(b) In 24–point type: For Medicare supplement policies marketed by direct response:
(insert company’s name) is not connected with Medicare.
(c) For Medicare cost policies as described in s. 600.03 (28p) a. and c., Stats.: (insert company’s name) has contracted with Medicare to provide Medicare benefits. Except for emergency care anywhere or urgently needed care when you are temporarily out of the service area, all services, including all Medicare services, must be provided or authorized by (insert company’s name).
(3) (a) For Medicare supplement policies, provide a brief summary of the major benefits and gaps in Medicare Parts A and B with a parallel description of supplemental benefits, including dollar amounts, as outlined in these charts.
(b) For Medicare cost policies, provide a brief summary of both the basic Medicare benefits in the policy and additional benefits using the basic format as outlined in these charts and modified to reflect accurately the benefits.
(c) If the coverage is provided by a health maintenance organization as defined in s. 609.01 (2), Stats., provide a brief summary of the coverage for emergency care anywhere and urgent care received outside the service area if this care is treated differently than other covered benefits. The following information shall be inserted AFTER the specific plan type outline of coverage that is provided to all insureds. The information shall include the information specific to the plan type.
(4) All limitations and exclusions, including each of the following, must be listed under the caption “LIMITATIONS AND EXCLUSIONS” if benefits are not provided:
(a) Nursing home care costs beyond what is covered by Medicare and the additional 30–day skilled nursing mandated by s. 632.895 (3), Stats. (b) Home health care above the number of visits covered by Medicare and the 365 visits mandated by s. 632.895 (2), Stats. [For Medicare select policies only.] (c) Physician charges above Medicare’s approved charge.
(d) Outpatient prescription drugs.
(e) Most care received outside of U.S.A.
(f) Dental care, dentures, checkups, routine immunizations, cosmetic surgery, routine foot care, examinations for and the cost of eyeglasses or hearing aids, unless eligible under Medicare.
(g) Coverage for emergency care anywhere or for care received outside the service area if this care is treated differently than other covered benefits.
(h) Waiting period for preexisting conditions.
(i) Limitations on the choice of providers or the geographical area served (if applicable for Medicare select policies only).
(j) Usual, customary, and reasonable limitations.
(5) CONSPICUOUS STATEMENTS AS FOLLOWS:
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult “Medicare & You” for more details.
(6) A description of policy provisions respecting renewability or continuation of coverage, including any reservation of rights to change premium.
(7) Information on how to file a claim for services received from non–participating providers because of an emergency within or outside of the service area shall be prominently disclosed.
(8) If there are restrictions on the choice of providers, a list of providers available to insureds shall be included with the outline of coverage.
(9) The definition of grievance as contained in s. Ins 18.01 (4). (10) The premium for the policy and riders, if any, in the following format:
MEDICARE SUPPLEMENT AND MEDICARE SELECT PREMIUM INFORMATION
Annual Premium
$ ( ) BASIC MEDICARE SUPPLEMENT OR MEDICARE SELECT COVERAGE
OPTIONAL BENEFITS FOR MEDICARE SUPPLEMENT OR MEDICARE SELECT POLICY
Each of these riders may be purchased separately.
(Note: Only optional coverages provided by rider shall be listed here.)
$ ( ) 1. 100% of the Medicare Part A hospital deductible
$ ( ) 2. 50% of the Medicare Part A hospital deductible per benefit period with no out-of-pocket maximum
$ ( ) 3. Additional home health care
An aggregate of 365 visits per year including those covered by Medicare
$ ( ) 4. 100% of the Medicare Part B medical coinsurance that is subject to copayment or coinsurance of no more than $20 per office visit and no more than $50 per emergency room visit in addition to the Medicare Part B coinsurance and in addition to out-of-pocket maximums. The emergency room copayment or coinsurance fee shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.
$ ( ) 5. Medicare Part B excess charges
Difference between the Medicare eligible charge and the amount charged by the provider that shall be no greater than the actual charge or the limited charge allowed by Medicare, whichever is less
$ ( ) 6. Foreign travel emergency rider
After a deductible not greater than $250, covers at least 80% of expenses associated with emergency medical care received outside the U.S.A. during the first 60 days of a trip with a lifetime maximum of at least $50,000
__________
$ ( ) TOTAL FOR BASIC POLICY AND SELECTED OPTIONAL BENEFITS
(Note: The soliciting agent shall enter the appropriate premium amounts and the total at the time this outline is given to the applicant. Medicare select policies and the Medicare Supplement 50% and 25% Cost-Sharing plans and Medicare Select 50% and 25% Cost-Sharing plans shall modify the outline to reflect the benefits that are contained in the policy or certificate and the optional or included riders.)
IN ADDITION TO THIS OUTLINE OF COVERAGE, [ISSUER] WILL SEND AN ANNUAL NOTICE TO YOU 30 DAYS PRIOR TO THE EFFECTIVE DATE OF MEDICARE CHANGES THAT WILL DESCRIBE THESE CHANGES AND THE CHANGES IN YOUR MEDICARE SUPPLEMENT COVERAGE.
(11) If premiums for each rating classification are not listed in the outline of coverage under subsection (10), then the issuer shall give a separate schedule of premiums for each rating classification with the outline of coverage.
(12) Include a summary of or reference to the coverage required by applicable statutes.
(13) The term “certificate” should be substituted for the word “policy” throughout the outline of coverage where appropriate.
Ins 3.39 APPENDIX 3m
OUTLINE OF COVERAGE
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT INSURANCE
(The designation and caption required by sub. (4m) (b) 4.)
MEDICARE SUPPLEMENT PART A – HOSPITAL SERVICES – PER BENEFIT PERIOD
Note: Issuers should include only the wording that applies to their policy’s “This Policy Pays” column and complete the “You Pay” column.
A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Note: This includes the Medicare deductibles for Part A and Part B, but does not include [the plan’s separate riders deductible.]
Note: Add the following text in a bold or contrasting color if the plan is a Medicare supplement insurance - high deductible plan as defined at sub. (5m) (k): This high deductible plan offers benefits after one has paid a calendar year [$2000] deductible. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
* These are optional riders. You purchased this benefit if the box is checked and you paid the premium.
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the issuer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy’s “Core Benefits.”
*** This optional rider may reduce your premium when you pay 50% of Medicare Part A deductible.
MEDICARE SUPPLEMENT POLICIES – PART B BENEFITS
Note: Issuers should include only the wording that applies to their policy’s “This Policy Pays” column and complete the “You Pay” column.
Note: Add the following text in a bold or contrasting color if the plan is a Medicare supplement insurance-high deductible plan as defined at sub. (5m) (k): This high deductible plan offers benefits after one has paid a calendar year [$2000] deductible. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
* Once you have been billed [$ ] of Medicare approved amounts for covered services (that are noted with an asterisk), your Medicare Part B deductible will have been met for the calendar year.
** These are optional riders. You purchased this benefit if the box is checked and you paid the premium.
*** This is an optional rider that may decrease your premium when you pay copayments for medical and emergency room visits.
INS 3.39 APPENDIX 3t
OUTLINE OF COVERAGE
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT INSURANCE
(The designation and caption required by sub. (4t) (b) 4.)
MEDICARE SUPPLEMENT PART A – HOSPITAL SERVICES – PER BENEFIT PERIOD
Note: Issuers should include only the wording that applies to their policy’s “This Policy Pays” column and complete the “You Pay” column.
A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Note: This includes the Medicare deductibles for Part A and Part B but does not include [the plan’s separate riders deductible.]
Note: Add the following text in a bold or contrasting color if the plan is a Medicare supplement insurance - high deductible plan as described at sub. (5t) (k): This high deductible plan offers benefits after one has paid a calendar year [$2000] deductible. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the plan’s separate foreign travel emergency deductible.
* These are optional riders. You purchased this benefit if the box is checked and you paid the premium.
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the issuer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy’s “Core Benefits.”
*** This optional rider may reduce your premium when you pay 50% of Medicare Part A deductible.
MEDICARE SUPPLEMENT POLICIES – PART B BENEFITS
Note: Issuers should include only the wording that applies to their policy’s “This Policy Pays” column and complete the “You Pay” column.
Note: Add the following text in a bold or contrasting color if the plan is a Medicare supplement insurance-high deductible plan as described at sub. (5t) (k): This high deductible plan offers benefits after one has paid a calendar year [$2000] deductible. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the plan’s separate foreign travel emergency deductible.
* Once you have been billed [$ ] of Medicare approved amounts for covered services (that are noted with an asterisk), your Medicare Part B deductible will have been met for the calendar year.
** These are optional riders. You purchased this benefit if the box is checked and you paid the premium.
