January 2022 – May 2022 Outline of Coverage - Blue Cross NC

1 January 2021 May 2021. Outline of Coverage D98, 11/20. Benefits Benefit Chart of medicare supplement Plans Effective On or After January 1, 2021. This chart shows the benefits included in each of the standard medicare supplement plans. Every company must make Plan A available. Some plans may not be available in your state. Attained-Age Plans1. High Plan A 2. Plan G 2. Deductible Plan K Plan N. Plan G3. Basic, including 100%. Hospitalization and Part B coinsurance, Basic, including Basic, including Basic, including preventive care paid except up to $20. 100% 100% 100%. at 100%; other basic copayment for office Part B coinsurance Part B coinsurance Part B coinsurance benefits paid at 50% visit, and up to $50. copayment for ER. Skilled nursing Skilled nursing 50% Skilled nursing Skilled nursing facility coinsurance facility coinsurance facility coinsurance facility coinsurance Part A deductible Part A deductible 50% Part A deductible Part A deductible Part B Part B.

2 Excess (100%) excess (100%). Foreign travel Foreign travel Foreign travel emergency emergency emergency Out-of-pocket limit $6,220; paid at 100%. after limit reached Basic Benefits Blood - First three pints of blood each year. edical Expenses - Part B coinsurance (generally M. Hospice - Part A coinsurance. 20% of medicare -approved expenses) or copayments for hospital outpatient services. Plans K and N. Hospitalization - Part A coinsurance, plus Coverage require insured to pay a portion of Part B. for 365 additional days after medicare benefits end. coinsurance or copayments. Notes: 1 When you enroll in an attained-age plan, your rates will increase as you age, due to your age. Your rates will only increase due to age when you move from one age band to the next. In addition, rate adjustments wiII also be due to medical inflation or overall claims experience. Rates are subject to change June 1 of each year and are guaranteed for 12 months from that date.

3 Any change in your rate will be preceded by a 30 day notice. 2 Individuals under 65 and on medicare are only eligible for Plan A or Plan G. 3 Plan G also has an option called a high deductible Plan G. This high deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,370 deductible. Benefits from high deductible Plan G will not begin until out-of-pocket expenses exceed $2,370. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible. BMS A, 12/18; BMS G, 12/18; BMS HDG, 12/18; BMS K, 12/18; BMS N, 12/18. 2. Non-Tobacco User Monthly Premium High Plan A 2. Plan G 2. Deductible Plan K Plan N. Plan G3. Age Female Male Female Male Female Male Female Male Female Male <65 $1, $1, $1, $1, N/A N/A N/A N/A N/A N/A.

4 65 $ $ $ $ $ $ $ $ $ $ 66 $ $ $ $ $ $ $ $ $ $ 67 $ $ $ $ $ $ $ $ $ $ 68 $ $ $ $ $ $ $ $ $ $ 69 $ $ $ $ $ $ $ $ $ $ 70-74 $ $ $ $ $ $ $ $ $ $ 75-79 $ $ $ $ $ $ $ $ $ $ 80+ $ $ $ $ $ $ $ $ $ $ Tobacco User Monthly Premium High Plan A2 Plan G2 Deductible Plan K Plan N. Plan G3. Age Female Male Female Male Female Male Female Male Female Male <65 $1, $1, $1, $1, N/A N/A N/A N/A N/A N/A. 65 $ $ $ $ $ $ $ $ $ $ 66 $ $ $ $ $ $ $ $ $ $ 67 $ $ $ $ $ $ $ $ $ $ 68 $ $ $ $ $ $ $ $ $ $ 69 $ $ $ $ $ $ $ $ $ $ 70-74 $ $ $ $ $ $ $ $ $ $ 75-79 $ $ $ $ $ $ $ $ $ $ 80+ $ $ $ $ $ $ $ $ $ $ Rates are effective through May 31, 2021. Note: Tobacco user rates do not apply during Guaranteed Issue period. 3. Attained-Age Plans blue Cross and blue Shield of North Carolina ( blue Cross NC). offers medicare supplement plans with attained-age rates. The federal When you enroll in an attained-age plan, your rates will increase as you age, due to your age.

5 Our rates will only increase due to government age when you move from one age band to the next. In addition, has asked us rate adjustments will also be due to medical inflation or overall claims experience. Note: Rates are subject to change June 1 of to provide each year and are guaranteed to remain the same for 12 months this Outline of from that date. Any change in your rate will be preceded by Coverage to help a 30 day notice. medicare policies that are attained-age rated should be compared to entry-age rated policies (also known you decide which as issue-age rated policies). Premiums for entry-age policies plan best fits do not increase due to age as the insured ages. your needs Example of Individual Rate Changes and meets your in Attained-Age Plans budget. The chart below illustrates attained-age rate changes due to age and claims trend over a 15 year period. 15 Year Rate Change Attained-Age $400. $350. $300. $250.

6 $200. $150. $100. $50. $0. 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80. Member's Age Notes: Source: Internal blue Cross NC data, 2019. T. he chart illustrates Plan G's cost over a 15 year period. Attained-age plans will adjust on medical trends, however the premium will increase due to age. For illustrative purposes only. 4. About medicare supplement Plans Premium Information blue Cross NC can only raise your premium if we raise the premium for all policies like yours in this state. For attained-age policies, your premium may change on June 1 each year. Disclosures Use this Outline to compare benefits and premiums among policies. Read Your Policy Very Carefully This is only an Outline describing 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 Policy If you find that you are not satisfied with your policy, you may return it to blue Cross NC, Attention: blue medicare supplement Enrollment, Box 17168, Winston-Salem, NC 27116.

7 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 Replacement If 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. Notice This policy may not fully cover all of your medical costs. Neither blue Cross NC nor its agents are connected with medicare . This Outline of Coverage does not give all the details of medicare Coverage . Contact your local Social Security office or consult medicare & You for more details. Complete Answers Are Very Important When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

8 Review the application carefully before you sign it. Be certain that all information has been properly recorded. medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with medicare . medicare deductibles and copayments are effective through December 31, 2021. 5. Plan A. medicare (Part A) Hospital services per benefit period medicare Plan You pays pays pay Hospitalization:1 All but $1,484 (Part A. First 60 days: $0. Semi-private room and $1,484 deductible). board, general nursing and miscellaneous All but 61st through 90th day: $371 a day $0. services and supplies. $371 a day 91st day and after: All but While using 60 $742 a day $0. $742 a day lifetime reserve days 100% of Once lifetime reserve medicare - days are used $0 $0 2. eligible additional 365 days: expenses Beyond the additional $0 $0 All costs 365 days: Skilled nursing All approved First 20 days: $0 $0. facility care:1 amounts You must meet medicare 's requirements, including 21st through All but Up to $ $0.

9 Having been in a hospital 100th day: $ a day per day for at least 3 days and entered a medicare - approved facility within 30 days after 101st day and after: $0 $0 All costs leaving the hospital. Blood: First three pints: $0 3 pints $0. Additional amounts: 100% $0 $0. Hospice care: All but very You must meet medicare 's limited requirements, including a copayment/ medicare doctor's certification of coinsurance for copayment/ $0. terminal illness. outpatient drugs coinsurance and inpatient respite care Footnotes: 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 Core Benefits.

10 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. 6. Plan A. medicare (Part B) Medical services per calendar year medicare Plan You pays pays pay Medical expenses $203 (Part B. in or out of the hospital First $203 of medicare - $0 $0. deductible). and outpatient hospital approved amounts:1. treatment: Such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and Remainder of medicare - Generally Generally $0. speech therapy, diagnostic approved amounts: 80% 20%. tests and durable medical equipment. Above medicare -approved Part B excess charges: amounts: $0 $0 All costs Blood: First three pints: $0 All costs $0. Next $203 of medicare - $203 (Part B. $0 $0. approved amounts:1 deductible). Remainder of medicare - 80% 20% $0. approved amounts: Clinical laboratory Tests for diagnostic services: 100% $0 $0.