Summary of Coverage and Disclosure of Information
III. EXCLUSIONS	IV. OTHER INFORMATION

II. SUMMARY OF ADDITIONAL BENEFITS There are some benefits on your contract that expand the coverage Medicare allows, or provide coverage that Medicare does not give or does not allow. These vary among our products. This is a general list of those benefits. Please read your contract language carefully to determine specific benefits and coverage. Benefits That Broaden Medicare Coverage Skilled Nursing Home Care Coverage is furnished for nursing home care in coordination with Medicare. Basic Medicare Select (Senior Gold): Medicare limit 100 days Extended Basic Medicare Supplement (Extended Basic Blue): 120 days Basic Medicare Supplement (Basic Medicare Blue): Medicare limit 100 days Home Health Care Coverage is furnished for home care in coordination with Medicare. Basic Medicare Select (Senior Gold): Medicare Limits Extended Basic Medicare Supplement (Extended Basic Blue): 180 additional visits for skilled home health care. Basic Medicare Supplement (Basic Medicare Blue): Medicare Limits Durable Medicare Equipment (DME) and Supplies Coverage is furnished for DME in coordination with Medicare. Basic Medicare Select (Senior Gold): Medicare Limits plus three (3) pints of blood Extended Basic Medicare Supplement (Extended Basic Blue): Medicare limits plus blood and blood products, casts, splints, trusses, braces, crutches, artificial limbs or eyes, prosthetic appliances (excluding dental), oxygen, medical equipment rental or purchase (when appropriate), radium and other radioactive materials, anesthetics and their administration, diagnostic x-rays, lab exams Basic Medicare Supplement (Basic Medicare Blue): Medicare Limits plus three (3) pints of blood Cancer Screening Coverage is furnished for routine screening procedures for cancer, including pap smears, mammograms, fecal occult blood tests, sigmoidoscopies, colonoscopies, anoscopies, prostate specific antigen tests when ordered or performed by a physician in accordance with the standard practice of medicine. All Plans: 100% for eligible expenses Immunizations/Vaccines Coverage is furnished at 100% for the cost of preventive immunizations and vaccines except if otherwise covered by Medicare Part D. All Plans: 100% for eligible expenses Treatment of Diagnosed Lyme Disease Coverage is provided for the treatment of diagnosed Lyme disease. All Plans: 80% for eligible expenses Management and Treatment of Diabetes Coverage is furnished for physician prescribed equipment and supplies used for the management and treatment of gestational, Type I or Type II diabetes, in coordination with Medicare and not otherwise covered by the Medicare Part D program. Coverage also includes urine testing tabs, diabetes outpatient self-management training and education including medical nutrition therapy that is provided by a certified, registered, or licensed health care professional working in a program consistent with the national standards of diabetes self-management education as established by the American Diabetes Association. Coverage does not include nonprescription supplies such as alcohol swabs and cotton balls. All Plans: 80% for urine test tabs, diabetes self-management training and nutrition therapy Mental Health Coverage is furnished for mental health care in coordination with Medicare guidelines. All Plans: Medicare Limits for outpatient benefits. Additional benefits for eligible inpatient mental health services Chiropractic Care Coverage is furnished for chiropractic care in coordination with Medicare. All Plans: Medicare Limits Benefits Beyond Medicare Coverage Residential Treatment Program Coverage is furnished for services and supplies received in a residential program for the treatment of alcoholism, chemical dependency or drug addiction. All Plans: 80% for eligible expenses Nonresidential Treatment Program Coverage is furnished for services and supplies received in a nonresidential program for the treatment of alcoholism, chemical dependency or drug addiction. All Plans: 80% for eligible expenses Temporomandibular Joint Disorder (TMJ) and Craniomandibular Joint Disorder (CMJ) Coverage is furnished for services and supplies received from a participating provider for the surgical or nonsurgical treatment of TMJ and CMJ in coordination with Medicare. Specific rules apply. Please read your contract language carefully to determine specific benefits and coverage. All Plans: 80% for eligible expenses Wigs Coverage is furnished for scalp hair prosthesis (wigs). Hair loss must be due to alopecia areata only. The maximum benefit is $350 per person per calendar year. All Plans: 80% for eligible expenses Ventilator-Dependent Communication Services Coverage is furnished for services provided by a private duty nurse for a ventilatordependent person in a hospital licensed by the State of Minnesota. There is a 120-hour lifetime maximum benefit. The private duty nurse shall perform only the services of interpreter or communicator for the patient during the transition period to assure adequate training of the hospital staff in communicating with the ventilator-dependent person. All Plans: 80% for eligible expenses Reconstructive Surgery Coverage is furnished for reconstructive surgery incidental to or following surgery resulting from injury, sickness or diseases of the involved body part including breast reconstruction and prosthesis following a mastectomy. Reconstruction surgery due to accident is not covered on this plan. All Plans: 80% for eligible expenses Foreign Travel Coverage is furnished for medically necessary emergency services received when traveling outside the United States. All Plans: 80% for eligible expenses Preventive/Routine Exams Coverage is furnished for routine or preventive physical examinations, eye examinations, hearing examinations when performed by a participating provider. Basic Medicare Select (Senior Gold): Optional coverage at 100% when performed by a participating provider if in Minnesota, for members enrolling with effective dates on or after 6/1/2010, $120 limit per calendar year Extended Basic Medicare Supplement (Extended Basic Blue): $120 limit per calendar year Basic Medicare Supplement (Basic Medicare Blue): Optional coverage at 100%, for members enrolling with effective dates on or after 6/1/2010, $120 limit per calendar year ember Out-of-Pocket Limitations Extended Basic Medicare Supplement (Extended Basic Blue): This product covers 100% of all eligible charges after a member total annual out-of-pocket maximum of $1,000 has been reached for eligible services. III. EXCLUSIONS The following is a summary of items that are excluded from coverage on all contracts. Please read your contract language carefully to determine specific benefits and coverage. Charges for services not allowed by Medicare (see page 4) Charges for services or supplies ordinarily covered by a liability policy and charges for any illness covered by Workers’ Compensation, a no-fault automobile policy or similar law, to the extent that the illness or accident is covered by that policy Charges for any illness or injury covered by an act of war or occurring while serving military duty Charges for cosmetic surgery, except to repair a defect caused by an accident or medical condition that is not covered by another insurance policy Charges for reconstructive surgery, except that which is incidental to or following surgery resulting from injury, sickness or diseases of the involved body part Charges for any treatment, service or supply that is not medically necessary according to the standard practice of medicine or for which you receive a nonmedical benefit Charges for inpatient hospital admissions for services that could be performed on an outpatient basis Charges for therapeutic acupuncture Charges for surgery or treatment that is investigative or experimental Charges for marriage or family counseling, or other counseling not approved by Medicare Charges for recreational or educational therapy or forms of nonmedical self-help training or diagnostic testing Charges for the services of clergy Charges for organ transplants, except for a bone marrow transplant related to breast cancer, or transplants covered by Medicare Charges for a stay in a hospital that does not usually impose charges for stays Charges for services or supplies outside the scope of the provider’s licensure Charges for routine care unless you have purchased such coverage, including screenings, research studies and other services or supplies not due to an illness Charges for eyeglasses not approved by Medicare, or hearing aids, or examinations for eyeglasses or hearing aids not specified in the contract Charges for surgery or other medical treatment of refractive errors Charges for most types of custodial care Charges for dental care Charges for most types of private duty nursing Charges that a provider gives one’s self or renders to family members Charges for drugs or supplies for high dose chemotherapy and the related course of cancer treatment, all drugs and supplies for a cancer treatment plan to rescue bone marrow or stem cells, or biotechnological drug therapy not allowed by Medicare. Other types of chemotherapy may be covered. Please read your contract language carefully to determine specific benefits and coverage Charges for over-the-counter drugs, vitamin therapy or treatment and appetite suppressants Charges for services, treatment, equipment, drugs, and devices that do not meet generally accepted standards of medical practice Charges for outpatient prescription drugs For Select Contract Only - Charges for inpatient and preventative care services received in the State of Minnesota from a nonparticipating provider. Please read the contract language carefully to determine specific benefits and coverage Charges for services or supplies for which the provider has entered into a private contract to give to any patient, exclusive of Medicare. (Note: If a private contract exists between a provider and a Medicare patient, Medicare will not cover any charges between that provider and all his/her Medicare patients for a period of two (2) years.) IV. OTHER INFORMATION Guarantee Issue: Notice of Medicare Supplement Insurance Portability for Persons Ending or Losing Other Health Coverage. Should you change, lose or cancel your Medicare Supplement and Select coverage with us, you may qualify for the following provision: Changes in federal and state law contain rights and obligations about issuing Medicare Supplement contracts. The guarantee issue provisions discussed here are in addition to the six (6)-month open-enrollment window that Medicare enrollees have when they enroll in Part B. Our Obligation Blue Cross must guarantee issue certain basic Medicare Supplement and Select contracts to eligible individuals in specific circumstances and may not deny them coverage. We cannot discriminate in the pricing of such a contract because of health status, claims experience, receipt of health care, medical condition or age. We cannot impose a preexisting condition exclusion. Your Rights If a Medicare beneficiary loses health coverage under the circumstances listed below, the beneficiary is guaranteed the right to purchase certain Medicare Supplement or Select contracts. In Minnesota, an eligible individual is a person who is eligible for Medicare and who: was enrolled in an employer provided retiree benefit plan that provided health benefits that supplement Medicare and the plan terminates or ceases to provide all supplemental benefits; or was enrolled in Medicare Part B and voluntarily disenrolls due to coverage under an employer plan and is subsequently applying within six (6) months of re-enrolling in Medicare Part B due to the termination of employer-sponsored coverage; was enrolled in a Medicare Advantage, Medicare Select, Medicare Cost, or Health Care Prepayment Plan, and the enrollment ends because: the plan’s certification under Medicare has been terminated or the plan discontinues providing benefits in the area in which the person resides; the individual cannot continue with the plan because the individual changes residence; or the individual demonstrates that the plan violated a material provision of the contract for coverage or that the organization materially misrepresented the plan’s provisions in marketing; was enrolled in a Medicare supplement contract and the enrollment ends because: the insurer becomes insolvent or other involuntary termination of coverage occurs; the insurer substantially violated a material provision of the contract or materially misrepresented the policy’s provisions in marketing the contract to the individual. Eligible individuals described in numbers 1 through 3 (above) are entitled to a Basic Medicare Supplement or a Basic Medicare Select contract from any Minnesota issuer. was enrolled under a Medicare Supplement contract and terminates coverage to enroll for the first time in a Medicare Advantage, Medicare Cost, Health Care Prepayment Plan, or Medicare Select plan, and the individual then disenrolls from that plan within the first 12 months. Eligible individuals are entitled to the same Medicare Supplement contract in which the individual was most recently enrolled, if available, from the same issuer. If the contract is not available, the person is entitled to a Basic Medicare Supplement or Select contract offered by any issuer. After first enrolling in Medicare Part B, enrolls in a Medicare Advantage plan and then disenrolls from that plan within 12 months. Eligible individuals are entitled to any Medicare Supplement or Select contract offered by any issuer. You must apply for Blue Cross Medicare Supplement or Select coverage within 63 calendar days of the date your coverage terminates (listed above) in order for us to determine if guarantee issue of coverage applies to you. If you apply after this 63-day period, you may be required to complete a health history application. If your Medicare Advantage plan is terminating, you have 63 days from the date of your plan’s official Notice of Termination, as well as 63 calendar days after the plan’s actual termination, to apply for Blue Cross coverage under guarantee issue. If your employer group coverage is being terminated you have 63 days from the date of official notice or from the date that you are notified of a denied claim. Applications outside of those periods may require a completed health history application, unless you are otherwise eligible for guarantee issue of coverage. Right To Return Contract If you are not satisfied with your coverage for any reason you may return your contract to: Blue Cross Blue Shield of Minnesota P.O. Box 64560 St. Paul, MN 55164-0560 If you send your contract back to us within 30 calendar days after receiving it we will treat the contract as if it had never been issued and return all of your premium payments within 10 business days. Replacing a Policy, Certificate or Contract If you are purchasing or canceling a supplement from Blue Cross, DO NOT cancel your old coverage until your new coverage is approved and you are certain that you want to keep it. This will prevent a lapse in coverage. Notice of Noncoverage Your Blue Cross Supplement or Select coverage may not fully cover all your medical costs. Please read your contract language carefully to determine specific benefits and coverage. Remember that Medicare determines if the services available on your Supplement or Select contract are eligible for coverage. Relationship to Medicare Neither Blue Cross nor its agents are associated with Medicare. Completing Your Application for Coverage Should you have any questions as you fill out your application for coverage, please call your Blue Cross agent or marketing associate for assistance. We are happy to help. As you fill out the application for new coverage or make optional benefit changes to your existing coverage, please be sure to answer all application questions about your medical and health history truthfully and completely. Blue Cross may cancel your coverage or refuse to pay your claims, or adjust your rate, if you omit or falsify important medical information. Carefully review the application before you sign it. Grievance Procedures (Basic Medicare Select) In compliance with state statutes governing Medicare Select Plans, Blue Cross has established the following procedures for resolution of complaints concerning either the provision of health care or Blue Cross’ administration of the terms of this contract: If you orally notify Blue Cross that you wish to register a complaint, Blue Cross shall promptly provide a complaint form that includes: the telephone number for service or other departments, or persons equipped to advise complaints; the address to which the form must be sent; a description of Blue Cross’ internal complaint system and time limits applicable to that system; and the telephone number to call to inform the Commissioner of Commerce. Blue Cross shall provide for informal discussions, consultations, conferences, or correspondence between you and a person with the authority to resolve or recommend the resolution of the complaint. Within 30 calendar days after receiving the written complaint, Blue Cross must notify you in writing of its decision and the reasons for it. If the decision is partially or wholly adverse to you, the notification must advise you of the right to appeal according to item 3, including your option for a written reconsideration or a hearing, the right to arbitrate according to item 4, and the right to notify the Commissioner of Commerce. If Blue Cross cannot make a decision within 30 calendar days due to circumstances outside the control of Blue Cross, Blue Cross may take up to an additional 14 calendar days to notify you, provided Blue Cross informs you in advance of the extension of the reasons for the delay. If you notify Blue Cross in writing of your desire to appeal Blue Cross’ initial decision, Blue Cross shall provide you the option of a hearing or a written reconsideration. If you choose a hearing, a person or persons with authority to resolve or recommend the resolution of the complaint shall preside, but the person or persons presiding must not be solely the same person or persons who made the decision under item 2. If you choose a written reconsideration, those with authority to resolve the complaint shall investigate the complaint, but the person or persons investigating must not be solely the same person or persons who made the decision under item 2. Hearings and written reconsiderations shall include the receipt of testimony, correspondence, explanations, or other information from you, staff persons, administrators, providers, or other persons, as is deemed necessary by the person or persons investigating the complaint in the case of a reconsideration or presiding person or persons in the case of a hearing for a fair appraisal and resolution of the complaint. In the case of a written reconsideration, a written notice of all key findings shall be given to you within 30 days of Blue Cross’ receipt or your written notice of appeal. In the case of a hearing, concise written notice of all key findings shall be given to you within 45 days after Blue Cross’ receipt of your written notice of appeal. You may request, or Blue Cross shall provide the opportunity for binding arbitration of any complaint which is unresolved by the mechanisms set forth in the appeal process noted in item 2. Arbitration must be conducted according to the American Arbitration Association and Minnesota Health Maintenance Organization Arbitration Rules. If the subject of the complaint relates to a malpractice claim, the complaint shall not be subject to arbitration. If a complaint involves a dispute about an immediately and urgently needed service that Blue Cross claims is experimental or investigative, not medically necessary, or otherwise not generally accepted by the medical profession, the procedures in items 1 to 4 do not apply. Blue Cross must use an expedited dispute resolution process appropriate to the particular situation. By the end of the next business day after the complaint is registered, Blue Cross shall notify the Commissioner of Commerce of the nature of the complaint, the decision of Blue Cross, if any, and a description of the review process used or being used. If a decision is not made by the end of the next business day following the registration of the complaint, Blue Cross shall notify the Commissioner of Commerce of its decision by the end of the next business day following its decision. For purposes of this item, complaints need not be in writing. You may contact the Commissioner of Commerce at any time.