medicare supplement outline of coverage · 65-select until the effective date of your replacement...

MC903A 10/19

2021 Benefit information for Plan 65 and Plan 65-Select

Blue Cross and Blue Shield offers five of Medicare’s ten standard supplement plans.

Benefit Plans: A, G, K, L, N Rates valid through Dec. 31, 2021

Medicare Supplement Outline of Coverage

Rev. 10/19MC921A 10/19 REV 11/20

Medicare Supplement Insurance - Medigap

Medicare Supplement Insurance helps pay for some out-of-pocket costs not covered by Original Medicare Part A and Part B.

If you are enrolled in Medicare Part A and Part B (Original Medicare), Medicare Supplement plans (Medigap) can help fill the coverage gaps. Medicare Supplement plans are sold by Medicare-approved private insurance companies and are designed to assist you with out-of-pocket costs from deductibles, copays and coinsurance which are not covered by Part A or Part B. A Medicare Supplement policy covers only one person so spouses must buy separate policies. All Medicare Supplement plans require you to continue to pay your Part B premium and a separate premium for the Medigap coverage. Once you enroll and continue to pay your premium, your plan will renew each year.

For help enrolling in a Medicare Supplement plan, call us at 866-842-2469, Monday – Friday, 8 a.m. to 4:30 p.m.

3 steps to compare and select the benefits and premium to fit your needs

Review and compare benefits (page 4)The Benefit Chart of Medicare Supplement Plans provides a look at Medicare’s ten standard plans and highlights the plans offered by Blue Cross.

Determine your monthly premium for each plan (page 6)

Consider plans offered by Blue Cross (pages 16 – 25)Compare medical services, including what Medicare pays for, what Blue Cross pays for, and the amount you pay.

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For help enrolling in a Medicare Supplement plan, call us at 866-842-2469, Monday – Friday, 8 a.m. to 4:30 p.m.

Medicare Supplement: Take a Closer Look. When you have a Medicare Supplement policy, Medicare will first pay its share of your medical expenses, and then your policy steps in to pay its share based on the supplement plan you select.

With Medicare Parts A & B Harry pays $2,006 out of pocket.

Hospital charge: $ 4,000.00

Medicare pays:

$2,516

Harry pays:Medicare

deductible and coinsurance

$1,484

Harry pays:

$0

Harry pays: $203

deductible

$203

Total Harry pays:

$203

Doctor charge: $2,000.00

Medicare pays:

$1,397

MedSup pays: $400

Harry pays:($203

deductible and 20% of all

other charges)$603

Total Harry pays:

$2,087

Doctor charge: $2,000.00

Medicare pays:

$1,397

Hospital charge: $ 4,000.00

Medicare pays: $2,516

MedSupp pays:

$1,484

With Medicare Parts A & B and Medicare Supplement Plan G Harry pays $203 out of pocket.

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Benefit Chart of Medicare Supplement PlansFor plans effective Jan. 1 – Dec. 31, 2021 | This chart shows the benefits included in each of the standard Medicare Supplement plans. Every company must make Plan A available. Blue Cross offers the plans highlighted in blue.

BenefitsPlans available to all applicants

A B D G 1,2 K 1,4 L4 M N1,5 C 7 F 2,7 F 2,3,7

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)

Medicare Part B coinsurance or copayment 50% 75%

Blood (first three pints each year) 50% 75%

Part A hospice care coinsurance or copayment 50% 75%

Skilled nursing facility coinsurance 50% 75%

Medicare Part A deductible 50% 75% 50%

Medicare Part B deductible

Medicare Part B excess charges

Foreign travel emergency (up to plan limits)

Out-of-pocket limit in 2021 4,6 $6,220 $3,110

1 Plan 65-Select affects Plans G, K & N only. See the Plan 65-Select section on page 5 for details of coverage.2 Plans F and G also have a high deductible option which require first paying a plan deductible of $2,370 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.3 High Deductible Plan F is not available from Blue Cross and Blue Shield of Kansas.4 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.5 Plan 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.6 The out-of-pocket annual limit will increase each year for inflation.7 For Medicare Supplement Plans sold on or after January 1, 2020, only applicants first eligible for Medicare before 2020 may purchase Plans C and F. Please contact Blue Cross if you are eligible to enroll in these plans.

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Reduce your premium with Plan 65-SelectPlan 65-Select plans offer a lower monthly premium and hospital network limitations. You can reduce your premium if you agree to use a “select” network hospital in the service area where you enroll for all hospital care that is not an emergency.

In an emergency situation, you may need to seek non-network hospital services. You will not be responsible for deductible or coinsurance payments when you receive treatment for symptoms requiring emergency care or you immediately require treatment for an unforeseen illness, injury or condition, and it is not reasonable for you to obtain services from a network hospital.

Plan 65-Select is available with benefit plans C, F, G, K and N onlyIf you live in Atchison, Brown, Butler, Chase, Chautauqua, Clay, Cowley, Doniphan, Douglas, Elk, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Leavenworth, Marion, Marshall, Osage, Pottawatomie, Pratt, Reno, Riley, Sedgwick, Shawnee, Sumner, Wabaunsee, or Washington counties, you are eligible for Plan 65-Select Benefit Plans C, F, G, K or N with lower monthly premiums.

The Plan 65-Select hospital networkTo receive full Plan 65-Select benefits, you must obtain your non-emergency Medicare Part A hospitalization services from one of the network hospitals.

If your doctor does not have admitting privileges to a network hospital, you must have your doctor refer you to another doctor who has admitting privileges to a network hospital. Or you may choose another doctor who can admit you to a network hospital.

If you receive non-emergency inpatient hospital services at a non-network hospital, and the services could have been provided at a network hospital in your service area, then you will be responsible for payment of the Medicare Part A deductible and applicable coinsurance charges.

If you move outside of the hospital network service area, you may continue to use a network hospital. If your move is permanent and it is no longer convenient for you to use a network hospital, you have the opportunity to convert to a Plan 65 non-restricted policy.

How to purchase or convert to another policyShould you no longer want Plan 65-Select coverage, you may change to another Plan 65 Benefit Plan that does not contain hospital network limitations. You will not be required to provide evidence of insurability in any of the following situations:» If your enrollment in Plan 65-Select was the first

Medicare supplemental policy you enrolled in after enrolling in Medicare Part B, and you have had coverage for 12 months or less, you may replace the coverage with any Medicare Supplement Plan offered by any insurance company.1

» If prior to enrolling in Plan 65-Select you had Medicare Supplemental coverage that did not contain hospital network limitations, and you have had your Plan 65-Select coverage for 12 months or less, you may re-enroll in the health care plan you previously had. However, if the previous health care plan is no longer available, you may enroll in Medicare Supplement A, B, G, K, L or N offered by any insurance company.1

You may change to a Plan 65 Benefit Plan with comparable or lesser benefits if:» You have had Plan 65-Select coverage for more than

12 months, or» Medicare Select coverage is no longer authorized by

the Secretary of Health and Human Services. You may change to Medicare Supplement Plans, A, B, G, K, L or N offered by offered by any insurance company if: 2

» Plan 65-Select coverage is no longer available where you live, or

» Material provisions of Plan 65-Select coverage are misrepresented or violated by Blue Cross and Blue Shield of Kansas.

1 Except during the first six months following your Medicare Part B effective date, you must remain continuously enrolled in Plan 65-Select until the effective date of your replacement coverage.2 You will need to apply for this coverage within 63 days from when your Plan 65-Select coverage was either terminated or you disenrolled. A new carrier may require evidence of the date your Plan 65-Select coverage was terminated.

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Select Plan Benefit Details

Select the column which represents your gender. Select if you are eligible for the same household discount. If you live in the same household as another member1, you may be eligible for a household discount. If you do not use2 tobacco products, find your premium in the “Non-Tobacco” column. If you use tobacco, find your premium in the “Tobacco” column.

1All individuals must have a Blue Cross and Blue Shield of Kansas Medicare Supplement Plan. You do not need to be related to apply for a discount, but you must live in the same household. Household is defined as a single-family home, condo or apartment unit within a complex. The following are excluded from the definition of household and therefore are not eligible: assisted living facilities, group homes, adult day care facilities, nursing homes or any other health residential facilities. 2Tobacco use is defined as using any tobacco product, other than for religious or ceremonial use, on average four or more times per week within no longer than the past six months.

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How to Calculate Your Premium

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3 Age 65 or disabled individuals under the age of 65. Blue Cross and Blue Shield of Kansas can only raise your premium if we raise the premium for all policies like yours in this state. The above premiums are effective through December 31, 2021, and are subject to change after that date.

Male Female Male Female

Attained Non-Same Household Non-Same Household Same Household Same Household

Ages Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

653 $135.90 $156.27 $119.58 $137.51 $126.38 $145.34 $111.21 $127.89

66 $135.90 $156.27 $119.58 $137.51 $126.38 $145.34 $111.21 $127.89

67 $135.90 $156.27 $119.58 $137.51 $126.38 $145.34 $111.21 $127.89

68 $141.32 $162.52 $124.37 $143.01 $131.44 $151.16 $115.66 $133.01

69 $146.98 $169.02 $129.34 $148.74 $136.69 $157.20 $120.29 $138.33

70 $152.87 $175.78 $134.51 $154.68 $142.16 $163.49 $125.09 $143.86

71 $158.98 $182.81 $139.89 $160.87 $147.85 $170.03 $130.10 $149.61

72 $165.34 $190.12 $145.49 $167.31 $153.76 $176.83 $135.31 $155.60

73 $171.12 $196.78 $150.58 $173.16 $159.14 $183.02 $140.04 $161.05

74 $177.11 $203.67 $155.84 $179.22 $164.71 $189.43 $144.95 $166.68

75 $183.31 $210.80 $161.30 $185.50 $170.48 $196.05 $150.02 $172.52

76 $189.72 $218.17 $166.95 $191.99 $176.45 $202.91 $155.26 $178.56

77 $196.36 $225.80 $172.79 $198.71 $182.62 $210.02 $160.70 $184.81

78 $202.26 $232.58 $177.98 $204.67 $188.09 $216.31 $165.52 $190.35

79 $208.33 $239.56 $183.31 $210.81 $193.74 $222.81 $170.49 $196.06

80 $214.58 $246.74 $188.81 $217.13 $199.55 $229.49 $175.60 $201.94

81 $221.01 $254.15 $194.48 $223.65 $205.54 $236.38 $180.87 $208.00

82 $227.64 $261.77 $200.31 $230.36 $211.71 $243.46 $186.30 $214.24

83 $234.47 $269.63 $206.32 $237.27 $218.05 $250.77 $191.89 $220.67

84 $241.51 $277.72 $212.51 $244.39 $224.60 $258.29 $197.64 $227.28

85 $248.75 $286.05 $218.89 $251.72 $231.34 $266.04 $203.58 $234.10

86 $256.22 $294.62 $225.46 $259.27 $238.28 $274.02 $209.68 $241.13

87 $263.89 $303.46 $232.21 $267.05 $245.42 $282.24 $215.97 $248.36

88 $271.81 $312.58 $239.18 $275.06 $252.79 $290.71 $222.45 $255.82

89 $279.97 $321.95 $246.36 $283.31 $260.37 $299.43 $229.12 $263.49

90+ $288.37 $331.61 $253.76 $291.82 $268.18 $308.42 $235.99 $271.39

Plan A Monthly Premium

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Plan G Monthly Premium




653 $167.02 $192.07 $146.96 $169.01 $155.33 $178.62 $136.68 $157.19

66 $167.02 $192.07 $146.96 $169.01 $155.33 $178.62 $136.68 $157.19

67 $167.02 $192.07 $146.96 $169.01 $155.33 $178.62 $136.68 $157.19

68 $173.70 $199.74 $152.85 $175.77 $161.54 $185.77 $142.15 $163.47

69 $180.65 $207.74 $158.96 $182.80 $168.00 $193.21 $147.84 $170.02

70 $187.87 $216.04 $165.32 $190.11 $174.73 $200.93 $153.75 $176.82

71 $195.39 $224.69 $171.93 $197.71 $181.71 $208.97 $159.90 $183.88

72 $203.21 $233.67 $178.81 $205.62 $188.98 $217.32 $166.30 $191.24

73 $210.31 $241.85 $185.06 $212.83 $195.59 $224.93 $172.12 $197.94

74 $217.67 $250.31 $191.55 $220.27 $202.44 $232.81 $178.14 $204.86

75 $225.30 $259.08 $198.25 $227.98 $209.52 $240.96 $184.38 $212.03

76 $233.18 $268.14 $205.19 $235.96 $216.86 $249.38 $190.83 $219.46

77 $241.34 $277.53 $212.37 $244.22 $224.44 $258.12 $197.50 $227.14

78 $248.58 $285.85 $218.74 $251.55 $231.18 $265.86 $203.43 $233.95

79 $256.04 $294.42 $225.30 $259.10 $238.12 $273.83 $209.53 $240.97

80 $263.73 $303.26 $232.07 $266.87 $245.26 $282.05 $215.83 $248.19

81 $271.63 $312.35 $239.03 $274.88 $252.62 $290.52 $222.30 $255.64

82 $279.78 $321.73 $246.20 $283.12 $260.20 $299.23 $228.96 $263.31

83 $288.17 $331.38 $253.58 $291.61 $268.00 $308.20 $235.84 $271.21

84 $296.82 $341.32 $261.19 $300.36 $276.04 $317.44 $242.91 $279.34

85 $305.72 $351.56 $269.03 $309.38 $284.33 $326.97 $250.20 $287.73

86 $314.90 $362.11 $277.09 $318.66 $292.85 $336.78 $257.71 $296.36

87 $324.34 $372.97 $285.41 $328.22 $301.64 $346.89 $265.44 $305.25

88 $334.08 $384.16 $293.97 $338.06 $310.69 $357.29 $273.40 $314.40

89 $344.10 $395.68 $302.79 $348.21 $320.01 $368.01 $281.60 $323.84

90+ $354.41 $407.56 $311.87 $358.65 $329.61 $379.05 $290.05 $333.56

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Plan G (Select) Monthly Premium




653 $121.46 $139.67 $106.88 $122.91 $112.96 $129.90 $99.40 $114.31

66 $121.46 $139.67 $106.88 $122.91 $112.96 $129.90 $99.40 $114.31

67 $121.46 $139.67 $106.88 $122.91 $112.96 $129.90 $99.40 $114.31

68 $126.32 $145.25 $111.15 $127.83 $117.47 $135.09 $103.37 $118.88

69 $131.37 $151.07 $115.60 $132.94 $122.17 $140.50 $107.51 $123.64

70 $136.63 $157.11 $120.23 $138.25 $127.06 $146.12 $111.81 $128.58

71 $142.08 $163.39 $125.03 $143.78 $132.15 $151.97 $116.29 $133.72

72 $147.78 $169.93 $130.04 $149.54 $137.43 $158.04 $120.93 $139.08

73 $152.94 $175.88 $134.59 $154.77 $142.24 $163.57 $125.17 $143.94

74 $158.29 $182.03 $139.30 $160.18 $147.22 $169.30 $129.55 $148.98

75 $163.84 $188.40 $144.17 $165.79 $152.37 $175.22 $134.08 $154.20

76 $169.57 $195.00 $149.21 $171.60 $157.70 $181.36 $138.77 $159.59

77 $175.51 $201.82 $154.44 $177.60 $163.23 $187.70 $143.63 $165.18

78 $180.78 $207.87 $159.08 $182.93 $168.12 $193.33 $147.94 $170.13

79 $186.19 $214.11 $163.84 $188.42 $173.16 $199.14 $152.38 $175.23

80 $191.78 $220.54 $168.76 $194.07 $178.36 $205.11 $156.95 $180.49

81 $197.54 $227.16 $173.82 $199.89 $183.71 $211.26 $161.66 $185.91

82 $203.46 $233.97 $179.03 $205.89 $189.21 $217.60 $166.51 $191.48

83 $209.56 $240.99 $184.41 $212.07 $194.90 $224.13 $171.50 $197.23

84 $215.86 $248.21 $189.94 $218.43 $200.75 $230.85 $176.65 $203.14

85 $222.33 $255.66 $195.63 $224.98 $206.76 $237.78 $181.95 $209.24

86 $228.99 $263.33 $201.51 $231.73 $212.96 $244.92 $187.41 $215.52

87 $235.87 $271.23 $207.56 $238.69 $219.35 $252.26 $193.03 $221.98

88 $242.94 $279.36 $213.78 $245.85 $225.94 $259.83 $198.82 $228.65

89 $250.23 $287.75 $220.20 $253.22 $232.71 $267.62 $204.78 $235.50

90+ $257.74 $296.39 $226.80 $260.81 $239.70 $275.65 $210.93 $242.56

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653 $72.15 $82.97 $63.49 $73.01 $67.10 $77.16 $59.04 $67.90

66 $72.15 $82.97 $63.49 $73.01 $67.10 $77.16 $59.04 $67.90

67 $72.15 $82.97 $63.49 $73.01 $67.10 $77.16 $59.04 $67.90

68 $75.03 $86.29 $66.02 $75.93 $69.78 $80.25 $61.41 $70.61

69 $78.04 $89.74 $68.67 $78.97 $72.57 $83.46 $63.86 $73.44

70 $81.15 $93.32 $71.42 $82.13 $75.47 $86.79 $66.41 $76.38

71 $84.41 $97.06 $74.27 $85.41 $78.49 $90.27 $69.07 $79.43

72 $87.77 $100.94 $77.24 $88.83 $81.63 $93.88 $71.84 $82.61

73 $90.85 $104.47 $79.94 $91.94 $84.49 $97.16 $74.35 $85.50

74 $94.03 $108.12 $82.74 $95.16 $87.45 $100.56 $76.95 $88.49

75 $97.32 $111.91 $85.64 $98.48 $90.51 $104.09 $79.64 $91.59

76 $100.73 $115.83 $88.63 $101.93 $93.68 $107.73 $82.43 $94.80

77 $104.25 $119.89 $91.73 $105.49 $96.95 $111.50 $85.31 $98.11

78 $107.38 $123.48 $94.49 $108.66 $99.87 $114.84 $87.88 $101.06

79 $110.61 $127.18 $97.32 $111.93 $102.85 $118.29 $90.51 $104.09

80 $113.92 $131.00 $100.25 $115.28 $105.95 $121.84 $93.23 $107.22

81 $117.34 $134.94 $103.26 $118.74 $109.13 $125.50 $96.02 $110.43

82 $120.86 $138.98 $106.35 $122.30 $112.40 $129.25 $98.90 $113.74

83 $124.48 $143.15 $109.54 $125.97 $115.77 $133.14 $101.87 $117.15

84 $128.22 $147.44 $112.82 $129.75 $119.24 $137.13 $104.93 $120.67

85 $132.06 $151.86 $116.21 $133.64 $122.82 $141.24 $108.08 $124.29

86 $136.02 $156.43 $119.70 $137.65 $126.51 $145.49 $111.32 $128.02

87 $140.11 $161.11 $123.29 $141.78 $130.30 $149.85 $114.66 $131.86

88 $144.31 $165.95 $126.98 $146.03 $134.21 $154.34 $118.10 $135.81

89 $148.64 $170.92 $130.80 $150.42 $138.23 $158.97 $121.64 $139.89

90+ $153.10 $176.06 $134.72 $154.93 $142.38 $163.74 $125.29 $144.09

Plan G (HDHP) Monthly Premium

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653 $78.00 $89.69 $68.63 $78.93 $72.54 $83.41 $63.82 $73.40

66 $78.00 $89.69 $68.63 $78.93 $72.54 $83.41 $63.82 $73.40

67 $78.00 $89.69 $68.63 $78.93 $72.54 $83.41 $63.82 $73.40

68 $81.11 $93.28 $71.38 $82.08 $75.43 $86.75 $66.38 $76.34

69 $84.35 $97.00 $74.23 $85.37 $78.45 $90.21 $69.03 $79.39

70 $87.73 $100.88 $77.19 $88.78 $81.59 $93.83 $71.80 $82.57

71 $91.24 $104.91 $80.29 $92.33 $84.85 $97.58 $74.67 $85.86

72 $94.89 $109.12 $83.50 $96.02 $88.25 $101.48 $77.66 $89.31

73 $98.21 $112.94 $86.42 $99.38 $91.33 $105.03 $80.37 $92.43

74 $101.65 $116.89 $89.44 $102.85 $94.53 $108.72 $83.18 $95.66

75 $105.21 $120.98 $92.58 $106.46 $97.84 $112.52 $86.10 $99.01

76 $108.88 $125.21 $95.81 $110.18 $101.26 $116.46 $89.11 $102.47

77 $112.70 $129.59 $99.17 $114.04 $104.81 $120.53 $92.23 $106.06

78 $116.08 $133.48 $102.15 $117.46 $107.95 $124.14 $95.00 $109.24

79 $119.56 $137.49 $105.21 $120.99 $111.19 $127.87 $97.85 $112.52

80 $123.15 $141.61 $108.37 $124.62 $114.52 $131.70 $100.78 $115.90

81 $126.85 $145.85 $111.62 $128.36 $117.97 $135.65 $103.80 $119.37

82 $130.65 $150.24 $114.97 $132.21 $121.50 $139.73 $106.92 $122.96

83 $134.57 $154.75 $118.41 $136.17 $125.15 $143.92 $110.13 $126.65

84 $138.60 $159.38 $121.97 $140.26 $128.91 $148.24 $113.42 $130.45

85 $142.76 $164.17 $125.62 $144.46 $132.77 $152.69 $116.84 $134.35

86 $147.05 $169.09 $129.39 $148.80 $136.75 $157.26 $120.34 $138.39

87 $151.45 $174.17 $133.28 $153.27 $140.85 $161.98 $123.94 $142.54

88 $156.00 $179.39 $137.27 $157.86 $145.08 $166.84 $127.67 $146.82

89 $160.68 $184.77 $141.39 $162.59 $149.43 $171.84 $131.49 $151.22

90+ $165.50 $190.31 $145.63 $167.47 $153.91 $177.01 $135.44 $155.76

Plan K Monthly Premium

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Plan K (Select) Premium




653 $58.38 $67.13 $51.37 $59.08 $54.29 $62.44 $47.78 $54.94

66 $58.38 $67.13 $51.37 $59.08 $54.29 $62.44 $47.78 $54.94

67 $58.38 $67.13 $51.37 $59.08 $54.29 $62.44 $47.78 $54.94

68 $60.72 $69.82 $53.43 $61.44 $56.47 $64.94 $49.69 $57.14

69 $63.14 $72.61 $55.56 $63.90 $58.72 $67.53 $51.68 $59.43

70 $65.67 $75.52 $57.79 $66.45 $61.07 $70.23 $53.74 $61.80

71 $68.30 $78.54 $60.10 $69.11 $63.52 $73.04 $55.89 $64.28

72 $71.03 $81.68 $62.50 $71.88 $66.06 $75.97 $58.13 $66.85

73 $73.51 $84.54 $64.69 $74.39 $68.37 $78.62 $60.16 $69.19

74 $76.09 $87.50 $66.95 $77.00 $70.76 $81.38 $62.27 $71.61

75 $78.75 $90.56 $69.30 $79.69 $73.24 $84.22 $64.45 $74.11

76 $81.51 $93.73 $71.72 $82.48 $75.80 $87.17 $66.70 $76.71

77 $84.36 $97.01 $74.23 $85.37 $78.45 $90.22 $69.04 $79.39

78 $86.89 $99.92 $76.46 $87.93 $80.81 $92.93 $71.11 $81.78

79 $89.50 $102.92 $78.75 $90.57 $83.23 $95.72 $73.24 $84.23

80 $92.18 $106.00 $81.12 $93.28 $85.73 $98.59 $75.44 $86.76

81 $94.95 $109.18 $83.55 $96.08 $88.30 $101.55 $77.70 $89.36

82 $97.80 $112.46 $86.06 $98.96 $90.95 $104.59 $80.03 $92.04

83 $100.73 $115.83 $88.64 $101.93 $93.68 $107.73 $82.43 $94.80

84 $103.75 $119.31 $91.30 $104.99 $96.49 $110.96 $84.91 $97.64

85 $106.86 $122.89 $94.04 $108.14 $99.38 $114.29 $87.45 $100.57

86 $110.07 $126.57 $96.86 $111.38 $102.36 $117.72 $90.08 $103.59

87 $113.37 $130.37 $99.76 $114.73 $105.44 $121.25 $92.78 $106.70

88 $116.77 $134.28 $102.75 $118.17 $108.60 $124.89 $95.56 $109.90

89 $120.28 $138.31 $105.84 $121.71 $111.86 $128.64 $98.43 $113.20

90+ $123.88 $142.46 $109.01 $125.36 $115.21 $132.49 $101.38 $116.59

Plan K (Select) Monthly Premium

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653 $105.22 $121.00 $92.59 $106.48 $97.86 $112.53 $86.11 $99.02

66 $105.22 $121.00 $92.59 $106.48 $97.86 $112.53 $86.11 $99.02

67 $105.22 $121.00 $92.59 $106.48 $97.86 $112.53 $86.11 $99.02

68 $109.43 $125.83 $96.30 $110.73 $101.77 $117.03 $89.55 $102.98

69 $113.81 $130.87 $100.14 $115.17 $105.84 $121.70 $93.13 $107.10

70 $118.36 $136.11 $104.15 $119.77 $110.08 $126.57 $96.86 $111.39

71 $123.09 $141.55 $108.31 $124.57 $114.48 $131.64 $100.73 $115.84

72 $128.02 $147.21 $112.64 $129.54 $119.05 $136.91 $104.77 $120.48

73 $132.50 $152.36 $116.59 $134.08 $123.22 $141.69 $108.43 $124.69

74 $137.13 $157.69 $120.67 $138.77 $127.53 $146.66 $112.22 $129.05

75 $141.94 $163.22 $124.89 $143.63 $132.00 $151.79 $116.15 $133.57

76 $146.90 $168.93 $129.26 $148.65 $136.61 $157.10 $120.22 $138.25

77 $152.04 $174.84 $133.80 $153.86 $141.40 $162.60 $124.43 $143.09

78 $156.60 $180.08 $137.81 $158.47 $145.64 $167.48 $128.16 $147.38

79 $161.30 $185.49 $141.94 $163.23 $150.02 $172.51 $132.00 $151.80

80 $166.14 $191.05 $146.19 $168.13 $154.51 $177.68 $135.96 $156.35

81 $171.12 $196.79 $150.59 $173.17 $159.15 $183.00 $140.05 $161.05

82 $176.26 $202.69 $155.11 $178.36 $163.92 $188.50 $144.24 $165.88

83 $181.55 $208.77 $159.75 $183.71 $168.84 $194.16 $148.57 $170.85

84 $187.00 $215.03 $164.55 $189.22 $173.90 $199.97 $153.02 $175.98

85 $192.60 $221.49 $169.48 $194.91 $179.12 $205.97 $157.62 $181.26

86 $198.38 $228.13 $174.57 $200.75 $184.49 $212.16 $162.35 $186.70

87 $204.34 $234.97 $179.81 $206.78 $190.03 $218.52 $167.22 $192.30

88 $210.46 $242.01 $185.20 $212.97 $195.73 $225.08 $172.23 $198.06

89 $216.78 $249.28 $190.76 $219.36 $201.60 $231.83 $177.40 $204.01

90+ $223.28 $256.76 $196.48 $225.94 $207.65 $238.78 $182.72 $210.13

Plan L Monthly Premium

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14

Plan N Premium




653 $128.62 $147.91 $113.18 $130.16 $119.62 $137.57 $105.26 $121.05

66 $128.62 $147.91 $113.18 $130.16 $119.62 $137.57 $105.26 $121.05

67 $128.62 $147.91 $113.18 $130.16 $119.62 $137.57 $105.26 $121.05

68 $133.77 $153.83 $117.71 $135.37 $124.41 $143.07 $109.48 $125.90

69 $139.12 $159.98 $122.42 $140.79 $129.38 $148.79 $113.85 $130.93

70 $144.68 $166.38 $127.31 $146.41 $134.56 $154.74 $118.41 $136.17

71 $150.47 $173.04 $132.41 $152.26 $139.94 $160.93 $123.14 $141.61

72 $156.49 $179.95 $137.70 $158.36 $145.54 $167.37 $128.07 $147.28

73 $161.97 $186.26 $142.53 $163.90 $150.63 $173.23 $132.55 $152.43

74 $167.64 $192.77 $147.51 $169.64 $155.90 $179.29 $137.18 $157.77

75 $173.50 $199.52 $152.68 $175.57 $161.36 $185.56 $141.99 $163.29

76 $179.57 $206.50 $158.02 $181.72 $167.01 $192.05 $146.96 $169.00

77 $185.87 $213.73 $163.55 $188.08 $172.86 $198.78 $152.11 $174.92

78 $191.44 $220.14 $168.45 $193.72 $178.04 $204.75 $156.67 $180.16

79 $197.19 $226.74 $173.51 $199.53 $183.37 $210.88 $161.37 $185.57

80 $203.10 $233.54 $178.72 $205.52 $188.88 $217.21 $166.21 $191.14

81 $209.19 $240.56 $184.08 $211.69 $194.55 $223.72 $171.20 $196.87

82 $215.47 $247.77 $189.60 $218.03 $200.39 $230.44 $176.33 $202.78

83 $221.93 $255.20 $195.29 $224.58 $206.40 $237.36 $181.62 $208.87

84 $228.59 $262.86 $201.15 $231.32 $212.58 $244.47 $187.07 $215.13

85 $235.45 $270.75 $207.18 $238.25 $218.96 $251.81 $192.68 $221.58

86 $242.51 $278.87 $213.40 $245.40 $225.53 $259.36 $198.46 $228.23

87 $249.79 $287.23 $219.80 $252.76 $232.30 $267.15 $204.42 $235.08

88 $257.27 $295.85 $226.40 $260.35 $239.27 $275.16 $210.55 $242.13

89 $264.99 $304.73 $233.19 $268.16 $246.45 $283.41 $216.87 $249.40

90+ $272.94 $313.87 $240.18 $276.21 $253.84 $291.92 $223.38 $256.87

Plan N Monthly Premium





653 $93.11 $107.07 $81.94 $94.22 $86.56 $99.55 $76.17 $87.60

66 $93.11 $107.07 $81.94 $94.22 $86.56 $99.55 $76.17 $87.60

67 $93.11 $107.07 $81.94 $94.22 $86.56 $99.55 $76.17 $87.60

68 $96.84 $111.36 $85.21 $97.99 $90.02 $103.53 $79.22 $91.10

69 $100.70 $115.80 $88.62 $101.90 $93.62 $107.67 $82.39 $94.74

70 $104.73 $120.44 $92.16 $105.98 $97.37 $111.98 $85.68 $98.54

71 $108.93 $125.25 $95.84 $110.23 $101.27 $116.46 $89.12 $102.48

72 $113.28 $130.27 $99.68 $114.63 $105.31 $121.11 $92.67 $106.58

73 $117.25 $134.82 $103.17 $118.64 $109.00 $125.36 $95.92 $110.31

74 $121.34 $139.54 $106.78 $122.79 $112.82 $129.74 $99.27 $114.17

75 $125.59 $144.43 $110.52 $127.09 $116.77 $134.28 $102.75 $118.17

76 $129.99 $149.48 $114.39 $131.55 $120.86 $138.98 $106.35 $122.31

77 $134.54 $154.71 $118.39 $136.15 $125.08 $143.85 $110.07 $126.58

78 $138.58 $159.35 $121.94 $140.23 $128.84 $148.17 $113.37 $130.38

79 $142.74 $164.13 $125.60 $144.44 $132.71 $152.61 $116.77 $134.29

80 $147.02 $169.06 $129.37 $148.77 $136.69 $157.19 $120.28 $138.31

81 $151.43 $174.13 $133.25 $153.24 $140.79 $161.91 $123.89 $142.46

82 $155.97 $179.35 $137.25 $157.83 $145.01 $166.76 $127.61 $146.74

83 $160.65 $184.74 $141.37 $162.57 $149.36 $171.76 $131.43 $151.15

84 $165.46 $190.28 $145.60 $167.44 $153.84 $176.91 $135.38 $155.68

85 $170.43 $195.98 $149.97 $172.47 $158.45 $182.22 $139.43 $160.35

86 $175.55 $201.86 $154.47 $177.64 $163.20 $187.69 $143.62 $165.16

87 $180.81 $207.93 $159.11 $182.97 $168.10 $193.32 $147.92 $170.11

88 $186.24 $214.16 $163.88 $188.45 $173.14 $199.12 $152.36 $175.22

89 $191.82 $220.59 $168.79 $194.11 $178.34 $205.10 $156.93 $180.48

90+ $197.58 $227.20 $173.86 $199.93 $183.69 $211.24 $161.64 $185.89

Plan N (Select) Monthly Premium

15


Plan A benefits

7

Medicare Part A (hospital services) – per benefit periodServices Medicare Pays Plan A Pays You Pay

Hospitalization | Semi-private room and board, general nursing, miscellaneous services and supplies 1

First 60 days All but $1,484 $0 $1,484 (Part A deductible)

61st through 90th day All but $371 a day $371 a day $0

91st day and after:

» while using 60 lifetime reserve days All but $742 a day $742 a day $0

» once lifetime reserve days are used:

– additional 365 days $0 100% of Medicare eligible expenses $0 2

– 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.1

First 20 days All approved amounts $0 $0

21st through 100th day All but $185.50 a day $0 Up to $185.50 a day

101st day and after $0 $0 All costs

Blood

First 3 pints (per calendar year) $0 3 pints $0

Additional amounts 100% $0 $0

Hospice Care | You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.

All but limited coinsurance for outpatient drugs and

inpatient respite care

Medicare copayment/coinsurance $0

1 A benefit period begins on the first day you receive services 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, 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.

1716

717

Medicare Part B (medical services) – per calendar yearServices Medicare Pays Plan A 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 and durable medical equipment

First $203 of Medicare-approved amounts 3 $0 $0 $203 (Part B deductible)

Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B excess charges $0 $0 All costs

Blood

First 3 pints (per calendar year) $0 All costs $0

Next $203 of Medicare-approved amounts 3 $0 $0 $203 (Part B deductible)

Remainder of Medicare-approved amounts Generally 80% 20% $0

Clinical Laboratory Services

Tests for diagnostic services 100% $0 $0

Medicare Parts A and B (home health care) – Medicare-approved servicesServices Medicare Pays Plan A Pays You Pay

Medically necessary skilled care services and medical supplies 100% $0 $0

Durable Medical Equipment


Remainder of Medicare-approved amounts 80% 20% $0

Foreign Travel | Medically necessary emergency care services during the first 60 days of each trip outside the USA

First $250 each calendar year $0 $0 All costs

Remainder of charges $0 $0 All costs

3 Once you have been billed $203 of Medicare-approved amounts for covered services, your Part B deductible will have been met for the year.

Plan A benefits

17

23

Medicare Part A (hospital services) – per benefit periodServices Medicare Pays Plan G Pays You Pay


First 60 days All but $1,484 $1,484 (Part A deductible) $0


91st day and after:







21st through 100th day All but $185.50 a day Up to $185.50 a day $0


Blood








Plan G or High Deductible Plan G benefits

18

High Deductible Plan G: If you choose the high deductible Plan G it pays the same benefits as Plan G AFTER you have paid a calendar year $2,370 deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are $2,370. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan’s separate foreign travel emergency deductible.

23

Medicare Part B (medical services) – per calendar yearServices Medicare Pays Plan G Pays You Pay



Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B excess charges $0 100% $0

Blood






Medicare Parts A and B (home health care) – Medicare-approved servicesServices Medicare Pays Plan G Pays You Pay






First $250 each calendar year $0 $0 $250

Remainder of charges $0 80% to lifetime max. benefit of $50,000

20% and amounts over $50,000 lifetime max.


Plan G or High Deductible Plan G benefits

19

High Deductible Plan G: If you choose the high deductible Plan G it pays the same benefits as Plan G AFTER you have paid a calendar year $2,370 deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are $2,370. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan’s separate foreign travel emergency deductible.

25

Medicare Part A (hospital services) – per benefit periodServices Medicare Pays Plan K Pays You Pay


First 60 days All but $1,484 $742 $742* (50% Part A Deductible)


91st day and after:







21st through 100th day All but $185.50 a day Up to $92.75 a day Up to $92.75 a day*


Blood

First 3 pints (per calendar year) $0 50% 50%*





50% of Medicare copayment/coinsurance

50% of Medicare copayment/coinsurance*


* You will pay half the cost-sharing of some covered services until the annual out-of-pocket is reached. The amounts that count toward your limit are noted with an asterisk above.

Plan K benefits

20

25

Medicare Part B (medical services) – per calendar yearServices Medicare Pays Plan K Pays You Pay


First $203 of Medicare-approved amounts 3 $0 $0 $203 (Part B deductible)*

Preventive benefits for covered services 80% or more of Medicare-approved amounts

Remainder of Medicare-approved amounts

All costs above Medicare-approved amounts

Remainder of Medicare-approved amounts Generally 80% Generally 10% Generally 10%*

Part B excess charges $0 $0All costs and they do

not count toward annual out-of-pocket limit

Blood


Next $203 of Medicare-approved amounts 3 $0 $0 $203 (Part B deductible)*




Medicare Parts A and B (home health care) – Medicare-approved servicesServices Medicare Pays Plan K Pays You Pay




Remainder of Medicare-approved amounts 80% 10% 10%*


* You will pay half the cost-sharing of some covered services until the annual out-of-pocket is reached. The amounts that count toward your limit are noted with an asterisk above.

Plan K benefits

21

Plan L benefits

22

Medicare Part A (hospital services) – per benefit periodServices Medicare Pays Plan L Pays You Pay


First 60 days All but $1,484 $1,113 (75% Part A Deductible) $371* (25% Part A Deductible)


91st day and after:







21st through 100th day All but $176 a day Up to $139.12 a day Up to $46.38 a day*


Blood






75% of Medicare copayment/coinsurance

25% of Medicare copayment/coinsurance*


* You will pay one-fourth the cost-sharing of some covered services until the annual out-of-pocket is reached. The amounts that count toward your limit are noted with an asterisk above.

Plan L benefits (continued)

23

Medicare Part B (medical services) – per calendar yearServices Medicare Pays Plan L Pays You Pay



Preventive benefits for covered services 80% or more of Medicare-approved amounts

Remainder of Medicare-approved amounts

All costs above Medicare-approved amounts


Part B excess charges $0 $0All costs and they do

not count toward annual out-of-pocket limit

Blood


Next $203 of Medicare-approved amounts 3 $0 $0 $203 (Part B deductible)*




Medicare Parts A and B (home health care) – Medicare-approved servicesServices Medicare Pays Plan L Pays You Pay




Remainder of Medicare-approved amounts 80% 15% 5%*


* You will pay one-fourth the cost-sharing of some covered services until the annual out-of-pocket is reached. The amounts that count toward your limit are noted with an asterisk above

27

Medicare Part A (hospital services) – per benefit periodServices Medicare Pays Plan N Pays You Pay


First 60 days All but $1,484 $1,484 (Part A deductible) $0


91st day and after:







21st through 100th day All but $185.50 a day Up to $185.50 a day $0


Blood








Plan N benefits

24

27

Medicare Part B (medical services) – per calendar yearServices Medicare Pays Plan N Pays You Pay



Remainder of Medicare-approved amounts Generally 80%

Balance, other than copays. $50 copay waived if

admitted and is covered as a Part A expense.

Up to $20 office visit Up to $50 ER visit

Part B excess charges $0 $0 All costs

Blood






Medicare Parts A and B (home health care) – Medicare-approved servicesServices Medicare Pays Plan N Pays You Pay






First $250 each calendar year $0 $0 $250

Remainder of charges $0 80% to lifetime max. benefit of $50,000

20% and amounts over $50,000 lifetime max.


Plan N benefits (continued)

25


29

Exclusions(not covered by any Medicare Supplement Plan)

» Custodial nursing home care

» Intermediate nursing home care costs

» Most dental care and hospital admissions for such care. Examples are treatment, filling, removal or replacement of teeth, root canal therapy, surgery for impacted teeth, and other surgical procedures involving teeth or structures directly supporting the teeth

» Routine physical examinations and tests, routine foot care, immunizations except injection of pneumococcal vaccine, mammograms and prostate exams

» Hearing aids and examinations for them, or consultations about them

» Eyeglasses or contact lenses and examinations about them, or consultations about them, unless for replacement of the lens following cataract surgery

» Benefits considered medically unnecessary by a committee of doctors representing Medicare and Blue Cross and Blue Shield of Kansas will not be paid

How to file a complaintA complaint may be directed to Blue Cross and Blue Shield of Kansas by telephone, in person or in writing, expressing the details of your concern.

You may obtain a grievance form from:

Blue Cross and Blue Shield of Kansas 1133 S.W. Topeka Blvd. Topeka, Kansas 66629-0001

26

29

Read your policy very carefully | This Medicare Supplement Outline of Coverage describes your policy’s most important features for comparison. The policy you receive after you enroll is your insurance contract. Please read the policy to understand the rights and duties for you and for Blue Cross and Blue Shield of Kansas (Blue Cross).

Right to return policy | If you are not satisfied with your policy, you may return it to Blue Cross at:

1133 S.W. Topeka Blvd., Topeka, Kansas 66629-0001

NOTE: If you return your policy within 30 days after you receive it, Blue Cross will treat the policy as if it had never been issued and return any applicable payments.

Renewal conditions | You may renew this Plan 65 policy as long as you live by paying the premium on time. We cannot cancel or refuse to renew your policy, or place any restrictions on it, other than for non-payment or for fraudulent misstatements made by you in your application for the policy.

Cancellation by insured (for individual policies only) | You may cancel this policy at any time by written notice delivered or mailed to Blue Cross, effective upon receipt of such notice or on such late date as may be specified in such notice. In the event of cancellation or death of the insured, Blue Cross will promptly return the unearned portion of any premium paid. The earned premium shall be computed on a pro-rata basis last filed with the state official having supervision of insurance in the state where the insured resided when the policy was issued pro-rata. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation.

Premium information | Any premium rate increase must be implemented on a class basis in Kansas. No rate adjustment may be made on an individual basis.

Policy replacement | If you are replacing another health insurance policy, do NOT cancel it until you are in possession of your new policy and are sure you want to keep it.

Complete answers are very important | You will need to complete an enrollment form for your new policy. If you are applying for Medicare Supplement coverage more than six months after the effective date of your Medicare Part B coverage, you may need to answer questions on the enrollment form about your medical and health history. Blue Cross may cancel your policy and refuse to pay claims if you leave out or falsify important medical information.

Review the enrollment form carefully and make sure all information has been properly recorded before you sign.

Important notices:

» This policy may not fully cover all your medical costs.

» Blue Cross and Blue Shield of Kansas is not connected with or endorsed by the U.S. Government or the Federal Medicare Program.

» This brochure does not give all details of Medicare coverage. Contact your local Social Security Office or consult “Medicare and You" handbook for more details.

» For costs and details of coverage, including exclusions, reductions or limitations and the terms under which the policy may be continued in force, write the company.

» Your contact for this coverage is:

Treena Mason Senior Vice President Sales and Operations, Blue Cross and Blue Shield of Kansas 1133 S.W. Topeka Blvd. Topeka, Kansas 66629-0001

Required Statements and Disclosures

27

Blue Cross and Blue Shield of Kansas is not connected with or endorsed by the U.S. Government or the federal Medicare program. Blue Cross and Blue Shield of Kansas, Inc. (BCBSKS) serves all counties in Kansas, except Johnson and Wyandotte. BCBSKS is an independent licensee of the Blue Cross Blue Shield Association.

866-842-2469In Topeka: 785-291-4301

bcbsks.com/medigap1133 SW Topeka Blvd. Topeka, KS 66629-0001

medicare supplement outline of coverage · 65-select until the effective date of your replacement...

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