(Medigap) Plans

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-36344-16/07-16-UT
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 Medicareapproved 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
Blood, first 3 pints
Hospice care
coinsurance/copays
Skilled nursing facility
coinsurance
Part A deductible
(per benefit period)
Part B deductible (annual)
Part B excess charges
Foreign travel emergency
Out-of-pocket annual limit
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**
X
X
X
X
X
X
X
X
X
X
X
X
50%
50%
75%
75%
X
X
X
X
X
X
X
X
50%
75%
X
X
X
X
X
X
50%
75%
50%
X
X
X
X
X
X
X
X
X
X
X
X
$4,960
$2,480
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.
Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the
policy. These expenses include the Medicare deductibles for Part A and Part B, but do not
include the plan’s separate foreign travel emergency deductible. Regence does not offer a
high deductible Plan F.
**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.
11
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 increase as you get older.
Rates effective August 1, 2016
Monthly Automatic Bank Withdrawal Rate
65
66
67
68
69
Age
Plan A
Plan C
Plan F
Plan G
Plan K
Plan N
$107
$140
$141
$117
$76
$105
$116
$157
$158
$131
$86
$117
$123
$163
$164
$136
$89
$122
$126
$172
$173
$143
$94
$128
70
$132
$178
$181
$150
$98
$134
$113
$151
$152
$126
$81
$113
$118
$159
$160
$133
$88
$119
$125
$165
$166
$138
$91
$124
$128
$174
$175
$145
$96
$130
$134
$180
$183
$152
$100
$136
$138
$188
$189
$157
$102
$141
$141
$196
$197
$164
$107
$147
$145
$203
$205
$170
$111
$153
$149
$209
$210
$174
$114
$156
$335
$449
$452
$374
$239
$335
$350
$473
$476
$395
$260
$353
$371
$491
$494
$410
$269
$368
$380
$518
$521
$431
$284
$386
$398
$536
$545
$452
$296
$404
$410
$560
$563
$467
$302
$419
$419
$584
$587
$488
$317
$437
$431
$605
$611
$506
$329
$455
$443
$623
$626
$518
$338
$464
$668
$896
$902
$746
$476
$668
$698
$944
$950
$788
$518
$704
$740
$980
$986
$818
$536
$734
$758
$1,034
$1,040
$860
$566
$770
$794
$1,070
$1,088
$902
$590
$806
$818
$1,118
$1,124
$932
$602
$836
$836
$1,166
$1,172
$974
$632
$872
$860
$1,208
$1,220
$1,010
$656
$908
$884
$1,244
$1,250
$1,034
$674
$926
$1,334
$1,790
$1,802
$1,490
$950
$1,334
$1,394
$1,886
$1,898
$1,574
$1,034
$1,406
$1,478
$1,958
$1,970
$1,634
$1,070
$1,466
$1,514
$2,066
$2,078
$1,718
$1,130
$1,538
$1,586
$2,138
$2,174
$1,802
$1,178
$1,610
$1,634 $1,670 $1,718 $1,766
$2,234 $2,330 $2,414 $2,486
$2,246 $2,342 $2,438 $2,498
$1,862 $1,946 $2,018 $2,066
$1,202 $1,262 $1,310 $1,346
$1,670 $1,742 $1,814 $1,850
$111
$149
$150
$124
$79
$111
71
$136
$186
$187
$155
$100
$139
72
$139
$194
$195
$162
$105
$145
73
$143
$201
$203
$168
$109
$151
74
$147
$207
$208
$172
$112
$154
Monthly Paper Bill Rate
Plan A
Plan C
Plan F
Plan G
Plan K
Plan N
$109
$142
$143
$119
$78
$107
Quarterly Rate
Plan A
Plan C
Plan F
Plan G
Plan K
Plan N
$323
$422
$425
$353
$230
$317
Semi-Annual Rate
Plan A
Plan C
Plan F
Plan G
Plan K
Plan N
$644
$842
$848
$704
$458
$632
Annual Rate
Plan A
Plan C
Plan F
Plan G
Plan K
Plan N
12
$1,286
$1,682
$1,694
$1,406
$914
$1,262
Medicare Supplement plans
$
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 Rate
75
76
77
78
79
Age
Plan A
Plan C
Plan F
Plan G
Plan K
Plan N
$150
$214
$215
$178
$116
$160
$157
$226
$227
$188
$123
$169
$158
$231
$232
$192
$125
$172
$159
$235
$237
$196
$127
$176
80
$160
$239
$240
$199
$130
$178
$156
$222
$223
$185
$123
$166
$159
$228
$229
$190
$125
$171
$160
$233
$234
$194
$127
$174
$161
$237
$239
$198
$129
$178
$162
$241
$242
$201
$132
$180
$163
$246
$249
$207
$134
$186
$164
$252
$253
$210
$138
$188
$164
$255
$256
$212
$139
$191
$164
$259
$261
$217
$141
$194
$164
$262
$262
$217
$141
$195
$464
$662
$665
$551
$365
$494
$473
$680
$683
$566
$371
$509
$476
$695
$698
$578
$377
$518
$479
$707
$713
$590
$383
$530
$482
$719
$722
$599
$392
$536
$485
$734
$743
$617
$398
$554
$488
$752
$755
$626
$410
$560
$488
$761
$764
$632
$413
$569
$488
$773
$779
$647
$419
$578
$488
$782
$782
$647
$419
$581
$926
$1,322
$1,328
$1,100
$728
$986
$944
$1,358
$1,364
$1,130
$740
$1,016
$950
$1,388
$1,394
$1,154
$752
$1,034
$956
$1,412
$1,424
$1,178
$764
$1,058
$962
$1,436
$1,442
$1,196
$782
$1,070
$968
$1,466
$1,484
$1,232
$794
$1,106
$974
$1,502
$1,508
$1,250
$818
$1,118
$974
$1,520
$1,526
$1,262
$824
$1,136
$974
$1,544
$1,556
$1,292
$836
$1,154
$974
$1,562
$1,562
$1,292
$836
$1,160
$1,850
$2,642
$2,654
$2,198
$1,454
$1,970
$1,886
$2,714
$2,726
$2,258
$1,478
$2,030
$1,898
$2,774
$2,786
$2,306
$1,502
$2,066
$1,910
$2,822
$2,846
$2,354
$1,526
$2,114
$1,922
$2,870
$2,882
$2,390
$1,562
$2,138
$1,934
$2,930
$2,966
$2,462
$1,586
$2,210
$1,946
$3,002
$3,014
$2,498
$1,634
$2,234
$1,946
$3,038
$3,050
$2,522
$1,646
$2,270
$1,946
$3,086
$3,110
$2,582
$1,670
$2,306
$1,946
$3,122
$3,122
$2,582
$1,670
$2,318
$154
$220
$221
$183
$121
$164
81
$161
$244
$247
$205
$132
$184
82
$162
$250
$251
$208
$136
$186
83
$162
$253
$254
$210
$137
$189
84
$162
$257
$259
$215
$139
$192
85+
$162
$260
$260
$215
$139
$193
Monthly Paper Bill Rate
Plan A
Plan C
Plan F
Plan G
Plan K
Plan N
$152
$216
$217
$180
$118
$162
Quarterly Rate
Plan A
Plan C
Plan F
Plan G
Plan K
Plan N
$452
$644
$647
$536
$350
$482
Semi-Annual Rate
Plan A
Plan C
Plan F
Plan G
Plan K
Plan N
$902
$1,286
$1,292
$1,070
$698
$962
Annual Rate
Plan A
Plan C
Plan F
Plan G
Plan K
Plan N
$1,802
$2,570
$2,582
$2,138
$1,394
$1,922
13
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 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.
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.
*Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums.
14
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 $1,288
$0
$1,288
(Part A deductible)
61st thru 90th day
All but $322 a day
$322 a day
$0
91st day and after:
While using 60 lifetime reserve days
All but $644 a day
$644 a day
$0
Once lifetime reserve days are used: $0
Additional 365 days
100% of Medicareeligible expenses
$0**
Beyond the additional 365 days
$0
All costs
$0
Skilled Nursing Facility Care* — You must meet Medicare’s requirements, including having been
in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving
the hospital
First 20 days
All approved
amounts
$0
$0
21st thru 100th day
All but $161
a day
$0
Up to $161
a day
101st day and after
$0
$0
All costs
First 3 pints
$0
3 pints
$0
Additional amounts
100%
$0
$0
All but very limited
coinsurance for
outpatient drugs
and inpatient
respite care
Medicare copay/
coinsurance
$0
Blood
Hospice Care
You must meet Medicare’s
requirements, including a doctor’s
certification of terminal illness.
*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.
15
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 $166 of Medicareapproved amounts***
$0
$0
$166
(Part B deductible)
Remainder of Medicareapproved amounts
Generally 80%
Generally 20%
$0
Part B Excess Charges (above
Medicare-approved amounts)
$0
$0
All costs
First 3 pints
$0
All costs
$0
Next $166 of Medicareapproved amounts***
$0
$0
$166
(Part B deductible)
Remainder of Medicareapproved amounts
80%
20%
$0
100%
$0
$0
Blood
Clinical Laboratory Services
Tests for diagnostic services
Home Health Care — Medicare-approved services
Medically necessary skilled care
services and medical supplies
100%
$0
$0
Durable medical equipment:
First $166 of Medicareapproved amounts***
$0
$0
$166
(Part B deductible)
Remainder of Medicareapproved amounts
80%
20%
$0
***Once you have been billed $166 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.
16
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 $1,288
$1,288
(Part A deductible)
$0
61st thru 90th day
All but $322 a day
$322 a day
$0
91st day and after:
While using 60 lifetime reserve days
All but $644 a day
$644 a day
$0
Once lifetime reserve days are used: $0
Additional 365 days
100% of Medicareeligible expenses
$0**
Beyond the additional 365 days
$0
All costs
$0
Skilled Nursing Facility Care* —You must meet Medicare’s requirements, including having been in
a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving
the hospital
All approved
amounts
$0
$0
21st thru 100th day
All but $161
a day
Up to $161
a day
$0
101st day and after
$0
$0
All costs
First 3 pints
$0
3 pints
$0
Additional amounts
100%
$0
$0
All but very limited
coinsurance for
outpatient drugs
and inpatient
respite care
Medicare copay/
coinsurance
$0
First 20 days
Blood
Hospice Care
You must meet Medicare’s
requirements, including a doctor’s
certification of terminal illness.
*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.
17
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 $166 of Medicareapproved amounts***
$0
$166
(Part B deductible)
$0
Remainder of Medicareapproved amounts
Generally 80%
Generally 20%
$0
Part B Excess Charges (above
Medicare-approved amounts)
$0
$0
All costs
First 3 pints
$0
All costs
$0
Next $166 of Medicareapproved amounts***
$0
$166
(Part B deductible)
$0
Remainder of Medicareapproved amounts
80%
20%
$0
100%
$0
$0
Blood
Clinical Laboratory Services
Tests for diagnostic services
Home Health Care —Medicare-approved services
Parts A & B
Medically necessary skilled care
services and medical supplies
100%
$0
$0
Durable medical equipment:
First $166 of Medicareapproved amounts***
$0
$166
(Part B deductible)
$0
Remainder of Medicareapproved amounts
80%
20%
$0
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
$0
$0
$250
Remainder of charges
$0
80% to lifetime
20% and amounts
maximum benefit
over the $50,000
of $50,000
lifetime maximum
***Once you have been billed $166 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.
18
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 $1,288
$1,288
(Part A deductible)
$0
61st thru 90th day
All but $322 a day
$322 a day
$0
91st day and after:
All but $644 a day
While using 60 lifetime reserve days
Once lifetime reserve days are used: $0
Additional 365 days
$644 a day
$0
100% of Medicareeligible expenses
$0**
Beyond the additional 365 days
$0
All costs
$0
Skilled Nursing Facility Care* —You must meet Medicare’s requirements, including having been in
a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving
the hospital
First 20 days
All approved
amounts
$0
$0
21st thru 100th day
All but $161 a day
Up to $161 a day
$0
101st day and after
$0
$0
All costs
First 3 pints
$0
3 pints
$0
Additional amounts
100%
$0
$0
All but very limited
coinsurance for
outpatient drugs
and inpatient
respite care
Medicare copay/
coinsurance
$0
Blood
Hospice Care
You must meet Medicare’s
requirements, including a doctor’s
certification of terminal illness.
*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.
19
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 $166 of Medicareapproved amounts***
$0
$166
(Part B deductible)
$0
Remainder of Medicareapproved amounts
Generally 80%
Generally 20%
$0
Part B Excess Charges (above
Medicare approved amounts)
$0
100%
$0
First 3 pints
$0
All Costs
$0
Next $166 of Medicareapproved amounts***
$0
$166
(Part B deductible)
$0
Remainder of Medicareapproved amounts
80%
20%
$0
100%
$0
$0
Blood
Clinical Laboratory Services
Tests for diagnostic services
Home Health Care —Medicare-approved services Parts A & B
Medically necessary skilled care
services and medical supplies
100%
$0
$0
Durable medical equipment:
First $166 of Medicareapproved amounts***
$0
$166
(Part B deductible)
$0
Remainder of Medicareapproved amounts
80%
20%
$0
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
$0
$0
$250
Remainder of charges
$0
80% to lifetime
maximum benefit
of $50,000
20% and amounts
over the $50,000
lifetime maximum
***Once you have been billed $166 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.
20
Medigap Plan G
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 $1,288
$1,288
(Part A deductible)
$0
61st thru 90th day
All but $322 a day
$322 a day
$0
91st day and after:
All but $644 a day
While using 60 lifetime reserve days
Once lifetime reserve days are used: $0
Additional 365 days
$644 a day
$0
100% of Medicareeligible expenses
$0**
Beyond the additional 365 days
$0
All costs
$0
Skilled Nursing Facility Care* —You must meet Medicare’s requirements, including having been in
a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving
the hospital
First 20 days
All approved
amounts
$0
$0
21st thru 100th day
All but $161 a day
Up to $161 a day
$0
101st day and after
$0
$0
All costs
First 3 pints
$0
3 pints
$0
Additional amounts
100%
$0
$0
All but very limited
copay/
coinsurance for
outpatient drugs
and inpatient
respite care
Medicare copay/
coinsurance
$0
Blood
Hospice Care
You must meet Medicare’s
requirements, including a doctor’s
certification of terminal illness.
*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.
21
Plan G (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 $166 of Medicareapproved amounts***
$0
$0
$166
(Part B deductible)
Remainder of Medicareapproved amounts
Generally 80%
Generally 20%
$0
Part B Excess Charges (above
Medicare-approved amounts)
$0
100%
$0
First 3 pints
$0
All Costs
$0
Next $166 of Medicareapproved amounts***
$0
$0
$166
(Part B deductible)
Remainder of Medicareapproved amounts
80%
20%
$0
100%
$0
$0
Blood
Clinical Laboratory Services
Tests for diagnostic services
Home Health Care —Medicare-approved services Parts A & B
Medically necessary skilled care
services and medical supplies
100%
$0
$0
Durable medical equipment:
First $166 of Medicareapproved amounts***
$0
$0
$166
(Part B deductible)
Remainder of Medicareapproved amounts
80%
20%
$0
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
$0
$0
$250
Remainder of charges
$0
80% to lifetime
maximum benefit
of $50,000
20% and amounts
over the $50,000
lifetime maximum
***Once you have been billed $166 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.
22
Medigap Plan K
You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket
limit of $4,960each 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
co-payment 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.
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 $1,288
$644 (50% of
Part A deductible)
$644 (50% of
Part A deductible)♦
61st thru 90th day
All but $322 a day
$322 a day
$0
91st day and after:
All but $644 a day
While using 60 lifetime reserve days
Once lifetime reserve days are used: $0
Additional 365 days
$644 a day
$0
100% of Medicareeligible expenses
$0**
Beyond the additional 365 days
$0
All costs
$0
Skilled Nursing Facility Care*—You
must meet Medicare’s requirements, including having been in
a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving
the hospital
First 20 days
All approved
amounts
$0
$0
21st thru 100th day
All but $161
a day
Up to $80.50 a day
Up to $80.50 a
day♦
101st day and after
$0
$0
All costs
First 3 pints
$0
50%
50%♦
Additional amounts
100%
$0
$0
All but very limited
coinsurance for
outpatient drugs
and inpatient
respite care
50% of copay/
coinsurance
50% of
Medicare copay/
coinsurance♦
Blood
Hospice Care
You must meet Medicare’s
requirements, including a doctor’s
certification of terminal illness.
*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.
23
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 $166 of Medicareapproved amounts***
$0
$0
Generally 80% or
more of Medicareapproved amounts
Remainder of
All costs above
Medicare-approved Medicare-approved
amounts
amounts
Remainder of Medicareapproved amounts
Generally 80%
Generally 10%
Generally 10%♦
Part B Excess Charges (above
Medicare-approved amounts)
$0
$0
All costs (and they
do not count
toward annual
out-of-pocket
limit of $4,960)
First 3 pints
$0
50%
50%♦
Next $166 of Medicareapproved amounts***
$0
$0
$166 (Part B
deductible)♦
Remainder of Medicareapproved amounts
80%
Generally 10%
Generally 10%♦
100%
$0
$0
Preventive Benefits for Medicare
covered services
$166 (Part B
deductible)♦
Blood
Clinical Laboratory Services
Tests for diagnostic services
Home Health Care —Medicare-approved services Parts A & B
Medically necessary skilled care
services and medical supplies
100%
$0
$0
Durable medical equipment:
First $166 of Medicareapproved amounts***
$0
$0
$166 (Part B
deductible)♦
Remainder of Medicareapproved amounts
80%
10%
10%♦
***Once you have been billed $166 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.
This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $4,960
per year. However, this limit does NOT include charges from your provider that exceed Medicareapproved amounts (these are called “Excess Charges”) and you will be responsible for paying the
difference between the amount charged by your provider and the amount paid by Medicare for the
item or service.
Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for
People with Medicare.
24
Medigap Plan N
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 $1,288
$1,288
(Part A deductible)
$0
61st thru 90th day
All but $322 a day
$322 a day
$0
91st day and after:
All but $644 a day
While using 60 lifetime reserve days
Once lifetime reserve days are used: $0
Additional 365 days
$644 a day
$0
100% of Medicareeligible expenses
$0**
Beyond the additional 365 days
$0
All costs
$0
Skilled Nursing Facility Care* —You must meet Medicare’s requirements, including having been in
a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving
the hospital
First 20 days
All approved
amounts
$0
$0
21st thru 100th day
All but $161 a day
Up to $161 a day
$0
101st day and after
$0
$0
All costs
First 3 pints
$0
3 pints
$0
Additional amounts
100%
$0
$0
Blood
Hospice Care
You must meet Medicare’s
requirements, including a doctor’s
certification of terminal illness.
All but very limited Medicare copay/
copay/ coinsurance coinsurance
for outpatient
drugs and inpatient
respite care
$0
*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.
25
Plan N (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 $166 of Medicare-approved
amounts***
$0
$0
$166
(Part B deductible)
Remainder of Medicareapproved amounts
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.
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.
Part B Excess Charges (above
Medicare-approved amounts)
$0
$0
All costs
First 3 pints
$0
All Costs
$0
Next $166 of Medicare-approved
amounts***
$0
$0
$166
(Part B deductible)
Remainder of Medicare-approved
amounts
80%
20%
$0
100%
$0
$0
Blood
Clinical Laboratory Services
Tests for diagnostic services
Home Health Care — Medicare-approved services Parts A & B
Medically necessary skilled care
services and medical supplies
100%
$0
$0
Durable medical equipment: First
$0
$166 of Medicare-approved amounts***
$0
$166
(Part B deductible)
Remainder of Medicare-approved
amounts
20%
$0
80%
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
$0
$0
$250
Remainder of charges
$0
80% to lifetime
maximum benefit
of $50,000
20% and amounts
over the $50,000
lifetime maximum
***Once you have been billed $166 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.
26
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: 1-844-REGENCE (1-844-734-3623)
TTY users should call 711
or contact your local insurance producer (agent)
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
© 2016 Regence BlueCross BlueShield of Utah
regence.com/medicare
REG-36344-16/07-16-UT
27