Summary of Coverage and Disclosure of Information
Medicare Supplement and Medicare Select Plans
Basic Medicare Select: Senior Gold
Basic Medicare Supplement: Basic Medicare Blue
Extended Basic Medicare Supplement: Extended Basic Blue
Summary of Benefits
Medicare Coverage 		Summary of Benefits
(Basic Medicare Blue) 		Summary of Coverage and
Disclosure of Information
Blue Cross and Blue Shield of Minnesota (Blue Cross) offers three (3) policies that fill in “gaps” to supplement your Medicare coverage. Our Basic Medicare Blue and Extended Basic Blue are standard Medigap Supplement policies where coverage is available with any provider that participates in Medicare. Senior Gold is a Basic Medicare Select plan. Select plans are also standardized supplements, but Select plan subscribers are required to use specific or preferred providers for the care they receive in Minnesota. Except for emergency care, if Select plan subscribers do not use plan providers, Blue Cross is not required to pay benefits. Select plan providers are available within Minnesota, and in all North Dakota, South Dakota, Iowa and Wisconsin counties that border Minnesota. Please consult your contract for details of coverage. Contact your local Social Security office or consult the Medicare Handbook for details of Medicare coverage.

As you read through this summary, please remember the following:
  1. For some services, Medicare determines if the services available on your Medicare Supplement or Select contract are eligible for coverage.
  2. It is possible for Medicare to allow a charge, but not pay for it. Whether your Blue Cross contract pays for it depends upon the contract language. Please read your contract carefully.
  3. For most services, if Medicare denies a charge, we must deny it, too. There are exceptions. Some benefits that are required by Minnesota state law are included in your supplement or Select contract, even though Medicare does not cover them.
  4. THESE CONTRACTS DO NOT COVER ALL MEDICAL EXPENSES BEYOND THOSE COVERED BY MEDICARE. THESE CONTRACTS DO NOT COVER ALL SKILLED NURSING HOME CARE EXPENSES AND DO NOT COVER CUSTODIAL OR RESIDENTIAL NURSING CARE. READ YOUR CONTRACT CAREFULLY TO DETERMINE WHICH NURSING HOME FACILITIES AND EXPENSES ARE COVERED BY YOUR CONTRACT.
  5. Your contract will not be cancelled/non-renewed because of a deterioration of your health. This contract is guaranteed renewable at a rate that does not take into account your individual claims experience or changes in your health status that occur after the initial issuance of coverage. You accept your renewal by paying monthly premiums when due. Rates are changed on an annual basis. Rates are based on information you provide indicating whether you use tobacco products. Refer to Section V for current rates.
  6. Your contract may be cancelled/non-renewed for nonpayment of premium.
  7. Your contract may be allowed to lapse at your request if you enroll in the Medicaid program. You may reinstate Medicare Supplement or Select coverage if your Medicaid benefits end within 24 months from the time you first suspend your Medicare Supplement or Medicare Select coverage.
  8. If you are enrolled in Medicare because you are disabled and are covered under a group health plan through your employer, you may not need this Medicare Supplement or Select contract. The benefits and charges you receive under this Medicare Supplement or Select contract may be suspended during your enrollment in a group health plan. You must request this suspension in writing by contacting Blue Cross. When your group health plan coverage ends, your Medicare Supplement or Select contract will be reactivated if you request us to do so in writing within 90 days of your group plan coverage termination.
  9. These contracts have a minimum anticipated loss ratio of 65%. On average, you may expect that $65 of every $100 in premium will be returned as benefits over the life of your contract.
  10. If you receive care within Minnesota or in any county which borders Minnesota, Select members must use providers who participate with Blue Cross and Blue Shield of Minnesota for certain benefits to be covered, while Supplement members may see any provider. If you receive care outside of Minnesota, claims are paid on the same basis as when you are in Minnesota if you see a provider who participates with Medicare. See your contract for specifics.
  11. The State of Minnesota provides counseling services through Senior LinkAge to provide advice concerning the purchase of Medicare Supplement policies and enrollment under Medicaid. You can contact Senior LinkAge at 1-800-333-2433 and ask for a Health Insurance Counselor.
  12. Contact the Minnesota Department of Commerce at 1-800-657-3602 for information about other medical insurance products currently available in Minnesota.