Health plans
for every body
Supplemental coverage
for Medicare members
Medicare
modahealth.com/medicare
Available April 1 through Dec. 31, 2015
Hello. Welcome to Moda Health, the place
you go when you want more than a health
plan — because you know good health is about
so much more than just the plan details.
At Moda Health, we have a long tradition of
flexibility and responsive service. In that spirit,
Moda Health SeniorSelect offers the choice and
service you deserve in Medicare Supplement plans.
Each plan is affordable, easy to understand and
administered by experienced professionals.
In addition, we allow you to choose any dentist
or Medicare-approved physician throughout the
country. By selecting a Moda Health SeniorSelect
plan, you can feel secure that where Medicare
coverage ends, your plan coverage begins.
3
Benefit information
Medicare supplemental coverage
Medicare Supplement insurance can be sold in only 10 standard plans.
The chart on the next page shows the benefits included in each plan.
Every company must make Plan A available. Some plans may not be
available in your state. We offer standardized Medicare Supplement
Plans A, F and N. We also offer Plan F with a $2,180 deductible option.
Basic benefits
All Moda Health SeniorSelect plans
offer basic benefits that help pay
for Medicare-eligible hospital
and physician expenses. These
benefits include the following.
Hospitalization
> Your Medicare Part A coinsurance
for hospital care, plus coverage
for 365 additional days after
Medicare benefits end
Medical expenses
> For plans A and F, coverage for the
20 percent coinsurance amount
(35 percent for mental health
services) for part B services after
the annual deductible is met
> For plan N, coverage for the 20
percent coinsurance amount will
be the lesser of $20 or the Part B
coinsurance for office visits, and
$50 or coinsurance for ER visits
Blood
> The first three pints of
blood each year
Hospice
> Your Medicare Part A coinsurance
4
Additional benefits
for plans F and N
The following benefits are specific to
Moda Health SeniorSelect plans F and
N. These additional benefits include:
> After a $250 calendar year
deductible, plans F and N pay
80 percent of eligible expenses
for foreign travel emergency
care beginning during the first
60 days of your trip, up to a
lifetime maximum of $50,000
> No Part A deductible
> Skilled nursing facility coinsurance
for Medicare-approved
stays of 100 days or less
Additional plan F benefits
The following benefits are specific
to Moda Health SeniorSelect plan F.
These additional benefits include:
> No Part B deductible
> Plan F pays the excess
charges above Medicareapproved amounts for Part
B covered services
Moda Health offers plans A, F and N
Plan options
A
B
C
D
Basic benefits
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Skilled nursing
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Part A deductible
Part B deductible
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Part B excess (100%)
Foreign travel
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1 Plan F also has an option called a high deductible plan F. This high deductible plan offers
the same benefits as plan F after one has paid a calendar-year $2,180 deductible. Benefits
from high deductible plan F will not begin until out-of-pocket expenses exceed $2,180. Outof-pocket expenses for this deductible are expenses that would ordinarily be paid by the
policy. These expenses include the Medicare deductibles for Parts A and B, but
do not include the separate foreign travel emergency deductible.
2 Plan K reimburses these expenses at 50 percent, up to an out-of-pocket
maximum of $4,940 in a calendar year. Plan L reimburses these expenses at
75 percent, up to an out-of-pocket maximum of $2,470 in a calendar year. Once the
out-of-pocket maximum is met, covered expenses are reimbursed at 100 percent.
3 Plan N requires copayment of up to $20 for office visits and $50 for emergency room visits.
5
When it comes
to better healthcare,
we think we can
do more together.
6
Medicare Supplement plans
Outline of coverage
Before you pick out your Medicare Supplement plan, take some time
to read through this basic information. It tells you about how you can
start, stop or change your policy. We’re here if you have questions.
Annual open enrollment
Policy replacement
Each year, starting on your birthday
and until 30 days after, you may cancel
your current Medicare Supplement
policy and select another guaranteed
issue Medicare Supplement policy that
has the same or lesser benefits. To
find other policies that qualify, contact
Moda Health Customer Service.
If you are replacing another health
insurance policy, do NOT cancel it until
you actually have received your new
policy and are sure you want to keep it.
Disclosures
Use this outline to compare benefits
and premiums among policies.
Read your policy very carefully
This brochure 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 Moda Health.
Right to return policy
If you find that you are not satisfied
with your policy, you may return it to
Moda Health, Attention: Individual
Eligibility Department, 601 S.W.
Second Ave., Portland, OR 97204. If
you send back the policy within 30
days of receiving it, we will treat the
policy as if it had never been issued
and return all of your premium.
Complete answers
are very important
Review the SeniorSelect application
carefully before you sign it. Be
certain that all information has
been properly recorded.
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. Moda Health may
cancel your policy and refuse to pay
any claims if you leave out or falsify
important medical information.
Notice
This policy may not fully cover all of
your medical costs. Neither Moda
Health nor its agents are connected
with Medicare. This outline of coverage
does not give all of the details about
Medicare coverage. For a complete
description of Medicare benefits,
contact your local Social Security office,
or refer to the "Medicare & You" 2015
handbook online at medicare.gov
or by calling 800-633-4227.
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Plan A
Medicare Part A
Medicare pays
Plan pays
You pay
Hospitalization1
Semi-private room and board, general nursing and miscellaneous services and supplies
All but $1,260
$0
$1,260
(Part A deductible)
All but $315
per day
$315 per day
$0
All but $630
per day
$630 per day
$0
Additional 365 days
$0
100% of Medicareeligible expenses
$02
Beyond the
additional 365 days
$0
$0
All costs
First 60 days
61st through 90th day
91st day and after:
While using 60
lifetime reserve days
Once lifetime
reserve days are used:
Skilled nursing facility care1
You must meet Medicare’s requirements, including hospitalization for at least three days
followed by entrance to a Medicare-approved facility within 30 days
All approved
First 20 days
$0
$0
amounts
All but $157.50
Up to $157.50
21st through 100th day
$0
per day
per day
101st day and after
$0
$0
All costs
$0
3 pints
$0
100%
$0
$0
All but very limited
coinsurance for
outpatient drugs
and inpatient
respite care
Medicare
coinsurance
or copay
$0
Blood
First three pints
Additional amounts
Hospice care
Available as long as your
doctor certifies you are terminally ill and you elect
to receive these services
8
1 A benefit period begins on the first day you receive services as a patient 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.
2 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 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.
Plan A (continued)
Medicare Part B
Medicare pays
Plan pays
You pay
Medical expenses
In or out of the hospital patient treatment, such as physician’s services, inpatient and
outpatient medical and surgical services and supplies, physical and speech therapy,
diagnostic tests and durable medical equipment
First $147 of Medicareapproved amounts1
Remainder of Medicareapproved amounts
Part B excess charges
(above Medicare-approved
amounts)
$0
$0
$147
(Part B deductible)
Generally 80%
Generally 20%
$0
$0
$0
All costs
First three pints
$0
All costs
$0
Next $147 of Medicareapproved amounts1
$0
$0
$147
(Part B deductible)
Remainder of Medicareapproved amounts
80%
20%
$0
100%
$0
$0
Medicare pays
Plan pays
You pay
100%
$0
$0
$0
$0
$147
(Part B deductible)
80%
20%
$0
Blood
Clinical laboratory services – blood tests
For diagnostic services
Medicare Parts A and B
Home healthcare Medicare-approved services
Medically necessary skilledcare services and medical
supplies
Durable medical equipment:
First $147 of Medicareapproved amounts1
Remainder of Medicareapproved amounts
1 Once you have been billed $147 for Medicare-approved amounts of covered services that
are noted with a 1, your Part B deductible will have been met for the calendar year.
9
Plan F — or high deductible plan F
Medicare Part A
Medicare pays
After you pay
In addition to
$2,180 deductible, 2 $2,180 deductible, 2
plan pays
you pay
Hospitalization1
Semi-private room and board, general nursing and miscellaneous services and supplies
$1,260
First 60 days
All but $1,260
$0
(Part A deductible)
All but $315
61st through 90th day
$315 per day
$0
per day
91st day and after:
While using 60
All but $630
$630 per day
$0
lifetime reserve days
per day
Once lifetime
reserve days are used:
100% of MedicareAdditional 365 days
$0
$0 3
eligible expenses
Beyond the
$0
$0
All costs
additional 365 days
Skilled nursing facility care1
You must meet Medicare’s requirements, including hospitalization for at least three days
followed by entrance to a Medicare-approved facility within 30 days
All approved
First 20 days
$0
$0
amounts
All but $157.50
Up to $157.50
21st through 100th day
$0
per day
per day
101st day and after
$0
$0
All costs
Blood
First three pints
Additional amounts
$0
100%
3 pints
$0
$0
$0
1 A benefit period begins on the first day you receive services 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.
2 This high deductible plan offers the same benefits as Plan F after a $2,180 deductible per
calendar year. Benefits from the high deductible Plan F will not begin until out-of-pocket
expenses are $2,180. Out-of-pocket expenses for this deductible are expenses that would
ordinarily be paid by the policy. This includes the Medicare deductibles for Parts A and
B, but does not include the plan’s separate foreign travel emergency deductible.
3 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 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.
10
Plan F — or high deductible plan F (continued)
Medicare Part A
Medicare pays
After you pay
In addition to
$2,180 deductible, 2 $2,180 deductible, 2
plan pays
you pay
Hospice care
Available as long as your
doctor certifies you are terminally ill and you elect
to receive these services
All but very
limited coinsurance
for outpatient drugs
and inpatient
respite care
Medicare
coinsurance
or copay
$0
Medicare Part B
Medicare pays
After you pay
In addition to
$2,180 deductible, 2 $2,180 deductible, 2
plan pays
you pay
Medical expenses
In or out of the hospital and outpatient hospital treatment, such as physician’s services,
inpatient and outpatient medical and surgical services and supplies, physical and speech
therapy, diagnostic tests and durable medical equipment
First $147 of Medicare$147
$0
$0
1
approved amounts
(Part B deductible)
Remainder of Medicare-apGenerally 80%
20%
$0
proved amounts
Part B excess charges
(above Medicare-approved
$0
100%
$0
amounts)
Blood
First three pints
Next $147 of Medicareapproved amounts1
Remainder of Medicare-approved amounts
$0
$0
80%
All costs
$147
(Part B deductible)
$0
$0
20%
$0
$0
$0
Clinical laboratory services – blood tests
For diagnostic services
100%
1 Once you have been billed $147 for Medicare-approved amounts of covered services that
are noted with a 1, your Part B deductible will have been met for the calendar year.
2T
his high deductible plan offers the same benefits as Plan F after a $2,180 deductible per
calendar year. Benefits from the high deductible Plan F will not begin until out-of-pocket
expenses are $2,180. Out-of-pocket expenses for this deductible are expenses that would
ordinarily be paid by the policy. This includes the Medicare deductibles for Parts A and
B, but does not include the plan’s separate foreign travel emergency deductible.
11
Plan F — or high deductible plan F (continued)
Medicare Parts A and B
Medicare pays
After you pay
In addition to
$2,180 deductible, 2 $2,180 deductible, 2
plan pays
you pay
Home healthcare Medicare-approved services
Medically necessary skilledcare services and medical
supplies
Durable medical equipment:
First $147 of Medicare-approved amounts1
Remainder of Medicareapproved amounts
100%
$0
$0
$0
$147
(Part B deductible)
$0
80%
20%
$0
Other benefits —
­ not covered by Medicare
Medicare pays
After you pay
In addition to
$2,180 deductible, 2 $2,180 deductible, 2
plan pays
you pay
Foreign travel
Medically necessary emergency care services beginning during the first 60 days
of each trip outside the United States­
First $250 each
$0
$0
$250
calendar year
20% and amounts
80% up to a lifetime
over $50,000
Remainder of charges
$0
maximum benefit
lifetime maximum
of $50,000
1 Once you have been billed $147 for Medicare-approved amounts of covered services that
are noted with a 1, your Part B deductible will have been met for the calendar year.
2T
his high deductible plan offers the same benefits as Plan F after a $2,180 deductible per
calendar year. Benefits from the high deductible Plan F will not begin until out-of-pocket
expenses are $2,180. Out-of-pocket expenses for this deductible are expenses that would
ordinarily be paid by the policy. This includes the Medicare deductibles for Parts A and
B, but does not include the plan’s separate foreign travel emergency deductible.
12
Plan N
Medicare Part A
Medicare pays
Plan pays
You pay
Hospitalization1
Semi-private room and board, general nursing and miscellaneous services and supplies
$1,260
First 60 days
All but $1,260
$0
(Part A deductible)
All but $315
61st through 90th day
$315 per day
$0
per day
91st day and after:
While using 60
All but $630
$630 per day
$0
lifetime reserve days
per day
Once lifetime
reserve days are used:
100% of MedicareAdditional 365 days
$0
$02
eligible expenses
Beyond the
$0
$0
All costs
additional 365 days
Skilled nursing facility care1
You must meet Medicare’s requirements, including hospitalization for at least three
days followed by entrance to a Medicare-approved facility within 30 days
All approved
First 20 days
$0
$0
amounts
All but $157.50
Up to $157.50
21st through 100th day
$0
per day
per day
101st day and after
$0
$0
All costs
Blood
First three pints
Additional amounts
$0
100%
3 pints
$0
$0
$0
Hospice care
Available as long as your
doctor certifies you are
terminally ill and you elect
to receive these services
All but very limited
copayment or
Medicare copaycoinsurance for
ment or coinsurance
outpatient drugs
and inpatient respite
care
$0
1 A benefit period begins on the first day you receive services 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.
2 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 up to an additional 365 days as provided in the plan’s "core benefits." During
this time, the hospital is prohibited from billing you for the balance based on any
difference between its billed charges and the amount Medicare would have paid.
13
Plan N (continued)
Medicare Part B
Medicare pays
Plan pays
You pay
Medical expenses
In or out of the hospital and outpatient hospital treatment, such as physician’s services,
inpatient and outpatient medical and surgical services and supplies, physical and speech
therapy, diagnostic tests and durable medical equipment
First $147 of Medicare-ap$147
$0
$0
proved amounts1
(Part B deductible)
Balance, other than
up to $20 per office Up to $20 per office
visit and up to $50
visit and up to $50
per emergency room
per emergency
visit. The copayment
room visit. The
of up to $50
copayment of up
is waived if the
to $50 is waived
Remainder of MedicareGenerally 80%
member is admitted
if the member is
approved amounts
to any hospital and
admitted to any
the emergency visit
hospital and the
is covered as a
emergency visit is
Medicare Part
covered as a
A expense.
Medicare Part
A expense.
Part B excess charges
(above Medicare-approved
$0
$0
All costs
amounts)
Blood
First three pints
Next $147 of Medicareapproved amounts1
Remainder of Medicareapproved amounts
$0
All costs
$0
$147
(Part B deductible)
$0
$0
80%
20%
$0
$0
$0
Clinical laboratory services – blood tests
For diagnostic services
100%
1 Once you have been billed $147 for Medicare-approved amounts of covered services that
are noted with a 1, your Part B deductible will have been met for the calendar year.
14
Plan N (continued)
Medicare Parts A and B
Medicare pays
Plan pays
You pay
100%
$0
$0
$0
$0
$147
(Part B deductible)
80%
20%
$0
Plan pays
You pay
Home healthcare Medicare-approved services
Medically necessary
skilled-care services
and medical supplies
Durable medical equipment:
First $147 of Medicareapproved amounts1
Remainder of Medicareapproved amounts
Other benefits —
­ not covered by Medicare
Medicare pays
Foreign travel
Medically necessary emergency care services beginning during the first 60 days
of each trip outside the United States­
First $250 each
$0
$0
$250
calendar year
20% and amounts
80% up to a lifetime
over $50,000
Remainder of charges
$0
maximum benefit
lifetime maximum
of $50,000
1 Once you have been billed $147 for Medicare-approved amounts of covered services that
are noted with a 1, your Part B deductible will have been met for the calendar year.
15
Rates
What supplement plans cost
Take a look at our Medicare Supplement monthly premiums
below. These rates are effective through Mar. 31, 2016.
Female Non-Tobacco/Preferred
Age
Medical plans
Plan A
ModaMSA 1-1-2015
Plan F
ModaMSF 1-1-2015
Plan F with $2,180
deductible
65 – 691
70 – 74
75 – 79
80 – 84
85+
$90
$105
$116
$128
$130
$150
$175
$193
$212
$216
$33
$38
$42
$46
$47
$109
$126
$139
$153
$155
ModaMSHDF 1-1-2015
Plan N
ModaMSN 1-1-2015
1 The 65- to 69-year-old rate applies to persons on Medicare
by reason of disability who are under age 65.
Male Non-Tobacco/Preferred
Age
Medical plans
Plan A
ModaMSA 1-1-2015
Plan F
ModaMSF 1-1-2015
Plan F with $2,180
deductible
65 – 691
70 – 74
75 – 79
80 – 84
85+
$95
$113
$136
$147
$159
$157
$188
$225
$243
$265
$35
$41
$49
$53
$58
$114
$136
$163
$176
$191
ModaMSHDF 1-1-2015
Plan N
ModaMSN 1-1-2015
1 The 65- to 69-year-old rate applies to persons on Medicare
by reason of disability who are under age 65.
16
Female Tobacco/Non-Preferred
Age
Medical plans
Plan A
ModaMSA 1-1-2015
Plan F
ModaMSF 1-1-2015
Plan F with $2,180
deductible
65 – 691
70 – 74
75 – 79
80 – 84
85+
$104
$121
$133
$147
$150
$173
$201
$222
$244
$248
$38
$44
$48
$53
$54
$125
$145
$160
$176
$178
ModaMSHDF 1-1-2015
Plan N
ModaMSN 1-1-2015
1 The 65- to 69-year-old rate applies to persons on Medicare
by reason of disability who are under age 65.
Male Tobacco/Non-Preferred
Age
Medical plans
Plan A
ModaMSA 1-1-2015
Plan F
ModaMSF 1-1-2015
Plan F with $2,180
deductible
65 – 691
70 – 74
75 – 79
80 – 84
85+
$109
$130
$156
$169
$183
$181
$216
$259
$279
$305
$40
$47
$56
$61
$67
$131
$156
$187
$202
$220
ModaMSHDF 1-1-2015
Plan N
ModaMSN 1-1-2015
1 The 65- to 69-year-old rate applies to persons on Medicare
by reason of disability who are under age 65.
17
FAQs
Answers to your questions
Am I eligible?
Is there a waiting period?
You may apply for coverage if you live
in Oregon and are enrolled in Medicare
Part B. This includes individuals who
may be under age 65 and are enrolled
in Medicare by reason of disability.
If you transfer directly to a Moda Health
SeniorSelect plan from a Medicare HMO,
a Medicare supplemental policy or other
coverage, we will credit day-for-day
the amount of time you were enrolled
under one of those plans. If you were
enrolled for six or more months, you will
not have a six-month waiting period.
When does coverage begin?
If you apply during an open enrollment
period (within six months of becoming
eligible for Part B), your coverage will
start the first of the month following
the date we receive your application.
If you do not apply during an open
enrollment period, we will notify you
of the date your coverage will begin
after your application is approved.
18
Will my premium change?
The required premium for the plan
is subject to change. Any change
in premiums will occur once in a
12-month period, and will apply to all
subscribers insured under the plan
who reside in the state of Oregon.
Special services and features
We make healthcare easy
At Moda Health, we design our benefits and member
services with you in mind. Here are just a few of the ways
we make managing your plan easier for you.
Electronic claims filing
Benefit and information updates
Electronic claims filing is now available
at no extra cost. Medicare Part B claims
will be forwarded directly to Moda
Health SeniorSelect after Medicare
pays its share. You will know that a bill
was submitted directly to Moda Health
SeniorSelect because it will have the
following statement printed on the
bottom: "This claim has been forwarded
to your secondary Medicare payor."
Your Moda Health SeniorSelect policy
will automatically coordinate with
changes in Medicare each year. We’ll
keep you informed about any changes.
Moda Health SeniorSelect will send
you an Explanation of Benefits
indicating the amount paid and
payment, if you are being reimbursed.
If you’re not completely satisfied with
your Moda Health SeniorSelect policy,
return it to us within 30 days and receive
a full refund of any premiums paid.
Guaranteed renewability
We will never cancel your policy because
of your age or claims experience.
30-day free trial
No claim forms
If you have a claim, just mail a
copy of the Medicare Summary
Notice (MSN) form you receive from
Medicare to us. We’ll do the rest.
19
Questions?
We’re here to help. Call us at 877-299-9062.
TTY users, please call 711.
www.modahealth.com/medicare
Health plans in Oregon provided by Moda Health Plan, Inc.
9252654 (2/15)