BLUE MEDICARE
SUPPLEMENT
SM
PLAN F
Your Health Care Benefit Policy
Medicare Supplement insurance plans are offered by Blue Cross and Blue Shield of Illinois, a Division of Health Care
Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association (hereinafter referred to as “Blue Cross and Blue Shield of Illinois” or “BCBSIL”).
300 East Randolph, Chicago, Illinois 60601
CB-45.6 HCSC Rev. 01/23
Blue Cross and Blue Shield, a Division of Health
Care Service Corporation A Mutual Legal
Reserve Company, an Independent Licensee of
the Blue Cross and Blue Shield Association
CB-45.6 HCSC Rev. 01/23 1
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
YOUR RIGHT TO EXAMINE
You have the right to examine this Policy for a 30-day period after it has been issued. If for any reason
you are not satisfied with the Medicare Supplement program described in this Policy, you may return this
Policy to Blue Cross and Blue Shield of Illinois as long as you do so within 30 days of receipt and as long
as you have not filed a claim. Blue Cross and Blue Shield of Illinois will refund any Medicare Supplement
Premiums you paid.
GUARANTEED RENEWABILITY
This Policy cannot be cancelled or not renewed by Blue Cross and Blue Shield of Illinois for any reason
other than non-payment of Medicare Supplement Premiums or a material misrepresentation. However,
Blue Cross and Blue Shield of Illinois may change the amount of Medicare Supplement Premiums due
or automatically increase Medicare Supplement Premiums based on the Policyholder’s age classification.
CB-45.6 HCSC Rev. 01/23 2
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
TABLE OF CONTENTS
A MESSAGE TO THE POLICYHOLDER ..................................................................................... 3
GLOSSARY ................................................................................................................................. 4
GENERAL INFORMATION ABOUT THIS POLICY ...................................................................... 7
Who is covered by this Policy?
When does my coverage start and end?
Notice.
Can you reinstate my Policy?
What does this Policy cover?
What if I become eligible for Medicaid?
How does this Policy supplement Medicare?
Medicare must approve service.
YOUR PART A SUPPLEMENT HOSPITAL BENEFITS .............................................................. 9
What do we mean by ‘‘Hospital”?
What do we mean by ‘‘Skilled Nursing Facility”?
What are my Hospital benefits?
What are my Hospice and Inpatient Respite Care benefits?
How are Medicare Benefit Periods calculated?
What coverage do I have?
What Inpatient Hospital services are covered?
What do we mean by ‘‘Medically Necessary”?
What if I need medical care in a Foreign country?
YOUR MEDICAL/SURGICAL BENEFITS .................................................................................... 12
How many times may I get benefits when I see my Physician?
What does this Policy pay?
Am I covered for Emergency Care?
What other services are covered?
What is the Outpatient prospective payment system?
How are Services paid under the Outpatient prospective payment system?
LIMITS ON COVERAGE ............................................................................................................. 14
What other expenses are not covered?
MEDICARE SUPPLEMENT PREMIUMS..................................................................................... 16
When are Medicare Supplement Premiums due?
In case of death.
What if I’m late paying my Medicare Supplement Premium?
How are my Medicare Supplement Premiums determined?
ADDITIONAL POLICY INFORMATION ............................................................................................... 17
How do I use my ID Card?
Can I choose my Physician and Hospital?
How do I file claims?
What if I can’t file my claim in time?
Who receives claim payments?
In case of death.
What if my claim is denied?
Department of Insurance addresses.
Can I assign my coverage?
Do you exchange medical information about me?
What about misstatements on my application?
CB-45.6 HCSC Rev. 01/23 3
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
What limits are there on legal action?
May I vote at the Annual Meeting?
CB-45.6 HCSC Rev. 01/23 4
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
A message to the Policyholder from
BLUE CROSS AND BLUE SHIELD OF ILLINOIS
Blue Cross and Blue Shield of Illinois agrees to pay certain Hospital, Skilled Nursing Facility, Physician and
medical/surgical charges you incur provided you pay your Medicare Supplement Premiums for this coverage.
This agreement is subject to all terms and conditions of this Policy.
THIS POLICY REPLACES ANY PREVIOUS POLICY OR CERTIFICATE YOU MAY HAVE BEEN ISSUED BY
BLUE CROSS AND BLUE SHIELD OF ILLINOIS.
This Policy will explain your Medicare Supplement insurance. Be sure to read this Policy very carefully. It
explains your rights and responsibilities and the rights and responsibilities of Blue Cross and Blue Shield of
Illinois.
In this Policy, you, your and yours mean the Policyholder. That’s the person insured by this Policy. We, us,
and our mean Blue Cross and Blue Shield of Illinois.
This Policy, your application for coverage, and any endorsements or riders attached to this Policy make up your
entire agreement with us.
Welcome to Blue Cross and Blue Shield of Illinois! We are happy to have you as a Member and pledge you our
best service.
Sincerely,
Blue Cross and Blue Shield of Illinois
A Division of Health Care Service Corporation
A Mutual Legal Reserve Company
Stephen Harris, President Illinois Division
CB-45.6 HCSC Rev. 01/23 5
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
GLOSSARY
You, the Policyholder, are the only insured. You must be covered by Medicare. The definitions stated below will
apply to the following terms when used in this Policy:
‘‘Accidental Injury’’ means a bodily injury you receive as the direct result of an accident. An Accidental Injury
cannot be the result of a disease or other bodily condition.
“Assignment” In the original Medicare plan, this means a doctor agrees to accept the Medicare-approved
amount as full payment. If you are in the original Medicare plan, it can save you money if your doctor accepts
Assignment. You still pay your share of the cost of the doctor's visit.
“Calendar Year” means the period commencing on January 1
st
and ending on the next succeeding December
31
st
, inclusive.
“Calendar Year Deductible” means the first dollar amount of your Part A and/or Part B charges incurred
outside of the United States during a Calendar Year.
“Coinsurance” means the percentage of the Medicare approved amount that a member pays after meeting the
Medicare Deductible.
“Effective Date” (also referred to as “Coverage Date”) means the date that the Member is enrolled on our
membership records for coverage under this Policy.
“Emergency Care” means care given for a medical emergency when you believe that your health is in serious
danger when every second counts.
“Excess Charges” If you are in the original Medicare plan, this is the difference between a doctor or other health
care Provider actual charge (which may be limited by Medicare or the state) and the Medicare-approved payment
amount.
“Explanation of Medicare Benefits Form” means the Medicare notice of what medical services or supplies were
covered, what charges were approved, how much was credited toward the Part A or B deductible, and the amount
that Medicare paid.
“Foreign” means any areas not included in the United States.
“Home Health Agency” means an organization that gives home care services, like skilled nursing care, physical
therapy, occupational therapy, speech therapy, and personal care by home health aides.
“Home Health Care” means limited part-time or intermittent skilled nursing care and home health aide services,
physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical
equipment (such as wheelchairs, Hospital beds, oxygen, and walkers), medical supplies, and other services.
“Hospice” means a Medicare-certified program that provides care and support to terminally ill patients and
their families.
‘‘Hospital’’ means an institution primarily engaged in providing, by or under the supervision of a licensed
Physician or staff of licensed Physicians, inpatient diagnostic and therapeutic services or rehabilitation services,
as further described in the Section of this Policy entitled “What Inpatient Hospital Services Are Covered”.
“Identification Card” (ID Card) means the card BCBSIL issues identifying the Member as a BCBSIL Member.
This card should be presented with your Medicare card whenever you receive health care services.
CB-45.6 HCSC Rev. 01/23 6
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
“Inpatient Hospital Care” means health care that you get when you are admitted to a Hospital.
“Lifetime Reserve Days” In the original Medicare plan, 60 days that Medicare will pay for when you are in a
Hospital more than 90 days during a benefit period. These 60 reserve days can be used only once during your
lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily Coinsurance.
“Medicaid” means a joint federal and state program that helps with medical costs for some people with low
incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are
covered if you qualify for both Medicare and Medicaid.
“Medically Necessary” means health care services or supplies needed to diagnose or treat a Sickness,
injury, condition, disease, or its symptoms and that meet accepted standards of medicine as set forth in this
Policy under section “What Do We Mean By Medically Necessary”.
‘‘Medicare’’ means the federal health insurance program for: people 65 years of age or older, certain younger people
with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant,
sometimes called ESRD).
‘Medicare Benefit Period’’ means the way that original Medicare measures your use of Hospital and Skilled
Nursing Facility (SNF) services. A benefit period begins the day you're admitted as an inpatient in a Hospital or SNF.
The benefit period ends when you haven't gotten any Inpatient Hospital Care (or skilled care in a SNF) for 60 days
in a row. If you go into a Hospital or a SNF after one benefit period has ended, a new benefit period begins. There's
no limit to the number of benefit periods.
‘‘Medicare Eligible Expense’’ means expenses of the kinds covered by Medicare Parts A and B, to the extent
recognized as reasonable and Medically Necessary by Medicare.
“Medicare Part A Benefits” means Hospital insurance that pays for inpatient Hospital stays, care in a Skilled
Nursing Facility, Hospice care, and some Home Health Care.
“Medicare Part B Benefits” means Medicare medical insurance that helps pay for doctor’s services, Outpatient
Hospital care, durable medical equipment, and some medical services that are not covered by Part A.
“Medicare Supplement” is also referred to as a Medigap policy. It is sold by private insurance companies to
fill "gaps" in original Medicare plan coverage. Except in Minnesota, Massachusetts, and Wisconsin, there are
10 standardized policies labeled Plan A through Plan N. Medigap policies only work with the original Medicare
plan.
“Medicare Supplement Benefits” means payments for health care services provided to a Member according
to the terms of this Policy.
“Medicare Supplement Premium” means the periodic payment to an insurance company or a health care
plan for health or prescription drug coverage.
“Member” means the insured person who is eligible for coverage under this Policy.
“Outpatient” means medical or surgical care you get from a Hospital when your doctor hasn’t written an
order to admit to the Hospital as an inpatient. Outpatient Hospital care may include emergency department
services, observation services, Outpatient surgery, lab tests, or X-rays. Your care may be considered
Outpatient Hospital care even if you spend the night at the Hospital.
‘‘Physician’’ means any types of professionals that are legally authorized by the state to practice medicine,
regardless of whether they are Medicare, Medicaid, or Children's Health Insurance Program (CHIP)
Providers.
CB-45.6 HCSC Rev. 01/23 7
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
‘‘Policyholder’’ means the person to whom this Policy is issued.
“Provider” means a general term for a person, practitioner, institution, or facility that is licensed by the state
or jurisdiction and while the insurance is in force.
“Sickness” means illness or disease of an insured person which first manifests itself after the Effective Date of
insurance and while the insurance is in force.
‘‘Skilled Nursing Facility’’ means a nursing facility with the staff and equipment to give skilled nursing care and/or
skilled rehabilitation services and other related health services.
“Tobacco User” is a person who is permitted under state and federal law to legally use Tobacco, with Tobacco
use (other than religious or ceremonial use of Tobacco) occurring on average of four or more times per week
that last occurred within the past six months. Tobacco products include but are not limited to: cigarettes, cigars,
smokeless tobacco products, electronic cigarettes, dissolvable tobacco products and vaping.
“United States” means all of the states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam,
American Samoa, and the Northern Mariana Islands.
CB-45.6 HCSC Rev. 01/23 8
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
GENERAL INFORMATION ABOUT THIS POLICY
WHO IS COVERED BY THIS POLICY?
You, the Policyholder, are the only insured. You must be covered by Medicare Parts A and B. There is no family
coverage.
WHEN DOES MY COVERAGE START AND END?
Coverage starts on your Effective Date (your ‘‘Coverage Date’’). However, inpatient benefits are covered
only when your admission occurs on or after your Coverage Date. Your Coverage Date is shown on your
ID Card. Your Medicare Supplement Premium must be paid before coverage can begin.
You may cancel at any time for any reason. Just send us written notice or call the number on the back of
your ID Card. Your benefits will end on the date your Policy is cancelled.
We may cancel your Policy if:
• you don’t pay Medicare Supplement Premiums when due; or
• you make a material misrepresentation; or
• you are no longer eligible for Medicare Parts A and B.
We’ll send you written notice if your Policy is going to be cancelled.
NOTICE
Written notice to us must be sent to:
Blue Medicare Supplement
c/o Member Services
P.O. Box 3388
Scranton, PA 18505
CAN YOU REINSTATE MY POLICY?
Yes. If we cancel your Policy because you don’t pay a Medicare Supplement Premium you may reapply.
We will reinstate your Policy:
1.
If we accept your application, and
2.
We bill you, and
3.
You pay, and we accept the billed Medicare Supplement Premium.
However, we’ll only cover treatment for:
• Accidental Injuries received after the date we accept payment; and
• Sicknesses beginning more than 10 days after we accept payment.
WHAT DOES THIS POLICY COVER?
This Policy provides Hospital service benefits and medical/surgical coverage. The
Hospital benefits cover Hospital or Skilled Nursing Facility care.
Medical/surgical coverage includes Physician’s visits. It also covers most Outpatient services.
CB-45.6 HCSC Rev. 01/23 9
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
WHAT IF I BECOME ELIGIBLE FOR MEDICAID?
If you become eligible for benefits under Medicaid, you may request that we suspend your coverage. You
may request that we suspend your coverage by giving us written notice or calling within 90 days after
the date you become eligible for Medicaid.
When we ‘‘suspend coverage’’ this means that we will no longer provide benefits under this Policy and
will refund any portion of your unused Medicare Supplement Premium to you. We will not suspend
your coverage for more than 24 months.
We will resume your coverage when your eligibility for benefits under Medicaid ends. However, you must
give us written notice within 90 days after the date you lose your Medicaid eligibility. When we reinstitute
your coverage, your Medicare Supplement Premiums and benefits will be the same or similar to the
Medicare Supplement Premiums and benefits you would have had if you had not suspended coverage
under this Policy. You will not be subject to a pre-existing conditions waiting period.
HOW DOES THIS POLICY SUPPLEMENT MEDICARE?
This Medicare Supplement Plan F is a full supplement to Medicare as defined in the Illinois Insurance
Code. This Policy pays your Medicare Part B deductible and it pays all remaining eligible charges after
Medicare makes payment - up to the limiting charge established by law and shown on your Medicare
Explanation of Benefits.
This Policy also pays your Medicare Part A Inpatient Hospital deductible. We’ll pay it even if Medicare
raises it.
MEDICARE MUST APPROVE SERVICE
We only pay for services which have been approved by Medicare.
CB-45.6 HCSC Rev. 01/23 10
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
YOUR PART A SUPPLEMENT HOSPITAL BENEFITS
You’re covered for Hospital stays. You’re also covered for Skilled Nursing Facility stays. Remember,
you’re covered only for care that begins on or after your Coverage Date.
WHAT DO WE MEAN BY ‘‘HOSPITAL”?
A Hospital is a properly licensed institution for care of the sick. It must:
• be supervised by a licensed Physician or staff of licensed Physicians;
• regularly provide bedside nursing by registered graduate professional nurses; and
• be approved by Medicare.
Rest homes or nursing homes are not considered Hospitals. Neither are institutions mainly offering:
• custodial, educational or rehabilitory care;
• care of the aged; or
• treatment for substance use disorder or alcoholism.
WHAT DO WE MEAN BY “SKILLED NURSING FACILITY”?
Skilled Nursing Facility is a properly licensed institution, that:
• is approved for payment of Medicare benefits or qualified for approval of Medicare benefits;
• is supervised by a licensed Physician or a staff of licensed Physicians;
• provides 24-hour skilled nursing care by, or is supervised by, registered graduate nurses;
and
• keeps a daily medical record for each patient.
Rest and retirement homes are not considered Skilled Nursing Facilities. Neither are institutions mainly
offering:
• custodial or educational care;
• care of the aged;
• care and treatment of mental illness; or
• treatment for substance use disorder or alcoholism.
WHAT ARE MY HOSPITAL BENEFITS?
Under this Policy, you have:
• Benefits covering the Medicare Part A inpatient deductible. This year’s deductible is shown in
the Outline of Coverage. We pay this deductible amount for you.
• Skilled Nursing Facility benefits each year. We will pay your copayments.
WHAT ARE MY HOSPICE AND INPATIENT RESPITE CARE BENEFITS?
Under this Policy:
• If the Member is receiving Hospice Care, Blue Cross and Blue Shield of Illinois will provide
benefits for the cost sharing for all Part A Medicare Eligible Expenses and respite care expenses.
• We pay the cost of the Medicare coinsurance/copayments.
CB-45.6 HCSC Rev. 01/23 11
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
HOW ARE MEDICARE BENEFIT PERIODS CALCULATED?
A benefit period begins on the first day you receive Inpatient Hospital Care and ends after you have
been out of the Hospital and have not received care in a Skilled Nursing Facility for 60 days in a row.
WHAT COVERAGE DO I HAVE?
For Hospital Stays
When you enter the Hospital for a Medicare eligible admission, Medicare will pay for the first 60 days
starting on the day you are admitted. Medicare will pay all of your eligible expenses for the first 60 days
except for the Medicare Part A deductible. We pay this Part A deductible for you.
If you are in the Hospital for more than 60 days, Medicare will no longer pay your covered expenses in
full. From the 61st through the 90th day, Medicare covers all eligible expenses except for a certain amount
which is deducted each day. The amount which is deducted each day is equal to
1/4 of the Medicare Part
A deductible. The actual dollar amount is shown in your Outline of Coverage. We pay this daily amount
from the 61st day through the 90th day for you.
Medicare will stop making payment after the 90th day unless you choose to use your Medicare
reserve days. You have 60 Medicare reserve days. These are extra days available to you if you must be
in the Hospital for more than 90 days. You may choose to use these days all at once or a few at a time.
Once you use your reserve days, they are not renewed by Medicare.
If you choose to use your reserve days, Medicare will continue to pay all eligible expenses except for a
certain amount which is deducted each day. The amount which is deducted each day is equal to
1/2 of the
Medicare Part A deductible. The actual dollar amount is shown in your Outline of Coverage. We will pay
this daily amount for you, even if you choose not to use your Medicare reserve days.
We will pay this daily amount for you from the 91st day through the 150th day of your Hospital
stay. Then we will pay 100% of the Medicare Eligible Expense beginning on the 151st day for an
additional 365 days.
For Skilled Nursing Facility Confinement
To receive benefits for services in a Skilled Nursing Facility, you must have been in the Hospital for at
least 3 days in a row (not counting the day of discharge) before you are admitted to the Skilled Nursing
Facility. You also must be admitted to the Skilled Nursing Facility within 30 days from the day you are
discharged from the Hospital.
Medicare will pay the first 20 days of your approved Skilled Nursing Facility stay in full.
Beginning on the 21st day through the 100th day, Medicare will pay all of your eligible expenses except
for a certain amount which is deducted each day. This daily amount is equal to
1/8 of the Medicare Part
A deductible. The actual dollar amount is shown in your Outline of Coverage. We pay this daily amount
for you.
For Hospice Care
To receive benefits for services for Hospice Care and inpatient respite care, you must meet Medicare’s
requirements, including a doctor’s certification of terminal illness. You can receive benefits for a stay in a
Medicare-approved facility, such as a Hospice facility, Hospital or nursing home, up to 5 days each time
you get respite care.
Medicare will pay all of your approved Hospice Care in full with limited Coinsurance/copayments for
Outpatient drugs and inpatient respite care.
We pay the cost of the Medicare Part A Coinsurance/copayment.
CB-45.6 HCSC Rev. 01/23 12
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
For Blood
When you need blood Medicare will pay the cost of all but the first 3 pints each year. We pay the cost of
the first 3 pints, if you do not replace the blood you received.
WHAT INPATIENT HOSPITAL SERVICES ARE COVERED?
You’re covered for all inpatient Hospital services. However, you must be admitted to the Hospital on or
after your Coverage Date. Also, the services must be:
• Medically Necessary;
• approved by Medicare; and
• under a Physician’s direction.
Typical inpatient charges are charges for bed and board or nursing care. You’re covered for these
charges and for other services, such as:
• use of operating and treatment rooms;
• inpatient drugs;
• surgical dressings;
• blood processing;
• diagnostic services; and
• administration of whole blood and blood components, when there is a charge.
WHAT DO WE MEAN BY ‘‘MEDICALLY NECESSARY”?
The fact that your Physician orders a medical service does not always mean that the service is Medically
Necessary or that the charge will be approved. By ‘‘Medically Necessary’’ we mean that the services:
• are required to diagnose or treat your Sickness or injury;
• meet generally accepted standards of medical practice; and
• are provided in the most cost-effective manner.
For Hospitalization to be Medically Necessary, you must need care that couldn’t be given to you as an
Outpatient. A Hospitalization primarily for custodial care would not qualify for benefits.
For Medicare-approved services we will never use standards more restrictive than Medicare’s.
WHAT IF I NEED MEDICAL CARE IN A FOREIGN COUNTRY?
If you are in a Foreign country and receive emergency treatment during the first 60 days of your trip, we
will pay 80% of the eligible charges for Medically Necessary services. If you are Hospitalized due to an
emergency, we will pay 80% of the eligible charges for Medically Necessary services as long as your
Hospitalization occurred during the first 60 days of your trip.
Your benefits for the services you receive in a Foreign country are subject to a $250.00 Calendar Year
Deductible. You must pay this amount.
The total lifetime maximum that we will pay for services received in a Foreign country is $50,000.00.
CB-45.6 HCSC Rev. 01/23 13
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
YOUR MEDICAL/SURGICAL BENEFITS
This section of your Policy describes benefits for services provided and charged for by a properly licensed
medical professional or by a Hospital when rendered on an Outpatient basis. Charges must be approved
by Medicare.
HOW MANY TIMES MAY I GET BENEFITS WHEN I SEE MY PHYSICIAN?
You’re covered for all Medicare approved visits. Most visits will be office appointments. However, we also cover
house calls or visits a Physician makes to your Hospital or Skilled Nursing Facility. You’re also covered for
Emergency Care.
Visits for routine physicals aren’t covered because Medicare doesn’t cover them.
WHAT DOES THIS POLICY PAY?
We pay:
• Your annual Medicare Part B Deductible;
• 100% of all eligible charges remaining after Medicare makes payment - up to the limiting charge
established by law and shown on your Medicare Explanation of Benefits.
You pay:
• Nothing (except for any charges that are not approved by Medicare).
AM I COVERED FOR EMERGENCY CARE?
Yes, you’re covered for Emergency Care if charges are approved by Medicare.
WHAT OTHER SERVICES ARE COVERED?
We pay charges for the services listed below. However, services are covered only if they’re approved by
Medicare.
Surgery and anesthesia
You’re covered for surgery in or out of the Hospital. This includes surgery in a properly licensed facility
specializing in Outpatient surgery.
You’re covered for anesthesia administered by a medical Provider other than the operating surgeon.
Oral surgery
Consultations
We’ll pay for a second surgical opinion prior to elective surgery.
Pre-admission testing
If you’re scheduled for inpatient surgery, we’ll cover pre-admission testing if:
• surgery has been scheduled and your room reserved;
• testing is done by the Hospital personnel or a Physician’s staff;
• the tests won’t be repeated once you’re admitted to the Hospital; and
• the tests would be covered by this Policy if they were done when you were an inpatient.
CB-45.6 HCSC Rev. 01/23 14
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
EEGs and EKGs
X-Rays
You’re covered for x-rays ordered by a qualified professional.
Clinical and surgical pathology
Speech and physical therapy
Radiation and chemotherapy
Diagnostic services
Outpatient renal dialysis treatments
You’re covered for treatments at a Hospital Outpatient, in a licensed dialysis facility or at home.
Mental health care
You’re covered for Outpatient visits for the treatment of mental illness. Treatment may be in the Physician’s
office or Hospital Outpatient department.
Medical equipment
You’re covered for the rental or purchase of medical equipment that you need. You’re also
covered for internal or permanent devices, such as:
• cardiac valves,
• pacemakers,
• mandibular reconstruction devices, and
• leg, back, arm or neck braces.
Prosthetic devices
Purchase of cataract lenses, and the purchase and adjustments of prosthetic devices, are covered.
Ambulance service
Organ transplants
Human organ and tissue transplants are covered if you’re the recipient.
Remember: These services are covered only when they are approved by Medicare.
WHAT IS THE OUTPATIENT PROSPECTIVE PAYMENT SYSTEM?
The Outpatient prospective payment system consists of specific payment amounts, set by Medicare, for
certain Outpatient services you receive from a Hospital, community mental health center, or other entity
providing Outpatient services. Medicare has also set a specific copayment amount that must be paid for
these services. Before receiving an Outpatient service you should check with your Physician or Hospital to
see if it will be paid under the Outpatient prospective payment system.
HOW ARE SERVICES PAID UNDER THE OUTPATIENT PROSPECTIVE PAYMENT SYSTEM?
We will pay your Medicare Part B Deductible and the copayment for these Outpatient services.
CB-45.6 HCSC Rev. 01/23 15
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
LIMITS ON COVERAGE
WHAT OTHER EXPENSES ARE NOT COVERED?
We pay only charges approved by MEDICARE. We won’t pay for services and supplies that are not
specifically mentioned in this Policy. Other services we do not cover are:
—
Employment-related problems
We don’t pay for treatment of Accidental Injuries or Sickness if they’re:
• related to work; or
• covered by an insurance or worker’s compensation law.
This is true even if you decide not to claim benefits under the law.
—
Treatment covered or provided by Government Programs
The only exception is for medical assistance under Article V, VI, or VII of the Illinois Public Aid Code.
—
Treatment for war-related injuries and Sickness
This limitation applies to injuries and Sicknesses caused by war or acts of war, whether declared or
undeclared.
—
Treatment provided by employers or unions
This limitation applies to treatment received from medical and dental departments maintained by or
for:
• an employer;
• a mutual benefit association;
• a labor union;
• a trustee; or
• a similar entity.
—
Free treatment
We don’t pay for free treatment, or treatment that would have been free if you were not insured under
this Policy.
—
Custodial Care
Custodial care means services which do not require technical skills or professional training. Assistance
with activities of daily living (bathing, feeding, meal preparation) is an example of custodial care.
—
Services you no longer need
—
Routine physical examinations
—
Cosmetic surgery
The only exception is for oral surgery.
—
Eye examinations
We don’t pay for eye exams or for eye glasses or contact lenses.
—
Hearing aids
We don’t pay for hearing aids or exams for their prescription and fitting.
—
Foot care
We don’t pay for routine foot care or the treatment of flat feet or subluxations of the foot.
CB-45.6 HCSC Rev. 01/23 16
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
—
Miscellaneous fees
We don’t pay for fees charged to complete a claim form or because you didn’t keep a scheduled
appointment.
—
Services from family members
We don’t pay for services performed by a member of your immediate family.
—
Outpatient prescription drugs
—
Private duty nursing services
—
At-home recovery services
—
Preventive medical care
CB-45.6 HCSC Rev. 01/23 17
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
MEDICARE SUPPLEMENT PREMIUMS
WHEN ARE MEDICARE SUPPLEMENT PREMIUMS DUE?
Your first Medicare Supplement Premium is due on the Effective Date of this Policy. Later Medicare
Supplement Premiums are due on the first day of the Medicare Supplement Premium period. Medicare
Supplement Premium periods and due dates are shown on your bill.
IN CASE OF DEATH
We’ll refund unearned Medicare Supplement Premiums to your estate or authorized individual. A
representative of your estate or authorized individual must send us a written request or call.
WHAT IF I’M LATE PAYING MY MEDICARE SUPPLEMENT PREMIUM?
After you have paid your first Medicare Supplement Premium you have a 31-day grace period after the
due date to pay your future Medicare Supplement Premiums. You must pay before the grace period ends.
If you don’t, we won’t pay benefits during those 31 days. We’ll also cancel your Policy at the end of the
grace period.
HOW ARE MY MEDICARE SUPPLEMENT PREMIUMS DETERMINED?
Your Medicare Supplement Premium may depend on your age, gender, Tobacco User status and/or
geographical location.
We may raise your Medicare Supplement Premiums if we increase your benefits under this Policy or your
age, gender, Tobacco User status and/or geographical category changes. When completing the
application, you may need to make a gender selection. Additionally, if you meet the definition of a Tobacco
User, you may pay a higher Medicare Supplement Premium for your health coverage. We may be
required by law to add to your benefits, or we may increase them for another reason. We may also raise
your Medicare Supplement Premium on any Policy anniversary or Medicare Supplement Premium due
date.
If we raise Medicare Supplement Premiums for any reason, we’ll give you 30 days prior written notice.
We’ll send any notice to you using the address on your application. Please notify us in writing or call 1-877-
384-9297 if you change your address.
Premium Discounts
Blue Cross and Blue Shield of Illinois Medicare Supplement premium discounts may be available. Eligibility
criteria are described below. If you are eligible for a discount, the discount will be applied to your next bill
and remain in effect as long as you are enrolled in your Blue Cross and Blue Shield of Illinois Medicare
Supplement plan.
Discounts cannot be combined; only one type of discount per member permitted.
Household Discount
You reside with a spouse or civil union/domestic partner or have resided with as many as three adults age
60 or older for the last 12 months. Applies to Blue Cross and Blue Shield of Illinois Medicare Supplement
policies issued with an effective date on or after May 1, 2019.
CB-45.6 HCSC Rev. 01/23 18
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
Continue with Blue Discount
You had commercial group or individual health insurance coverage with a Blue Cross and Blue Shield Plan
issued in Illinois, Montana, New Mexico, Oklahoma or Texas and that coverage was within one year of
your Blue Cross and Blue Shield of Illinois Medicare Supplement policy becoming effective. Applies to Blue
Cross and Blue Shield of Illinois Medicare Supplement policies issued with an effective date on or after
April 1, 2022.
CB-45.6 HCSC Rev. 01/23 19
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
ADDITIONAL POLICY INFORMATION
HOW DO I USE MY ID CARD?
Present it when you receive medical services. Your ID Card shows your Policy number and the Effective
Date of your Policy.
Do not lend your ID Card to anyone. If someone uses your ID Card, any payments we make may be
credited against your benefits. We may, but are not required to, try to get the payment back.
CAN I CHOOSE MY PHYSICIAN AND HOSPITAL?
Yes. You select your Physician and all other medical Providers.
We don’t recommend specific medical Providers. We aren’t evaluating the quality or skill of a medical
Provider when we report that the Provider:
• is or isn’t approved by Medicare;
• is or isn’t qualified by Medicare; or
• participates or doesn’t participate in Medicare.
We will not furnish any medical service. We’re not responsible if any Physician or other medical Provider
refuses to serve you. We’re also not responsible for any of their actions.
HOW DO I FILE CLAIMS?
Be sure to use your ID Card when you receive Hospital and medical services. This will speed up claims
processing. Your Hospital and related Physician service claims will be sent to Medicare for you. Medicare
will send your claims to Blue Cross and Blue Shield of Illinois for additional processing.
If you receive services from a Provider that does not accept Medicare Assignment and the Provider will
not file claims on your behalf, you can obtain a Medicare claim form by visiting www.Medicare.gov, or by
contacting Medicare Customer Service, or from any Social Security office. The claim must be submitted
to Medicare first. Once Medicare has processed, you will receive a Medicare Explanation of Benefits that
will tell you what Medicare has paid. Send us a copy of the Medicare Explanation of Benefits within 60
days of receipt.
Be sure to print your Blue Cross and Blue Shield of Illinois ID number at the top. You’ll find the number on
your ID Card.
Please send it to:
Blue Cross and Blue Shield of Illinois
P. O. Box 2620
Chicago, IL 60690-2620
WHAT IF I CAN’T FILE MY CLAIM IN TIME?
File as soon as you can. We’ll still process your claim up to 12 months or one Calendar Year, after the
date of service, if you show us that:
• it wasn’t reasonably possible to file earlier; and
• you filed as soon as you reasonably could.
CB-45.6 HCSC Rev. 01/23 20
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
WHO RECEIVES CLAIM PAYMENTS?
We’ll usually pay your medical Provider if payment is due. Otherwise, we’ll pay you.
You may not ask us not to pay your medical Provider for covered expenses. We won’t be liable to you if
we pay your expenses to your Provider after you ask us not to.
IN CASE OF DEATH
In case of your death, benefits owed to you, will be paid to your estate or authorized individual.
WHAT IF MY CLAIM IS DENIED?
You can call or write and request a review or verbal approval if we deny all or part of your claim. Write to:
Claim Review Section
BlueCross and BlueShield of Illinois
P.O. Box 2401
Chicago, Illinois 60690; or
call 1-877-384-9297
Be sure to write or call within 60 days of denial. Within 30 days of asking for a review, you may send more
information or comments.
You may also review our records. However, you must make an appointment in writing to do so. You may
have someone represent you. We must have your representative’s name in writing. Within 60 days of your
review request, we’ll:
• send you our decision on the claim; or
• notify you that we’ll need another 60 days.
A review may not take more than 120 days, even if you request it.
DEPARTMENT OF INSURANCE ADDRESSES
You may discuss your claim with the Department of Insurance. The addresses of the Department’s
Consumer Divisions are:
Illinois Department of Insurance
122 South Michigan Ave, 19
th
Floor
Chicago, Illinois 60603
or
Illinois Department of Insurance
Consumer Services Section
320 West Washington Street
Springfield, Illinois 62767
CAN I ASSIGN MY COVERAGE?
No. Rights under this Policy aren’t assignable. That means you can’t give your rights to someone else.
You’ll lose your coverage if you allow someone else to claim benefits under your Policy.
CB-45.6 HCSC Rev. 01/23 21
Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company,
an
Independent Licensee of the Blue Cross and
Blue Shield Association
DO YOU EXCHANGE MEDICAL INFORMATION ABOUT ME?
Yes. We may exchange medical information with:
• anyone who provides medical services and supplies to you;
• other Blue Cross or Blue Shield plans;
• other insurance companies;
• employee benefit associations;
• governmental bodies or programs; or
• any other person or group (only for the purpose of processing and paying claims).
We may only ask about or give information on:
• a problem for which you’re claiming benefits;
• your medical history, if relevant; or
• any benefits you’ve received.
WHAT ABOUT MISSTATEMENTS ON MY APPLICATION?
If a misstatement on your application affects your coverage, we’ll use the correct fact to decide your
benefits.
Medicare Supplement Premiums are based on your correct age, gender, Tobacco User status and/or
geographical location. If you’ve misstated your age, Tobacco User status and/or geographic location and
the correct Medicare Supplement Premium is more than you’ve been paying, you’ll have to pay us the
amount due from the date your coverage began.
WHAT LIMITS ARE THERE ON LEGAL ACTION?
If we deny a claim, you may choose to sue us for benefits. However, you can’t sue until 60 days after a
claim denial. You must sue within three years of a claim denial. If we extend the time allowed for filing a
claim, that extension won’t affect these limits.
MAY I VOTE AT THE ANNUAL MEETING?
Yes. Our annual meetings are scheduled to be held at 12:30 p.m. on the last Tuesday in October. They’re
held at our main office:
BlueCross and BlueShield of Illinois
300 East Randolph
Chicago, Illinois 60601-5099
You may vote in person or by proxy (a person you have selected to represent you).
CB-45.6 HCSC Rev. 01/23 Blue Cross and Blue Shield of Illinois, a
Division of Health Care Service Corporation,
A Mutual Legal Reserve Company, an
Independent Licensee of the Blue Cross and
Blue Shield Association
