DECISION GUIDE Regence Bridge Medicare Supplement (Medigap) Plans Regence BlueCross BlueShield of Utah is an Independent Licensee of the Blue Cross and Blue Shield Association REG-36414-17/05-17-UT
Learn more 2 Choosing a Medigap plan 3 Regence Bridge Medigap options 4 What does each Medigap benefit cover? 5 Tools to help you make the most of your health 6 How to apply 7 Frequently asked questions 7 Exclusions 8 Outline of coverage
Welcome Original Medicare is good coverage, but it was never designed to cover everything. Often, people with Original Medicare Parts A and B want additional coverage for things that aren t covered by Medicare, such as deductibles and coinsurance. Medigap plans were intended for just that purpose to supplement Medicare coverage, providing you with a more complete health care package. This booklet explains the benefits of Medigap plans, and more specifically, the benefits of Regence Bridge Medigap Plans. Because we offer a wide range of coverage options, we are confident you ll find a plan that suits both your health and financial needs. Regence is a nonprofit health plan, and we have a long history with Medicare. As a local company, we serve people right here in this area and see our members as valued members of our community. With a Regence Medigap plan you get: Help paying eligible expenses not covered by Medicare Free fitness membership* Toll-free access to a nurse 24/7* Secure members-only website* Discounts on health-related products and services* *These programs are not insurance and may be changed or discontinued at any time. 1
Choosing a Medigap plan that s right for you When it comes to choosing a Medigap plan, there s a lot to think about. We re here to make it easy. That s why we re committed to helping you through the entire process. We ll help you identify your needs, review your options and answer your questions while you fill out your paperwork. Then, when you become a member, we re here to answer your claims questions and give you the information you need to make the health care decisions that are right for you. To see which plan will fit you best, first determine what you need. Do you have a chronic condition that requires frequent doctor visits? If so, Plan F or G may be a good choice for you, as they both cover Excess Charges. If you rarely need care, Plan A might be all you need. Or, you might want to take a look at Plan K, which has a lower premium but greater cost-sharing. If you travel outside the United States on a regular basis, Plans C, F, G and N cover foreign travel emergencies. As you think about what plan to choose, take a look at your past medical bills to see what kind of costs you might have in the future. Or, give one of our Medigap sales representatives a call. You can also call your insurance producer. With all our Medigap plans, you have total control over your choice of providers. There are no network restrictions or referrals needed, so you can see any provider who accepts Medicare coverage. 2
Regence Medigap Bridge options Regence offers Medigap Plans A, C, F, G, K and N. All Medigap plans offer the same basic benefits : Medicare Part A coinsurance; Medicare Part B coinsurance/copays; the first three pints of blood; and hospice care coinsurance/copays. Please note that Plan K covers many benefits at 50% and also has an out-of-pocket annual limit. The basic benefits cover some of the health care costs that can escalate and become a financial burden. These benefits are meant to supplement Medicare coverage, providing you with a more complete health care package. If you want more coverage than the basic benefits, all of the plans except Plan A have additional benefits. The chart below gives you a quick look at the plans and benefits. Check marks or indicate the benefit is provided in that plan. Immediately following the chart is an explanation of the benefits. Regence Bridge Plans Basic (core) benefits A C F G K N Medicare Part A coinsurance/copays Medicare Part B coinsurance/copays 50% ** Blood first 3 pints 50% Hospice care coinsurance/copays Additional benefits Skilled nursing facility coinsurance Part A deductible (per benefit period) Part B deductible (annual) 50% 50% 50% Part B Excess Charges 100% 100% Foreign travel emergency 80% 80% 80% 80% Out-of-pocket annual limit $5,240* *This amount is for 2018 and may change in 2019. **Plan N pays 100% of the Part B coinsurance, except for a copay of up to $20 for some office visits and up to a $50 copay for emergency room visits that don t result in inpatient admission. 3
What does each Medigap benefit cover? Basic benefits offered in all plans Medicare Part A (inpatient hospital) coinsurance This is the amount you may have to pay after you meet the Part A deductible. The Part A deductible is explained below. Medicare Part B (medical services) coinsurance This is the percentage of the Medicare-approved amount you may have to pay after you meet the Part B deductible.* Blood Medigap plans cover the first 3 pints each year.* Hospice care coinsurance/copays You must meet Medicare s requirements for hospice, including a doctor s certificate of terminal illness.* Additional benefits offered by some plans Medicare Part A deductible (Plans C, F, G, K* and N) When hospitalized, you re required to pay a Medicare Part A deductible before Medicare begins to pay for any covered services. In 2018 the Part A deductible is $1,340.** The deductible is required once per benefit period. A benefit period begins the day you re admitted to a hospital or skilled nursing facility. It ends when you haven t received any inpatient hospital care (or care in a skilled nursing facility) for 60 days in a row. If you go into a hospital or a skilled nursing facility after a benefit period has ended, a new benefit period begins and you ll be required to pay the Part A deductible again. Medicare Part B deductible (Plans C and F) Medicare Part B pays for many physician services and other medical care. However, before Medicare begins to pay for services each year, you have to pay the Medicare Part B deductible. In 2018 the Part B deductible is $183.** Medicare Part B Excess Charges (Plans F and G) Sometimes you may receive Medicare Part B services from a doctor or provider who does not accept Medicare Assignment. This means the doctor may charge more for medical services than Medicare will pay. This extra amount is called Excess Charges. Plans F and G cover Part B Excess Charges for Medicare-eligible expenses. Foreign travel emergency (Plans C, F, G and N) In most cases, Medicare doesn t pay for care provided outside the United States. During a trip to a foreign country, you may need emergency hospital, physician or medical care. If you receive medically necessary emergency care for an illness or injury that begins during the first 60 days of a trip and your care isn t covered by Medicare, then you pay the first $250 (once every calendar year) for Medicare-eligible expenses. Once you ve paid this amount, your Medigap plan pays 80% of the billed charges for Medicare-eligible expenses up to a lifetime maximum of $50,000. Skilled nursing facility coinsurance (Plans C, F, G, K* and N) You share a portion of skilled nursing facility expenses with Medicare. Your share of the cost is called your coinsurance. There is no coinsurance for the first 20 days of a benefit period. For days 21 100 of a benefit period the coinsurance is $167.50** per day. *PLEASE NOTE: Plan K covers 50% of the charges and you cover 50%. **This amount is for 2018 and may change in 2019. 4
Tools that help you make the most of your health We provide more than benefits. We also offer ways to help you stay healthy and better manage your health care costs, including access to online tools and information, and discounts on health-related products and services. The Silver&Fit Program With the Silver&Fit program you get access to more than 12,000 participating fitness facility locations across the country, where you can use the equipment, attend group fitness classes or participate in fun quarterly social events (where available). Or, you can enroll in the Home Fitness Program, which offers members up to two home fitness kits each calendar year. The Silver&Fit program enables active older adults to be healthy, meet their fitness goals, and maintain an active, social lifestyle. Regence Advice24 Get around-the-clock answers from a registered nurse. If you have a question, don t know how to treat a condition or are not sure what kind of care you need, a free call to a registered nurse can get you on the right track. Regence Advantages discount program Our Regence Advantages discount program offers you savings from several nationally recognized, health-related companies to help you get and stay well. Just have your member ID card ready at the time of service. Discounts include a variety of options, from local gyms to weight loss programs, and from hearing aids to alternative medicine providers, such as chiropractors and massage therapists. THESE PROGRAMS ARE NOT INSURANCE BUT ARE OFFERED IN ADDITION TO YOUR MEDIGAP PLAN TO HELP YOU GET INFORMATION AND SUPPORT WHEN YOU NEED IT. WE RESERVE THE RIGHT TO CHANGE OR DISCONTINUE THESE SERVICES AT ANY TIME. Manage your health with our members - only website Your good health is important to us. That s why we offer programs and tools to help you better understand your health needs, prescriptions and wellness options. For example, if you log in at regence.com/ medicare to your secure, members - only website, you can see your claims history, participate in a wellness program, and learn about health conditions and prescription drugs. Access to this site comes with your Regence membership. 5
Applying is easy! How to enroll If you are ready to enroll, here s what you need to do: 1 Determine eligibility To apply for a Regence Medigap plan, you must be 65 or older, enrolled in Medicare Part A and Part B, and reside in Utah (or will at the time of coverage). If you need help deciding which plan will work for you, please call us at 1-844-REGENCE (1-844-734-3623), visit our website at regence.com/medicare, or talk to an insurance producer. 2 Choose plan 3 Complete application 4 Select payment method Review the plan options in the Outline of Coverage to find the right plan that works with your budget and lifestyle. Fill out the enclosed application. Be sure to complete all parts that pertain to you in ink, and then sign and mail. A return envelope is enclosed for your convenience. You may also apply online at regence.com/medicare, over the phone with one of our sales representatives by calling 1-844-734-3623, or through an insurance producer. Choose to pay your premium by one of the options listed on the application form: 1) direct paper bill monthly, quarterly, semi-annually or annually; or 2) automatic deduction monthly from your bank account. There are discounts for using quarterly, semi-annual or annual paper billing, or automatic monthly deduction from your bank account. A household discount may also be available, see page 5 in the Outline of Coverage for more information. 6
Frequently asked questions When will my coverage be effective? If you meet eligibility requirements and your application is accepted, your coverage will usually begin on the first day of the following month, unless otherwise indicated. How do I begin to receive care under this plan? Simply show your member ID card to your health care providers so they know who to bill. That s it! In most cases, there s virtually no paperwork. When you enroll, you ll receive a new member welcome kit with additional information. You can also give us a call if you have any questions. What happens if I m traveling and am outside the service area? Wherever you are in the United States you can receive care at any Medicare-approved provider or medical facility. In most cases, Medicare doesn t pay for care outside the United States. Regence Bridge Medigap Plans C, F, G and N help with emergency care expenses in a foreign country. See page 4 for more information about this benefit. Does it cost more to buy coverage through an insurance producer? No. There s never an extra cost or obligation if you use an appointed insurance producer. Are prescription drugs covered? No. Only Medicare Part B drugs are covered. You may be able to enroll in a Medicare Part D plan that will give you prescription drug coverage. Please contact your producer or Regence Medigap a sales representative 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 at 1-844-REGENCE (1-844-734-3623) (TTY: 711) Monday through Friday, 8 a.m. to 5 p.m. Pacific time for more information. How are eye exams covered? Medicare provides coverage for diagnosis and treatment of eye conditions. Additionally, members with diabetes are eligible for a dilated eye exam once every calendar year. Routine medical eye exams are not a benefit of Medigap plans. What can I do if I have a grievance or appeal? If you aren t completely satisfied with our service or the quality of the medical care you received, please call Customer Service at 1 (888) 319-4181. Our goal is always to protect your rights and find a solution as quickly as possible. On what basis could my Regence Medigap coverage be cancelled? Here are some circumstances when your coverage could be cancelled: If you don t retain Medicare Parts A and B If you fail to pay the monthly premium, subject to a 30-day grace period If you commit fraud or allow another person to use your member ID card to obtain services If you make misrepresentations on your individual application form that affect your eligibility to enroll in this plan Is there a waiting period before pre-existing conditions are covered? No. 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. 7
OUTLINE OF COVERAGE Regence Bridge Medicare Supplement (Medigap) Plans Regence BlueCross BlueShield of Utah is an Independent Licensee of the Blue Cross and Blue Shield Association REG-36344-17/05-17-UT
Regence BlueCross BlueShield of Utah 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. See Outlines of Coverage sections for details about plans available from Regence. Plans E, H, I and J are no longer available. 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 copays for hospital outpatient services. Plans K, L, and N require insured to pay a portion of Part B coinsurance or copays Blood: First three pints of blood each year Hospice: Part A coinsurance Medicare Part A (Hospital) coinsurance/copays Medicare Part B coinsurance/copays A B C D F* G K L M N X X X X X X X X X X X X X X X X 50% 75% X X** Blood, first 3 pints X X X X X X 50% 75% X X Hospice care X X X X X X 50% 75% X X coinsurance/copays Skilled nursing facility X X X X 50% 75% X X coinsurance Part A deductible X X X X X 50% 75% 50% X (per benefit period) Part B deductible (annual) X X Part B Excess Charges 100% 100% Foreign travel emergency X X X X X X Out-of-pocket annual limit $5,240 $2,620 NOTE: Plan benefits offered by Regence BlueCross BlueShield of Utah are shaded in grey. *Plan F also has an option called a high deductible plan F. Regence 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. ** Pays the Part B coinsurance, except you pay up to a $20 copay per physician visit and up to a $50 copay per emergency room visit. 2
Table of Contents 4 Premium Information 6 Disclosures Plan Descriptions 7 Plan A 9 Plan C 11 Plan F 13 Plan G 15 Plan K 17 Plan N 3
Premium information Medicare Supplement plans Regence BlueCross BlueShield of Utah can only raise your premium 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. Rates effective August 1, 2017 Monthly Automatic Bank Withdrawal Age 65 66 67 68 69 70 71 72 73 74 Plan A $109 $113 $118 $125 $128 $134 $138 $141 $145 $149 Plan C $142 $151 $159 $165 $175 $181 $189 $197 $204 $210 Plan F $143 $152 $160 $166 $176 $184 $190 $198 $206 $211 Plan G $117 $124 $131 $136 $143 $150 $155 $162 $168 $172 Plan K $77 $80 $87 $90 $95 $99 $102 $107 $111 $114 Plan N $105 $111 $117 $122 $128 $134 $139 $145 $151 $154 Monthly Paper Bill Age 65 66 67 68 69 70 71 72 73 74 Plan A $111 $115 $120 $127 $130 $136 $140 $143 $147 $151 Plan C $144 $153 $161 $167 $177 $183 $191 $199 $206 $212 Plan F $145 $154 $162 $168 $178 $186 $192 $200 $208 $213 Plan G $119 $126 $133 $138 $145 $152 $157 $164 $170 $174 Plan K $79 $82 $89 $92 $97 $101 $104 $109 $113 $116 Plan N $107 $113 $119 $124 $130 $136 $141 $147 $153 $156 Quarterly Rate Age 65 66 67 68 69 70 71 72 73 74 Plan A $329 $341 $356 $377 $386 $404 $416 $425 $437 $449 Plan C $428 $455 $479 $497 $527 $545 $569 $593 $614 $632 Plan F $431 $458 $482 $500 $530 $554 $572 $596 $620 $635 Plan G $353 $374 $395 $410 $431 $452 $467 $488 $506 $518 Plan K $233 $242 $263 $272 $287 $299 $308 $323 $335 $344 Plan N $317 $335 $353 $368 $386 $404 $419 $437 $455 $464 Semi-Annual Rate Age 65 66 67 68 69 70 71 72 73 74 Plan A $656 $680 $710 $752 $770 $806 $830 $848 $872 $896 Plan C $854 $908 $956 $992 $1,052 $1,088 $1,136 $1,184 $1,226 $1,262 Plan F $860 $914 $962 $998 $1,058 $1,106 $1,142 $1,190 $1,238 $1,268 Plan G $704 $746 $788 $818 $860 $902 $932 $974 $1,010 $1,034 Plan K $464 $482 $524 $542 $572 $596 $614 $644 $668 $686 Plan N $632 $668 $704 $734 $770 $806 $836 $872 $908 $926 Annual Rate Age 65 66 67 68 69 70 71 72 73 74 Plan A $1,310 $1,358 $1,418 $1,502 $1,538 $1,610 $1,658 $1,694 $1,742 $1,790 Plan C $1,706 $1,814 $1,910 $1,982 $2,102 $2,174 $2,270 $2,366 $2,450 $2,522 Plan F $1,718 $1,826 $1,922 $1,994 $2,114 $2,210 $2,282 $2,378 $2,474 $2,534 Plan G $1,406 $1,490 $1,574 $1,634 $1,718 $1,802 $1,862 $1,946 $2,018 $2,066 Plan K $926 $962 $1,046 $1,082 $1,142 $1,190 $1,226 $1,286 $1,334 $1,370 Plan N $1,262 $1,334 $1,406 $1,466 $1,538 $1,610 $1,670 $1,742 $1,814 $1,850 4
Premium information Medicare Supplement plans These plans have an annual renewal date of August 1. You may experience a rate change within your first year of enrollment. After your first year, rates are guaranteed not to increase for 12 months. A household discount of $10 per-member, per-month may be available if two or more members reside at the same 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 Automatic Bank Withdrawal Age 75 76 77 78 79 80 81 82 83 84 85+ Plan A $152 $156 $159 $160 $161 $162 $163 $164 $164 $164 $164 Plan C $217 $223 $229 $234 $239 $243 $248 $254 $257 $261 $264 Plan F $218 $224 $230 $236 $241 $244 $251 $255 $258 $263 $264 Plan G $178 $183 $188 $192 $196 $199 $205 $208 $210 $215 $215 Plan K $118 $123 $125 $127 $129 $132 $134 $138 $139 $141 $141 Plan N $160 $164 $169 $172 $176 $178 $184 $186 $189 $192 $193 Monthly Paper Bill Age 75 76 77 78 79 80 81 82 83 84 85+ Plan A $154 $158 $161 $162 $163 $164 $165 $166 $166 $166 $166 Plan C $219 $225 $231 $236 $241 $245 $250 $256 $259 $263 $266 Plan F $220 $226 $232 $238 $243 $246 $253 $257 $260 $265 $266 Plan G $180 $185 $190 $194 $198 $201 $207 $210 $212 $217 $217 Plan K $120 $125 $127 $129 $131 $134 $136 $140 $141 $143 $143 Plan N $162 $166 $171 $174 $178 $180 $186 $188 $191 $194 $195 Quarterly Rate Age 75 76 77 78 79 80 81 82 83 84 85+ Plan A $458 $470 $479 $482 $485 $488 $491 $494 $494 $494 $494 Plan C $653 $671 $689 $704 $719 $731 $746 $764 $773 $785 $794 Plan F $656 $674 $692 $710 $725 $734 $755 $767 $776 $791 $794 Plan G $536 $551 $566 $578 $590 $599 $617 $626 $632 $647 $647 Plan K $356 $371 $377 $383 $389 $398 $404 $416 $419 $425 $425 Plan N $482 $494 $509 $518 $530 $536 $554 $560 $569 $578 $581 Semi-Annual Rate Age 75 76 77 78 79 80 81 82 83 84 85+ Plan A $914 $938 $956 $962 $968 $974 $980 $986 $986 $986 $986 Plan C $1,304 $1,340 $1,376 $1,406 $1,436 $1,460 $1,490 $1,526 $1,544 $1,568 $1,586 Plan F $1,310 $1,346 $1,382 $1,418 $1,448 $1,466 $1,508 $1,532 $1,550 $1,580 $1,586 Plan G $1,070 $1,100 $1,130 $1,154 $1,178 $1,196 $1,232 $1,250 $1,262 $1,292 $1,292 Plan K $710 $740 $752 $764 $776 $794 $806 $830 $836 $848 $848 Plan N $962 $986 $1,016 $1,034 $1,058 $1,070 $1,106 $1,118 $1,136 $1,154 $1,160 Annual Rate Age 75 76 77 78 79 80 81 82 83 84 85+ Plan A $1,826 $1,874 $1,910 $1,922 $1,934 $1,946 $1,958 $1,970 $1,970 $1,970 $1,970 Plan C $2,606 $2,678 $2,750 $2,810 $2,870 $2,918 $2,978 $3,050 $3,086 $3,134 $3,170 Plan F $2,618 $2,690 $2,762 $2,834 $2,894 $2,930 $3,014 $3,062 $3,098 $3,158 $3,170 Plan G $2,138 $2,198 $2,258 $2,306 $2,354 $2,390 $2,462 $2,498 $2,522 $2,582 $2,582 Plan K $1,418 $1,478 $1,502 $1,526 $1,550 $1,586 $1,610 $1,658 $1,670 $1,694 $1,694 Plan N $1,922 $1,970 $2,030 $2,066 $2,114 $2,138 $2,210 $2,234 $2,270 $2,306 $2,318 5
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: 2890 East Cottonwood Parkway, Salt Lake City, Utah 84121 Attention Membership 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 less any claims paid. 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 Utah nor its agents 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. 6
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 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 $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 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. 7
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 ) $183 (Part B deductible) Generally 80% Generally 20% All costs Blood First 3 pints All costs Next $183 of Medicare-approved *** Clinical Laboratory Services $183 (Part B deductible) 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 (Part B deductible) 80% 20% 8
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 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 $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 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. 9
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 ) $183 (Part B deductible) Generally 80% Generally 20% All costs Blood First 3 pints All costs Next $183 of Medicare-approved *** Clinical Laboratory Services $183 (Part B deductible) 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 (Part B deductible) 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 10 20% and over the $50,000 lifetime maximum
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 $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 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. 11
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 ) $183 (Part B deductible) Generally 80% Generally 20% 100% Blood First 3 pints All costs Next $183 of Medicare-approved *** Clinical Laboratory Services $183 (Part B deductible) 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 (Part B deductible) 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
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 $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 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. 13
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 ) $183 (Part B deductible) Generally 80% Generally 20% 100% Blood First 3 pints All costs Next $183 of Medicare-approved *** Clinical Laboratory Services $183 (Part B deductible) 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 (Part B deductible) 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 14 20% and over the $50,000 lifetime maximum
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 $167.50 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 Medicare 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. 15
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 (Part B deductible) 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. 16
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 $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 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. 17
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 ) 18 $183 (Part B deductible) 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 Blood 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 (Part B deductible) 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 (Part B deductible) 80% 20%
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 19
20
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: 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). 2890 East Cottonwood Parkway P.O. Box 30270 Salt Lake City, Utah 84130-0270 regence.com/medicare 2017 Regence BlueCross BlueShield of Utah REG-36344-17/05-17-UT
22
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: 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). 2890 East Cottonwood Parkway P.O. Box 30270 Salt Lake City, Utah 84130-0270 regence.com/medicare 2017 Regence BlueCross BlueShield of Utah REG-36414-17/05-17-UT