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 duties of both you and your insurance company.
RIGHT TO RETURN POLICY
If you find that you are not satisfied with your policy, you may return it to (insert issuer’s address). 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 your payments directly to you.
POLICY REPLACEMENT
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.
NOTICE
This policy may not fully cover all of your medical costs.
(1) The outline of coverage for a Medicare cost policy as described in s. 600.03 (28p) a. and c., Stats., shall contain the following language: Medicare cost policy: This policy provides basic Medicare hospital and physician benefits. It also includes benefits beyond those provided by Medicare. This policy is a replacement for Medicare and is subject to certain limitations in choice of providers and area of service. The policy does not provide benefits for custodial care such as help in walking, getting in and out of bed, eating, dressing, bathing, and taking medicine. (2) (a) In 24–point type: For Medicare supplement policies marketed by intermediaries:
Neither (insert company’s name) nor its agents are connected with Medicare.
(b) In 24–point type: For Medicare supplement and Medicare select 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, as described in s. 600.03 (28p) a. and c., Stats., 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 accurately reflect 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. (4) If the plan is a Medicare Supplement High Deductible Plan as described in sub. (5) (n) or (o), add the following text in a bold or contrasting color: You will pay [half (for plans described in sub. (5) (n))] [one quarter (for plans described in sub. (5) (o))] of the cost-sharing of some covered services until you reach the annual out-of-pocket maximum of [$4,000 (for plans described in sub. (5) (n))] [$2,000 (for plan described in sub. (5) (o))] each calendar year. The amounts you must pay are noted in the chart below. Once you reach the annual limit, the plan pays for 100% for the items or services noted in the chart.
The following information shall be inserted AFTER the specific plan type, Medicare supplement, Medicare supplement cost-sharing, Medicare cost, or Medicare select outline of coverage that is provided to all insureds. The information shall include the information specific to the plan type.
(5) 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 pre–existing 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.
(6) 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.
(7) A description of policy provisions respecting renewability or continuation of coverage, including any reservation of rights to change premium.
(8) 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.
(9) If there are restrictions on the choice of providers, a list of providers available to enrollees shall be included with the outline of coverage.
(10) The definition of grievance as contained in s. Ins 18.01 (4). (11) The premium for the policy and riders, if any, in the following format:
MEDICARE SUPPLEMENT, MEDICARE SELECT AND MEDICARE COST PREMIUM INFORMATION
Annual Premium
$ ( ) BASIC MEDICARE SUPPLEMENT, MEDICARE SELECT, OR MEDICARE COST COVERAGE
OPTIONAL BENEFITS FOR MEDICARE SUPPLEMENT, MEDICARE SELECT, OR MEDICARE COST
POLICY
Each of these riders may be purchased separately.
(Note: Only optional coverages provided by rider shall be listed here.)
$ ( ) 1. Medicare Part A deductible
100% of Medicare Part A deductible
$ ( ) 2. Additional home health care
An aggregate of 365 visits per year including those covered by Medicare
$ ( ) 3. Medicare Part B deductible
100% of Medicare Part B deductible
$ ( ) 4. Medicare Part B excess charges
Difference between the Medicare eligible charge and the amount charged by the provider which shall be no greater than the actual charge or the limited charge allowed by Medicare, whichever is less
$ ( ) 5. Foreign travel 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. beginning 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 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 WITH WILL DESCRIBE THESE CHANGES AND THE CHANGES IN YOUR MEDICARE SUPPLEMENT COVERAGE.
(12) If premiums for each rating classification are not listed in the outline of coverage under subsection (11), then the issuer shall give a separate schedule of premiums for each rating classification with the outline of coverage.
(13) Include a summary of or reference to the coverage required by applicable statutes.
(14) The term “certificate” should be substituted for the word “policy” throughout the outline of coverage where appropriate.
Issuers shall select the appropriate outline of coverage specific to the type of plan being presented, Medicare supplement, Medicare supplement cost-sharing, Medicare cost, or Medicare select, from among the following Outlines of Coverage A through D, respectively.
OUTLINE OF COVERAGE - A
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT INSURANCE
(The designation and caption required by sub. (4) (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: Add the following text in a bold or contrasting color if the policy is a Medicare Supplement High Deductible Plan as defined in sub. (5) (k) or (m), only until December 31, 2005: This high deductible plan pays the same as a non-high deductible plan after one has paid a calendar year [$ ] deductible. Benefits will not begin until out-of-pocket expenses are [$]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include [the plan’s separate foreign travel emergency deductible.]
* These are optional riders. You purchased this benefit if the box is checked and you paid the premium
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy’s “Core Benefits.”
MEDICARE SUPPLEMENT POLICIES - PART B BENEFITS
Note: Issuers should include only the wording that applies to their policy’s “This Policy Pays” column and complete the “You Pay” column.
Note: Add the following text in a bold or contrasting color if the policy is a Medicare Supplement High Deductible Plan as defined in sub. (5) (k) or (m) only until December 31, 2005: This high deductible plan pays the same as a non-high deductible plan after one has paid a calendar year [$ ] deductible. Benefits will not begin until out-of-pocket expenses are $[ ]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include [the plan’s separate foreign travel emergency deductible].
*Once you have been billed [$ ] of Medicare approved amounts for covered services (which 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.
OUTLINE OF COVERAGE - B
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT 50% and 25% COST-SHARING PLANS
(The designation required by sub. (5) (n) 1. and (o) 1.)
You will pay [half or one quarter] the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[ ] each calendar year. The amounts that count toward your annual limit are noted with diamonds (⋄) in the chart below. Once you reach the annual limit, the policy plays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE COST-SHARING 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.
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy’s “Core Benefits.”
MEDICARE COST-SHARING POLICIES - PART B BENEFITS
Note: Issuers should include only the wording which applies to their policy’s “This Policy Pays” column and complete the “You Pay” column.
