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1 Supplemental Coverage Option 2 + 1

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3 Supplemental coverage gives you total health protection Our Blues Supplemental coverage fills in many of the Medicare gaps like deductible, and copayment amounts that you pay each year. This means lower out-of-pocket costs and more money in your pocket. Here s how our Supplemental coverage works: Step 1 As your primary coverage, Medicare pays your health costs first. Step 2 As your secondary coverage, Blue Cross then pays your Medicare deductible and or set copayment if the service is a Supplemental benefit. Here are three important tips to remember: Always give your Medicare and Blue Cross Blue Shield ID cards to your health care provider. This ensures that both Medicare and Blue Cross Blue Shield review your claims for payment. Don t destroy or misplace your Medicare Summary Notice Part B or Notice of Utilization because if you need to file for Supplemental coverage payment, you must send them to Blue Cross Blue Shield of Michigan. Always include your Blue Cross Blue Shield contract number on all correspondence to us. Supplemental Coverage Option 2+1 1

4 Medicare Part A Hospital Services Per Benefit Period Hospitalization Semiprivate room and board, general nursing care and miscellaneous services and supplies Days 1 60 Days Lifetime reserve days (60 days) Medicare-approved amount less Part A deductible Medicare-approved amount less Part A daily Medicare-approved amount less Part A daily. Because lifetime reserve days are not renewed, Medicare will not pay once all 60 days are used. Medicare Part A deductible $0 Medicare Part A daily Medicare Part A daily Additional days $0 not covered by Medicare Blue Cross-approved amount up to an additional 275 days $0 $0 $0 until you use all additional 275 days, then you pay all costs Skilled Nursing Facility Care You must meet Medicare requirements, including having been in a hospital for at least three consecutive days and having entered a Medicare-approved facility within 30 days of discharge from the hospital Days 1 20 Medicare-approved amount $0 covered in full by Medicare $0 Days Medicare-approved amount less Part A daily Medicare Part A daily Days 101 and after $0 not covered by Medicare $0 not covered by Supplemental coverage $0 All costs Hospice Care Supportive services needed for care and pain relief for terminally ill patients provided by a Medicare-participating hospice program when the patient elects this type of care Medicare-approved amount less small copayment for outpatient drugs and less small for inpatient respite care Limited costs not covered by Medicare $0 Medicare Part B Medical Services Per Calendar Year Home and Office Visits Medicare-approved amount less Part B deductible and $0 not covered by Supplemental coverage Medicare Part B deductible and Outpatient Mental Health Care Medicare-approved amount less Part B deductible and or set copayment Medicare Part B deductible and or set copayment $0 2 Supplemental Coverage Option 2+1

5 Medicare Part B Medical Services Per Calendar Year (continued) Medical Expenses Inpatient 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 and durable medical equipment First $131 of Medicareapproved amounts for covered services $0 applied to Medicare Part B deductible Medicare Part B deductible $0 Covered services after Part B deductible is met Medicare-approved amount less Part B Medicare Part B $0 except for outpatient medical visits, consultations, injections, and some chiropractic services Clinical Laboratory Services Laboratory and pathology tests used in the diagnosis and treatment of illness or injury Medicare-approved amount $0 covered in full by Medicare $0 Medicare Part A&B Services Home Health Care Medically necessary home health visits when you are under a physician s care and homebound; also includes aide services, therapy, medical social services and medical supplies when criteria are met Medically approved home health services Medicare-approved amount $0 covered in full by Medicare $0 Durable medical equipment Medicare-approved amount less Part B Medicare Part B $0 Blood Pints 1 3 after Medicare deductible is met Note: Three-pint blood deductible is not applicable when services are received in Michigan Additional pints after Medicare deductible is met $0 not covered by Medicare Note: If the 3-pint deductible has been met under Part A, it need not be met again for Part B Medicare-approved amount less Part B Medicare blood deductible $0 Medicare Part B $0 Foreign Travel $0 not covered by Medicare Covered hospital services for up to 30 days and covered physician services up to Blue Cross-approved amount All costs for non-covered services Once you have paid $131 of Medicare-approved amounts for covered services, your Medicare Part B deductible is met for the calendar year. Note: You may be responsible for additional amounts if your doctor does not accept Medicare s assignment. Supplemental Coverage Option 2+1 3

6 Here s an example to help you understand How Supplemental coverage works with Medicare Example Pat has outpatient surgery which is subject to the Medicare Part B deductible and a 20 percent. (We ve used a 20 percent for illustration purposes. The Medicare amount varies according to the service.) The total cost for the surgery is $550. Pat has not met the Medicare Part B $131 deductible. Medicare Supplemental Coverage Pat Approves $400 and applies the first $131 of the Medicare-approved amount to Pat s Part B deductible: $ $269 Medicare then pays 80 percent of the $269: $269 x 80% $ leaving a balance: $ $ Note: Pat s doctor accepts Medicare s assignment*; therefore, Pat is not responsible for the difference between the doctor s charge ($550) and the Medicare-approved amount ($400). Covers Pat s Medicare Part B deductible and : $ $ Pays nothing *If your doctor does not accept Medicare s assignment, you may be responsible for additional amounts. To limit your out-of-pocket costs, be sure to discuss Medicare participation and assignment as well as fees with your doctor before you receive services. 4 Supplemental Coverage Option 2+1

7 Here are answers to frequently asked questions about Medicare and Blue Cross Blue Shield Supplemental coverage. What does it mean when a doctor accepts assignment? This is a Medicare term that refers to doctors, medical suppliers and other health care providers who agree to accept the Medicare-approved amount as full payment for covered services. If my doctor submits my claim to Medicare, is he or she required to accept the Medicare-approved amount as payment in full? No. Although doctors are required to file your claim with Medicare, this does not mean he or she will accept the Medicare assignment. If my doctor accepts the Medicare payment as payment in full, does he or she also have to accept the Supplemental payment? Yes. When your doctor accepts assignment on a Medicare claim, he or she also agrees to accept the Blue Cross Blue Shield Supplemental payment as payment in full. How do I file for Supplemental coverage payment? To file for Supplemental payment, send your Medicare Summary Notice to: Blue Cross Blue Shield of Michigan P.O. Box 2888 Detroit, MI Be sure to write your Blue Cross Blue Shield contract number and a daytime telephone number at the top of the Medicare Summary Notice. You should include the doctor s complete name and address. If payment is to be sent to your doctor, his or her federal tax ID number must also be included. Failure to provide this information will delay claims processing. If the tax ID number is not on the doctor s statement, call your doctor and ask for this information. If I have questions about information in this brochure, who should I call? Call your local Blue Cross Blue Shield Customer Service Center. A representative will be happy to help you. Supplemental Coverage Option 2+1 5

8 bcbsm.com This is not a Medicare document. It is a summary of many important features of Blue Cross Blue Shield of Michigan Supplemental health care benefits. This is not a contract. An official description of benefits is contained in applicable Blue Cross Blue Shield of Michigan certificates and riders. CB 1565 MAY CUCM

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