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
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
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
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
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-
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
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.