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Regence Application Packet
Thank you for your interest in applying for the Regence Blue Shield Medicare Supplement plan!
This application packet provides you with access to a printable copy of the Enrollment Form, a link to their online enrollment form and the Outline of Coverage in addition to a link to the Choosing a Medigap Policy Guide.
Should you decide to apply by secure upload/mail/fax/email, the printable application needs to be reviewed and signed by an Agent before it can be submitted to Regence Blue Shield. You may upload, email, fax or mail it in to CDA Insurance:
• Fax: 1.541.284.2994
• Email: [email protected]
• Secure File Upload: Click here
• Mail: CDA Insurance LLC PO Box 26540 Eugene, Oregon 97402
Other Important Information Download Medicare’s Choosing a Medigap Policy Guide (.pdf) Online application Download Policy Outline (.pdf) Download Application (.pdf)
Our website: http://www.medicare-idaho.com
If you should have any questions on the application, please call us at 1.800.884.2343 or 1.541.434.9613.
OUTLINE OF COVERAGE
Regence BridgeMedicare Supplement (Medigap) PlansIncludes Senior Selection (Modified Plan F)
Regence BlueShield of Idaho, Inc., is an Independent Licensee of the Blue Cross and Blue Shield Association
REG-36344-17/02-17-ID
II0117PMBAIII0117PMBAIDII0117PMBCIII0117PMBCIDII0117PMBFIII0117PMBFIDII0117PMBKI
II0117PMBKIDII0117PMBSSIII0117PMBSSIDII0517PMBGI II0517PMBGIDII0517PMBNIII0517PMBNID
Regence BlueShield of Idaho, Inc.
Benefit Chart of Medicare Supplement Plans sold on or after June 1, 2010This 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 our state. The plans offered by Regence BlueShield of Idaho, Inc., are shaded in the chart below. See Outlines of Coverage sections for details about all plans. 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 endMedical Expenses: Part B coinsurance (generally 20% of the Medicare-approved expenses) or
copayments for hospital outpatient services. Plans K, L and N require insured to pay a portion of Part B coinsurance or copayments
Blood: First three pints of blood each yearHospice: Part A coinsurance
A B C D F/F* G
Basic, including 100% Part B coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Part A Deductible
Part A Deductible
Part A Deductible
Part A Deductible
Part A Deductible
Part B Deductible
Part B Deductible
Part B Excess Charges (100%)
Part B Excess Charges (100%)
Foreign Travel Emergency
Foreign Travel Emergency
Foreign Travel Emergency
Foreign Travel Emergency
*Plan F also has an option called a high deductible plan F. The high deductible plan pays the same benefits as Plan F after one has paid a $2,200 calendar-year deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2,200. Out-of-pocket expenses for this deductible are expenses that would ordinarily 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. Regence does not offer the high deductible Plan F.
3
Regence BlueShield of Idaho, Inc.
Outline of Medicare Supplement (Medigap) Coverage – Page 2
Senior Selection(Modified Plan F)
K L M N
Basic Benefits Hospitalization and preventive care paid at 100%; other basic benefits paid at 50%
Hospitalization and preventive care paid at 100%; other basic benefits paid at 75%
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER
Skilled Nursing Facility Coinsurance
50% Skilled Nursing Facility Coinsurance
75% Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Part A Deductible 50% Part A Deductible
75% Part A Deductible
50% Part A Deductible
Part A Deductible
Part B Deductible
Part B Excess (100%)
Foreign Travel Emergency
Foreign Travel Emergency
Foreign Travel Emergency
Out-of-pocket limit $5,120; paid at 100% after limit reached
Out-of-pocket limit $2,560; paid at 100% after limit reached
80% Diagnostic and Preventive Dental Services up to $500 per year.
Individual Assistance Program; 8 counseling sessions
A B C D F/F* G
Basic, including 100% Part B coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Part A Deductible
Part A Deductible
Part A Deductible
Part A Deductible
Part A Deductible
Part B Deductible
Part B Deductible
Part B Excess Charges (100%)
Part B Excess Charges (100%)
Foreign Travel Emergency
Foreign Travel Emergency
Foreign Travel Emergency
Foreign Travel Emergency
4
Table of Contents
5 Premium Information
10 Disclosures
Plan Descriptions
11 Plan A
13 Plan C
15 Senior Selection (Modified Plan F)
18 Plan G
20 Plan K
22 Plan N
25 Exclusions
25 Dental Exclusions
54
Premium information — Medicare Supplement plansRegence BlueShield of Idaho, Inc., can raise your premium only if we raise the premium for all policies like yours in this state. Rates effective May 1, 2017
Monthly Automatic Bank WithdrawalAge <65 65 66 67 68 69 70 71 72 73 74
Plan A NA $151 $155 $160 $164 $168 $172 $175 $178 $182 $184
Plan C NA $281 $290 $300 $311 $320 $327 $339 $348 $354 $362
Plan SS* NA $222 $231 $240 $247 $256 $263 $270 $276 $283 $290
Plan G (Non- Smoker) NA $164 $171 $178 $183 $190 $195 $200 $204 $209 $214
Plan G (Smoker)
NA $194 $202 $210 $216 $225 $230 $236 $241 $247 $253
Plan K NA $153 $158 $164 $169 $175 $178 $182 $188 $191 $196
Plan N (Non- Smoker) NA $142 $148 $154 $159 $165 $170 $175 $179 $184 $189
Plan N (Smoker)
NA $168 $175 $182 $188 $195 $201 $207 $212 $217 $223
Monthly Automatic Bank WithdrawalAge 75 76 77 78 79 80 81 82 83 84 85+
Plan A $186 $188 $189 $190 $191 $191 $193 $193 $193 $193 $193
Plan C $369 $377 $385 $389 $394 $398 $403 $408 $412 $414 $415
Plan SS* $294 $300 $305 $310 $314 $318 $321 $325 $326 $327 $328
Plan G (Non- Smoker) $217 $221 $225 $229 $232 $235 $237 $240 $241 $242 $243
Plan G (Smoker) $256 $261 $266 $271 $274 $278 $280 $284 $285 $286 $287
Plan K $200 $205 $208 $210 $213 $216 $219 $220 $222 $223 $225
Plan N (Non- Smoker) $192 $196 $199 $202 $205 $208 $210 $213 $214 $215 $216
Plan N (Smoker) $227 $232 $235 $239 $242 $246 $248 $252 $253 $254 $255
*Senior Selection (Modified Plan F)
6
These plans have an annual renewal date of March 1. Because of this, you may experience a rate change within 12 months during your initial year of enrollment. After your first year, rates are guaranteed not to increase for 12 months. A household discount of $15 for Plan A, $25 for Plan C, $20 for Senior Selections, $20 for Plan G, $15 for Plan K and $15 for Plan N per member, per month may be available if two or more members have a policy with Regence or its affiliates, reside at the same physical address and are married, domestic partners, or otherwise immediately related. Also, discounts are reflected in the premiums listed below for all payment options other than monthly paper bill. There is no discount for monthly paper billing.
Monthly Paper BillAge <65 65 66 67 68 69 70 71 72 73 74
Plan A NA $153 $157 $162 $166 $170 $174 $177 $180 $184 $186
Plan C NA $283 $292 $302 $313 $322 $329 $341 $350 $356 $364
Plan SS* NA $224 $233 $242 $249 $258 $265 $272 $278 $285 $292
Plan G (Non- Smoker) NA $166 $173 $180 $185 $192 $197 $202 $206 $211 $216
Plan G (Smoker)
NA $196 $204 $212 $218 $227 $232 $238 $243 $249 $255
Plan K NA $155 $160 $166 $171 $177 $180 $184 $190 $193 $198
Plan N (Non- Smoker) NA $144 $150 $156 $161 $167 $172 $177 $181 $186 $191
Plan N (Smoker)
NA $170 $177 $184 $190 $197 $203 $209 $214 $219 $225
Monthly Paper BillAge 75 76 77 78 79 80 81 82 83 84 85+
Plan A $188 $190 $191 $192 $193 $193 $195 $195 $195 $195 $195
Plan C $371 $379 $387 $391 $396 $400 $405 $410 $414 $416 $417
Plan SS* $296 $302 $307 $312 $316 $320 $323 $327 $328 $329 $330
Plan G (Non- Smoker) $219 $223 $227 $231 $234 $237 $239 $242 $243 $244 $245
Plan G (Smoker) $258 $263 $268 $273 $276 $280 $282 $286 $287 $288 $289
Plan K $202 $207 $210 $212 $215 $218 $221 $222 $224 $225 $227
Plan N (Non- Smoker) $194 $198 $201 $204 $207 $210 $212 $215 $216 $217 $218
Plan N (Smoker) $229 $234 $237 $241 $244 $248 $250 $254 $255 $256 $257
*Senior Selection (Modified Plan F)
76
Quarterly RateAge <65 65 66 67 68 69 70 71 72 73 74
Plan A NA $455 $467 $482 $494 $506 $518 $527 $536 $548 $554
Plan C NA $845 $872 $902 $935 $962 $983 $1,019 $1,046 $1,064 $1,088
Plan SS* NA $668 $695 $722 $743 $770 $791 $812 $830 $851 $872
Plan G (Non- Smoker) NA $494 $515 $536 $551 $572 $587 $602 $614 $629 $644
Plan G (Smoker)
NA $584 $608 $632 $650 $677 $692 $710 $725 $743 $761
Plan K NA $461 $476 $494 $509 $527 $536 $548 $566 $575 $590
Plan N (Non- Smoker) NA $429 $446 $464 $479 $497 $512 $527 $539 $554 $569
Plan N (Smoker)
NA $506 $527 $548 $566 $587 $605 $623 $638 $653 $671
Quarterly RateAge 75 76 77 78 79 80 81 82 83 84 85+
Plan A $560 $566 $569 $572 $575 $575 $581 $581 $581 $581 $581
Plan C $1,109 $1,133 $1,157 $1,169 $1,184 $1,196 $1,211 $1,226 $1,238 $1,244 $1,247
Plan SS* $884 $902 $917 $932 $944 $956 $965 $977 $980 $983 $986
Plan G (Non- Smoker) $653 $665 $677 $689 $698 $707 $713 $722 $725 $728 $731
Plan G (Smoker) $770 $785 $800 $815 $824 $836 $842 $854 $857 $860 $863
Plan K $602 $617 $626 $632 $641 $650 $659 $662 $668 $671 $677
Plan N (Non- Smoker) $578 $590 $599 $608 $617 $626 $632 $641 $644 $647 $650
Plan N (Smoker) $683 $698 $707 $719 $728 $740 $746 $758 $761 $764 $767
Monthly Paper BillAge <65 65 66 67 68 69 70 71 72 73 74
Plan A NA $153 $157 $162 $166 $170 $174 $177 $180 $184 $186
Plan C NA $283 $292 $302 $313 $322 $329 $341 $350 $356 $364
Plan SS* NA $224 $233 $242 $249 $258 $265 $272 $278 $285 $292
Plan G (Non- Smoker) NA $166 $173 $180 $185 $192 $197 $202 $206 $211 $216
Plan G (Smoker)
NA $196 $204 $212 $218 $227 $232 $238 $243 $249 $255
Plan K NA $155 $160 $166 $171 $177 $180 $184 $190 $193 $198
Plan N (Non- Smoker) NA $144 $150 $156 $161 $167 $172 $177 $181 $186 $191
Plan N (Smoker)
NA $170 $177 $184 $190 $197 $203 $209 $214 $219 $225
Monthly Paper BillAge 75 76 77 78 79 80 81 82 83 84 85+
Plan A $188 $190 $191 $192 $193 $193 $195 $195 $195 $195 $195
Plan C $371 $379 $387 $391 $396 $400 $405 $410 $414 $416 $417
Plan SS* $296 $302 $307 $312 $316 $320 $323 $327 $328 $329 $330
Plan G (Non- Smoker) $219 $223 $227 $231 $234 $237 $239 $242 $243 $244 $245
Plan G (Smoker) $258 $263 $268 $273 $276 $280 $282 $286 $287 $288 $289
Plan K $202 $207 $210 $212 $215 $218 $221 $222 $224 $225 $227
Plan N (Non- Smoker) $194 $198 $201 $204 $207 $210 $212 $215 $216 $217 $218
Plan N (Smoker) $229 $234 $237 $241 $244 $248 $250 $254 $255 $256 $257
*Senior Selection (Modified Plan F)
8
Semi-Annual RateAge <65 65 66 67 68 69 70 71 72 73 74
Plan A NA $908 $932 $962 $986 $1,010 $1,034 $1,052 $1,070 $1,094 $1,106
Plan C NA $1,688 $1,742 $1,802 $1,868 $1,922 $1,964 $2,036 $2,090 $2,126 $2,174
Plan SS* NA $1,334 $1,388 $1,442 $1,484 $1,538 $1,580 $1,622 $1,658 $1,700 $1,742
Plan G (Non- Smoker) NA $987 $1,028 $1,070 $1,100 $1,142 $1,172 $1,202 $1,226 $1,256 $1,286
Plan G (Smoker)
NA $1,166 $1,214 $1,262 $1,298 $1,352 $1,382 $1,418 $1,448 $1,484 $1,520
Plan K NA $920 $950 $986 $1,016 $1,052 $1,070 $1,094 $1,130 $1,148 $1,178
Plan N (Non- Smoker) NA $856 $890 $926 $956 $992 $1,022 $1,052 $1,076 $1,106 $1,136
Plan N (Smoker)
NA $1,010 $1,052 $1,094 $1,130 $1,172 $1,208 $1,244 $1,274 $1,304 $1,340
Semi-Annual RateAge 75 76 77 78 79 80 81 82 83 84 85+
Plan A $1,118 $1,130 $1,136 $1,142 $1,148 $1,148 $1,160 $1,160 $1,160 $1,160 $1,160
Plan C $2,216 $2,264 $2,312 $2,336 $2,366 $2,390 $2,420 $2,450 $2,474 $2,486 $2,492
Plan SS* $1,766 $1,802 $1,832 $1,862 $1,886 $1,910 $1,928 $1,952 $1,958 $1,964 $1,970
Plan G (Non- Smoker) $1,304 $1,328 $1,352 $1,376 $1,394 $1,412 $1,424 $1,442 $1,448 $1,454 $1,460
Plan G (Smoker) $1,538 $1,568 $1,598 $1,628 $1,646 $1,670 $1,682 $1,706 $1,712 $1,718 $1,724
Plan K $1,202 $1,232 $1,250 $1,262 $1,280 $1,298 $1,316 $1,322 $1,334 $1,340 $1,352
Plan N (Non- Smoker) $1,154 $1,178 $1,196 $1,214 $1,232 $1,250 $1,262 $1,280 $1,286 $1,292 $1,298
Plan N (Smoker) $1,364 $1,394 $1,412 $1,436 $1,454 $1,478 $1,490 $1,514 $1,520 $1,526 $1,532
*Senior Selection (Modified Plan F)
98
Annual RateAge <65 65 66 67 68 69 70 71 72 73 74
Plan A NA $1,814 $1,862 $1,922 $1,970 $2,018 $2,066 $2,102 $2,138 $2,186 $2,210
Plan C NA $3,374 $3,482 $3,602 $3,734 $3,842 $3,926 $4,070 $4,178 $4,250 $4,346
Plan SS* NA $2,666 $2,774 $2,882 $2,966 $3,074 $3,158 $3,242 $3,314 $3,398 $3,482
Plan G (Non- Smoker) NA $1,971 $2,054 $2,138 $2,198 $2,282 $2,342 $2,402 $2,450 $2,510 $2,570
Plan G (Smoker)
NA $2,330 $2,426 $2,522 $2,594 $2,702 $2,762 $2,834 $2,894 $2,966 $3,038
Plan K NA $1,838 $1,898 $1,970 $2,030 $2,102 $2,138 $2,186 $2,258 $2,294 $2,354
Plan N (Non- Smoker) NA $1,710 $1,778 $1,850 $1,910 $1,982 $2,042 $2,102 $2,150 $2,210 $2,270
Plan N (Smoker)
NA $2,018 $2,102 $2,186 $2,258 $2,342 $2,414 $2,486 $2,546 $2,606 $2,678
Annual RateAge 75 76 77 78 79 80 81 82 83 84 85+
Plan A $2,234 $2,258 $2,270 $2,282 $2,294 $2,294 $2,318 $2,318 $2,318 $2,318 $2,318
Plan C $4,430 $4,526 $4,622 $4,670 $4,730 $4,778 $4,838 $4,898 $4,946 $4,970 $4,982
Plan SS* $3,530 $3,602 $3,662 $3,722 $3,770 $3,818 $3,854 $3,902 $3,914 $3,926 $3,938
Plan G (Non- Smoker) $2,606 $2,654 $2,702 $2,750 $2,786 $2,822 $2,846 $2,882 $2,894 $2,906 $2,918
Plan G (Smoker)
$3,074 $3,134 $3,194 $3,254 $3,290 $3,338 $3,362 $3,410 $3,422 $3,434 $3,446
Plan K $2,402 $2,462 $2,498 $2,522 $2,558 $2,594 $2,630 $2,642 $2,666 $2,678 $2,702
Plan N (Non- Smoker) $2,306 $2,354 $2,390 $2,426 $2,462 $2,498 $2,522 $2,558 $2,570 $2,582 $2,594
Plan N (Smoker)
$2,726 $2,786 $2,822 $2,870 $2,906 $2,954 $2,978 $3,026 $3,038 $3,050 $3,062
Semi-Annual RateAge <65 65 66 67 68 69 70 71 72 73 74
Plan A NA $908 $932 $962 $986 $1,010 $1,034 $1,052 $1,070 $1,094 $1,106
Plan C NA $1,688 $1,742 $1,802 $1,868 $1,922 $1,964 $2,036 $2,090 $2,126 $2,174
Plan SS* NA $1,334 $1,388 $1,442 $1,484 $1,538 $1,580 $1,622 $1,658 $1,700 $1,742
Plan G (Non- Smoker) NA $987 $1,028 $1,070 $1,100 $1,142 $1,172 $1,202 $1,226 $1,256 $1,286
Plan G (Smoker)
NA $1,166 $1,214 $1,262 $1,298 $1,352 $1,382 $1,418 $1,448 $1,484 $1,520
Plan K NA $920 $950 $986 $1,016 $1,052 $1,070 $1,094 $1,130 $1,148 $1,178
Plan N (Non- Smoker) NA $856 $890 $926 $956 $992 $1,022 $1,052 $1,076 $1,106 $1,136
Plan N (Smoker)
NA $1,010 $1,052 $1,094 $1,130 $1,172 $1,208 $1,244 $1,274 $1,304 $1,340
Semi-Annual RateAge 75 76 77 78 79 80 81 82 83 84 85+
Plan A $1,118 $1,130 $1,136 $1,142 $1,148 $1,148 $1,160 $1,160 $1,160 $1,160 $1,160
Plan C $2,216 $2,264 $2,312 $2,336 $2,366 $2,390 $2,420 $2,450 $2,474 $2,486 $2,492
Plan SS* $1,766 $1,802 $1,832 $1,862 $1,886 $1,910 $1,928 $1,952 $1,958 $1,964 $1,970
Plan G (Non- Smoker) $1,304 $1,328 $1,352 $1,376 $1,394 $1,412 $1,424 $1,442 $1,448 $1,454 $1,460
Plan G (Smoker) $1,538 $1,568 $1,598 $1,628 $1,646 $1,670 $1,682 $1,706 $1,712 $1,718 $1,724
Plan K $1,202 $1,232 $1,250 $1,262 $1,280 $1,298 $1,316 $1,322 $1,334 $1,340 $1,352
Plan N (Non- Smoker) $1,154 $1,178 $1,196 $1,214 $1,232 $1,250 $1,262 $1,280 $1,286 $1,292 $1,298
Plan N (Smoker) $1,364 $1,394 $1,412 $1,436 $1,454 $1,478 $1,490 $1,514 $1,520 $1,526 $1,532
*Senior Selection (Modified Plan F)
10
Disclosures
Use this outline to compare benefits and premiums among policies. This outline shows benefits and premium of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates prior to June 1, 2010, have different benefits and premiums. Plans E, H, I and J are no longer available for sale.
Read your policy very carefullyThis is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.
Right to return policyIf you find that you are not satisfied with your policy, you may return it to Regence BlueShield of Idaho, Inc., P.O. Box 1106, Lewiston, ID 83501. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.
Policy replacementIf you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
NoticeThis policy may not fully cover all of your medical costs. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security office or consult Medicare and You for more details. Neither Regence BlueShield of Idaho, Inc., nor its producers are connected with Medicare.
Complete answers are very importantWhen you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
1110
Regence Bridge Plan A Medicare (Part A) – Hospital Services – Per Benefit Period* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Services Medicare Pays Plan Pays You Pay
Hospitalization* — Semi-private room & board, general nursing and miscellaneous services and supplies
First 60 days All but $1,316 $0 $1,316 (Part A deductible)
61st thru 90th day All but $329 a day $329 a day $0
91st day and after:While using 60 lifetime reserve days
All but $658 a day $658 a day $0
Once lifetime reserve days are used:Additional 365 days
$0 100% of Medicare- eligible expenses
$0**
Beyond the additional 365 days $0 $0 All costs
Skilled Nursing Facility Care* — You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day $0 Up to $164.50 a day
101st day and after $0 $0 All costs
Blood
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Hospice Care
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
12
Plan A (cont.)Medicare (Part B) – Medical Services – Per Calendar Year***Once you have been billed $183 of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan Pays You PayMedical expenses — in or out of hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests and durable medical equipment
First $183 of Medicare-approved amounts***
$0 $0 $183 (Part B deductible)
Remainder of Medicare-approved amounts
Generally 80% Generally 20% $0
Part B Excess Charges (above Medicare-approved amounts)
$0 $0 All costs
Blood
First 3 pints $0 All costs $0
Next $183 of Medicare-approved amounts***
$0 $0 $183 (Part B deductible)
Remainder of Medicare-approved amounts
80% 20% $0
Clinical Laboratory Services
Tests for diagnostic services 100% $0 $0
Parts A & BHome Health Care — Medicare-Approved Services
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment: First $183 of Medicare-approved amounts***
$0 $0 $183 (Part B deductible)
Remainder of Medicare-approved amounts
80% 20% $0
1312
Regence Bridge Plan CMedicare (Part A) – Hospital Services – Per Benefit Period* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Services Medicare Pays Plan Pays You Pay
Hospitalization* — Semi-private room & board, general nursing and miscellaneous services and supplies
First 60 days All but $1,316 $1,316 (Part A deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0
91st day and after:While using 60 lifetime reserve days
All but $658 a day $658 a day $0
Once lifetime reserve days are used:Additional 365 days
$0 100% of Medicare- eligible expenses
$0**
Beyond the additional 365 days $0 $0 All costs
Skilled Nursing Facility Care* — You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day Up to $164.50 a day $0
101st day and after $0 $0 All costs
Blood
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Hospice Care
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
14
Plan C (cont.)Medicare (Part B) – Medical Services – Per Calendar Year***Once you have been billed $183 of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan Pays You PayMedical expenses — in or out of hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests and durable medical equipment
First $183 of Medicare-approved amounts***
$0 $183 (Part B deductible)
$0
Remainder of Medicare-approved amounts
Generally 80% Generally 20% $0
Part B Excess Charges (above Medicare-approved amounts)
$0 $0 All costs
Blood
First 3 pints $0 All costs $0
Next $183 of Medicare-approved amounts***
$0 $183 (Part B deductible)
$0
Remainder of Medicare-approved amounts
80% 20% $0
Clinical Laboratory Services
Tests for diagnostic services 100% $0 $0
Parts A & BHome Health Care — Medicare-Approved Services
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment: First $183 of Medicare-approved amounts***
$0 $183 (Part B deductible)
$0
Remainder of Medicare-approved amounts
80% 20% $0
Other Benefits — Not Covered by MedicareForeign Travel — Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
1514
Regence Bridge Senior Selection (Modified Plan F) Medicare (Part A) – Hospital Services – Per Benefit Period* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Services Medicare Pays Plan Pays You Pay
Hospitalization* — Semi-private room & board, general nursing and miscellaneous services and supplies
First 60 days All but $1,316 $1,316 (Part A deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0
91st day and after:While using 60 lifetime reserve days
All but $658 a day $658 a day $0
Once lifetime reserve days are used:Additional 365 days
$0 100% of Medicare- eligible expenses
$0**
Beyond the additional 365 days $0 $0 All costs
Skilled Nursing Facility Care* — You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day Up to $164.50 a day $0
101st day and after $0 $0 All costs
Blood
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Hospice Care
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
16
Plan F (cont.)Medicare (Part B) – Medical Services – Per Calendar Year***Once you have been billed $183 of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan Pays You PayMedical expenses — in or out of hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests and durable medical equipment
First $183 of Medicare-approved amounts***
$0 $183 (Part B deductible)
$0
Remainder of Medicare-approved amounts
Generally 80% Generally 20% $0
Part B Excess Charges (above Medicare-approved amounts)
$0 100% $0
Blood
First 3 pints $0 All costs $0
Next $183 of Medicare-approved amounts***
$0 $183 (Part B deductible)
$0
Remainder of Medicare-approved amounts
80% 20% $0
Clinical Laboratory Services
Tests for diagnostic services 100% $0 $0
Parts A & BHome Health Care — Medicare-Approved Services
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment: First $183 of Medicare-approved amounts***
$0 $183 (Part B deductible)
$0
Remainder of Medicare-approved amounts
80% 20% $0
Other Benefits — Not Covered by MedicareForeign Travel — Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
1716
Plan F (cont.)
Other Benefits — Not Covered by MedicareForeign Travel — Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
Dental Services
$500 annual maximum for diagnostic and preventive services
$0 80% 20%
Individual Assistance Program Benefits
Eight (8) professional, confidential counseling sessions (may be a duplication of Medicare benefits)
$0 All costs $0
Individual Assistance Program Services
Toll-free 24-hours crisis line access, legal services, and Web-based and telephonic consultations regarding senior care and financial planning.
$0 All costs $0
18
Regence Bridge Plan G Medicare (Part A) – Hospital Services – Per Benefit Period* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Services Medicare Pays Plan Pays You Pay
Hospitalization* — Semi-private room & board, general nursing and miscellaneous services and supplies
First 60 days All but $1,316 $1,316 (Part A deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0
91st day and after:While using 60 lifetime reserve days
All but $658 a day $658 a day $0
Once lifetime reserve days are used:Additional 365 days
$0 100% of Medicare- eligible expenses
$0**
Beyond the additional 365 days $0 $0 All costs
Skilled Nursing Facility Care* — You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day
Up to $164.50 a day
$0
101st day and after $0 $0 All costs
Blood
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Hospice Care
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
1918
Regence Bridge Plan G Plan G (cont.)Medicare (Part B) – Medical Services – Per Calendar Year***Once you have been billed $183 of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan Pays You PayMedical expenses — in or out of hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests and durable medical equipment
First $183 of Medicare-approved amounts***
$0 $0 $183 (Part B deductible)
Remainder of Medicare-approved amounts
Generally 80% Generally 20% $0
Part B Excess Charges (above Medicare-approved amounts)
$0 100% $0
Blood
First 3 pints $0 All costs $0
Next $183 of Medicare-approved amounts***
$0 $0 $183 (Part B deductible)
Remainder of Medicare-approved amounts
80% 20% $0
Clinical Laboratory Services
Tests for diagnostic services 100% $0 $0
Parts A & BHome Health Care — Medicare-Approved Services
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment: First $183 of Medicare-approved amounts***
$0 $0 $183 (Part B deductible)
Remainder of Medicare-approved amounts
80% 20% $0
Other Benefits — Not Covered by MedicareForeign Travel — Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
20
Regence Bridge Plan K*You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $5,120 each calendar year. The amounts that count toward your annual limit are noted with diamonds (♦) in the chart. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference between the amount charged by your provider and the amount paid by Medicare for the items or service.
Medicare (Part A) – Hospital Services – Per Benefit Period** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends
after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Services Medicare Pays Plan Pays You Pay*
Hospitalization** — Semi-private room & board, general nursing and miscellaneous services and supplies
First 60 days All but $1,316 $658 (50% of Part A deductible)
$658 (50% of Part A deductible)♦
61st thru 90th day All but $329 a day $329 a day $0
91st day and after:While using 60 lifetime reserve days
All but $658 a day $658 a day $0
Once lifetime reserve days are used:Additional 365 days
$0 100% of Medicare- eligible expenses
$0***
Beyond the additional 365 days $0 $0 All costs
Skilled Nursing Facility Care** — You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day Up to $82.25 a day Up to $82.25
a day♦
101st day and after $0 $0 All costs
Blood
First 3 pints $0 50% 50%♦
Additional amounts 100% $0 $0
Hospice Care
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited coinsurance for out- patient drugs and inpatient respite care
50% of copayment/coinsurance
50% of Medicare copayment/coinsurance♦
***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
2120
Plan K (cont.)Medicare (Part B) – Medical Services – Per Calendar Year****Once you have been billed $183 of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan Pays You Pay*Medical expenses — in or out of hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests and durable medical equipment
First $183 of Medicare-approved amounts****
$0 $0 $183 (Part B deductible)****♦
Preventive benefits for Medicare- covered services
Generally 80% or more of Medicare- approved amounts
Remainder of Medicare-approved amounts
All costs above Medicare-approved amounts
Remainder of Medicare-approved amounts
Generally 80% Generally 10% Generally 10%♦
Part B Excess Charges (above Medicare-approved amounts)
$0 $0 All costs (and they do not count toward annual out-of-pocket limit of $5,120)*
Blood
First 3 pints $0 50% 50%♦
Next $183 of Medicare-approved amounts****
$0 $0 $183 (Part B deductible)****♦
Remainder of Medicare-approved amounts
80% Generally 10% Generally 10%♦
Clinical Laboratory Services
Tests for diagnostic services 100% $0 $0
Parts A & B Home Health Care — Medicare-Approved Services
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment: First $183 of Medicare-approved amounts****
$0 $0 $183 (Part B deductible)♦
Remainder of Medicare-approved amounts
80% 10% 10% ♦
*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $5,120 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying the difference between the amount charged by your provider and the amount paid by Medicare for the item or service.Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
22
Regence Bridge Plan N Medicare (Part A) – Hospital Services – Per Benefit Period* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Services Medicare Pays Plan Pays You Pay
Hospitalization* — Semi-private room & board, general nursing and miscellaneous services and supplies
First 60 days All but $1,316 $1,316 (Part A deductible)
$0
61st thru 90th day All but $329 a day $329 a day $0
91st day and after:While using 60 lifetime reserve days
All but $658 a day $658 a day $0
Once lifetime reserve days are used:Additional 365 days
$0 100% of Medicare- eligible expenses
$0**
Beyond the additional 365 days $0 $0 All costs
Skilled Nursing Facility Care* — You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st thru 100th day All but $164.50 a day
Up to $164.50 a day
$0
101st day and after $0 $0 All costs
Blood
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Hospice Care
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
2322
Regence Bridge Plan N Plan N (cont.)Medicare (Part B) – Medical Services – Per Calendar Year***Once you have been billed $183 of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan Pays You PayMedical expenses — in or out of hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests and durable medical equipment
First $183 of Medicare-approved amounts***
$0 $0 $183 (Part B deductible)
Remainder of Medicare-approved amounts
Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copay of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
Up to $20 per office visit and up to $50 per emergency room visit. The copay of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
Part B Excess Charges (above Medicare-approved amounts)
$0 $0 All costs
Blood
First 3 pints $0 All costs $0
Next $183 of Medicare-approved amounts***
$0 $0 $183 (Part B deductible)
Remainder of Medicare-approved amounts
80% 20% $0
Clinical Laboratory Services
Tests for diagnostic services 100% $0 $0
Parts A & B Home Health Care — Medicare-Approved Services
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipment: First $183 of Medicare-approved amounts***
$0 $0 $183 (Part B deductible)
Remainder of Medicare-approved amounts
80% 20% $0
24
Plan N (cont.)
Services Medicare Pays Plan Pays You Pay
Other Benefits — Not Covered by MedicareForeign Travel — Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
2524
Exclusions We will not provide benefits for any of the following:
– Expenses duplicated by Medicare. – Expenses not covered by Medicare. – Services and supplies provided by a provider not recognized by
Medicare —any services or supplies provided by a physician, hospital, skilled nursing facility, or any other provider that is not recognized as payable under the Medicare Act, except as specifically covered under the policy for foreign travel. This includes services provided by a provider who has opted out of Medicare, and who must by federal law, enter into an agreement with you regarding your liability for the care that provider gives you.
– Third party liability — services and suppliesfor treatment of illness or injury for which a third party is responsible.
Dental Exclusions In addition to the exclusions listed above, we will not provide benefits for
any of the following conditions, including any direct complications or consequences that arise from them: Non-Covered Dental Services Any procedure, treatment, supply, or service not specifically listed as a Covered Dental Service.
Not Dentally Appropriate Services that are not considered Dentally Appropriate.
26 Rev. 02-17
Regence Bridge Medicare Supplement (Medigap) Plans
For more information, call one of our Plan’s sales representatives, 8 a.m. to 5 p.m., Monday through Friday toll-free: 1-844-REGENCE (734-3623)TTY users should call 711.
Or contact your local insurance producer.
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-344-6347 (TTY: 711).
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-888-344-6347 (TTY: 711).
P.O. Box 1106Lewiston, ID 83501
regence.com/medicare
© 2017 Regence BlueShield of Idaho, Inc.
REG-36344-17/02-17-ID