Subscriber Agreement PLAN 65 Medicare Supplement Plan SELECT C

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1 Subscriber Agreement PLAN 65 Medicare Supplement Plan SELECT C MEDICARE SUPPLEMENT SUBSCRIBER AGREEMENT This agreement describes your benefits from Blue Cross & Blue Shield of Rhode Island. This is a Medicare Supplement Insurance Plan, which provides supplemental coverage for the Original Medicare Plan recipients who are enrolled in Medicare Part A and Medicare Part B. To receive maximum benefits under this agreement, you must obtain Medicare Part A health care services from within the PLAN 65 SELECT HOSPITAL NETWORK unless the services are required for emergency treatment or the services are not available within the PLAN 65 SELECT HOSPITAL NETWORK. To obtain a copy of the PLAN 65 SELECT HOSPITAL NETWORK list please call the Customer Service Department at or Telecommunications Device for the Deaf users (TTY/TDD) may call 711. See Section 7.0 for the definition of PLAN 65 SELECT HOSPITAL NETWORK. RENEWABLE This agreement begins on the effective date and remains in effect until December 31. You may renew this agreement each calendar year by paying us the required subscriber fee. CHANGES IN BENEFITS Benefits under this agreement will change automatically if Medicare eligible expenses change. Subscriber fees may increase or decrease to reflect any change in benefits. We will give you written notice and a description of any change of benefits at least thirty (30) days prior to the effective date of change. 30 DAY RIGHT TO EXAMINE You have the right to return this agreement within thirty (30) days of receipt if you are not satisfied with it for any reason. We will refund your subscriber fee if this agreement is returned within that time. NOTICE TO BUYER This agreement may not cover all of your medical expenses. Read this agreement CAREFULLY. Peter Andruszkiewicz President and Chief Executive Officer Plan 65 SELECT C (01/11)

2 Plan 65 SELECT C (01/11)

3 BLUE CROSS & BLUE SHIELD OF RHODE ISLAND PLAN 65 MEDICARE SUPPLEMENT PLAN SELECT C SUMMARY OF BENEFITS This is a Medicare supplement insurance plan, which provides supplemental coverage for individuals enrolled in the Original Medicare Plan. This Summary of Benefits and the Benefit Provisions together form your subscriber agreement for Medicare Supplement Plan Select C. This subscriber agreement replaces any previous subscriber agreement issued for this type of coverage. The intent of this summary is to give you a general understanding of benefits available under this agreement. For more details, read section 3.0 for a description of coverage for specific benefits and section 5.0 for a list of general exclusions. You have selected Medicare Supplement Plan Select C. This type of Medicare Supplement policy requires you to use hospitals within its PLAN 65 SELECT HOSPITAL NETWORK, unless the services are required for emergency treatment or the services are NOT available within the PLAN 65 SELECT HOSPITAL NETWORK, to be eligible for Medicare Part A benefits. To obtain a copy of the PLAN 65 SELECT HOSPITAL NETWORK list please call Customer Service Department at or Telecommunications Device for the Deaf users (TTY/TDD) may call 711. You may receive services from doctors that accept Medicare; there is not a list of network physicians to select from. This plan includes all of the benefits shown in the Summary of Benefits when you obtain Medicare Part A services from PLAN 65 SELECT HOSPITAL NETWORK. Refer to your Benefit Provisions for a detailed description of each benefit. SUMMARY OF BENEFITS Medicare Supplement Plan SELECT C BASIC BENEFIT PROVISIONS Basic Benefits Section Plan Covers The 61 st though 90 th day of inpatient hospital services for Medicare eligible expenses when you obtain the services from PLAN 65 SELECT HOSPITAL NETWORK. 3.1 Medicare Part A copayment: $304 per day Sixty (60) lifetime inpatient reserve days for Medicare eligible expenses when you obtain the services from PLAN 65 SELECT HOSPITAL NETWORK. Up to a lifetime maximum of three hundred and sixty five (365) inpatient hospital days for Medicare eligible expenses after exhausting all Medicare inpatient hospital benefits when you obtain the services from PLAN 65 SELECT HOSPITAL NETWORK. 3.1 Medicare Part A copayment: $608 per day % of Medicare eligible expenses First three (3) pints of blood % of Medicare eligible expenses Plan 65 SELECT C (01/11) Summary of Benefits i

4 Doctor services and outpatient services for Medicare eligible expenses. 3.1 Medicare Part B copayment: Generally 20% Hospice Care 3.1 Medicare copayment Medicare Supplement Plan SELECT C ADDITIONAL BENEFIT PROVISIONS Additional Benefits Section Plan Covers Inpatient hospital services for the first sixty (60) days of Medicare eligible expenses when you obtain the services from PLAN 65 SELECT HOSPITAL NETWORK. 3.2 Medicare Part A deductible: $1216 per Skilled nursing facility care for 21 st though 100 th day of inpatient skilled nursing facility care for Medicare eligible expenses. Doctor services and outpatient services for Medicare eligible expenses. benefit period 3.2 Medicare Part A copayment: $152 per day 3.2 Medicare Part B deductible: Emergency medical care in foreign countries for Medicare eligible expenses for medically necessary emergency care beginning during the first 60 consecutive days of each trip outside the United States. You will be responsible to pay a $250 deductible per calendar year, the 20% remaining copayment, and all charges that exceed the lifetime maximum of $50,000. $147 per calendar year % of billed charges less the $250 deductible up to the $50,000 lifetime maximum payment. IF YOU HAVE ANY QUESTIONS OR REQUIRE ASSISTANCE PLEASE CALL US AT OR TO CONTACT OUR TELECOMMUNICATIONS DEVICE FOR THE DEAF (TTY/TDD) PLEASE CALL 711. Plan 65 SELECT C (01/11) Summary of Benefits ii

5 Plan 65 SELECT C (01/11) BLUE CROSS & BLUE SHIELD OF RHODE ISLAND PLAN 65 MEDICARE SUPPLEMENT PLAN SELECT C TABLE OF CONTENTS SUMMARY OF BENEFITS i Basic Benefits... i Additional Benefits... ii 1.0 INTRODUCTION How to Find What You Need to Know You and Blue Cross & Blue Shield of Rhode Island Words With Special Meaning General Information ELIGIBILITY Who is Eligible for Coverage Medicaid Eligibility Extension of Benefits When Your Coverage Ends PROVISIONS FOR COVERED BENEFITS Basic Benefit Provisions Inpatient Hospital Services... 3 Lifetime Inpatient Reserve Days... 3 Lifetime Maximum Benefit for Inpatient Hospital Days... 3 Blood Services... 4 Doctor Services and Outpatient Services Additional Benefit Provisions Inpatient Hospital Services... 4 Skilled Nursing Facility Care... 4 Doctor Services and Outpatient Services... 5 Emergency Medical Care in Foreign Countries CHANGES IN BENEFITS GENERAL EXCLUSIONS HOW TO FILE AND APPEAL A CLAIM How to File a Claim Payment of Benefits How to File a Complaint/Grievance and Appeal How to File a Complaint/Grievance or Administrative Appeal... 8 How to File a Medical Appeal Legal Action Grievances Unrelated to Claims Our Right to Withhold Payments Subrogation and Reimbursement Table of Contents

6 7.0 GLOSSARY 15 ATTACHMENTS A Plan Chart A Plan 65 SELECT C (01/11) Table of Contents

7 1.0 INTRODUCTION The entire contract consists of the application, this agreement, and any attached amendments. Statements made by you to obtain insurance under this agreement will be deemed representations and not warranties. 1.1 How to Find What You Need to Know The Summary of Benefits at the front of this agreement will show you what Medicare eligible expenses are covered under this agreement. The Table of Contents will help you find more details about eligibility, how we pay for Medicare eligible expenses, changes in benefits, services which are not covered under this agreement, how to file a claim, and how to file a complaint/grievance. 1.2 You and Blue Cross & Blue Shield of Rhode Island In consideration of the application and the payment of subscriber fees, we, Blue Cross & Blue Shield of Rhode Island, agree to provide benefits under the terms of this agreement. This is a Medicare supplement plan which provides supplemental coverage for Medicare recipients who are enrolled in the Original Medicare Plan. You can only be covered under one (1) Medicare Supplement plan at any one time. If you enroll in another Medicare Supplement Plan or a Medicare Advantage Plan it is recommended that you disenroll in this plan. If you are enrolled in a Medicare Supplement Plan and a Medicare Advantage Plan at the same time, benefits will only be provided under the Medicare Advantage Plan. Refer to the Summary of Benefits to determine your plan. Please read the Summary of Benefits and the benefit provisions carefully. 1.3 Words With Special Meaning Some words and phrases used in this agreement are in italics. This means that the words or phrases have a special meaning as they relate to this agreement. The glossary at the end of this agreement defines many of these words. Other sections of this agreement also contain definitions of certain words and phrases. These sections include Section 3.0 which describes covered benefits and Section 6.0 which describes claim procedures and how to file a complaint. 1.4 General Information If you have questions or issues regarding your benefits under this agreement, call the Blue Cross & Blue Shield of Rhode Island (BCBSRI) Customer Service Department at (401) or Telecommunications Device for the Deaf users (TTY/TDD) may call 711. Our normal business hours are Monday - Friday from 8:00 a.m. - 8:00 p.m. If you call after normal business hours, our answering service will document your call. A BCBSRI Customer Service Representative will return your call on the next business day. When you call, identify yourself as a subscriber. Also, have your member identification (ID) card available. To find out all the latest Blue Cross & Blue Shield of Rhode Island news and plan information, visit our Web site at BCBSRI/medicare.com. Introduction Plan 65 SELECT C (01/11) 1

8 2.0 ELIGIBILITY This section of this agreement describes rules for who is eligible for coverage, how eligible persons are enrolled, and how and when coverage may be terminated. 2.1 Who is Eligible for Coverage Only residents of Rhode Island who are Medicare recipients enrolled in the Original Medicare Plan are eligible for coverage under this agreement. 2.2 Medicaid Eligibility If you become eligible for Medicaid, you may request that we suspend the benefits and subscriber fees under this agreement. You must notify us within ninety (90) days from the date you become entitled to Medicaid assistance. Upon receipt of this notice, we will suspend benefits and subscriber fees due under this agreement for up to twentyfour (24) months. We will automatically reinstate this agreement (or if no longer available, an agreement that is a substantially equivalent) if you: (a) are no longer eligible for Medicaid within this twenty-four (24) month period; AND (b) notify us within ninety (90) days of the date you were no longer eligible for Medicaid; AND (c) pay the subscriber fee due as of the date of reinstatement. The effective date of reinstatement is the date you cease to be eligible for Medicaid assistance. Benefits and subscriber fees will be reinstated as if this agreement (or a substantially equivalent agreement) remained in force. We will NOT reinstate your coverage after the twenty-four (24) month suspension. 2.3 Extension of Benefits If you are totally disabled on the date this agreement ends, we will continue to provide benefits under this agreement until the earliest of the date: (a) you are no longer totally disabled; (b) the Medicare benefit period ends; OR (c) maximum benefit payments have been paid. Extended benefits apply only to the care or treatment for the disability for which this extension applies. 2.4 When Your Coverage Ends This agreement will end automatically: (a) one (1) month after the date subscriber fees due are not paid; OR (b) the date fraud is determined by us; OR (c) if we cease to offer this type of coverage. You may end this agreement by telling us that you want this agreement to end or by not paying the subscriber fee when due. Reinstatement We have the right to reinstate a terminated agreement. Eligibility Plan 65 SELECT C (01/11) 2

9 3.0 PROVISIONS FOR COVERED BENEFITS We will cover the copayments and deductibles required by Medicare for the services listed in this section. Benefits under this agreement will change automatically to coincide with any changes to the Original Medicare Plan deductible and copayment amounts. We may modify the premiums to correspond with such changes. See Section 4.0 for more information. This agreement may not cover all of your medical expenses. Read this agreement CAREFULLY. Please see the Summary of Benefits at the front of this agreement to determine the amount of coverage we provide for benefits under this agreement. 3.1 Basic Benefit Provisions Medicare Part A inpatient hospital services are covered under this agreement ONLY when you use a participating PLAN 65 SELECT HOSPITAL, unless the services are required for emergency treatment or the services are not available within the PLAN 65 SELECT HOSPITAL NETWORK. See Section 7.0 for the definition of PLAN 65 SELECT HOSPITAL NETWORK. When a non-participating PLAN 65 SELECT HOSPITAL renders inpatient services and the services are NOT required for emergency treatment or the services are available within the PLAN 65 SELECT HOSPITAL NETWORK you will be responsible to pay the applicable Medicare eligible expenses, Part A deductible, and or Part A copayment. To obtain a copy of the PLAN 65 SELECT HOSPITAL NETWORK listing, please call Customer Service Department at or Telecommunications Device for the Deaf users (TTY/TDD) may call 711. Inpatient Hospital Services When inpatient hospital services are rendered by a participating PLAN 65 SELECT HOSPITAL we will cover the copayment required by Medicare Part A for Medicare eligible expenses relating to the 61 st through 90 th day of inpatient hospitalization. Lifetime Inpatient Reserve Days Lifetime inpatient reserve days are limited to sixty (60) additional days of inpatient hospitalization ONCE in your lifetime. If you are hospitalized for more than ninety (90) days and your inpatient hospital services are rendered by a participating PLAN 65 SELECT HOSPITAL, we will cover the copayment required by Medicare Part A for Medicare eligible expenses relating to the 91 st to 150 th day of lifetime inpatient reserve days. Lifetime Maximum Benefit for Inpatient Hospital Days Upon exhaustion of all Medicare hospital inpatient coverage, including the lifetime inpatient reserve days, we will cover Medicare eligible expenses for hospitalization not covered by Medicare Part A subject to a lifetime maximum benefit of 365 days. The hospital must be a participating PLAN 65 SELECT HOSPITAL unless the services are required for emergency treatment or the services are not available at a PLAN 65 SELECT HOSPITAL. See Section 7.0 for the definition of PLAN 65 SELECT Provisions for Covered Benefits Plan 65 SELECT C (01/11) 3

10 HOSPITAL NETWORK and Medicare eligible expense. Such expenses shall be paid as follows: (a) To the extent and in the amount Medicare would have covered such services had the lifetime reserve days not been exhausted and if Medicare were still prime; or (b) The lesser of (a) or the hospital s charge. Blood Services We will cover the replacement costs, if any, required by Medicare for the first three (3) pints of blood (or equivalent quantities of packed red blood cells as defined under federal regulations) unless the blood is replaced in accordance with federal regulations. Doctor Services and Outpatient Services We will pay the copayment amount required by Medicare Part B for Medicare eligible expenses. Hospice Care We will pay the copayment required by Medicare for Medicare eligible expenses relating to hospice care and respite care. 3.2 Additional Benefit Provisions The following provisions apply to additional benefits covered under your plan. Additional benefits for Medicare Part A for Medicare eligible expenses are payable ONLY when you use a participating PLAN 65 SELECT HOSPITAL, unless the services are required for emergency treatment or the services are not available through a PLAN 65 SELECT HOSPITAL NETWORK. See Section 7.0 for the definition of PLAN 65 SELECT HOSPITAL NETWORK. Inpatient Hospital Services The inpatient hospital deductible required by Medicare Part A for Medicare eligible expenses relating to the first sixty (60) days of inpatient hospitalization per benefit period is covered ONLY when you use a participating PLAN 65 SELECT HOSPITAL, unless the services are required for emergency treatment or the services are not available within the PLAN 65 SELECT HOSPITAL NETWORK. See Section 7.0 for the definition of PLAN 65 SELECT HOSPITAL NETWORK. When a non-participating PLAN 65 SELECT HOSPITAL renders inpatient services and the services are NOT required for emergency treatment or the services are available within the PLAN 65 SELECT HOSPITAL NETWORK you will be responsible to pay the applicable Medicare eligible expenses, Part A deductible, and or Part A copayment. Skilled Nursing Facility Care We will cover the copayment required by Medicare Part A for Medicare eligible expenses relating to skilled nursing facility care from the 21 st day through the 100 th day in a Medicare benefit period for post hospital skilled nursing facility care. You may receive services from a Skilled Nursing Facility that accepts Medicare; the PLAN 65 SELECT HOSPITAL NETWORK does not include Skilled Nursing Facilities. See the Summary of Benefits for the benefit limit and level of coverage. Provisions for Covered Benefits Plan 65 SELECT C (01/11) 4

11 Doctor Services and Outpatient Services We will pay the Medicare Part B deductible required each calendar year by Medicare for Medicare eligible expenses. Emergency Medical Care in Foreign Countries We will cover Medicare eligible expenses for medically necessary emergency hospital, doctor, and medical care received in a foreign country, if Medicare would have covered the emergency care services as Medicare eligible expenses had the accident or medical emergency occurred in the United States. To qualify for this coverage, the following conditions must be met: (a) treatment must be for emergency care and not eligible for payment under any Medicare program; AND (b) emergency care must begin during the first 60 consecutive days per trip outside the United States and received on or after your plan's effective date. For the purposes of coverage under this agreement, emergency care shall mean care needed immediately because of an injury or illness of sudden and unexpected onset. We will cover eighty percent (80%) of billed charges, subject to a calendar year deductible of two hundred fifty dollar ($250), and a lifetime maximum benefit of fifty thousand dollars ($50,000). You are responsible to pay the two hundred fifty dollar ($250) calendar year deductible, the remaining twenty percent (20%) copayment, and charges exceeding the lifetime maximum benefit payment amount of fifty thousand dollars ($50,000). Benefits for emergency medical care in foreign countries are payable to you only in United States currency. The amount paid to you is based on the bank transfer exchange rate in effect on the date the services were rendered. When you receive medically necessary emergency medical care in a foreign country, you may be required to pay up front for these services. You will then need to file the claim yourself. Before filing the claim, please contact our Customer Service Department at or Telecommunications Device for the Deaf users (TTY/TDD) may call 711 to obtain a foreign claim research form. To file a claim, please submit a copy of the itemized bill and a copy of the completed foreign claim research form. The itemized bill must include: (a) member s name; (b) your Plan 65 subscriber identification (ID) number; (c) name of the doctor who performed the service; (d) date and description of the service; AND (e) the charge for the service. You must file the claim within one calendar year of the date the services were rendered. Provisions for Covered Benefits Plan 65 SELECT C (01/11) 5

12 4.0 CHANGES IN BENEFITS Benefits listed in Sections 3, Provisions for Covered Benefits, will change automatically if Medicare eligible expenses change. We will send written notice to you with a description of the benefit change(s) at least thirty (30) days prior to the effective date. The effective date of the change is the same date that Medicare implements changes to the Original Medicare Plan. Subscriber fees may be increased or decreased to reflect any change of benefits under this agreement. If this agreement changes, we will issue an amendment or a new agreement. Payment of your subscriber fee will be considered acceptance by you of the change. Changes In Benefits Plan 65 SELECT C (01/11) 6

13 5.0 GENERAL EXCLUSIONS AMOUNTS PAYABLE UNDER MEDICARE In no event will medical payments under this agreement duplicate any amounts payable under Medicare. BENEFITS NOT LISTED IN THE SUMMARY OF BENEFITS This agreement will not cover any benefit that is not listed in the Summary of Benefits. Any benefit listed in the Summary of Benefits will be covered only to the extent described in this agreement. CARE PROVIDED BY NON-PARTICIPATING PLAN 65 SELECT HOSPITALS No benefits are provided for inpatient hospital services for which you do not use a participating PLAN 65 SELECT HOSPITAL, unless the inpatient hospital services are required for emergency treatment or the services are not available within the PLAN 65 SELECT HOSPITAL NETWORK. CARE PROVIDED WITHOUT CHARGE No benefits are provided for services for which no charge would be made to you in absence of insurance. WAR Injury or sickness caused by or resulting from any future act of war is not covered even if the war is not declared. WORKERS' COMPENSATION This agreement will not cover any injury or sickness for which you are entitled to any benefits under workers' compensation or similar law. General Exclusions Plan 65 SELECT C (01/11) 7

14 6.0 HOW TO FILE AND APPEAL A CLAIM 6.1 How to File a Claim Most providers will submit claims directly to Medicare for you. Medicare will process the claim, send you a notice called a Medicare Summary Notice, and send the claim information to us. We will pay the provider directly for Medicare eligible expenses covered under this plan. In some instances you may be required to file a claim. You must file all claims within one calendar year of the date the claim was processed by Medicare. The process date is on the Medicare Summary Notice. Member submitted claims that arrive after this deadline are invalid unless: we determine that it was not reasonably possible for you to file your claim prior to the filing deadline; AND you file your claim as soon as possible but no later than ninety (90) calendar days after the filing deadline elapses (unless you are legally incapable). Our payments to you or the doctor fulfill our responsibility under this agreement. Your benefits are personal to you and cannot be assigned, in whole or in part, to another person or organization. To file a claim, please send us a copy of the Medicare Summary Notice and include your Plan 65 member identification (ID) card number. Please mail the claim to: Blue Cross & Blue Shield of Rhode Island Attention: Claims Department 500 Exchange St Providence, RI Payment of Benefits We may make payments directly to the doctor, hospital, or to you. Your benefits under this agreement are personal to you and may not be assigned to another person or organization. 6.3 How to File a Complaint/Grievance and Appeal A Complaint/Grievance is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because we determined that the services were excluded from coverage or because you or your provider did not follow Blue Cross & Blue Shield of Rhode Island s requirements. How to File a Complaint/Grievance or Administrative Appeal If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits made by us (for example, a denial due to a member filing a claim after our established time limits, See Section 6.1-How to File a Claim), please call our Customer Service How to File and Appeal a Claim Plan 65 SELECT C (01/11) 8

15 Department at (401) or TTY/TDD (Telecommunications Device for the Deaf) users may call 711. The Customer Service Representative will log your call and the nature of the issue and attempt to resolve your concern. If your concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file an administrative appeal, you must do so within 180 days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information: name, address, Plan 65 subscriber ID number; summary of the issue; any previous contact with Blue Cross & Blue Shield of Rhode Island; a brief description of the relief or solution you are seeking; any additional information such as referral forms, claims, or any other documentation that you would like us to review; the date of incident or service; and your signature. You can use the Member Appeal Form, which is on our website BCBSRI/medicare.com or a Customer Service Representative can provide it to you. You can also send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. You may also complete a Member s Designation of a Personal Representative form which a Customer Service Representative can provide to you. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Unit 500 Exchange St Providence, Rhode Island We will acknowledge your complaint or administrative appeal in writing or by phone within ten (10) business days of our receipt of your written complaint or administrative appeal. The Grievance and Appeals Unit will conduct a thorough review of your complaint or administrative appeal and respond in the timeframes set forth below. Level 1 Complaint We will respond to your Level 1 complaint in writing within thirty (30) calendar days of the date we receive your complaint. The determination letter will provide you with the rationale for our response. It will also give you information on the next steps available to you, if any, if you are not satisfied with the outcome of the complaint. Level 2 Complaint (when applicable) A Level 2 complaint may be submitted only when you have been offered a second level of complaint in your Level 1 determination letter. The Grievance and Appeals Unit will conduct a thorough review of your Level 2 complaint and respond to you in writing within thirty (30) business days. The determination letter will provide you with the How to File and Appeal a Claim Plan 65 SELECT C (01/11) 9

16 rationale for our response. It will also give you the next steps if you are not satisfied with the outcome of the complaint. Administrative Appeal We will respond to your administrative appeal in writing within sixty (60) calendar days of our receipt of your administrative appeal. The determination letter will provide you with information regarding our decision. Blue Cross & Blue Shield of Rhode Island does not offer a Level 2 administrative appeal. You may notify the State of Rhode Island Department of Health or the State of Rhode Island Office of the Health Insurance Commissioner regarding your concerns. Please refer to the Legal Action section below for additional information. How to File a Medical Appeal A Medical Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services. The services were denied because we determined one of the following: The services were not medically necessary; or The services are experimental or investigational. If you disagree with a full or partial medical denial made by Medicare, you may dispute the decision through the Medicare appeals process. To start this process, follow the directions given in the letter you receive from Medicare about the denial. We do NOT process Medicare medical appeals. If we deny payment for a service for medical reasons, you will receive the denial in writing. An example of a medical denial reason we may provide is a denial of payment for services because you were rendered inpatient services at a hospital that does NOT participate in the PLAN 65 SELECT HOSPITAL NETWORK. The written denial you receive will explain the reason for the denial. The written denial will also provide specific instructions for filing a medical appeal. To file a medical appeal verbally, you may call our Customer Service Department at (401) or You may also file a medical appeal in writing. To do so, you must provide the following information: name, address, and Plan 65 subscriber ID number; summary of the medical appeal, any previous contact with Blue Cross & Blue Shield of Rhode Island, and a brief description of the relief or solution you are seeking; any additional information such as referral forms, claims or any other documentation that you would like us to review; the date of service; and your signature. If a medical appeal is being filed on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. How to File and Appeal a Claim Plan 65 SELECT C (01/11) 10

17 Written medical appeals should be sent to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Unit 500 Exchange St Providence, Rhode Island Your doctor may also file a medical appeal on your behalf. Your doctor can contact the Physician and Provider Service Center to begin the medical appeal. Within ten (10) business days of receipt of a written or verbal medical appeal, the Grievance and Appeals Unit will mail or phone acknowledgement of our receipt of the medical appeal. You are entitled to the following levels of review when seeking a medical appeal. Level 1 Review You may request a Level 1 review of any matter subject to medical appeal by making a request for such review to us within one hundred and eighty (180) calendar days of the initial determination letter. You may request this review by calling our Customer Service Department, but we strongly suggest that you submit your request in writing to ensure your request is accurately reflected. For pre-service or concurrent appeals, you will receive written notification of the determination on a Level 1 review within fifteen (15) calendar days of receipt of the appeal request. If you are requesting reconsideration (Level 1 review) of a service that was denied after you already obtained the service (retrospectively), then you will receive written notification of our determination within fifteen (15) business days of our receipt of the appeal. Level 2 Review You may request a Level 2 review (preferably in writing) if our denial was upheld during the Level 1 review process. Your Level 2 review will be reviewed by a provider in the same or similar specialty as your treating provider. You must submit your request for a Level 2 review within one hundred and eighty (180) calendar days of the date of the Level 1 determination letter. Upon request for a Level 2 review, we will provide you with the opportunity to inspect the medical file and add information to the file. You will receive written notification of a determination on a Level 2 pre-service or concurrent review within fifteen (15) calendar days of receipt of the appeal request. If the service you are requesting review of was denied after you already obtained the service (retrospectively), you will receive written notification of our determination within fifteen (15) business days of receipt of the appeal request. Note: You may ask for an expedited review if the circumstances are an emergency or if you are in an inpatient setting. Due to the urgent nature of an expedited Medical Appeal, to request an expedited Medical Appeal you or your physician or provider must call the Grievance and Appeals Unit at (401) or or fax your request to (401) An expedited determination will be made not later than seventy-two (72) hours from the receipt of the appeal. How to File and Appeal a Claim Plan 65 SELECT C (01/11) 11

18 External Appeal If you remain dissatisfied with the determination of our Level 1 and Level 2 medical review, you may request an external review by an outside review agency. If you choose to do so, you will select the external appeal agency that will perform the external appeal from a list of Department of Health-approved agencies. You will be responsible for fifty percent (50%) of the charges and fees from the external agency and we will pay the remaining fifty percent (50%). However, if the external appeal agency overturns our denial determination, we will reimburse you for your half of the cost of the review. To request an external review you must submit your request in writing to us within sixty (60) calendar days of your receipt of the Level 2 denial notification. For all non-emergency appeals, the external appeal agency will notify you of its determination within ten (10) business days of the agency s receipt of the information. For all emergency external appeals, the external appeals agency will notify you of its determination no later than seventy-two (72) hours from the agency s receipt of the appeal. Legal Action If you are dissatisfied with the decision on your claim, and have complied with applicable state and federal law, you are entitled to seek judicial review. This review will take place in an appropriate court of law. Note: Once a member or provider receives a decision at an appeal level, the provider or the member may not ask for an appeal at the same level again, unless additional information that could impact such decisions can be provided. Under state law, you may not begin court proceedings prior to the expiration of sixty (60) days after the date you filed your claim. In no event may legal action be taken against us later than three (3) years from the date you were required to file the claim (see Section 6.1). Grievances Unrelated to Claims We encourage you to discuss any complaint that you may have about any aspect of your medical treatment with the health care provider that treated you. In most cases, issues can be more easily resolved when they are raised when they occur. If, however, you remain dissatisfied or prefer not to take up the issue with your provider, you may access our complaint and grievance procedures. You may also use our complaint and grievance procedures if you have a complaint about our service or about one of our employees. To begin a grievance, please call our Customer Service Department at (401) or or TTY/TDD (Telecommunications for the Deaf) users at 711. The Customer Service Department will log in your call and begin working towards the resolution of your complaint. The appeal and complaint procedure described in this section do not apply to the following: Medicare claims determinations; medical necessity determinations; complaints regarding payments; claims of medical malpractice; or How to File and Appeal a Claim Plan 65 SELECT C (01/11) 12

19 allegations that we are liable for the professional negligence of any doctor, hospital, health care facility, or other health care doctor furnishing services under this agreement. Our Right to Withhold Payments We have the right to keep back payment during the period of investigation on any claim we receive that we have reason to believe might not be eligible for coverage. We will also conduct a pre-payment review on a claim we have reason to believe has been submitted for a service not covered under this agreement. We will make a final decision on these claims within sixty (60) days after the date that you filed your claim. We also have the right to carry out post-payment review of claims. If we determine fraud or misrepresentation was used when you filed the claim, we reserve the right to take the necessary steps (including legal action) to recover funds. These funds may have been paid to you or to a doctor, hospital, or other health care doctor. We may review a claim if we have reason to believe it was submitted for a service we do not cover under this agreement. Subrogation and Reimbursement Subrogation We may recover money from a third party that causes you to be hurt or sick. If that party has insurance, we may recover money from the insurance company. Our recovery will be based on the benefit or payment we made under this agreement. For example, if you are hurt in a car accident and we pay for your hospital stay, we can collect the amount we paid for your hospital stay from the auto insurer. If you do not try to collect money from the third party who caused you to be hurt or sick, you agree that we can. We may do so on your behalf or in your name. Our right to be paid will take priority over any claim for money by a third party. This is true even if you have a claim for punitive or compensatory damages. Reimbursement If we give you benefits or make payment for services under this agreement and you get money from a third party for those services, you must pay us back. This is true even if you receive the money after a settlement or a judgment. For example, if your auto insurance pays for your emergency room visit after a car accident, you must reimburse us for any benefit payment that we made. We can collect the money no matter where it is or how it is designated. You must pay us back even if you do not get back the total amount of your claim against the third party. We can collect the money you receive even if it is described as a payment for something other than health care expenses. We may offset future payments under this agreement until we have been paid an amount equal to what you were paid by a third party. If we must pay legal fees in order to recover money from you, we can recover these costs from you. Also, the amount that you must pay us cannot be reduced by any legal costs that you have. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us quickly so we can respond in court. How to File and Appeal a Claim Plan 65 SELECT C (01/11) 13

20 Member Cooperation You must give us information and help us. This means you must complete and sign all necessary documents to help us get money back. You must tell us in a timely manner about the progress of your claim with a third party. This includes filing a claim or lawsuit, beginning settlement discussions, or agreeing to a settlement in principle, etc. It also means that you must give us timely notice before you settle any claim. You must not do anything that might limit our rights under this Section. We may take any action necessary to protect our right of subrogation and/or reimbursement. How to File and Appeal a Claim Plan 65 SELECT C (01/11) 14

21 7.0 GLOSSARY BENEFIT means the amount this agreement pays to supplement Medicare eligible expenses. CALENDAR YEAR means a twelve (12) month period beginning on January 1 and ending December 31. COPAYMENT means the amount Medicare requires that you pay for covered benefits. DEDUCTIBLE means the amount Medicare requires that you pay before Medicare will provide covered benefits. DOCTOR means a licensed practitioner who is qualified and authorized under that license to perform the services covered under this agreement of the healing arts acting within the scope of his or her license. EMERGENCY means the sudden and unexpected onset of symptoms due to an illness or injury which requires immediate medical treatment. HOSPITAL means any facility which provides medical and surgical care for patients who have acute illnesses or injuries. The facility must be accredited by the Joint Commission on Accreditation of Hospitals. Hospital does NOT include: (a) convalescent, rest or nursing homes and facilities; (b) facilities primarily for custodial, educational or rehabilitative care; (c) (d) substance abuse treatment facilities; OR facilities operated by any national government or agency for the medical treatment of members or ex-members of the armed forces (except in an emergency if you are responsible to pay for services received). INJURY means accidental bodily injury sustained: (a) as the direct result of an accident; (b) independent of disease or bodily infirmity or any other cause; AND (c) which occurs while this agreement is in force. Injury does not include injuries for which benefits are provided under any workers' compensation, employer's liability or similar law, or motor vehicle no-fault plan, unless prohibited by law. MEDICAID means The Health Insurance for the Aged Act, Title XIX of the United States Social Security Amendments of 1965, as amended. MEDICARE means "The Health Insurance for the Aged Act," Title XVIII of the United States Social Security Amendments of 1965, as then constituted or later amended. MEDICARE BENEFIT PERIOD (BENEFIT PERIOD) A Medicare benefit period begins the day you are admitted into a hospital or skilled nursing facility (SNF). The Medicare benefit period ends when you have not received any hospital care (or skilled care in a SNF) for 60 days in a row. If you go into the hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. An inpatient hospital deductible applies to each Medicare benefit period. There is no limit to the number of benefit periods you can have. Glossary Plan 65 SELECT C (01/11) 15

22 MEDICARE ELIGIBLE EXPENSE means health care expenses of the kinds covered by the Original Medicare Plan, to the extent recognized as reasonable and medically necessary by Medicare. ORIGINAL MEDICARE PLAN is the Medicare traditional fee-for-service federal health insurance. It has two parts Medicare Part A (Hospital insurance) and Medicare Part B (Medical insurance). PLAN means the basic benefits and the additional benefits, if any, listed in the Summary of Benefits. There are ten (10) separate Medicare supplement plans allowed by law. All ten (10) are listed in the plan chart attached to this agreement. We may offer less than ten (10) separate plans. We may also offer the same plan with and without limited provider network restrictions. Your plan is the plan shown in the Summary of Benefits. PLAN 65 SELECT HOSPITAL NETWORK means a hospital that has agreed to participate in our PLAN 65 SELECT HOSPITAL NETWORK. These hospitals agree to accept Medicare's payment and waive the Medicare Part A copayment and/or deductible amounts for Medicare Part A health care services covered under this agreement. To obtain the list of the PLAN 65 SELECT HOSPITAL NETWORK please call the Customer Service Department at or Telecommunications Device for the Deaf users (TTY/TDD) may call 711. We will NOT pay any benefits if the Medicare Part A health care services are NOT provided by a participating PLAN 65 SELECT HOSPITAL unless: (a) the services are required for emergency treatment and it is not reasonable to obtain services through a participating PLAN 65 SELECT HOSPITAL; OR (b) the Medicare eligible expenses are not available within the PLAN 65 SELECT HOSPITAL NETWORK. REIMBURSEMENT means our right to be paid back any payments, awards or settlements that you receive from a third party. We can collect up to the amount of any benefit or any payment we made. SICKNESS means an illness or disease which first manifests itself after the effective date of this agreement and while this agreement is in force. SKILLED NURSING FACILITY means a facility primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under the supervision of a doctor. A Skilled Nursing Facility must: (a) provide continuous 24-hour a day nursing services by or under the supervision of a registered graduate professional nurse (R.N.); (b) maintain the daily medical record of each patient; AND (c) be approved or qualified to receive approval for payment of Medicare benefits. Skilled Nursing Facility does NOT include a home or facility which is used: (a) primarily for rest; (b) to care for the aged or for the care of substance abuse treatment; OR (c) primarily for the care and treatment of mental diseases or disorders, or custodial or educational care. Glossary Plan 65 SELECT C (01/11) 16

23 SUBROGATION means we can use your right to recover money from a third party who caused you to be hurt or sick. We may also recover from any insurance company (including uninsured and underinsured motorist clauses and no-fault insurance) or other party. SUBSCRIBER/MEMBER means you, the eligible person listed on your application who is enrolled in the plan. WE, US, and OUR means Blue Cross & Blue Shield of Rhode Island. We are located at 500 Exchange St Providence, Rhode Island, For the purpose of this agreement we, us, or our will have the same meaning whether italicized or not. YOU and YOUR means the individual subscriber whose application for coverage under this agreement has been approved by us. For the purpose of this agreement you and your will have the same meaning whether italicized or not. Glossary Plan 65 SELECT C (01/11) 17

24

25 ATTACHMENTS Plan Chart Plan 65 SELECT C (01/11) Attachment A

26

27 BLUE CROSS & BLUE SHIELD OF RHODE ISLAND Plan 65 SELECT C (01/11) 3 Benefit Plans: A, C, and SELECT C Benefit Chart of Medicare Supplement Plans Sold 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. Plans E, H, I, and J are no longer available for sale. BASIC BENEFITS: Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. Blood: First three pints of blood each year. Hospice: Part A coinsurance. A B C D F F* G K L M N Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance Part A Deductible Basic, including 100% Part B coinsurance Skilled Nursing Facility Co- Insurance Part A Deductible Part B Deductible Foreign Travel Emergency Basic, including 100% Part B coinsurance Skilled Nursing Facility Co- Insurance Part A Deductible Foreign Travel Emergency Basic, including 100% Part B coinsurance* Skilled Nursing Facility Co- Insurance Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency Basic, including 100% Part B coinsurance Skilled Nursing Facility Co- Insurance Part A Deductible Part B Excess (100%) Foreign Travel Emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2140 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2140. 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. Attachment A Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility Coinsurance 50% Part A Deductible Out- of pocket limit $4940 paid at 100% after limit reached Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% 75% Skilled Nursing Facility Coinsurance 75% Part A Deductible Out- of pocket limit $2470 paid at 100% after limit reached Basic, including 100% Part B coinsurance Skilled Nursing Facility Co- Insurance 50% Part A Deductible Foreign Travel Emergency Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Co- Insurance Part A Deductible Foreign Travel Emergency

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