Part 1 Schedule of Benefits Do not rely on this alone. It merely highlights some of the benefits available to a member enrolled under Medicare Hospital Insurance (Part A), Medicare Medical Insurance (Part B) and this Medex plan. Be sure to read the most current edition of your Medicare handbook, the explanations in Part 4 and the limitations and exclusions in Part 5, as well as all provisions of this Benefit Description. Note: Your group or Blue Cross and Blue Shield may change these benefits. If this is the case, the change is described in a rider. Your plan sponsor can supply you with any riders that apply to your benefits. Please keep any riders with this booklet for easy reference. Medicare Provides Provides Your Cost* Page Admissions for Inpatient Medical and Surgical Care In a general hospital: Full semiprivate benefits less the Part A deductible for day 160 and Part A coinsurance for day 6190 per benefit period; and full semiprivate benefits less the Part A coinsurance for 60 Medicare lifetime reserve days In a general hospital: The Part A deductible for day 160 and Part A coinsurance for day 6190 per benefit period; the Part A coinsurance for any Medicare lifetime reserve days used; then after Medicare days are used up, full semiprivate benefits through the 365th day per benefit period In a general hospital: Nothing through the 365th day per benefit period; then all charges 20 In a skilled nursing facility that participates with Medicare: Full semiprivate benefits for day 1-20 per benefit period; and full semiprivate benefits less the Medicare Part A coinsurance for day 21100 per benefit period In a skilled nursing facility that participates with Medicare: The Part A coinsurance for day 21100 per benefit period; and $10 per day from day 101-365 per benefit period In a skilled nursing facility that participates with Medicare: Nothing for day 1-100 per benefit period; and the charge over $10 per day from day 101365 per benefit period; then all charges 20 In a skilled nursing facility that does not participate with Medicare: Nothing In a skilled nursing facility that does not participate with Medicare: $8 per day for day 1365 per benefit period In a skilled nursing facility that does not participate with Medicare: The charge over $8 per day for day 1365 per benefit period; then all charges 20 *Benefits for covered services are provided based on the allowed charge. You may have to pay any amount over the allowed charge. (See Parts 2 and 9.)
Admissions for Inpatient Medical and Surgical Care (continued) Physician and other covered professional provider services: Full benefits less the Part B deductible and Part B coinsurance for as many days as are medically necessary Physician and other covered professional provider services: The Part B deductible and Part B coinsurance (full benefits when covered by Medex only) for as many days as are medically necessary Physician and other covered professional provider services: Nothing for as many days as are medically necessary 21 Chiropractor Services Full benefits less the Part B deductible and Part B coinsurance The Part B deductible and Part B coinsurance Nothing 22 Continued Active Care within 100 days after hospital discharge to treat a condition for which you were an inpatient in a hospital for at least three days in a row Full benefits less the Part B deductible and Part B coinsurance (includes: cardiac rehabilitation; drugs covered by Medicare Part B; medical care services; and Medicare approved shortterm rehabilitation therapy) The Part B deductible and Part B coinsurance (includes: cardiac rehabilitation; covered by Medicare Part B; medical care services; and Medicare approved shortterm rehabilitation therapy) Nothing 22 Diabetic Testing Materials, Enteral Formulas and Food Products When covered by Medicare, full benefits less the Part B deductible and Part B coinsurance When covered by Medicare, the Part B deductible and Part B coinsurance When covered by Medicare, nothing 23 When not covered by Medicare, nothing When not covered by Medicare, full benefits for: diabetic testing materials; certain enteral formulas; and low protein food products for up to $2,500 per calendar year When not covered by Medicare, nothing for diabetic testing materials and certain enteral formulas: and all charges Medex has provided benefits for $2,500 per calendar year for low protein food products 23 *Benefits for covered services are provided based on the allowed charge. You may have to pay any amount over the allowed charge. (See Parts 2 and 9.) Dialysis Services
Full benefits less the Part B deductible and Part B coinsurance The Part B deductible and Part B coinsurance Nothing 23 Emergency Medical Outpatient Services Full benefits less the Part B deductible and Part B coinsurance The Part B deductible and Part B coinsurance Nothing 23 Home Health Care For home health care visits, full benefits For home health care visits, nothing For home health care visits, nothing** 23 For durable medical equipment covered by Medicare, full benefits less the Part B deductible (when applicable) and Part B coinsurance For durable medical equipment covered by Medicare, nothing For durable medical equipment covered by Medicare, the Part B deductible (when applicable) and Part B coinsurance 23 Hospice Services When covered by Medicare, full benefits for most services When Medicare does not provide full benefits, the difference between the amount Medicare pays and the allowed charge When covered by Medicare, nothing 24 When not covered by Medicare, nothing When not covered by Medicare, full benefits When not covered by Medicare, nothing 24 Lab Tests, X-Rays and Other Tests Full benefits less the Part B deductible and Part B coinsurance The Part B deductible and Part B coinsurance Nothing 24 *Benefits for covered services are provided based on the allowed charge. You may have to pay any amount over the allowed charge. (See Parts 2 and 9.) **These services are covered in full by Medicare as long as Medicare conditions are met. Mental Health Treatment for Biologically-Based Mental or Nervous Conditions***
Inpatient admissions in a general or mental hospital: Full semiprivate benefits less the Part A deductible for day 160 and Part A coinsurance for day 6190 per benefit period; and full semiprivate benefits less the Part A coinsurance for 60 Medicare lifetime reserve days (Benefits in a mental hospital are limited to 190 days per lifetime) Inpatient admissions in a general or mental hospital: The Part A deductible for day 160 and Part A coinsurance for day 6190 per benefit period; the Part A coinsurance for any Medicare lifetime reserve days used; then after Medicare days are used up, full semiprivate benefits through the 365th day per benefit period Inpatient admissions in a general or mental hospital: Nothing through the 365th day per benefit period; then all charges 25 Inpatient physician and covered professional mental health provider services: Full benefits less the Part B deductible and Part B coinsurance for as many days as are medically necessary Inpatient physician and other covered professional mental health provider services: The Part B deductible and Part B coinsurance (full benefits when covered by Medex only) for as many days as are medically necessary Inpatient Physician and other covered professional mental health provider services: Nothing for as many days as are medically necessary 25 Outpatient treatment: Full benefits less the Part B deductible and Part B coinsurance (Nothing for services not covered by Medicare) Outpatient treatment: The Part B deductible and Part B coinsurance (full benefits when covered by Medex only) for as many visits as are medically necessary Outpatient treatment: Nothing for as many visits as are medically necessary 25 *Benefits for covered services are provided on the allowed charge. You may have to pay any amount over the allowed charge. (See Parts 2 and 9.) ***Treatment for rape-related mental or emotional conditions is covered to the same extent as biologically-based mental or nervous conditions. Mental Health Treatment for Non-Biologically-Based Mental or Nervous Conditions not included in above section (includes drug addiction and alcoholism)
Inpatient admissions in a general or mental hospital: Full semiprivate benefits less the Part A deductible for day 160 and Part A coinsurance for day 6190 per benefit period; and full semiprivate benefits less the Part A coinsurance for 60 Medicare lifetime reserve days (Benefits in a mental hospital are limited to 190 days per lifetime) Inpatient admissions in a general or mental hospital: The Part A deductible for day 160 and Part A coinsurance for day 6190 per benefit period; the Part A coinsurance for any Medicare lifetime reserve days; then Medicare days are used up, full semiprivate benefits through the 365th day per benefit period in a general hospital (up to 120 days per benefit period but up to at least 60 days per calendar year in a mental hospital), less any days in a hospital already covered by Medicare in that benefit period (or calendar year) Inpatient admissions in a general or mental hospital: Nothing through the 365th day per benefit period in a general hospital; and nothing for up to 120 days per benefit period (but up to at least 60 days per calendar year) in a mental hospital; then all charges 25 Inpatient physician and covered professional mental health provider services: Full benefits less the Part B deductible and Part B coinsurance for as many days as are medically necessary Inpatient physician and other covered professional mental health provider services: The Part B deductible and Part B coinsurance for Medicare and Medex covered services for as many days as are medically necessary in a general or mental hospital; full benefits for as many days as are medically necessary in a general hospital and for up to 120 days per benefit period (but up to at least 60 days per calendar year) in a mental hospital when covered by Medex only Inpatient Physician and covered professional mental health provider services: Nothing for Medicare and Medex covered services for as many days as are medically necessary in a general or mental hospital; nothing for as many days as are medically necessary in a general hospital and for up to 120 days per benefit period, (but up to at least 60 days per calendar year) in a mental hospital when covered by Medex only; then all charges 26 *Benefits for covered services are provided based on the allowed charge. You may have to pay any amount over the allowed charge. (See Parts 2 and 9.) Mental Health Treatment for Non-Biologically-Based Mental or Nervous Conditions (continued)
Outpatient treatment: Full benefits less the Part B deductible and Part B coinsurance (Nothing for services not covered by Medicare) Outpatient treatment: The Part B deductible and Part B coinsurance for as many visits as are medically necessary for Medicare and covered services; and full benefits when covered by Medex only for up to 24 visits per calendar year Outpatient treatment: Nothing for Medicare and Medex covered services for as many visits as are medically necessary; and nothing for up to 24 visits per calendar year for services covered by Medex only; then all charges 26 Physical Therapist Services Full benefits less the Part B deductible and Part B coinsurance for Medicare approved physical therapy The Part B deductible and Part B coinsurance for Medicare approved physical therapy Nothing for Medicare approved physical therapy 26 Podiatry Care Full benefits less the Part B deductible and Part B coinsurance The Part B deductible and Part B coinsurance Nothing 26 Radiation and X-Ray Therapy Full benefits less the Part B deductible and Part B coinsurance The Part B deductible and Part B coinsurance Nothing 27 Routine Tests For routine mammograms: Full benefits less the Part B coinsurance (the Part B deductible does not apply) for one baseline mammogram between age 35 through 39 and one routine mammogram per year for a member age 40 or older For routine mammograms: The Part B coinsurance (the Part B deductible does not for one baseline mammogram between age 35 through 39 and one routine mammogram per year for a member age 40 or older For routine mammograms: Nothing for one baseline mammogram between age 35 through 39; and one routine mammogram per year for a member age 40 or older 27 *Benefits for covered services are provided on the allowed charge. You may have to pay any amount over the allowed charge. (See Parts 2 and 9.) Routine Tests (continued)
For routine Pap tests covered by Medicare: Full benefits less the Part B coinsurance (the Part B deductible does not apply) for one routine Pap smear test per two years (one per year for a member at high risk for cervical or vaginal cancer) For routine Pap tests covered by Medicare: The Part B coinsurance (the Part B deductible does not apply) for one routine Pap smear test per two years (one per year for a member at high risk for cervical or vaginal cancer) For routine Pap smear tests covered by Medicare: Nothing for one routine Pap smear test per two years (one per year for a member at high risk for cervical or vaginal cancer) 27 For routine Pap smear tests not covered by Medicare: Nothing For routine Pap smear tests not covered by Medicare: Full benefits for one routine Pap smear test per calendar year For routine Pap smear tests not covered by Medicare: Nothing for one routine Pap smear test per calendar year 27 Surgery as an Outpatient Full benefits less the Part B deductible and Part B coinsurance The Part B deductible and Part B coinsurance Nothing 28 *Benefits for covered services are provided based on the allowed charge. You may have to pay any amount over the allowed charge. (See Parts 2 and 9.)
Medicare The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended. Medicare Eligible Expenses Expenses that are covered by Medicare to the extent recognized as reasonable and necessary by Medicare. (See your Medicare handbook for details.) Member You, the person who has the right to the benefits described in this Benefit Description. A member is enrolled as the subscriber in this Medex plan. Mental or Nervous Conditions Psychiatric illnesses or diseases. include drug addiction and alcoholism.) The illnesses or diseases that qualify as mental or nervous conditions are listed in the latest edition, at the time you receive treatment, of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. Outpatient A patient who is not a registered bed patient in a facility. For example, a patient at a health center, provider's office, surgical day care unit or ambulatory surgical facility is considered an outpatient. A patient who is kept overnight in a hospital solely for observation is also considered an outpatient. This is true even though the patient uses a bed. Physician A physician as defined by Medicare, or a person licensed as a physician by the appropriate jurisdiction where he or she is located. Medex provides benefits as described in this Benefit Description for physician services that are covered by Medex only. This means that Medicare does not make any payment for these services. Plan Sponsor The plan sponsor is usually your employer and is the same as the plan sponsor designated under the Employee Retirement Income Security Act of 1974 (ERISA), as amended. If you are not sure who your plan sponsor is, contact your employer. Room and Board Your room, and general nursing services while you are an inpatient. This includes hospital services furnished in an intensive care or similar unit.
Required by a Third Party No benefits are provided for physical, psychiatric and psychological exams, treatments and related services that are required by third parties. Some examples of non-covered services are: immunizations; exams and tests required for recreational activities, employment, insurance and school; and courtordered exams and services, except for medically necessary services. Experimental Services and Procedures The benefits described in this Benefit Description are provided only when covered services are furnished in accordance with medical technology assessment guidelines. No benefits are provided for health care charges that are received for or related to care that Blue Cross and Blue Shield considers to be experimental services or procedures. The fact that a treatment is offered as a last resort does not mean that benefits will be provided for it. There are two exceptions to this exclusion. Medex does provide benefits for: One or more stem cell transplants for a member who has been diagnosed with breast cancer that has spread. (These stem cell transplants are not eligible for benefits under Medicare.) Certain used on an off label basis. Some examples are: drugs used to treat cancer; and drugs used to treat HIV/AIDS. Note: For covered services not eligible for benefits under Medicare but eligible for benefits under Medex, Blue Cross and Blue Shield determines whether a service is furnished in accordance with medical technology assessment guidelines. Eye Exams/Eyewear No benefits are provided for eyeglasses and contact lenses, except as described in Part 4, or exams to prescribe, fit or change them. Foot Care No benefits are provided for: Routine foot care services such as trimming of corns, trimming of nails and other hygienic care except when they are covered by Medicare and medically necessary because you have systemic circulatory disease (such as diabetes). Certain nonroutine foot care services and supplies such as: treatment of flat feet or partial dislocations in the feet; foot orthotics, arch supports, shoe (foot) inserts, orthopedic and corrective shoes; and fittings, castings and other services related to devices for the feet. Hearing Aids No benefits are provided for hearing aids or to prescribe, fit or change them. Human Organ and Stem Cell (“Bone Marrow”) Transplants No benefits are provided for the harvesting of the organ or stem cells when the recipient is not a member.
Immunizations and Shots No benefits are provided for immunizations and shots, unless they are required because of an injury or immediate risk of infection. Note: Medicare provides full benefits for: pneumococcal vaccine and its administration; and influenza vaccine and its administration. (See your Medicare handbook for details.) Medical Care Outpatient Visits No benefits are provided for outpatient medical care (for example, office visits) except as described in Part 4. Medical Devices, Appliances, Materials and Supplies No benefits are provided for medical devices, appliances, materials and supplies, except as otherwise described in Part 4. Some examples of non-covered items are: air conditioners; air purifiers; arch supports; bath seats; bed pans; bath tub grip bars; chair lifts; computers; dehumidifiers; dentures; elevators; foot orthotics; hearing aids; heating pads; hot water bottles; humidifiers; orthopedic and corrective shoes that are not part of a leg brace; raised toilet seats; and shoe (foot) inserts. Also, no benefits are provided for durable medical equipment and prosthetic devices such as artificial arms, legs and eyes. There are a few exceptions to this exclusion. Benefits are provided as described in Part 4 for: diabetic testing materials, including glucometers (which are classified under the same category as durable medical equipment when covered by Medicare); and durable medical equipment supplied as part of approved home dialysis or hospice services. Missed Appointments No benefits are provided for charges for appointments that you do not keep. Physicians and other providers may charge you if you do not keep your scheduled appointments. They may do so if you do not give reasonable notice to the office. You must pay for these charges. Appointments that you do not keep are not counted against any visit or dollar limits for benefits described in this Benefit Description. Non-Covered Providers Unless otherwise specified, this Medex plan provides benefits only for covered services furnished by providers: eligible to provide services covered by Medicare; that have a payment agreement with Blue Cross and Blue Shield; and that have been approved by Blue Cross and Blue Shield for payment for the specific covered service. No benefits are provided for any services and supplies furnished by the kinds of providers that are not covered by this Medex plan. This Benefit Description specifies the kinds of providers that are covered. (See Part 9, “Providers.”)
Part 8 Grievance Program You have the right to a review when you disagree with a decision by Blue Cross and Blue Shield to deny payment for services that may be eligible for benefits under Medex, or if you have a complaint about the care or service you received from Blue Cross and Blue Shield or a covered provider. When making a determination under this Medex plan, Blue Cross and Blue Shield has full discretionary authority to interpret this Benefit Description and to determine whether a health service or supply is a covered service under this Medex plan. All determinations by Blue Cross and Blue Shield with respect to benefits under this Medex plan will be conclusive and binding unless it can be shown that the interpretation or determination was arbitrary and capricious. Making an Inquiry and/or Resolving Medex Claim Problems or Concerns Most Medex problems or concerns can be handled with just one phone call. (See page 2 for more information about Member Services.) For help resolving a Medex problem or concern, you should first call the Blue Cross and Blue Shield customer service office at 1-800-258-2226. Or, if a different telephone number appears on your Medex identification card, you may call that number. A customer service representative will work with you to help you understand your Medex benefits or resolve your problem or concern as quickly as possible. When resolving a problem or concern, Blue Cross and Blue Shield will consider all aspects of the particular case, including the terms of your group benefits as described in this Benefit Description, Blue Cross and Blue Shield policies and procedures that support the administration of these benefits, the provider’s input, as well as your understanding and expectation of benefits. Blue Cross and Blue Shield will use every opportunity to be reasonable in finding a solution that makes sense for all parties and may use an individual case management approach when it is judged to be appropriate. Blue Cross and Blue Shield will follow its standard business practices guidelines when resolving your problem or concern. If you disagree with the decision given to you by the customer service representative, you may request a review through the formal internal grievance program as described below. Note: Medicare has its own policies and procedures for handling appeals and grievances. See “Medicare Appeals and Grievances” below for information about resolving Medicare problems and concerns. (Medicare has its own policies and procedures for handling appeals and grievances. See “Medicare Appeals and Grievances” below for information about resolving Medicare problems and concerns.)