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Bridge Plan Bridge Plan

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The Bridge Plan
“Bridging the Gap to Medicare Eligibility”
e Bridge Plan is a major medical insurance plan intended for persons aged 60-95 who are awaiting acceptance
as a participant in the U.S. Medicare System. All permanent residents of the United States are eligible for
Medicare at some point in time. Foreign nationals are usually eligible to purchase Medicare Parts A & B ve
years aer becoming U.S. residents. While awaiting enrollment in Medicare, they may apply for coverage
through e Bridge Plan. e Bridge Plan is set up to be as simple as possible - No co-pay & No coinsurance.
All eligible expenses are applied toward the deductible.
Once the deductible has been fullled, the policy will cover 100% up to the policy maximum.
Part A: Hospitalization
Hospitalization: Covered expenses include semi-private room and board charges, general nursing,
miscellaneous hospital services and supplies, drugs, x-rays, laboratory tests and operating rooms.
Hospice Facilities: Such costs are covered, including medically necessary out-patient treatment. A physician
must certify the need of such care.
Skilled Nursing Facilities: Such costs are covered following a necessary hospital connement of three days or
longer and begins within 30 days following the hospital connement.
Home Healthcare: Skilled care at home is covered if such care is deemed to be medically necessary.
Part B : Physicians and Surgeons
Physicians and Surgeons: e costs of physician and surgeon services are covered on either an in-patient
or out-patient basis.
Additional Benets: Supplies, therapy and ambulance services, along with out-patient x-rays, laboratory tests
and advanced imaging services are covered if prescribed as medically necessary.
The Bridge Plan
Bridge Plan - 01/01/2022© Petersen International Underwriters
Policy Period
e Bridge Plan is a temporary plan and has a maximum policy period of 364 days. At the end of the 364 days,
you may apply for a new term of insurance. Individual state restrictions apply which may restrict policy term
lengths and the ability to reapply for new coverage.
Free Look Period
is plan allows you to cancel coverage and receive a full refund up to 10 days from when the certicate of
insurance was received.
Additional Information
• e insured may be treated by any doctor or at any hospital.
• Benets paid are based on usual, customary and reasonable charges.
• e deductible is on a per policy period basis.
• e plan may include coverage for Part A, Part B or both.
In-Network Coverage
e First Health Network has providers in all 50 states. e network has more than 5,000 hospitals, over 90,000
ancillary facilities, and over 1 million health care professional service locations in the network. To locate a
provider please use the following information:
www.doctorsearchnow.com or 800-226-5116
You may receive diagnosis and treatment of your Sickness or Injury from a Provider within the PPO
Network, at your option. To nd a Provider within the PPO Network please review the information on Your
identication card. By utilizing the PPO network, you may receive discounts and savings for any incurred
eligible expenses. Utilizing the PPO network is not required, and it does not guarantee that benets will be
payable or that the Provider will bill us directly. You have the option to see any provider whether they are in-
network or out-of-network.
Out-of-Network Coverage
We allow the insured to see any provider even if they are outside of the PPO Network. PPO Network discounts
do not apply for treatment received out of network and expenses will be reimbursed up to UCR.
Bridge Plan - 01/01/2022© Petersen International Underwriters
Monthly Premium Rates
Additional Calculations:
• For Part A coverage only = above rates x .60
• For Part B coverage only = above rates x .60
Additional Calculations:
• For Part A coverage only = above rates x .60
• For Part B coverage only = above rates x .60
Age
Platinum Gold Silver Bronze
$1,000,000
Maximum Benefit
$500,000
Maximum Benefit
$250,000
Maximum Benefit
$100,000
Maximum Benefit
$1,000
Deductible
$2,500
Deductible
$5,000
Deductible
$10,000
Deductible
60 $767 $516 $342 $258
61 $771 $533 $361 $274
62 $776 $549 $381 $291
63 $780 $564 $403 $309
64 $783 $581 $422 $326
65 $788 $597 $444 $342
66 $792 $614 $464 $359
67 $796 $629 $483 $377
68 $799 $645 $505 $393
69 $804 $662 $525 $410
70 - $678 $545 $428
71 - $695 $566 $446
72 - $711 $586 $463
73 - $728 $606 $479
74 - $743 $627 $496
75 - $759 $647 $514
76 - $776 $668 $530
77 - $792 $688 $547
78 - $807 $708 $563
79 - $823 $729 $581
80 - - - $711
81 - - - $734
82 - - - $754
83 - - - $775
84 - - - $796
85 - - - $819
86 - - - $840
87 - - - $861
88 - - - $884
89 - - - $905
90+ Contact Our Oce For Options.
Additional Calculations:
• For Part A coverage only = above rates x .60
• For Part B coverage only = above rates x .60
Bridge Plan - 01/01/2022© Petersen International Underwriters
Medicare Restriction #1: Medicare will usually accept people who have been a permanent resident of the United
States for at least ve years. is does not require citizenship or any pre-payment into Social Security prior to
eligibility. e only requirement is that they must pay a monthly premium to have both Part A and Part B.
Solution: e Bridge Plan is available to persons who have become permanent residents of the United States and
who are within the ve year waiting period for Medicare eligibility.
Medicare Restriction #2: Some people may be eligible for Medicare due to age and qualications, but have
failed to enroll. Enrollment is not automatic. Social Security does not remind people to enroll. If a person misses
the enrollment period, that person must wait to enroll at a later date. is process may take as long as 18 months!
Solution: e Bridge Plan will cover that person with benets similar to Medicare until the next enrollment op-
portunity.
Medicare Restriction #3: Some people, for various reasons, have only Part A or Part B. ey may be able to ac-
quire the additional part through Medicare, but at a later date. Solution: e Bridge Plan may be sold with both
Part A and Part B, just Part A, or just Part B.
FAQ’s
Question #1: If I have a claim under the rst policy, will the condition be considered a pre-existing condition
on the renewal? Answer: e condition will be considered a pre-existing condition on any new
term of insurance.
Question #2: If I have a chronic pre-existing condition such as diabetes necessitating regular treatment, will the
policy provide coverage for medical expenses related to diabetes? Answer: Each policy has an
exclusion for pre-existing conditions which has a 12 month look back. Since the condition will
always require medication and regular care, it will fall into the pre-existing condition denition.
Question #3: I had a heart attack ve years ago, will this still be considered a pre-existing condition? Answer:
Due to the cardiac event, underwriters will most likely place a permanent exclusion for the entire
cardiovascular system including heart attack and stroke.
Question #4: How will my premiums be determined on the renewals? Answer: Premiums will adjust every
new term of insurance by age and any other underwriting ratings at that time. Premiums typi
cally follow the chart from the current brochure.
Question #5: Will my prescription medications be covered under this plan? Answer: Prescriptions will be
covered during a hospitalization. Maintenance medication is typically covered by a Medicare
supplement under Medicare Part D and is not covered under the Bridge Plan.
Question #6: Do I need to pay the premium when I apply for the coverage? Answer: No, the premium is not
due until the coverage has been approved by underwriters. If the payment is set up to be
automated on a monthly basis, the payment will be draed the day of the month the coverage
became eective.
Who Needs The Bridge Plan
Bridge Plan - 01/01/2022© Petersen International Underwriters
The Bridge Plan Application Form
To be eligible for the Bridge Plan coverage, you must attest to the following statements:
q I attest that I am not eligible for Medicare or Aordable Care Act (PPACA) compliant insurance.
q I attest that I have tried, but was unable to obtain short-term medical insurance.
Reason why: _________________________________________________________________________
Applicant’s Name:
Date of Birth:
Residence Address:
Email Address:
First ________________________ M.I. ________ Last____________________________
_______ / _______ / ___________ Height: ______ Weight: ___________ Sex:
__________________________________________________________________________
City ________________________ State _________________ Zip Code _______________
____________________________ Telephone (_____) _______ - _________
Producer Number:______________
If “Yes” is answered, please provide full details in the area provided or attach a separate page if needed
1. Do you intend to engage in sports or any other pastimes that expose you to extra personal injury?
2. Have you ever been declined or accepted on special terms for life, accident or illness insurance?
3. Have you ever had any abnormal tests or blood work that have required additional evaluation or
treatment?
4. Has your weight changed in the past year?
5. Have you ever undergone a surgical operation?
6. Have you taken any medicines in the past 12 months?
7. Have you ever been recommended to have any procedure(s), exam(s), treatment(s), and/or test(s)
that have not been completed?
8. Do you need any assistance to perform activities of daily living (feeding, bathing, dressing)?
9. Date and results of last colonoscopy: ___________________________________________
10. Date and results of last pap (female): __________________________________________
11. Date and results of last mammogram (female): __________________________________
12. Date and results of last PSA (male): ___________________________________________
Requested Start Date: _________________ Date you expect to be eligible for Medicare: ____________________
Plan Type: q   Platinum ($1,000,000 Max. & $1,000 Deductible) q    Gold ($500,000 Max. & $2,500 Deductible)
    q   Silver ($250,000 Max. & $5,000 Deductible) q    Bronze ($100,000 Max. & $10,000 Deductible)
Coverage Type: q Bridge Part A & B q Bridge Part A Only q Bridge Part B Only
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
Question # ________
Question # ________
Question # ________
Question # ________
Dates & Details: _________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Primary Care Physician:
a. Name: _________________________________________________________________
b. Address: _________________________________________________________________
c. Date and reason last seen: _________________________________________________________________
d. Results of last visit: _________________________________________________________________
qMale
qFemale
PLEASE INITIAL THE FOLLOWING
I have read or had read to me and understand each of the questions and statements on this entire application and no one has prevented me
from spending as much time as I felt was necessary to understand this application. ___________________
DECLARATION
I declare that the above statements are true and complete. I am in good health and ordinarily enjoy good health. I agree that this proposal shall form the basis of
the contract should the insurance be eected and any misstatements above may be grounds for rescission. I understand that this is a temporary insurance policy
designed to cover the insured person for medical expenses incurred during the policy period and a new period of insurance is only available at the option of the
underwriter and is subject to a new pre-existing condition exclusion. I understand the terms and conditions of this product. I also understand that since this is a
temporary policy it is exempt from the Patient Protection and Aordable Care Act (PPACA) so pre-existing conditions are not covered by this policy.
Proposed Insured__________________________________Signature ________________________________________Date___________________
Please Print
a. Eyes/Ears
b. Gout
c. Skin
d. Hernia
e. Diabetes
f. HIV/AIDS
g. Sleep apnea
h. Gallbladder
i. Concussions
j. Chronic Pain
k. Lymph nodes
l. Cancer/Growth
m. High blood pressure
n. Heart/Chest Pain/Stroke
o. Back/spine/neck
p. roat/yroid/Glands
q. Bones/Bone Density
r. Arthritis/Joints (Hips Knees, Shoulders)
s. Fainting/Dizziness/Unconsciousness
t. Fatigue/Tiredness/Paralysis/Weakness
u. Nervous System/Alzheimer’s/Dementia
v. Mental/Emotional/Psychiatric
w. Respiratory System/Asthma
x. Circulatory system
y. Reproductive system
z. Gastrointestinal System
aa. Urinary system/Prostate
ab. Any other condition not listed above
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
Last Healthcare Provider Seen:
a. Name: _________________________________________________________________
b. Address: _________________________________________________________________
c. Date and reason last seen: _________________________________________________________________
d. Results of last visit: _________________________________________________________________
If “Yes” is answered, please provide full details in the area provided or attach a separate page if needed
13. Have you ever been evaluated or treated for any injury, condition or disorder involving the following:
14. To the best of your knowledge and belief, are you in good health and free from any mental or physical
impairment, except as described in this application? q Yes q No - If No, please provide details: ___________
_________________________________________________________________________________________
_________________________________________________________________________________________
Ques-
tion#
Details of
Conditions/Treatment
Date &
Duration
Details and
Degree of Recovery
Bridge Plan - 01/01/2022© Petersen International Underwriters
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23929 Valencia Boulevard • Second Floor • Valencia, CA 91355
800.345.8816 toll-free • 661-254-0604 fax
www.piu.org • piu@piu.org
Authorization to Release Personal Information
I, the proposed insured, authorize all Healthcare Providers that have been involved in my care, diagnosis
or treatment including, but not limited to Physicians, Medical Practitioners, Hospitals, Clinics, Medically
related facilities, Rehabilitation facilities, Laboratories, Pharmacy, Insurance or Reinsurance Company,
or Consumer Reporting Agency, to disclose my medical records to Petersen International Underwriters, or
its assigned authorized agent/representative including, but not limited to: Secure Image Solutions, for the
purpose of insurance underwriting or claims administration.
For purposes of this authorization, medical records shall include all health information pertaining to any
medical history or physical condition and treatment received including, but not be limited to patient
histories, progress notes, test results, X-ray/laboratory and other reports, psychiatric evaluations, drug
and/or Alcohol Treatment, HIV Tests/Test Results, and any other pertinent medical information.
I understand and agree that Petersen International Underwriters may disclose my medical records and the
information contained in those records to third parties such as insurance companies or insurance
underwriters, attorneys, or to representatives of such third parties (including reinsurers and information
agencies) for the purpose as stated in the above. Additionally, it is understood that disclosure of medical
conditions as they relate to my insurability may be disclosed to persons with a direct insurable interest.
Medical or  nancial information, as it a ects my insurability or any claim, may also be discussed with my
insurance agent or broker. I also understand that when my medical records are disclosed pursuant to this
Authorization, my medical records and the information contained in those records may be subject to
re-disclosure by the recipient and may no longer be protected by Federal Privacy Laws.
I understand that I may revoke this Authorization, except to the extent that any health care provider or
Petersen International Underwriters, has acted in reliance upon this Authorization. My revocation of this
Authorization must be in writing to Petersen International Underwriters.
A copy of this signed Authorization is valid as the original. I have the right to a copy of this Authorization.
 i s Authorization will expire 2 years a er the date that I have signed this Authorization.
Signature of Proposed Insured Date
Date
Signature of Legal Representative
(if other than Proposed Insured)
*If the individual whose information is being disclosed is a minor, a parent or legal guardian must sign.
In Compliance with HIPAA & Financial Privacy Regulation
Proposed Insured Name Date of Birth
Legal Representative* Relationship
Email
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Limitations
• Alzheimer’s disease is limited to a lifetime maximum benet of $25,000.
• Cataract surgery and procedures are limited to a maximum benet of $2,000.
• Cardiac and/or Cancer related conditions are limited to a maximum benet of $25,000.00 the rst 180 days aer inception
of the rst Certicate. Aer 180 days of continuous coverage, benets will be paid as for any other condition.
Conditions
1. e policy is issued on the basis of information given in the application. A copy of the application becomes a part of the
policy of insurance.
2. Material misstatement or concealment of health information made by or on behalf of you may render the insurance null
and void.
3. Notice of claim is to be given at the earliest possible date.
4. Benets shall be paid for all eligible expenses which are necessarily incurred due to an illness manifesting itself or an
accidental bodily injury occurring during the period of insurance.
5. ese benets are available only if there is no other source of funding available through any government insurance or
private programs.
Pre-Existing Conditions
Pre-existing Condition means a condition caused or contributed to by a Sickness or Injury for which medical advice, diagnosis,
care or treatment, including the use of prescription medication, including but not limited to ongoing conditions(s), was
recommended by or received from a licensed health care practitioner, and/or any symptom(s) and/or any condition(s) which
would have caused a reasonably prudent person to seek medical attention during the twelve (12) months immediately preceding
the eective date of the insurance described in this Certicate, whether disclosed or not on your application.
Complications Due To Hypertension Benet
Health complications resulting from Medically-Controlled Hypertension will not be considered a Pre-existing Condition.
Termination of Benets
e insurance described in this Certicate will terminate upon the Expiry Date of this Certicate, or your eligibility for the
United States Medicare System, whichever occurs rst. It is your responsibility to enroll in Medicare when you are rst eligible.
Bridge Plan - 01/01/2022© Petersen International Underwriters
Exclusions
1. Any expense which You are not legally obligated to pay.
2. Services which are not Medically Necessary or are not furnished by and under supervision of a Physician.
3. Expenses for services and supplies for which You are entitled to benets, services or reimbursement through the
Veterans' Administration, Workers' Compensation insurance, any private health plan or from any other source except
Medicaid.
4. Expenses in excess of UCR.
5. Self-inicted injuries while sane or insane.
6. Treatment for alcoholism, drug addiction, allergies, and/or Mental or Nervous Disorders.
7. Rest cures, quarantine or isolation.
8. Cosmetic surgery unless necessitated by an accidental Injury.
9. Dental exams, dental x-rays and general dental care except as a result of an accidental Injury.
10. Eye glasses or eye examinations.
11. Hearing aids or hearing examinations.
12. General or routine examinations.
13. Injuries sustained from participation in Hazardous Sports or Activities.
14. Injuries or Sicknesses due to War or any Act of War whether declared or undeclared.
15. Injuries or Sicknesses due to Terrorism or any Act of Terrorism whether declared or undeclared.
16. Injuries or Sicknesses due to an Act of Terrorism involving the use or release of any nuclear weapon or device or
chemical or biological agent, regardless of any contributory cause(s).
17. Injuries or Sicknesses sustained while committing a criminal or felonious act.
18. Expenses incurred for or resulting from pain which is not supported by medical diagnosis.
19. Outpatient drugs.
20. Any elective surgery, including but not limited to complications of previous elective or cosmetic surgeries.
21. Custodial Care.
22. Expenses for supplies and services incurred outside of United States boundaries.
23. Pre-existing conditions.
24. Racing of any kind, all professional or semi-professional sports, and collegiate, sponsored, or interscholastic athletics.
Important Notice regarding the Patient Protection and Affordable Care Act
is coverage is not required to comply with certain federal market requirements for health
insurance, principally those contained in the Aordable Care Act. Be sure to check your policy
carefully to make sure you are aware of any exclusions or limitations regarding coverage of
preexisting conditions or health benets (such as hospitalization, emergency services, maternity
care, preventive care, prescription drugs, and mental health and substance use disorder services).
Your policy might also have lifetime and/or annual dollar limits on health benets. If this coverage
expires or you lose eligibility for this coverage, you might have to wait until an open enrollment
period to get other health insurance coverage. Also, this coverage is not ‘‘minimum essential
coverage.’’ If you don’t have minimum essential coverage for any month in 2018, you may have
to make a payment when you le your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.
This plan is not compliant with the Aordable Care Act
This is not intended to be a complete outline of coverage. Actual wording may change without notice.
Underwriters reserve the right to modify terms and benets at time of underwriting.
Bridge Plan - 01/01/2022© Petersen International Underwriters
This is not intended to be a complete outline of coverage. Actual wording may change without notice.
Underwriters reserve the right to modify terms and conditions at time of underwriting.
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Completed 17 December 2021

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