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BCBSTX Medicare Supplement Plan G

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Plan G

Plan G covers:

Your $1,632 Part A deductible and coinsurance
The cost of 365 extra days of hospital care during your lifetime after Medicare coverage ends
Your Part B coinsurance and the cost of the first three pints of blood
80% of Part B physician charges that are in excess of the Medicare-approved amount (By law no physician may charge more than 115% of Medicare-approved amounts).
Skilled nursing facility copayment
Foreign travel emergency care

Plan G does NOT cover:

Your $240 Medicare Part B deductible

There is also a BCBSTX Medicare-Select Plan G that offers the same benefits as Standard Plan G but provides costs savings by agreeing to use a Medicare Select participating hospital for non-emergencies. You may still see any doctor you choose with Medicare-Select plans. If your hospital is part of the Medicare Select network, the Med-Select plan is a good option to consider.

Benefit Summary

Benefit	What Plan G Covers
Part A Deductible You may need this benefit if you have to stay in the hospital. The Part A deductible is $1,632. This amount can change every year. You have to pay this deductible for each benefit period.	Plan G covers 100% of Part A deductible
Part B Deductible You may want to consider this benefit if you have Medicare Part B. Each year you must pay the Part B deductible (which is $240) before Medicare starts to pay its share. If you have this benefit, the Medigap plan would pay this amount each year.	Plan G does NOT cover the $240 Part B deductible, you must pay out of pocket.
Part B Coinsurance Without this benefit, you generally pay 20% of the Medicare-approved amount for Medicare Part B covered services and supplies (like doctor services and outpatient hospital care). This benefit will help you to reduce your out of pocket after Part B deductible.	Plan G covers 100% of the 20% remainder costs
365 Extra Days of Hospital Stay After you use all Medicare hospital benefits, you can receive up to 365 more days for hospital stays during your lifetime.	Plan G covers all of the costs for an additional 365 additional hospital days
3 Pints of Blood The first 3 pints of blood or equal amounts of packed red blood cells per calendar year, unless this blood is replaced.	Plan G covers all of the costs of 3 pints of blood per calendar year
Part B Excess Charges Under federal law, doctors who don’t accept “assignment ” (take Medicare’s approved amount as payment in full) may charge up to 15% more than the approved amount. You might want to think about this benefit if your doctors don’t accept assignment. You may also want this benefit if you have to stay in the hospital and can’t control whether the doctors you see accept assignment.	Plan G covers 100% of the excess charges
Foreign Travel Emergency If you travel outside the United States, this benefit could save you money for emergency care.	Plan G covers 80% (after a $250 deductible) to a lifetime maximum benefit of $50,000.
Skilled Nursing Coinsurance Medicare pays for the first 20 days of a skilled nursing facility. If you need to go to a Skilled Nursing Facility (SNF) after a hospital stay and stay in the SNF longer than 20 days, this benefit begins.	Plan G covers up to $167.50 per day for days 21-100.
Home Health Care Home Health Care is skilled nursing care and certain other health care services you get in your home for the treatment of an illness or injury.	Plan G covers the 20% remainder not paid by Medicare Part B.

Plan G Rates

Eligibility

• Texas Resident age 65 and over
• Must have Medicare Parts A & B
• May not duplicate an inforce Medicare Supplement

Area is determined by the first 3 digits of your Zip Code:

Area 1: 754-759; 763-769; 778-792; 795-799; 885
Area 2: 750-753; 760-762; 770-777; 793-794
Area 3: out-of-state

Plan	Ages	Area 1	Area 2	Area 3
Plan G	65-66	$137.00	$146.00	$163.00
	67-69	$156.00	$168.00	$185.00
	70-74	$183.00	$197.00	$217.00
	75-79	$204.00	$222.00	$244.00
	80-84	$231.00	$250.00	$279.00
	85+	$250.00	$272.00	$299.00