Medicare Supplement Plans This chart highlights the health plans offered by MIT in 2012 for eligible retirees and their spouses age 65 and older as well as qualified Medicare recipients on the MIT Long Term Disability Plan. MIT retirees are generally
eligible for retiree health benefits if they retire from the Institute on or after age 55 with at least ten years of MIT Retirement Plan membership occurring after the age of 45. The chart briefly indicates how authorized covered
services will be paid under each plan at designated participating providers or facilities. To qualify for benefits, services must be considered medically necessary and approved by the plan. This comparison is not a legal
2012 Comparison Chart
document. It reflects limited plan information as of January 2012. The plan document for each plan governs all questions.
Massachusetts Institute of Technology
Human Resources Department
Original Medicare Plans Indemnity Supplement Plan HMO Supplement Plans Medicare HMO Plan
77 Massachusetts Avenue
Building E19-215
Cambridge, MA 02139-4307
Tel: 617.253.6151 or Toll Free: 855.253.6151
Medicare Part A and Part B* Medex 2 Managed Blue for Seniors Tufts Medicare Complement Tufts Medicare Preferred
*2011 Information - Medicare has not yet published 2012
Parts A and B information. www.medicare.gov
Plan Provisions Deductible $0 payment until you meet the $162.00 Medicare Part B Medex deductible only applies to prescription drugs No deductibles; small copayments for some No deductibles; small copayments for some No deductibles; small copayments for some
deductible for doctor services, outpatient care and other purchased at a retail pharmacy. services noted below. services noted below. services noted below.
medical services. After that, Medicare generally pays
80% and you pay 20%. (2011)
Notes You must continue paying your Medicare Part B You must continue paying your Medicare Part B You must continue paying your Medicare Part B You must continue paying your Medicare Part B
premium. premium. All services must be provided or premium. You must use plan providers to get premium. Must use plan providers to get your
arranged by your Managed Blue for Seniors your covered services with few exceptions. You covered services with few exceptions. Must
(MBS) Primary Care Physician. For care not must choose a plan provider to be your Primary choose a plan provider to be your Primary Care
authorized by your MBS physician, refer to Care Physician (PCP). Physician (PCP).
Medicare coverage.
Inpatient Covered Services Semi-private room and hospital Day 1 to 60, you pay a $1,132.00 Part A deductible; Days Full coverage of 1) Medicare deductible and Covered in full. Covered in full. Covered in full after one initial deductible of $300
services 61 - 90, you pay a $283.00 copayment per day; Days 91 - copayment; 2) Lifetime reserve day copayment; 3) Up per calendar year for services received at a
150, you pay a $566.00 copayment per "lifetime reserve to 365 additional hospital days in your lifetime when network hospital.
day" (up to 60 days over a lifetime); Beyond 150 days: no Medicare benefits are used up.*
coverage. (2011)
Inpatient mental health care Day 1 to 60, you pay a $1,132.00 Part A deductible; Days For biologically-based mental health conditions, plan For biologically-based mental health conditions, $0 copayment, covered in full, 190-day lifetime $0 copayment, covered in full, 190-day lifetime
61 - 90, you pay a $283.00 copayment per day; Days 91 - pays Medicare hospital deductible and copayments. there is no inpatient limit in a network general or maximum in a psychiatric hospital. This limit does maximum in a psychiatric hospital. This limit does
150 you pay a $566.00 copayment per day; Beyond 150 Full coverage of lifetime reserve day copayment. Full psychiatric hospital. For non biologically-based not apply to inpatient mental health care in a not apply to inpatient mental health care in a
days: not covered. Inpatient mental health care in a coverage up to 365 additional hospital days in your mental health conditions, you have a limit of 60 general hospital. See Tufts Medicare general hospital. See Tufts Medicare Preferred
psychiatric hospital limited to 190 days in a lifetime. lifetime when your Medicare benefits are used up**. days per calendar year after Medicare days Complement Benefit Summary. Summary of Benefits.
(2011) For non-biologically-based mental conditions, see end. See Managed Blue for Seniors Summary
Medex 2 Summary of Benefits. of Benefits.
Private duty nursing Not covered. Not covered. Not covered. Not covered. Not covered.
Outpatient Covered Services Emergency care You pay a copayment for each emergency room visit and Pays Medicare deductible and copayment. You pay $50 copayment for covered services. You pay $50 copayment for emergency room. You pay $50 copayment for emergency room.
you pay 20% of the Medicare-approved amount for the copayment is waived if you are admitted. When copayment waived if admitted within 24 hours for copayment waived if admitted within 24 hours for
doctor's services. (2011) you are out of the Service Area, you must notify the same condition. Worldwide emergency care the same condition. Worldwide emergency care
your MBS physician within 48 hours of a coverage. coverage.
hospital admission and service must be deemed
a medical necessity.
Outpatient surgery You pay 20% of the Medicare-approved amount for the Full coverage of Medicare deductible and copayment. Covered in full. $0 copayment per day. You pay $50 copayment per day.
doctor after the Part B deductible. You pay 20% of the
Medicare-approved amount for each service you receive
in an outpatient hospital setting after the Part B
deductible.
Skilled nursing facility (SNF) Coverage for maximum of 100 days; Days 1 - 20: $0 Pays in full for days 21-100; then $10 daily for days Covered in full up to 100 days per benefit $0 copayment per day. 100 days covered for each $0 copayment per day. 100 days covered for
(for non-custodial care) copayment; Days 21 - 100: you pay up to $141.50 per 101-365 for SNF participating with Medicare. Pays $8 period.* benefit period each benefit period. No prior hospital stay
day; Days 100+: You pay 100%. (2011) daily for 365 days for SNF not participating with required.
Medicare. Combined maximum of 365 days per
benefit period* both participating and non-
participating facilities.
Non-custodial home health Covered in full. Medicare provides full coverage for Medicare- Covered in full if approved by Medicare. Covered in full for Medicare-covered home health Covered in full for Medicare-covered home health
services approved home health care furnished by a Medicare- visits and supplies. visits and supplies.
covered provider. No benefits are provided for
services not covered by Medicare.
Limited chiropractic services You pay 20% of the Medicare-approved amount. Pays Medicare deductible and copayment for You pay $10 copayment for each Medicare- You pay $10 copayment for each Medicare- You pay $15 copayment for each Medicare-
Medicare-approved charges only. covered visit. covered visit. covered visit.
* A benefit period begins when you first receive inpatient services in a hospital or skilled nursing facility. If you do not receive inpatient care for 60 days after your discharge, that benefit period will end. A new benefit period will begin when you again receive inpatient services.
** The 365 additional days per lifetime are a combination of days in a general or psychiatric hospital.
Medicare Part A and Part B* Medex 2 Managed Blue for Seniors Tufts Medicare Complement Tufts Medicare Preferred
*2011 Information - Medicare has not yet published 2012
Parts A and B information. www.medicare.gov
Outpatient Covered Services continued Doctor's office visits for You pay 20% of the Medicare-approved amount. Pays Medicare deductible and copayment. You pay $10 per visit. You pay $10 copayment per visit to PCP or You pay $10 copayment per visit to PCP and $15
specific treatment specialist. copayment per visit to a specialist.
Immunizations/ Inoculation Not covered. Not covered. You pay $10 per visit. Covered in full. Office copayment may apply if Covered in full. Office copayment may apply if
services are provided in conjunction with a services are provided in conjunction with a
physician visit. physician visit.
Routine physicals "Welcome to Medicare" one-time preventive physical Not covered. (Benefits available for pap smear, You pay $10 per visit. Covered in full. Covered in full.
exam within the first 12 months of enrollment in Part B mammogram and colorectal cancer screenings. See
coverage. After 12 months, a yearly "Wellness" exam (if Plan Document.)
you've had Part B longer than 12 months) if doctor
Routine eye and hearing Not covered. Not covered. You pay $10 copayment per eye exam. Hearing You pay $10 copayment per visit. Discount on You pay $15 copayment for each annual routine
exams/Eyewear and hearing exams are not covered. lenses, frames and contacts. eye exam. You receive up to $150 allowance for
aids eyeglasses (prescription lenses and frames) or
contact lenses every calendar year. You pay $15
copayment for each annual routine hearing test.
You receive up to $500 allowance for hearing
aids every 3 years.
Diagnostic x-rays and lab tests Covered in full. Pays Medicare medical insurance deductible and Covered in full. Covered in full. Covered in full.
copayment of approved charges including pap smears
and mammograms once per year.
Medicare Part D Prescription Drug Plan Prescription Drugs Express Scripts Retail Pharmacy: 30-day supply: Express Scripts Retail Pharmacy: 30-day Express Scripts Retail Pharmacy: 30-day Express Scripts Retail Pharmacy: 30-day
(administered by Express Scripts, Inc.) Tier 1 (generic) - $8, Tier 2 (preferred brand name) - supply: Tier 1 (generic) - $8, Tier 2 (preferred supply: Tier 1 (generic) - $8, Tier 2 (preferred supply: Tier 1 (generic) - $8, Tier 2 (preferred
$35, Tier 3 (non-preferred brand name) - $50. brand name) - $35, Tier 3 (non-preferred brand brand name) - $35, Tier 3 (non-preferred brand brand name) - $35, Tier 3 (non-preferred brand
name) - $50. name) - $50. name) - $50.
Express Scripts Mail Order Pharmacy: 90-day Express Scripts Mail Order Pharmacy: 90-day Express Scripts Mail Order Pharmacy: 90-day Express Scripts Mail Order Pharmacy: 90-day
supply: Tier 1 (generic) - $16, Tier 2 (preferred brand supply: Tier 1 (generic) - $16, Tier 2 (preferred supply: Tier 1 (generic) - $16, Tier 2 (preferred supply: Tier 1 (generic) - $16, Tier 2 (preferred
name) - $50, Tier 3 (non-preferred brand name) - $80. brand name) - $50, Tier 3 (non-preferred brand brand name) - $50, Tier 3 (non-preferred brand brand name) - $50, Tier 3 (non-preferred brand
name) - $80. name) - $80. name) - $80.
Occupational, physical and You pay 20% of the Medicare-approved amount. Pays Medicare deductible and copayment for You pay $10 copayment per visit. You pay $10 copayment per visit. You pay $15 copayment per visit.
speech therapy physiotherapy, occupational and speed therapy
services approved by Medicare.
Prosthetic devices and durable You pay 20% of the Medicare-approved amount. Pays Medicare deductible and copayment for all You pay $10 for Medicare-approved supplies You pay $0 copayment for Medicare-covered You pay $0 copayment for Medicare-covered
medical equipment equipment approved by Medicare. and equipment when prescribed by an MBS items. items.
physician and obtained from a participating
provider.
Ambulance service You pay 20% of the Medicare-approved amount. Pays Medicare deductible and copayment for Covered in full for emergency transport. You Covered in full. There is no copayment for You pay $50 copayment per day for ambulance
ambulance services approved by Medicare. pay $40 for each non-emergency transport in Medicare-covered ambulance services. service.
certain medically-necessary circumstances.
Outpatient mental health care You pay 45% of the Medicare-approved amount. For biologically-based conditions, when covered by You pay $10 per visit. For biologically-based You pay $10 copayment per visit. There is no You pay $15 copayment per visit.
Medicare, full coverage of Medicare deductible and mental health conditions, there is no visit limit. visit limit for either biologically-based or non-
copayment with no visit maximum. When visits are For non-biologically-based mental health biologically-based mental health conditions.
not covered by Medicare, full coverage with no visit conditions, you have a limit of 24 visits. See
maximum. For non-biologically-based mental health Summary of Benefits.
conditions, see Medex 2 Summary of Benefits.
For medical coverage questions contact plans directly: Medicare: 1-800-633-4227; Medex 2: 1-800-258-2226; Managed Blue for Seniors: 1-800-325-2583; Tufts Medicare Complement: 1-800-462-0224; Tufts Medicare Preferred: 1-800-701-9000.
MIT reserves the right to alter, amend or terminate the provisions of this benefit plan to any extent and in any manner that it may deem advisable.
Note: This comparison chart is not a legal document. It reflects limited plan information as of January 1, 2011. The following are not covered under any plan: custodial confinement, routine foot care, treatment covered by Workers' Compensation, and disabilities related to service in the armed
forces. Under Massachusetts state law, physicians and other covered professional providers may not bill you for any balance over the amount approved by Medicare.