Anthem Blue Cross and Blue Shield 2014 Outline of Medicare ... · Administrative Office PO o 0 San...

2014 Outline of Medicare Supplement Coverage 1

Anthem Blue Cross and Blue Shield – Kentucky

Administrative Office: P.O. Box 659806, San Antonio, TX 78265-9106 Toll Free Telephone Number: 1-866-803-5169

2014 Outline of Medicare Supplement Coverage Cover Page (1 of 2)Plans A, F & N

PLAN At B C D Ft|F*1 G K L M N

Basic coverage

Basic, including 100% Part B coinsur-ance




Basic, including 100% Part B coinsur-ance*


Hospital-ization and preventive care paid at 100%; other basic benefits paid at 50%

Hospital-ization and preventive care paid at 100%; other basic benefits paid at 75%


Basic, including 100% Part B co-insurance, except up to $20 copayment for office visit, and up to $50 copayment for ER

1 High Deductible Plan F is not available.

(continued on next page)WPOOC001M(Rev. 4/14)-KY

Benefit Chart of Medicare Supplement Plans Sold for Effective Dates On or After June 1, 2010

This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan A, and either Plan C or F available. Some plans may not be available in your state. Plans shown in gray are available for purchase.

Plan A and Plan F are available to those under age 65 and qualify for Medicare due to disability (plans noted with a diamond “t”).

Plans noted with a triangle ‘’ are Medicare Select Plans and contain the same benefits, except for restrictions on your use of hospitals.

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 copayments.• Blood – First three pints of blood each year.•Hospice – Part A coinsurance.




2014 Outline of Medicare Supplement Coverage Cover Page (2 of 2)Plans A, F & N

PLAN At B C D Ft|F*1 G K L M N

Skilled Nurs-ing Facilitycoinsurance P P P P 50% 75% P PPart A Deductible P P P P P 50% 75% 50% PPart B Deductible P PPart B Excess (100%) P PForeign Travel Emergency P P P P P POut-of- pocket limit

$4,940; paid at 100%

after limit reached

$2,470; paid at 100%

after limit reached

* 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 $2,140 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,140. 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.

1 High Deductible Plan F is not available.




Plans A, F & NEffective January 1, 2014Premiums are subject to change.

Premium Information

Here’s some important information, before we get started: Premiums are subject to change on or after the Renewal Date in accordance with the terms of the Policy. Renewal Date is defined as generally January 1, subject to state approval. Your Premium Billing Preference does not guarantee your premium for any specific time period. Any state-approved premium changes will be applied starting on your next Renewal Date following your Coverage Effective Date, regardless of your Premium Billing Preference. The selected Premium Billing Preference will take effect on the first day of payment period which immediately follows your Coverage Effective Date. For example, if your Coverage Effective Date is September 1 and you pick the Quarterly Premium Billing Preference, Quarterly premium billing will start on October 1; if you select the Annual Premium Billing Preference, Annual premium billing will start on January 1. Any premiums billed for the period of time from your Coverage Effective Date to the start of your selected Premium Billing Preference will be prorated to reflect the Premium Billing Preference selected.

We, Anthem, can only raise your premium if we raise the premium for all plans like yours in this State. We will recalculate your age each year to determine your new attained age. Premiums will be based on your gender and age during Open Enrollment and Guaranteed Issue periods. Outside Open Enrollment and Guaranteed Issue periods, premiums will be based on your gender, age and whether or not you use tobacco. Your premium may increase annually at your renewal based upon your new attained age and your gender.

About Your Premium

Save $2 on your monthly premium! Enroll in our Automatic Bank Draft or Electronic Fund Transfer (EFT) program and you will save $2 on your monthly premium. (To enroll, simply complete the Premium Payment Form.)

Save $48 by paying your premium for the entire year! (Note: Based on the policy effective date, the discount may be pro-rated the first year.)

Save 5% when more than one member in the household enrolls in a Medicare Supplement plan with us. The discount is for policies with effective dates of June 1, 2010 or after and available to those members who occupy the same housing unit.

OR

LET’S BEGIN

Don’t miss out on a chance to SAVE!These optional discounts are offered for all of the following Premium Tables, for ages 65 and over.





Premium Information

Find Your Monthly Premium

We’re here to help you make choices to match your coverage needs. First, you’ll need to locate your premium. Premiums (and future changes to premiums) are determined by several factors, including whether you are applying during your Open Enrollment Period, are eligible for Guaranteed Issue coverage, your tobacco use, age, gender, plan, and the costs of medical services and supplies. After locating your monthly premium, you’ll refer to individual plan pages. These pages will provide details of coverage and benefits, for comparison purposes.

Here’s how to find your premium, in one easy step:

Determine which Premium

Table applies to you. If you are applying during your Open Enrollment Period or are eligible for Guaranteed Issue coverage*, use Table 1.

Otherwise, refer to the appropriate Premium Table, according to your tobacco use:

Find your

premium.

Now you’re ready to compare premiums

for each plan available to you.

We sort this information by gender and age.If you did not use any

tobacco products in the past 12 months:

> see Table 1 .

If you did use any tobacco products

in the past 12 months:

> see Table 2 .—or—

P

* The most common reason you could qualify for guaranteed issue coverage is, 1) Your coverage will start 3 months before or after your 65th birthday, or 2) Your coverage will start when you are age 65 or older and within 6 months of your Medicare Part B coverage effective date. Other reasons are shown in “Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare” available on the Medicare.gov website.





Monthly Premium

(see next page for Table 2)

Use this table if: 1. You are in your Open Enrollment Period, or are eligible for Guaranteed Issue; OR, 2. You do not use tobacco products. ( Tobacco users should use Table 2.) Premium is based upon your age, gender and plan.

Find your Premium Table 1 | Non-Tobacco Users and/or Open Enrollment Guaranteed Issue (continued)

Age

Male Female

Plan A Plan F Plan N Plan A Plan F Plan N65 $145.56 $183.28 $137.46 $138.63 $174.55 $130.9166 150.80 189.88 142.41 143.62 180.84 135.6367 156.23 196.71 147.54 148.79 187.35 140.5168 161.86 203.80 152.85 154.15 194.09 145.5769 167.68 211.13 158.35 159.70 201.08 150.8170 173.72 218.73 164.05 165.45 208.32 156.2471 179.97 226.61 169.96 171.40 215.82 161.8672 186.45 234.76 176.07 177.57 223.59 167.6973 193.17 243.22 182.41 183.97 231.63 173.7374 200.12 251.97 188.98 190.59 239.97 179.9875 207.32 261.04 195.78 197.45 248.61 186.4676 214.79 270.44 202.83 204.56 257.56 193.1777 222.52 280.18 210.13 211.92 266.83 200.1378+ 230.53 290.26 217.70 219.55 276.44 207.33

Plans Use your attained age at the time of enrollment.

Male Female

Plan A Plan F Plan A Plan F

$311.51 $392.22 $296.67 $373.54

Under Age 65 Premiums For those qualified for Medicare by reason other than age.

Male Female

Plan F Plan F

$277.15 $263.96

Under Age 65 Select Premiums (must use a network hospital.) For those qualified for Medicare by reason other than age.

Age

Male Female

Plan F Plan N Plan F Plan N65 $125.98 $ 94.48 $119.98 $ 89.9966 130.51 97.89 124.30 93.2267 135.21 101.41 128.77 96.5868 140.08 105.06 133.41 100.0669 145.12 108.84 138.21 103.6670 150.35 112.76 143.19 107.3971 155.76 116.82 148.34 111.2672 161.37 121.03 153.68 115.2673 167.18 125.38 159.22 119.4174 173.20 129.90 164.95 123.7175 179.43 134.57 170.89 128.1676 185.89 139.42 177.04 132.7877 192.58 144.44 183.41 137.5678+ 199.51 149.64 190.01 142.51

Select Plans (must use a network hospital.) Use your attained age at the time of enrollment.

or





Monthly Premium

If you have used tobacco products in the past 12 months, use this table —or— if you are not a tobacco user, are in your Open Enrollment Period, or are eligible for Guaranteed Issue, see Table 1. Premium is based upon your age, gender and plan.

Find your Premium Table 2 | Tobacco Users

Age

Male Female

Plan A Plan F Plan N Plan A Plan F Plan N65 $163.03 $205.27 $153.96 $155.27 $195.50 $146.62 66 168.90 212.66 159.50 160.86 202.54 151.9067 174.98 220.32 165.24 166.65 209.83 157.3768 181.28 228.25 171.19 172.65 217.38 163.0469 187.81 236.47 177.35 178.86 225.21 168.9170 194.57 244.98 183.74 185.30 233.31 174.9971 201.57 253.80 190.35 191.97 241.71 181.2972 208.83 262.94 197.20 198.88 250.42 187.8173 216.35 272.40 204.30 206.04 259.43 194.5774 224.13 282.21 211.66 213.46 268.77 201.5875 232.20 292.37 219.28 221.15 278.45 208.8376 240.56 302.89 227.17 229.11 288.47 216.3577 249.22 313.80 235.35 237.36 298.86 224.1478+ 258.19 325.09 243.82 245.90 309.61 232.21

Plans Use your attained age at the time of enrollment.

Male Female

Plan A Plan F Plan A Plan F

$348.89 $439.29 $332.27 $418.37

Under Age 65 Premiums For those qualified for Medicare by reason other than age.

Male Female

Plan F Plan F

$310.41 $295.63

Under Age 65 Select Premiums (must use a network hospital.) For those qualified for Medicare by reason other than age.

Age

Male Female

Plan F Plan N Plan F Plan N65 $141.10 $105.82 $134.38 $100.78 66 146.18 109.63 139.22 104.4167 151.44 113.58 144.23 108.1768 156.89 117.67 149.42 112.0669 162.54 121.90 154.80 116.1070 168.39 126.29 160.37 120.2871 174.45 130.84 166.14 124.6172 180.73 135.55 172.13 129.0973 187.24 140.43 178.32 133.7474 193.98 145.48 184.74 138.5675 200.96 150.72 191.39 143.5476 208.20 156.15 198.28 148.7177 215.69 161.77 205.42 154.0778+ 223.46 167.59 212.82 159.61

Select Plans (must use a network hospital.) Use your attained age at the time of enrollment.

or




Disclosure Page

Retain this outline for your records.

Use this outline to compare benefits and premiums among policies.

Medicare deductibles and coinsurance amounts are effective as of January 1, 2014. Medicare may change their amounts annually.

Read Your Policy Very CarefullyThis is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and Anthem.

Right to Return PolicyIf you find that you are not satisfied with your policy, you may return it to us at our Administrative Office: P.O. Box 659806, San Antonio, TX 78265-9106. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.

Policy ReplacementIf you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.

NoticeThis policy may not fully cover all of your medical costs.

Neither Anthem nor its agents are connected with Medicare.

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details.

Complete Answers are Very ImportantWhen you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

Disclosures

Disclosure PagePlans A, F & N




Disclosure Page


Our customer service representatives are specially trained to answer your questions about your Medicare Supplement Select Plan. Please call during business hours, Monday through Friday, with questions regarding:

· your coverage and benefit levels, including copayment amounts;

· specific claims or services you have received; and/or authorizations.

You will be notified, in writing, if a claim or other request for benefits is denied in whole or in part. If such a request is denied, the notice of denial will explain why benefits were denied and describe your rights under the appeals procedure. A complaint appeals procedure also exists to help you understand Anthem’s determinations.

The Complaint ProcedureA complaint procedure is available to provide reasonable, informative responses to complaints that you may have concerning Anthem. A complaint is an expression of dissatisfaction that can often be resolved by an explanation from Anthem of its procedures and contracts. Anthem invites you to share any concerns that you may have over benefit determinations, coverage cancellations, or the quality of care rendered by medical providers.

If you have a complaint or problem concerning benefits or services, please contact us. Please refer to your identification card for our address and telephone number. You may submit your complaint by letter or by telephone call. Or, if you wish, you may meet with your local service representative to discuss your complaint.

You are encouraged to file complaints within 60 days of an initial, adverse action, but must file within six months after receipt of notice of the initial, adverse action. The time required to review complaints does not extend the time in which appeals must be filed.

The Appeals ProcedureAn appeal is a formal request from you for Anthem to change a previous determination. An initial determination by Anthem with which you disagree can be appealed for further review through an internal appeal review process provided by Anthem. During the internal appeal, the issue in question is reviewed by a person or persons who did not make the initial determination. Anthem’s appeal decision letters will explain any rights you may have to further review after the internal appeals decision.

“Standard Appeal” review is available for formal requests to change a previous determination and is completed within 30 days of receipt of the first request for appeal. You may designate an authorized person to exercise your appeal rights.

Disclosures — Grievance Procedures (Complaint and Appeals)

Disclosure PagePlans F & N




Disclosure Page


An ”Expedited Appeal” is available for clinical issues when the service is ongoing, including when you are hospitalized. For clinical issues where services have not yet been rendered, an appeal will be an Expedited Appeal if your treating physician believes that the service or supply is urgently needed, or if Anthem determines that the appeal should be expedited. Urgently needed care is that care which would seriously jeopardize your life or health if delayed during the time required for non-expedited review. Anthem will provide notice of the decision on Expedited Appeals within three business days of a request for an Expedited Appeal. Expedited Appeals may be filed by telephone, but oral requests must be followed by a written request for the appeal.

An ”External Review” is available if a service or supply has been denied as not medically necessary or as experimental/investigative and all other appeal rights with Anthem are exhausted. The service denied by Anthem must create liability for you of $100.00 or more. External Review must be requested by you or a person authorized to act on your behalf. It is coordinated by Anthem and involves a review of your appeal by an independent reviewer. For appeals that involve urgently needed care, Anthem and you may agree to bypass some levels of internal appeal to send a case directly to External Review. External Review is not available for services or supplies that are

limited or excluded by Contract. The expense of the external review service is paid by Anthem.

An expedited External Review request will be granted if it meets the criteria described above for Expedited Appeals and the criteria for External Review are met. Anthem forwards requests for expedited External Review to the independent review organization within 24 hours of receipt of the request for External Review. The independent review organization makes its determination within 24 hours of receipt of the request for External Review from Anthem. An option for a 24-hour extension exists if you and Anthem agree to the extension. Expedited External Review requests may be filed by telephone, but oral requests must be followed by a written request for these reviews.

For non-expedited External Reviews, we will forward the request to the independent review organization within three business days of selection of the independent review organization. The independent review organization will make its decision within 21 days of receipt of the request for External Review. An extension of up to 14 days may be allowed if you and Anthem agree to the extension.

If you have any questions, contact the customer service telephone number listed on the back of your Identification Card. Records provided to independent review organizations are handled as confidential records.

Disclosures — Grievance Procedures (Complaint and Appeals) (con’t.)





Disclosure Page


Anthem encourages you to submit requests for appeal in writing. The request for appeal should describe the problem in detail. Attach copies of bills, medical records, or other appropriate documentation to support the appeal that may be in your possession.

You must file appeals on a timely basis. You are encouraged to file internal appeals within 60 days of your receipt of Anthem’s initial decision. Internal appeals must be filed, however, within six months of your receipt of the initial decision. If the right to External Review exists as described above, the External Review request must be filed with Anthem within 60 days of your receipt of the final, internal appeal decision.


Disclosures — Grievance Procedures (Complaint and Appeals) (con’t.)



Part

aServices

PlanMedicare (Part a) hoSPital ServiceS — Per benefit Period

(continued on next page)

A1

1 Plan A is not available as a Select Plan option.* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out

of the hospital and have not received skilled care in any other facility for 60 days in a row.** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and

will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

Services Medicare Pays Plan Pays You Pay

Hospitalization*Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1,216 $0 $1,216 (Part A deductible)

61st thru 90th day All but $304 a day $304 a day $0

91st day and after:•Whileusing60lifetime

reserve days All but $608 a day $608 a day $0

•Oncelifetimereserve days are used:

— Additional 365 days $0 100% of Medicare

eligible expenses $0**

— Beyond the additional 365 days

$0 $0 All costs


Part

aServices



Skilled Nursing Facility Care*You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0

21st thru 100th day All but $152 a day $0 Up to $152 a day

101st day and after $0 $0 All costs

Blood

First 3 pints $0 3 pints $0

Additional amounts 100% $0 $0

Hospice CareYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/ coinsurance

$0

A1

1 Plan A is not available as a Select Plan option.* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out

of the hospital and have not received skilled care in any other facility for 60 days in a row.


Plan Medicare (Part B) Medical services — Per calendar year

Part

Bservices


Medical Expenses — In or Out of the Hospital and Outpatient Hospital TreatmentSuch as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $147 of Medicare Approved Amounts* $0 $0 $147 (Part B deductible)

Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0

Part B Excess ChargesAbove Medicare Approved Amounts $0 $0 All costs

Blood

First 3 pints $0 All costs $0

Next $147 of Medicare Approved Amounts* $0 $0 $147 (Part B deductible)

Remainder of Medicare Approved Amounts 80% 20% $0

Clinical Laboratory Services

Tests for Diagnostic Services 100% $0 $0

1 Plan A is not available as a Select Plan option.* Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk),

your Part B deductible will have been met for the calendar year.

A1


Plan Medicare (Part a) hosPital & (Part B) Medical services

Parts

a+Bservices

1 Plan A is not available as a Select Plan option.* Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk),

your Part B deductible will have been met for the calendar year.


Home Health Care — Medicare Approved Services•Medicallynecessary

skilled care services and medical supplies

100% $0 $0

•Durable medical equipment:

— First $147 of Medicare approved amounts* $0 $0 $147 (Part B deductible)

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

A1


Part

aServices


F


* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.



First 60 days All but $1,216 $1,216 (Part A deductible) $0


91st day and after:• While using 60 lifetime






$0 $0 All costs


Part

aServices


F





21st thru 100th day All but $152 a day Up to $152 a day $0


Blood





Medicare copayment/ coinsurance

$0



Part

Bservices

F



First $147 of Medicare Approved Amounts* $0 $147 (Part B deductible) $0

Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0

Part B Excess ChargesAbove Medicare Approved Amounts $0 100% $0

Blood


Next $147 of Medicare Approved Amounts* $0 $147 (Part B deductible) $0




* Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.


Plan Medicare (Part a) hosPital & (Part B) Medical services other Benefits — not covered By Medicare

Parts

a+Bservices

F

Foreign Travel — Not Covered by MedicareMedically necessary emergency care services beginning during the first 60 days of each trip outside the USA

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

Remainder of Charges $0 80% to a lifetime maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum

OTHER BENEFITS

—Not Covered by Medicare





100% $0 $0

•Durable medical equipment:

— First $147 of Medicare approved amounts* $0 $147 (Part B deductible) $0



Part

aServices


N



** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.



First 60 days All but $1,216 $1,216 (Part A deductible) $0


91st day and after:• While using 60 lifetime






$0 $0 All costs


Part

aServices


N





21st thru 100th day All but $152 a day Up to $152 a day $0


Blood





Medicare copayment/ coinsurance $0



Part

Bservices

N



First $147 of Medicare Approved Amounts* $0 $0 $147 (Part B deductible)

Remainder of Medicare Approved Amounts

Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admit-ted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Part B Excess ChargesAbove Medicare Approved Amounts $0 $0 All costs

Blood


Next $147 of Medicare Approved Amounts* $0 $0 $147 (Part B deductible)






Part

Bservices

N







100% $0 $0

•Durable medical equipment:— First $147 of Medicare

approved amounts* $0 $0 $147 (Part B deductible)


Foreign Travel — Not Covered by MedicareMedically necessary emergency care services beginning during the first 60 days of each trip outside the USA

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

Remainder of Charges $0 80% to a lifetime maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum

OTHER BENEFITS

—Not Covered by Medicare

PARTS

A+BServices

MEDICARE (PART A) HOSPITAL & (PART B) MEDICAL SERVICES OTHER BENEFITS — NOT COVERED BY MEDICARE

PART

BServices

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

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Transcript of Anthem Blue Cross and Blue Shield 2014 Outline of Medicare ... · Administrative Office PO o 0 San...