medicareblue supplement sm · medicareblue supplement sm plans a, d, f, g, high deductible plan g...

2020 Outlines of Coverage

MedicareBlue SupplementSM

Plans A, D, F, G, High Deductible Plan G and N

Choosing a MedicareBlue Supplement plan starts with your specific needs. Use the information in the Outlines of Coverage to learn more about the plans available from Wellmark. The benefits shown in this booklet are for plans sold for effective dates on or after Jan. 1, 2020.

These tables show an overview of benefits included in all standard Medicare supplement plans. The first table includes plans offered by Wellmark. The second table includes plans not offered by Wellmark.

Medicare supplement plans offered by Wellmark Blue Cross and Blue Shield of Iowa

Plan A

Plan D

Plan F

Plan G

HD Plan G1

Plan N

Basic benefits This includes hospitalization, medical expenses, blood and hospice care.

2

Skilled nursing facility coinsurance Without this coverage, beneficiaries are partially responsible for their stay in a skilled nursing facility.

Part A Deductible ($1,408 in 2020) This amount is set by Medicare, and is used for hospital care.

Part B Deductible ($198 in 2020) This amount is set by Medicare, and is applied to medical costs.

Part B excess charges Coverage when a provider charges over the Medicare approved amount.

Foreign travel emergencyCoverage for when emergency care outside the United States is needed.

80% 80% 80% 80% 80%

1 Benefits for this plan begin after one has paid a calendar year deductible of $2,340 for out-of-pocket expenses. 2 Exceptions: up to $20 copay for office visits and up to $50 copay for emergency room.

See more details in the Outlines of Coverage for each plan.

2

Standard Medicare supplement plans in this table are NOT offered by Wellmark Blue Cross and Blue Shield of Iowa, but may be available through another carrier.

Plan B

Plan C

HD Plan F1

Plan K

Plan L

Plan M

Basic benefitsThis includes hospitalization, medical expenses, blood and hospice care.

2 3

Skilled nursing facility coinsuranceWithout this coverage, beneficiaries are partially responsible for their stay in a skilled nursing facility.

50% 75%

Part A Deductible ($1,408 in 2020)This amount is set by Medicare, and is used for hospital care.

50% 75% 50%

Part B Deductible ($198 in 2020)This amount is set by Medicare, and is applied to medical costs.

Part B excess chargesCoverage when a provider charges over the Medicare approved amount.

Foreign travel emergencyCoverage for when emergency care outside the United States is needed.

80% 80% 80%

Out-of-pocket limits $5,880 $2,940

1 Benefits for this plan begin after one has paid a calendar year deductible of $2,340 for out-of-pocket expenses.2 Hospitalization and preventive care paid at 100 percent; other basic benefits paid at 50 percent.3 Hospitalization and preventive care paid at 100 percent; other basic benefits paid at 75 percent.

3

2020 MedicareBlue SupplementPreferred: Non-Tobacco Premiums — MalePremium effective Jan. 1, 2020, for Iowa residents. Applicants should refer to the 2020 MedicareBlue Supplement application to determine eligibility for preferred or standard premiums.

Age Plan D Plan F1Plan G without

Household Discount2

Plan G with Household Discount2

HD Plan G without Household Discount2

HD Plan G with Household Discount2

Plan N

64 and under $251.90 $264.90 $234.50 $211.10 $93.80 $84.40 $185.90

65 $140.10 $147.40 $130.50 $117.50 $52.20 $47.00 $103.40

66 $144.70 $152.10 $134.70 $121.20 $53.90 $48.50 $106.70

67 $149.10 $156.90 $138.90 $125.00 $55.60 $50.00 $110.00

68 $153.70 $161.70 $143.20 $128.90 $57.30 $51.60 $113.30

69 $158.70 $166.80 $147.60 $132.80 $59.00 $53.10 $117.00

70 $162.90 $171.50 $151.80 $136.60 $60.70 $54.60 $120.20

71 $176.80 $186.00 $164.70 $148.20 $65.90 $59.30 $130.50

72 $182.10 $191.60 $169.60 $152.60 $67.80 $61.00 $134.40

73 $187.50 $197.20 $174.60 $157.10 $69.80 $62.80 $138.30

74 $193.10 $203.30 $179.90 $161.90 $72.00 $64.80 $142.50

75 $199.00 $209.30 $185.30 $166.80 $74.10 $66.70 $146.90

76 $208.60 $219.40 $194.20 $174.80 $77.70 $69.90 $153.90

77 $219.00 $230.40 $203.90 $183.50 $81.60 $73.40 $161.60

78 $230.40 $242.60 $214.70 $193.20 $85.90 $77.30 $170.10

79 $241.80 $254.40 $225.20 $202.70 $90.10 $81.10 $178.60

80 $254.10 $267.30 $236.60 $212.90 $94.60 $85.10 $187.40

81 and over $280.70 $295.30 $261.40 $235.30 $104.60 $94.10 $207.10

1 Plan F is available for anyone who is eligible for Medicare before Jan. 1, 2020.2 To be eligible to receive the Household Discount, members must have a legal spouse or another adult living at their

residence (but no more than three other persons age 60 or older) who is 18 years of age or older with whom they have continuously resided with for the last 12 months.

Premiums are based upon the most current Medicare deductible and cost-sharing amounts and are subject to changes.

If you are applying for Plans D, F, G, High Deductible Plan G or N within six months after your Medicare Part B effective date and turning age 65 (or older) or the first day of the month in which you turn age 65 and you are currently enrolled in Medicare Part B, you are within your Medicare Supplement Open Enrollment Period. This means your acceptance is guaranteed and you do not have to answer health questions. You also do not have to answer health questions if you are within a Guaranteed Issue Rights Period.

4

2020 MedicareBlue SupplementPreferred: Non-Tobacco Premiums — FemalePremiums effective Jan. 1, 2020, for Iowa residents. Applicants should refer to the 2020 MedicareBlue Supplement application to determine eligibility for preferred or standard premiums.


Household Discount2


HD Plan G without

Household Discount2


Plan N

64 and under $222.70 $234.30 $207.40 $186.70 $83.00 $74.70 $164.30

65 $124.00 $130.40 $115.40 $103.90 $46.20 $41.60 $91.50

66 $127.90 $134.40 $119.00 $107.10 $47.60 $42.80 $94.30

67 $131.90 $138.80 $122.90 $110.60 $49.20 $44.30 $97.30

68 $135.90 $142.90 $126.50 $113.90 $50.60 $45.50 $100.30

69 $140.30 $147.50 $130.60 $117.50 $52.20 $47.00 $103.50

70 $144.00 $151.60 $134.20 $120.80 $53.70 $48.30 $106.30

71 $156.30 $164.50 $145.70 $131.10 $58.30 $52.50 $115.30

72 $161.00 $169.40 $149.90 $134.90 $60.00 $54.00 $118.80

73 $165.80 $174.40 $154.40 $139.00 $61.80 $55.60 $122.30

74 $170.80 $179.80 $159.10 $143.20 $63.60 $57.20 $126.10

75 $175.90 $185.10 $163.90 $147.50 $65.60 $59.00 $129.80

76 $184.40 $194.10 $171.80 $154.60 $68.70 $61.80 $136.00

77 $193.70 $203.70 $180.30 $162.30 $72.10 $64.90 $142.90

78 $203.70 $214.50 $189.80 $170.80 $75.90 $68.30 $150.40

79 $213.70 $225.00 $199.20 $179.30 $79.70 $71.70 $157.80

80 $224.60 $236.40 $209.30 $188.40 $83.70 $75.30 $165.90

81 and over $248.10 $261.00 $231.10 $208.00 $92.40 $83.20 $183.10





5

2020 MedicareBlue SupplementPreferred: Tobacco Premiums — MalePremiums effective Jan. 1, 2020, for Iowa residents. Applicants should refer to the 2020 MedicareBlue Supplement application to determine eligibility for preferred or standard premiums.


Household Discount2


HD Plan G without

Household Discount2


Plan N

64 and under $277.00 $291.50 $258.00 $232.20 $103.20 $92.90 $204.50

65 $154.10 $162.20 $143.50 $129.20 $57.40 $51.70 $113.70

66 $159.10 $167.40 $148.10 $133.30 $59.20 $53.30 $117.40

67 $164.00 $172.60 $152.80 $137.50 $61.10 $55.00 $121.00

68 $169.00 $177.90 $157.50 $141.80 $63.00 $56.70 $124.70

69 $174.60 $183.50 $162.40 $146.20 $65.00 $58.50 $128.70

70 $179.20 $188.70 $167.00 $150.30 $66.80 $60.10 $132.20

71 $194.50 $204.70 $181.10 $163.00 $72.40 $65.20 $143.50

72 $200.30 $210.80 $186.60 $167.90 $74.60 $67.10 $147.80

73 $206.20 $217.00 $192.00 $172.80 $76.80 $69.10 $152.20

74 $212.40 $223.60 $197.90 $178.10 $79.20 $71.30 $156.80

75 $218.90 $230.30 $203.80 $183.40 $81.50 $73.40 $161.50

76 $229.40 $241.40 $213.60 $192.20 $85.40 $76.90 $169.30

77 $240.90 $253.40 $224.30 $201.90 $89.70 $80.70 $177.70

78 $253.40 $266.80 $236.20 $212.60 $94.50 $85.10 $187.10

79 $265.90 $279.90 $247.70 $222.90 $99.10 $89.20 $196.40

80 $279.50 $294.10 $260.30 $234.30 $104.10 $93.70 $206.20

81 and over $308.80 $324.80 $287.50 $258.80 $115.00 $103.50 $227.80





6

2020 MedicareBlue SupplementPreferred: Tobacco Premiums — FemalePremium effective Jan. 1, 2020, for Iowa residents. Applicants should refer to the 2020 MedicareBlue Supplement application to determine eligibility for preferred or standard premiums.


Household Discount2


HD Plan G without

Household Discount2


Plan N

64 and under $245.00 $257.70 $228.10 $205.30 $91.20 $82.10 $180.70

65 $136.30 $143.50 $127.00 $114.30 $50.80 $45.70 $100.60

66 $140.70 $147.90 $130.90 $117.80 $52.40 $47.20 $103.80

67 $145.00 $152.70 $135.10 $121.60 $54.00 $48.60 $107.00

68 $149.50 $157.30 $139.20 $125.30 $55.70 $50.10 $110.30

69 $154.30 $162.30 $143.60 $129.20 $57.40 $51.70 $113.90

70 $158.40 $166.70 $147.60 $132.80 $59.00 $53.10 $116.90

71 $171.90 $181.00 $160.20 $144.20 $64.10 $57.70 $126.90

72 $177.10 $186.30 $164.90 $148.40 $66.00 $59.40 $130.60

73 $182.40 $191.90 $169.80 $152.80 $67.90 $61.10 $134.50

74 $187.90 $197.80 $175.00 $157.50 $70.00 $63.00 $138.70

75 $193.40 $203.70 $180.30 $162.30 $72.10 $64.90 $142.80

76 $202.80 $213.50 $189.00 $170.10 $75.60 $68.00 $149.60

77 $213.10 $224.10 $198.40 $178.60 $79.40 $71.50 $157.20

78 $224.00 $235.90 $208.80 $187.90 $83.50 $75.20 $165.40

79 $235.10 $247.50 $219.10 $197.20 $87.60 $78.80 $173.60

80 $247.10 $260.10 $230.20 $207.20 $92.10 $82.90 $182.50

81 and over $272.90 $287.20 $254.10 $228.70 $101.60 $91.40 $201.40





7

2020 MedicareBlue SupplementStandard: Non-Tobacco Premiums — MalePremiums effective Jan. 1, 2020, for Iowa residents. Applicants should refer to the 2020 MedicareBlue Supplement application to determine eligibility for preferred or standard premiums.

Age Plan A Plan D Plan F1Plan G without

Household Discount2


HD Plan G without

Household Discount2


Plan N

64 and under $491.20 $328.40 $365.00 $323.10 $290.80 $129.20 $116.30 $260.00

65 $208.70 $182.70 $203.10 $179.80 $161.80 $71.90 $64.70 $144.60

66 $215.30 $188.70 $209.60 $185.50 $167.00 $74.20 $66.80 $149.30

67 $222.20 $194.50 $216.20 $191.40 $172.30 $76.60 $68.90 $153.90

68 $228.80 $200.40 $222.80 $197.30 $177.60 $78.90 $71.00 $158.50

69 $236.10 $207.00 $229.80 $203.40 $183.10 $81.40 $73.30 $163.60

70 $242.50 $212.40 $236.30 $209.10 $188.20 $83.60 $75.20 $168.10

71 $263.30 $230.60 $256.30 $226.90 $204.20 $90.80 $81.70 $182.50

72 $271.20 $237.40 $264.00 $233.70 $210.30 $93.50 $84.20 $187.90

73 $279.10 $244.50 $271.70 $240.50 $216.50 $96.20 $86.60 $193.50

74 $287.70 $251.80 $280.10 $247.90 $223.10 $99.20 $89.30 $199.40

75 $296.20 $259.50 $288.40 $255.30 $229.80 $102.10 $91.90 $205.40

76 $310.60 $272.00 $302.30 $267.60 $240.80 $107.00 $96.30 $215.30

77 $326.00 $285.60 $317.40 $280.90 $252.80 $112.40 $101.20 $226.00

78 $343.10 $300.40 $334.20 $295.80 $266.20 $118.30 $106.50 $237.90

79 $360.00 $315.30 $350.50 $310.30 $279.30 $124.10 $111.70 $249.80

80 $378.20 $331.40 $368.30 $326.00 $293.40 $130.40 $117.40 $262.20

81 and over $417.80 $366.10 $406.80 $360.10 $324.10 $144.00 $129.60 $289.70





8

2020 MedicareBlue SupplementStandard: Non-Tobacco Premiums — FemalePremiums effective Jan. 1, 2020, for Iowa residents. Applicants should refer to the 2020 MedicareBlue Supplement application to determine eligibility for preferred or standard premiums.


Household Discount2


HD Plan G without

Household Discount2


Plan N

64 and under $434.30 $290.40 $322.80 $285.70 $257.10 $114.30 $102.90 $229.80

65 $184.50 $161.60 $179.70 $159.00 $143.10 $63.60 $57.20 $127.90

66 $190.50 $166.80 $185.20 $163.90 $147.50 $65.60 $59.00 $131.90

67 $196.50 $171.90 $191.20 $169.30 $152.40 $67.70 $60.90 $136.10

68 $202.50 $177.30 $196.90 $174.30 $156.90 $69.70 $62.70 $140.30

69 $208.90 $182.90 $203.30 $179.90 $161.90 $72.00 $64.80 $144.80

70 $214.30 $187.70 $208.80 $184.80 $166.30 $73.90 $66.50 $148.60

71 $232.70 $203.80 $226.70 $200.70 $180.60 $80.30 $72.30 $161.30

72 $239.70 $209.90 $233.30 $206.50 $185.90 $82.60 $74.30 $166.10

73 $246.80 $216.20 $240.30 $212.70 $191.40 $85.10 $76.60 $171.10

74 $254.30 $222.70 $247.70 $219.20 $197.30 $87.70 $78.90 $176.30

75 $262.00 $229.30 $255.10 $225.80 $203.20 $90.30 $81.30 $181.60

76 $274.40 $240.40 $267.40 $236.70 $213.00 $94.70 $85.20 $190.20

77 $288.10 $252.60 $280.70 $248.40 $223.60 $99.40 $89.50 $199.80

78 $303.50 $265.60 $295.50 $261.50 $235.40 $104.60 $94.10 $210.40

79 $318.30 $278.70 $310.00 $274.40 $247.00 $109.80 $98.80 $220.70

80 $334.50 $292.90 $325.70 $288.30 $259.50 $115.30 $103.80 $232.00

81 and over $369.40 $323.60 $359.60 $318.30 $286.50 $127.30 $114.60 $256.10





9

2020 MedicareBlue SupplementStandard: Tobacco Premiums — MalePremiums effective Jan. 1, 2020, for Iowa residents. Applicants should refer to the 2020 MedicareBlue Supplement application to determine eligibility for preferred or standard premiums.


Household Discount2


HD Plan G without

Household Discount2


Plan N

64 and under $540.30 $361.20 $401.50 $355.40 $319.90 $142.20 $128.00 $286.00

65 $229.50 $201.00 $223.40 $197.70 $177.90 $79.10 $71.20 $159.10

66 $236.80 $207.50 $230.50 $204.10 $183.70 $81.60 $73.40 $164.20

67 $244.40 $213.90 $237.80 $210.50 $189.50 $84.20 $75.80 $169.30

68 $251.70 $220.40 $245.10 $217.00 $195.30 $86.80 $78.10 $174.40

69 $259.70 $227.60 $252.80 $223.70 $201.30 $89.50 $80.60 $180.00

70 $266.70 $233.70 $259.90 $230.00 $207.00 $92.00 $82.80 $184.90

71 $289.60 $253.60 $281.90 $249.50 $224.60 $99.80 $89.80 $200.80

72 $298.30 $261.20 $290.40 $257.10 $231.40 $102.80 $92.50 $206.70

73 $307.00 $268.90 $298.90 $264.60 $238.10 $105.80 $95.20 $212.90

74 $316.40 $277.00 $308.10 $272.70 $245.40 $109.10 $98.20 $219.30

75 $325.80 $285.40 $317.20 $280.80 $252.70 $112.30 $101.10 $226.00

76 $341.60 $299.20 $332.50 $294.30 $264.90 $117.70 $105.90 $236.80

77 $358.60 $314.10 $349.10 $309.00 $278.10 $123.60 $111.20 $248.60

78 $377.40 $330.50 $367.60 $325.40 $292.90 $130.20 $117.20 $261.70

79 $396.00 $346.80 $385.60 $341.30 $307.20 $136.50 $122.90 $274.80

80 $416.00 $364.50 $405.10 $358.60 $322.70 $143.40 $129.10 $288.40

81 and over $459.60 $402.70 $447.50 $396.10 $356.50 $158.40 $142.60 $318.70





10

2020 MedicareBlue SupplementStandard: Tobacco Premiums — FemalePremiums effective Jan. 1, 2020, for Iowa residents. Applicants should refer to the 2020 MedicareBlue Supplement application to determine eligibility for preferred or standard premiums.


Household Discount2


HD Plan G without

Household Discount2


Plan N

64 and under $477.70 $319.50 $355.00 $314.30 $282.90 $125.70 $113.10 $252.80

65 $202.90 $177.80 $197.60 $174.90 $157.40 $70.00 $63.00 $140.70

66 $209.50 $183.50 $203.70 $180.30 $162.30 $72.10 $64.90 $145.10

67 $216.10 $189.10 $210.30 $186.20 $167.60 $74.50 $67.10 $149.70

68 $222.70 $195.00 $216.60 $191.70 $172.50 $76.70 $69.00 $154.30

69 $229.80 $201.20 $223.60 $197.90 $178.10 $79.20 $71.30 $159.30

70 $235.70 $206.50 $229.70 $203.30 $183.00 $81.30 $73.20 $163.50

71 $255.90 $224.20 $249.40 $220.70 $198.60 $88.30 $79.50 $177.50

72 $263.70 $230.90 $256.70 $227.20 $204.50 $90.90 $81.80 $182.70

73 $271.50 $237.80 $264.30 $233.90 $210.50 $93.60 $84.20 $188.20

74 $279.70 $245.00 $272.40 $241.10 $217.00 $96.40 $86.80 $194.00

75 $288.20 $252.20 $280.60 $248.30 $223.50 $99.30 $89.40 $199.70

76 $301.80 $264.40 $294.10 $260.40 $234.40 $104.20 $93.80 $209.30

77 $316.90 $277.80 $308.70 $273.30 $246.00 $109.30 $98.40 $219.80

78 $333.80 $292.10 $325.00 $287.70 $258.90 $115.10 $103.60 $231.40

79 $350.10 $306.60 $341.00 $301.80 $271.60 $120.70 $108.60 $242.80

80 $368.00 $322.20 $358.30 $317.10 $285.40 $126.80 $114.10 $255.20

81 and over $406.40 $355.90 $395.60 $350.10 $315.10 $140.00 $126.00 $281.80





11

Premium InformationWellmark Blue Cross and Blue Shield can only raise premiums for all members of the same plan uniformly. This means that we cannot increase your rate because you had claims. On the effective date of premium rates (or if there is a change in Medicare’s benefit structure), members will receive a premium based on their age. If we do change your premium, we will notify you at least 30 days in advance. However, if you are applying for coverage within 60 days of a premium change with an effective date prior to the premium change, Wellmark will provide notice of the new premium within a reasonable period of the time after the enrollment of your application.

DisclosuresUse these outlines to compare benefits and premiums among policies.

These outlines show benefits and premiums of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates prior to June 1, 2010, have different benefits and premiums.

Read Your PolicyThese outlines describe your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.

Right to Return PolicyIf you find that you are not satisfied with your policy, you may return it to:

Wellmark Blue Cross and Blue Shield of IowaP.O. Box 14527Des Moines, IA 50306-3527

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.

Policy ReplacementIf you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.

NoticeThis policy may not fully cover all of your medical costs.

Neither Wellmark Blue Cross and Blue Shield of Iowa nor its agents are connected with Medicare.

These outlines do not give all the details of Medicare coverage. Contact your local Social Security office or consult Medicare and You for more details.

Complete Answers are ImportantWhen you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. Wellmark Blue Cross and Blue Shield 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.

12

MedicareBlue Supplement Plan A

Medicare (Part A) Hospital Services Per Benefit Period

Services Medicare Pays

Wellmark Plan A Pays

You Pay

Hospitalization1

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

First 60 days All but $1,408 $0 $1,408 (Part A deductible)

Days 61–90 All but $352 a day $352 a day $0

Day 91 and after• While using 60 lifetime

reserve days All but $704 a day $704 a day $0

• Once lifetime reserve days are used: – Additional 365 days

$0 100% of Medicare eligible expenses

$02

– Beyond the additional 365 days

$0 $0 All costs

Skilled Nursing Facility Care1

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 leaving the hospital

First 20 days All approved amounts $0 $0

Days 21–100 All but $176 a day $0 Up to $176 a day

Beyond 100 days $0 $0 All costs

Blood First 3 pints $0 3 pints $0

Additional amounts 100% $0 $0

Hospice Care You must meet Medicare’s requirements, including doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

$0

1 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.

2 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 “Basic 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.

13

MedicareBlue Supplement Plan A (continued)

Medicare (Part B) Medical Services Per Calendar Year



You Pay

Medical ExpensesIN 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, durable medical equipment

First $198 of Medicare approved amounts3

$0 $0 $198 (Part B deductible)

Remainder of Medicare approved amounts

Generally 80% Generally 20% $0

Part B Excess Charges(Above Medicare approved amounts)

$0 $0 All costs

Blood First 3 pints $0 All costs $0

Next $198 of Medicare approved amounts3

$0 $0

$198 (Part B deductible)


80% 20% $0

Clinical Laboratory ServicesTESTS FOR DIAGNOSTIC SERVICES

100% $0 $0

3 Once you have been billed $198 of Medicare approved amounts for covered services, your Part B deductible will have been met for the calendar year.

14

MedicareBlue Supplement Plan A (continued)

Medicare Parts A and B



You Pay

Home Health CareMEDICARE APPROVED SERVICES

Medically necessary skilled care services and medical supplies

100% $0 $0

Durable medical equipment: • First $198 of Medicare

approved amounts3


• Remainder of Medicare approved amounts

80% 20% $0


Medicare benefits are subject to changes. Please visit Medicare.gov and consult the latest Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare.

https://www.medicare.gov/

15

MedicareBlue Supplement Plan D



Wellmark Plan D Pays

You Pay

Hospitalization1


First 60 days All but $1,408 $1,408(Part A deductible)

$0



reserve daysAll but $704 a day $704 a day $0

• Once lifetime reserve days are used:

– Additional 365 days


$02


$0 $0 All costs




Days 21–100 All but $176 a day Up to $176 a day $0







$0



16

MedicareBlue Supplement Plan D (continued)




You Pay






Part B Excess Charges (Above Medicare approved amounts)

$0 $0 All costs





80% 20% $0


100% $0 $0


17

MedicareBlue Supplement Plan D (continued)




You Pay



100% $0 $0


approved amounts3



80% 20% $0

Other Benefits Not Covered by Medicare



You Pay

Foreign TravelNOT COVERED BY MEDICARE

Medically necessary emergency care services during the first 60 days of each trip outside the United States • First $250 each calendar

year

$0 $0 $250

• Remainder of charges $0 80% to a lifetime maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum




18

MedicareBlue Supplement Plan FPlan F is available for anyone who is eligible for Medicare before Jan. 1, 2020.



Wellmark Plan F Pays

You Pay

Hospitalization1



$0


Day 91• While using 60 lifetime



– Additional 365 days$0 100% of Medicare

eligible expenses$02


$0 $0 All costs











$0



19

MedicareBlue Supplement Plan F (continued)Plan F is available for anyone who is eligible for Medicare before Jan. 1, 2020.




You Pay



$0 $198 (Part B deductible)

$0




$0 100% $0




$0


80% 20% $0


100% $0 $0


20

MedicareBlue Supplement Plan F (continued)Plan F is available for anyone who is eligible for Medicare before Jan. 1, 2020.




You Pay



100% $0 $0


approved amounts3


$0


80% 20% $0




You Pay



year

$0 $0 $250






21

MedicareBlue Supplement Plan G



Wellmark Plan G Pays

You Pay

Hospitalization1



$0







$02


$0 $0 All costs











$0



22

MedicareBlue Supplement Plan G (continued)




You Pay







$0 100% $0





80% 20% $0


100% $0 $0


23

MedicareBlue Supplement Plan G (continued)




You Pay



100% $0 $0


approved amounts3



80% 20% $0




You Pay



year

$0 $0 $250




24

MedicareBlue Supplement High Deductible Plan G


Services

Medicare Pays

After You Pay $2,340 Deductible, Wellmark HD Plan G1 Pays

You Pay

Hospitalization2



$0



reserve days

All but $704 a day $704 a day $0




$03


$0 $0 All costs











$0

1 This high-deductible plan pays the same benefits as Plan G after you have paid a calendar year $2,340 deductible. Benefits from the High Deductible Plan G will not begin until out-of-pocket expenses are $2,340. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare Part A deductible, Part B deductible and excess charges. This does not include the plan’s separate foreign travel emergency deductible.



25

MedicareBlue Supplement High Deductible Plan G (continued)


Services

Medicare Pays

After You Pay $2,340 deductible, Wellmark HD Plan G1 Pays

You Pay







$0 100% $0



$0 $0 $198(Part B deductible)


80% 20% $0


100% $0 $0



NOTE: Members enrolled in High Deductible Plan G for 12 consecutive months will be allowed to move to Plan G during the Annual Enrollment Period (AEP) from Oct. 15–Dec. 7 for coverage to be effective Jan. 1. Moving from High Deductible Plan G to Plan G outside the AEP would require you to answer health questions on the application.

26

MedicareBlue Supplement High Deductible Plan G (continued)


Services

Medicare Pays

After You Pay $2,340 Deductible, Wellmark HD Plan G1 Pays

You Pay



100% $0 $0


approved amounts2



80% 20% $0


Services

Medicare Pays

After You Pay $2,340 deductible, Wellmark HD Plan G1 Pays

You Pay


Medically necessary emergency care services during the first 60 days of each trip outside the United States • First $250 each

calendar year

$0 $0 $250







27

MedicareBlue Supplement Plan N



Wellmark Plan N Pays

You Pay

Hospitalization1

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

First 60 days All but $1,408 $1,408 (Part A deductible)

$0




• days are used: – Additional 365 days


$02


$0 $0 All costs











$0



28

MedicareBlue Supplement Plan N (continued)




You Pay





Generally 80%

Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the member is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the member is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.


$0 $0 All costs





80% 20% $0


100% $0 $0


29

MedicareBlue Supplement Plan N (continued)




You Pay



100% $0 $0


approved amounts3



80% 20% $0




You Pay


Medically necessary emergency care services during the first 60 days of each trip outside the United States• First $250 each calendar

year

$0 $0 $250






30

Premium payments may be made on a calendar month, calendar quarter, semi-annual calendar year, or calendar year basis. For example, a monthly premium would be for the first day of a month through the last day of such month. A quarterly payment would be for any calendar quarterly period, such as January 1 through March 31. A semi-annual payment would be for the period of either January 1 through June 30 or July 1 through December 31. An annual premium would be for January 1 through December 31 of the applicable year.

The amount of your periodic premium payment will change as provided in the policy and from time to time based on changes in your coverage, including but not limited to, changes in benefits, payment obligations (such as deductible, coinsurance and copayments), your age, or other factors that require adjustments to the total premium. These changes may occur at times other than an annual or other policy renewal.

If you elected to authorize automatic premium withdrawals from an account, the automatic withdrawal will change periodically to correspond with the applicable premium. Your authorization for automatic premium withdrawals shall include authorization for automatic withdrawal of any changed amount unless you call or provide your bank with written notice not less than three (3) business days before a scheduled withdrawal to stop the payment. If you call your bank to stop payment, you may be required to provide a written request within fourteen (14) days after your call. You will be responsible for any fee assessed by your bank for stop-payment orders that you make.

MedicareBlue SupplementSM is a Medicare Supplement insurance plan. MedicareBlue SupplementSM is not connected with or endorsed by the U.S. government or the federal Medicare program.

31

Required Federal Accessibility and Nondiscrimination Notice

Discrimination is against the lawWellmark complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Wellmark does not exclude people or treat them differently because of their race, color, national origin, age, disability or sex.

Wellmark provides:• Free aids and services to people with disabilities so they may

communicate effectively with us, such as:• Qualified sign language interpreters• Written information in other formats (large print, audio,

accessible electronic formats, other formats)• Free language services to people whose primary language is not

English, such as:• Qualified interpreters• Information written in other languages

If you need these services, call 800-524-9242. If you believe that Wellmark has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: Wellmark Civil Rights Coordinator, 1331 Grand Avenue, Station 5W189, Des Moines, IA 50309-2901, 515-376-4500, TTY 888-781-4262, Fax 515-376-9073, Email [email protected]. You can file a grievance in person, by mail, fax or email. If you need help filing a grievance, the Wellmark Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail, phone or fax at: U.S. Department of Health and Human Services, 200 Independence Avenue S.W., Room 509F, HHH Building, Washington DC 20201, 800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATENCIÓN: Si habla español, los servicios de asistencia de idiomas se encuentran disponibles gratuitamente para usted. Comuníquese al 800-524-9242 o al (TTY: 888-781-4262).

注意：如果您说普通话，我们可免费为您提供语言协助服务。请拨打 800-524-9242 或（听障专线： 888-781-4262）。

CHÚ Ý: Nếu quý vị nói tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ miễn phí có sẵn cho quý vị. Xin hãy liên hệ 800-524-9242 hoặc (TTY: 888-781-4262).

NAPOMENA: Ako govorite hrvatski, dostupna Vam je besplatna podrška na Vašem jeziku. Kontaktirajte 800-524-9242 ili (tekstualni telefon za osobe oštećena sluha: 888-781-4262).

ACHTUNG: Wenn Sie deutsch sprechen, stehen Ihnen kostenlose sprachliche Assistenzdienste zur Verfügung. Rufnummer: 800-524-9242 oder (TTY: 888-781-4262).

تنبيه: إذا كنت تتحدث اللغة العربية, فإننا نوفر لك خدمات المساعدة اللغوية، المجانية. اتصل بالرقم.(888-781-4262 9242-524-800 أو (خدمة الهاتف النصي:

ສິ່ ງຄວນເອົາໃຈໃສ,່ ພາສາລາວ ຖາ້ທາ່ນເວ້ົາ: ພວກເຮົາມບໍີລິການຄວາມຊວ່ຍເຫືຼອດາ້ນພາສາໃຫທ້າ່ນໂດຍບ່ໍເສຍຄາ່ ຫືຼ 800-524-9242 ຕດິຕ່ໍທ່ີ. (TTY: 888-781-4262.)

주의: 한국어 를 사용하시는 경우, 무료 언어 지원 서비스를 이용하실 수 있습니다. 800-524-9242번 또는 (TTY: 888-781-4262)번으로 연락해 주십시오.

ध्यान रखें : अगर आपकी भयाषया हिन्दी ि,ै तो आपके हिए भयाषया सिया्तया सवेयाएँ, हनःशलुक उपिब्ध िैं। 800-524-9242 पर सपंक्क करें ्या (TTY: 888-781-4262)।

ATTENTION : si vous parlez français, des services d’assistance dans votre langue sont à votre disposition gratuitement. Appelez le 800 524 9242 (ou la ligne ATS au 888 781 4262).

Geb Acht: Wann du Deitsch schwetze duscht, kannscht du Hilf in dei eegni Schprooch koschdefrei griege. Ruf 800-524-9242 odder (TTY: 888-781-4262) uff.

โปรดทราบ: หากคุณพูด ไทย เรามีบริการช่วยเหลือด้านภาษาสำาหรับคุณโดยไม่คิดค่าใช้จ่าย ติดต่อ 800-524-9242 หรือ (TTY: 888-781-4262)

PAG-UKULAN NG PANSIN: Kung Tagalog ang wikang ginagamit mo, may makukuha kang mga serbisyong tulong sa wika na walang bayad. Makipag-ugnayan sa 800-524-9242 o (TTY: 888-781-4262).

w>'k;oh.ng= erh>uwdR unDusdm< usdmw>rRpXRw>zH;w>rRwz.< vXwb.vXmbl;vJ< td.vXe*D>vDRI qJ;usd;ql

800=524=9242 rhwrh> (TTY: 888=781=4262) wuh>I

ВНИМАНИЕ! Если ваш родной язык русский, вам могут быть предоставлены бесплатные переводческие услуги. Обращайтесь 800-524-9242 (телетайп: 888-781-4262).

सयाव्धयान: ्द् तपयाईं नेपयािदी बोलनुहुन्छ भने, तपयाईंकया ियाहग हन:शुलक रूपमया भयाषया सिया्तया सेवयािरू उपिब्ध गरयाइन्छ । 800-524-9242 वया (TTY: 888-781-4262) मया समपक्क गनु्किोस् ।

ማሳሰቢያ፦ አማርኛ የሚናገሩ ከሆነ፣ የቋንቋ እገዛ አገልግሎቶች፣ ከክፍያ ነፃ፣ ያገኛሉ። በ 800-524-9242 ወይም (በTTY: 888-781-4262) ደውለው ያነጋግሩን።

HEETINA To a wolwa Fulfulde laabi walliinde dow wolde, naa e njobdi, ene ngoodi ngam maaɗa. Heɓir 800-524-9242 malla (TTY: 888-781-4262).

FUULEFFANNAA: Yo isin Oromiffaa, kan dubbattan taatan, tajaajiloonni gargaarsa afaanii, kaffaltii malee, isiniif ni jiru. 800-524-9242 yookin (TTY: 888-781-4262) quunnamaa.

УВАГА! Якщо ви розмовляєте українською мовою, для вас доступні безкоштовні послуги мовної підтримки. Зателефонуйте за номером 800-524-9242 або (телетайп: 888-781-4262).

Ge’: Diné k’ehj7 y1n7[ti’go n7k1 bizaad bee 1k1’ adoowo[, t’11 jiik’4, n1h0l=. Koj8’ h0lne’ 800-524-9242 doodaii’ (TTY: 888-781-4262)

mailto:CRC%40Wellmark.com?subject=

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

http://www.hhs.gov/ocr/office/file/index.html

If you have questions or need additional information, call toll-free.

Not Enrolled: 800-336-0505

Already Enrolled: 800-245-6106

TTY hearing impaired users call 711

Wellmark Blue Cross and Blue Shield of Iowa is an independent licensee of the Blue Cross and Blue Shield Association.

Blue Cross®, Blue Shield®, and the Cross® and Shield® Symbols are registered marks, and MedicareBlue SupplementSM is a service mark of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

Wellmark® is a registered mark of Wellmark, Inc. © 2019 Wellmark, Inc.

M-53892 11/19 AN-T

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