medicare, this does not mean he or she will accept the Medicare assignment.

If my doctor accepts the Medicare payment as payment in full, does he or she also have to accept the Supplemental payment?

Yes. When your doctor accepts assignment on a Medicare claim, he or she also agrees to accept the Blue Cross Blue Shield Supplemental payment as payment in full.

How do I file for Supplemental coverage payment?

To file for Supplemental payment, send your Medicare Summary Notice to:

Blue Cross Blue Shield of Michigan P.O. Box 2888

Detroit, MI 48231

Be sure to write your Blue Cross Blue Shield contract number and a daytime telephone number at the top of the Medicare Summary Notice. You should include the doctor’s complete name and address. If payment is to be sent to your doctor, his or her federal tax ID number must also be included. Failure to provide this information will delay claims processing. If the tax ID number is not on the doctor’s statement, call your doctor and ask for this information.

Supplemental Coverage Option 2 + 1