OUTLINE OF COVERAGE Regence Bridge Medicare Supplement (Medigap) Plans Includes Senior Selection (Modified Plan F) Regence BlueShield of Idaho, Inc. is an Independent Licensee of the Blue Cross and Blue Shield Association REG-36344-18/09-17-ID II0118PMBAI II0118PMBAID II0118PMBCI II0118PMBCID II0118PMBFI II0118PMBFID II0118PMBKI II0118PMBKID II0118PMBSSI II0118PMBSSID II0118PMBGI II0118PMBGID II0118PMBNI II0118PMBNID
Regence BlueShield of Idaho, Inc. Benefit Chart of Medicare Supplement Plans sold on or after June 1, 2010 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 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 plus coverage for 365 additional days after Medicare benefits end Medical Expenses: Part B (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 or copayments Blood: Hospice: First three pints of blood each year Part A A B C D F/F* G Basic, including 100% Part B Skilled nursing facility Skilled nursing facility Skilled nursing facility Skilled nursing facility 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. Regence does not offer the high deductible Plan F. The high deductible plan pays the same benefits as Plan F after one has paid a $2,240 calendar-year deductible. Benefits from high deductible plan F will not begin until outof-pocket expenses exceed $2,240. 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 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 Basic, including 100% Part B, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility 50% skilled nursing facility 75% skilled nursing facility Skilled nursing facility Skilled nursing facility 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 $5,240; paid at 100% after limit reached Out-of-pocket limit $2,620; paid at 100% after limit reached 80% Diagnostic and Preventive Dental Services up to $500 per year. Individual Assistance Program; 8 counseling sessions 3
Premium information Medicare Supplement plans Non-smoking rates Regence BlueShield of Idaho, Inc., can raise your premium only if we raise the premium for all policies like yours in this state. These non-smoking rates effective January 1, 2018 Monthly Automatic Bank Withdrawal Non-Smoking Rates Age <65 65 66 67 68 69 70 71 72 73 74 Plan A $226 $151 $155 $160 $164 $168 $172 $175 $178 $182 $184 Plan C $421 $281 $290 $300 $311 $320 $327 $339 $348 $354 $362 Plan SS* $333 $222 $231 $240 $247 $256 $263 $270 $276 $283 $290 Plan G $246 $164 $171 $178 $183 $190 $195 $200 $204 $209 $214 Plan K $229 $153 $158 $164 $169 $175 $178 $182 $188 $191 $196 Plan N $213 $142 $148 $154 $159 $165 $170 $175 $179 $184 $189 Monthly Paper Bill Age <65 65 66 67 68 69 70 71 72 73 74 Plan A $228 $153 $157 $162 $166 $170 $174 $177 $180 $184 $186 Plan C $423 $283 $292 $302 $313 $322 $329 $341 $350 $356 $364 Plan SS* $335 $224 $233 $242 $249 $258 $265 $272 $278 $285 $292 Plan G $248 $166 $173 $180 $185 $192 $197 $202 $206 $211 $216 Plan K $231 $155 $160 $166 $171 $177 $180 $184 $190 $193 $198 Plan N $215 $144 $150 $156 $161 $167 $172 $177 $181 $186 $191 Quarterly Rate Age <65 65 66 67 68 69 70 71 72 73 74 Plan A $680 $455 $467 $482 $494 $506 $518 $527 $536 $548 $554 Plan C $1,265 $845 $872 $902 $935 $962 $983 $1,019 $1,046 $1,064 $1,088 Plan SS* $1,001 $668 $695 $722 $743 $770 $791 $812 $830 $851 $872 Plan G $740 $494 $515 $536 $551 $572 $587 $602 $614 $629 $644 Plan K $689 $461 $476 $494 $509 $527 $536 $548 $566 $575 $590 Plan N $641 $428 $446 $464 $479 $497 $512 $527 $539 $554 $569 Semi-Annual Rate Age <65 65 66 67 68 69 70 71 72 73 74 Plan A $1,358 $908 $932 $962 $986 $1,010 $1,034 $1,052 $1,070 $1,094 $1,106 Plan C $2,528 $1,688 $1,742 $1,802 $1,868 $1,922 $1,964 $2,036 $2,090 $2,126 $2,174 Plan SS* $2,000 $1,334 $1,388 $1,442 $1,484 $1,538 $1,580 $1,622 $1,658 $1,700 $1,742 Plan G $1,478 $986 $1,028 $1,070 $1,100 $1,142 $1,172 $1,202 $1,226 $1,256 $1,286 Plan K $1,376 $920 $950 $986 $1,016 $1,052 $1,070 $1,094 $1,130 $1,148 $1,178 Plan N $1,280 $854 $890 $926 $956 $992 $1,022 $1,052 $1,076 $1,106 $1,136 Annual Rate Age <65 65 66 67 68 69 70 71 72 73 74 Plan A $2,714 $1,814 $1,862 $1,922 $1,970 $2,018 $2,066 $2,102 $2,138 $2,186 $2,210 Plan C $5,054 $3,374 $3,482 $3,602 $3,734 $3,842 $3,926 $4,070 $4,178 $4,250 $4,346 Plan SS* $3,998 $2,666 $2,774 $2,882 $2,966 $3,074 $3,158 $3,242 $3,314 $3,398 $3,482 Plan G $2,954 $1,970 $2,054 $2,138 $2,198 $2,282 $2,342 $2,402 $2,450 $2,510 $2,570 Plan K $2,750 $1,838 $1,898 $1,970 $2,030 $2,102 $2,138 $2,186 $2,258 $2,294 $2,354 Plan N $2,558 $1,706 $1,778 $1,850 $1,910 $1,982 $2,042 $2,102 $2,150 $2,210 $2,270 4 *Senior Selection (Modified Plan F)
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. 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 Automatic Bank Withdrawal Non-Smoking Rates Age 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 $217 $221 $225 $229 $232 $235 $237 $240 $241 $242 $243 Plan K $200 $205 $208 $210 $213 $216 $219 $220 $222 $223 $225 Plan N $192 $196 $199 $202 $205 $208 $210 $213 $214 $215 $216 Monthly Paper Bill Age 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 $219 $223 $227 $231 $234 $237 $239 $242 $243 $244 $245 Plan K $202 $207 $210 $212 $215 $218 $221 $222 $224 $225 $227 Plan N $194 $198 $201 $204 $207 $210 $212 $215 $216 $217 $218 Quarterly Rate Age 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 $653 $665 $677 $689 $698 $707 $713 $722 $725 $728 $731 Plan K $602 $617 $626 $632 $641 $650 $659 $662 $668 $671 $677 Plan N $578 $590 $599 $608 $617 $626 $632 $641 $644 $647 $650 Semi-Annual Rate Age 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 $1,304 $1,328 $1,352 $1,376 $1,394 $1,412 $1,424 $1,442 $1,448 $1,454 $1,460 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 $1,154 $1,178 $1,196 $1,214 $1,232 $1,250 $1,262 $1,280 $1,286 $1,292 $1,298 Annual Rate Age 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 $2,606 $2,654 $2,702 $2,750 $2,786 $2,822 $2,846 $2,882 $2,894 $2,906 $2,918 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 $2,306 $2,354 $2,390 $2,426 $2,462 $2,498 $2,522 $2,558 $2,570 $2,582 $2,594 *Senior Selection (Modified Plan F) 5
Premium information Medicare Supplement plans Smoking rates Regence BlueShield of Idaho, Inc., can raise your premium only if we raise the premium for all policies like yours in this state. These smoking rates effective January 1, 2018 Monthly Automatic Bank Withdrawal Smoking Rates Age <65 65 66 67 68 69 70 71 72 73 74 Plan A $266 $178 $182 $188 $193 $198 $202 $206 $209 $214 $216 Plan C $495 $331 $341 $353 $366 $376 $385 $399 $409 $416 $426 Plan SS* $391 $261 $272 $282 $291 $301 $309 $318 $325 $333 $341 Plan G $291 $194 $202 $210 $216 $225 $230 $236 $241 $247 $253 Plan K $269 $180 $186 $193 $199 $206 $209 $214 $221 $225 $231 Plan N $252 $168 $175 $182 $188 $195 $201 $207 $212 $217 $223 Monthly Paper Bill Age <65 65 66 67 68 69 70 71 72 73 74 Plan A $268 $180 $184 $190 $195 $200 $204 $208 $211 $216 $218 Plan C $497 $333 $343 $355 $368 $378 $387 $401 $411 $418 $428 Plan SS* $393 $263 $274 $284 $293 $303 $311 $320 $327 $335 $343 Plan G $293 $196 $204 $212 $218 $227 $232 $238 $243 $249 $255 Plan K $271 $182 $188 $195 $201 $208 $211 $216 $223 $227 $233 Plan N $254 $170 $177 $184 $190 $197 $203 $209 $214 $219 $225 Quarterly Rate Age <65 65 66 67 68 69 70 71 72 73 74 Plan A $800 $536 $548 $566 $581 $596 $608 $620 $629 $644 $650 Plan C $1,487 $995 $1,025 $1,061 $1,100 $1,130 $1,157 $1,199 $1,229 $1,250 $1,280 Plan SS* $1,175 $785 $818 $848 $875 $905 $929 $956 $977 $1,001 $1,025 Plan G $875 $584 $608 $632 $650 $677 $692 $710 $725 $743 $761 Plan K $809 $542 $560 $581 $599 $620 $629 $644 $665 $677 $695 Plan N $758 $506 $527 $548 $566 $587 $605 $623 $638 $653 $671 Semi-Annual Rate Age <65 65 66 67 68 69 70 71 72 73 74 Plan A $1,598 $1,070 $1,094 $1,130 $1,160 $1,190 $1,214 $1,238 $1,256 $1,286 $1,298 Plan C $2,972 $1,988 $2,048 $2,120 $2,198 $2,258 $2,312 $2,396 $2,456 $2,498 $2,558 Plan SS* $2,348 $1,568 $1,634 $1,694 $1,748 $1,808 $1,856 $1,910 $1,952 $2,000 $2,048 Plan G $1,748 $1,166 $1,214 $1,262 $1,298 $1,352 $1,382 $1,418 $1,448 $1,484 $1,520 Plan K $1,616 $1,082 $1,118 $1,160 $1,196 $1,238 $1,256 $1,286 $1,328 $1,352 $1,388 Plan N $1,514 $1,010 $1,052 $1,094 $1,130 $1,172 $1,208 $1,244 $1,274 $1,304 $1,340 Annual Rate Age <65 65 66 67 68 69 70 71 72 73 74 Plan A $3,194 $2,138 $2,186 $2,258 $2,318 $2,378 $2,426 $2,474 $2,510 $2,570 $2,594 Plan C $5,942 $3,974 $4,094 $4,238 $4,394 $4,514 $4,622 $4,790 $4,910 $4,994 $5,114 Plan SS* $4,694 $3,134 $3,266 $3,386 $3,494 $3,614 $3,710 $3,818 $3,902 $3,998 $4,094 Plan G $3,494 $2,330 $2,426 $2,522 $2,594 $2,702 $2,762 $2,834 $2,894 $2,966 $3,038 Plan K $3,230 $2,162 $2,234 $2,318 $2,390 $2,474 $2,510 $2,570 $2,654 $2,702 $2,774 Plan N $3,026 $2,018 $2,102 $2,186 $2,258 $2,342 $2,414 $2,486 $2,546 $2,606 $2,678 6 *Senior Selection (Modified Plan F)
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. 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 Automatic Bank Withdrawal Smoking Rates Age 75 76 77 78 79 80 81 82 83 84 85+ Plan A $219 $221 $222 $224 $225 $225 $227 $227 $227 $227 $227 Plan C $434 $444 $453 $458 $464 $468 $474 $480 $485 $487 $488 Plan SS* $346 $353 $359 $365 $369 $374 $378 $382 $384 $385 $386 Plan G $256 $261 $266 $271 $274 $278 $280 $284 $285 $286 $287 Plan K $235 $241 $245 $247 $251 $254 $258 $259 $261 $262 $265 Plan N $227 $232 $235 $239 $242 $246 $248 $252 $253 $254 $255 Monthly Paper Bill Age 75 76 77 78 79 80 81 82 83 84 85+ Plan A $221 $223 $224 $226 $227 $227 $229 $229 $229 $229 $229 Plan C $436 $446 $455 $460 $466 $470 $476 $482 $487 $489 $490 Plan SS* $348 $355 $361 $367 $371 $376 $380 $384 $386 $387 $388 Plan G $258 $263 $268 $273 $276 $280 $282 $286 $287 $288 $289 Plan K $237 $243 $247 $249 $253 $256 $260 $261 $263 $264 $267 Plan N $229 $234 $237 $241 $244 $248 $250 $254 $255 $256 $257 Quarterly Rate Age 75 76 77 78 79 80 81 82 83 84 85+ Plan A $659 $665 $668 $674 $677 $677 $683 $683 $683 $683 $683 Plan C $1,304 $1,334 $1,361 $1,376 $1,394 $1,406 $1,424 $1,442 $1,457 $1,463 $1,466 Plan SS* $1,040 $1,061 $1,079 $1,097 $1,109 $1,124 $1,136 $1,148 $1,154 $1,157 $1,160 Plan G $770 $785 $800 $815 $824 $836 $842 $854 $857 $860 $863 Plan K $707 $725 $737 $743 $755 $764 $776 $779 $785 $788 $797 Plan N $683 $698 $707 $719 $728 $740 $746 $758 $761 $764 $767 Semi-Annual Rate Age 75 76 77 78 79 80 81 82 83 84 85+ Plan A $1,316 $1,328 $1,334 $1,346 $1,352 $1,352 $1,364 $1,364 $1,364 $1,364 $1,364 Plan C $2,606 $2,666 $2,720 $2,750 $2,786 $2,810 $2,846 $2,882 $2,912 $2,924 $2,930 Plan SS* $2,078 $2,120 $2,156 $2,192 $2,216 $2,246 $2,270 $2,294 $2,306 $2,312 $2,318 Plan G $1,538 $1,568 $1,598 $1,628 $1,646 $1,670 $1,682 $1,706 $1,712 $1,718 $1,724 Plan K $1,412 $1,448 $1,472 $1,484 $1,508 $1,526 $1,550 $1,556 $1,568 $1,574 $1,592 Plan N $1,364 $1,394 $1,412 $1,436 $1,454 $1,478 $1,490 $1,514 $1,520 $1,526 $1,532 Annual Rate Age 75 76 77 78 79 80 81 82 83 84 85+ Plan A $2,630 $2,654 $2,666 $2,690 $2,702 $2,702 $2,726 $2,726 $2,726 $2,726 $2,726 Plan C $5,210 $5,330 $5,438 $5,498 $5,570 $5,618 $5,690 $5,762 $5,822 $5,846 $5,858 Plan SS* $4,154 $4,238 $4,310 $4,382 $4,430 $4,490 $4,538 $4,586 $4,610 $4,622 $4,634 Plan G $3,074 $3,134 $3,194 $3,254 $3,290 $3,338 $3,362 $3,410 $3,422 $3,434 $3,446 Plan K $2,822 $2,894 $2,942 $2,966 $3,014 $3,050 $3,098 $3,110 $3,134 $3,146 $3,182 Plan N $2,726 $2,786 $2,822 $2,870 $2,906 $2,954 $2,978 $3,026 $3,038 $3,050 $3,062 *Senior Selection (Modified Plan F) 7
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 carefully This 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 policy If 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. Notice This 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 important When 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. Policy replacement If 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. 8
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 $1,340 $1,340 (Part A deductible) 61st thru 90th day All but $335 a day $335 a day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days All but $670 a day $670 a day 100% of Medicareeligible expenses Beyond the additional 365 days 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 21st thru 100th day All approved All but $167.50 a day ** Up to $167.50 a day 101st day and after All costs Blood First 3 pints 3 pints Additional 100% Hospice Care You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited for outpatient drugs and inpatient respite care Medicare copayment/ **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. 9
Plan A (cont.) Medicare (Part B) Medical Services Per Calendar Year ***Once you have been billed $183 of Medicare-approved 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 *** Part B Excess Charges (above Medicare-approved ) Blood $183 Generally 80% Generally 20% All costs First 3 pints All costs Next $183 of Medicare-approved *** Clinical Laboratory Services $183 80% 20% Tests for diagnostic services 100% Parts A & B Home Health Care Medicare-Approved Services Medically necessary skilled care services and medical supplies Durable medical equipment: First $183 of Medicare-approved *** 100% $183 80% 20% 10
Regence Bridge Plan C 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 $1,340 $1,340 (Part A deductible) 61st thru 90th day All but $335 a day $335 a day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days All but $670 a day $670 a day 100% of Medicareeligible expenses Beyond the additional 365 days 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 21st thru 100th day All approved All but $167.50 a day ** Up to $167.50 a day 101st day and after All costs Blood First 3 pints 3 pints Additional 100% Hospice Care You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited for outpatient drugs and inpatient respite care Medicare copayment/ **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. 11
Plan C (cont.) Medicare (Part B) Medical Services Per Calendar Year ***Once you have been billed $183 of Medicare-approved 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 *** Part B Excess Charges (above Medicare-approved ) Blood $183 Generally 80% Generally 20% All costs First 3 pints All costs Next $183 of Medicare-approved *** Clinical Laboratory Services $183 80% 20% Tests for diagnostic services 100% Parts A & B Home Health Care Medicare-Approved Services Medically necessary skilled care services and medical supplies Durable medical equipment: First $183 of Medicare-approved *** 100% $183 80% 20% Other Benefits Not Covered by Medicare Foreign Travel Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States First $250 each calendar year $250 Remainder of charges 80% to lifetime maximum benefit of $50,000 12 20% and over the $50,000 lifetime maximum
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 $1,340 $1,340 (Part A deductible) 61st thru 90th day All but $335 a day $335 a day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days All but $670 a day $670 a day 100% of Medicareeligible expenses Beyond the additional 365 days 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 21st thru 100th day All approved All but $167.50 a day ** Up to $167.50 a day 101st day and after All costs Blood First 3 pints 3 pints Additional 100% Hospice Care You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited for outpatient drugs and inpatient respite care Medicare copayment/ **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. 13
Plan F (cont.) Medicare (Part B) Medical Services Per Calendar Year ***Once you have been billed $183 of Medicare-approved 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 *** Part B Excess Charges (above Medicare-approved ) Blood $183 Generally 80% Generally 20% 100% First 3 pints All costs Next $183 of Medicare-approved *** Clinical Laboratory Services $183 80% 20% Tests for diagnostic services 100% Parts A & B Home Health Care Medicare-Approved Services Medically necessary skilled care services and medical supplies Durable medical equipment: First $183 of Medicare-approved *** 100% $183 80% 20% 14
Plan F (cont.) Other Benefits Not Covered by Medicare Foreign Travel Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States First $250 each calendar year $250 Remainder of charges 80% to lifetime maximum benefit of $50,000 Dental Services $500 annual maximum for diagnostic and preventive services Individual Assistance Program Benefits Eight (8) professional, confidential counseling sessions (may be a duplication of Medicare benefits) 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. 80% 20% All costs All costs 20% and over the $50,000 lifetime maximum 15
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 $1,340 $1,340 (Part A deductible) 61st thru 90th day All but $335 a day $335 a day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days All but $670 a day $670 a day 100% of Medicareeligible expenses Beyond the additional 365 days 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 21st thru 100th day All but $167.50 a day ** Up to $167.50 a day 101st day and after All costs Blood First 3 pints 3 pints Additional 100% Hospice Care You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited for outpatient drugs and inpatient respite care Medicare copayment/ **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 G (cont.) Medicare (Part B) Medical Services Per Calendar Year ***Once you have been billed $183 of Medicare-approved 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 *** Part B Excess Charges (above Medicare-approved ) Blood $183 Generally 80% Generally 20% 100% First 3 pints All costs Next $183 of Medicare-approved *** Clinical Laboratory Services $183 80% 20% Tests for diagnostic services 100% Parts A & B Home Health Care Medicare-Approved Services Medically necessary skilled care services and medical supplies Durable medical equipment: First $183 of Medicare-approved *** 100% $183 80% 20% Other Benefits Not Covered by Medicare Foreign Travel Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States First $250 each calendar year $250 Remainder of charges 80% to lifetime maximum benefit of $50,000 20% and over the $50,000 lifetime maximum 17
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 $5,240 each calendar year. The 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 for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved (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 $1,340 $670 (50% of Part A deductible) 61st thru 90th day All but $335 a day $335 a day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days All but $670 a day $670 a day 100% of Medicareeligible expenses $670 (50% of Part A deductible) ***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. 18 *** Beyond the additional 365 days 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 21st thru 100th day All but $167.50 a day Up to $83.75 a day 101st day and after All costs Blood First 3 pints 50% 50% Additional 100% Hospice Care You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited for outpatient drugs and inpatient respite care 50% of copayment/ Up to $83.75 a day 50% of Medicare copayment/
Plan K (cont.) Medicare (Part B) Medical Services Per Calendar Year ****Once you have been billed $183 of Medicare-approved 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 **** Preventive benefits for Medicarecovered services Part B Excess Charges (above Medicare-approved ) Blood $183 (Part B deductible)**** Generally 80% or more of Medicareapproved Remainder of Medicare-approved All costs above Medicare-approved Generally 80% Generally 10% Generally 10% All costs (and they do not count toward annual out-of-pocket limit of $5,240)* First 3 pints 50% 50% Next $183 of Medicare-approved **** Clinical Laboratory Services $183 (Part B deductible)**** 80% Generally 10% Generally 10% Tests for diagnostic services 100% Parts A & B Home Health Care Medicare-Approved Services Medically necessary skilled care services and medical supplies Durable medical equipment: First $183 of Medicare-approved **** 100% $183 80% 10% 10% *This plan limits your annual out-of-pocket payments for Medicare-approved to $5,240 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved (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. 19
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 $1,340 $1,340 (Part A deductible) 61st thru 90th day All but $335 a day $335 a day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days All but $670 a day $670 a day 100% of Medicareeligible expenses Beyond the additional 365 days 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 21st thru 100th day All but $167.50 a day ** Up to $167.50 a day 101st day and after All costs Blood First 3 pints 3 pints Additional 100% Hospice Care You must meet Medicare s requirements, including a doctor s certification of terminal illness. All but very limited for outpatient drugs and inpatient respite care Medicare copayment/ **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. 20
Plan N (cont.) Medicare (Part B) Medical Services Per Calendar Year ***Once you have been billed $183 of Medicare-approved 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 *** Part B Excess Charges (above Medicare-approved ) Blood $183 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. All costs First 3 pints All costs Next $183 of Medicare-approved *** Clinical Laboratory Services 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. $183 80% 20% Tests for diagnostic services 100% Parts A & B Home Health Care Medicare-Approved Services Medically necessary skilled care services and medical supplies Durable medical equipment: First $183 of Medicare-approved *** 100% $183 80% 20% 21
Plan N (cont.) Services Medicare Pays Plan Pays You Pay Other Benefits Not Covered by Medicare Foreign Travel Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States First $250 each calendar year $250 Remainder of charges 80% to lifetime maximum benefit of $50,000 20% and over the $50,000 lifetime maximum 22
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 supplies for 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. 23
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 1106 Lewiston, ID 83501 regence.com/medicare 2018 Regence BlueShield of Idaho, Inc. REG-36344-18/09-17-ID Rev. 01-18