Regence BCBSO Application Packet

Transcription

1 Regence BCBSO Application Packet Thank you for your interest in the Regence BlueCross BlueShield of Oregon Medicare Supplement plan! This application packet provides you with access to the online application, a printable copy of the 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/ , the printable application needs to be reviewed and signed by an Agent before it can be submitted to Regence BlueCross BlueShield of Oregon. You may upload/ , fax or mail it in to CDA Insurance: Fax: cs@cda-insurance.com Secure File Upload: Click here Mail: CDA Insurance LLC PO Box Eugene, Oregon Other Important Information Download Medicare s Choosing a Medigap Policy Guide (.pdf) Online application Click here Download Policy Outline (.pdf) Download Application (.pdf) Our website: If you should have any questions on the application, please call us at or

2 OUTLINE OF COVERAGE Regence Bridge Medicare Supplement (Medigap) Plans A, C, F, G, K and N Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association REG /09-17-OR

3 Learn more 5-8 Premium information 9 Disclosures 10 Medigap Plan A 12 Medigap Plan C 14 Medigap Plan F 16 Medigap Plan G 18 Medigap Plan K 20 Medigap Plan N 2

4 Regence BlueCross BlueShield of Oregon 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 BlueCross BlueShield of Oregon 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 end Medical 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 year Hospice: 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. Regence BlueCross BlueShield of Oregon does not offer a 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 out-of-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. 3

5 Regence BlueCross BlueShield of Oregon Outline of Medicare Supplement (Medigap) Coverage Page 2 K L M N 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 50% skilled nursing facility coinsurance 75% skilled nursing facility coinsurance Skilled nursing facility coinsurance Skilled nursing facility coinsurance 50% Part A deductible 75% Part A deductible 50% Part A deductible Part A deductible 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 4

6 Premium information Medicare Supplement plans Non-smoking rates are effective January 1, 2018 Regence BlueCross BlueShield of Oregon can raise your premium only if we raise the premium for all policies like yours in this state. Premiums are based on your age and may increase as you get older. Monthly Automatic Bank Withdrawal Age < Plan A $140 $140 $146 $152 $158 $165 $171 $178 $182 $186 $192 Plan C $174 $174 $183 $193 $203 $212 $222 $230 $241 $247 $256 Plan F $175 $175 $184 $194 $204 $213 $224 $232 $243 $248 $257 Plan G $164 $164 $172 $182 $191 $198 $209 $217 $228 $232 $241 Plan K $94 $94 $97 $103 $107 $113 $116 $122 $128 $134 $137 Plan N $137 $137 $144 $151 $159 $165 $174 $180 $189 $193 $200 Monthly Paper Bill Age < Plan A $142 $142 $148 $154 $160 $167 $173 $180 $184 $188 $194 Plan C $176 $176 $185 $195 $205 $214 $224 $232 $243 $249 $258 Plan F $177 $177 $186 $196 $206 $215 $226 $234 $245 $250 $259 Plan G $166 $166 $174 $184 $193 $200 $211 $219 $230 $234 $243 Plan K $96 $96 $99 $105 $109 $115 $118 $124 $130 $136 $139 Plan N $139 $139 $146 $153 $161 $167 $176 $182 $191 $195 $202 Quarterly Rate Age < Plan A $422 $422 $440 $458 $476 $497 $515 $536 $548 $560 $578 Plan C $524 $524 $551 $581 $611 $638 $668 $692 $725 $743 $770 Plan F $527 $527 $554 $584 $614 $641 $674 $698 $731 $746 $773 Plan G $494 $494 $518 $548 $575 $596 $629 $653 $686 $698 $725 Plan K $284 $284 $293 $311 $323 $341 $350 $368 $386 $404 $413 Plan N $413 $413 $434 $455 $479 $497 $524 $542 $569 $581 $602 Semi-Annual Rate Age < Plan A $842 $842 $878 $914 $950 $992 $1,028 $1,070 $1,094 $1,118 $1,154 Plan C $1,046 $1,046 $1,100 $1,160 $1,220 $1,274 $1,334 $1,382 $1,448 $1,484 $1,538 Plan F $1,052 $1,052 $1,106 $1,166 $1,226 $1,280 $1,346 $1,394 $1,460 $1,490 $1,544 Plan G $986 $986 $1,034 $1,094 $1,148 $1,190 $1,256 $1,304 $1,370 $1,394 $1,448 Plan K $566 $566 $584 $620 $644 $680 $698 $734 $770 $806 $824 Plan N $824 $824 $866 $908 $956 $992 $1,046 $1,082 $1,136 $1,160 $1,202 Annual Rate Age < Plan A $1,682 $1,682 $1,754 $1,826 $1,898 $1,982 $2,054 $2,138 $2,186 $2,234 $2,306 Plan C $2,090 $2,090 $2,198 $2,318 $2,438 $2,546 $2,666 $2,762 $2,894 $2,966 $3,074 Plan F $2,102 $2,102 $2,210 $2,330 $2,450 $2,558 $2,690 $2,786 $2,918 $2,978 $3,086 Plan G $1,970 $1,970 $2,066 $2,186 $2,294 $2,378 $2,510 $2,606 $2,738 $2,786 $2,894 Plan K $1,130 $1,130 $1,166 $1,238 $1,286 $1,358 $1,394 $1,466 $1,538 $1,610 $1,646 Plan N $1,646 $1,646 $1,730 $1,814 $1,910 $1,982 $2,090 $2,162 $2,270 $2,318 $2,402 5

7 These plans have an annual renewal date of January 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 $40 per member, per month may also be available if two members reside at the same physical address, are both enrolled in a Regence 2010 Standard plan, 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. The rates below are the non-smoking rates. Monthly Automatic Bank Withdrawal Age Plan A $197 $200 $203 $204 $207 $208 $209 $212 $212 $212 $212 Plan C $264 $271 $279 $286 $290 $297 $301 $308 $312 $318 $321 Plan F $265 $272 $282 $287 $291 $298 $302 $309 $313 $319 $322 Plan G $248 $255 $264 $269 $272 $278 $282 $288 $292 $299 $302 Plan K $140 $144 $147 $151 $155 $157 $161 $164 $166 $168 $171 Plan N $206 $212 $220 $224 $227 $232 $235 $240 $244 $248 $251 Monthly Paper Bill Age Plan A $199 $202 $205 $206 $209 $210 $211 $214 $214 $214 $214 Plan C $266 $273 $281 $288 $292 $299 $303 $310 $314 $320 $323 Plan F $267 $274 $284 $289 $293 $300 $304 $311 $315 $321 $324 Plan G $250 $257 $266 $271 $274 $280 $284 $290 $294 $301 $304 Plan K $142 $146 $149 $153 $157 $159 $163 $166 $168 $170 $173 Plan N $208 $214 $222 $226 $229 $234 $237 $242 $246 $250 $253 Quarterly Rate Age Plan A $593 $602 $611 $614 $623 $626 $629 $638 $638 $638 $638 Plan C $794 $815 $839 $860 $872 $893 $905 $926 $938 $956 $965 Plan F $797 $818 $848 $863 $875 $896 $908 $929 $941 $959 $968 Plan G $746 $767 $794 $809 $818 $836 $848 $866 $878 $899 $908 Plan K $422 $434 $443 $455 $467 $473 $485 $494 $500 $506 $515 Plan N $620 $638 $662 $674 $683 $698 $707 $722 $734 $746 $755 Semi-Annual Rate Age Plan A $1,184 $1,202 $1,220 $1,226 $1,244 $1,250 $1,256 $1,274 $1,274 $1,274 $1,274 Plan C $1,586 $1,628 $1,676 $1,718 $1,742 $1,784 $1,808 $1,850 $1,874 $1,910 $1,928 Plan F $1,592 $1,634 $1,694 $1,724 $1,748 $1,790 $1,814 $1,856 $1,880 $1,916 $1,934 Plan G $1,490 $1,532 $1,586 $1,616 $1,634 $1,670 $1,694 $1,730 $1,754 $1,796 $1,814 Plan K $842 $866 $884 $908 $932 $944 $968 $986 $998 $1,010 $1,028 Plan N $1,238 $1,274 $1,322 $1,346 $1,364 $1,394 $1,412 $1,442 $1,466 $1,490 $1,508 Annual Rate Age Plan A $2,366 $2,402 $2,438 $2,450 $2,486 $2,498 $2,510 $2,546 $2,546 $2,546 $2,546 Plan C $3,170 $3,254 $3,350 $3,434 $3,482 $3,566 $3,614 $3,698 $3,746 $3,818 $3,854 Plan F $3,182 $3,266 $3,386 $3,446 $3,494 $3,578 $3,626 $3,710 $3,758 $3,830 $3,866 Plan G $2,978 $3,062 $3,170 $3,230 $3,266 $3,338 $3,386 $3,458 $3,506 $3,590 $3,626 Plan K $1,682 $1,730 $1,766 $1,814 $1,862 $1,886 $1,934 $1,970 $1,994 $2,018 $2,054 Plan N $2,474 $2,546 $2,642 $2,690 $2,726 $2,786 $2,822 $2,882 $2,930 $2,978 $3,014 6

8 Premium information Medicare Supplement plans Smoking rates are effective January 1, 2018 Regence BlueCross BlueShield of Oregon can raise your premium only if we raise the premium for all policies like yours in this state. Premiums are based on your age and may increase as you get older. Monthly Automatic Bank Withdrawal Age < Plan A $164 $164 $171 $179 $186 $194 $201 $210 $214 $219 $226 Plan C $205 $205 $215 $227 $239 $249 $261 $270 $283 $291 $301 Plan F $206 $206 $217 $229 $240 $250 $263 $273 $286 $292 $302 Plan G $193 $193 $202 $214 $225 $233 $246 $255 $268 $273 $283 Plan K $111 $111 $114 $121 $126 $133 $137 $144 $150 $157 $161 Plan N $161 $161 $169 $177 $187 $194 $205 $212 $223 $227 $236 Monthly Paper Bill Age < Plan A $166 $166 $173 $181 $188 $196 $203 $212 $216 $221 $228 Plan C $207 $207 $217 $229 $241 $251 $263 $272 $285 $293 $303 Plan F $208 $208 $219 $231 $242 $252 $265 $275 $288 $294 $304 Plan G $195 $195 $204 $216 $227 $235 $248 $257 $270 $275 $285 Plan K $113 $113 $116 $123 $128 $135 $139 $146 $152 $159 $163 Plan N $163 $163 $171 $179 $189 $196 $207 $214 $225 $229 $238 Quarterly Rate Age < Plan A $494 $494 $515 $539 $560 $584 $605 $632 $644 $659 $680 Plan C $617 $617 $647 $683 $719 $749 $785 $812 $851 $875 $905 Plan F $620 $620 $653 $689 $722 $752 $791 $821 $860 $878 $908 Plan G $581 $581 $608 $644 $677 $701 $740 $767 $806 $821 $851 Plan K $335 $335 $344 $365 $380 $401 $413 $434 $452 $473 $485 Plan N $485 $485 $509 $533 $563 $584 $617 $638 $671 $683 $710 Semi-Annual Rate Age < Plan A $986 $986 $1,028 $1,076 $1,118 $1,166 $1,208 $1,262 $1,286 $1,316 $1,358 Plan C $1,232 $1,232 $1,292 $1,364 $1,436 $1,496 $1,568 $1,622 $1,700 $1,748 $1,808 Plan F $1,238 $1,238 $1,304 $1,376 $1,442 $1,502 $1,580 $1,640 $1,718 $1,754 $1,814 Plan G $1,160 $1,160 $1,214 $1,286 $1,352 $1,400 $1,478 $1,532 $1,610 $1,640 $1,700 Plan K $668 $668 $686 $728 $758 $800 $824 $866 $902 $944 $968 Plan N $968 $968 $1,016 $1,064 $1,124 $1,166 $1,232 $1,274 $1,340 $1,364 $1,418 Annual Rate Age < Plan A $1,970 $1,970 $2,054 $2,150 $2,234 $2,330 $2,414 $2,522 $2,570 $2,630 $2,714 Plan C $2,462 $2,462 $2,582 $2,726 $2,870 $2,990 $3,134 $3,242 $3,398 $3,494 $3,614 Plan F $2,474 $2,474 $2,606 $2,750 $2,882 $3,002 $3,158 $3,278 $3,434 $3,506 $3,626 Plan G $2,318 $2,318 $2,426 $2,570 $2,702 $2,798 $2,954 $3,062 $3,218 $3,278 $3,398 Plan K $1,334 $1,334 $1,370 $1,454 $1,514 $1,598 $1,646 $1,730 $1,802 $1,886 $1,934 Plan N $1,934 $1,934 $2,030 $2,126 $2,246 $2,330 $2,462 $2,546 $2,678 $2,726 $2,834 7

9 These plans have an annual renewal date of January 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 $40 per member, per month may also be available if two members reside at the same physical address, are both enrolled in a Regence 2010 Standard plan, 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. The rates below are the smoking rates. Monthly Automatic Bank Withdrawal Age Plan A $232 $236 $239 $240 $244 $245 $246 $249 $249 $249 $249 Plan C $311 $319 $329 $337 $342 $349 $354 $362 $367 $374 $377 Plan F $312 $320 $332 $338 $343 $350 $355 $363 $368 $375 $379 Plan G $292 $300 $311 $317 $320 $327 $332 $339 $344 $351 $355 Plan K $164 $169 $173 $177 $182 $185 $189 $193 $195 $198 $201 Plan N $243 $249 $258 $263 $267 $273 $276 $282 $287 $292 $295 Monthly Paper Bill Age Plan A $234 $238 $241 $242 $246 $247 $248 $251 $251 $251 $251 Plan C $313 $321 $331 $339 $344 $351 $356 $364 $369 $376 $379 Plan F $314 $322 $334 $340 $345 $352 $357 $365 $370 $377 $381 Plan G $294 $302 $313 $319 $322 $329 $334 $341 $346 $353 $357 Plan K $166 $171 $175 $179 $184 $187 $191 $195 $197 $200 $203 Plan N $245 $251 $260 $265 $269 $275 $278 $284 $289 $294 $297 Quarterly Rate Age Plan A $698 $710 $719 $722 $734 $737 $740 $749 $749 $749 $749 Plan C $935 $959 $989 $1,013 $1,028 $1,049 $1,064 $1,088 $1,103 $1,124 $1,133 Plan F $938 $962 $998 $1,016 $1,031 $1,052 $1,067 $1,091 $1,106 $1,127 $1,139 Plan G $878 $902 $935 $953 $962 $983 $998 $1,019 $1,034 $1,055 $1,067 Plan K $494 $509 $521 $533 $548 $557 $569 $581 $587 $596 $605 Plan N $731 $749 $776 $791 $803 $821 $830 $848 $863 $878 $887 Semi-Annual Rate Age Plan A $1,394 $1,418 $1,436 $1,442 $1,466 $1,472 $1,478 $1,496 $1,496 $1,496 $1,496 Plan C $1,868 $1,916 $1,976 $2,024 $2,054 $2,096 $2,126 $2,174 $2,204 $2,246 $2,264 Plan F $1,874 $1,922 $1,994 $2,030 $2,060 $2,102 $2,132 $2,180 $2,210 $2,252 $2,276 Plan G $1,754 $1,802 $1,868 $1,904 $1,922 $1,964 $1,994 $2,036 $2,066 $2,108 $2,132 Plan K $986 $1,016 $1,040 $1,064 $1,094 $1,112 $1,136 $1,160 $1,172 $1,190 $1,208 Plan N $1,460 $1,496 $1,550 $1,580 $1,604 $1,640 $1,658 $1,694 $1,724 $1,754 $1,772 Annual Rate Age Plan A $2,786 $2,834 $2,870 $2,882 $2,930 $2,942 $2,954 $2,990 $2,990 $2,990 $2,990 Plan C $3,734 $3,830 $3,950 $4,046 $4,106 $4,190 $4,250 $4,346 $4,406 $4,490 $4,526 Plan F $3,746 $3,842 $3,986 $4,058 $4,118 $4,202 $4,262 $4,358 $4,418 $4,502 $4,550 Plan G $3,506 $3,602 $3,734 $3,806 $3,842 $3,926 $3,986 $4,070 $4,130 $4,214 $4,262 Plan K $1,970 $2,030 $2,078 $2,126 $2,186 $2,222 $2,270 $2,318 $2,342 $2,378 $2,414 Plan N $2,918 $2,990 $3,098 $3,158 $3,206 $3,278 $3,314 $3,386 $3,446 $3,506 $3,542 8

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, 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 BlueCross BlueShield of Oregon, P.O. Box 1271, Portland, OR 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 BlueCross BlueShield of Oregon 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. 9

11 Medigap 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 $ a day ** Up to $ 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 coinsurance for outpatient drugs and inpatient respite care 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. 10

12 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% 11

13 Medigap 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 $ a day ** Up to $ 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 coinsurance for outpatient drugs and inpatient respite care 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. 12

14 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 20% and over the $50,000 lifetime maximum 13

15 Medigap 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 All but $670 a day $670 a day Once lifetime reserve days are used: Additional 365 days 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 $ a day Up to $ 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 coinsurance for outpatient drugs and inpatient respite care 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. 14

16 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% 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 15

17 Medigap 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 All but $670 a day $670 a day Once lifetime reserve days are used: Additional 365 days 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 $ a day Up to $ 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 coinsurance for outpatient drugs and inpatient respite care 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. 16

18 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

19 Medigap 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 coinsurance 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: All but $670 a day $670 a day While using 60 lifetime reserve days Once lifetime reserve days are used: 100% of Medicare- *** Additional 365 days eligible expenses Beyond the additional 365 days All costs $670 (50% of Part A deductible) 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 $ a day Up to $83.75 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 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. 18

20 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 ) $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)* Blood 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

21 Medigap 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 All but $670 a day $670 a day Once lifetime reserve days are used: Additional 365 days 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 $ a day Up to $ 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 coinsurance for outpatient drugs and inpatient respite care 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. 20

22 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

23 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

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25 Regence 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: REGENCE ( ) 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 (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 (TTY: 711). P.O. Box 1271 Portland, OR regence.com/medicare 2018 Regence BlueCross BlueShield of Oregon REG /09-17-OR OO0610PMBAID OO0610PMBAI OO0610PMBCID OO0610PMBCI OO0610PMBFID OO0610PMBFI OO0610PMBKID OO0610PMBKI OO0117PMBGD OO0117PMBGI OO0117PMBND OO0117PMBNI