2015 PRIME 65 Benefits at a Glance Form No. 3-023 (10-14) Policy Form No. 3-020 (06-10) Policy Form No. 3-021 (06-10) Policy Form No. 3-022 (06-10) Policy Form No. 3-030 (06-10) Policy Form No. 3-031 (06-10) Policy Form No. 3-073 (10-10) Policy Form No. 3-075 (10-10) Policy Form No. 3-074 (10-10)
Medicare Supplement Health Insurance Blue Cross of Idaho s An affordable choice for Medicare supplement coverage. BLUE CROSS OF IDAHO MEDICARE SUPPLEMENTS: Automatically pay higher benefits when Medicare and amounts increase Pay benefits immediately without any waiting period for preexisting conditions Cannot be cancelled because of age, changes in health or use of benefits Offer the same coverage for services anywhere in the U.S. 1
Medicare Supplement Health Insurance Blue Cross of Idaho Medicare Supplement Plans If you have Medicare, you probably know it is not designed to pay for everything. Blue Cross of Idaho offers low-cost Medicare supplement plans to help fill the gaps in your Medicare coverage. If you have enrolled in Medicare Part A and Part B, you are eligible to enroll in a Medicare supplement plan. Medicare supplement plans from Blue Cross of Idaho help pay the eligible expenses not covered by Medicare. 2
Why a Medicare Supplement? Medicare Part A provides hospital insurance and helps pay for inpatient care. Part B is medical insurance that helps pay for doctors services and outpatient care. While Medicare Part A and Part B pay for many healthcare services you need, there are many costs that are not covered. You must pay some, copayments and s. These costs are sometimes called gaps in Medicare coverage and a Medicare supplement plan will help you cover the gaps. Which plan is right for you? Blue Cross of Idaho offers Medicare supplement plans A, F, K, M and N. Plan A is the most basic and least expensive. Plan F pays your Part A and Part B s and covers a few other services such as foreign travel emergencies. Plan K is a good option if you re willing to trade a low monthly premium for higher copayments and an out-of-pocket limit. Plans M and N also cover foreign travel emergencies; however, Plan N includes a copayment for doctor and emergency room visits. For more information call 800-365-2345 or contact your local Blue Cross of Idaho district office at the numbers listed below. Meridian Office 3000 East Pine Avenue Meridian, Idaho 83642-5995 208-387-6683 Coeur d Alene Office 1450 Northwest Boulevard, Suite 106 Coeur d Alene, Idaho 83814 208-666-1495 Idaho Falls Office 1910 Channing Way Idaho Falls, Idaho 83404 208-522-8813 Lewiston Office 1010 17th Street Lewiston, Idaho 83501 208-746-0531 Pocatello Office 275 South 5th Avenue, Suite 150 Pocatello, Idaho 83206 208-232-6206 Twin Falls Office 1431 North Fillmore Street, Suite 200 Twin Falls, Idaho 83301 208-733-7258 3
Outline of Medicare Supplement Coverage The chart below shows the various benefit plans included in each of the standard Medicare supplement plans. Every company must make Plan A available. Some plans may not be available in Idaho. The plans highlighted in blue are Blue Cross of Idaho plans. Basic Benefits: Hospitalization: Part A plus coverage for 365 additional days after Medicare benefits end Medical Expenses: Part B (generally 20% of Medicare approved expenses) or copayments for hospital outpatient services. Plans K, M and N require insureds to pay a portion of Part B or copayments. Blood: First three pints of blood each year Hospice: Part A Plan A B C D Plan F* G Plan K L M N Basic Benefits, including 100% Part B Basic Benefits, including 100% Part B Basic Benefits, including 100% Part B Basic Benefits, including 100% Part B Basic Benefits, including 100% Part B Basic Benefits, including 100% Part B 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 Benefits, including 100% Part B Basic Benefits, including 100% Part B, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility Skilled nursing facility Skilled nursing facility Skilled nursing facility 50% skilled nursing facility 75% skilled nursing facility Skilled nursing facility Skilled nursing facility Part A Part A Part A Part A Part A 50% Part A 75% Part A 50% Part A Part A Part B Part B Part B excess (100%) Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency *Plan F has an option, not offered by Blue Cross of Idaho, called a high Plan F. This high plan pays the same benefits as Plan F after one has paid a calendar year $2,070. Benefits from high Plan F will not begin until out-of-pocket expenses exceed $2,070. Out-of-pocket expenses for this are expenses that would ordinarily be paid by the policy. These expenses include the Medicare s for Part A and Part B, but do not include the plan s separate foreign travel emergency. Out-of-pocket limit $4,800; paid at 100% after limit reached Out-of-pocket limit $2,400; paid at 100% after limit reached 4
Payment Method When you choose a Blue Cross of Idaho Medicare Supplement plan, you get to choose the payment method and schedule that works best for you. Monthly Automatic Bank Withdrawal Blue Cross of Idaho accepts payment through electronic funds transfer from most financial institutions. To set up automatic payments from your bank account, call your local Blue Cross of Idaho district office at 800-365-2345. Monthly Direct Coupon You will receive a bill that will be due on the first of each month. A $2.00 monthly billing fee will be charged when you choose this payment method. Age at issue Under 65 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 plus Non- Plan A Non- Plan F Non- Plan K Non- Plan M Non- Plan N $198.25 $228.08 $386.03 $444.16 $183.41 $210.96 $306.98 $353.18 $308.76 $355.23 $101.80 $117.23 $199.35 $229.04 $94.91 $108.99 $158.60 $182.20 $159.52 $183.26 $103.86 $119.58 $203.46 $234.07 $96.86 $111.37 $161.87 $186.20 $162.81 $187.28 $106.21 $122.22 $207.72 $238.94 $98.88 $113.68 $165.26 $190.07 $166.22 $191.17 $108.41 $124.86 $212.14 $243.82 $100.97 $115.99 $168.77 $193.94 $169.74 $195.07 $110.47 $127.22 $216.25 $248.99 $102.92 $118.44 $172.03 $198.06 $173.03 $199.21 $112.67 $129.71 $220.67 $253.86 $105.01 $120.75 $175.55 $201.93 $176.56 $203.10 $114.73 $132.06 $224.63 $258.58 $106.89 $122.99 $178.69 $205.68 $179.73 $206.88 $117.08 $134.71 $229.04 $263.61 $108.99 $125.37 $182.20 $209.68 $183.26 $210.89 $119.14 $137.21 $233.31 $268.33 $111.01 $127.61 $185.59 $213.43 $186.67 $214.67 $121.19 $139.56 $237.27 $273.06 $112.88 $129.85 $188.74 $217.19 $189.83 $218.45 $123.54 $142.20 $241.38 $277.77 $114.83 $132.08 $192.01 $220.93 $193.12 $222.21 $125.75 $144.70 $245.95 $282.95 $117.00 $134.54 $195.64 $225.05 $196.77 $226.35 $128.10 $147.34 $250.06 $287.82 $118.95 $136.85 $198.91 $228.92 $200.06 $230.25 $130.45 $150.13 $254.93 $293.15 $121.26 $139.38 $202.78 $233.16 $203.96 $234.51 $132.80 $152.92 $259.50 $298.33 $123.42 $141.83 $206.41 $237.27 $207.61 $238.65 $135.00 $155.42 $264.07 $303.66 $125.59 $144.36 $210.04 $237.27 $211.26 $242.91 $137.50 $158.36 $268.79 $309.14 $127.83 $146.96 $213.79 $245.87 $215.03 $247.29 $140.29 $161.30 $273.81 $315.08 $130.21 $149.77 $217.79 $250.59 $219.05 $252.04 $142.79 $164.38 $278.84 $320.72 $132.59 $149.77 $221.78 $255.07 $223.07 $256.55 $145.43 $167.32 $284.02 $326.66 $135.05 $155.26 $225.90 $259.79 $227.21 $261.29 $146.46 $168.50 $285.39 $326.66 $135.69 $156.05 $226.98 $261.12 $228.30 $262.63 5
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 facility and ends after you are out of the hospital and don t receive skilled nursing care in any other facility for 60 days in a row. The following chart outlines coverage limits for Blue Cross of Idaho s plans A, F, K, M and N. Services Medicare Plan A Plan F Plan K Hospitalization Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days Days 61 through 90 Days 91 and after, while using 60 lifetime reserve days After lifetime reserve days are used, additional 365 days Beyond the additional 365 days all but $1,260 all but $315 a day all but $630 a day $0 $0 $315 a day $630 a day of Medicare eligible charges $1,260 (your Part A ) $315 a day $630 a day of Medicare eligible charges 50% of the Part A $315 a day $630 a day of Medicare eligible charges Plan M 50% of the Part A $315 a day $630 a day of Medicare eligible charges Plan N $1,260 (your Part A ) $315 a day $630 a day of Medicare eligible charges $0 $0 $0 $0 $0 $0 Skilled Nursing Facility Care You must meet Medicare s requirements, including having been in the hospital for at least three days and entered a Medicare approved facility within 30 days after leaving the hospital all First 20 days approved amounts $0 $0 $0 $0 $0 Days 21 through 100 all but $152 a day $0 up to $152 a day up to $76 a day up to $152 a day up to $152 a day Day 101 and after $0 $0 $0 $0 $0 $0 Blood First 3 pints $0 50% Additional amounts $0 $0 $0 $0 $0 Hospice Care Available as long as you meet Medicare s requirements, including a doctor s certification of terminal illness all but limited copayment/ for outpatient drugs and inpatient respite care Medicare eligible Part A copayments/ Medicare eligible Part A copayments/ 50% Medicare eligible Part A copayments/ Medicare eligible Part A copayments/ Medicare eligible Part A copayments/ 6
Medicare (Part B) Medical Services Per Calendar Year Once you have been billed $147 of Medicare approved amounts for covered services, noted below with an asterisk (*), your Part B will have been met for the calendar year. Services Medicare Plan A Plan F Plan K Plan M Plan N Medical Expenses Inpatient and outpatient hospital treatment such as, physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, outpatient facility charges First $147 of Medicare approved amounts* Remainder of Medicare approved amounts* Preventive Benefits for Medicare covered services Part B excess charges (above Medicare approved amounts) $0 $0 $147 (your Part B ) $0 $0 $0 80% 20% 20% 10% 20% Generally 100% or more of Medicare approved amounts $0 $0 Plan pays the balance** $0 $0 $0 $0 $0 of Medicare Part B excess charges up to a limiting charge as determined by Medicare $0 $0 $0 ** Members are responsible for up to $20 copayment per doctor s office visit and up to $50 for emergency room visits. The plan pays the remaining balance and waives up to a $50 copayment if a hospital admits the insured and the Medicare Part A expense covers the emergency visit. Blood First 3 pints $0 all costs all costs 50% all costs all costs $147 Next $147 of Medicare $0 $0 (your Part B approved amounts* ) $0 $0 $0 Remainder of Medicare approved amounts* 80% 20% 20% 10% 20% 20% Home Health Care Medicare approved services Medically necessary skilled care services and $0 $0 $0 $0 $0 medical supplies Durable Medical Equipment First $147 of Medicare approved amounts* $0 $0 $147 (your Part B ) $0 $0 $0 Remainder of Medicare 80% 20% 20% 10% 20% 20% approved amounts Clinical Laboratory Services Tests for diagnostic $0 $0 $0 $0 $0 services 7
Additional Services Services Medicare Plan A Plan F Plan K Plan M Plan N Foreign Travel Emergency Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year** $0 $0 $0 $0 $0 $0 Remainder of charges** $0 $0 80% to a lifetime maximum benefit of $50,000 $0 80% to a lifetime maximum benefit of $50,000 80% to a lifetime maximum benefit of $50,000 At-home Recovery all approved $0 $0 $0 $0 $0 amounts Vision Please note, the vision benefits for some plans exceed the standard Medicare requirement. The benefit for vision care services is for routine eye exams not covered by Medicare. $0 $0 after $10 copayment on exam only at contracting providers, $45 toward exam at noncontracting providers after $10 copayment on exam only at contracting providers, $45 toward exam at noncontracting providers after $10 copayment on exam only at contracting providers, $45 toward exam at noncontracting providers after $10 copayment on exam only at contracting providers, $45 toward exam at noncontracting providers **not covered by Medicare 8
Healthy Smiles Dental Option Healthy Smiles is a family of flexible and affordable individual dental plans (Preventive, Plus, and Preferred) that include varying degrees of coverage so you can select a dental plan that best fits your needs. Healthy Smiles uses Blue Cross of Idaho s preferred provider organization (PPO) network of over 900 dental providers in Idaho, or thousands of providers nationwide through our dental GRID, giving you flexibility when choosing a provider. Healthy Smiles sm Preventive Healthy Smiles Preventive covers preventive dental services after a $20 copayment with no benefit period coverage limits, in-network s or waiting periods and is a good option for anyone looking for a low premium dental plan that encourages good oral habits that help maintain a healthy smile. Healthy Smiles sm Plus Healthy Smiles Plus includes the same benefit plan as Healthy Smiles Preventive and adds benefits for fillings, sealants and extractions after a 6-month waiting period. The program also features a $50, with a benefit period coverage limit of $1,000. Healthy Smiles sm Preferred Healthy Smiles Preferred is the most comprehensive plan available. The program builds on the Healthy Smiles Plus benefit plan and adds coverage for endodontics, periodontics, crowns, bridges, dentures, and implants after a 12-month waiting period. In addition, the plan includes a maximum carryover feature. Enrollees may carry over unused dental benefit dollars (up to $250 per year) to a maximum of $1,000. Policy Form No. 3-073 (10-10) Policy Form No. 3-075 (10-10) Policy Form No. 3-074 (10-10) For more information, please contact a local Blue Cross of Idaho district office at 800-365-2345. General exclusions and limitations No benefits are available for services that are: Not specifically included in the list of Covered Services in your policy; Considered to be not medically necessary or investigational in nature; Rendered prior to your effective date of coverage; or Not prescribed by a dental care provider. Healthy Smiles is a separate policy. does not include any dental benefits. 9
Important Information to Note Premium Information Blue Cross of Idaho can raise your premium only if we raise the premium for all individuals within your Blue Cross of Idaho Medicare supplement benefit plan. Exclusions Except as outlined previously in the policy, all services not eligible for Medicare are excluded. Disclosures Use this brochure to compare benefits and premiums among policies. Complete Answers are Very Important When you fill out the application for the new policy, be sure to answer truthfully and complete all questions about your medical and health history. Blue Cross of Idaho 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. Right to Return Policy If you find that you are not satisfied with your policy, you may return it to Blue Cross of Idaho at P.O. Box 7408 Boise ID, 83707. 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. Read your Policy 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 responsibilities of both you and Blue Cross of Idaho. Notice The policy you choose may not fully cover all of your medical costs. Blue Cross of Idaho s Medicare supplement programs and its independent producers (agents) are not affiliated with Medicare. This summary only briefly describes Medicare benefits. Consult your local Social Security Administration office or consult The Medicare Handbook for more details on Medicare. Policy Information 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. Visit our website at www.bcidaho.com/ MEDICARE or call your local Blue cross of Idaho district office to find out which Blue Cross of Idaho Medicare supplement plan is right for you. 10
Application/Enrollment Checklist To enroll in a Blue Cross of Idaho Medicare supplement plan, simply follow the checklist below: Read and review the Notice to Applicant Regarding Replacement of Medicare Supplement Insurance below. Accurately complete the first three pages of the application, including all pertinent medical information if you are not enrolling during Medicare s annual open enrollment period. Make sure there are no unmarked boxes and no information is missing. Sign and date the Statement of Understanding on the bottom of the third page. Remove the application from the booklet. Include a copy of your Medicare identification card if: n Your Medicare A and B effective dates are different; or n You are under 65 and disabled; or n You are not currently in your open enrollment period; or n You are applying for a Medicare supplement and this is not the first time you enrolled in a supplement program. Remember to include your first month s premium. Mail the application and your first month s premium to Blue Cross of Idaho. Notice to Applicant Regarding Replacement of Medicare Supplement Insurance Save this notice! It may be important to you in the future! If you intend to terminate your existing Medicare supplement insurance and replace it with a Blue Cross of Idaho policy, federal and state law provides a 30 day window when you may decide, without cost, whether you desire to keep either your old or new policy. Review any new coverage carefully. Compare it with all accident and sickness coverage you have now. Terminate your present policy only if, after due consideration, you find the purchase of Medicare supplement coverage is the choice you wish to make. Keep in mind: 1. You do not need more than one Medicare supplement policy. 2. If you are 65 or older, you may be eligible for benefits under Medicaid and may not need a Medicare supplement policy. 3. If you become eligible for Medicaid after purchasing a policy, you do not need coverage. You can request to have the policy suspended for up to 24 months during your entitlement to benefits under Medicaid. However, you must request the suspension within 90 days of becoming eligible for Medicaid. When you are no longer entitled to Medicaid, we will reinstate your policy, upon your request along with evidence of the loss of Medicaid coverage, within 90 days of losing Medicaid eligibility. 4. Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement insurance and concerning Medicaid. 11
Supplement to Applicant by Agent Independent Producer or Other Representative I have reviewed your current medical or health insurance coverage. The replacement of insurance involved in this transaction does not duplicate coverage, to the best of my knowledge. The replacement policy is being purchased for the following reason (check one): q q q q Additional benefits No change in benefits, but lower premiums Fewer benefits and lower premiums Other (please specify) If you still wish to terminate your present policy and replace it with new coverage, be certain to completely and accurately answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in effect. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded. Do not cancel your present policy until you have received your new policy and are sure that you want to keep it. Signature of Agent, Independent Producer, or Other Representative Type or print name and address of Insurer, Agent, or Independent Producer and phone number The above Notice to Applicant was delivered to me on: Date Applicant s Signature Form No. 3-023A (11-11) An Independent Licensee of the Blue Cross and Blue Shield Association
Medicare Supplement Application Applicant Information Your Name (first, initial, last) Date of Birth (mm/dd/yy) Age Height Weight Male Female Mailing Address (street or route) City, State, Zip Code County Billing Address (if different from mailing address) City, State, Zip Code County Marital Status Single Married Do you or have you ever smoked or used tobacco in the past 12 months? Yes No Preferred Phone Alternate Phone I don t have a phone Are you applying during open enrollment? Yes No Do you have Part A of Medicare? Yes No Effective Date Do you have Part B of Medicare? Yes No Effective Date Medicare Number Are you currently enrolled with Blue Cross or Blue Shield? Yes No If yes, Identification Number Headquarters City and State Social Security Number We require a copy of the front and back of your current Medigap or Medicare Advantage enrollment card to determine eligibility for our programs. Failure to provide this information will result in a delayed effective date of this new coverage until this information is obtained. Program Information sm Plan A sm Plan F sm Plan K sm Plan M sm Plan N Requested Effective Date: The effective date on the policy will be the first of the month following receipt and acceptance of the application by the Blue Cross of Idaho Underwriting Department. If, after health statement review, I am not eligible for my selection marked above, please consider me for: (First choice) (Second choice) Do not enroll me. Please refund my payment. Independent Producer Statement I hereby certify that I personally solicited and completed this application, that I personally asked each question on this application, and have accurately recorded the answers; That the answers to all of the questions are complete and accurate to the best of my knowledge and belief; That I have explained the eligibility provisions to the applicant and have not made any representations about benefits, conditions, or limitations of the policy, except through written material furnished by Blue Cross of Idaho; That I have verified the dates on the applicant s Medicare card. Type of Company Appointment: Personal Agency (Name) Independent Producer s Printed Name Independent Producer s Signature Date Phone No. Blue Cross of Idaho No. Form No. 3-334 (04-13) An Independent Licensee of the Blue Cross and Blue Shield Association Other Carrier Information Blue Cross of Idaho is currently considering a Medicare supplement application for the insured named below. The policy may or may not replace an existing Medicare supplement policy. Insurer Name of Insured: Name and Address: Other Carrier Policy Number:
Health Statement (Disregard this section if you are applying during the Medicare open enrollment period or if you now have other Blue Cross of Idaho coverage and are applying for Plan A.) Answer each question YES or NO. If YES, circle the specific condition. Then, in the chart below, write the number or letter in which the condition is listed, along with specific details. A. Has any company refused or restricted insurance on the applicant within the last year? YES NO B. Has the applicant been advised, in the past five years, to have surgery or hospitalization? YES NO C. Has the applicant ever had or been told he or she has any of the following: YES NO 1. Cancer, cyst, tumor, or tumorous growth (malignant or benign)within the last 20 years? 2. Heart trouble, heart murmur, chest pain, stroke, or any other disorder of the blood or circulatory system within the last 20 years? 3. An ulcer or any disorder or difficulty of the stomach, liver, intestines, or gall bladder within the last 10 years? 4. Diabetes, thyroid disorder, or any disorder of the glands within the last 20 years? 5. Convulsions, loss of consciousness, or paralysis within the last 10 years? 6. Any disorder of the kidneys, bladder, or prostate within the last 10 years? YES NO 7. Disease or disorder of the eyes within the last 10 years? 8. Emphysema, tuberculosis, or removal of any part of lung within the last 20 years? 9. Rheumatoid arthritis or osteoarthritis within the last 10 years? 10. A physical examination, check-up, or doctor s visit within the past six months? 11. High blood pressure within the last 10 years? (If YES, last reading ) 12. Has the applicant ever tested positive for HIV infection within the last 20 years? 13. Does the applicant have any illness, condition, or irregular symptoms not named above within the last 20 years? If you answered YES to any question above, please explain below. Use extra paper if needed. Item No. Diagnosis Type of Treatment Date of Illness Date of Last Visit Was Recovery Complete? List any medications or drugs taken by all applicants within the past 12 months. Use extra paper if necessary. Item No. Medication Name (Dosage) Condition Requiring Medication Still Taking? FOR AGENT USE ONLY List policies you have sold to this applicant that are still in force. (Use extra sheet of paper if necessary.) List policies you have sold to this applicant in the past five years that are no longer in force. (Use extra sheet of paper if necessary.)
Other Coverage To the best of your knowledge: 1. Do you currently or have you had in the past another Medicare supplement policy or certificate in force (including any health care service contract or health maintenance organization contract)? YES NO (a) (b) (c) (d) If YES, with which company? In what state? What was the termination date of the policy? What plan? (A-N) 2. Do you have any other health insurance policies or certificates? YES NO (a) (b) If YES, with which company? What kind of policy or certificate? 3. If the answer to question 1 or 2 is YES, do you intend to replace these policies or certificates with this policy? YES NO 4. Are you covered by Medicaid? YES NO Statement of Understanding I understand and agree that the statements and answers on this Application and Health Statement are complete and accurate, and that any false statement, misrepresentation, or concealment of fact may, at the option of Blue Cross of Idaho, bar recovery of any benefits, and shall be grounds for voidance or cancellation of the policy. I acknowledge and understand my health plan may request or disclose health information about me from time to time for the purpose of facilitating health care treatment, payment or for the purpose of business operations necessary to administer health care benefits; or as required by law. For more information about such uses and disclosures, including uses and disclosures required by law, please refer to the Blue Cross of Idaho Notice of Privacy Practices that is available at www.bcidaho.com. I understand and agree that the deposit, $ (if any), submitted with the Application is not binding upon Blue Cross of Idaho for the benefits applied for herein until the Application is approved; after approval the deposit then is payment of premiums for month(s) from the effective date. The Notice to Applicant and Outline of Coverage were furnished to me on Date Applicant s Signature Date
For Independent Producers Only Independent Producer Checklist Are the Medicare Part A and B effective dates filled in on the first page? Is the application completed in ink and signed by the applicant? (A dependent s signature is not acceptable.) Are all questions marked yes or no? (Check to make certain that specific condition(s), date(s) of occurrence, or date(s) last treated is (are) included and note if condition(s) is (are) resolved; make certain that condition explanation is complete; include prescription name, dosage, strength, duration and reason; if there are broken bones, are there any pins or hardware?) Is the Notice to Applicant Regarding Replacement of Medicare Supplement Insurance section signed and dated? Did the applicant indicate the program they are applying for? (Only one program is allowed.) Is height and weight noted for the applicant listed on the application? Is the requested effective date on the first page filled in? Are all payments attached to the front of the application? If one check is written for split applications, is a breakdown of amounts to apply to each application included? Does the payment include a $2.00 monthly billing fee if the applicant chose Monthly Direct Coupon? Did you verify eligibility on applicant s card? Independent Producer Certification 1. Who actually completed this application? Applicant Independent Producer Other If Independent Producer or Other, please explain: 2. Were you present at the time the application was filled out? YES NO If NO, please explain: 3. Are you aware of any medical information relating to the applicant or any family member that has not been disclosed on this application? YES NO If YES, please explain: 4. Was money collected from the applicant? YES NO Amount $ I have explained the eligibility provisions to the applicant. I have not made any representations about benefits, conditions, or limitations of the policy except through written material furnished by Blue Cross of Idaho. I hereby certify that the information supplied to me by the applicant has been completely and accurately recorded. Independent Producer s Printed Name Independent Producer s Signature Date Blue Cross of Idaho No. Type of Company Appointment Personal Agency (Name)
3000 East Pine Avenue Meridian, Idaho 83642-5995 Mailing Address: P.O. Box 7408 Boise, Idaho 83707-1408 1-800-365-2345 TTY 1-800-377-1363 www.bcidaho.com/medicare 2014 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association