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Outline of Medicare Supplement Coverage – Cover Page

Standard Medicare Supplement Benefit Plans A, B, F, I, J, L, and SmartChoice High Deductible Plan F

 

Medicare Supplement insurance can be sold in only twelve standard plans plus two high deductible plans.
This chart shows the benefits included in each plan. Every company must make available Plan “A”.
Some plans may not be available in Colorado.

 

BASIC BENEFITS:  Included in Plans A-J.

Hospitalization:  Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

Medical Expenses:  Part B coinsurance (20% of Medicare-approved expenses) or, in the case of hospital outpatient department services under a prospective payment system, applicable Copayments.

Blood:  First three pints of blood each year.

You have the option to purchase an Anthem Medicare Supplement Plan shown in gray.

Download application Anthem Medicare Supplement Application Printable Application ( A, C, F, I and J)

 

† Standard Medicare Supplement Plans F and J have an option called a high deductible Plan F and high deductible Plan J. These high deductible plans pay the same or offer the same benefits a Plans F and J after one has paid a calendar year $1,860 deductible. Benefits from high deductible Plans F and J will not begin until out-of-pocket expenses are $1,860. 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 does not include in Plans F and J, the plan’s separate foreign travel emergency deductible.

Anthem does not offer a high deductible option for Standard Medicare Supplement Plan J.

 

An independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. ® Registered marks Blue Cross and Blue Shield Association. © 2007 Anthem

98775 (1/07)

STANDARD MEDICARE SUPPLEMENT PLANS K AND L

 

 

**Plans K and L provide for different cost-sharing for items and services than Plans A-J.

Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance, and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called "Excess Charges". You will be responsible for paying excess charges.

 

*** The out-of-pocket annual limit will increase for each year for inflation.

 

See Outlines of Coverage for details and exceptions.

PREMIUM INFORMATION

Download application Anthem Medicare Supplement Application Printable Application ( A, C, F, I and J)

Age at Enrollment	PLAN A		PLAN B		PLAN I
	Male	Female	Male	Female	Male	Female
<65 Disabled	M1     $146.30 M2     $134.20	M1     $137.40 M2     $125.90	M1     $159.70 M2     $146.50	M1     $152.10 M2     $139.40	M1     $218.70 M2     $200.50	M1     $207.80 M2     $190.60
65 - 69	M1       $99.60 M2       $91.40	M1       $92.40 M2       $84.70	M1     $113.10 M2     $103.80	M1     $104.60 M2       $95.90	M1     $154.60 M2     $141.80	M1     $143.00 M2     $131.20
70 – 74	M1     $131.30 M2     $109.40	M1     $108.70 M2       $99.60	M1     $135.20 M2     $123.90	M1     $123.20 M2     $113.00	M1     $186.60 M2     $171.10	M1     $169.40 M2     $155.40
75 -79	M1     $136.60 M2     $125.30	M1     $131.90 M2     $114.50	M1     $154.70 M2     $141.80	M1     $141.00 M2     $129.30	M1     $214.30 M2     $196.60	M1     $194.60 M2     $178.50
80+	M1     $151.40 M2     $138.80	M1     $134.40 M2     $123.20	M1     $170.60 M2     $156.50	M1     $152.40 M2     $139.80	M1     $235.90 M2     $216.30	M1     $210.50 M2     $193.10

 

 

Age at Enrollment	PLAN J
	Male	Female
<65 Disabled	M1     $241.90 M2     $220.90	M1     $229.80 M2     $209.90
65 - 69	M1     $171.10 M2     $156.10	M1     $158.20 M2     $144.40
70 – 74	M1     $206.50 M2     $188.50	M1     $187.40 M1 – Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson, Larimer, and Pueblo counties   M2 – El Paso, Mesa, Weld and rural counties   M2     $171.10
75 -79	M1     $237.10 M2     $216.40	M1     $215.30 M2     $196.60
80+	M1     $260.90 M2     $248.30	M1     $232.90 M2     $212.60

Rural counties include: Alamosa, Archuleta, Baca, Bent, Chaffee, Cheyenne, Clear Creek, Conejos, Costilla, Crowley, Custer, Delta, Dolores, Eagle, Elbert, Fremont, Garfield, Gilpin, Grand, Gunnison, Hinsdale, Huerfano, Jackson, Kiowa, Kit Carson, La Plata, Lake, Las Animas, Lincoln, Logan, Mineral, Moffat, Montezuma, Montrose, Morgan, Otero, Ouray, Park, Phillips, Pitkin, Prowers, Rio Blanco, Rio Grande, Routt, Saguache, San Juan, San Miguel, Sedgwick, Summit, Teller, Washington and Yuma.

 

 

PREMIUM INFORMATION

 

These monthly premiums are effective August 1, 2006. We, Anthem Blue Cross and Blue Shield, can only raise your premium if we raise the premium for all policies like yours in this state. Premiums automatically increase as you get older. You can expect your premiums to increase due to changes in age.
Age at Enrollment	Plan F		SmartChoice High Deductible Plan F		Plan L
	Male	Female	Male	Female	Male	Female
<65 Disabled	M1     $188 M2     $171 M3     $154	M1     $162 M2     $147 M3     $132	M1     $63 M2     $57 M3     $51	M1     $54 M2     $49 M3     $44	M1     $120 M2     $109 M3     $ 98	M1     $103 M2     $ 94 M3     $ 85
65	M1     $139 M2     $126 M3     $113	M1     $120 M2     $109 M3     $98	M1     $46 M2     $42 M3     $38	M1     $41 M2     $37 M3     $33	M1     $ 89 M2     $ 81 M3     $ 73	M1     $ 77 M2     $ 70 M3     $ 63
66	M1     $144 M2     $131 M3     $118	M1     $131 M2     $113 M3     $102	M1     $48 M2     $44 M3     $40	M1     $42 M2     $38 M3     $34	M1     $ 92 M2     $ 84 M3     $ 76	M1     $ 79 M2     $ 72 M3     $ 65
67	M1     $151 M2     $137 M3     $123	M1     $130 M2     $118 M3     $106	M1     $51 M2     $46 M3     $41	M1     $44 M2     $40 M3     $36	M1     $ 96 M2     $ 87 M3     $ 78	M1     $ 83 M2     $ 75 M3     $ 68
68	M1     $156 M2     $142 M3     $128	M1     $135 M2     $123 M3     $111	M1     $53 M2     $48 M3     $43	M1     $45 M2     $41 M3     $37	M1     $100 M2     $ 91 M3     $ 82	M1     $ 86 M2     $ 78 M3     $ 70
69	M1     $163 M2     $148 M3     $133	M1     $141 M2     $128 M3     $115	M1     $55 M2     $50 M3     $45	M1     $47 M2     $43 M3     $39	M1     $105 M2     $ 95 M3     $ 86	M1     $ 90 M2     $ 82 M3     $ 74
70	M1     $169 M2     $154 M3     $139	M1     $146 M2     $133 M3     $120	M1     $57 M2     $52 M3     $47	M1     $50 M2     $45 M3     $41	M1     $109 M2     $ 99 M3     $ 89	M1     $ 94 M2     $ 85 M3     $ 77
71	M1     $176 M2     $160 M3     $144	M1     $152 M2     $138 M3     $131	M1     $59 M2     $54 M3     $49	M1     $52 M2     $47 M3     $42	M1     $113 M2     $103 M3     $ 93	M1     $ 98 M2     $ 89 M3     $ 80
72	M1     $184 M2     $167 M3     $150	M1     $158 M2     $144 M3     $130	M1     $62 M2     $56 M3     $50	M1     $53 M2     $48 M3     $43	M1     $118 M2     $107 M3     $ 96	M1     $101 M2     $ 92 M3     $ 83
Premium Information (continued)                                                                                                                                                                        Effective August 1, 2006.
Age at	Plan F		SmartChoice High Deductible Plan F		Plan L
Enrollment	Male	Female	Male	Female	Male	Female
73	M1     $195 M2     $177 M3     $159	M1     $167 M2     $152 M3     $137	M1     $65 M2     $59 M3     $53	M1     $56 M2     $51 M3     $46	M1     $131 M2     $113 M3     $102	M1     $108 M2     $ 98 M3     $ 88
74	M1     $206 M2     $187 M3     $168	M1     $177 M2     $161 M3     $145	M1     $69 M2     $63 M3     $57	M1     $59 M2     $54 M3     $49	M1     $132 M2     $120 M3     $108	M1     $113 M2     $103 M3     $ 93
75	M1     $218 M2     $198 M3     $178	M1     $188 M2     $171 M3     $154	M1     $74 M2     $67 M3     $60	M1     $63 M2     $57 M3     $51	M1     $140 M2     $127 M3     $114	M1     $120 M2     $109 M3     $ 98
76	M1     $230 M2     $209 M3     $188	M1     $199 M2     $181 M3     $163	M1     $77 M2     $70 M3     $63	M1     $67 M2     $61 M3     $55	M1     $147 M2     $134 M3     $121	M1     $128 M2     $116 M3     $104
77	M1     $244 M2     $222 M3     $200	M1     $210 M2     $191 M3     $172	M1     $83 M2     $75 M3     $68	M1     $70 M2     $64 M3     $58	M1     $156 M2     $142 M3     $128	M1     $134 M2     $122 M3     $110
78	M1     $251 M2     $228 M3     $205	M1     $217 M2     $197 M3     $177	M1     $85 M2     $77 M3     $69	M1     $73 M2     $66 M3     $59	M1     $161 M2     $146 M3     $131	M1     $139 M2     $126 M3     $113
79	M1     $259 M2     $235 M3     $212	M1     $223 M2     $203 M3     $183	M1     $87 M2     $79 M3     $71	M1     $75 M2     $68 M3     $61	M1     $166 M2     $151 M3     $136	M1     $143 M2     $130 M3     $117
80+	M1     $267 M2     $243 M3     $219	M1     $230 M2     $209 M3     $188	M1     $90 M2     $82 M3     $74	M1     $77 M2     $70 M3     $63	M1     $171 M2     $155 M3     $140	M1     $147 M2     $134 M3     $121

Plan L available in the following counties: M1 – Adams, Arapahoe, Archuleta, Denver, Douglas, and Jefferson counties M2 – Boulder, Larimer, Pueblo and Broomfield counties M3 – All other counties

Plan F and SmartChoice High Deductible Plan F available in the following counties: M1 – Adams, Arapahoe, Archuleta, Denver, Douglas, and Jefferson counties M2 – Boulder, Larimer, Pueblo and Broomfield counties M3 – All other counties

DISCLOSURES

(all plans)

Use this outline to compare benefits and premiums among policies.

 

 

READ YOUR POLICY VERY CAREFULY

This 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 your insurance company.

 

RIGHT TO RETURN POLICY

If you find you are not satisfied with your policy, you may return it to Anthem Blue Cross and Blue Shield, P.O. Box 9063, Oxnard, CA 93031-9063. 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 minus any amounts paid in claims.

 

 

POLICY REPLACEMENT

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

 

NOTICE

This policy may not fully cover all of your medical costs. Neither Anthem Blue Cross and Blue Shield 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 & You” for more details.

 

 

COMPLETE ANSWERS ARE VERY IMPORTANT

When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history, if required. 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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLANS A & B

Medicare (Part A) – Hospital Services – Per Benefit Period

 

*  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 changes and the amount Medicare would have paid.

 

(Plans A & B continued)             Medicare (Part B) – Medical Services – Per Calendar Year

 

***  Once you have been billed $131 of Medicare – Approved amounts for covered services your Part B       Deductible will have been met for the calendar year.

**** In the case of the hospital outpatient department services under a prospective payment system, generally Medicare pays a pre-determined fee for a specific service, and this plan pays the remaining applicable Copayment.

 

PLAN F

Medicare (Part A) – Hospital Services – Per Benefit Period

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 $992/benefit period*	$992* (Part A Deductible)	$0
61st through 90th day	All but $248 a day	$248/ day	$0
91st day and after: While using 60 lifetime reserve days	All but $496 a day	$496/day	$0
Once lifetime reserve days are used –Additional 365 days	$0	100% of Medicare eligible expenses	$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 3 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 $124 a day	Up to $124 a day	$0
101st day and after	$0	$0	All Costs
BLOOD
First three pints	$0	3 pints	$0
Additional amounts	100%	$0	$0
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited co-insurance for outpatient drugs and inpatient respite care.	$0	Balance

 

*  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 changes and the amount Medicare would have paid.

(Plan F Continued)                     Medicare (Part B) – Medical Services – Per Calendar Year

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment.   First $131 of Medicare-Approved Amounts *** (Part B Deductible)	$0	$131	$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 $131 of Medicare-Approved Amounts ***	$0	$131	$0
Remainder of Medicare-Approved Amounts	80%	20%	$0
CLINICAL LABORATORY SERVICES – Tests For Diagnostic Services	100%	$0	$0
MEDICARE PARTS A AND B
HOME HEALTH CARE MEDICARE-APPROVED SERVICES – Medically necessary skilled care services and medical supplies	100%	$0	$0
Durable medical equipment – first $131 of Medicare-Approved Amounts ***	$0	$131	$0
Remainder of Medicare-Approved Amounts	80%	20%	$0
OTHER BENEFITS – NOT COVERED BY MEDICARE
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 maximum

 

***  Once you have been billed $131 of Medicare-Approved amounts for covered services your Part B deductible will have been met for the calendar year.

**** In the case of the hospital outpatient department services under a prospective payment system, generally Medicare pays a pre-determined fee for a specific service, and this plan pays the remaining applicable Copayment.

 

 

 

PLAN I

 

Medicare (Part A) – Hospital Services – Per Benefit Period

 

*  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 changes and the amount Medicare would have paid.

 

(Plan I Continued)                      Medicare (Part B) – Medical Services – Per Calendar Year

 

***  Once you have been billed $131 of Medicare-Approved amounts for covered services your Part B Deductible will have been met for the calendar year.

**** In the case of the hospital outpatient department services under a prospective payment system, generally Medicare pays a pre-determined fee for a specific service, and this plan pays the remaining applicable Copayment.

 

(Plan I continued)

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
OTHER BENEFITS – NOT COVERED BY MEDICARE
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 maximum

 

PLAN J

 

Medicare (Part A) – Hospital Services – Per Benefit Period

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 $992/benefit period*	$992* (Part A Deductible)	$0
61st through 90th day	All but $248 a day	$248/day	$0
91st day and after: While using 60 lifetime reserve days	All but $496 a day	$496/day	$0
Once lifetime reserve days are used- Additional 365 days	$0	100% of Medicare eligible expenses	$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 3 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 $124 a day	Up to $124 a day	$0