InterM
SM
AN INTERIM MEDICAL PLAN FOR OREGON RESIDENTS
An Independent Licensee of the Blue Cross and Blue Shield Association
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Insecurity can have many faces. A parent between jobs. A student on his own. A graduate trying to land a job. An employee who’s ineligible for benefits. A person like you.
InterMSM: An Interim Medical Plan
Face it. Things don’t feel secure without a medical plan. Even a temporary loss of coverage can disrupt your peace of mind. Well, relax. Here’s a plan to help you live more and worry less.
InterM SM InterM SM is an interim medical plan that provides temporary coverage for injuries and sudden illnesses. This plan can protect you and your family for 30 to 185 days until a more permanent type of coverage becomes available. Your good health is a priceless asset. The responsible thing to do is protect it. With InterM, there’s no need to go a single day without coverage. WHO NEEDS IT?
InterM is ideal for people who are: • Between jobs, laid off or on strike • Waiting to be covered under a group plan • Waiting for issuance of an individual policy • Recent graduates • Starting a business • Taking time off from school WHO’S ELIGIBLE FOR IT?
You are eligible if you and any family members meet the following requirements: • Under age 65 for the term of the policy • Unmarried dependent children must be under age 23 and dependent upon you for support. Generally, the child must live with you; the exception is when you are legally required to pay for part of the child’s support and there is no court order requiring that someone else provide insurance for the child. • Not eligible for Medicare • Not pregnant • Not covered under any other hospital or medical plan
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Your good health is a priceless asset The responsible thing to do is protect it. With InterMSM there’s no need to go a single day without coverage.
InterMSM: An Interim Medical Plan
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Application InterM SM An Interim Medical Insurance Policy Non-renewable Regence Life and Health Insurance Company 100 Southwest Market St. P.O. Box 1271, MS E-3A Portland, OR 97207-1271 (503) 225-6918 (800) 794-5390 Ext. 6918
NOTE: Coverage begins at 12:01 a.m. on the later of the day after the postmark date stamped on the application envelope or the date you request. Coverage will take effect only upon receipt of full premium.
MISSING INFORMATION MAY CAUSE YOUR EFFECTIVE DATE TO BE DELAYED. INSURED’S NAME (PRINT LAST, FIRST, MIDDLE)
SOCIAL SECURITY NUMBER
STREET ADDRESS
REQUESTED EFFECTIVE DATE
TELEPHONE NUMBER
CITY, STATE, ZIP CODE
INSURED’S INSURED’S BIRTHDATE SEX
SPOUSE’S NAME – IF TO BE INSURED
SPOUSE’S SOCIAL SECURITY NUMBER
SPOUSE’S BIRTHDATE
DEPENDENT CHILDREN MUST BE UNDER 23 YEARS OF AGE AND DEPENDENT ON YOU FOR SUPPORT. CHILD’S FULL NAME – IF TO BE INSURED
SEX
BIRTHDATE
SEX
BIRTHDATE
(1)
FULL NAME
SEX
BIRTHDATE
SEX
BIRTHDATE
(3)
(2)
(4)
DEDUCTIBLE AMOUNT/FAMILY DEDUCTIBLE $250/$750
$500/$1,500
POLICY TERM (30 – 185 DAYS)
$1,000/$3,000
RATE OF PAYMENT AFTER DEDUCTIBLE
NO. OF DAYS _______________
$2,500/$7,500
80% to $5,000
PREMIUM APPLICATION FEE TOTAL
50% to $5,000
1. Are you, or any person to be insured, age 65 or older?
YES
NO If YES, this policy cannot be issued.
2. Are you, or any person to be insured, eligible for Medicare?
YES
NO If YES, this policy cannot be issued.
3. Do you, or any person to be insured, now have any hospital, major medical, group health or medical insurance coverage that will not terminate prior to the beginning of this policy?
YES
NO If YES, this policy cannot be issued.
4. Are you, or any family member, now pregnant?
YES
$ ___________ $ ___________ 20.00 $ ___________
NO If YES, this policy cannot be issued.
Please be sure to complete the following page.
RLH 175 04/04
Continued
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$1,000 Deductible
$1,000 Deductible
AGE
SINGLE
TWO-PARTY
FAMILY
SINGLE
TWO-PARTY
FAMILY
Under 20 20 – 24 25 – 29 30 – 34 35 – 39 40 – 44 45 – 49 50 – 54 55 – 59 60 – 64
$1 .10 $1 .30 $1 .30 $1 .50 $1 .70 $2.00 $2.60 $3.30 $4.10 $5.50
$2.20 $2.60 $2.60 $3.00 $3.40 $4.00 $5.20 $6.60 $8.20 $11 .00
$3.50 $3.80 $3.80 $4.20 $4.60 $5.20 $6.40 $7.80 $9.40 $12.20
$0.90 $1 .10 $1 .10 $1 .20 $1 .40 $1 .70 $2.20 $2.70 $3.40 $4.60
$1 .80 $2.20 $2.20 $2.40 $2.80 $3.40 $4.40 $5.40 $6.80 $9.20
$2.90 $3.10 $3.10 $3.50 $3.80 $4.40 $5.30 $6.50 $7.90 $10.10
$2,500 Deductible
$2,500 Deductible
AGE
SINGLE
TWO-PARTY
FAMILY
SINGLE
TWO-PARTY
FAMILY
Under 20 20 – 24 25 – 29 30 – 34 35 – 39 40 – 44 45 – 49 50 – 54 55 – 59 60 – 64
$0.90 $0.90 $0.90 $1 .00 $1 .30 $1 .60 $1 .90 $2.50 $3.20 $4.00
$1 .80 $1 .80 $1 .80 $2.00 $2.60 $3.20 $3.80 $5.00 $6.40 $8.00
$2.70 $2.70 $2.70 $2.90 $3.30 $4.10 $4.60 $5.80 $7.20 $8.90
$0.70 $0.70 $0.80 $0.80 $1 .00 $1 .30 $1 .50 $2.00 $2.60 $3.30
$1 .40 $1 .40 $1 .60 $1 .60 $2.00 $2.60 $3.00 $4.00 $5.20 $6.60
$2.10 $2.20 $2.20 $2.40 $2.80 $3.40 $3.80 $4.80 $5.90 $7.30
Have a question? Your insurance representative is well qualified to provide the answer you need in plain English. Feel free to call Regence Life and Health, too. We’re here to serve you today, tomorrow, and for life. SIMPLY GIVE US A CALL.
Today. Tomorrow. For Life.SM 1 800 794-5390 100 SOUTHWEST MARKET STREET P.O. BOX 1271 MS E3A PORTLAND, OREGON 97207-1271
www.regencelife.com This brochure is designed to give you a very brief description of the important features of the policy. This is not the insurance contract and only the actual policy provisions will govern. Please refer to the policy for a detailed description of the rights and obligations of both you and Regence Life and Health Insurance Company.
LIT 6138/2500/804