2018 Idaho MedPlus Medicare Benefit Guide · BENEFIT GUIDE Blue Cross of Idaho Care Plus, Inc....

2018 BENEFIT GUIDE

Blue Cross of Idaho Care Plus, Inc. Idaho MedPlus Medicare Benefit Guide

Idaho MedPlus Medicare

Policy Form No. 18-544 (01-17) Policy Form No. 18-545 (01-17) Policy Form No. 18-546 (01-17) Policy Form No. 18-547 (01-17) Form No. 16-707 (10-17)


Idaho MedPlus Medicare supplement plans help pay eligible expenses not covered by Medicare.

An affordable choice for Medicare supplement coverage. How Medicare Supplements Work • Medicare Part A provides hospital insurance and helps pay for inpatient care.

• Medicare 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, there are many costs that are not covered. You must pay some coinsurance, copays and deductibles. These costs are referred to as gaps in Medicare coverage.

• Medicare supplement plans will help you cover those gaps in coverage.

Idaho MedPlus Medicare Supplements: • Automatically pay higher benefits when Medicare deductible and coinsurance

amounts increase

• Pay benefits 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.

Did You Know? Medicare is not designed to pay for all healthcare expenses. Low-cost Idaho MedPlus Medicare supplement plans help fill the gaps in your Medicare coverage. If you have enrolled in Medicare Part A and Part B, you might be eligible to enroll in an Idaho MedPlus Medicare supplement plan.

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.

Basic Benefits: • Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end

• Medical Expenses: Part B coinsurance (generally 20 percent of Medicare approved expenses) or copays for hospital outpatient services. Plans K, M and N require insureds to pay a portion of Part B coinsurance or copays.

• Blood: First three pints of blood each year

• Hospice: Part A coinsurance

The plans highlighted in blue are offered by Blue Cross of Idaho Care Plus.

Plan A B C D Plan F* G Plan K L M N

Basic Benefits, including

100% Part B

coinsurance


100% Part B

coinsurance


100% Part B

coinsurance


100% Part B

coinsurance


100% Part B

coinsurance


100% Part B

coinsurance

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%


100% Part B

coinsurance


100% Part B coinsurance, except up to

$20 copayment

for office visit, and

up to $50 copay

for ER

Skilled nursing facility

coinsurance


coinsurance


coinsurance


coinsurance

50% skilled

nursing facility

coinsurance

75% skilled

nursing facility

coinsurance


coinsurance


coinsurance

Part A deductible

Part A deductible

Part A deductible

Part A deductible

Part A deductible

50% Part A

deductible

75% Part A

deductible

50% Part A

deductible

Part A deductible

Part B deductible

Part B deductible

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 Care Plus, called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,240 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.

Out-of-pocket limit $5,240; paid at 100%

after limit reached

Out-of-pocket limit $2,620; paid at 100%

after limit reached

4

Which plan is right for you? We offer Medicare supplement plans A, F, K and N. Here is a look at some basic features of each plan:

• Plan A is the most basic and least expensive. • Plan F pays your Part A and Part B deductibles 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. • Plan N also covers foreign travel emergencies; however, Plan N includes a copay for doctor and emergency room visits.

Non-Tobacco User Rates Tobacco User Rates*

Plan A Plan F Plan K Plan N Plan A Plan F Plan K Plan NIssue Age #18-544 #18-545 #18-546 #18-547 #18-544 #18-545 #18-546 #18-547

$186.52 $273.80 $140.83 $210.75 Under 65 $214.50 $314.87 $161.95 $242.36 $124.35 $182.54 $93.89 $140.50 65 $143.00 $209.92 $107.97 $161.58 $127.82 $187.63 $96.51 $144.42 66 $146.99 $215.77 $110.99 $166.08 $131.38 $192.85 $99.19 $148.44 67 $151.09 $221.78 $114.07 $170.71 $134.92 $198.06 $101.87 $152.44 68 $155.16 $227.77 $117.15 $175.31 $138.43 $203.20 $104.52 $156.40 69 $159.19 $233.68 $120.20 $179.86 $141.91 $208.31 $107.15 $160.34 70 $163.20 $239.56 $123.22 $184.39 $145.35 $213.37 $109.75 $164.23 71 $167.15 $245.38 $126.21 $188.86 $148.77 $218.39 $112.33 $168.09 72 $171.09 $251.15 $129.18 $193.30 $152.14 $223.34 $114.87 $171.90 73 $174.96 $256.84 $132.10 $197.69 $155.46 $228.21 $117.38 $175.65 74 $178.78 $262.44 $134.99 $202.00 $158.72 $232.99 $119.84 $179.33 75 $182.53 $267.94 $137.82 $206.23 $161.92 $237.69 $122.25 $182.95 76 $186.21 $273.34 $140.59 $210.39 $165.02 $242.25 $124.60 $186.46 77 $189.77 $278.59 $143.29 $214.43 $168.44 $247.27 $127.18 $190.32 78 $193.71 $284.36 $146.26 $218.87 $171.35 $251.54 $129.38 $193.61 79 $197.05 $289.27 $148.79 $222.65 $174.19 $255.70 $131.52 $196.81 80 $200.32 $294.06 $151.25 $226.33 $176.90 $259.68 $133.57 $199.88 81 $203.44 $298.63 $153.61 $229.86 $179.46 $263.44 $135.50 $202.77 82 $206.38 $302.96 $155.83 $233.19 $181.50 $266.44 $137.04 $205.07 83 $208.73 $306.41 $157.60 $235.83 $183.70 $269.67 $138.70 $207.56 84 $211.26 $310.12 $159.51 $238.69 $185.63 $272.50 $140.16 $209.74 85 plus $213.47 $313.38 $161.18 $241.20

*Includes hookah, e-cigarettes, dissolvables, smokeless tobacco, cigarettes, all cigars, roll-your-own tobacco, pipe tobacco, and future tobacco products that meet the statutory definition of a tobacco product.

Add an additional $2.00 billing charge for persons electing to pay premium monthly not using electronic means.

Payment Method When you choose a Idaho Med Plus plan, you choose the payment method and schedule that works best for you.

Monthly Automatic Bank Withdrawal Blue Cross of Idaho Care Plus accepts payment through electronic funds transfer from most financial institutions. To set up automatic payments from your bank account, call your 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 monthly billing fee applies to this payment method.

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 plans A, F, K and N.

Idaho MedPlus Plan A

Idaho MedPlus Plan F

Idaho MedPlus Plan K

Idaho MedPlus Plan NServices Medicare

Hospitalization Semi-private room and board, general nursing and miscellaneous services and supplies

First 60 days Covers all but $1,340 Covers $0

Covers $1,340 (your Part A deductible)

Covers 50% of the Part A deductible

Covers $1,340 (your Part A deductible)

Days 61 through 90 Covers all but $335

a day Covers

$335 a day Covers

$335 a day Covers

$335 a day Covers

$335 a day

Days 91 and after, while using 60lifetime reserve days

Covers all but $670

a day Covers

$670 a day Covers

$670 a day Covers

$670 a day Covers

$670 a day

After lifetime reserve Covers 100% of Covers 100% of Covers 100% of Covers 100% of days are used, Covers $0 Medicare eligible Medicare eligible Medicare eligible Medicare eligible additional 365 days charges charges charges charges Beyond the additional 365 days Covers $0 Covers $0 Covers $0 Covers $0 Covers $0

Skilled Nursing Facility CareYou 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

First 20 days Covers all approved amounts

Covers $0 Covers $0 Covers $0 Covers $0

Days 21 through 100 Covers all but $167.50 a day Covers $0 Covers up to

$167.50 a day Covers up to $83.75 a day

Covers up to $167.50 a day

Day 101 and after Covers $0 Covers $0 Covers $0 Covers $0 Covers $0 Blood First 3 pints Covers $0 Covers 100% Covers 100% Covers 50% Covers 100% Additional amounts Covers 100% Covers $0 Covers $0 Covers $0 Covers $0 Hospice CareAvailable as long as you meet Medicare’s requirements, including a doctor’s certification of terminal illness

Covers all but limited copay/

coinsurance for outpatient drugs

and inpatient respite care

Covers 100% Medicare eligible

Part A copays/

coinsurance


Part A copays/

coinsurance


Part A copays/

coinsurance


Part A copays/

coinsurance

6

Medicare (Part B) Medical Services – Per Calendar Year Once you have been billed $183 of Medicare approved amounts for covered services, noted below with an asterisk (*), your Part B deductible will have been met for the calendar year.





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 $183 of Medicare approved amounts* Covers $0 Covers $0

Covers $183 (your Part B deductible)

Covers $0 Covers $0

Remainder of Medicare approved amounts*

Covers 80% Covers 20% Covers 20% Covers 10% Plan pays the balance**

Preventive Benefits for Medicare covered services

Generally 100% or more

of Medicare approved amounts

Covers $0 Covers $0 Covers 100% Covers $0

Part B excess charges (above Medicare approved amounts)

Covers $0 Covers $0

Covers 100% of Medicare

Part B excess charges up to a limiting charge

as determined by Medicare

Covers $0 Covers $0

** Members are responsible for up to $20 copay 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 copay if a hospital admits the insured and the Medicare Part A expense covers the emergency visit.

Blood First 3 pints Covers $0 Covers all costs Covers all costs Covers 50% Covers all costs

Next $183 of Medicare approved amounts* Covers $0 Covers $0


Covers $0 Covers $0

Remainder of Medicare approved amounts*

Covers 80% Covers 20% Covers 20% Covers 10% Covers 20%

Home Health Care Medicare approved services Medically necessary skilled care services and medical supplies

Covers 100% Covers $0 Covers $0 Covers $0 Covers $0

Durable Medical Equipment First $183 of Medicare approved amounts* Covers $0 Covers $0


Covers $0 Covers $0

Remainder of Medicare approved amounts

Covers 80% Covers 20% Covers 20% Covers 10% Covers 20%

Clinical Laboratory Services Tests for diagnostic services Covers 100% Covers $0 Covers $0 Covers $0 Covers $0

7

Additional Services





Foreign Travel Emergency Medically necessary emergency care services beginning during the first 60 days of each trip outside the U.S.

First $250 each calendar year** Covers $0 Covers $0 Covers $0 Covers $0 Covers $0

Remainder of charges** Covers $0 Covers $0

Covers 80% to a lifetime maximum benefit of $50,000

Covers $0

Covers 80% to a lifetime maximum benefit of $50,000

Vision Please note: The vision benefits for some Idaho MedPlus plans exceed the standard Medicare requirement. The benefit for vision care services is for routine eye exams not covered by Medicare.

Covers $0 Covers $0

Covers 100% after $10 copay on exam only at contracting providers, $45

toward exam at non-contracting

providers



providers



providers

**not covered by Medicare

8

How to Contact Blue Cross of Idaho toll-free at 800-365-2345 or visit

one of our district offices

MERIDIAN OFFICE 3000 E. 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 866-841-2583 208-746-0531

POCATELLO OFFICE 275 South 5th Avenue,

Suite 150 Pocatello, Idaho 83206

208-232-6206

TWIN FALLS OFFICE 1503 Blue Lakes Boulevard N.

Twin Falls, Idaho 83301 208-733-7258

9

Important Information to Note Premium Information Blue Cross of Idaho Care Plus can raise your premium only if we raise the premium for all individuals within your Blue Cross of Idaho Care Plus Medicare supplement benefit plan.

Exclusions Except as outlined previously in the Idaho MedPlus policy, all services not eligible for Medicare are excluded.

Disclosures Use this brochure to compare benefits and premiums among policies. The Idaho MedPlus Medicare Supplement programs and its independent producers (agents) are not affiliated with Medicare.

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, if required. Blue Cross of Idaho Care Plus 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 Care Plus 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 Care Plus.

Notice The policy you choose may not fully cover all of your medical costs. This summary only briefly describes Medicare benefits. Consult your local Social Security Administration office or consult “The Medicare & You 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.

10

Application/Enrollment Checklist To enroll in an Idaho MedPlus 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. Remember to include your first month’s premium.

Mail the application and your first month’s premium to Blue Cross of Idaho Care Plus.

11 11

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 Care Plus 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 Idaho MedPlus 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. 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 an Idaho MedPlus policy, you do not need Idaho MedPlus coverage. You can request to have the Idaho MedPlus 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 Idaho MedPlus 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.

_____________________________________ ______________________________________ _________________________

_____________________________________ ______________________________________

Medicare Supplement Application

Applicant Information Your Name (first, initial, last) Date of Birth (mm/dd/yy) Age Height Weight

❑ Male ❑ Female

Physical Address (street or route) City, State, Zip Code County

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

Medicare Supplement plans are offered by Blue Cross of Idaho Care Plus, Inc. When this document says Blue Cross of Idaho Care Plus, it means Blue Cross of Idaho Care Plus, Inc.

Program Information

❑ Idaho MedPlus – Plan A ❑ Idaho MedPlus – Plan F ❑ Idaho MedPlus – Plan K ❑ Idaho MedPlus – 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 Care Plus;

• 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 Number Blue Cross of Idaho No.

• Form No. 16-708 (01-17) © 2016 by Blue Cross of Idaho Care Plus, an independent licensee of the Blue Cross and Blue Shield Association, with services provided by Blue Cross of Idaho 1

Health Statement

22

– FOR AGENT USE ONLY –

List policies you have sold to this applicant that are still in force. (Use extra sheet of paper if needed.)

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

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 needed.)

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

(Please disregard if you are applying during Medicare initial enrollment period, have guarantee issue rights or if you currently have other Blue Cross of Idaho coverage and are applying for Idaho MedPlus 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 past 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 YES NO 1. Cancer, cyst, tumor, or tumorous growth 7. Disease or disorder of the eyes within

(malignant or benign) within past 20 years? ❑ ❑ the past 10 years? ❑ ❑

2. Heart trouble, heart murmur, chest pain, 8. Emphysema, tuberculosis or removal of stroke or any other disorder of the blood or any part of lung within the past 20 years? ❑ ❑ circulatory system within the past 20 years? ❑ ❑ 9. Rheumatoid arthritis or osteoarthritis

3. An ulcer or any disorder or difficulty of within the past 10 years? ❑ ❑ the stomach, liver, intestines or 10. A physical examination, check-up orgall bladder within the past 10 years? ❑ ❑ doctor’s visit within the past six months? ❑ ❑

4. Diabetes, thyroid disorder or any disorder 11. High blood pressure within the past 10 years?of the glands within the past 20 years? ❑ ❑ (If YES, last reading ________________) ❑ ❑

5. Convulsions, loss of consciousness, 12. Has the applicant ever tested positiveor paralysis within the past 10 years? ❑ ❑ for HIV infection within the past 20 years? ❑ ❑

6. Any disorder of the kidneys, bladder, 13. Does the applicant have any illness,or prostate within the past 10 years? ❑ ❑ condition or irregular symptoms not

named above within the past 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 needed. Item No. Medication Name (Dosage) Condition Requiring Medication Still Taking?

_________________________________________________________________ _________________________________________________________________

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) If YES, with which company? ________________________________________________________

(b) In what state? ___________________________________________________________________

(c) What was the termination date of the policy? _____________________________________________

(d) What plan? (A-N) _________________________________________________________________

2. Do you have any other health insurance policies or certificates? ❑ YES ❑ NO

(a) If YES, with which company? ________________________________________________________

(b) 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 Care Plus, 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 idahomedplus.com.

• I understand and agree that the deposit, $ ___________________ (if any), submitted with the Application is not binding upon Blue Cross of Idaho Care Plus 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 ____________________

Other Carrier Information Blue Cross of Idaho Care Plus 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: ______________________________________________________ 3

http://idahomedplus.com

_____________________________________ ______________________________________ _________________________

_____________________________________ ______________________________________

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.)

❑ Are 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 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 Care Plus. 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

Phone Number Blue Cross of Idaho No.

Type of Company Appointment ❑ Personal ❑ Agency (Name) ____________________________________________________________

44

OFFICE USE ONLY

________________________________________________________________________________________

________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

__________________________________________________________________

Notice Regarding Replacement of Medicare Supplement Coverage

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):

❑ 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. 16-708A (01-17)

© 2016 by Blue Cross of Idaho Care Plus, an independent licensee of the Blue Cross and Blue Shield Association, with services provided by Blue Cross of Idaho 5

©2016 by BlueCross of Idaho, an independent licenseeof theBlueCross and BlueShield Association.

ATTENTION: If you speak Arabic, Chinese, French, German, Korean, Japanese, Persian (Farsi), Romanian, Russian, Serbo-Croatian, Spanish, Sudanic Fulfulde, Tagalog, Ukrainian, or Vietnamese, language assistance services, free of charge, are availableto you. Call 1-800-627-1188 (TTY: 1-800-377-1363).

Chinese 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 1-800-627-1188(TTY：1-800-377-1363)。

French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le1-800-627-1188 (ATS : 1-800-377-1363).

German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.Rufnummer: 1-800-627-1188 (TTY: 1-800-377-1363).

Japanese注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-627-1188(TTY: 1-800-377-1363）まで、お電話にてご連絡ください。

Korean주의:한국어를사용하시는경우,언어지원서비스를무료로이용하실수있습니다. 1-800-627-1188(TTY: 1-800-377-1363)번으로전화해주십시오.

Persian-Farsiشما بریا ارن اگی برت تسھیالتینابزوص دینک، می گفتگو فارسی ابزن بھ ار گ توجھ:

ی. بگیرد تماس 1-800-627-1188 (TTY: 1-800-377-1363) با ب. ا دش می مھ فرا

Romanian ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la1-800-627-1188 (TTY: 1-800-377-1363).

Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните1-800-627-1188 (телетайп: 1-800-377-1363).

Serbo-Croation OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite1-800-627-1188 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-800-377-1363).

Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al1-800-627-1188 (TTY: 1-800-377-1363).

Sudanic Fulfulde MAANDO: To a waawi [Adamawa], e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu 1-800-627-1188(TTY: 1-800-377-1363).

Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walangbayad. Tumawag sa 1-800-627-1188 (TTY: 1-800-377-1363).

Ukrainian УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовноїпідтримки. Телефонуйте за номером 1-800-627-1188 (телетайп: 1-800-377-1363).

Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-627-1188(TTY: 1-800-377-1363).

Language Assistance



Arabic(رقم 1-800-627-1188 برقم اتصل بالمجان. لك تتوافر اللغویة المساعدة خدمات فإن اللغة، اذكر تتحدث كنت اذ إ ملظوحة:

. ولابكم:1-800-377-1363 الصم اھتف















Language Assistance




.( ولابكم:1-800-377-1363 الصم اھتف















Language Assistance



















Language Assistance



















Language Assistance








Japanese注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-627-1188TTY: 1-800-377-1363）まで、お電話にてご連絡ください。











Language Assistance









Korean주의:한국어를사용하시는경우,언어지원서비스를무료로이용하실수있습니다. 1-800-627-1188TTY: 1-800-377-1363 번으로전화해주십시오.









Language Assistance



















Language Assistance



















Language Assistance



















Language Assistance



















Language Assistance



















Language Assistance



















Language Assistance



















Language Assistance



















Language Assistance

Nondiscrimination Statement: Care Discrimination is Against the Law Plus

Blue Cross of Idaho complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Blue Cross of Idaho does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Blue Cross of Idaho: • Provides free aids and services to people with disabilities to

communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio,

accessible electronic formats, other formats) • Provides free language services to people whose primary

language is not English, such as: • Qualified interpreters • Information written in other languages

If you need these services, contact Blue Cross of Idaho’s Customer Service Department. Call 18006271188 (TTY: 18003771363), or call the customer service phone number on the back of your card. If you believe that Blue Cross of Idaho has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with Blue Cross of Idaho’s Grievances and Appeals Department at:

Manager, Grievances and Appeals3000 East Pine Avenue, Meridian, Idaho 83642 Telephone: (800) 2744018 ext.3838, Fax: (208) 3317493Email: grievances&[email protected]: 18003771363

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Grievances and Appeals team is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 18003681019, 8005377697 (TTY). Complaint forms are available at http://www.hhs.gov/ ocr/office/file/index.html. Reference: https://federalregister. gov/a/201611458 ATTENTION: If you speak Arabic, Chinese, French, German, Korean, Japanese, Persian (Farsi), Romanian, Russian, SerboCroatian, Spanish, Sudanic Fulfulde, Tagalog, Ukrainian, or Vietnamese, language assistance services, free of charge, are available to you. Call 18884942583 (TTY: 18003771363).

Arabic ( مقبر لصتا .نجاملبا لك فراوتت یةوغللا ةدعساملا تامدخ نفإ ،ةغللا ركذا ثدحتت نتك اذ إ :ةحظولم مقر 1-800-627-1188 .)1- 800-377-1363:مبكالوملصافتاھ

Chinese 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 1-800-627-1188 (TTY：1-800-377-1363)。 French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le1-800-627-1188 (ATS : 1-800-377-1363). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.Rufnummer: 1-800-627-1188 (TTY: 1-800-377-1363). Japanese注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 1-800-627-1188 (TTY: 1-800-377-1363）まで、お電話にてご連絡ください。(

Korean 주의: 한국어를 사용하시는 경우 , 언어 지원 서비스를 무료로 이용하실 수 있습니다 . 1-800-627-1188 ( )(TTY: 1-800-377-1363)번으로 전화해 주십시오. Persian-Farsi

ماش یاربنرایاگ ترب وصز یناب تالھیست،کدین می وگگفت سیرفا نبزا بھ راگ:جھوت1188-627-800-1 با .بادش می مھ ارف (TTY: یریگب سامت (1-800-377-1363 .د

Romanian ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-800-627-1188 (TTY: 1-800-377-1363). Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-627-1188 (телетайп: 1-800-377-1363). Serbo-Croation OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-800-627-1188 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-800-377-1363). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al1-800-627-1188 (TTY: 1-800-377-1363). Sudanic Fulfulde MAANDO: To a waawi [Adamawa], e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu 1-800-627-1188 (TTY: 1-800-377-1363).

Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walangbayad. Tumawag sa 1-800-627-1188 (TTY: 1-800-377-1363). Ukrainian УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-800-627-1188 (телетайп: 1-800-377-1363). Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-627-1188 (TTY: 1-800-377-1363).

© 2016 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association Form No. 3-1187 (10-16)

https://federalregister.gov/a/2016-11458

http://www.hhs.gov/ocr/of�ce/�le/index.html

mailto:grievances&[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

https://federalregister.gov/a/2016-11458

http://www.hhs.gov/ocr/of�ce/�le/index.html


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

On our website www.idahomedplus.com

© 2018 by Blue Cross of Idaho Care Plus Inc., an independent licensee of the Blue Cross and Blue Shield Association, with services provided by Blue Cross of Idaho Form No. 16-707 (10-17)

http://idahomedplus.com

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