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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.

https://regence.isf.io/2017?AgentCreditCode=6b9b98b7-5ace-4e04-b734-2086c0f69497

mailto:[email protected]

https://cda-insurance.citrixdata.com/r/r7a05451975a43c2b

https://www.medicare.gov/Pubs/pdf/02110-Medicare-Medigap.guide.pdf

https://regence.isf.io/2017?AgentCreditCode=6b9b98b7-5ace-4e04-b734-2086c0f69497

http://www.medicare-idaho.com/shared/ID/dl/Regence/2017/ms/rbs.id.ms.ooc.5.2017.pdf

http://www.medicare-idaho.com/shared/ID/dl/Regence/2017/ms/rbs.id.ms.app.4.2017.pdf

http://www.medicare-idaho.com/medigap/regence_blue_shield.html

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




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%)


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, except up to $20 copayment for office visit, and up to $50 copayment for ER


50% Skilled Nursing Facility Coinsurance

75% 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%)




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






Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part B Deductible

Part B Deductible







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 (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 (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


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 (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 (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 (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 (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


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


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


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***



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***



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.



First 60 days All but $1,316 $1,316 (Part A deductible)

$0






$0**




$0 $0

21st thru 100th day All but $164.50 a day Up to $164.50 a day $0


Blood



Hospice Care




$0


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.



$0 $183 (Part B deductible)

$0




$0 $0 All costs

Blood




$0


80% 20% $0





100% $0 $0



$0


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.




$0






$0**




$0 $0

21st thru 100th day All but $164.50 a day Up to $164.50 a day $0


Blood



Hospice Care




$0


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.




$0




$0 100% $0

Blood




$0


80% 20% $0





100% $0 $0



$0


80% 20% $0





1716

Plan F (cont.)





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.




$0






$0**




$0 $0

21st thru 100th day All but $164.50 a day

Up to $164.50 a day

$0


Blood



Hospice Care




$0


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.







$0 100% $0

Blood





80% 20% $0





100% $0 $0




80% 20% $0





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)♦






$0***


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


$0 $0

21st thru 100th day All but $164.50 a day Up to $82.25 a day Up to $82.25

a day♦


Blood

First 3 pints $0 50% 50%♦


Hospice Care


All but very limited coinsurance for outpatient 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


All costs above Medicare-approved amounts


Generally 80% Generally 10% Generally 10%♦


$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)****♦


80% Generally 10% Generally 10%♦



Parts A & B Home Health Care — Medicare-Approved Services


100% $0 $0

Durable medical equipment: First $183 of Medicare-approved amounts****

$0 $0 $183 (Part B deductible)♦


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.




$0






$0**




$0 $0

21st thru 100th day All but $164.50 a day

Up to $164.50 a day

$0


Blood



Hospice Care




$0


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.





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.


$0 $0 All costs

Blood





80% 20% $0



Parts A & B Home Health Care — Medicare-Approved Services


100% $0 $0




80% 20% $0

24

Plan N (cont.)






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

http://regence.com/medicare

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