Qualifying Events that can qualify you for a Special Enrollment Period

Life changes that can qualify you for a Special Enrollment Period

Loss of health insurance

You may qualify for a Special Enrollment Period if you or anyone in your household lost qualifying health coverage in the past 60 days OR expects to lose coverage in the next 60 days.

Coverage losses that may qualify you for a Special Enrollment Period:

Losing job-based coverage

You may qualify for a Special Enrollment Period if you lose health coverage through your employer or the employer of a family member, including if:

Your employer stops offering coverage.
You leave a job where you had health coverage (even if you left your job by choice or were fired).
You have a reduction in work hours that causes you to lose your job-based plan.
Your job-based plan doesn’t offer qualifying health coverage and as a result you become newly eligible for a premium tax credit. Most job-based plans count as qualifying health coverage. To find out if your employer’s coverage meets the standards, ask your employer to complete the Employer Coverage Tool (PDF).
Your job-based health plan is ending for the year and you choose not to renew it. Note: If the plan is affordable and meets minimum value standards, you can buy Marketplace insurance but won’t qualify for a premium tax credit or other savings.
Your former employer stops contributing to your retirement coverage, requiring you to pay full cost.

Note: You DON’T qualify for a Special Enrollment Period if:

You voluntarily drop your job-based coverage during your coverage year while still working for your employer.
You lose your job-based coverage because you didn’t pay your premium.

Losing COBRA coverage

Some special rules apply if you’re losing COBRA continuation coverage.

You DO qualify for a Special Enrollment Period if:

Your COBRA coverage runs out.
Your former employer stops contributing to your COBRA coverage, requiring you to pay the full cost.

You DON’T qualify for a Special Enrollment Period if:

You decide to end COBRA early (and are paying the full cost yourself).
You lose your COBRA coverage because you didn’t pay your premiums.

Note: You don’t need a Special Enrollment Period if you voluntarily end COBRA early during a Marketplace Open Enrollment Period. You can drop your COBRA plan and enroll in a Marketplace plan at that time.

Losing individual health coverage for a plan or policy you bought yourself

You may qualify for a Special Enrollment Period if you lose individual health coverage, including if:

Your individual plan or your Marketplace plan is discontinued (no longer exists).
You lose eligibility for a student health plan.
You lose eligibility for a plan because you no longer live in the plan’s service area.
Your individual or group health plan coverage year is ending in the middle of the calendar year and you choose not to renew it.

Important: Losing individual coverage doesn’t qualify for a Special Enrollment Period if you voluntarily drop coverage, if you lose coverage because you didn’t pay your premiums, or if you lose Marketplace coverage because you didn’t provide required documentation when the Marketplace asked for more information.

Losing eligibility for Medicaid or CHIP

You may qualify for a Special Enrollment Period if you lose Medicaid or the Children’s Health Insurance Program (CHIP) because:

You lose your eligibility. For example, you may have a change in household income that makes you ineligible for Medicaid, or you may become ineligible for pregnancy-related or medically needy Medicaid.
Your child ages off CHIP.

Losing eligibility for Medicare

You may qualify for a Special Enrollment Period if you become no longer eligible for premium-free Medicare Part A.

You don’t qualify for a Special Enrollment Period if:

You lose Medicare Part A because you didn’t pay your Medicare premium.
You lose Medicare Parts B, C, or D only.

Losing coverage through a family member

You may qualify for a Special Enrollment Period if you lose qualifying health coverage you had through a parent, spouse, or other family member. This might happen if:

You turn 26 (or the maximum dependent age allowed in your state) and can no longer be on a parent’s health plan.
You lose job-based health coverage through a family member’s employer because that family member loses health coverage or coverage for dependents.
You lose health coverage through a spouse due to a divorce or legal separation.
You lose health coverage due to the death of a family member.
You lose health coverage through a parent or guardian because you’re no longer a dependent.

Important: Losing coverage you have as a dependent doesn’t qualify for a Special Enrollment Period if you voluntarily drop the coverage. You also don’t qualify if you or your family member lose coverage because you don’t pay your premium.

Changes in household size

You may qualify for a Special Enrollment Period if you or anyone in your household in the past 60 days:

Got married. Pick a plan by the last day of the month and your coverage can start the first day of the next month.
Had a baby, adopted a child, or placed a child for foster care. Your coverage can start the day of the event — even if you enroll in the plan up to 60 days afterward.
Got divorced or legally separated and lost health insurance. Note: Divorce or legal separation without losing coverage doesn’t qualify you for a Special Enrollment Period.
Death. You’ll be eligible for a Special Enrollment Period if someone on your Marketplace plan dies and as a result you’re no longer eligible for your current health plan.

Changes in residence

Household moves that qualify you for a Special Enrollment Period:

Moving to a new home in a new ZIP code or county
Moving to the U.S. from a foreign country or United States territory
A student moving to or from the place they attend school
A seasonal worker moving to or from the place they both live and work
Moving to or from a shelter or other transitional housing

Note: Moving only for medical treatment or staying somewhere for vacation doesn’t qualify you for an SEP.

Important: You must prove you had qualifying health coverage for one or more days during the 60 days before your move. You don’t need to provide proof if you’re moving from a foreign country or United States territory.

More qualifying changes

Other life circumstances that may qualify you for a Special Enrollment Period:

Changes that make you no longer eligible for Medicaid or the Children’s Health Insurance Program (CHIP)
Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
Becoming newly eligible for Marketplace coverage because you became a U.S. citizen
Leaving incarceration
AmeriCorps VISTA members starting or ending their service

Plan N Details

Medicare Supplement Insurance — Plan N

Get a no-obligation quote for Medicare Supplement coverage from Blue Cross and Blue Shield of Texas

If you are willing to share certain health care costs, this Medicare Supplement insurance plan can help you save on premiums while still receiving dependable coverage.

COST

Medicare Supplement insurance costs include monthly premium payments and may include deductibles, out-of-pocket expenses, copayments and coinsurance. Here are some of the costs you can expect to pay with Plan N:

Your Part B deductible
Part B excess charges
All hospitalization costs beyond the additional 365 days after the Lifetime Reserve are used
All skilled nursing facility costs after 101 days
A $20 copayment for office visits and $50 for emergency room visits – these copayments apply to Part B coinsurance only
Foreign travel: $250 per calendar year; 20 percent of costs within the first $50,000; all costs thereafter

For more information on costs, get a quick quote or see the Medicare Supplement Outline of Coverage.

WHAT’S INCLUDED

Basic benefits:
- Part A coinsurance for hospitalization services plus coverage for 365 additional days after Medicare benefits end
- Part B coinsurance for medical expenses (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services
- First three pints of blood each year
- Part A coinsurance for hospice care
Skilled nursing facility coinsurance
Part A deductible
Foreign travel emergency care*

It’s important to know the critical features of the Medicare Supplement insurance plan you are considering. The Outline of Medicare Supplement Coverage provides brief descriptions of the basic provisions of the Medicare Supplement insurance plans, as well as details on policy renewability, benefit exclusions and coverage limitations.

* Plans cover medically necessary emergency care services needed immediately because of an injury or illness of sudden and unexpected onset, beginning during the first 60 days of each trip outside the USA.

PLAN RENEWALS

Blue Cross and Blue Shield of Texas (BCBSTX) will never terminate or refuse to renew your Medicare Supplement Insurance policy because of the condition of your health. However, to protect you and the rights of all policy holders, there are situations when a Medicare Supplement insurance plan may be terminated or a renewal refused:

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	Plan Pays	You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	$1,316 (Part A deductible)	$0
61st through 90th day	All but $329 a day	$329 a day	$0
91st day and after: – While using 60 Lifetime Reserve Days – Once Lifetime Reserve Days are used: Additional 365 days	All but $658 a day$0	$658 a day 100% of Medicare eligible expenses	$0$0**
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
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	Up to $164.50 a day	$0
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	Three 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 very limited copayment/coinsurance for outpatient drugs and inpatient respite care	Medicare copayment/ coinsurance	$0

* 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.

** 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.

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$0	$183 (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.**	Up to $20 per office visit and up to $50 per emergency room visit.**
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	$0	All costs
BLOOD
First three pints	$0	All costs	$0
Next $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES— TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 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.

** 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.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
– Medically necessary skilled care services and medical supplies	100%	$0	$0
– Durable medical equipment First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	20%	$0

* Once you have been billed $183 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.

OTHER BENEFITS – NOT COVERED BY MEDICARE

Services	Medicare Pays	Plan Pays	You Pay
FOREIGN TRAVEL —NOT COVERED BY MEDICARE: Medically 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	maximum benefit of $50,000	over the $50,000 lifetime maximum

Plan L Details

Medicare Supplement Insurance — Plan L

Get a no-obligation quote for Medicare Supplement coverage from Blue Cross and Blue Shield of Texas

If you are willing to share certain health care costs, this Medicare Supplement insurance plan can help you save on premiums while still receiving dependable coverage.

COST

Medicare Supplement insurance costs include monthly premium payments and may include deductibles, out-of-pocket expenses, copayments and coinsurance. Here are some of the costs you can expect to pay with Plan L:

Your Part B deductible
Part B excess charges
25 percent of your Part A deductible
All hospitalization costs beyond the additional 365 days after the Lifetime Reserve are used
A portion of cost after 21 days in a skilled nursing facility, and all costs after 101 days
25 percent of the cost of the first three pints of blood

For more information on costs, get a quick quote or see the Medicare Supplement Outline of Coverage.

WHAT’S INCLUDED

Basic benefits:
- 75% of Part A deductible for hospitalization services
- 75% of the costs for the first three pints of blood each year
- 75% of Medicare coinsurance for hospice care
Skilled nursing facility coinsurance (75%)
Part A deductible (75%)

It’s important to know the critical features of the Medicare Supplement insurance plan you are considering. The Outline of Medicare Supplement Coverage provides brief descriptions of the basic provisions of the Medicare Supplement insurance plans, as well as details on policy renewability, benefit exclusions and coverage limitations.

PLAN RENEWALS

Blue Cross and Blue Shield of Texas (BCBSTX) will never terminate or refuse to renew your Medicare Supplement Insurance policy because of the condition of your health. However, to protect you and the rights of all policy holders, there are situations when a Medicare Supplement insurance plan may be terminated or a renewal refused:

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	Plan Pays	You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	75% of Part A deductible	25% of Part A deductible
61st through 90th day	All but $329 a day	$329 a day	$0
91st day and after: – While using 60 Lifetime Reserve Days – Once Lifetime Reserve Days are used: Additional 365 days	All but $658 a day $0	$658 a day 100% of Medicare eligible expenses	$0 $0**
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
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	Up to $123.38 a day	Up to $41.12 a day
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	75%	25%
Additional amounts	100%	$0	$0
HOSPICE CARE: You 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	75% of Medicare copayment/ coinsurance	25% of Medicare copayment/ coinsurance

* 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.

** 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.

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Preventive benefits for Medicare-covered services	Generally 75% 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 15%	Generally 5%
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	$0	All costs (and they do not count toward annual out-of pocket limit of $2,560 )**
BLOOD
First three pints	$0	75%	25%
Next $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	Generally 80%	Generally 15%	Generally 5%
CLINICAL LABORATORY SERVICES— TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 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.

** This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2,560 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (“excess charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or services.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
– Medically necessary skilled care services and medical supplies	100%	$0	$0
– Durable medical equipment First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	15%	5%

* Once you have been billed $183 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 F High Deductible

Medicare Supplement Insurance — High Deductible Plan F

Get a no-obligation quote for Medicare Supplement coverage from Blue Cross and Blue Shield of Texas

If you are willing to share certain health care costs, this Medicare Supplement insurance plan can help you save on premiums while still receiving dependable coverage.

High Deductible Plan F includes cost-sharing features that allow you to save on premiums while still receiving dependable coverage. For more detailed information about cost, coverage and renewability, click on the sections below.

COST

Medicare Supplement insurance costs include monthly premium payments and may include deductibles, out-of-pocket expenses, copayments and coinsurance.

This high deductible Medicare Supplement insurance plan pays the same benefits as Plan F after you have paid a calendar-year $2,220 deductible.
Benefits from the High Deductible Plan F will not begin until out-of-pocket expenses are $2,220.
Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy, which includes the Medicare deductibles for Part A and Part B, but not the separate foreign travel emergency deductible.

Other costs you can expect to pay with High Deductible Plan F:

Part B deductible
All costs beyond the additional 365 days after the Lifetime Reserve are used
All costs after 101 days in a skilled nursing facility
Foreign travel: $250 per calendar year; 20 percent of costs within the first $50,000; all costs thereafter

For more information on costs, get a quick quote or see the Medicare Supplement Outline of Coverage.

WHAT’S INCLUDED

Basic benefits:

- Part A coinsurance for hospitalization services plus coverage for 365 additional days after Medicare benefits end
- Part B coinsurance for medical expenses (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services
- First three pints of blood each year
- Part A coinsurance for hospice care
Skilled nursing facility coinsurance
Part A deductible
Part B deductible
Part B excess charges (100%)
Foreign travel emergency care

It’s important to know the critical features of the Medicare Supplement insurance plan you are considering. The Outline of Medicare Supplement Coverage provides brief descriptions of the basic provisions of the Medicare Supplement insurance plans, as well as details on policy renewability, benefit exclusions and coverage limitations.

* Plans cover medically necessary emergency care services needed immediately because of an injury or illness of sudden and unexpected onset, beginning during the first 60 days of each trip outside the USA.

PLAN RENEWALS

Blue Cross and Blue Shield of Texas (BCBSTX) will never terminate or refuse to renew your Medicare Supplement Insurance policy because of the condition of your health. However, to protect you and the rights of all policy holders, there are situations when a Medicare Supplement insurance plan may be terminated or a renewal refused:

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	After you pay $2,180 Deductible**, Plan Pays	After you pay $2,180 Deductible, You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	$1,316 (Part A Deductible)	$0
61st through 90th day	All but $329	$329 a day	$0
91st day and after: — While using 60 Lifetime Reserve days — Once Lifetime Reserve days are used: Additional 365 days	All but $658$0	$658 a day 100% of Medicare eligible expenses	$0$0 **
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
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	Up to $164.50 a day	$0
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	Three 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 very limited copayment/coinsurance for outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

* 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.

** 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.

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
Remainder of Medicare-approved amounts	Generally 80%	Generally 20%	$0
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	100%	$0
BLOOD
First three pints	$0	All costs	$0
Next $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
Remainder of Medicare-approved amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES—TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 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.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
— Medically necessary skilled care services and medical supplies	100%	$0	$0
— Durable medical equipment First $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
— Durable medical equipment Remainder of Medicare-approved amounts	80%	20%	$0

* Once you have been billed $183 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.

OTHER BENEFITS — NOT COVERED BY MEDICARE

Services	Medicare Pays	Plan Pays	You Pay
FOREIGN TRAVEL—NOT COVERED BY MEDICARE: Medically 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

Plan K Details

COST

Medicare Supplement insurance costs include monthly premium payments and may include deductibles, out-of-pocket expenses, copayments and coinsurance. Here are some of the costs you can expect to pay with Plan K:

50 percent of your Part A deductible
100 percent of your Part B deductible
Part B excess charges
A portion of cost after 21 days in a skilled nursing facility, and all costs after 101 days
50 percent of the cost of the first three pints of blood

For more information on costs, get a quick quote or see the Medicare Supplement Outline of Coverage.

WHAT’S INCLUDED

Basic benefits:
- 50% of Part A deductible for hospitalization services
- 50% of the costs for the first three pints of blood each year
- 50% of Medicare coinsurance for hospice care
Skilled nursing facility coinsurance (50%)
Part A deductible (50%)

It’s important to know the critical features of the Medicare Supplement insurance plan you are considering. The Outline of Medicare Supplement Coverage provides brief descriptions of the basic provisions of the Medicare Supplement insurance plans, as well as details on policy renewability, benefit exclusions and coverage limitations.

PLAN RENEWALS

Blue Cross and Blue Shield of Texas (BCBSTX) will never terminate or refuse to renew your Medicare Supplement Insurance policy because of the condition of your health. However, to protect you and the rights of all policy holders, there are situations when a Medicare Supplement insurance plan may be terminated or a renewal refused:

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	Plan Pays	You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	50% of Part A deductible	50% of Part A deductible
61st through 90th day	All but $329 a day	$329 a day	$0
91st day and after: – While using 60 Lifetime Reserve Days – Once Lifetime Reserve Days are used: Additional 365 days	All but $658 a day$0	$658 a day 100% of Medicare eligible expenses	$0$0**
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
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	Up to $82.25 a day	Up to $82.25 a day
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	50%	50%
Additional amounts	100%	$0	$0
HOSPICE CARE: You 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	50% of Medicare copayment/ coinsurance	50% of Medicare copayment/ coinsurance

* 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.

** 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.

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Preventive benefits for Medicare-covered services	Generally 75% 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 (above Medicare-approved amounts)
	$0	$0	All costs (and they do not count toward annual out-of pocket limit of $5,120 )**
BLOOD
First three pints	$0	50%	50%
Next $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	Generally 80%	Generally 10%	Generally 10%
CLINICAL LABORATORY SERVICES— TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 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.

** This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $5,120 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (“excess charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or services.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
– Medically necessary skilled care services and medical supplies	100%	$0	$0
– Durable medical equipment First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	10%	10%

* Once you have been billed $183 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 G Details

COST

Medicare Supplement insurance costs include monthly premium payments and may include deductibles, out-of-pocket expenses, copayments and coinsurance. Here is what you can expect to pay with Plan G:

The Part B deductible
All hospitalization costs beyond the additional 365 days after the Lifetime Reserve are used
All costs after 101 days in a skilled nursing facility
Foreign travel: $250 per calendar year; 20 percent of costs within the first $50,000; all costs thereafter

For more information on costs, get a quick quote or see the Medicare Supplement Outline of Coverage.

WHAT’S INCLUDED

Basic benefits:
- Part A coinsurance for hospitalization services plus coverage for 365 additional days after Medicare benefits end
- Part B coinsurance for medical expenses (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services
- First three pints of blood each year
- Part A coinsurance for hospice care
Skilled nursing facility coinsurance
Part A deductible
Part B excess charges (100%)
Foreign travel emergency care

It’s important to know the critical features of the Medicare Supplement insurance plan you are considering. The Outline of Medicare Supplement Coverage provides brief descriptions of the basic provisions of the Medicare Supplement insurance plans, as well as details on policy renewability, benefit exclusions and coverage limitations.

PLAN RENEWALS

Blue Cross and Blue Shield of Texas (BCBSTX) will never terminate or refuse to renew your Medicare Supplement Insurance policy because of the condition of your health. However, to protect you and the rights of all policy holders, there are situations when a Medicare Supplement insurance plan may be terminated or a renewal refused:

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	Plan Pays	You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	$1,316 (Part A Deductible)	$0
61st through 90th day	All but $329 a day	$329 a day	$0
91st day and after: – While using 60 Lifetime Reserve Days – Once Lifetime Reserve Days are used: Additional 365 days	All but $658 a day$0	$658 a day 100% of Medicare eligible expenses	$0$0**
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
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	Up to $164.50 a day	$0
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	Three 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 very limited copayment/coinsurance for outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

* 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.

** 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.

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	20%	$0
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	100%	$0
BLOOD
First three pints	$0	All costs	$0
Next $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES— TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 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.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
– Medically necessary skilled care services and medical supplies	100%	$0	$0
– Durable medical equipment First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	20%	$0

* Once you have been billed $183 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 A Details

COST

Medicare Supplement insurance costs include monthly premium payments and may include deductibles, out-of-pocket expenses, copayments and coinsurance. Here are some of the costs you can expect to pay with Plan A:

Your Part A deductible
Your Part B deductible
Part B excess charges
All hospitalization costs beyond the additional 365 days after the Lifetime Reserve are used

For more information on costs, get a quick quote or see the Medicare Supplement Outline of Coverage.

WHAT’S INCLUDED

Basic benefits:

Part A coinsurance for hospitalization services plus coverage for 365 additional days after Medicare benefits end
Part B coinsurance for medical expenses (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services
First three pints of blood each year
Part A coinsurance for hospice care

It’s important to know the critical features of the Medicare Supplement insurance plan you are considering. The Outline of Medicare Supplement Coverage provides brief descriptions of the basic provisions of the Medicare Supplement insurance plans, as well as details on policy renewability, benefit exclusions and coverage limitations.

PLAN RENEWALS

Blue Cross and Blue Shield of Texas (BCBSTX) will never terminate or refuse to renew your Medicare Supplement Insurance policy because of the condition of your health. However, to protect you and the rights of all policy holders, there are situations when a Medicare Supplement insurance plan may be terminated or a renewal refused:

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	Plan Pays	You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	$0	$1,316 (Part A Deductible)
61st through 90th day	All but $329 a day	$329 a day	$0
91st day and after: – While using 60 Lifetime Reserve Days – Once Lifetime Reserve Days are used: Additional 365 days	All but $658 a day $0	$658 a day 100% of Medicare eligible expenses	$0 $0**
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
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	$0	Up to $164.50 a day
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	Three 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 very limited copayment/coinsurance for outpatient drugs and inpatient respite care	Medicare copayment/ coinsurance	$0

* 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.

** 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.

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	Generally 80%	Generally 20%	$0
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	$0	All costs
BLOOD
First three pints	$0	All costs	$0
Next $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES— TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 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.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
– Medically necessary skilled care services and medical supplies	100%	$0	$0
– Durable medical equipment First $183 of Medicare-approved amounts*	$0	$0	$183 (Part B deductible)
Remainder of Medicare-approved amounts	80%	20%	$0

* Once you have been billed $183 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 F Details

COST

Medicare Supplement insurance costs include monthly premium payments and may include deductibles, out-of-pocket expenses, copayments and coinsurance. Here is what you can expect to pay with Plan F:

All hospitalization costs beyond the additional 365 days after the Lifetime Reserve are used
All costs after 101 days in a skilled nursing facility
Foreign travel: $250 per calendar year; 20 percent of costs within the first $50,000; all costs thereafter

For more information on costs, get a quick quote or refer to the Outline of Medicare Supplement Coverage.

WHAT’S INCLUDED

Basic benefits:
- Part A coinsurance for hospitalization services plus coverage for 365 additional days after Medicare benefits end
- Part B coinsurance for medical expenses (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services
- First three pints of blood each year
- Part A coinsurance for hospice care
Skilled nursing facility coinsurance
Part A deductible
Part B deductible
Part B excess charges (100%)
Foreign travel emergency care

More Plan Details

It’s important to know the critical features of the Medicare Supplement insurance plan you are considering. The Outline of Medicare Supplement Coverage provides brief descriptions of the basic provisions of the Medicare Supplement insurance plans, as well as details on policy renewability, benefit exclusions and coverage limitations.

PLAN RENEWALS

Blue Cross and Blue Shield of Texas (BCBSTX) will never terminate or refuse to renew your Medicare Supplement Insurance policy because of the condition of your health. However, to protect you and the rights of all policy holders, there are situations when a Medicare Supplement insurance plan may be terminated or a renewal refused:

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	Plan Pays	You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	$1,316 (Part A Deductible)	$0
61st through 90th day	All but $329	$329 a day	$0
91st day and after: — While using 60 Lifetime Reserve days — Once Lifetime Reserve days are used: Additional 365 days	All but $658 $0	$658 a day 100% of Medicare eligible expenses	$0 $0**
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
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	Up to $164.50 a day	$0
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	Three 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 very limited copayment/coinsurance for outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

*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.

** 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.

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
Remainder of Medicare-approved amounts	Generally 80%	Generally 20%	$0
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	100%	$0
BLOOD
First three pints	$0	All costs	$0
Next $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
Remainder of Medicare-approved amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES—TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 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.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
— Medically necessary skilled care services and medical supplies	100%	$0	$0
— Durable medical equipment First $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
— Durable medical equipment Remainder of Medicare-approved amounts	80%	20%	$0

* Once you have been billed $183 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.

OTHER BENEFITS — NOT COVERED BY MEDICARE

Services	Medicare Pays	Plan Pays	You Pay
FOREIGN TRAVEL—NOT COVERED BY MEDICARE: Medically 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

Medicaid Plan F Details

COST

Medicare Supplement insurance costs include monthly premium payments and may include deductibles, out-of-pocket expenses, copayments and coinsurance. Here is what you can expect to pay with Plan F:

All hospitalization costs beyond the additional 365 days after the Lifetime Reserve are used
All costs after 101 days in a skilled nursing facility
Foreign travel: $250 per calendar year; 20 percent of costs within the first $50,000; all costs thereafter

For more information on costs, get a quick quote or refer to the Outline of Medicare Supplement Coverage.

WHAT’S INCLUDED

Basic benefits:
- Part A coinsurance for hospitalization services plus coverage for 365 additional days after Medicare benefits end
- Part B coinsurance for medical expenses (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services
- First three pints of blood each year
- Part A coinsurance for hospice care
Skilled nursing facility coinsurance
Part A deductible
Part B deductible
Part B excess charges (100%)
Foreign travel emergency care

More Plan Details

It’s important to know the critical features of the Medicare Supplement insurance plan you are considering. The Outline of Medicare Supplement Coverage provides brief descriptions of the basic provisions of the Medicare Supplement insurance plans, as well as details on policy renewability, benefit exclusions and coverage limitations.

PLAN RENEWALS

Blue Cross and Blue Shield of Texas (BCBSTX) will never terminate or refuse to renew your Medicare Supplement Insurance policy because of the condition of your health. However, to protect you and the rights of all policy holders, there are situations when a Medicare Supplement insurance plan may be terminated or a renewal refused:

Failure to pay
Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

Services	Medicare Pays	Plan Pays	You Pay
HOSPITALIZATION*: Semi-private room and board, general nursing, and miscellaneous services and supplies
First 60 days	All but $1,316	$1,316 (Part A Deductible)	$0
61st through 90th day	All but $329	$329 a day	$0
91st day and after: — While using 60 Lifetime Reserve days — Once Lifetime Reserve days are used: Additional 365 days	All but $658 $0	$658 a day 100% of Medicare eligible expenses	$0 $0**
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
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $164.50 a day	Up to $164.50 a day	$0
101st day and after	$0	$0	All costs
BLOOD
First three pints	$0	Three 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 very limited copayment/coinsurance for outpatient drugs and inpatient respite care	Medicare copayment/coinsurance	$0

*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.

** 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.

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

Services	Medicare Pays	Plan Pays	You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
Remainder of Medicare-approved amounts	Generally 80%	Generally 20%	$0
PART B EXCESS CHARGES (above Medicare-approved amounts)
	$0	100%	$0
BLOOD
First three pints	$0	All costs	$0
Next $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
Remainder of Medicare-approved amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES—TESTS FOR DIAGONOSTIC SERVICES
	100%	$0	$0

* Once you have been billed $183 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.

MEDICARE (PARTs A and B)

Services	Medicare Pays	Plan Pays	You Pay
HOME HEALTH CARE MEDICARE-APPROVED SERVICES
— Medically necessary skilled care services and medical supplies	100%	$0	$0
— Durable medical equipment First $183 of Medicare-approved amounts*	$0	$183 (Part B deductible)	$0
— Durable medical equipment Remainder of Medicare-approved amounts	80%	20%	$0

* Once you have been billed $183 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.

OTHER BENEFITS — NOT COVERED BY MEDICARE

Services	Medicare Pays	Plan Pays	You Pay
FOREIGN TRAVEL—NOT COVERED BY MEDICARE: Medically 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

ENROLLMENT IS CLOSED…

OPEN ENROLLMENT PERIOD

November 1 – December 15

ENROLL NOW OPTIONS

COST

WHAT’S INCLUDED

PLAN RENEWALS

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

MEDICARE (PARTs A and B)

OTHER BENEFITS – NOT COVERED BY MEDICARE

COST

WHAT’S INCLUDED

PLAN RENEWALS

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

MEDICARE (PARTs A and B)

COST

WHAT’S INCLUDED

PLAN RENEWALS

HOSPITAL SERVICES PER BENEFIT PERIOD—MEDICARE PART A

MEDICAL SERVICES PER CALENDAR YEAR—MEDICARE PART B

MEDICARE (PARTs A and B)

OTHER BENEFITS — NOT COVERED BY MEDICARE