Subscriber Agreement

					Subscriber Agreement
                                       PLAN 65
                             Medicare Supplement PLAN A

MEDICARE SUPPLEMENT SUBSCRIBER AGREEMENT
This agreement describes your benefits from Blue Cross & Blue Shield of Rhode Island.
This is a Medicare Supplement Insurance Plan, which provides supplemental coverage
for the Original Medicare Plan recipients who are enrolled in Medicare Part A and
Medicare Part B.

RENEWABLE
This agreement begins on the effective date and remains in effect until December 31.
You may renew this agreement each calendar year by paying us the required
subscriber fee.

CHANGES IN BENEFITS
Benefits under this agreement will change automatically if Medicare eligible expenses
change. Subscriber fees may increase or decrease to reflect any change in benefits.
We will give you written notice and a description of any change of benefits at least thirty
(30) days prior to the effective date of change.

30 DAY RIGHT TO EXAMINE
You have the right to return this agreement within thirty (30) days of receipt if you are
not satisfied with it for any reason. We will refund your subscriber fee if this agreement
is returned within that time.

NOTICE TO BUYER
This agreement may not cover all of your medical expenses. Read this agreement
CAREFULLY.




James E. Purcell
President and Chief Executive Officer




Plan 65 A (01/11)
Plan 65 A (01/11)
                 BLUE CROSS & BLUE SHIELD OF RHODE ISLAND
                                 PLAN 65
                       MEDICARE SUPPLEMENT PLAN A

SUMMARY OF BENEFITS
This is a Medicare supplement insurance plan, which provides supplemental coverage
for individuals enrolled in the Original Medicare Plan.

This Summary of Benefits and the Benefit Provisions together form your subscriber
agreement for Medicare Supplement Plan A. This subscriber agreement replaces any
previous subscriber agreement issued for this type of coverage. The intent of this
summary is to give you a general understanding of benefits available under this
agreement. For more details, read section 3.0 for a description of coverage for specific
benefits. See section 5.0 for a list of general exclusions.

You have selected Medicare Supplement Plan A. This plan includes all of the benefits
shown in the Summary of Benefits chart below. This agreement may not cover all of
your Medicare eligible expenses; you will be responsible to pay for Medicare eligible
expenses not covered under this plan. Refer to your Benefit Provisions for a
detailed description of each benefit.



                     SUMMARY OF BENEFITS
                    Medicare Supplement Plan A
                            BASIC BENEFIT PROVISIONS

 Basic Benefits                                                Section      Plan Pays
 The 61st though 90th day of inpatient hospital services for     3.1      Medicare Part A
 Medicare eligible expenses.                                               copayment:

                                                                           $283 per day
 Sixty (60) lifetime inpatient reserve days for Medicare         3.1      Medicare Part A
 eligible expenses.                                                        copayment:

                                                                           $566 per day
 Up to a lifetime maximum of three hundred and sixty five        3.1         100% of
 (365) inpatient hospital days for Medicare eligible                      Medicare eligible
 expenses after exhausting all Medicare inpatient hospital                  expenses
 benefits.
 First three (3) pints of blood.                                 3.1          100% of
                                                                          Medicare eligible
                                                                             expenses
 Doctor services and outpatient services for Medicare            3.1      Medicare Part B
 eligible expenses.                                                         copayment:

                                                                           Generally 20%
 Hospice Care                                                    3.1         Medicare
                                                                            copayment


                                  Summary of Benefits
Plan 65 A (01-11)                             i
IF YOU HAVE ANY QUESTIONS OR REQUIRE ASSISTANCE PLEASE CALL US AT
401-459-5000 OR 1-800-639-2227. TO CONTACT OUR TELECOMMUNICATIONS
DEVICE FOR THE DEAF (TTY/TDD) PLEASE CALL 1-888-252-5051.




                        Summary of Benefits
Plan 65 A (01-11)                  ii
                        BLUE CROSS & BLUE SHIELD OF RHODE ISLAND
                                        PLAN 65
                              MEDICARE SUPPLEMENT PLAN A

                                                  TABLE OF CONTENTS

SUMMARY OF BENEFITS _______________________________________________ i
    Basic Benefits ........................................................................................................ i

1.0      INTRODUCTION __________________________________________________ 1
1.1   -- How to Find What You Need to Know --------------------------------------------------------- 1
1.2   -- You and Blue Cross & Blue Shield of Rhode Island --------------------------------------- 1
1.3   -- Words With Special Meaning -------------------------------------------------------------------- 1
1.4   -- General Information -------------------------------------------------------------------------------- 1

2.0      ELIGIBILITY ______________________________________________________ 2
2.1   -- Who is Eligible for Coverage -------------------------------------------------------------------- 2
2.2   -- Medicaid Eligibility ---------------------------------------------------------------------------------- 2
2.3   -- Extension of Benefits ------------------------------------------------------------------------------ 2
2.4   -- When Your Coverage Ends ---------------------------------------------------------------------- 2

3.0 PROVISIONS FOR COVERED BENEFITS ______________________________ 3
3.1 -- Basic Benefit Provisions -------------------------------------------------------------------------- 3
        Inpatient Hospital Services ................................................................................... 3
        Lifetime Inpatient Reserve Days ........................................................................... 3
        Lifetime Maximum Benefit for Inpatient Hospital Days ......................................... 3
        Blood Services...................................................................................................... 3
        Doctor Services and Outpatient Services ............................................................. 3

4.0     CHANGES IN BENEFITS ___________________________________________ 4

5.0     GENERAL EXCLUSIONS ___________________________________________ 5

6.0 HOW TO FILE AND APPEAL A CLAIM ________________________________ 6
6.1 -- How to File a Claim -------------------------------------------------------------------------------- 6
6.2 -- Payment of Benefits ------------------------------------------------------------------------------- 6
6.3 -- How to File a Complaint/Grievance and Appeal -------------------------------------------- 6
        How to File a Complaint/Grievance or Administrative Appeal .............................. 7
        Administrative Appeal ........................................................................................... 8
        Legal Action .......................................................................................................... 8
        Grievances Unrelated to Claims ........................................................................... 8
        Our Right to Withhold Payments .......................................................................... 9
        Subrogation and Reimbursement ......................................................................... 9

7.0     GLOSSARY _____________________________________________________ 11

ATTACHMENTS ______________________________________________________ A
Plan Chart --------------------------------------------------------------------------------------------------- A
Copy of Application ---------------------------------------------------------------------------------------- A

Plan 65 A (01/11)                                Table of Contents
Plan 65 A (01/11)   Table of Contents
1.0   INTRODUCTION
The entire contract consists of the application, this agreement, and any attached
amendments. Statements made by you to obtain insurance under this agreement will
be deemed representations and not warranties.

1.1     How to Find What You Need to Know
The Summary of Benefits at the front of this agreement will show you what Medicare
eligible expenses are covered under this agreement. The Table of Contents will help
you find more details about eligibility, how we pay for Medicare eligible expenses,
changes in benefits, services which are not covered under this agreement, how to file a
claim, and how to file a complaint/grievance.

1.2    You and Blue Cross & Blue Shield of Rhode Island
In consideration of the application and the payment of subscriber fees, we, Blue Cross
& Blue Shield of Rhode Island, agree to provide benefits under the terms of this
agreement. This is a Medicare supplement plan which provides supplemental coverage
for Medicare recipients who are enrolled in the Original Medicare Plan.

You can only be covered under one (1) Medicare supplement plan at any one time. If
you enroll in another Medicare Supplement Plan or a Medicare Advantage Plan it is
recommended that you disenroll in this plan. If you are enrolled in a Medicare
Supplement Plan and a Medicare Advantage Plan at the same time, benefits will only
be provided under the Medicare Advantage Plan.

Refer to the Summary of Benefits to determine your plan. Please read the
Summary of Benefits and the benefit provisions carefully.

1.3    Words With Special Meaning
Some words and phrases used in this agreement are in italics. This means that the
words or phrases have a special meaning as they relate to this agreement. The
glossary at the end of this agreement defines many of these words. Other sections of
this agreement also contain definitions of certain words and phrases. These sections
include Section 3.0 which describes covered benefits. Section 6.0 describes claim
procedures and how to file a complaint.

1.4    General Information
If you have questions or issues regarding your benefits under this agreement, call the
Blue Cross & Blue Shield of Rhode Island (BCBSRI) Customer Service Department at
(401) 459-5000 or 1-800-639-2227. Telecommunications Device for the Deaf users
(TTY/TDD) may call 1-888-252-5051. Our normal business hours are Monday - Friday
from 8:00 a.m. - 8:00 p.m. If you call after normal business hours, our answering service
will document your call. A BCBSRI Customer Service Representative will return your
call on the next business day. When you call, identify yourself as a subscriber. Also,
have your member identification (ID) card available.

To find out all the latest Blue Cross & Blue Shield of Rhode Island news and plan
information, visit our Web site at BCBSRI.com.




                                      Introduction
Plan 65 A (01/11)                        1
2.0     ELIGIBILITY
This section of this agreement describes rules for who is eligible for coverage, how
eligible persons are enrolled, and how and when coverage may be terminated.

2.1    Who is Eligible for Coverage
Only residents of Rhode Island who are Medicare recipients enrolled in the Original
Medicare Plan are eligible for coverage under this agreement.

2.2     Medicaid Eligibility
If you become eligible for Medicaid, you may request that we suspend the benefits and
subscriber fees under this agreement. You must notify us within ninety (90) days from
the date you become entitled to Medicaid assistance. Upon receipt of this notice, we
will suspend benefits and subscriber fees due under this agreement for up to twenty-
four (24) months.

We will automatically reinstate this agreement (or if no longer available, an agreement
that is a substantially equivalent) if you:
(a)     are no longer eligible for Medicaid within this twenty-four (24) month period; AND
(b)     notify us within ninety (90) days of the date you were no longer eligible for
        Medicaid; AND
(c)     pay the subscriber fee due as of reinstatement.

The effective date of reinstatement is the date you cease to be eligible for Medicaid
assistance. Benefits and subscriber fees will be reinstated as if this agreement (or a
substantially equivalent agreement) remained in force. We will NOT reinstate your
coverage after the twenty-four (24) month suspension.

2.3    Extension of Benefits
If you are totally disabled on the date this agreement ends, we will continue to provide
benefits under this agreement until the earliest of the date:
(a)    you are no longer totally disabled;
(b)    the Medicare benefit period ends; OR
(c)    maximum benefit payments have been paid.

Extended benefits apply only to the care or treatment for the disability for which this
extension applies.

2.4   When Your Coverage Ends
This agreement will end automatically:
(a)   one (1) month after the date subscriber fees due are not paid; OR
(b)   the date fraud is determined by us; OR
(c)   if we cease to offer this type of coverage.

You may end this agreement by telling us that you want this agreement to end or by not
paying the subscriber fee when due.

Reinstatement
We have the right to reinstate a terminated agreement.




                                         Eligibility
Plan 65 A (01/11)                         2
3.0    PROVISIONS FOR COVERED BENEFITS
We will cover the copayments required by Medicare for the services listed in this
section. Benefits under this agreement will change automatically to coincide with any
changes to the Original Medicare Plan deductible and copayment amounts. We may
modify the premiums to correspond with such changes. See Section 4.0 for more
information.

This agreement may not cover all of your medical expenses. Read this agreement
CAREFULLY.

Please see the Summary of Benefits at the front of this agreement to determine
the amount of coverage we provide for benefits under this agreement.

3.1     Basic Benefit Provisions
Inpatient Hospital Services
We will pay the copayment required by Medicare Part A for Medicare eligible expenses
relating to the 61st through 90th day of inpatient hospitalization, subject to payment of the
Medicare Part A deductible. You are responsible to pay the Medicare Part A deductible.

Lifetime Inpatient Reserve Days
Lifetime inpatient reserve days are limited to sixty (60) additional days of inpatient
hospitalization ONCE in your lifetime. If you are hospitalized for more than ninety (90)
days, we will pay the copayment required by Medicare Part A for Medicare eligible
expenses relating to the 91st to 150th day of lifetime inpatient reserve days.

Lifetime Maximum Benefit for Inpatient Hospital Days
Upon exhaustion of all Medicare hospital inpatient coverage, including the lifetime
inpatient reserve days, we will cover Medicare eligible expenses for hospitalization not
covered by Medicare Part A subject to a lifetime maximum benefit of 365 days.

Such expenses shall be paid as follows:
(a)   To the extent and in the amount Medicare would have covered such services had
      the lifetime reserve days not been exhausted and if Medicare were still prime; or
(b)   The lesser of (a) or the hospital’s charge.

Blood Services
We will cover the replacement costs, if any, required by Medicare for the first three (3)
pints of blood (or equivalent quantities of packed red blood cells as defined under
federal regulations) unless the blood is replaced in accordance with federal regulations.

Doctor Services and Outpatient Services
We will pay the copayment amount required by Medicare Part B for Medicare eligible
expenses.

Hospice Care
We will pay the copayment required by Medicare for Medicare eligible expenses relating
to hospice care and respite care.




                             Provisions for Covered Benefits
Plan 65 A (01/11)                         3
4.0    CHANGES IN BENEFITS
Benefits listed in Sections 3, Provisions for Covered Benefits, will change automatically
if Medicare eligible expenses change. We will send written notice to you with a
description of the benefit change(s) at least thirty (30) days prior to the effective date.
The effective date of the change is the same date that Medicare implements changes to
the Original Medicare Plan. Subscriber fees may be increased or decreased to reflect
any change of benefits under this agreement.

If this agreement changes, we will issue an amendment or a new agreement. Payment
of your subscriber fee will be considered acceptance by you of the change.




                                   Changes In Benefits
Plan 65 A (01/11)                              4
5.0    GENERAL EXCLUSIONS
AMOUNTS PAYABLE UNDER MEDICARE
In no event will medical payments under this agreement duplicate any amounts payable
under Medicare.

BENEFITS NOT LISTED IN THE SUMMARY OF BENEFITS
This agreement will not cover any benefit that is not listed in the Summary of Benefits.
Any benefit listed in the Summary of Benefits will be covered only to the extent
described in this agreement.

CARE PROVIDED WITHOUT CHARGE
No benefits are provided for services for which no charge would be made to you in
absence of insurance.

WAR
Injury or sickness caused by or resulting from any future act of war is not covered even
if the war is not declared.

WORKER’S COMPENSATION
This agreement will not cover any injury or sickness for which you are entitled to any
benefits under workers' compensation or similar law.




                                   General Exclusions
Plan 65 A (01/11)                       5
6.0    HOW TO FILE AND APPEAL A CLAIM

6.1    How to File a Claim
Most providers will submit claims directly to Medicare for you. Medicare will process the
claim, send you a notice called a Medicare Summary Notice, and send the claim
information to us. We will pay the provider directly for Medicare eligible expenses
covered under this plan.

In some instances you may be required to file a claim. You must file all claims within
one calendar year of the date the claim was processed by Medicare. The process date
is on the Medicare Summary Notice. Member submitted claims that arrive after this
deadline are invalid unless:
•       we determine that it was not reasonably possible for you to file your claim prior to
        the filing deadline; AND
•       you file your claim as soon as possible but no later than ninety (90) calendar
        days after the filing deadline elapses (unless you are legally incapable).

Our payments to you or the doctor fulfill our responsibility under this agreement. Your
benefits are personal to you and cannot be assigned, in whole or in part, to another
person or organization.

To file a claim, please send us a copy of the Medicare Summary Notice and include
your Plan 65 member identification (ID) card number.

Please mail the claim to:
             Blue Cross & Blue Shield of Rhode Island
             Attention: Claims Department
             500 Exchange St
             Providence, RI 02903

6.2    Payment of Benefits
We may make payments directly to the doctor, hospital, or to you. Your benefits under
this agreement are personal to you and may not be assigned to another person or
organization.

6.3    How to File a Complaint/Grievance and Appeal
A Complaint/Grievance is a verbal or written expression of dissatisfaction with any
aspect of our operation or the quality of care you received. A complaint is not an
appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing
up the misunderstanding or supplying the appropriate information to your satisfaction.

An Administrative Appeal is a verbal or written request for us to reconsider a full or
partial denial of payment for services that were denied because we determined that the
services were excluded from coverage or because you or your provider did not follow
Blue Cross & Blue Shield of Rhode Island’s requirements.

A Medical appeal is a verbal or written request to reconsider a full or partial denial of
payment for services that were denied because Medicare determined one of the
following:
       •     the services were not medically necessary; or
       •     the services are experimental or investigational.

             How to File a Claim and How to File a Complaint and Appeal
Plan 65 A (01/11)                      6
If you disagree with a full or partial medical denial or an administrative denial made by
Medicare, you may dispute the decision through the Medicare appeals process. To
start this process, follow the directions given in the letter you receive from Medicare
about the denial. We do NOT process Medicare medical appeals.

How to File a Complaint/Grievance or Administrative Appeal
If you are dissatisfied with any aspect of our operation, the quality of care you have
received, or you have a request for us to reconsider a full or partial denial of benefits
made by us (for example, a denial due to a member filing a claim after our established
time limits, see Section 6.1-How to File a Claim), please call our Customer Service
Department at (401) 459-5000 or 1-800-639-2227. TTY/TDD (Telecommunications
Device for the Deaf) users may call 1-888-252-5051.

The Customer Service Representative will log your call and the nature of the issue and
attempt to resolve your concern. If your concern is not resolved to your satisfaction, you
may file a complaint or administrative appeal verbally with the Customer Service
Representative. If you wish to file an administrative appeal, you must do so within 180
days of receiving a denial of benefits. You are not required to file a complaint before
filing an administrative appeal.

You may also file a complaint or administrative appeal in writing. To do so, you must
provide the following information:
•     name, address, Plan 65 subscriber ID number;
•     summary of the issue;
•     any previous contact with Blue Cross & Blue Shield of Rhode Island;
•     a brief description of the relief or solution you are seeking;
•     any additional information such as referral forms, claims, or any other
      documentation that you would like us to review;
•      the date of incident or service; and
•     your signature.

You can use the Member Appeal Form, which is available on our website BCBSRI.com
or a Customer Service Representative can provide it to you. You can also send us a
letter with the information requested above. If someone is filing a complaint or
administrative appeal on your behalf, you must send us a notice with your signature,
authorizing the individual to represent you in this matter. You may also complete a
Member’s Designation of a Personal Representative form which a Customer Service
Representative can provide to you.

Please mail the complaint or administrative appeal to:
                           Blue Cross & Blue Shield of Rhode Island
                           Attention: Grievance and Appeals Unit
                           500 Exchange Street
                           Providence, Rhode Island 02903

We will acknowledge your complaint or administrative appeal in writing or by phone
within ten (10) business days of our receipt of your written complaint or administrative
appeal. The Grievance and Appeals Unit will conduct a thorough review of your
complaint or administrative appeal and respond in the timeframes set forth below.


             How to File a Claim and How to File a Complaint and Appeal
Plan 65 A (01/11)                      7
Level 1 Complaint
We will respond to your Level 1 complaint in writing within thirty (30) calendar days of
the date we receive your complaint. The determination letter will provide you with the
rationale for our response. It will also give you information on the next steps available to
you, if any, if you are not satisfied with the outcome of the complaint.

Level 2 Complaint (when applicable)
A Level 2 complaint may be submitted only when you have been offered a second level
of complaint in your Level 1 determination letter. The Grievance and Appeals Unit will
conduct a thorough review of your Level 2 complaint and respond to you in writing
within thirty (30) business days. The determination letter will provide you with the
rationale for our response. It will also give you the next steps if you are not satisfied with
the outcome of the complaint.

Administrative Appeal
We will respond to your administrative appeal in writing within sixty (60) calendar days
of our receipt of your administrative appeal. The determination letter will provide you
with information regarding our decision.

Blue Cross & Blue Shield of Rhode Island does not offer a Level 2 administrative
appeal. You may notify the State of Rhode Island Department of Health or the State of
Rhode Island Office of the Health Insurance Commissioner regarding your concerns.
Please refer to the Legal Action section below for additional information.
.
Legal Action
If you are dissatisfied with the decision on your claim, and have complied with
applicable state and federal law, you are entitled to seek judicial review. This review will
take place in an appropriate court of law.

Note: Once a member or provider receives a decision at an appeal level, the provider
or the member may not ask for an appeal at the same level again, unless additional
information that could impact such decisions can be provided.

Under state law, you may not begin court proceedings prior to the expiration of sixty
(60) days after the date you filed your claim. In no event may legal action be taken
against us later than three (3) years from the date you were required to file the claim
(See Section 6.1).

Grievances Unrelated to Claims
We encourage you to discuss any complaint that you may have about any aspect of
your medical treatment with the health care provider that treated you. In most cases,
issues can be more easily resolved when they are raised when they occur. If, however,
you remain dissatisfied or prefer not to take up the issue with your provider, you may
access our complaint and grievance procedures. You may also use our complaint and
grievance procedures if you have a complaint about our service or about one of our
employees. To begin, a grievance, please call our Customer Service Department at
(401) 274-3500 or 1-800-564-0888 or TTY/TDD (Telecommunications for the Deaf)
users at 1-888-252-5051. The Customer Service Department will log in your call and
begin working towards the resolution of your complaint.



             How to File a Claim and How to File a Complaint and Appeal
Plan 65 A (01/11)                      8
The appeal and complaint procedure described in this section do not apply to the
following:
    • Medicare claims determinations;
    • medical necessity determinations;
    • complaints regarding payments;
    • claims of medical malpractice; or
    • allegations that we are liable for the professional negligence of any doctor,
       hospital, health care facility, or other health care doctor furnishing services under
       this agreement.

Our Right to Withhold Payments
We have the right to keep back payment during the period of investigation on any claim
we receive that we have reason to believe might not be eligible for coverage. We will
also conduct a pre-payment review on a claim we have reason to believe has been
submitted for a service not covered under this agreement. We will make a final decision
on these claims within sixty (60) days after the date that you filed your claim.

We also have the right to carry out post-payment review of claims. If we determine
fraud or misrepresentation was used when you filed the claim, we reserve the right to
take the necessary steps (including legal action) to recover funds. These funds may
have been paid to you or to a doctor, hospital, or other health care doctor. We may
review a claim if we have reason to believe it was submitted for a service we do not
cover under this agreement.

Subrogation and Reimbursement
Subrogation
We may recover money from a third party that causes you to be hurt or sick. If that
party has insurance, we may recover money from the insurance company. Our
recovery will be based on the benefit or payment we made under this agreement. For
example, if you are hurt in a car accident and we pay for your hospital stay, we can
collect the amount we paid for your hospital stay from the auto insurer. If you do not try
to collect money from the third party who caused you to be hurt or sick, you agree that
we can. We may do so on your behalf or in your name. Our right to be paid will take
priority over any claim for money by a third party. This is true even if you have a claim
for punitive or compensatory damages.

Reimbursement
If we give you benefits or make payment for services under this agreement and you get
money from a third party for those services, you must pay us back. This is true even if
you receive the money after a settlement or a judgment. For example, if your auto
insurance pays for your emergency room visit after a car accident, you must reimburse
us for any benefit payment that we made.

We can collect the money no matter where it is or how it is designated. You must pay us
back even if you do not get back the total amount of your claim against the third party.
We can collect the money you receive even if it is described as a payment for
something other than health care expenses. We may offset future payments under this
agreement until we have been paid an amount equal to what you were paid by a third
party. If we must pay legal fees in order to recover money from you, we can recover
these costs from you. Also, the amount that you must pay us cannot be reduced by any
legal costs that you have.

             How to File a Claim and How to File a Complaint and Appeal
Plan 65 A (01/11)                      9
If you receive money in a settlement or a judgment and do not agree with our right to
reimbursement, you must keep an amount equal to our claim in a separate account until
the dispute is resolved. If a court orders that money be paid to you or any third party
before your lawsuit is resolved, you must tell us quickly so we can respond in court.

Member Cooperation
You must give us information and help us. This means you must complete and sign all
necessary documents to help us get money back. You must tell us in a timely manner
about the progress of your claim with a third party. This includes filing a claim or lawsuit,
beginning settlement discussions, or agreeing to a settlement in principle, etc. It also
means that you must give us timely notice before you settle any claim. You must not do
anything that might limit our rights under this Section. We may take any action
necessary to protect our right of subrogation and/or reimbursement.




             How to File a Claim and How to File a Complaint and Appeal
Plan 65 A (01/11)                      10
7.0   GLOSSARY
BENEFIT means the amount this agreement pays to supplement Medicare eligible
expenses.

CALENDAR YEAR means a twelve (12) month period beginning on January 1 and
ending December 31.

COPAYMENT means the amount Medicare requires that you pay for covered benefits.

DEDUCTIBLE means the amount Medicare requires that you pay before Medicare will
provide covered benefits.

DOCTOR means a licensed practitioner who is qualified and authorized under that
license to perform the services covered under this agreement of the healing arts acting
within the scope of his or her license.

EMERGENCY means the sudden and unexpected onset of symptoms due to an illness
or injury which requires immediate medical treatment.

HOSPITAL means any facility which provides medical and surgical care for patients
who have acute illnesses or injuries. The facility must be accredited by the Joint
Commission on Accreditation of Hospitals. Hospital does NOT include:
(a)   convalescent, rest or nursing homes and facilities;
(b)   facilities primarily for custodial, educational or rehabilitative care;
(c)   substance abuse treatment facilities; OR
(d)   facilities operated by any national government or agency for the medical
      treatment of members or ex-members of the armed forces (except in an
      emergency if you are responsible to pay for services received).

INJURY means accidental bodily injury sustained:
(a)  as the direct result of an accident;
(b)  independent of disease or bodily infirmity or any other cause; AND
(c)  which occurs while this agreement is in force.

Injury does not include injuries for which benefits are provided under any workers'
compensation, employer's liability or similar law, or motor vehicle no-fault plan, unless
prohibited by law.

MEDICAID means “The Health Insurance for the Aged Act”’, Title XIX of the United
States Social Security Amendments of 1965, as amended.

MEDICARE means "The Health Insurance for the Aged Act," Title XVIII of the United
States Social Security Amendments of 1965, as then constituted or later amended.

MEDICARE BENEFIT PERIOD (BENEFIT PERIOD) A Medicare benefit period begins
the day you are admitted into a hospital or skilled nursing facility (SNF). The Medicare
benefit period ends when you have not received any hospital care (or skilled care in a
SNF) for 60 days in a row. If you go into the hospital or a skilled nursing facility after one
benefit period has ended, a new benefit period begins. An inpatient hospital deductible
applies to each Medicare benefit period. There is no limit to the number of benefit
periods you can have.

                                          Glossary
Plan 65 A (01/11)                          11
MEDICARE ELIGIBLE EXPENSE means health care expenses of the kinds covered by
the Original Medicare Plan, to the extent recognized as reasonable and medically
necessary by Medicare.

ORIGINAL MEDICARE PLAN is the Medicare traditional fee-for-service federal health
insurance. It has two parts Medicare Part A (Hospital insurance) and Medicare Part B
(Medical insurance).

PLAN means the basic benefits and the additional benefits, if any, listed in the
Summary of Benefits. There are ten (10) separate Medicare supplement plans allowed
by law. All ten (10) plans are listed in the plan chart attached to this agreement. We
may offer less than ten (10) separate plans. We may also offer the same plan with and
without limited provider network restrictions. Your plan is the plan shown in the
Summary of Benefits.

REIMBURSEMENT means our right to be paid back any payments, awards or
settlements that you receive from a third party. We can collect up to the amount of any
benefit or any payment we made.

SICKNESS means an illness or disease which first manifests itself after the effective
date of this agreement and while this agreement is in force.

SKILLED NURSING FACILITY means a facility primarily engaged in providing, in
addition to room and board accommodations, skilled nursing care under the supervision
of a doctor. A Skilled Nursing Facility must:
(a)    provide continuous 24-hour a day nursing services by or under the supervision of
       a registered graduate professional nurse (R.N.);
(b)    maintain the daily medical record of each patient; AND
(c)    be approved or qualified to receive approval for payment of Medicare benefits.

Skilled Nursing Facility does NOT include a home or facility which is used:
(a)    primarily for rest;
(b)    to care for the aged or for the care of substance abuse treatment; OR
(c)    primarily for the care and treatment of mental diseases or disorders, or custodial
       or educational care.

This plan does NOT cover Medicare eligible expenses for Skilled Nursing Facility
services.

SUBROGATION means we can use your right to recover money from a third party who
caused you to be hurt or sick. We may also recover from any insurance company
(including uninsured and underinsured motorist clauses and no-fault insurance) or other
party.

SUBSCRIBER/MEMBER means you, the eligible person listed on your application who
is enrolled in the plan.

WE, US, and OUR means Blue Cross & Blue Shield of Rhode Island. We are located
at 500 Exchange St Providence, Rhode Island, 02903. For the purpose of this
agreement we, us, or our will have the same meaning whether italicized or not.

                                        Glossary
Plan 65 A (01/11)                        12
YOU and YOUR means the individual subscriber whose application for coverage under
this agreement has been approved by us. For the purpose of this agreement you and
your will have the same meaning whether italicized or not.




                                    Glossary
Plan 65 A (01/11)                    13
ATTACHMENTS




Plan Chart



Copy of Application




                      Attachment A
Plan 65 A (01/11)
                    Attachment B
Plan 65 A (01/11)
                                                BLUE CROSS & BLUE SHIELD OF RHODE ISLAND
                                                          Benefit Plans: A, C, and SELECT C
                                                 Benefit Chart of Medicare Supplement Plans Sold
This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan "A" available. Some plans
may not be available in your state. Plans E, H, I, and J are no longer available for sale.

BASIC BENEFITS: Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses: Part
B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to
pay a portion of Part B coinsurance or co-payments. Blood: First three pints of blood each year. Hospice: Part A coinsurance.

      A             B              C               D          F      F*           G                K                   L               M               N
  Basic,        Basic,         Basic,         Basic,         Basic,          Basic,         Hospitalization     Hospitalization    Basic,         Basic,
  including     including      including      including      including       including      and preventive      and preventive     including      including
  100% Part     100% Part      100% Part      100% Part B    100% Part B     100% Part B    care paid at        care paid at       100% Part      100% Part B
  B             B              B             coinsurance    coinsurance*    coinsurance     100%; other        100%; other         B              coinsurance,
 coinsurance   coinsurance    coinsurance                                                                                         coinsurance     except up to
                                                                                            basic benefits     basic benefits                     $20
                                                                                            paid at 50%        paid at 75%                        copayment
                                                                                                                                                  for office
                                                                                                                                                  visit, and up
                                                                                                                                                  to $50
                                                                                                                                                 copayment for
                                                                                                                                                 ER
                              Skilled        Skilled          Skilled        Skilled        50% Skilled        75% Skilled        Skilled        Skilled
                              Nursing        Nursing          Nursing        Nursing        Nursing Facility   Nursing Facility   Nursing        Nursing
                              Facility Co-   Facility Co-     Facility Co-   Facility Co-   Coinsurance        Coinsurance        Facility Co-   Facility Co-
                              Insurance      Insurance        Insurance      Insurance                                            Insurance      Insurance
                Part A        Part A         Part A           Part A         Part A         50% Part A         75% Part A         50% Part A     Part A
                Deductible    Deductible     Deductible       Deductible     Deductible     Deductible         Deductible         Deductible     Deductible
                              Part B                          Part B
                              Deductible                      Deductible
                                                              Part B         Part B
                                                              Excess         Excess
                                                              (100%)         (100%)
                               Foreign        Foreign         Foreign        Foreign                                              Foreign        Foreign
                               Travel         Travel          Travel         Travel                                               Travel         Travel
                               Emergency      Emergency       Emergency      Emergency                                            Emergency      Emergency
 *Plan F also has an option called a high deductible plan F. This high deductible plan      Out- of pocket     Out- of pocket
 pays the same benefits as Plan F after one has paid a calendar year $2000 deductible.      limit $4640 paid   limit $2320 paid
 Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed    at 100% after      at 100% after
 $2000. Out-of-pocket expenses for this deductible are expenses that would ordinarily       limit reached      limit reached
 be paid by the policy. These expenses include the Medicare deductibles for Part A and
 Part B, but do not include the plan’s separate foreign travel emergency deductible.


Plan 65 A (01/11)                                                   Attachment A
Plan 65 A (01/11)   PL65-8337.7729

				
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