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2008

Medicare &
You

PUBLICATION
CONTENTS:

Introduction

What Is
Medicare?

Medicare's
Gaps

Medicare
Part A Gaps

Medicare
Part B Gaps

Who Pays
First

Making A
Wise Choice

Preferred
Providers

Submitting
Claims

Prescription
Drugs

Medicare
Advantage

Preventive
Care

FEP BlueVision

Discount Drug
Program

Vision Care
Affinity
Program

Blue Health
Connection

Fraud And
Abuse

Terms And
Definitions

If You Have
Questions

Medicare Does Not Pay The Full Cost Of Your Expenses

Although the original Medicare pays for a significant portion of your health care costs, it does not pay the full cost of your expenses. There are still many expenses that you must pay. That's why many retired federal employees choose to supplement their Medicare coverage with Blue Cross and Blue Shield Service Benefit Plan coverage. In many cases, Medicare is your primary coverage (it pays your health care costs first), and your Service Benefit Plan coverage fills the gaps. However, the Service Benefit Plan may be primary and Medicare the secondary payer under certain circumstances. (See the Who Pays First chapter in this publication.)

If You Have Medicare Part A

If you have Medicare Part A as your primary coverage, Medicare provides hospital benefits to help pay for the cost of inpatient care. Although Medicare will pay a portion of the covered expenses, there are still expenses that you will be responsible for paying — you might consider these expenses to be "gaps" in your Medicare coverage. For example, if you receive hospital care, you will be responsible for a Medicare hospital deductible for the first 60 days of hospital care and a daily coinsurance amount for hospital care each day beyond 60 days. Also, Medicare generally does not cover inpatient hospital care received outside of the US.

If you have Medicare Part A and it's your primary coverage, the Blue Cross and Blue Shield Service Benefit Plan provides benefits for covered services applied to your Medicare hospital deductible and coinsurance amounts. If you need to go into the hospital, the Service Benefit Plan hospital copayments and coinsurance amounts for inpatient care are waived including:

• The Standard Option $100 per admission copayment for Preferred hospitals

• The Standard Option $300 per admission copayment for Member and Non-member hospitals

• The Standard Option 30 percent coinsurance for inpatient care in Non-member hospitals

• The Basic Option $100 per day copayment (limit of $500) for Preferred hospitals

And you don't have to get precertification for hospital stays.

If You Have Medicare Part B

If you have Medicare Part B and it's your primary coverage, Medicare provides benefits to help you pay for the cost of medical care, but you will be responsible for paying some of the costs. For example, Medicare will pay 80 percent of most approved physicians' charges, after you pay the $135 Medicare annual deductible.

Your Service Benefit Plan coverage provides benefits for covered services applied to the $135 deductible and the 20 percent coinsurance amounts not covered by Medicare.

Standard Option:

If Medicare Part B is your primary coverage, the annual deductible, copayment and coinsurance amounts are waived, except for prescription drugs. This means that if you need to visit your physician for services covered by the Service Benefit Plan, you don't have to worry about meeting your annual deductible or paying your share (the copayment or coinsurance) of the physician's bill. The Service Benefit Plan will pay the balance, after Medicare's payment, up to the Medicare-allowed amount on assigned claims and up to Medicare's limiting charge on unassigned claims. You eliminate your out-of-pocket costs for covered physician services if you have Standard Option in addition to Medicare Part B and you use a physician who accepts Medicare assignment.

Basic Option:

If Medicare Part B is primary, the Basic Option coinsurance and copayment amounts are only waived if you use Service Benefit Plan Preferred network providers. Prescription drug coinsurance and copayments are not waived.

The Service Benefit Plan will pay the balance after Medicare's payment up to the Medicare-allowed amount on assigned claims and up to Medicare's limiting charge on unassigned claims. When you use Preferred network providers and providers who accept Medicare assignment, you eliminate your out-of-pocket expenses for covered physician services.

Medicare Part D

If Medicare Part D is primary, we will review claims for your prescription drug costs not covered by Medicare Part D and consider them for payment.

If You Have Medicare Part A Only

If you have Medicare Part A only as your primary coverage (without Part B), the Standard Option and Basic Option coinsurance and copayment amounts, and the Standard Option calendar year deductible are not waived.

Standard Option offers a limited benefit for care in qualified skilled nursing facilities for members who also have Medicare Part A. Generally, these facilities include nursing homes that specialize in skilled care and meet Medicare's special qualifying criteria. Medicare Part A covers up to 100 days of post-hospital care in such facilities for each benefit period. Medicare Part A pays for all covered services during the first 20 days. Your Medicare copayment is $128 each day for the 21st through the 100th day of care. If Medicare Part A is your primary coverage and you use an approved facility, your Standard Option coverage covers the $128 Medicare copayment in full through the 30th day of your confinement per benefit period. Your Standard Option skilled nursing facility benefits end after the 30th day of each benefit period covered by Medicare Part A. However, we will pay for medically necessary prescription drugs throughout your stay. (See the Prescription Drugs chapter in this publication for more information.)

Basic Option does not provide benefits for care in a skilled nursing facility.

If You Have Medicare Part B Only

If you have Medicare Part B only as your primary coverage (without Part A) and you need hospitalization, you would still need to pay your inpatient hospital coinsurance or copayment amounts. Also, precertification is required for all planned hospital admissions. Emergency admissions must be certified within two business days after you are admitted.

Standard Option benefits for "reasonable charges" are also provided for care in Department of Veterans Affairs (VA) facilities if the care is for a condition not related to military service and for inpatient medical care in military hospitals by non-active duty military personnel. Basic Option benefits are available only if the VA facility is a Preferred provider. Medicare does not pay for services furnished by VA hospitals or medical facilities except under emergency situations.

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