medicare supplement application -...
TRANSCRIPT
.. , BlueCross BlueShield oflllinois
2014 Policy Checklist
000619560 Applicant's Name. ____________________________________ _
Name of Existing Insurer ________________ Expiration Date of Existing Insurance _ ___./:...___..~-/_
Medicare Supplement Plans: Important- You must indicate your choice of coverage. Mark only one box, please.
Plan A D Standard Plan C D Standard D Med-Select Plan F 0 Standard Plan G D Standard D Med·Select Plan 8 D Standard D Med-Select Plan F D Stondord D Med-Select (High Dedudib/e) ** Plan N D Standard D Med-Select
MEDICARE EXISTING SERVICE BENEFIT PAYS COVERAGE SUPPLEMENT COVERS YOU PAY
PAYS Days 1-60 All but S1,216 D $1,216 Port A Deductible* or 0 $0or
0 SO Plan A Only D S1,216 Port A Deductible
HOSPITAL Days 61-90 All but $304 a day $304 a day so INPATIENT
Days 91-150 SERVICES All but $608 a day S608 a day so (Lifetime Reserve)
Days 151 and beyond so All Medicare-approved amounts for on additional 365 days so
Days 1·20 (All Plans) All costs so so SKILLED D S152 a day or D SOor NURSING Doys 21-100 All but S152 a day HOME CARE D $0 Pions A, B 0 $152 a day
Days l 01 and beyond so so All costs (All Pions) Physician's Services in 80% of the D After $147 Medicare Port B Deductible per calendar year, 20% Charges not covered by hospital, office, or home; Medicare· of Medicare-approved amounts for Pions A,B,C,F,High F,G policy and Medicare inpatient and outpatient determined 0 After $147 Medicare Port B Deductible per colendor year
MEDICAL medical services and allowable changes Pion N pays the balance, other than up to S20 per office visit
EXPENSES supplies at o hospital; after o $147 and up to $50 per emergency room visit. The copoyment of up physical and speech deductible per to $50 is waived if the insured is admitted to any hospital and D $147 Port B deductible therapy; and ambulance calendar year the emergency visit is covered as a Medicare Port A expense for Pions A, B, G, N . D $147 Port 8 deductible for Pions C, F, High F D Port 8 Excess Charges
0 100% Port B Excess Charges for Pions F, High F and G for Pions A, 8, C, N Inpatient Prescription Drugs - 80% of
PRESCRIPTION allowable charges for
DRUGS immunosuppressive No benefit All costs; outpatient drugs drugs during the first year following a covered tronsolont .
This policy does comp~ with the minimum standards set forth in Section 363 of the Illinois Insurance Code.
Date _ __;.../_~/_ Signature of Applicant ....:.X~ _______________ _.__ _____ _
Signature of Producer --=-=X~------------------'------
* Med-Select Pions require that you use Blue Cross and Blue Shield of Illinois porticipoftng Med-Select hospitals for non-emergency admissions to receive coverage for the Medicare Port A deducftble.
••High Deductible Plan F offers the some benefits as Plan F oher you hove paid a S2,140 calendar-year deductible.
WHITE: RETURN WITH APPUCATION • YELLOW: FOR CUENT'S RECORDS A Division of Health Core Service Corporation, o Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association APrrrr~r
31601.01141L
2014 Policy Checklist
SERVICE BENEFIT MEDICARE PAYS
EXISTING COVERAGE
PAYSSUPPLEMENT COVERS YOU PAY
HOSPITAL INPATIENT SERVICES
Days 1-60 All but $1,216 Plan K: $608 Part A Deductible* Plan L: $912 Part A Deductible*
p �Plan K: $608 Part A deductible
p �Plan L: $304 Part A deductible
Days 61-90 All but $304 a day $304 a day $0
Days 91-150 (Lifetime Reserve) All but $608 a day $608 a day $0
Days 151 and beyond $0 All Medicare-approved amounts for an additional 365 days $0
SKILLED NURSING HOME CARE
Days 1-20 All costs $0 $0
Days 21-100 All but $152 a dayp Plan K: $76 a day p Plan L: $114 a day
p Plan K: $76 a day p Plan L: $38 a day
Days 101 and beyond $0 $0 All costs
MEDICAL EXPENSES
Physician’s Services in hospital, office, or home; inpatient and outpatient medical services and supplies at a hospital; physical and speech therapy; and ambulance
80% of the Medicare- determined allowable changes after a $147 deductible per calendar year
p After $147 Medicare Calendar Year deductible, Plan K generally pays 10% and Plan L generally pays 15% of Medicare-approved amounts
Charges not covered by policy and Medicare
PRESCRIPTION DRUGS
Inpatient Prescription Drugs – 80% of allowable charges for immunosuppressive drugs during the first year following a covered transplant
No benefit All costs; outpatient drugs
Applicant’s Name _________________________________________________________________________________________
Name of Existing Insurer_______________________________________ Expiration Date of Existing Insurance______________
Medicare Supplement Plans: Important — You must indicate your choice of coverage. Mark only one box, please.
/ /
/ /Date ______________ Signature of Applicant ___________________________________________________________
Signature of Producer ___________________________________________________________
* Med-Select Plans require that you use Blue Cross and Blue Shield of Illinois participating Med-Select hospitals for non-emergency admissions to receive coverage for the Medicare Part A deductible.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 30346.0114 IL KLCKLIST
This policy does comply with the minimum standards set forth in Section 363 of the Illinois Insurance Code.
X
X
Plan K p Standard p Med-Select (Annual out-of-pocket limit of $4,894)
Plan L p Standard p Med-Select (Annual out-of-pocket limit of $2,470)
WHITE: RETURN WITH APPLICATION • YELLOW: FOR CLIENT’S RECORDS
Health & Retirement Services of Illinois (800)-739-4700
Fax (800)979-0155
SUBMITING YOUR APPLICATION:
• Fill out the application • Print • Sign • Submit ( Note: if you need help enrolling, please call us 800-739-4700
and we will be glad to help you) There are three ways to submit the application: Submit by Mail: Mail Application & Policy Checklist to Health & Retirement Services of Illinois 7101 N Cicero Ave Ste 202 Lincolnwood, IL 60712 Attn: Processing Department Submit by Fax: Fax Application & Policy Checklist to: (800)-979-0155 Attn: Administration Submit by E-mail: E-mail Application & Policy Checklist to [email protected]