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bcbsm.com/medicareMedicare supplement coverage offered by Blue Cross Blue Shield of Michigan.

Outline of Medicare supplement coverage — Plans A, C, F, HD‑F and N

Blue Cross® Medicare Supplement

2018

Medicare made easy

What is supplement coverage?Supplement coverage, also called Medigap coverage, is a health policy that works together with Original Medicare Part A (hospital) and Part B (medical) to help cover certain costs Original Medicare doesn’t. It offers great benefits and lowers your out-of-pocket costs. As your primary health coverage, Original Medicare provides hospital and medical coverage, but it doesn’t cover all health care costs and has deductibles and coinsurance that must be paid before Medicare pays benefits. Medicare also limits coverage for certain services.

Supplement works with Original Medicare coverage and, depending on the plan you select, covers all or a portion of your Medicare deductibles and coinsurances. Blue Cross Blue Shield of Michigan offers Blue Cross Medicare Supplement options for Plans A, C, F, HD-F or N only. Other Michigan insurance carriers may offer other or additional plans, but Supplement plans can be sold in only 10 standard plans plus one high-deductible plan. (Plans A, B, C, D, F, G, K, L, M and N; plans E, H, I, and J are no longer available for sale.) Every Supplement insurer must make Plan A available. Plan A covers basic benefits:

� Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

� Medical expenses: Part B coinsurance (generally 20 percent of Medicare-approved expenses) or copayments for hospital outpatient services.

� Blood: First three pints of blood each year.

Now that you’re eligible for Medicare, you have new options

for health care coverage. Blue Cross Medicare Supplement

offers coverage that’s convenient and helps protect you from

the high cost of health care.

Medicare made easy

Blue Cross Medicare Supplement made easy

1Blue Cross Medicare Supplement

Blue Cross Medicare Supplement premiumsFor Blue Cross Medicare Supplement plans, certain factors may affect your monthly premium. We base your premium on the area you live in and your age, gender, health status and whether you use tobacco. The charts in this booklet show the monthly cost for Plans A, C, F, HD-F and N based on these factors. The deductible, coinsurance and copay amounts listed in this brochure are based on the 2018 CMS-approved values and are subject to change in 2019.

If you are enrolled in Medicare Part B and are submitting your application prior to or within 6 months of turning 65 years of age or if you are within a guaranteed issue period, your premium will not be affected by your tobacco use, health status (including body mass index value), claims experience, receipt of health care or medical condition. (In this document, we refer to either status as your “Special Enrollment” period.)

This Outline of Medicare Supplement Coverage is a summary only. Specific provisions for coverage, limitations and exclusions are contained in certificates and, if applicable, riders to those certificates. Although every effort has been made to accurately describe the benefits, if there is a discrepancy between this outline and applicable certificates and riders, the certificates and riders will govern.

This request for information is insurance related and if you respond you may be contacted in an attempt to sell you insurance.

Blue Cross Medicare Supplement is not connected with or endorsed by the U.S. government or the federal Medicare program.

Blue Cross Medicare Supplement

IMPORTANT INFORMATION REGARDING PLAN A AND PLAN CIf you are currently enrolled in Plans A or C, you can stay with that plan as long as you pay your premium. If you are interested in enrolling in Plan C, you are eligible if you’ll no longer be insured because you’ve become eligible for Medicare, you’ve lost coverage under a group policy after becoming eligible for Medicare or you were enrolled in Plan C, subsequently enrolled in a Medicare Advantage plan and now would like to return to Plan C (but only if you are returning within the first 12 months of enrolling in the Medicare Advantage Plan). If you are interested in enrolling in Plan A and are 65 years of age or older, you are eligible to enroll. If you are under age 65, you are eligible to enroll in Plan A if you’ll no longer be insured because you’ve become eligible for Medicare, you’ve lost coverage under a group policy after becoming eligible for Medicare or you were enrolled in Plan A, subsequently enrolled in a Medicare Advantage Plan and now would like to return to Plan A (but only if you are returning within the first 12 months of enrolling in the Medicare Advantage plan).

2

� You are applying within six months of first enrolling in Part B and are age 65 years or older, regardless of when you first became eligible for Medicare (in other words, you elect part B upon retirement at age 70 years).

� You were enrolled in an employer group health plan (including retiree or COBRA coverage) plan and your employer group terminated that coverage within the past 63 days.

� You were enrolled in a Medicare Advantage plan, Program of All Inclusive Care for the Elderly (PACE), Health Care Pre-Payment Plan, other Medicare demonstration project or Medicare Select plan and, within the past 63 days:

– The certification of the organization or plan was terminated.

– The plan terminated and/or discontinued providing coverage in the area in which you reside.

– You moved out of the plan’s service area and are no longer eligible to participate in the plan.

– You voluntarily disenrolled because the plan substantially violated a material provision of the organization’s contract with you. This includes:

- Failing to provide an enrollee, on a timely basis, medically necessary care for which benefits are available under the plan

- Failing to provide covered care in accordance with applicable standards

- The organization, agent or other entity acting on the organizations behalf, materially misrepresenting the plan’s provisions in marketing the plan to you.

� You voluntarily disenrolled from a Medicare Advantage plan within 12 months after the effective date of enrollment, upon first becoming eligible for benefits under Medicare Part A at age 65.

� You were enrolled in a supplement policy within the past 63 days and:

Involuntarily lost coverage due to insolvency of the insurer or bankruptcy of the organization offering the coverage, or...

You voluntarily disenrolled because the plan violated a material provision of the policy or the insurer materially misrepresented the policy’s provisions in marketing the policy to you.

� You terminated enrollment and subsequently enrolled, for the first time, in a Medicare Advantage plan, Medicare Select Plan, Medicare Cost Plan or Program of All Inclusive Care for the Elderly (PACE), and the subsequent enrollment is terminated by you within the first 12 months.

Do you qualify for a Special Enrollment Period?Insurance companies are required by law to offer a Supplement policy without conditions or constraints on coverage to individuals who meet certain requirements. The following scenarios qualify you for Special Enrollment rates:

4

Your payment optionsYou may make payments through authorized automatic deductions from your bank account or by personal check, money order or cashier’s check. See the enrollment application in this brochure for details on payment methods. Premium payments are due the 25th of each month.

To find your estimated monthly premium cost, follow these steps:1 Select a plan option: Plan A, C, F, HD-F or N.

2 Using the following tables:

If you are within one of the Special Enrollment Periods, use the tables on Pages 6 and 7 to find your monthly premium.

If you are not within a Special Enrollment Period, use the tables on Pages 8 through 11.

If you qualify for Conversion Plans A or C, use the table on Page 12.

Instructions � Find the plan option that’s right for you.

– If you live in a ZIP code that begins with 480 through 485, you are in Area 1. – If you live in any other ZIP code in Michigan, you are in Area 2.

� Once you find the correct table, scroll down the first column to find your age. Your premium will be shown at the right, based on whether you’re male or female, and whether you use tobacco if you are applying outside of a Special Enrollment Period.

5

* Members who enroll prior to age 65 will remain in the <65 community rated pool for the duration of the policy unless they reapply for coverage after turning 65 years of age.

Blue Cross Medicare Supplement Plan A, Special Enrollment Tier rates

AGE

Area 1 (Southeast Michigan)

Area 2 (Rest of Michigan)

Male Female Male Female

Under age 65* $227.62 $227.62 $227.62 $227.62

65 $111.42 $106.11 $103.65 $98.71

66 $118.06 $111.90 $109.82 $104.10

67 $124.75 $117.69 $116.05 $109.48

68 $130.48 $122.51 $121.37 $113.97

69 $136.25 $127.34 $126.75 $118.45

70 $141.69 $131.20 $131.81 $122.04

71 $147.21 $135.06 $136.94 $125.63

72 $152.81 $138.91 $142.14 $129.22

73 $158.48 $142.77 $147.42 $132.81

74 $164.23 $146.63 $152.77 $136.40

75 $167.87 $148.56 $156.16 $138.20

76 $171.56 $150.49 $159.59 $139.99

77 $175.28 $152.42 $163.05 $141.79

78 $179.04 $154.35 $166.55 $143.58

79 $182.85 $156.28 $170.09 $145.38

80 and

Over

$186.68 $158.21 $173.66 $147.17

Blue Cross Medicare Supplement Plan F, Special Enrollment Tier rates

AGE




Under age 65* $453.72 $453.72 $453.72 $453.72

65 $147.56 $140.54 $137.27 $130.73

66 $159.28 $150.97 $148.16 $140.44

67 $171.09 $161.41 $159.16 $150.15

68 $181.16 $170.10 $168.52 $158.24

69 $191.32 $178.80 $177.97 $166.33

70 $200.62 $185.76 $186.62 $172.80

71 $210.06 $192.71 $195.40 $179.27

72 $219.64 $199.67 $204.31 $185.74

73 $229.36 $206.63 $213.36 $192.21

74 $239.22 $213.58 $222.53 $198.68

75 $245.28 $217.06 $228.17 $201.92

76 $251.42 $220.54 $233.88 $205.16

77 $257.62 $224.02 $239.65 $208.39

78 $263.90 $227.50 $245.49 $211.63

79 $270.24 $230.98 $251.39 $214.86

80 and

Over

$276.66 $234.46 $257.36 $218.10

Monthly premiums for individuals applying within a Special Enrollment Period

6 Blue Cross Medicare Supplement


Blue Cross Medicare Supplement Plan HD‑F, Special Enrollment Tier rates

AGE




Under age 65* $184.88 $184.88 $184.88 $184.88

65 $66.29 $63.13 $61.66 $58.73

66 $71.55 $67.82 $66.56 $63.09

67 $76.85 $72.50 $71.49 $67.45

68 $81.38 $76.41 $75.70 $71.08

69 $85.94 $80.32 $79.94 $74.71

70 $90.12 $83.44 $83.83 $77.62

71 $94.36 $86.57 $87.77 $80.53

72 $98.66 $89.69 $91.78 $83.43

73 $103.03 $92.82 $95.84 $86.34

74 $107.46 $95.94 $99.96 $89.25

75 $110.18 $97.50 $102.49 $90.70

76 $112.94 $99.07 $105.06 $92.16

77 $115.72 $100.63 $107.65 $93.61

78 $118.54 $102.19 $110.27 $95.06

79 $121.39 $103.75 $112.92 $96.52

80 and

Over

$124.27 $105.32 $115.60 $97.97

Blue Cross Medicare Supplement Plan N, Special Enrollment Tier rates

AGE




Under age 65* $368.78 $368.78 $368.78 $368.78

65 $121.89 $116.08 $113.39 $107.99

66 $131.56 $124.70 $122.38 $116.00

67 $141.32 $133.32 $131.46 $124.02

68 $149.64 $140.51 $139.20 $130.70

69 $158.03 $147.69 $147.00 $137.39

70 $165.71 $153.44 $154.15 $142.73

71 $173.51 $159.18 $161.40 $148.08

72 $181.42 $164.93 $168.76 $153.42

73 $189.45 $170.68 $176.23 $158.77

74 $197.59 $176.42 $183.81 $164.11

75 $202.60 $179.29 $188.47 $166.79

76 $207.67 $182.17 $193.18 $169.46

77 $212.80 $185.04 $197.95 $172.13

78 $217.98 $187.91 $202.77 $174.80

79 $223.22 $190.79 $207.65 $177.48

80 and

Over

$228.52 $193.66 $212.58 $180.15

Monthly premiums for individuals applying within a Special Enrollment Period continued



Please note: the rates shown are the preferred rates and members applying outside of their special enrollment period could be subject to higher rates due to claims experience or health status.

Blue Cross Medicare Supplement Plan A, Non-Special Enrollment Tier rates

AGE



Tobacco user Non-tobacco user Tobacco user Non-tobacco user

Male Female Male Female Male Female Male Female

Under age 65* N/A N/A N/A N/A N/A N/A N/A N/A

65 $122.56 $116.73 $111.42 $106.11 $114.01 $108.58 $103.65 $98.71

66 $129.86 $123.09 $118.06 $111.90 $120.80 $114.51 $109.82 $104.10

67 $137.23 $129.46 $124.75 $117.69 $127.65 $120.43 $116.05 $109.48

68 $143.53 $134.77 $130.48 $122.51 $133.51 $125.36 $121.37 $113.97

69 $149.88 $140.07 $136.25 $127.34 $139.42 $130.30 $126.75 $118.45

70 $155.86 $144.32 $141.69 $131.20 $144.99 $134.25 $131.81 $122.04

71 $161.93 $148.56 $147.21 $135.06 $150.63 $138.20 $136.94 $125.63

72 $168.09 $152.81 $152.81 $138.91 $156.36 $142.14 $142.14 $129.22

73 $174.33 $157.05 $158.48 $142.77 $162.16 $146.09 $147.42 $132.81

74 $180.65 $161.29 $164.23 $146.63 $168.05 $150.04 $152.77 $136.40

75 $184.66 $163.42 $167.87 $148.56 $171.78 $152.02 $156.16 $138.20

76 $188.71 $165.54 $171.56 $150.49 $175.55 $153.99 $159.59 $139.99

77 $192.81 $167.66 $175.28 $152.42 $179.36 $155.96 $163.05 $141.79

78 $196.95 $169.78 $179.04 $154.35 $183.21 $157.94 $166.55 $143.58

79 $201.13 $171.91 $182.85 $156.28 $187.10 $159.91 $170.09 $145.38

80 and

Over

$205.35 $174.03 $186.68 $158.21 $191.03 $161.89 $173.66 $147.17

Monthly premiums for individuals not applying within a Special Enrollment Period




Blue Cross Medicare Supplement Plan F, Non-Special Enrollment Tier rates

AGE





Under age 65* $453.72 $453.72 $453.72 $453.72 $453.72 $453.72 $453.72 $453.72

65 $162.32 $154.59 $147.56 $140.54 $151.00 $143.81 $137.27 $130.73

66 $175.20 $166.07 $159.28 $150.97 $162.98 $154.48 $148.16 $140.44

67 $188.20 $177.55 $171.09 $161.41 $175.07 $165.16 $159.16 $150.15

68 $199.28 $187.11 $181.16 $170.10 $185.37 $174.06 $168.52 $158.24

69 $210.45 $196.68 $191.32 $178.80 $195.77 $182.96 $177.97 $166.33

70 $220.68 $204.33 $200.62 $185.76 $205.28 $190.08 $186.62 $172.80

71 $231.06 $211.99 $210.06 $192.71 $214.94 $197.20 $195.40 $179.27

72 $241.60 $219.64 $219.64 $199.67 $224.75 $204.31 $204.31 $185.74

73 $252.29 $227.29 $229.36 $206.63 $234.69 $211.43 $213.36 $192.21

74 $263.14 $234.94 $239.22 $213.58 $244.78 $218.55 $222.53 $198.68

75 $269.81 $238.77 $245.28 $217.06 $250.99 $222.11 $228.17 $201.92

76 $276.56 $242.60 $251.42 $220.54 $257.26 $225.67 $233.88 $205.16

77 $283.39 $246.42 $257.62 $224.02 $263.61 $229.23 $239.65 $208.39

78 $290.29 $250.25 $263.90 $227.50 $270.04 $232.79 $245.49 $211.63

79 $297.27 $254.07 $270.24 $230.98 $276.53 $236.35 $251.39 $214.86

80 and

Over

$304.32 $257.90 $276.66 $234.46 $283.09 $239.91 $257.36 $218.10

Monthly premiums for individuals not applying within a Special Enrollment Period continued





Blue Cross Medicare Supplement Plan HD‑F, Non-Special Enrollment Tier rates

AGE





Under age 65* $184.88 $184.88 $184.88 $184.88 $184.88 $184.88 $184.88 $184.88

65 $72.91 $69.44 $66.29 $63.13 $67.83 $64.60 $61.66 $58.73

66 $78.70 $74.60 $71.55 $67.82 $73.21 $69.39 $66.56 $63.09

67 $84.54 $79.75 $76.85 $72.50 $78.64 $74.19 $71.49 $67.45

68 $89.52 $84.05 $81.38 $76.41 $83.27 $78.19 $75.70 $71.08

69 $94.53 $88.35 $85.94 $80.32 $87.94 $82.18 $79.94 $74.71

70 $99.13 $91.79 $90.12 $83.44 $92.21 $85.38 $83.83 $77.62

71 $103.79 $95.22 $94.36 $86.57 $96.55 $88.58 $87.77 $80.53

72 $108.53 $98.66 $98.66 $89.69 $100.96 $91.78 $91.78 $83.43

73 $113.33 $102.10 $103.03 $92.82 $105.42 $94.98 $95.84 $86.34

74 $118.20 $105.54 $107.46 $95.94 $109.95 $98.17 $99.96 $89.25

75 $121.20 $107.26 $110.18 $97.50 $112.74 $99.77 $102.49 $90.70

76 $124.23 $108.97 $112.94 $99.07 $115.56 $101.37 $105.06 $92.16

77 $127.30 $110.69 $115.72 $100.63 $118.42 $102.97 $107.65 $93.61

78 $130.40 $112.41 $118.54 $102.19 $121.30 $104.57 $110.27 $95.06

79 $133.53 $114.13 $121.39 $103.75 $124.22 $106.17 $112.92 $96.52

80 and

Over

$136.70 $115.85 $124.27 $105.32 $127.16 $107.77 $115.60 $97.97





Blue Cross Medicare Supplement Plan N, Non-Special Enrollment Tier rates

AGE





Under age 65* $368.78 $368.78 $368.78 $368.78 $368.78 $368.78 $368.78 $368.78

65 $134.08 $127.69 $121.89 $116.08 $124.72 $118.78 $113.39 $107.99

66 $144.72 $137.17 $131.56 $124.70 $134.62 $127.60 $122.38 $116.00

67 $155.46 $146.66 $141.32 $133.32 $144.61 $136.42 $131.46 $124.02

68 $164.60 $154.56 $149.64 $140.51 $153.12 $143.77 $139.20 $130.70

69 $173.83 $162.46 $158.03 $147.69 $161.70 $151.12 $147.00 $137.39

70 $182.28 $168.78 $165.71 $153.44 $169.56 $157.00 $154.15 $142.73

71 $190.86 $175.10 $173.51 $159.18 $177.54 $162.88 $161.40 $148.08

72 $199.56 $181.42 $181.42 $164.93 $185.64 $168.76 $168.76 $153.42

73 $208.39 $187.74 $189.45 $170.68 $193.86 $174.64 $176.23 $158.77

74 $217.35 $194.06 $197.59 $176.42 $202.19 $180.52 $183.81 $164.11

75 $222.86 $197.22 $202.60 $179.29 $207.31 $183.46 $188.47 $166.79

76 $228.44 $200.38 $207.67 $182.17 $212.50 $186.40 $193.18 $169.46

77 $234.08 $203.55 $212.80 $185.04 $217.75 $189.34 $197.95 $172.13

78 $239.78 $206.71 $217.98 $187.91 $223.05 $192.28 $202.77 $174.80

79 $245.54 $209.87 $223.22 $190.79 $228.41 $195.22 $207.65 $177.48

80 and

Over

$251.37 $213.03 $228.52 $193.66 $233.83 $198.16 $212.58 $180.15


Blue Cross Medicare Supplement Plan C, Conversion rates

AGE




Under age

65 $362.14 $362.14 $362.14 $362.14

65 $191.05 $181.96 $177.73 $169.26

66 $202.44 $191.88 $188.31 $178.49

67 $213.92 $201.81 $198.99 $187.73

68 $223.73 $210.08 $208.12 $195.42

69 $233.63 $218.35 $217.33 $203.11

70 $242.96 $224.96 $226.01 $209.27

71 $252.42 $231.58 $234.81 $215.42

72 $262.02 $238.20 $243.74 $221.58

73 $271.74 $244.81 $252.79 $227.73

74 $281.60 $251.43 $261.96 $233.89

75 $287.86 $254.74 $267.77 $236.97

76 $294.17 $258.05 $273.65 $240.04

77 $300.56 $261.36 $279.59 $243.12

78 $307.01 $264.66 $285.59 $246.20

79 $313.53 $267.97 $291.65 $249.28

80 and

Over

$320.11 $271.28 $297.78 $252.35

Blue Cross Medicare Supplement Plan A, Conversion rates

AGE




Under age

65 $227.62 $227.62 $227.62 $227.62

65 $111.42 $106.11 $103.65 $98.71

66 $118.06 $111.90 $109.82 $104.10

67 $124.75 $117.69 $116.05 $109.48

68 $130.48 $122.51 $121.37 $113.97

69 $136.25 $127.34 $126.75 $118.45

70 $141.69 $131.20 $131.81 $122.04

71 $147.21 $135.06 $136.94 $125.63

72 $152.81 $138.91 $142.14 $129.22

73 $158.48 $142.77 $147.42 $132.81

74 $164.23 $146.63 $152.77 $136.40

75 $167.87 $148.56 $156.16 $138.20

76 $171.56 $150.49 $159.59 $139.99

77 $175.28 $152.42 $163.05 $141.79

78 $179.04 $154.35 $166.55 $143.58

79 $182.85 $156.28 $170.09 $145.38

80 and

Over

$186.68 $158.21 $173.66 $147.17

Monthly premiums for individuals who qualify for conversion applying for Plan C or Plan A

If you are currently enrolled in Plans A or C, you can stay with that plan as long as you pay your premium. If you are interested in enrolling in Plan C, you are eligible if you’ll no longer be insured because you’ve become eligible for Medicare, you’ve lost coverage under a group policy after becoming eligible for Medicare or you were enrolled in Plan C, subsequently enrolled in a Medicare Advantage plan and now would like to return to Plan C (but only if you are returning within the first 12 months of enrolling in the Medicare Advantage Plan. If you are interested in enrolling in Plan A and are 65 years of age or older, you are eligible to enroll. If you are under age 65, you are eligible to enroll in Plan A if you’ll no longer be insured because you’ve become eligible for Medicare, you’ve lost coverage under a group policy after becoming eligible for Medicare or you were enrolled in Plan A, subsequently enrolled in a Medicare Advantage Plan and now would like to return to Plan A (but only if you are returning within the first 12 months of enrolling in the Medicare Advantage plan).


Medicare Supplement plansHow to read the chart:If a check mark appears in a column of this chart, the supplement policy covers 100 percent of the described benefit. If a row lists a percentage, the policy covers that percentage of the described benefit. If row is blank, the policy doesn’t cover that benefit. Note: The supplement policy covers coinsurance only after you have paid the deductible unless the supplement policy also covers the deductible.

BenefitsPlans

A B C D F* G K L M NMedicare Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up

ü ü ü ü ü ü ü ü ü ü

Medicare Part B coinsurance or copayment ü ü ü ü ü ü 50% 75% ü ü***

Blood (first 3 pints) ü ü ü ü ü ü 50% 75% ü ü

Part A hospice care coinsurance or copayment ü ü ü ü ü ü 50% 75% ü ü

Skilled nursing facility care coinsurance ü ü ü ü 50% 75% ü ü

Medicare Part A deductible ü ü ü ü ü 50% 75% 50% ü

Medicare Part B deductible ü ü

Medicare Part B excess charges ü ü

Foreign travel emergency (up to plan limits) 80% 80% 80% 80% 80% 80%

Out-of-pocket limit**

$5,240 $2,620

This document is the Blue Cross Medicare Supplement outline of coverage and the details and exceptions of Blue Cross Medicare Supplement follow. The deductible, coinsurance and copay amounts listed in this brochure are based on the 2018 CMS-approved values and could change for 2019.

Like Medicare, Blue Cross Medicare Supplement coverage is accepted nationwide and the plan is easy to use. There are no provider networks or referrals — just use any health care provider who accepts Medicare. Simply present your Blue Cross Medicare Supplement ID card along with your red, white and blue Medicare health insurance card whenever you receive health care services. We’ll coordinate payment with Medicare and your health care providers. In most cases, you’ll never have to bother with claim filing or paperwork.

* There is also a high-deductible plan, HD-F. If you choose this option, this means you must pay for Medicare-covered costs up to the deductible amount of $2,240 for 2018 before your supplement plan pays anything.

** After you meet your out-of-pocket yearly limit and your yearly Part B deductible, the supplement plan pays 100% of covered services for the rest of the calendar year.

*** Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in an inpatient admission.


Premium informationFor Blue Cross Medicare Supplement plans, certain factors may affect your monthly premium cost. We base your premium on the area you live in and your age, gender, health status and whether you use tobacco. Please note: If you are submitting your application during a Special Enrollment Period, your rate will not be affected by your tobacco use, health status, claims experience, receipt of health care or medical condition.

We will also change your premium if you move into a different rating area. Other than premium adjustments due to age or relocation, we can only raise your premium if we raise the premium for all policies like yours.

Disenrollment may occur if premium payments are not received. In such cases, there will be a six-month waiting period before you are eligible to reapply.

Coverage replacementBecause Blue Cross Medicare Supplement expands Original Medicare benefits, you need only one supplement plan. If you have other coverage, such as coverage through an employer-sponsored health plan or another supplement plan, you should not cancel that coverage until you have actually received your new ID card and are sure you want to keep Blue Cross Medicare Supplement coverage.

If you are currently enrolled in a Medicare Advantage plan and wish to enroll in supplement, you must disenroll in writing from Medicare Advantage before enrolling in supplement. You can disenroll from Medicare Advantage only at certain times of the year. Call your Medicare Advantage customer service department for information on how to disenroll from that plan and prevent a lapse in coverage.

Choose a plan option that meets your needs.The chart on Pages 16 and 17 outlines the four coverage options offered by Blue Cross Blue Shield of Michigan (BCBSM) Plans A, C, F, HD-F and N. The outline of coverage does not give all the details of Medicare coverage. For information about your Medicare Part A and Part B coverage, contact your local Social Security office or consult Medicare & You* (online at www.medicare.gov). Medicare benefits are subject to change. Please consult the latest Choosing a Medigap Policy: Guide to Health Insurance for People with Medicare, which can be found on the Web* at www.medicare.gov.

Note: The Blue Cross Medicare Supplement plan may not fully cover all of your medical costs. When you receive covered services from a provider who does not accept Medicare assignment, you are responsible for the difference between the provider’s charge and the Medicare-approved amount, plus any deductible or coinsurance amounts required by the Blue Cross Medicare Supplement plan you select.

Once enrolled in Blue Cross Medicare Supplement, we’ll send you a member ID card and plan handbook that provides comprehensive details about your coverage. We will also give you a Certificate of Coverage. It is your legal contract with BCBSM. You must read the certificate to understand all of the rights and duties of both you and BCBSM. For more information about Blue Cross Medicare Supplement coverage, call 1-888-563-3307 or contact an insurance agent authorized to sell BCBSM policies. TTY users should call 711.

*Please note: BCBSM does not control the third‑party Web sites referred to in this publication and is not responsible for their content.

Blue Cross Medicare Supplement 15

Outline of coverageThe Medicare deductibles, coinsurance and copay amounts listed are based upon the 2018 CMS-approved numbers and could change for 2019.

Covered servicePlan option Plan A** Plan C*** Plans F and HD-F* Plan N

Medicare pays Plan pays You pay Plan pays You pay Plan pays You pay Plan pays You payMedicare Part A hospital coverage – Semi-private room, general nursing care, miscellaneous services and supplies*Deductible Nothing Nothing $1,340 $1,340 Nothing $1,340 Nothing $1,340 NothingFirst 60 days of care 100% Nothing Nothing Nothing Nothing Nothing Nothing Nothing NothingDays 61 – 90 All but the $335 daily copayment $335 daily copay Nothing $335 daily copay Nothing $335 daily copay Nothing $335 daily copay NothingDays 91 – 150 (Lifetime Reserve Days) All but the $670 daily copayment $670 daily copay Nothing $670 daily copay Nothing $670 daily copay Nothing $670 daily copay NothingDay 151 and beyond (additional 365 days after Lifetime Reserve Days used) Nothing 100% of Medicare-

eligible expenses Nothing 100% of Medicare-eligible expenses Nothing 100% of Medicare-

eligible expenses Nothing 100% of Medicare-eligible expenses Nothing

Blood benefit All but the first three pints Your first three pints Nothing Your first three pints Nothing Your first three pints Nothing Your first three pints NothingSkilled nursing facility care – You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days of care 100% Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full)

Days 21 – 100 All but $167.50 daily skilled nursing facility copayment Nothing $167.50 daily copay $167.50 daily copay Nothing $167.50 daily copay Nothing $167.50 daily copay Nothing

Hospice careAll but very limited copayment/

coinsurance for outpatient drugs and inpatient respite care

Medicare copay/coinsurance Nothing Medicare copay/

coinsurance Nothing Medicare copay/coinsurance Nothing Medicare copay/

coinsurance Nothing

Emergency care outside the U.S.

No benefits for care outside U.S. No benefits for care outside U.S. All costs for services

80% of approved amount for covered services, after $250 deductible is met. Lifetime maximum

of $50,000

$250 deductible, plus 20% coinsurance


of $50,000



of $50,000


Medicare Part B physician and outpatient services – In- or out-of-the-hospital and outpatient hospital physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic treatment (such as tests) and durable medical equipment, per calendar yearDeductible (annual) Nothing Nothing $183 $183 Nothing $183 Nothing Nothing $183

Coinsurance 80% of the approved amount after $183 deductible is met

20% coinsurance after the $183

deductible is metNothing





Balance, other than up to $20 per office

visit and up to $50 per emergency room visit, after the

$183 deductible is met

Up to $20 per office visit and up to $50 per emergency room visit

Blood benefit All but the first three pints Your first three pints Nothing Your first three pints Nothing Your first three pints Nothing Your first three pints NothingClinical laboratory services – tests for diagnostic services All charges Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full)

Home health care services – Medicare-approved servicesMedically necessary skilled care services and medical supplies All charges Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full)

Durable medical equipment 80% of the approved amount after the $183 deductible is met









Excess charges Nothing Nothing All costs Nothing All costs All remaining charges** Nothing Nothing All costs

* Per benefit period. A benefit period begins on the first day you are hospitalized and ends after you have been out of the hospital and have not received skilled nursing care in any other facility for 60 consecutive days.** If you are currently enrolled in Plans A or C, you can stay with that plan as long as you pay your premium. If you are interested in enrolling in Plan C, you are eligible if you’ll no longer be insured because you’ve become eligible for Medicare, you’ve lost coverage under a group policy after becoming eligible for Medicare or you were enrolled in Plan C, subsequently enrolled in a Medicare Advantage plan and now would like to return to Plan C (but only if you are returning within the first 12 months of enrolling in the Medicare Advantage Plan. If you are interested in enrolling in Plan A and are 65 years of age or older, you are eligible to enroll. If you are under age 65, you are eligible to enroll in Plan A if you’ll no longer be insured because you’ve become eligible for Medicare, you’ve lost coverage under a group policy after becoming eligible for Medicare or you were enrolled in Plan A, subsequently enrolled in a Medicare Advantage Plan and now would like to return to Plan A (but only if you are returning within the first 12 months of enrolling in the Medicare Advantage plan).


Outline of coverageThe Medicare deductibles, coinsurance and copay amounts listed are based upon the 2018 CMS-approved numbers and could change for 2019.

Covered servicePlan option Plan A** Plan C*** Plans F and HD-F* Plan N

Medicare pays Plan pays You pay Plan pays You pay Plan pays You pay Plan pays You payMedicare Part A hospital coverage – Semi-private room, general nursing care, miscellaneous services and supplies*Deductible Nothing Nothing $1,340 $1,340 Nothing $1,340 Nothing $1,340 NothingFirst 60 days of care 100% Nothing Nothing Nothing Nothing Nothing Nothing Nothing NothingDays 61 – 90 All but the $335 daily copayment $335 daily copay Nothing $335 daily copay Nothing $335 daily copay Nothing $335 daily copay NothingDays 91 – 150 (Lifetime Reserve Days) All but the $670 daily copayment $670 daily copay Nothing $670 daily copay Nothing $670 daily copay Nothing $670 daily copay NothingDay 151 and beyond (additional 365 days after Lifetime Reserve Days used) Nothing 100% of Medicare-

eligible expenses Nothing 100% of Medicare-eligible expenses Nothing 100% of Medicare-

eligible expenses Nothing 100% of Medicare-eligible expenses Nothing

Blood benefit All but the first three pints Your first three pints Nothing Your first three pints Nothing Your first three pints Nothing Your first three pints NothingSkilled nursing facility care – You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days of care 100% Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full)

Days 21 – 100 All but $167.50 daily skilled nursing facility copayment Nothing $167.50 daily copay $167.50 daily copay Nothing $167.50 daily copay Nothing $167.50 daily copay Nothing

Hospice careAll but very limited copayment/

coinsurance for outpatient drugs and inpatient respite care

Medicare copay/coinsurance Nothing Medicare copay/

coinsurance Nothing Medicare copay/coinsurance Nothing Medicare copay/

coinsurance Nothing

Emergency care outside the U.S.

No benefits for care outside U.S. No benefits for care outside U.S. All costs for services


of $50,000



of $50,000



of $50,000


Medicare Part B physician and outpatient services – In- or out-of-the-hospital and outpatient hospital physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic treatment (such as tests) and durable medical equipment, per calendar yearDeductible (annual) Nothing Nothing $183 $183 Nothing $183 Nothing Nothing $183

Coinsurance 80% of the approved amount after $183 deductible is met







Balance, other than up to $20 per office

visit and up to $50 per emergency room visit, after the

$183 deductible is met

Up to $20 per office visit and up to $50 per emergency room visit

Blood benefit All but the first three pints Your first three pints Nothing Your first three pints Nothing Your first three pints Nothing Your first three pints NothingClinical laboratory services – tests for diagnostic services All charges Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full)

Home health care services – Medicare-approved servicesMedically necessary skilled care services and medical supplies All charges Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full)

Durable medical equipment 80% of the approved amount after the $183 deductible is met









Excess charges Nothing Nothing All costs Nothing All costs All remaining charges** Nothing Nothing All costs

* The high-deductible plan pays the same benefits as Plan F after the annual $2,240 deductible is paid. Benefits from High-Deductible Plan F will not begin until out-of-pocket expenses exceed $2,240. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the contract. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.** The Part B deductible needs to be met only once each calendar year (Jan. 1 through Dec. 31). After, Medicare makes payments up to the Limiting Charge established by law and shown on your Medicare Explanation of Benefits.Note: Based on 2018 premiums, deductibles, coinsurance and copays, which are subject to change in 2019.*** If you are currently enrolled in Plan C, you can stay with that plan as long as you pay your premium. If you are interested in enrolling in Plan C, you are eligible if you’ll no longer be insured because you’ve become eligible for Medicare, you’ve lost coverage under a group policy after becoming eligible for Medicare or you were enrolled in Plan C, subsequently enrolled in a Medicare Advantage plan and now would lie to return to Plan C (but only if you are returning within the first 12 months of enrolling in the Medicare Advantage plan). 17

Eligibility for coverageAnyone who has Medicare Part A and Part B and lives in Michigan at least six months of the year is eligible to apply for a Blue Cross Medicare Supplement plan.

Please note: If you are submitting your application during a Special Enrollment Period, your eligibility for coverage under Blue Cross Medicare Supplement will not be subject to medical underwriting. See Page 4 for further details on Special Enrollment Periods.

Enrolling in Blue Cross Medicare Supplement is easyYou can apply for coverage on the Web at www.bcbsm.com/medicare, by contacting an agent, or by calling 1-888-563-3307 from 8 a.m. to 9 p.m., Monday through Friday, with weekend hours Oct. 1 through Feb. 14. TTY users, call 711.

You can also complete the application in this brochure and send it to one of the following:

Mail: Blue Cross Blue Shield of Michigan P.O. Box 44407 Detroit, MI 48244-0407

Fax: 1-866-392-7528

Use one application for each person. Be sure to answer truthfully and completely all questions about your medical and health history. BCBSM may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Providing fraudulent information about your permanent residence, date of birth, health status and tobacco use may also result in possible legal action by BCBSM for fraud.

Please note: Whether you are applying for coverage on the Web or through an authorized insurance agent, it is important to know that neither Blue Cross Blue Shield of Michigan nor its authorized agents are connected with Medicare.

Complete answers are very important

1

1

2

Last name

First nameMiddle initial Social Security number

Primary street address

City

State ZIP code

Mailing street address (if different from above)City

State ZIP code

CountyPhone number £ Home

£ CellAlternate number (optional) £ Home

£ Cell

Email

£ Male £ Female Birth date

Number of months you reside in MI each yearAre you currently covered under a Blue Cross Blue Shield of Michigan or Blue Care Network policy?

£ Yes £ NoIf yes, contract number

Information about you

Choose a Blue Cross Medicare Supplement plan

Please refer to your red, white and blue Medicare health insurance card to complete this section.Please fill in these blanks so they match the

information on your Medicare card.

Please print in black or blue ink. All sections must be completed unless otherwise indicated. All information

provided will be used and disclosed only as permitted by our Notice of Privacy Practices which can be found

at www.bcbsm.com.

Before you choose a Blue Cross Medicare Supplement option, it’s important you know the following:

• You must be enrolled in Medicare Parts A and B. • You cannot have more than one Medicare supplement plan. • You cannot be enrolled in a Medicare supplement plan and a Medicare Advantage health plan at the same time.

• You must be a permanent resident of Michigan and physically reside in Michigan for at least six months of every

year in order to be eligible for coverage. • Once enrolled, if you permanently move outside of Michigan or reside in Michigan for fewer than six months of

every year, your premium may change.Coverage will only continue provided all other eligibility requirements continue to be satisfied. Refer to the Outline

of Coverage at www.bcbsm.com/medicare for the monthly cost and description of the plan. Continued

2018 Medicare Supplement application

________________

________________

____________________

When you fill out the application for Blue Cross Medicare Supplement coverage, be sure to answer truthfully and completely all questions about your medical and health history. BCBSM may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded.


Please call 1-888-563-3307 from 8 a.m. to 8 p.m., seven days a week. (TTY users should call 711) or contact your agent for information on how to enroll in the Blue Cross Medicare Supplement plan. Indicate that you’re switching to a supplement plan from your current coverage. We’ll help you enroll and ensure that you have no lapse in coverage.

If you’re covered under a health policy from any other insurer, do not cancel that coverage until you receive your Blue Cross Medicare Supplement certificate and are sure you want to keep it. We will mail a booklet to you that includes your certificate when we enroll you in the plan. If you have questions, please call 1-888-216-4858 or contact your agent. TTY users should call 711.

Changing your coverageYou may switch to a different Blue Cross Medicare Supplement policy at any time, but you may be subject to medical underwriting. If you’re switching to a Medicare Advantage plan, you can enroll only during certain times of the year.

IMPORTANT: If you are currently enrolled in a Medicare Advantage plan and wish to enroll in supplement, you must separately disenroll in writing from Medicare Advantage. Submitting this application does not automatically disenroll you from your current Medicare Advantage insurance carrier. Call your Medicare Advantage customer service department for information on how to disenroll from that plan and prevent duplication of coverage or a lapse in coverage. Medicare Advantage plans only allow disenrollment at certain times of the year.

You may cancel this coverage if it’s not right for youIf you find that you are not satisfied with Blue Cross Medicare Supplement coverage, notify us by phone or write to us at the address below. We will treat the coverage as if it had never been issued and return all of your payments, less the reasonable cost of any health services paid by BCBSM during that time. You will be responsible for any deductibles or coinsurance for Medicare Part A and Part B claims or any services not covered by Original Medicare incurred during that 30-day period.

If you choose to cancel Blue Cross Medicare Supplement coverage after the first 30 days, BCBSM requires a 30-day advance notice to terminate coverage. The signature of the policy holder is required for cancellation/termination of coverage.

Send your request to one of the following:

Mail: Blue Cross Blue Shield of Michigan P.O. Box 44407 Detroit, MI 48244-0407

Fax: 1-866-392-7528

Do you also need prescription drug coverage?There are no supplement plans sold today that offer Part D prescription drug benefits. You may purchase Medicare Part D drug coverage with Blue Cross Blue Shield of Michigan’s Prescription BlueSM PDP plan. Call 1-888-563-3307 from 8 a.m. to 8 p.m., seven days a week (TTY users, call 711).

19

Notes ...


www.bcbsm.com/medicare

To enroll:

• See your Blue Cross Blue Shield of Michigan agent

• Enroll online at www.bcbsm.com/medicare

• Call 888-563-3307 (TTY: 711) 8 a.m. to 9 p.m., Monday through Friday, with weekend hours from Oct. 1 through Feb. 14.

Blue Cross Medicare Supplement

CB 15975 NOV 17R074227

blue cross medicare supplement - bcbsm.com · bcbsm.com/medicare medicare supplement coverage...

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