OUTLINE OF COVERAGE. Regence Bridge. Medicare Supplement (Medigap) Plans

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1 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 09713rep07355-ut UT 2016

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3 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 Medicareapproved 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 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 X X Foreign travel emergency X X X X X X Out-of-pocket annual limit $4,940 $2,470 NOTE: Plan benefits offered by Regence BlueCross BlueShield of Utah are shaded in blue. *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 $2,180 calendar year deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2,180. Outof-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 sell High Deductible Plan F. **Pays the Part B coinsurance, except you pay a $20 copay per physician visit and a $50 copay per emergency room visit. 3

4 $ Premium information 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 rise as you get older. Rates effective August 1, 2015 Monthly Automatic Bank Withdrawal Rate Age Plan A $98 $102 $107 $113 $116 $121 $125 $128 $132 $135 Plan C $128 $136 $143 $149 $157 $163 $170 $177 $184 $189 Plan F $129 $137 $144 $150 $158 $165 $171 $178 $185 $190 Plan K $70 $73 $79 $82 $87 $90 $92 $97 $100 $103 Monthly Paper Bill Rate Age Plan A $100 $104 $109 $115 $118 $123 $127 $130 $134 $137 Plan C $130 $138 $145 $151 $159 $165 $172 $179 $186 $191 Plan F $131 $139 $146 $152 $160 $167 $173 $180 $187 $192 Plan K $72 $75 $81 $84 $89 $92 $94 $99 $102 $105 Quarterly Rate Age Plan A $296 $308 $323 $341 $350 $365 $377 $386 $398 $407 Plan C $386 $410 $431 $449 $473 $491 $512 $533 $554 $569 Plan F $389 $413 $434 $452 $476 $497 $515 $536 $557 $572 Plan K $212 $221 $239 $248 $263 $272 $278 $293 $302 $311 Semi-Annual Rate Age Plan A $590 $614 $644 $680 $698 $728 $752 $770 $794 $812 Plan C $770 $818 $860 $896 $944 $980 $1,022 $1,064 $1,106 $1,136 Plan F $776 $824 $866 $902 $950 $992 $1,028 $1,070 $1,112 $1,142 Plan K $422 $440 $476 $494 $524 $542 $554 $584 $602 $620 Annual Rate Age Plan A $1,178 $1,226 $1,286 $1,358 $1,394 $1,454 $1,502 $1,538 $1,586 $1,622 Plan C $1,538 $1,634 $1,718 $1,790 $1,886 $1,958 $2,042 $2,126 $2,210 $2,270 Plan F $1,550 $1,646 $1,730 $1,802 $1,898 $1,982 $2,054 $2,138 $2,222 $2,282 Plan K $842 $878 $950 $986 $1,046 $1,082 $1,106 $1,166 $1,202 $1,238 4

5 Medicare Supplement plans A household discount 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 Rate Age Plan A $138 $142 $144 $145 $146 $147 $148 $149 $149 $149 $149 Plan C $195 $201 $206 $211 $215 $218 $223 $228 $231 $235 $237 Plan F $196 $202 $207 $212 $216 $219 $225 $229 $232 $236 $237 Plan K $107 $111 $113 $115 $117 $120 $122 $125 $126 $128 $128 Monthly Paper Bill Rate Age Plan A $140 $144 $146 $147 $148 $149 $150 $151 $151 $151 $151 Plan C $197 $203 $208 $213 $217 $220 $225 $230 $233 $237 $239 Plan F $198 $204 $209 $214 $218 $221 $227 $231 $234 $238 $239 Plan K $109 $113 $115 $117 $119 $122 $124 $127 $128 $130 $130 Quarterly Rate Age Plan A $416 $428 $434 $437 $440 $443 $446 $449 $449 $449 $449 Plan C $587 $605 $620 $635 $647 $656 $671 $686 $695 $707 $713 Plan F $590 $608 $623 $638 $650 $659 $677 $689 $698 $710 $713 Plan K $323 $335 $341 $347 $353 $362 $368 $377 $380 $386 $386 Semi-Annual Rate Age Plan A $830 $854 $866 $872 $878 $884 $890 $896 $896 $896 $896 Plan C $1,172 $1,208 $1,238 $1,268 $1,292 $1,310 $1,340 $1,370 $1,388 $1,412 $1,424 Plan F $1,178 $1,214 $1,244 $1,274 $1,298 $1,316 $1,352 $1,376 $1,394 $1,418 $1,424 Plan K $644 $668 $680 $692 $704 $722 $734 $752 $758 $770 $770 Annual Rate Age Plan A $1,658 $1,706 $1,730 $1,742 $1,754 $1,766 $1,778 $1,790 $1,790 $1,790 $1,790 Plan C $2,342 $2,414 $2,474 $2,534 $2,582 $2,618 $2,678 $2,738 $2,774 $2,822 $2,846 Plan F $2,354 $2,426 $2,486 $2,546 $2,594 $2,630 $2,702 $2,750 $2,786 $2,834 $2,846 Plan K $1,286 $1,334 $1,358 $1,382 $1,406 $1,442 $1,466 $1,502 $1,514 $1,538 $1,538 5

6 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.* 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 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. 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. 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. 6 * Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums.

7 Medigap Plan A Services Medicare Pays Plan Pays You Pay Medicare (Part A) Hospital Services Per Benefit Period Hospitalization* Semi-private room & board, general nursing and miscellaneous services and supplies First 60 days All but $1,260 $1,260 (Part A deductible) 61st thru 90th day All but $315 a day $315 a day 91st day and after: All but $630 a day $630 a day While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days 100% of Medicare eligible 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 amounts 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 amounts 100% Hospice Care You must meet Medicare s All but very limited Medicare requirements including a doctor s coinsurance for copayment/ certification of terminal illness. outpatient drugs coinsurance and inpatient respite care * 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. **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

8 Plan A (cont.) Services Medicare Pays Plan Pays You Pay Medicare (Part B) Medical Services Per Calendar Year 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 $147 of Medicare Part B Excess Charges (Above Medicare ) Blood $147 Generally 80% Generally 20% All costs First 3 pints All costs Next $147 of Medicare Clinical Laboratory Services $147 80% 20% Tests for diagnostic services 100% Home Health Care Medicare-approved services Medically necessary skilled care services and medical supplies Durable medical equipment: First $147 of Medicare 100% $147 80% 20% ***Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. 8

9 Medigap Plan C Services Medicare Pays Plan Pays You Pay Medicare (Part A) Hospital Services Per Benefit Period Hospitalization* Semi-private room & board, general nursing and miscellaneous services and supplies First 60 days All but $1,260 $1,260 (Part A deductible) 61st thru 90th day All but $315 a day $315 a day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days All but $630 a day $630 a day 100% of Medicare eligible 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 amounts All but $ a day ** Up to $ a day 101st day and after All costs Blood First 3 pints 3 pints Additional amounts 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 * 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. **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

10 Plan C (cont.) Services Medicare Pays Plan Pays You Pay Medicare (Part B) Medical Services Per Calendar Year 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 $147 of Medicare $147 Part B Excess Charges (Above Medicare ) Generally 80% Generally 20% All costs Blood First 3 pints All costs Next $147 of Medicare $147 80% 20% Clinical Laboratory Services Tests for diagnostic services 100% Home Health Care Medicare-approved services Parts A & B Medically necessary skilled care services and medical supplies 100% Durable medical equipment: First $147 of Medicare $147 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 USA First $250 each calendar year $250 Remainder of charges 80% to lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum ***Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. 10

11 Medigap Plan F Services Medicare Pays Plan Pays You Pay Medicare (Part A) Hospital Services Per Benefit Period Hospitalization* Semi-private room & board, general nursing and miscellaneous services and supplies First 60 days All but $1,260 $1,260 (Part A deductible) 61st thru 90th day All but $315 a day $315 a day 91st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days All but $630 a day $630 a day 100% of Medicare eligible 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 amounts ** 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 amounts 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 * 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. **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

12 Plan F (cont.) Services Medicare Pays Plan Pays You Pay Medicare (Part B) Medical Services Per Calendar Year 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 $147 of Medicare Part B Excess Charges (Above Medicare ) Blood $147 Generally 80% Generally 20% 100% First 3 pints All Costs Next $147 of Medicare Clinical Laboratory Services $147 80% 20% Tests for diagnostic services 100% Home Health Care Medicare-approved services Parts A & B Medically necessary skilled care services and medical supplies Durable medical equipment: First $147 of Medicare 100% $147 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 USA First $250 each calendar year $250 Remainder of charges 80% to lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum ***Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. 12

13 Medigap Plan K Services Medicare Pays Plan Pays You Pay Medicare (Part A) Hospital Services Per Benefit Period Hospitalization* Semi-private room & board, general nursing and miscellaneous services and supplies First 60 days All but $1,260 $630 (50% of Part A deductible) 61st thru 90th day All but $315 a day $315 a day 91st day and after: All but $630 $630 a day While using 60 lifetime reserve days a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare eligible expenses $630 (50% of Part A deductible) 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 amounts 21st thru 100th day All but $ a day Up to $78.75 a day ** Up to $78.75 a day 101st day and after All costs Blood First 3 pints 50% 50% Additional amounts 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 * 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. **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. You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $4,940 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 in the amount charged by your provider and the amount paid by Medicare for the items or service. 13

14 Plan K (cont.) Services Medicare Pays Plan Pays You Pay Medicare (Part B) Medical Services Per Calendar Year 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 $147 of Medicare Preventive Benefits for Medicare covered services Part B Excess Charges (Above Medicare ) Blood $147 (Part B deductible) Generally 80% or more of Medicare approved amounts Remainder of Medicare approved amounts All costs above Medicare approved amounts Generally 80% Generally 10% Generally 10% All costs (and they do not count toward annual out-of-pocket limit of $4,940) First 3 pints 50% 50% Next $147 of Medicare Clinical Laboratory Services $147 (Part B deductible) 80% Generally 10% Generally 10% Tests for diagnostic services 100% Home Health Care Medicare-approved services Parts A & B Medically necessary skilled care services and medical supplies Durable medical equipment: First $147 of Medicare 100% $147 (Part B deductible) 80% 10% 10% ***Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $4,940 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 in the amount charged by your provider and the amount paid by Medicare for the items or service. Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. 14

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16 Regence Medicare Supplement (Medigap) Plans For more information, call one of our Plan s sales representatives, 8 a.m. to 5 p.m., Pacific time, Monday through Friday toll-free: REGENCE ( ) TTY users should call 711 or contact your local insurance producer (agent) 09713rep07355-ut/ Regence BlueCross BlueShield of Utah 2890 East Cottonwood Parkway P.O. Box Salt Lake City, Utah regence.com/medicare