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O65BROGUIDE (3/15) Medicare Made Simple Helping you navigate Medicare enrollment
Transcript of Medicare Made Simple - Insurance Marketing Center › uploadedFiles › Broker_Portal... ·...
O65BROGUIDE (3/15)
Medicare Made Simple Helping you navigate Medicare enrollment
Table of Contents
What is Medicare? . . . . . . . .1
Original Medicare basics . . .3
Getting comprehensive coverage . . . . . . . . . . . . . . . .9
Original Medicare and Supplemental coverage . . . 12
Medicare Advantage (Part C) . . . . . . . . . . . . . . . . 17
Other plan types . . . . . . . .20
Medicare prescription drug coverage (Part D) . . . . 21
Glossary of key terms . . . . 24
Exclusions and Limitations . . . . . . . . . . . . .26
In the past, you’ve probably had someone there to
help you choose the right health insurance—whether
it was family, friends or your company’s Human
Resources department.
Now you’re sitting at a crossroads with lots of unanswered
questions about where to turn next. Here at CareFirst
BlueCross BlueShield (CareFirst), we understand Medicare
and want to guide you along the way. We are here
to help simplify things as you make your decision on
Medicare coverage.
1
What is Medicare?
A brief historyCreated in 1965, Medicare is a health insurance program for individuals age 65 and over and for those who meet certain special criteria. The program now covers over 43 million people throughout the United States and is projected to continually increase in the coming years.
Oversight and enforcement for all Medicare plans is provided by the Centers for Medicare and Medicaid (CMS).
Projected Medicare Eligible Population*
0
20
40
60
80
100
1900 1920 1940 1960 1980 2000 2013 2020 2040 2060
3.1 4.99
16.6
25.5
35
44.7
56.4
82.3
98.2
Pers
ons
elig
ible
for
Med
icar
e (i
n m
illio
ns)
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Note: Increments in years are uneven.*Source: U.S. Census Bureau, Population Estimates and Projections 2014.
2
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Understanding MedicareMedicare is comprised of four parts. The chart below summarizes what each part covers.
Medicare Part A Hospital Insurance
■ Inpatient care in hospitals
■ Skilled nursing facility care
■ Hospice care
■ Home health care
Medicare Part B Doctor InsuranceServices from doctors and other health care providers
■ Outpatient care
■ Home health care
■ Durable medical equipment
■ Some preventive services
Medicare Part C Medicare Advantage
■ Covers all the same benefits and services as Medicare Parts A & B
■ Run by Medicare-approved private insurance companies
■ Usually includes Medicare prescription drug coverage (Part D) as part of the plan
■ May include extra benefits and services (for an extra cost)
Medicare Part D Prescription Drug Coverage
■ Provides coverage for prescription drugs
■ Run by Medicare-approved private insurance companies
■ May help lower your prescription drug costs and help protect against higher costs in the future
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Original Medicare
basics
4
Part A and Part B are considered to be “Original Medicare” and are administered by the federal government.
Some people receive Part A and Part B automatically starting the first day of the month they turn age 65 because they are already receiving Social Security or Railroad Retirement benefits. If you are automatically enrolled, you’ll receive a red, white and blue Medicare card in the mail three months before your 65th birthday.
If you are not already receiving Social Security or Railroad Retirement benefits, you will need to apply for Medicare Parts A and B.
In most cases, Medicare Part B coverage will be listed on your Medicare card when you receive it. However, this coverage is voluntary. You are not required to keep Part B (medical) coverage. If you do not want it, or if you would like to wait to receive Part B coverage (if you are postponing retirement, for example), follow the instructions that come with the card and send the card back. If you keep the original card that you receive, you are essentially agreeing to keep Part B and will be responsible for Part B premiums.
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5
A closer look at Medicare Part A Medicare Part A covers your hospital stays and other medical facility costs including:
■ Inpatient care in hospitals
■ Skilled nursing facility
■ Hospice care
■ Home health care
■ Inpatient care in a religious non-medical health care institution
Most people are automatically enrolled in Part A on the first day of the month they turn age 65 because they receive benefits through Social Security or Railroad Retirement.
The premiums for Part A are based on the number of quarters worked in your lifetime, or the number of quarters your spouse has worked. If you paid Medicare taxes while working at least 120 months (40 quarters), you won’t have to pay a premium for Part A.
If you (or your spouse) did not work the required 40 quarters, you may be able to purchase Medicare Part A. The chart below will give you a better idea of how the Part A premium is applied based on the number of quarters worked.
$0
$200
$400
$600
Less than 30 quarters
30–39 quarters
40 or more quarters
2016
Mon
thly
Par
t A
Pre
miu
m
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6
When you receive Part A coverage, you are responsible for paying a deductible, copayment and/or coinsurance during each benefit period throughout the year. The charts below will help you determine the out-of-pocket costs you are responsible for paying each benefit period before Medicare Part A begins to pay its share.
Inpatient Hospital Stay
Length of Stay What You Pay
Days 1–60 in benefit period $1,288 member deductible
Days 61–90 in benefit period $322 copayment, per day
Days 91–150 in benefit period (Lifetime Reserve Days)
$644 coinsurance, per day
Skilled Nursing Facility
Length of Stay What You Pay
Days 21–100 in benefit period $161 coinsurance, per day
Each day after Day 100 in benefit period
All costs for stay
Did you know that according to AAA, seniors are safe drivers compared to other age groups, since they often reduce risk of injury by wearing seat belts, observing
speed limits and not drinking and driving?
Refer to the glossary
at the end of this
Guide for details on
“Benefit Periods.”
7
A closer look at Medicare Part B Medicare Part B helps cover your medically-necessary doctor services including:
■ Inpatient and outpatient doctor visits
■ Inpatient and outpatient medical services
■ Inpatient and outpatient surgical services and supplies
■ Physical and speech therapies
■ Diagnostic tests
■ Durable medical equipment
■ Outpatient wellness exams and preventive care
■ Approved home health and clinical lab services
In order to receive Part B coverage, you must:
■ Be enrolled in Medicare Part A
■ Pay a monthly premium of $121.80* (in 2016).
The other gapsThere are many services which Medicare Part A and Part B do not cover. If you need certain services that are not covered under Medicare Part A and Part B, you’ll have to pay for them yourself, unless:
■ You have other insurance (or Medicaid) to cover the costs, or
■ You’re in a Medicare health plan that covers these services
Some of the services Medicare does not cover are listed below. For a full list, visit www.medicare.gov.
■ Medical and surgical charges above Medicare-approved amounts
■ Outpatient prescription drugs
■ Acupuncture
■ Cosmetic surgery
■ Dental care and dentures
■ Custodial care (long-term care)
■ Hearing aids
■ Routine eye care and most eyeglasses
■ Routine foot care
What does Part B not cover?
■ Yearly deductible of $166
■ 20 percent of medical expenses for inpatient and outpatient physician services
■ 20 percent of outpatient mental health services
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____________________________________________Because the benefits listed above are not covered by Medicare, they are not covered by Medicare supplemental coverage (Medigap).
* Some people may pay a higher Part B premium if their modified adjusted gross income as reported on their IRS tax return from two years ago (the most recent tax return information provided to Social Security by the IRS) is above a certain amount.
8
Original Medicare doesn’t cover it allHere’s a real-life example to illustrate the costs you could be responsible for under Medicare Part A.
Mary was admitted to the hospital as an inpatient.
Days 0–60For the first 60 days of her inpatient stay within the benefit period, Mary will be responsible for a $1,288 member deductible.
Days 61–90If Mary’s inpatient stay extends beyond the initial 60-day period during the same benefit period, for the next 30 days she is receiving inpatient care, she will be responsible for an additional copayment of $322 for each additional day she is in the hospital.
So, in total, Mary is now responsible for:
■■ $1,288 deductible
+■■ $322 x number of
additional days she is in the hospital, for days 61–90.
If Mary’s inpatient stays reach 90 consecutive days in the same benefit period, her total out-of-pocket cost will be $10,948.
Days 91–150Though it is unlikely, if Mary’s inpatient stay extended beyond 90 days within the same benefit period, she would enter her Lifetime Reserve Days.
For the next 60 days of the same benefit period that Mary is an inpatient, she will be responsible for an additional $644 coinsurance, per day.
So, for Mary’s total 150-day inpatient stay at the hospital, she could be responsible for:
■■ $1,288 deductible
+■■ $322 x number of
additional days she is in the hospital for days 61–90
+■■ $644 x number of
additional days she is in the hospital, for days 91–150.
That is $49,588* in out-of-pocket costs if she has Original Medicare alone.
*The total out-of-pocket costs were calculated based on an individual staying a full 150 consecutive days as an inpatient in the hospital within the same benefit period. The out-of-pocket costs an individual will pay can vary, depending on where they are within a benefit period. To determine out-of-pocket costs, an individual should pay close attention to the benefit period cycle.
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Getting comprehensive
coverage
10
Monthly premiums in addition to Part B premiums unless you choose a plan that covers your Part B premium
Predictable out-of-pocket
costs
No referrals required
Prescription drug coverage
available separately
Foreign travel
coverage available
When mapping out your Medicare route, there are options to consider:
Medicare and Medigap (Supplemental Plans)
Freedom to choose any doctor, specialist
or hospital that accepts Medicare
Can switch Medicare Supplemental plans at any time during
the year
Guaranteed acceptance
during your Open Enrollment period or you could be underwritten
11
Usually includes prescription
drug coverage
Network restrictions
usually apply
Low or no monthly premiums in
addition to your Part B premium
Guaranteed acceptance during
your Open Enrollment
Plan terms and rates
vary widely
Only emergency coverage in U.S.
Referrals may be required and you may need to use
network specialists
Only allowed to switch Medicare Advantage plans during specific
periods during the year
Medicare Advantage
12
As you can see from the previous section and Mary’s example on page 8, Part A and Part B have deductibles, copays and coinsurance charges. A serious illness or lengthy hospital stay could put a big dent in your retirement savings if you rely on Part A and Part B alone.
That’s why it’s important for you to have additional coverage. Here are your options for obtaining comprehensive health insurance coverage when you become Medicare eligible:
Original Medicare and supplemental coverage
Medicare supplemental plans, or Medigap plans, are designed to supplement Original Medicare by paying for those health care costs—the gaps in coverage—that Original Medicare doesn’t pay. Medicare will pay its share first, and then your Medigap plan will pay its share. With a Medigap plan, you can go to any doctor, specialist or hospital that accepts Medicare.
Medigap explainedMedigap plans are offered through private health insurance companies. The federal government has outlined the coverage for 11 different Medigap plans, identified alphabetically (e.g. Plan A, Plan B, etc.). Each is tied to a specific benefit and coverage level as described by the government. What this means is that your benefits will be the same no matter the company you choose.
However, that does not make every carrier the same. Each carrier decides which of the 11 plans to offer (CareFirst offers 8 of the 11). Many also offer advantages such as lower monthly premiums, special discounts and online tools to better serve their members.
Careful! Do not
confuse Medicare
Parts A–D with
Medigap Plans A–N.
For example, you could
have Medicare Part A
and Part B and then
purchase Medigap
Plan A to fill in
the gaps.
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Enrolling in MedigapYou must meet both of the following conditions in order to enroll in a Medigap plan:
■ Must be age 65 or older
■ Must be enrolled in Medicare Part B
If you qualify, you’ll enter your Open Enrollment period which lasts for six months beginning the first day of the month that you are first enrolled in Medicare Part B.
What can doctors charge me? ■ A doctor or provider who accepts assignment, which is when your doctor
or provider agrees to accept the Medicare-approved amount as full payment for covered services, cannot collect more than the Medicare deductible or coinsurance from you.
■ A doctor or provider who does NOT accept assignment can charge up to 15 percent over Medicare’s approved amounts and require you to pay the entire charge at the time of your appointment.
If you miss your Open
Enrollment period
and decide later that
you want Medigap
coverage, you risk:
■ Denial of coverage
■ More expensive
monthly premiums
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What you pay with Original Medicare vs. what you pay with CareFirst Medigap plans
With Original Medicare alone,
You Pay:
Choose Medigap Plan A and You Pay:
Choose Medigap Plan B and You Pay:
Choose Medigap Plan F and You Pay:
Choose Medigap High-Deductible
Plan F* and You Pay:
Choose MedigapPlan G and You Pay:
Choose MedigapPlan L** and
You Pay:
Choose Medigap Plan M and You Pay:
Choose Medigap Plan N and You Pay:
Hospital Services (Part A)
Inpatient hospital deductible
$1,288 $1,288 $0 $0 $0 after plan deductible
$0 $322 $644 $0
Hospital days 61–90 $322/day $0 $0 $0 $0 after plan deductible
$0 $0 $0 $0
Hospital days 91–150 (lifetime reserve)
$644/day $0 $0 $0 $0 after plan deductible
$0 $0 $0 $0
365 days after hospital benefits stop
All Costs $0 $0 $0 $0 after plan deductible
$0 $0 $0 $0
Skilled nursing facility days 21–100
$161/day $161/day $161/day $0 $0 after plan deductible
$0 $40.25/day $0 $0
Medical Expenses (Part B)
Medical expense deductible
$166 $166 $166 $0 $0 after plan deductible
$166 $166 $166 $166
Medical expenses after deductible
20% 0% 0% 0% 0% after plan deductible
0% 5% 0% Office visit: Up to $20; ER visit: Up to $50
Excess charges above Medicare-approved amounts
100% 100% 100% 0% 0% after plan deductible
0% 100% 100% 100%
Other Expenses
Foreign country emergency care (up to $50,000 lifetime max)
100% 100% 100% $250 deductible, then 20%
$250 deductible after plan deductible, then 20%
$250 deductible, then 20%
100% $250 deductible, then 20%
$250 deductible, then 20%
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With Original Medicare alone,
You Pay:
Choose Medigap Plan A and You Pay:
Choose Medigap Plan B and You Pay:
Choose Medigap Plan F and You Pay:
Choose Medigap High-Deductible
Plan F* and You Pay:
Choose MedigapPlan G and You Pay:
Choose MedigapPlan L** and
You Pay:
Choose Medigap Plan M and You Pay:
Choose Medigap Plan N and You Pay:
$0 after plan deductible
$0 $322 $644 $0
$0 after plan deductible
$0 $0 $0 $0
$0 after plan deductible
$0 $0 $0 $0
$0 after plan deductible
$0 $0 $0 $0
$0 after plan deductible
$0 $40.25/day $0 $0
$0 after plan deductible
$166 $166 $166 $166
0% after plan deductible
0% 5% 0% Office visit: ER visit: Up
Up to
to $20; $50
0% after plan deductible
0% 100% 100% 100%
$250 after then
deductible plan deductible, 20%
$250 then
deductible, 20%
100% $250 then
deductible, 20%
$250 then
deductible, 20%
Hospital Services (Part A)
Inpatient hospital deductible
$1,288 $1,288 $0 $0
Hospital days 61–90 $322/day $0 $0 $0
Hospital days 91–150 (lifetime reserve)
$644/day $0 $0 $0
365 days after hospital benefits stop
All Costs $0 $0 $0
Skilled nursing facility days 21–100
$161/day $161/day $161/day $0
Medical Expenses (Part B)
Medical expense deductible
$166 $166 $166 $0
Medical expenses after deductible
20% 0% 0% 0%
Excess charges above Medicare-approved amounts
100% 100% 100% 0%
Other Expenses
Foreign country emergency care (up to $50,000 lifetime max)
100% 100% 100% $250 deductible, then 20%
What you pay with Original Medicare vs. what you pay with CareFirst Medigap plans
Dollar amounts shown are the 2016 deductibles, copayment and coinsurance. These amounts may change on January 1, 2017.
* With High-Deductible Plan F, there is an annual plan deductible of $2,180; after you meet the $2,180 annual plan deductible, you pay $0.
** With Plan L, there is an out-of-pocket limit of $2,480; After you meet $2,480 in out-of-pocket expenses, you pay $0.
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The coverage you needAll Medigap plans provide you with:
■ Coverage for the 20 percent of costs not paid by Medicare
■ Coverage for your eligible copays and deductibles
■ Coverage for other medical services (for example: outpatient services)
■ The opportunity to let you make choices about your health care
When deciding which Medigap plan is right for you, it is important to consider a few key features that differ among the 11 standardized plans:
How much can I afford to spend on supplemental coverage?
Your monthly premium budget Each plan charges a different monthly premium based on the kind of coverage you desire.
How much am I comfortable paying out-of-pocket before my supplemental coverage begins?
Deductible and yearly out-of-pocket costs Each plan covers a certain percentage of your medical expenses, while you cover the rest.
Does my doctor accept Medicare’s reimbursement as payment for his services?
Balanced billing protection If you see a doctor who does not accept Medicare’s reimbursement as payment in full for services (some doctors charge you up to 15% more than Medicare allows), Medigap Plans G, F and High-Deductible F will protect against these extra charges.
Will I be traveling out of the country for an extended period of time?
Coverage for foreign travel Some plans offer coverage to you even when you are out of the country. Others do not.
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Keep in mind that services not covered by Original Medicare are not covered by Medigap. To compare each Medigap plan, consult the chart on pages 14–15 and decide which plan is right for you.
17
Medicare Advantage (Part C)
An alternative to Original Medicare and a Medicare supplemental plan is Medicare Advantage (MA), commonly referred to as Medicare Part C. MA plans are Medicare-approved private health insurance plans that provide all of your Part A (hospital) and Part B (medical) coverage and must include medically-necessary services. Many of these plans include prescription drug coverage (Medicare Part D) as part of the core plan benefits.
MA plans often have restricted networks, which means that individuals who choose to enroll in MA may have to see specific doctors and go to certain hospitals within the plan’s network to receive care. In addition, each Medicare Advantage plan can charge different out-of-pocket costs and have different rules for how you receive services.
Key plan features of Medicare Advantage:
■ Not guaranteed renewable
■ Beneficiaries are locked in to the plan until the next available enrollment opportunity unless the beneficiary qualifies for a special enrollment period
■ Not underwritten
■ Year-to-year contract with the federal government
■ Enrollment only allowed during certain times of the year, unless you are enrolling when you are first eligible
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The most common plan options are: HMOs (Health Maintenance Organization), PPOs (Preferred Provider Organization) and PFFS (Private Fee-for-Service) plans. The chart below provides a comprehensive overview of all the plan types available through Medicare Advantage.
HMO:You can only go to doctors, other health care providers or hospitals in the plan’s network except in an emergency. You may also require a referral from your PCP.
PPO:You have the option to use doctors, hospitals and other health care providers in- or out-of-network, but you will generally pay more for out-of-network.
PFFS:
Commonly called “Private Fee For Service” plans, these plans are similar to Original Medicare and allow you to go to any doctor, other health care provider, or hospital as long as they agree to treat you. The plan will determine how much it will pay and you will pay once you receive care.
SNP:Special Needs Plans provide specialized and focused health care for people who have both Medicare and Medicaid, live in a nursing home, or have certain chronic medical conditions.
HMP:HMP Point of Service plans are HMO plans that allow for certain out-of-network services for a higher copayment or coinsurance.
MSA:
Medical Savings Accounts are high deductible health plans that are joined to a bank account. Medicare deposits money into the account that you can use for health services throughout the year; however, this does not cover prescription drugs, thus you will need to join Medicare Part D coverage.
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19
Enrolling in Medicare Advantage There are three specified times you can join a Medicare Advantage plan:
■ When you first become eligible for Medicare—A seven-month period that begins three months before the month of your 65th birthday, includes the month of your 65th birthday, and continues three months after the month of your 65th birthday.
■ If you get Medicare due to a disability—You can join during the seven-month period that begins three months before your 25th month of disability and ends three months after your 25th month of disability.
■ Between October 15 and December 7 every year—Anyone can join, switch, or drop a Medicare Advantage plan during this Open Enrollment period. Coverage will begin on January 1.
There are a few exceptions to the above enrollment periods, known as Special Enrollment Periods, during which you may join, switch or drop a Medicare Advantage plan. The life events are as follows:
■ You move out of or into a plan’s service area
■ You have Medicaid
■ You live in an institution (like a nursing home)
■ You qualify for Extra Help (a Medicare program that helps people with limited income pay for Medicare costs)
Each year, between January 1 and February 14, Medicare Advantage members have the opportunity to leave their plan and return to Original Medicare. If your Medicare Advantage plan included prescription drug coverage, you also have until February 14 to join Medicare Part D Plan for prescription drug coverage. Coverage will begin the first day of the month after your request to change. During this period, you will not be able to:
■ Switch from Original Medicare to Medicare Advantage
■ Switch from one Medicare Advantage plan to another
■ Switch from one Medicare prescription drug plan to another
■ Join, switch or drop a Medicare Medical Savings Account plan
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20
Other plan types
In addition to Medigap and Medicare Advantage plans, there are a few other plans that can either work with or replace Original Medicare:
Employer group plans come directly from an individual’s current or former employer. You should check with the benefits administrator of your employer or retiree group before changing or replacing your health plan to keep from possibly losing coverage. You may be able to use employer coverage along with the new plan you join.
Cost plans are available based on an annual contract with CMS. When an individual enrolls in a cost plan, he or she does not assign their original Medicare benefits. Instead, the individual retains their coverage for Medicare-eligible services outside the network. Then:
■ For Part A Services, Medicare is the primary payer and the cost plan is secondary
■ For Part B Services, the cost plan is the single primary payer
It’s important to keep in mind that cost plans are not guaranteed renewable and are not supplement plans. In addition, Medicare reimburses the health plan for the cost of any covered services.
Programs of All-Inclusive Care for the Elderly (PACE) combine medical, social, and long-term care services for frail individuals to help them stay independent and living in their community for as long as possible, while receiving the high-quality care they need. PACE plans are available only in states that have chosen to offer them under Medicaid. To be eligible for a PACE plan, an individual must:
■ Be 55 years old or older
■ Live in the service area of the PACE program
■ Be certified as eligible for a nursing home
Thanks to the internet, the term Silver Surfers has a whole new meaning. According to the U.S. Census Bureau, in 2013 the number of seniors age 65+ using the internet is now over 62 percent.
Many internet users search for everything from simple travel directions to planning the trip of a lifetime.
Medicare prescription
drug coverage (Part D)
22
Medicare prescription drug coverage, or Part D, was created to help cover the costs of your prescription drugs. In order to be eligible for enrollment in a Part D plan, you must either:
■ Be enrolled in Medicare Part B, or
■ Be enrolled in a Medicare Advantage plan (Part C)
If you choose to enroll in Part D, you will have to pay an additional premium on top of your Part B premium. The best time to enroll in a Part D plan is during your Initial Enrollment Period. This period begins three months before the month of your 65th birthday and ends three months after your birthday month.
Using Part D coverageThere are four drug payment stages for prescription drug coverage. See below (and illustration at right) for the various stages and the standard amounts for 2016. Keep in mind, each plan has its own list of drugs that are covered. This is referred to as the plan’s formulary or drug list. The formulary specifies the cost-sharing amounts based on the tier that a drug is listed under.
Stage 1: Yearly deductible stage
■ Begins when the beneficiary fills his or her first prescription
■ Ends when a deductible of up to $360 is met
Stage 2: Initial coverage stage
■ Beneficiaries and health plan share drug costs until total shared cost reaches $3,310
Stage 3: Coverage gap stage
■ For brand name drugs:
Beneficiaries receive a 50 percent discount at the point of sale
In 2016, the plan then pays 5 percent, and you pay the remaining 45, which counts toward the coverage gap
■ For generic drugs:
The plan pays 42 percent of the cost, and you pay 58 percent toward the coverage gap
Beneficiaries remain in the gap until their true out-of-pocket costs (deductible, Stage 2 and 3 cost-sharing) reach $4,850
Stage 4: Catastrophic coverage stage
■ Your plan pays most of your costs for the rest of the year
If you need help paying for prescription drug costs, you may be eligible for an “extra help” program offered to people who meet minimum income requirements. To see if you’re eligible, call 800-772-1213 or visit www.socialsecurity.gov.
Please Note! If you
miss this enrollment
period and go without
an equal or better
prescription drug
plan for more than 62
continuous days, you
will be charged a late
enrollment penalty
when you apply for
Part D.
23
Beware of the
doughnut hole! Most
of the prescription
drug plans have a
coverage gap, also
known as a “doughnut
hole.” Once your
prescription drug costs
exceed your limit, you
enter the doughnut
hole. In this stage you
may be responsible
for covering all of your
prescription drug costs
until you reach a fixed
amount. Once that
amount is reached,
you will qualify for
catastrophic coverage
and the cost to you
will be minimal.
Stage 1
Stage 2
Stage 4
Stage 3 the “doughnut hole”
24
Glossary of key terms
Admitted: when an individual is placed under the supervision of the hospital for at least one night and is too sick to stay at home, requires 24-hour nursing care, and/or is receiving medications and undergoing tests/surgery that can only be performed in the hospital setting.
Assignment: when your doctor or provider agrees to accept the Medicare-approved amount as full payment for covered services.
Benefit period: a specific period of time that begins the day you are formally admitted as an inpatient in a hospital or skilled nursing facility, and ends when you have not received any type of inpatient care for 60 days in a row.
Coinsurance: the percentage of the allowed benefit that you pay after you meet your deductible.
Copayment (copay): a fixed dollar amount you pay when you visit a doctor or other provider of service.
Cost-Sharing: the part of your health care costs that your plan doesn’t pay is your share; see deductible, copayment, coinsurance.
Deductible: this is the amount you must pay before the insurance company or Medicare begins to pay its portion of the claims.
Doughnut hole: also known as the “Coverage Gap” in Medicare Part D prescription drug coverage; a temporary limit on what the drug plan will cover for drugs that begins after an individual and the drug plan have spent a pre-determined amount on covered drugs.
Home care: skilled nursing and related services provided to patients in a home setting. Other home care services include physical therapy, occupational therapy, speech therapy, medical social services, home health services and medical supplies and equipment.
Hospice: a program or facility that provides care, comfort, and support services for terminally ill patients and their families. Hospice care concentrates on reducing the severity of disease symptoms, rather than halting or delaying progression of the disease itself.
Inpatient: a patient who has been formally admitted to the hospital under a doctor’s orders.
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Lifetime reserve days: additional days Medicare will pay for when you’re in a hospital for more than 90 consecutive days of the same benefit period, but once used, cannot be renewed. Individuals have 60 total lifetime reserve days for their lifetime.
Out-of-pocket max: the most you will have to pay for medical and prescription drugs in a calendar year.
Outpatient: a patient who is not hospitalized overnight but who visits a hospital, clinic or associated facility for diagnosis or treatment and is discharged on the same day.
Premium: the money you pay each month for your plan based on where you live, family size and other variables.
Skilled nursing facility care (SNF): a level of care that requires the daily involvement of a skilled nursing or rehabilitation staff like physical therapy and intravenous injections. You qualify only after a 3-day minimum hospital stay for a related illness or injury for up to 100 days in a benefit period that includes semi-private room and meals. Medicare doesn’t cover long-term care or custodial care in this setting.
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Exclusions and Limitations
DISTRICT OF COLUMBIA AND MARYLAND SUBROGATION
Subrogation gives CareFirst BlueCross BlueShield a legal right to recover benefits that have been provided under this Policy when a third party is liable. This provision applies only to the amount of benefits paid by CareFirst BlueCross BlueShield for services where the third party is liable. Medicare has separate subrogation rights that Medicare may pursue separately.
1. You shall notify CareFirst BlueCross BlueShield as soon as reasonably possible that a third party may be liable for the services for which benefits are being paid.
2. To the extent that benefits are paid under this Policy, CareFirst BlueCross BlueShield shall be subrogated and succeed to any rights or recovery You receive against any person or organization.
3. You shall pay to CareFirst BlueCross BlueShield the amount recovered by suit, settlement, or otherwise from any third party or third party’s insurer to the extent of the benefits paid under this Policy. The amount paid to CareFirst BlueCross BlueShield will be reduced by CareFirst BlueCross BlueShield’s pro-rata share of the court costs and legal fees incurred to produce such settlement.
4. You shall take any action, furnish information and assistance, and execute papers that CareFirst BlueCross BlueShield may require to facilitate enforcement of these rights. You shall not commit any action prejudicing the rights and interests of CareFirst BlueCross BlueShield under this Policy.
DISTRICT OF COLUMBIA AND VIRGINIA EXCLUSIONS
Benefits will not be provided under this Policy for the following:
1. Any service, supply or item that is not a Medicare eligible expense as determined by Medicare.
2. Unless stated otherwise in this Plan, any service, supply or item for which no actual determination was made by Medicare that the specific service, supply or item is a Medicare eligible expense.
3. Any amount that duplicates benefits actually provided on your behalf by Medicare.
4. Any amount that exceeds the Medicare fee schedule set by the Medicare program.
5. For care furnished by or received as a result of a Provider referral that is prohibited by law.
6. For Plan A: This Policy does not provide coverage for the Medicare Part A or Part B deductibles.
7. For Plans B, N, G, L, M: This Policy does not provide coverage for the Medicare Part B deductible.
MARYLAND EXCLUSIONS
Benefits will not be provided under this Policy for the following:
1. Any amount that duplicates benefits actually provided on your behalf by Medicare.
2. Any claim for a benefit that is not specifically described in the Basic (Core) Benefits or Additional Benefits Sections of this Policy.
The purpose of this brochure is the solicitation of insurance.
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MARYLAND PRE-EXISTING CONDITIONS LIMITATIONS
For Medigap Plans A, B, F, High-Deductible Plan F and N, check your enrollment application to see if a pre-existing conditions waiting period or a reduction in the pre-existing conditions waiting period applies to your coverage.
No benefits will be provided for services rendered during the first 90 days of coverage under this Policy for a pre-existing condition if you are applying for Plans A, B, F, High-Deductible Plan F and Plan N. However, if you are applying for Plans G, L or M, the pre-existing condition waiting period does not apply. A pre-existing condition is any condition for which medical advice or treatment was recommended by or received from a physician within 6 months before the effective date of this Policy. Covered services rendered to treat pre-existing conditions, and any complications arising out of a pre-existing condition, will be covered under this Policy if the covered service is rendered after this Policy has been in effect for 90 days.
If immediately prior to the effective date of this Policy You were covered under any other Medicare Supplemental Policy, the period of time You were covered under the prior Policy will be credited to this 90 days waiting period.
THE BENEFITS DESCRIBED ARE ISSUED UNDER POLICIES:
CFMI/MG PLAN A (6/10), CFMI/MG PLAN B (6/10), CFMI/MG PLAN F (6/10), CFMI/MG PLAN N (6/10), CFMI/MG PLAN HI DED F (6/10), CFMI/2010 PLAN HI F SOB (6/10), MD/CF/MG PLAN A (6/10), MD/CF/MG PLAN B (6/10), MD/CF/MG PLAN F (6/10), MD/CF/MG PLAN N (6/10), MD/CF/MG PLAN HI DED F (6/10), MD/CF/2010 PLAN HI F SOB (6/10), CFMI/MG PLAN G (2/12), CFMI/MG PLAN L (2/12), CFMI/MG PLAN M (2/12), MD/CF/MG PLAN G (2/12), MD/CF/MG PLAN L (2/12), MD/CF/MG PLAN M (2/12), as amended
DC/CF/MG PLAN A (6/10), DC/CF/MG PLAN B (6/10), DC/CF/MG PLAN F (6/10), DC/CF/MG PLAN HI DED F (6/10), DC/CF/MG PLAN N (6/10), DC/CF/2010 PLAN HI F SOB, DC/CF/MG PLAN G (2/12), DC/CF/MG PLAN L (2/12), DC/CF/MG PLAN M (2/12), as amended
VA/CF/MG PLAN A (6/10), VA/CF/MG PLAN B (6/10), VA/CF/MG PLAN F (6/10), VA/CF/MG PLAN HI DED F (6/10), VA/CF/MG PLAN HI F SOB (6/10), VA/CF/MG PLAN N (6/10), VA/CF/MG PLAN G (2/12), VA/CF/MG PLAN L (2/12), VA/CF/MG PLAN M (2/12), as amended
Neither CareFirst BlueCross BlueShield nor its agents represent, work for or are compensated by the Federal or State government or Medicare. CareFirst BlueCross BlueShield is a private not-for-profit health service plan.
If you reside in either Prince George’s or Montgomery counties then a Group Hospitalization and Medical Services, Inc. policy will be issued. For Baltimore City and all other Counties in the State of Maryland a CareFirst of Maryland, Inc. policy will be issued.
Not connected with or endorsed by the U.S. Government or the Federal Medicare Program.
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CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc., which are independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association.
®’ Registered trademark of CareFirst of Maryland, Inc.
O65BROGUIDE (3/15) BOK5463-1S (12/15)
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