Medicare Supplement Plans Comparison Chart Human Resources by alicejenny

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									                                                                                                           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
                                                                                                            2012 Comparison Chart                    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 document. It

Massachusetts Institute of Technology
Human Resources Department
                                                                                                                       Original Medicare Plans                                              Indemnity Supplement Plan                                             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                                                 Tufts Medicare Preferred
Plan Provisions                                Deductible                                              $0 payment until you meet the $140.00 Medicare Part B                     No deductible; small copayments for some services                   No deductible; small copayments for some
                                                                                                       deductible for doctor services, outpatient care and other                 as noted below.                                                     services as noted below.
                                                                                                       medical services. After that, Medicare generally pays
                                                                                                       80% and you pay 20%.
                                               Notes                                                                                                                             You must continue paying your Medicare Part B                       You must continue paying your Medicare Part B
                                                                                                                                                                                 premium.                                                            premium. Must use plan providers to get your
                                                                                                                                                                                                                                                     covered services with few exceptions. Must
                                                                                                                                                                                                                                                     choose a plan provider to be your Primary Care
                                                                                                                                                                                                                                                     Provider (PCP).


Inpatient Covered Services                     Semi-private room and hospital services                 Day 1 to 60, you pay a $1,156.00 Part A deductible;                       Full coverage of 1) Medicare deductible and                         Covered in full after one initial deductible of
                                                                                                       Days 61 - 90, you pay a $289.00 copayment per day;                        copayment; 2) Lifetime reserve day copayment; 3) Up                 $300 per calendar year for services received at
                                                                                                       Days 91 - 150, you pay a $578.00 copayment per                            to 365 additional hospital days in your lifetime when               a network hospital.
                                                                                                       "lifetime reserve day" (up to 60 days over a lifetime);                   Medicare benefits are used up.*
                                                                                                       Beyond 150 days: no coverage.

                                               Inpatient mental health care                            Day 1 to 60, you pay a $1,156.00 Part A deductible;                       For biologically-based mental health conditions, plan               $0 copayment, covered in full, 190-day lifetime
                                                                                                       Days 61 - 90, you pay a $289.00 copayment per day;                        pays Medicare hospital deductible and copayments.                   maximum in a psychiatric hospital. This limit
                                                                                                       Days 91 - 150 you pay a $578.00 copayment per day;                        Full coverage of lifetime reserve day copayment. Full               does not apply to inpatient mental health care
                                                                                                       Beyond 150 days: not covered. Inpatient mental health                     coverage up to 365 additional hospital days in your                 in a general hospital. See Tufts Medicare
                                                                                                       care in a psychiatric hospital limited to 190 days in a                   lifetime when your Medicare benefits are used up**.                 Preferred Summary of Benefits.
                                                                                                       lifetime.                                                                 For non-biologically-based mental conditions, see
                                                                                                                                                                                 Medex 2 Summary of Benefits.

                                               Private duty nursing                                    Not covered.                                                              Not covered.                                                        Not covered.

Outpatient Covered Services                    Emergency care                                          You pay a copayment for each emergency room visit and                     Full coverage of Medicare deductible and copayment.                 You pay $50 copayment for emergency room.
                                                                                                       you pay 20% of the Medicare-approved amount for the                                                                                           copayment waived if admitted within 24 hours
                                                                                                       doctor's services.                                                                                                                            for the same condition. Worldwide emergency
                                                                                                                                                                                                                                                     care coverage.



                                               Outpatient surgery                                      You pay 20% of the Medicare-approved amount for the                       Full coverage of Medicare deductible and copayment.                 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) (for non-                Coverage for maximum of 100 days; Days 1 - 20: $0                         Pays in full for days 21-100; then $10 daily for days               $0 copayment per day. 100 days covered for
                                               custodial care)                                         copayment; Coverage for Days 21 - 100 after daily                         101-365 for SNF participating with Medicare. Pays                   each benefit period. No prior hospital stay
                                                                                                       $144.50 co-insurance; Days 100+: You pay 100%.                            $8 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 services                      Covered in full.                                                          Covered in full if approved by Medicare.                            Covered in full for Medicare-covered home
                                                                                                                                                                                                                                                     health visits and supplies.



                                               Limited chiropractic services                           You pay 20% of the Medicare-approved amount for                           Pays Medicare deductible and copayment for                          You pay $15 copayment for each Medicare-
                                                                                                       manual                                                                    Medicare-approved charges only.                                     covered visit.
                                                                                                       manipulation of the spine to correct a subluxation
                                                                                                       d      t t db        X


                                               * 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                                                   Tufts Medicare Preferred
Outpatient Covered Services continued     Doctor's office visits for specific treatment               You pay 20% of the Medicare-approved amount.                                  Pays Medicare deductible and copayment.                               You pay $10 copayment per visit to PCP and
                                                                                                                                                                                                                                                          $15 copayment per visit to a specialist.

                                          Immunizations/ Inoculation                                  Coverage for some preventive vaccinations. See the                            $0 copay for all preventive services covered under                    $0 copay for all preventive services
                                                                                                      "2012 Medicare & You" handbook for details or visit                           Medicare. Office copayment may apply if services are                  covered under Medicare. Office copayment
                                                                                                      www.medicare.gov.                                                             required due to an injury or immediate risk of infection              may apply if services are provided in
                                                                                                                                                                                    and are provided in conjunction with a Provider visit.                conjunction with a Provider visit.
                                                                                                                                                                                    Otherwise, not covered.
                                          Routine physicals                                           "Welcome to Medicare" one-time preventive physical                            Covered by Medicare.                                                  Covered by Medicare.
                                                                                                      exam within the first 12 months of enrollment in Part B
                                                                                                      coverage. After 12 months, a yearly "Wellness" exam (if
                                                                                                      you've had Part B longer than 12 months) if doctor
                                                                                                      accepts assignment.
                                          Routine eye and hearing exams/Eyewear and                   Not covered.                                                                  Not covered.                                                          You pay $15 copayment for each annual
                                          hearing aids                                                                                                                                                                                                    routine eye exam. You receive up to $150
                                                                                                                                                                                                                                                          allowance for 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.
                                                                                                                                                                                    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
(administered by Express Scripts, Inc.)                                                                                                                                             Tier 1 (generic) - $8, Tier 2 (preferred brand name) -                supply: Tier 1 (generic) - $8, Tier 2 (preferred
                                                                                                                                                                                    $35, Tier 3 (non-preferred brand name) - $50.                         brand name) - $35, Tier 3 (non-preferred brand
                                                                                                                                                                                                                                                          name) - $50.
                                                                                                                                                                                    Express Scripts Mail Order Pharmacy: 90-day                           Express Scripts Mail Order Pharmacy: 90-
                                                                                                                                                                                    supply: Tier 1 (generic) - $16, Tier 2 (preferred brand               day supply: Tier 1 (generic) - $16, Tier 2
                                                                                                                                                                                    name) - $50, Tier 3 (non-preferred brand name) -                      (preferred brand name) - $50, Tier 3 (non-
                                                                                                                                                                                    $80.                                                                  preferred brand name) - $80.
                                          Occupational, physical and speech therapy                   You pay 20% of the Medicare-approved amount.                                  Pays Medicare deductible and copayment for                            You pay $15 copayment per visit.
                                                                                                                                                                                    services approved by Medicare.

                                          Prosthetic devices and durable medical                      You pay 20% of the Medicare-approved amount.                                  Pays Medicare deductible and copayment for all                        You pay $0 copayment for Medicare-covered
                                          equipment                                                                                                                                 equipment approved by Medicare.                                       items.

                                          Ambulance service                                           You pay 20% of the Medicare-approved amount.                                  Pays Medicare deductible and copayment for                            You pay $50 copayment per day for Medicare-
                                                                                                                                                                                    ambulance services approved by Medicare.                              covered ambulance services



                                          Outpatient mental health care                               You pay 40% of the Medicare-approved amount for most                          For biologically-based conditions, when covered by                    You pay $15 copayment per visit.
                                                                                                      outpatient mental health care.                                                Medicare, full coverage of Medicare deductible and
                                                                                                                                                                                    copayment with no visit maximum. When visits are
                                                                                                                                                                                    not covered by Medicare, full coverage with 24 visits
                                                                                                                                                                                    per calendar year maximum. For non-biologically-
                                                                                                                                                                                    based mental health 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; 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, 2012. 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, Providers and other covered professional providers may not bill you for any balance over the amount approved by Medicare.

								
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