Plan 65 SELECT C (07/06) - Blue Cross Blue Shield of RI · Plan 65 Select F (01/16) Subscriber Agreement PLAN 65 Medicare Supplement Plan Select F MEDICARE SUPPLEMENT SUBSCRIBER AGREEMENT

Plan 65 Select F (01/16)

Subscriber Agreement

PLAN 65 Medicare Supplement Plan Select F

MEDICARE SUPPLEMENT SUBSCRIBER AGREEMENT This agreement describes your benefits from Blue Cross & Blue Shield of Rhode Island. This is a Medicare Supplement Insurance Plan, which provides supplemental coverage for the Original Medicare Plan recipients who are enrolled in Medicare Part A and Medicare Part B. To receive maximum benefits under this agreement, you must obtain Medicare Part A health care services from within the PLAN 65 SELECT HOSPITAL NETWORK unless the services are required for emergency treatment or the services are not available within the PLAN 65 SELECT HOSPITAL NETWORK. To obtain a copy of the PLAN 65 SELECT HOSPITAL NETWORK list please call the Customer Service Department at 401- 459-5000 or 1-800-639-2227. Telecommunications Device for the Deaf users (TTY/TDD) may call 711. See Section 7.0 for the definition of PLAN 65 SELECT HOSPITAL NETWORK.

RENEWABLE This agreement begins on the effective date and remains in effect until December 31. You may renew this agreement each calendar year by paying us the required subscriber fee.

CHANGES IN BENEFITS Benefits under this agreement will change automatically if Medicare eligible expenses change. Subscriber fees may increase or decrease to reflect any change in benefits. We will give you written notice and a description of any change of benefits at least thirty (30) days prior to the effective date of change.

30 DAY RIGHT TO EXAMINE You have the right to return this agreement within thirty (30) days of receipt if you are not satisfied with it for any reason. We will refund your subscriber fee if this agreement is returned within that time.

NOTICE TO BUYER This agreement may not cover all of your medical expenses. Read this agreement CAREFULLY.

Kim A. Keck President and Chief Executive Officer

Nondiscrimination and Language AssistanceBlue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex.

BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us.

If you need these services, contact us at 800-639-2227.

If you believe that BCBSRI has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence RI 02903, or by calling 401-459-5000 or 800-639-2227 (TTY/TDD: 888-252-5051). You can file a grievance in person, by phone or by mail, fax at 401-459-5005, or electronically through our member portal at bcbsri.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

I

English: If you, or someone you’re helping, has questions about Blue Cross & Blue Shield of Rhode Island, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-800-639-2227.

Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue Cross & Blue Shield of Rhode Island, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-800-639-2227.

Portuguese: Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue Cross & Blue Shield of Rhode Island, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-800-639-2227.

Chinese: Blue Cross & Blue Shield of Rhode Island .

1-800-639-2227.

French Creole: Si oumenm oswa yon moun w ap ede gen kesyon konsènan Blue Cross & Blue Shield of Rhode Island, se dwa w pou resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1-800-639-2227.

Cambodian-Mon-Khmer: Blue Cross & Blue Shield of Rhode Island

1-800-639-2227.

French: Si vous, ou quelqu’un que vous êtes en train d’aider, a des questions à propos de Blue Cross & Blue Shield of Rhode Island, vous avez le droit d’obtenir de l’aide et l’information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-800-639-2227.

Italian: Se tu o qualcuno che stai aiutando avete domande su Blue Cross & Blue Shield of Rhode Island, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare 1-800-639-2227.

English:

Spanish:

Portuguese:

Chinese:

French Creole:

Cambodian-Mon-Khmer:

French:

Italian:

Laotian: Blue Cross & Blue

Shield of Rhode Island,

. 1-800-639-2227.

Arabic:

Appendix B: Sample Translated Taglines - Languages Are Listed in Alphabetical Order

Language Translated Taglines 1. Albanian General Tagline:

Nëse ju, ose dikush që po ndihmoni, ka pyetje për [insert SBM program name], keni të drejtë të merrni ndihmë dhe informacion falas në gjuhën tuaj. Për të folur me një përkthyes, telefononi numrin [insert number here].

Tagline for Notices: Ky njoftim përmban informacion të rëndësishëm. Ky njoftim përmban informacion të rëndësishëm për aplikimin ose mbulimin tuaj nëpërmjet [insert SBM program name]. Kontrolloni për data të rëndësishme në këtë njoftim. Mund t'ju duhet të ndërmerrni veprim brenda afatave të caktuara për të mbajtur mbulimin tuaj shëndetësor ose për ndihmën me koston. Keni të drejtë ta merrni këtë informacion dhe ndihmë falas në gjuhën tuaj. Telefononi numrin [insert number here].

2. Amharic General Tagline: እርስዎ፣ ወይም እርስዎ የሚያግዙት ግለሰብ፣ ስለ [insert SBM program name] ጥያቄ ካላችሁ፣ ያለ ምንም ክፍያ በቋንቋዎ እርዳታና መረጃ የማግኘት መብት አላችሁ። ከአስተርጓሚ ጋር ለመነጋገር፣ [insert number here] ይደውሉ።

Tagline for Notices: ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ[insert SBM program name] ሽፋን አስፈላጊ መረጃ አለው። በዚሀ ማስታወቂያ ውስጥ ቁልፍ ቀኖችን ፈልጉ። የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት አለዎት። [insert number here] ይደውሉ።

3. Arabic General Tagline: (، فلديك الحق في الحصول على المساعدة والمعلومات insert SBM program nameإن كان لديك أو لدى شخص تساعده أسئلة بخصوص )

(. insert number hereالضرورية بلغتك من دون اية تكلفة. للتحدث مع مترجم اتصل بـ )

Tagline for Notices: insert SBM programيحوي هذا الاشعار معلومات مهمة بخصوص طلبك للحصول على التغطية من خلال ) يحوي هذا الاشعار معلومات هامة.

name here ابحث عن التواريخ الهامة في هذا الاشعار. قد تحتاج لاتخاذ اجراء في تواريخ معينة للحفاظ على تغطيتك الصحية او للمساعدة في دفع .) (.insert number hereلمعلومات والمساعدة بلغتك من دون أي تكلفة. اتصل بـ )التكاليف. لك الحق في الحصور على ا

4. Armenian General Tagline: Եթե Դուք կամ Ձեր կողմից օգնություն ստացող անձը հարցեր ունի [insert SBM program name] մասին, Դուք իրավունք ունեք անվճար օգնություն և տեղեկություններ ստանալու Ձեր նախընտրած լեզվով։ Թարգմանչի հետ խոսելու համար զանգահարե՛ք [insert number here]։

Blue Cross & Blue Shield of Rhode Island


































.1-800-639-2227












Russian:

Rhode Island Language Assistance Taglines:

English If you, or someone you’re helping, has questions about Blue Cross & Blue Shield of Rhode Island, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1‐800‐267‐0439.

1. Spanish Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue Cross & Blue Shield of Rhode Island, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1‐800‐267‐0439.

2. Portuguese Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue Cross & Blue Shield of Rhode Island, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1‐800‐267‐0439.

3. Chinese 如果您，或是您正在協助的對象，有關於[插入SBM項目的名稱 Blue Cross & Blue Shield of Rhode Island 方面的問題，您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話在

此插入數字1‐800‐267‐0439。 4. French

Creole Si oumenm oswa yon moun w ap ede gen kesyon konsènan Blue Cross & Blue Shield of Rhode Island, se dwa w pou resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1‐800‐267‐0439.

5. Cambodian‐Mon‐Khmer

របសិនបេរីអនក ឬនរណាមននក់ែដលអនកកំពុងែដជួយ មននសំណួរអ្◌ពីំ Blue Cross & Blue Shield of Rhode Island េប, អនកមននសិេ◌ធិេ◌េ◌◌ួលជំនួយនិងព័ែ◌◌ម៌នន េបៅកនុងភាសា ររស់អនក េបាយមិនអស់ប្◌ាក់ ។ ែបេ◌ើមបីនិយាយជាមួយអនករកដរប សូម 1‐800‐267‐0439 ។

6. French Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Blue Cross & Blue Shield of Rhode Island, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1‐800‐267‐0439.

7. Italian Se tu o qualcuno che stai aiutando avete domande su Blue Cross & Blue Shield of Rhode Island, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare 1‐800‐267‐0439.

8. Laotian ຖ້າທ່ານ, ຫ ◌ຼ ◌ື ຄົນທ ◌່ ທ່ານກໍາລັງຊ່ວຍເຫ ◌ຼ ◌ື ອ, ມ ຄໍ າຖາມກ່ຽວກັບ Blue Cross & Blue Shield of Rhode Island, ທ່ານມ ສິ ດທ ◌່ ຈະໄດ້ຮັບການຊ່ວຍເຫ ◌ຼ ◌ື ອແລະຂໍ ້ ມູນຂ່າວສານທ ◌່ ເປັນພາສາຂອງທ່ານບໍ່ ມ ຄ່າໃຊ້ຈ່າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ໂທຫາ 1‐800‐267‐0439.

9. Arabic ��د�� ، Blue Cross & Blue Shield of Rhode Island ��و� أ�� د� �� د� أو ��د�� ن إنو��م��وم�� م��د� �� و� ��

.0439‐267‐800‐1 ب �� م�� مع ��د� .�� دون من �� و��10. Russian Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Blue Cross & Blue

Shield of Rhode Island, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 1‐800‐267‐0439.

11. Vietnamese Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Blue Cross & Blue Shield of Rhode Island, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1‐800‐267‐0439.

12. Kru I bale we, tole mut u ye hola, a gwee mbarga inyu [insert SBM program name], U gwee Kunde I kosna mahola ni biniiguene I hop wong nni nsaa wogui wo. I Nyu ipot ni mut a nla koblene we hop, sebel [insert number here].

13. Ibo Ọ bụrụ gị, ma o bụ onye I na eyere‐aka, nwere ajụjụ gbasara Blue Cross & Blue Shield of Rhode Island, I nwere ohere iwenta nye maka na ọmụma na asụsụ gị na akwu gị ụgwọ. I chọrọ I kwụrụ onye‐ntapịa okwu, kpọ 1‐800‐267‐0439.

14. Yoruba Bí ìwọ, tàbí ẹnikẹni tí o n ranlọwọ, bá ní ibeere nípa Blue Cross & Blue Shield of Rhode Island, o ní ẹtọlati rí iranwọ àti ìfitónilétí gbà ní èdè rẹ láìsanwó. Láti bá ongbufọ kan sọrọ, pè sórí 1‐800‐267‐0439

15. Polish Jeśli Ty lub osoba, której pomagasz ,macie pytania odnośnie (insert SBM program), masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku .Aby porozmawiać z tłumaczem, zadzwoń pod numer 1‐800‐267‐0439

16. Korean 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이Blue Cross & Blue Shield of Rhode Island 에 관해서

질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는

권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1‐800‐267‐0439 로 전화하십시오. 17. Tagalog Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue Cross & Blue Shield of

Rhode Island, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1‐800‐267‐0439.






此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French



















1-800-639-2227.

Vietnamese: Blue Cross & Blue Shield of Rhode Island,

1-800-639-2227.

Kru: I bale we, tole mut u ye hola, a gwee mbarga inyu Blue Cross & Blue Shield of Rhode Island, U gwee Kunde I kosna mahola ni biniiguene I hop wong nni nsaa wogui wo. I Nyu ipot ni mut a nla koblene we hop, sebel 1-800-639-2227.

Ibo:






此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French



















1-800-639-2227.

Yoruba: Blue Cross & Blue Shield of Rhode Island,

1-800-639-2227.

Polish: Blue Cross & Blue Shield of Rhode Island, .

1-800-639-2227.

Korean:






此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French



















1-800-639-2227






此插入數字1‐800‐267‐0439。 4. French



















Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue Cross & Blue Shield of Rhode Island, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-800-639-2227.

This notice is being provided to you in compliance with federal law.

Laotian:

Arabic:

Russian:

Vietnamese:

Kru:

Ibo:

Yoruba:

Polish:

Korean:

Tagalog:

500 Exchange Street • Providence, RI 02903-2699Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. 09/16 MLTI-87235 GeneralTagline

Summary of Benefits Plan 65 Select F (01/16) i

BLUE CROSS & BLUE SHIELD OF RHODE ISLAND PLAN 65

MEDICARE SUPPLEMENT PLAN SELECT F SUMMARY OF BENEFITS This is a Medicare supplement insurance plan, which provides supplemental coverage for individuals enrolled in the Original Medicare Plan. This Summary of Benefits and the Benefit Provisions together form your subscriber agreement for Medicare Supplement Plan Select F. This subscriber agreement replaces any previous subscriber agreement issued for this type of coverage. The intent of this summary is to give you a general understanding of benefits available under this agreement. For more details, read section 3.0 for a description of coverage for specific benefits and section 5.0 for a list of general exclusions. You have selected Medicare Supplement Plan Select F. This type of Medicare Supplement policy requires you to use hospitals within its PLAN 65 SELECT HOSPITAL NETWORK, unless the services are required for emergency treatment or the services are NOT available within the PLAN 65 SELECT HOSPITAL NETWORK, to be eligible for Medicare Part A benefits. To obtain a copy of the PLAN 65 SELECT HOSPITAL NETWORK list please call Customer Service Department at 401- 459-5000 or 1-800-639-2227. Telecommunications Device for the Deaf users (TTY/TDD) may call 711. You may receive services from doctors that accept Medicare; there is not a list of network physicians to select from. This plan includes all of the benefits shown in the Summary of Benefits when you obtain Medicare Part A services from PLAN 65 SELECT HOSPITAL NETWORK. Refer to your Benefit Provisions for a detailed description of each benefit.

SUMMARY OF BENEFITS

Medicare Supplement Plan Select F BASIC BENEFIT PROVISIONS

Basic Benefits Section Plan Covers

The 61st through 90th day of inpatient hospital services for Medicare eligible expenses when you obtain the services from PLAN 65 SELECT HOSPITAL NETWORK.

3.1 Medicare Part A copayment:

$329 per day

Sixty (60) lifetime inpatient reserve days for Medicare eligible expenses when you obtain the services from PLAN 65 SELECT HOSPITAL NETWORK.


$658 per day

Up to a lifetime maximum of three hundred and sixty five (365) inpatient hospital days for Medicare eligible expenses after exhausting all Medicare inpatient hospital benefits when you obtain the services from PLAN 65 SELECT HOSPITAL NETWORK.

3.1 100% of Medicare eligible

expenses

First three (3) pints of blood. 3.1

100% of Medicare eligible

expenses

Summary of Benefits Plan 65 Select F (01/16) ii

Doctor services and outpatient services for Medicare eligible expenses.

3.1 Medicare Part B copayment:

Generally 20%

Hospice Care 3.1 Medicare copayment

Medicare Supplement Plan Select F ADDITIONAL BENEFIT PROVISIONS

Additional Benefits

Section

Plan Covers

Inpatient hospital services for the first sixty (60) days of Medicare eligible expenses when you obtain the services from PLAN 65 SELECT HOSPITAL NETWORK.

3.2 Medicare Part A deductible:

$1316 per

benefit period

Skilled nursing facility care for 21st through 100th day of inpatient skilled nursing facility care for Medicare eligible expenses.


$164.50 per day

Doctor services and outpatient services for Medicare eligible expenses.

3.2 Medicare Part B deductible:

$183 per

calendar year

Medicare Part B Excess Charges 3.2 Medicare Part B Excess Charges

100%

Emergency medical care in foreign countries for Medicare eligible expenses for medically necessary emergency care beginning during the first 60 consecutive days of each trip outside the United States. You will be responsible to pay a $250 deductible per calendar year, the 20% remaining copayment, and all charges that exceed the lifetime maximum of $50,000.

3.2 80% of billed charges less the $250 deductible

up to the $50,000 lifetime

maximum payment.

IF YOU HAVE ANY QUESTIONS OR REQUIRE ASSISTANCE PLEASE CALL US AT 401-459-5000 OR 1-800-639-2227. TO CONTACT OUR TELECOMMUNICATIONS DEVICE FOR THE DEAF (TTY/TDD) PLEASE CALL 711.

Table of Contents Plan 65 Select F (01/16)

BLUE CROSS & BLUE SHIELD OF RHODE ISLAND PLAN 65

MEDICARE SUPPLEMENT PLAN SELECT F

TABLE OF CONTENTS

SUMMARY OF BENEFITS ______________________________________________ i Basic Benefits ........................................................................................................ i Additional Benefits ................................................................................................. ii

1.0 INTRODUCTION __________________________________________________ 1

1.1 --- How to Find What You Need to Know ---------------------------------------------------------- 1 1.2 --- You and Blue Cross & Blue Shield of Rhode Island ---------------------------------------- 1 1.3 --- Words With Special Meaning --------------------------------------------------------------------- 1 1.4 --- General Information --------------------------------------------------------------------------------- 1 1.5 --- Premiums ---------------------------------------------------------------------------------------------- 2

2.0 ELIGIBILITY _____________________________________________________ 3 2.1 --- Who is Eligible for Coverage---------------------------------------------------------------------- 3

2.2 --- Medicaid Eligibility ----------------------------------------------------------------------------------- 3 2.3 --- Extension of Benefits ------------------------------------------------------------------------------- 3

2.4 --- When Your Coverage Ends ----------------------------------------------------------------------- 3

3.0 PROVISIONS FOR COVERED BENEFITS _____________________________ 4 3.1 --- Basic Benefit Provisions --------------------------------------------------------------------------- 4

Inpatient Hospital Services ................................................................................... 4 Lifetime Inpatient Reserve Days ........................................................................... 4

Lifetime Maximum Benefit for Inpatient Hospital Days ......................................... 4

Blood Services ...................................................................................................... 5

Doctor Services and Outpatient Services ............................................................. 5 3.2 --- Additional Benefit Provisions --------------------------------------------------------------------- 5

Inpatient Hospital Services ................................................................................... 5 Skilled Nursing Facility Care ................................................................................. 5 Doctor Services and Outpatient Services ............................................................. 5

Emergency Medical Care in Foreign Countries .................................................... 6

4.0 CHANGES IN BENEFITS ___________________________________________ 7

5.0 GENERAL EXCLUSIONS __________________________________________ 8

6.0 HOW TO FILE AND APPEAL A CLAIM ________________________________ 9 6.1 --- How to File a Claim --------------------------------------------------------------------------------- 9 6.2 --- Payment of Benefits --------------------------------------------------------------------------------- 9 6.3 --- How to File a Complaint/Grievance and Appeal --------------------------------------------- 9

How to File a Complaint/Grievance or Administrative Appeal .............................. 9 How to File a Medical Appeal ............................................................................. 11

Legal Action ........................................................................................................ 13 Grievances Unrelated to Claims ......................................................................... 13 Our Right to Withhold Payments ........................................................................ 14

Table of Contents Plan 65 Select F (01/16)

Subrogation and Reimbursement ....................................................................... 14

7.0 GLOSSARY ____________________________________________________ 16

ATTACHMENTS _____________________________________________________ 19

Introduction Plan 65 Select F (01/16) 1

1.0 INTRODUCTION The entire contract consists of the application, this agreement, and any attached amendments. Statements made by you to obtain insurance under this agreement will be deemed representations and not warranties. 1.1 How to Find What You Need to Know The Summary of Benefits at the front of this agreement will show you what Medicare eligible expenses are covered under this agreement. The Table of Contents will help you find more details about eligibility, how we pay for Medicare eligible expenses, changes in benefits, services which are not covered under this agreement, how to file a claim, and how to file a complaint/grievance. 1.2 You and Blue Cross & Blue Shield of Rhode Island In consideration of the application and the payment of subscriber fees, we, Blue Cross & Blue Shield of Rhode Island, agree to provide benefits under the terms of this agreement. This is a Medicare supplement plan which provides supplemental coverage for Medicare recipients who are enrolled in the Original Medicare Plan. You can only be covered under one (1) Medicare Supplement plan at any one time. If you enroll in another Medicare Supplement Plan or a Medicare Advantage Plan, it is recommended that you disenroll in this plan. If you are enrolled in a Medicare Supplement Plan and a Medicare Advantage Plan at the same time, benefits will only be provided under the Medicare Advantage Plan. Refer to the Summary of Benefits to determine your plan. Please read the Summary of Benefits and the benefit provisions carefully. 1.3 Words With Special Meaning Some words and phrases used in this agreement are in italics. This means that the words or phrases have a special meaning as they relate to this agreement. The glossary at the end of this agreement defines many of these words. Other sections of this agreement also contain definitions of certain words and phrases. These sections include Section 3.0 which describes covered benefits and Section 6.0 which describes claim procedures and how to file a complaint. 1.4 General Information If you have questions or issues regarding your benefits under this agreement, call the Blue Cross & Blue Shield of Rhode Island (BCBSRI) Customer Service Department at (401) 459-5000 or 1-800-639-2227. Telecommunications Device for the Deaf users (TTY/TDD) may call 711. Our normal business hours are Monday - Friday from 8:00 a.m. - 8:00 p.m. If you call after normal business hours, our answering service will document your call. A BCBSRI Customer Service Representative will return your call on the next business day. When you call, identify yourself as a subscriber. Also, have your member identification (ID) card available. To find out all the latest Blue Cross & Blue Shield of Rhode Island news and plan information, visit our Web site at BCBSRI.com/medicare.

Introduction Plan 65 Select F (01/16) 2

1.5 Premiums Members enrolling on or after May 1, 2016, with no tobacco use within the last 12 months, may be eligible for the non-tobacco rate by submitting an attestation form. The non-tobacco rate would become effective on the first of the month following receipt of the attestation, if received by the 15th day of the prior month. We may discontinue this rate in our discretion concurrent with a filed and approved rate change. We will provide prior written notice of such discontinuance.

Members who opt to pay their bill using electronic funds transfer are eligible for a discount off their rate in the amount of $2 per month. The electronic funds transfer

discount becomes effective on the next monthly bill if the electronic funds transfer form is received by the 13th day of the prior month. Please contact our Customer Service Department for additional information about these premium options.

Eligibility Plan 65 Select F (01/16) 3

2.0 ELIGIBILITY This section of this agreement describes rules for who is eligible for coverage, how eligible persons are enrolled, and how and when coverage may be terminated. 2.1 Who is Eligible for Coverage Only residents of Rhode Island who are Medicare recipients enrolled in the Original Medicare Plan are eligible for coverage under this agreement. 2.2 Medicaid Eligibility If you become eligible for Medicaid, you may request that we suspend the benefits and subscriber fees under this agreement. You must notify us within ninety (90) days from the date you become entitled to Medicaid assistance. Upon receipt of this notice, we will suspend benefits and subscriber fees due under this agreement for up to twenty-four (24) months. We will automatically reinstate this agreement (or if no longer available, an agreement that is a substantially equivalent) if you: (a) are no longer eligible for Medicaid within this twenty-four (24) month period; AND (b) notify us within ninety (90) days of the date you were no longer eligible for

Medicaid; AND (c) pay the subscriber fee due as of the date of reinstatement. The effective date of reinstatement is the date you cease to be eligible for Medicaid assistance. Benefits and subscriber fees will be reinstated as if this agreement (or a substantially equivalent agreement) remained in force. We will NOT reinstate your coverage after the twenty-four (24) month suspension. 2.3 Extension of Benefits If you are totally disabled on the date this agreement ends, we will continue to provide benefits under this agreement until the earliest of the date: (a) you are no longer totally disabled; (b) the Medicare benefit period ends; OR (c) maximum benefit payments have been paid. Extended benefits apply only to the care or treatment for the disability for which this extension applies. 2.4 When Your Coverage Ends This agreement will end automatically: (a) one (1) month after the date subscriber fees due are not paid; OR (b) the date fraud is determined by us; OR (c) if we cease to offer this type of coverage. You may end this agreement by telling us that you want this agreement to end or by not paying the subscriber fee when due. Reinstatement We have the right to reinstate a terminated agreement.

Provisions for Covered Benefits Plan 65 Select F (01/16) 4

3.0 PROVISIONS FOR COVERED BENEFITS We will cover the copayments and deductibles required by Medicare for the services listed in this section. Benefits under this agreement will change automatically to coincide with any changes to the Original Medicare Plan deductible and copayment amounts. We may modify the premiums to correspond with such changes. See Section 4.0 for more information. This agreement may not cover all of your medical expenses. Read this agreement CAREFULLY. Please see the Summary of Benefits at the front of this agreement to determine the amount of coverage we provide for benefits under this agreement. 3.1 Basic Benefit Provisions Medicare Part A inpatient hospital services are covered under this agreement ONLY when you use a participating PLAN 65 SELECT HOSPITAL, unless the services are required for emergency treatment or the services are not available within the PLAN 65 SELECT HOSPITAL NETWORK. See Section 7.0 for the definition of PLAN 65 SELECT HOSPITAL NETWORK. When a non-participating PLAN 65 SELECT HOSPITAL renders inpatient services and the services are NOT required for emergency treatment or the services are available within the PLAN 65 SELECT HOSPITAL NETWORK you will be responsible to pay the applicable Medicare eligible expenses, Part A deductible, and or Part A copayment. To obtain a copy of the PLAN 65 SELECT HOSPITAL NETWORK listing, please call Customer Service Department at 401- 459-5000 or 1-800-639-2227. Telecommunications Device for the Deaf users (TTY/TDD) may call 711. Inpatient Hospital Services When inpatient hospital services are rendered by a participating PLAN 65 SELECT HOSPITAL, we will cover the copayment required by Medicare Part A for Medicare eligible expenses relating to the 61st through 90th day of inpatient hospitalization. Lifetime Inpatient Reserve Days Lifetime inpatient reserve days are limited to sixty (60) additional days of inpatient hospitalization ONCE in your lifetime. If you are hospitalized for more than ninety (90) days and your inpatient hospital services are rendered by a participating PLAN 65 SELECT HOSPITAL, we will cover the copayment required by Medicare Part A for Medicare eligible expenses relating to the 91st to 150th day of lifetime inpatient reserve days. Lifetime Maximum Benefit for Inpatient Hospital Days Upon exhaustion of all Medicare hospital inpatient coverage, including the lifetime inpatient reserve days, we will cover Medicare eligible expenses for hospitalization not covered by Medicare Part A subject to a lifetime maximum benefit of 365 days. The hospital must be a participating PLAN 65 SELECT HOSPITAL unless the services are required for emergency treatment or the services are not available at a PLAN 65 SELECT HOSPITAL. See Section 7.0 for the definition of PLAN 65 SELECT HOSPITAL NETWORK and Medicare eligible expense. Such expenses shall be paid as follows:


(a) To the extent and in the amount Medicare would have covered such services had the lifetime reserve days not been exhausted and if Medicare were still prime; or

(b) The lesser of (a) or the hospital’s charge. Blood Services We will cover the replacement costs, if any, required by Medicare for the first three (3) pints of blood (or equivalent quantities of packed red blood cells as defined under federal regulations) unless the blood is replaced in accordance with federal regulations. Doctor Services and Outpatient Services We will pay the copayment amount required by Medicare Part B for Medicare eligible expenses. Hospice Care We will pay the copayment required by Medicare for Medicare eligible expenses relating to hospice care and respite care. 3.2 Additional Benefit Provisions The following provisions apply to additional benefits covered under your plan. Additional benefits for Medicare Part A for Medicare eligible expenses are payable ONLY when you use a participating PLAN 65 SELECT HOSPITAL, unless the services are required for emergency treatment or the services are not available through a PLAN 65 SELECT HOSPITAL NETWORK. See Section 7.0 for the definition of PLAN 65 SELECT HOSPITAL NETWORK. Inpatient Hospital Services The inpatient hospital deductible required by Medicare Part A for Medicare eligible expenses relating to the first sixty (60) days of inpatient hospitalization per benefit period is covered ONLY when you use a participating PLAN 65 SELECT HOSPITAL, unless the services are required for emergency treatment or the services are not available within the PLAN 65 SELECT HOSPITAL NETWORK. See Section 7.0 for the definition of PLAN 65 SELECT HOSPITAL NETWORK.

When a non-participating PLAN 65 SELECT HOSPITAL renders inpatient services and the services are NOT required for emergency treatment or the services are available within the PLAN 65 SELECT HOSPITAL NETWORK you will be responsible to pay the applicable Medicare eligible expenses, Part A deductible, and or Part A copayment. Skilled Nursing Facility Care We will cover the copayment required by Medicare Part A for Medicare eligible expenses relating to skilled nursing facility care from the 21st day through the 100th day in a Medicare benefit period for post hospital skilled nursing facility care. You may receive services from a Skilled Nursing Facility that accepts Medicare; the PLAN 65 SELECT HOSPITAL NETWORK does not include Skilled Nursing Facilities. See the Summary of Benefits for the benefit limit and level of coverage. Doctor Services and Outpatient Services We will pay the Medicare Part B deductible required each calendar year by Medicare for Medicare eligible expenses.


Medicare Part B Excess Charges We will pay 100% of the difference between the amount paid by Medicare and the amount billed by the provider. The amount paid is not to exceed any charge limitation established by Medicare or by state law. Emergency Medical Care in Foreign Countries We will cover Medicare eligible expenses for medically necessary emergency hospital, doctor, and medical care received in a foreign country, if Medicare would have covered the emergency care services as Medicare eligible expenses had the accident or medical emergency occurred in the United States. To qualify for this coverage, the following conditions must be met: (a) treatment must be for emergency care and not eligible for payment under any

Medicare program; AND (b) emergency care must begin during the first 60 consecutive days per trip outside

the United States and received on or after your plan's effective date. For the purposes of coverage under this agreement, emergency care shall mean care needed immediately because of an injury or illness of sudden and unexpected onset. We will cover eighty percent (80%) of billed charges, subject to a calendar year deductible of two hundred fifty dollar ($250), and a lifetime maximum benefit of fifty thousand dollars ($50,000). You are responsible to pay the two hundred fifty dollar ($250) calendar year deductible, the remaining twenty percent (20%) copayment, and charges exceeding the lifetime maximum benefit payment amount of fifty thousand dollars ($50,000). Benefits for emergency medical care in foreign countries are payable to you only in United States currency. The amount paid to you is based on the bank transfer exchange rate in effect on the date the services were rendered. When you receive medically necessary emergency medical care in a foreign country, you may be required to pay up front for these services. You will then need to file the claim yourself. Before filing the claim, please contact our Customer Service Department at 401-459-5000 or 1-800-639-2227. Telecommunications Device for the Deaf users (TTY/TDD) may call 711 to obtain a” foreign claim research form”. To file a claim, please submit a copy of the itemized bill and a copy of the completed “foreign claim research form”. The itemized bill must include: (a) member’s name; (b) your Plan 65 subscriber identification (ID) number; (c) name of the doctor who performed the service; (d) date and description of the service; AND (e) the charge for the service. You must file the claim within one calendar year of the date the services were rendered.

Changes In Benefits Plan 65 Select F (01/16) 7

4.0 CHANGES IN BENEFITS Benefits listed in Sections 3, Provisions for Covered Benefits, will change automatically if Medicare eligible expenses change. We will send written notice to you with a description of the benefit change(s) at least thirty (30) days prior to the effective date. The effective date of the change is the same date that Medicare implements changes to the Original Medicare Plan. Subscriber fees may be increased or decreased to reflect any change of benefits under this agreement. If this agreement changes, we will issue an amendment or a new agreement. Payment of your subscriber fee will be considered acceptance by you of the change.

General Exclusions Plan 65 Select F (01/16) 8

5.0 GENERAL EXCLUSIONS AMOUNTS PAYABLE UNDER MEDICARE In no event will medical payments under this agreement duplicate any amounts payable under Medicare. BENEFITS NOT LISTED IN THE SUMMARY OF BENEFITS This agreement will not cover any benefit that is not listed in the Summary of Benefits. Any benefit listed in the Summary of Benefits will be covered only to the extent described in this agreement. CARE PROVIDED BY NON-PARTICIPATING PLAN 65 SELECT HOSPITALS No benefits are provided for inpatient hospital services for which you do not use a participating PLAN 65 SELECT HOSPITAL, unless the inpatient hospital services are required for emergency treatment or the services are not available within the PLAN 65 SELECT HOSPITAL NETWORK. CARE PROVIDED WITHOUT CHARGE No benefits are provided for services for which no charge would be made to you in absence of insurance. WAR Injury or sickness caused by or resulting from any future act of war is not covered even if the war is not declared. WORKERS' COMPENSATION This agreement will not cover any injury or sickness for which you are entitled to any benefits under workers' compensation or similar law.

How to File and Appeal a Claim Plan 65 Select F (01/16) 9

6.0 HOW TO FILE AND APPEAL A CLAIM 6.1 How to File a Claim Most providers will submit claims directly to Medicare for you. Medicare will process the claim, send you a notice called a Medicare Summary Notice, and send the claim information to us. We will pay the provider directly for Medicare eligible expenses covered under this plan. In some instances, you may be required to file a claim. You must file all claims within one calendar year of the date the claim was processed by Medicare. The process date is on the Medicare Summary Notice. Member submitted claims that arrive after this deadline are invalid unless:

we determine that it was not reasonably possible for you to file your claim prior to the filing deadline; AND

you file your claim as soon as possible but no later than ninety (90) calendar days after the filing deadline elapses (unless you are legally incapable).

Our payments to you or the doctor fulfill our responsibility under this agreement. Your benefits are personal to you and cannot be assigned, in whole or in part, to another person or organization. To file a claim, please send us a copy of the Medicare Summary Notice and include your Plan 65 member identification (ID) card number. Please mail the claim to:

Blue Cross & Blue Shield of Rhode Island Attention: Claims Department 500 Exchange St Providence, RI 02903

6.2 Payment of Benefits We may make payments directly to the doctor, hospital, or to you. Your benefits under this agreement are personal to you and may not be assigned to another person or organization. 6.3 How to File a Complaint/Grievance and Appeal A Complaint/Grievance is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction.

An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because we determined that the services were excluded from coverage or because you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements. How to File a Complaint/Grievance or Administrative Appeal If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits made by us (for example, a denial due to a member filing a claim after our established time limits, See Section 6.1-How to File a Claim), please call our Customer Service


Department at (401) 459-5000 or 1-800-639-2227. TTY/TDD (Telecommunications Device for the Deaf) users may call 711. The Customer Service Representative will log your call and the nature of the issue and attempt to resolve your concern. If your concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file an administrative appeal, you must do so within 180 days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:

name, address, Plan 65 subscriber ID number;

summary of the issue;

any previous contact with Blue Cross & Blue Shield of Rhode Island;

a brief description of the relief or solution you are seeking;

any additional information such as referral forms, claims, or any other documentation that you would like us to review;

the date of incident or service; and

your signature. You can use the Member Appeal Form, which is on our website BCBSRI/medicare.com or a Customer Service Representative can provide it to you. You can also send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. You may also complete a Member’s Designation of a Personal Representative form which a Customer Service Representative can provide to you. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Unit 500 Exchange St Providence, Rhode Island 02903

We will acknowledge your complaint or administrative appeal in writing or by phone within ten (10) business days of our receipt of your written complaint or administrative appeal. The Grievance and Appeals Unit will conduct a thorough review of your complaint or administrative appeal and respond in the timeframes set forth below. Level 1 Complaint We will respond to your Level 1 complaint in writing within thirty (30) calendar days of the date we receive your complaint. The determination letter will provide you with the rationale for our response. It will also give you information on the next steps available to you, if any, if you are not satisfied with the outcome of the complaint. Level 2 Complaint (when applicable) A Level 2 complaint may be submitted only when you have been offered a second level of complaint in your Level 1 determination letter. The Grievance and Appeals Unit will conduct a thorough review of your Level 2 complaint and respond to you in writing within thirty (30) business days. The determination letter will provide you with the


rationale for our response. It will also give you the next steps if you are not satisfied with the outcome of the complaint.

Administrative Appeal We will respond to your administrative appeal in writing within sixty (60) calendar days of our receipt of your administrative appeal. The determination letter will provide you with information regarding our decision.

Blue Cross & Blue Shield of Rhode Island does not offer a Level 2 administrative appeal. You may notify the State of Rhode Island Department of Health or the State of Rhode Island Office of the Health Insurance Commissioner regarding your concerns. Please refer to the Legal Action section below for additional information. How to File a Medical Appeal A Medical Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services. The services were denied because we determined one of the following:

The services were not medically necessary; or

The services are experimental or investigational. If you disagree with a full or partial medical denial made by Medicare, you may dispute the decision through the Medicare appeals process. To start this process, follow the directions given in the letter you receive from Medicare about the denial. We do NOT process Medicare medical appeals. If we deny payment for a service for medical reasons, you will receive the denial in writing. An example of a medical denial reason we may provide is a denial of payment for services because you were rendered inpatient services at a hospital that does NOT participate in the PLAN 65 SELECT HOSPITAL NETWORK. The written denial you receive will explain the reason for the denial. The written denial will also provide specific instructions for filing a medical appeal. To file a medical appeal verbally, you may call our Customer Service Department at (401) 459-5000 or 1-800-639-2227. You may also file a medical appeal in writing. To do so, you must provide the following information:

name, address, and Plan 65 subscriber ID number;

summary of the medical appeal, any previous contact with Blue Cross & Blue Shield of Rhode Island, and a brief description of the relief or solution you are seeking;

any additional information such as referral forms, claims or any other documentation that you would like us to review;

the date of service; and

your signature. If a medical appeal is being filed on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter.


Written medical appeals should be sent to: Blue Cross & Blue Shield of Rhode Island

Attention: Grievance and Appeals Unit 500 Exchange St

Providence, Rhode Island 02903 Your doctor may also file a medical appeal on your behalf. Your doctor can contact the Physician and Provider Service Center to begin the medical appeal. Within ten (10) business days of receipt of a written or verbal medical appeal, the Grievance and Appeals Unit will mail or phone acknowledgement of our receipt of the medical appeal. You are entitled to the following levels of review when seeking a medical appeal. Level 1 Review You may request a Level 1 review of any matter subject to medical appeal by making a request for such review to us within one hundred and eighty (180) calendar days of the initial determination letter. You may request this review by calling our Customer Service Department, but we strongly suggest that you submit your request in writing to ensure your request is accurately reflected. For pre-service or concurrent appeals, you will receive written notification of the determination on a Level 1 review within fifteen (15) calendar days of receipt of the appeal request. If you are requesting reconsideration (Level 1 review) of a service that was denied after you already obtained the service (retrospectively), then you will receive written notification of our determination within fifteen (15) business days of our receipt of the appeal. Level 2 Review You may request a Level 2 review (preferably in writing) if our denial was upheld during the Level 1 review process. Your Level 2 review will be reviewed by a provider in the same or similar specialty as your treating provider. You must submit your request for a Level 2 review within one hundred and eighty (180) calendar days of the date of the Level 1 determination letter. Upon request for a Level 2 review, we will provide you with the opportunity to inspect the medical file and add information to the file. You will receive written notification of a determination on a Level 2 pre-service or concurrent review within fifteen (15) calendar days of receipt of the appeal request. If the service you are requesting review of was denied after you already obtained the service (retrospectively), you will receive written notification of our determination within fifteen (15) business days of receipt of the appeal request. Note: You may ask for an expedited review if the circumstances are an emergency or if you are in an inpatient setting. Due to the urgent nature of an expedited Medical Appeal, to request an expedited Medical Appeal you or your physician or provider must call the Grievance and Appeals Unit at (401) 459-5000 or 1-800-639-2227 or fax your request to (401) 459-5005. An expedited determination will be made no later than seventy-two (72) hours from the receipt of the appeal.


External Appeal If you remain dissatisfied with the determination of our Level 1 and Level 2 medical review, you may request an external review by an outside review agency. If you choose to do so, you will select the external appeal agency that will perform the external appeal from a list of Department of Health-approved agencies. You will be responsible for fifty percent (50%) of the charges and fees from the external agency and we will pay the remaining fifty percent (50%). However, if the external appeal agency overturns our denial determination, we will reimburse you for your half of the cost of the review. To request an external review you must submit your request in writing to us within sixty (60) calendar days of your receipt of the Level 2 denial notification. For all non-emergency appeals, the external appeal agency will notify you of its determination within ten (10) business days of the agency’s receipt of the information. For all emergency external appeals, the external appeals agency will notify you of its determination no later than seventy-two (72) hours from the agency’s receipt of the appeal. Legal Action If you are dissatisfied with the decision on your claim, and have complied with applicable state and federal law, you are entitled to seek judicial review. This review will take place in an appropriate court of law. Note: Once a member or provider receives a decision at an appeal level, the provider or the member may not ask for an appeal at the same level again, unless additional information that could impact such decisions can be provided. Under state law, you may not begin court proceedings prior to the expiration of sixty (60) days after the date you filed your claim. In no event may legal action be taken against us later than three (3) years from the date you were required to file the claim (see Section 6.1). Grievances Unrelated to Claims We encourage you to discuss any complaint that you may have about any aspect of your medical treatment with the health care provider that treated you. In most cases, issues can be more easily resolved when they are raised when they occur. If, however, you remain dissatisfied or prefer not to take up the issue with your provider, you may access our complaint and grievance procedures. You may also use our complaint and grievance procedures if you have a complaint about our service or about one of our employees. To begin a grievance, please call our Customer Service Department at (401) 274-3500 or 1-800-564-0888 or TTY/TDD (Telecommunications for the Deaf) users at 711. The Customer Service Department will log in your call and begin working towards the resolution of your complaint. The appeal and complaint procedure described in this section do not apply to the following: Medicare claims determinations; medical necessity determinations; complaints regarding payments; claims of medical malpractice; or


allegations that we are liable for the professional negligence of any doctor, hospital, health care facility, or other health care doctor furnishing services under this agreement.

Our Right to Withhold Payments We have the right to keep back payment during the period of investigation on any claim we receive that we have reason to believe might not be eligible for coverage. We will also conduct a pre-payment review on a claim we have reason to believe has been submitted for a service not covered under this agreement. We will make a final decision on these claims within sixty (60) days after the date that you filed your claim.

We also have the right to carry out post-payment review of claims. If we determine fraud or misrepresentation was used when you filed the claim, we reserve the right to take the necessary steps (including legal action) to recover funds. These funds may have been paid to you or to a doctor, hospital, or other health care doctor. We may review a claim if we have reason to believe it was submitted for a service we do not cover under this agreement. Subrogation and Reimbursement Subrogation We may recover money from a third party that causes you to be hurt or sick. If that party has insurance, we may recover money from the insurance company. Our recovery will be based on the benefit or payment we made under this agreement. For example, if you are hurt in a car accident and we pay for your hospital stay, we can collect the amount we paid for your hospital stay from the auto insurer. If you do not try to collect money from the third party who caused you to be hurt or sick, you agree that we can. We may do so on your behalf or in your name. Our right to be paid will take priority over any claim for money by a third party. This is true even if you have a claim for punitive or compensatory damages. Reimbursement If we give you benefits or make payment for services under this agreement and you get money from a third party for those services, you must pay us back. This is true even if you receive the money after a settlement or a judgment. For example, if your auto insurance pays for your emergency room visit after a car accident, you must reimburse us for any benefit payment that we made. We can collect the money no matter where it is or how it is designated. You must pay us back even if you do not get back the total amount of your claim against the third party. We can collect the money you receive even if it is described as a payment for something other than health care expenses. We may offset future payments under this agreement until we have been paid an amount equal to what you were paid by a third party. If we must pay legal fees in order to recover money from you, we can recover these costs from you. Also, the amount that you must pay us cannot be reduced by any legal costs that you have. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us quickly so we can respond in court.


Member Cooperation You must give us information and help us. This means you must complete and sign all necessary documents to help us get money back. You must tell us in a timely manner about the progress of your claim with a third party. This includes filing a claim or lawsuit, beginning settlement discussions, or agreeing to a settlement in principle, etc. It also means that you must give us timely notice before you settle any claim. You must not do anything that might limit our rights under this Section. We may take any action necessary to protect our right of subrogation and/or reimbursement.

Glossary Plan 65 Select F (01/16) 16

7.0 GLOSSARY BENEFIT means the amount this agreement pays to supplement Medicare eligible expenses. CALENDAR YEAR means a twelve (12) month period beginning on January 1 and ending December 31. COPAYMENT means the amount Medicare requires that you pay for covered benefits. DEDUCTIBLE means the amount Medicare requires that you pay before Medicare will provide covered benefits. DOCTOR means a licensed practitioner who is qualified and authorized under that license to perform the services covered under this agreement of the healing arts acting within the scope of his or her license. EMERGENCY means the sudden and unexpected onset of symptoms due to an illness or injury which requires immediate medical treatment. EXCESS CHARGE is the amount a doctor or other health care provider is legally permitted to charge that is higher than the Medicare-approved amount, the difference is called the excess charge. HOSPITAL means any facility which provides medical and surgical care for patients who have acute illnesses or injuries. The facility must be accredited by the Joint Commission on Accreditation of Hospitals. Hospital does NOT include: (a) convalescent, rest or nursing homes and facilities; (b) facilities primarily for custodial, educational or rehabilitative care; (c) substance abuse treatment facilities; OR (d) facilities operated by any national government or agency for the medical

treatment of members or ex-members of the armed forces (except in an emergency if you are responsible to pay for services received).

INJURY means accidental bodily injury sustained: (a) as the direct result of an accident; (b) independent of disease or bodily infirmity or any other cause; AND (c) which occurs while this agreement is in force.

Injury does not include injuries for which benefits are provided under any workers' compensation, employer's liability or similar law, or motor vehicle no-fault plan, unless prohibited by law.

MEDICAID means “The Health Insurance for the Aged Act”’, Title XIX of the United States Social Security Amendments of 1965, as amended. MEDICARE means "The Health Insurance for the Aged Act," Title XVIII of the United States Social Security Amendments of 1965, as then constituted or later amended. MEDICARE BENEFIT PERIOD (BENEFIT PERIOD) A Medicare benefit period begins the day you are admitted into a hospital or skilled nursing facility (SNF). The Medicare benefit period ends when you have not received any hospital care (or skilled care in a


SNF) for 60 days in a row. If you go into the hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. An inpatient hospital deductible applies to each Medicare benefit period. There is no limit to the number of benefit periods you can have. MEDICARE ELIGIBLE EXPENSE means health care expenses of the kinds covered by the Original Medicare Plan, to the extent recognized as reasonable and medically necessary by Medicare. ORIGINAL MEDICARE PLAN is the Medicare traditional fee-for-service federal health insurance. It has two parts Medicare Part A (Hospital insurance) and Medicare Part B (Medical insurance). PLAN means the basic benefits and the additional benefits, if any, listed in the Summary of Benefits. There are ten (10) separate Medicare supplement plans allowed by law. All ten (10) are listed in the plan chart attached to this agreement. We may offer less than ten (10) separate plans. We may also offer the same plan with and without limited provider network restrictions. Your plan is the plan shown in the Summary of Benefits. PLAN 65 SELECT HOSPITAL NETWORK means a hospital that has agreed to participate in our PLAN 65 SELECT HOSPITAL NETWORK. These hospitals agree to accept Medicare's payment and waive the Medicare Part A copayment and/or deductible amounts for Medicare Part A health care services covered under this agreement. To obtain the list of the PLAN 65 SELECT HOSPITAL NETWORK please call the Customer Service Department at 401- 459-5000 or 1-800-639-2227. Telecommunications Device for the Deaf users (TTY/TDD) may call 711. We will NOT pay any benefits if the Medicare Part A health care services are NOT provided by a participating PLAN 65 SELECT HOSPITAL unless: (a) the services are required for emergency treatment and it is not reasonable to

obtain services through a participating PLAN 65 SELECT HOSPITAL; OR (b) the Medicare eligible expenses are not available within the PLAN 65 SELECT

HOSPITAL NETWORK. REIMBURSEMENT means our right to be paid back any payments, awards or settlements that you receive from a third party. We can collect up to the amount of any benefit or any payment we made. SICKNESS means an illness or disease which first manifests itself after the effective date of this agreement and while this agreement is in force. SKILLED NURSING FACILITY means a facility primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under the supervision of a doctor. A Skilled Nursing Facility must: (a) provide continuous 24-hour a day nursing services by or under the supervision of

a registered graduate professional nurse (R.N.); (b) maintain the daily medical record of each patient; AND (c) be approved or qualified to receive approval for payment of Medicare benefits. Skilled Nursing Facility does NOT include a home or facility which is used:


(a) primarily for rest; (b) to care for the aged or for the care of substance abuse treatment; OR (c) primarily for the care and treatment of mental diseases or disorders, or custodial

or educational care. SUBROGATION means we can use your right to recover money from a third party who caused you to be hurt or sick. We may also recover from any insurance company (including uninsured and underinsured motorist clauses and no-fault insurance) or other party. SUBSCRIBER/MEMBER means you, the eligible person listed on your application who is enrolled in the plan. WE, US, and OUR means Blue Cross & Blue Shield of Rhode Island. We are located at 500 Exchange St Providence, Rhode Island, 02903. For the purpose of this agreement we, us, or our will have the same meaning whether italicized or not. YOU and YOUR means the individual subscriber whose application for coverage under this agreement has been approved by us. For the purpose of this agreement you and your will have the same meaning whether italicized or not.

BLUE CROSS & BLUE SHIELD OF RHODE ISLAND

Attachment A Plan 65 Select F (01/16) 19

ATTACHMENTS Plan Chart

BLUE CROSS & BLUE SHIELD OF RHODE ISLAND

Attachment A Plan 65 Select F (01/16) 20

Benefit Plans: A, F, and SELECT F

Benefit Chart of Medicare Supplement Plans Sold This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan "A" available. Some plans may not be available in your state. BASIC BENEFITS: Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. Blood: First three pints of blood each year. Hospice: Part A coinsurance.

A B C D F F* G K L M N

Basic, including 100% Part B

coinsurance


coinsurance


coinsurance


coinsurance


coinsurance*


coinsurance

Hospitalization and preventive care paid at

100%; other

basic benefits

paid at 50%

Hospitalization and preventive care paid at

100%; other

basic benefits

paid at 75%


coinsurance

Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50

copayment for

ER

Skilled

Nursing

Facility Co-

Insurance

Skilled

Nursing

Facility Co-

Insurance

Skilled

Nursing

Facility Co-

Insurance

Skilled

Nursing

Facility Co-

Insurance

50% Skilled

Nursing Facility

Coinsurance

75% Skilled

Nursing Facility

Coinsurance

Skilled

Nursing

Facility Co-

Insurance

Skilled

Nursing

Facility Co-

Insurance

Part A

Deductible

Part A

Deductible

Part A

Deductible

Part A

Deductible

Part A

Deductible

50% Part A

Deductible

75% Part A

Deductible

50% Part A

Deductible

Part A

Deductible

Part B

Deductible

Part B

Deductible

Part B

Excess

(100%)

Part B

Excess

(100%)

Foreign

Travel

Emergency

Foreign

Travel

Emergency

Foreign

Travel

Emergency

Foreign

Travel

Emergency

Foreign

Travel

Emergency

Foreign

Travel

Emergency

*Plan F also has an option called a high deductible plan F. This high deductible plan

pays the same benefits as Plan F after one has paid a calendar year $2200 deductible.

Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed

$2200. 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 do not include the plan’s separate foreign travel emergency deductible.

Out- of pocket

limit $5120 paid

at 100% after

limit reached

Out- of pocket limit $2560 paid at 100% after limit reached

Plan 65 Select F (01/16)

Effec. 1/1/17

11/16 PL65-119245.7741

Documents

Plan 65 SELECT C (07/06) - Blue Cross Blue Shield of RI · Plan 65 Select F (01/16) Subscriber Agreement PLAN 65 Medicare Supplement Plan Select F MEDICARE SUPPLEMENT SUBSCRIBER AGREEMENT