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Blue Shield Medicare Supplement plans

blue Shield Medicare Supplement plans Summary of benefits and provisions Benefit plans A, F Extra, G, G Extra, and N. Effective January 1, 2020. blue Shield of california Medicare Supplement plans Please take a few minutes to review the information in this booklet. Benefit chart of Medicare Supplement plans .. 3. Charts comparing blue Shield 's five Medicare Supplement plans plan A .. 5. plan F 8. plan G .. 14. plan G 17. plan N .. 24. Enrolling in our plans .. 28. Conditions of coverage .. 32. Principal exclusions and limitations on 35. 2 blue Shield of california Medicare Supplement plans Benefit chart of Medicare Supplement plans sold on or after January 1, 2020. This chart shows the benefits included in each of the standard Medicare Supplement plans . Every insurance company must offer plan A. Some plans may not be available. blue Shield offers plans A, F Extra, G, G Extra, and N, which are shaded in gray in the chart below.

Blue Shield of California Medicare Supplement plans 3 Benefit chart of Medicare Supplement plans sold on or after January 1, 2020 This chart shows the benefits included in each of the standard Medicare Supplement plans.

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Transcription of Blue Shield Medicare Supplement plans

1 blue Shield Medicare Supplement plans Summary of benefits and provisions Benefit plans A, F Extra, G, G Extra, and N. Effective January 1, 2020. blue Shield of california Medicare Supplement plans Please take a few minutes to review the information in this booklet. Benefit chart of Medicare Supplement plans .. 3. Charts comparing blue Shield 's five Medicare Supplement plans plan A .. 5. plan F 8. plan G .. 14. plan G 17. plan N .. 24. Enrolling in our plans .. 28. Conditions of coverage .. 32. Principal exclusions and limitations on 35. 2 blue Shield of california Medicare Supplement plans Benefit chart of Medicare Supplement plans sold on or after January 1, 2020. This chart shows the benefits included in each of the standard Medicare Supplement plans . Every insurance company must offer plan A. Some plans may not be available. blue Shield offers plans A, F Extra, G, G Extra, and N, which are shaded in gray in the chart below.

2 Basic benefits Medical expenses Part B coinsurance (generally 20% of Hospitalization Medicare -approved expenses) or copay- Part A coinsurance plus coverage for 365 ments for hospital outpatient services. plans K, additional days after Medicare benefits end. L, and N require the insured to pay a portion of Part B coinsurance or copayments. Blood Hospice First three pints of blood each year. Part A coinsurance. Medicare first eligible plans Available to All Applicants before 2020 only4. Benefits A B D G1 G Extra K L M N C F1 F Extra Medicare Part A coinsurance and hospital coverage (up to 3 3 3 3 3 3 3 3 3 3 3 3. an additional 365 days after Medicare benefits are used up). 3. copays Medicare Part B coinsurance or Copayment 3 3 3 3 3 50% 75% 3 3 3 3. apply3. Blood (first three pints) 3 3 3 3 3 50% 75% 3 3 3 3 3. Part A hospice care coinsurance or copayment 3 3 3 3 3 50% 75% 3 3 3 3 3.

3 Skilled nursing facility coinsurance 3 3 3 50% 75% 3 3 3 3 3. Medicare Part A deductible 3 3 3 3 50% 75% 50% 3 3 3 3. Medicare Part B deductible 3 3 3. Medicare Part B excess charges 3 3 3 3. Foreign travel emergency (up to plan limits) 3 3 3 3 3 3 3 3. Fitness program 3 3 3 3 3. Hearing aid services 3 3. Vision services 3 3. Personal Emergency Response System (PERS) 3. Teladoc 3. Over-the-counter items 3. Out-of-pocket limit in [2019]2 $5,8802 $2,9402. 1 P lans F and G also have a high deductible option which require first paying a plan deductible of $2,340 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B. deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.

4 2 P lans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit. 3 P lan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that do not result in an inpatient admission. 4 plan F Extra will only be available to applicants who attain age 65 or first become eligible for Medicare benefits due to disability before January 1, 2020. blue Shield of california Medicare Supplement plans 3. DISCLOSURES. Use this outline to compare benefits and POLICY REPLACEMENT. charges among policies. If you are replacing other health coverage, do NOT cancel it until you have actually INFORMATION ABOUT PREPAID OR received your new contract and are sure PERIODIC CHARGES you want to keep it. blue Shield can only raise your charges only if it raises the charges for all NOTICE.

5 Contracts like yours in the state. Because This contract may not fully cover all of plan dues are based on age, your dues your medical costs. Neither blue Shield of will increase when you turn 67, 69, 71, 73, california nor its agents are connected 75, 77, 79, 81, 83, and/or 85 years old. with Medicare . If you're applying more than 60 days This outline of coverage does not give before your effective date, the rates all the details of Medicare coverage. listed are subject to change. Contact your local Social Security office or consult The Medicare Handbook for READ YOUR POLICY VERY CAREFULLY further details and limitations applicable This is only an outline describing the most to Medicare . important features of your Medicare Supplement plan contract. This is not COMPLETE ANSWERS ARE. the plan contract, and only the actual VERY IMPORTANT. contract provisions will prevail. You must When you fill out the application for the read the contract itself to understand all new contract, be sure to answer truthfully of the rights and duties of both you and and completely all questions about blue Shield of california .

6 Your medical and health history. The company may cancel your contract and RIGHT TO RETURN POLICY refuse to pay any claims if you leave out If you find that you are not satisfied or falsify important medical information. with your contract, you may return it to Review the application carefully before blue Shield of california , Box 7168, you sign it. Be certain that all information San Francisco, CA 94120. If you send the has been properly recorded. contract back to us within 30 days after you receive it, we will treat the contract as if it had never been issued, and will return all of your payments. 4 blue Shield of california Medicare Supplement plans plan A. Medicare (PART A). HOSPITAL SERVICES PER BENEFIT PERIOD. * 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.

7 SERVICES Medicare PAYS plan PAYS YOU PAY. HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,408 $0 $1,408 (Part A. deductible). 61 through 90 day st th All but $352 a day $352 a day $0. 91st day and after: All but $704 a day $704 a day $0. while using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare - $0**. eligible expenses Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* 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 $0 $0. amounts 21st through 100th day All but $176 $0 Up to $176. a day a day 101 day and after st $0 $0 All costs BLOOD. First 3 pints $0 3 pints $0.

8 Additional amounts 100% $0 $0. HOSPICE CARE. You must meet Medicare 's All but very limited Medicare $0. requirements, including a doctor's copayment/ copayment/. certification of terminal illness. coinsurance for coinsurance outpatient drugs and inpatient respite care ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. blue Shield of california Medicare Supplement plans 5. plan A. Medicare (PART B). MEDICAL SERVICES PER CALENDAR YEAR. * Once you have been billed $198 of Medicare -approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

9 SERVICES Medicare PAYS plan PAYS YOU PAY. MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $198 of Medicare -approved $0 $0 $198 (Part B. amounts* deductible). Remainder of Medicare -approved Generally 80% Generally 20% $0. amounts Part B excess charges (above $0 $0 All costs Medicare -approved amounts). BLOOD. First 3 pints $0 All costs $0. Next $198 of Medicare -approved $0 $0 $198 (Part B. amounts* deductible). Remainder of Medicare -approved 80% 20% $0. amounts CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES. 100% $0 $0. 6 blue Shield of california Medicare Supplement plans plan A. PARTS A & B. * Once you have been billed $198 of Medicare -approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

10 SERVICES Medicare PAYS plan PAYS YOU PAY. HOME HEALTH CARE Medicare -APPROVED SERVICES. Medically necessary skilled care 100% $0 $0. services and medical supplies Durable medical equipment $0 $0 $198 (Part B. First $198 of Medicare -approved deductible). amounts*. Remainder of Medicare -approved 80% 20% $0. amounts OTHER BENEFITS NOT COVERED BY Medicare . SERVICES Medicare PAYS plan PAYS YOU PAY. BASIC GYM ACCESS THROUGH SILVERSNEAKERS FITNESS PROGRAM. $0 100% $0. blue Shield of california Medicare Supplement plans 7. plan F EXTRA. Medicare (PART A). HOSPITAL SERVICES PER BENEFIT PERIOD. * 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. SERVICES Medicare PAYS plan PAYS YOU PAY. HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,408 $1,408 (Part A $0.)


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