(e) [For indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.]
-
See PDF for table 
This is not Medicare Supplement Insurance
This insurance pays a fixed amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
○ any expenses or services covered by the policy are also covered by Medicare.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
○ hospitalization
○ physician services
○ hospice
○ [outpatient prescription drugs if you are enrolled in Medicare
Part D]
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the “Wisconsin Guide to Health Insurance for People with Medicare," available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
(f) [Alternative disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.]
-
See PDF for table
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
○ hospitalization
○ physician services
○ hospice
○ [outpatient prescription drugs if you are enrolled in Medicare
Part D]
○ other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
- See PDF for table
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the “Wisconsin Guide to Health Insurance for People with Medicare," available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
(g) [For other health insurance policies not specifically identified in the previous statements.]
-
See PDF for table
This is not Medicare Supplement Insurance
This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
○ the benefits stated in the policy and coverage for the same event is provided by Medicare
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
○ hospitalization
○ physician services
○ hospice
○ [outpatient prescription drugs if you are enrolled in Medicare
Part D]
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the “Wisconsin Guide to Health Insurance for People with Medicare," available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
(h) [Alternative disclosure statement for other health insurance policies not specifically identified in the preceding statements.]
-
See PDF for table
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
○ hospitalization
○ physician services
○ hospice
○ [outpatient prescription drugs if you are enrolled in Medicare
Part D]
○ other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
- See PDF for table
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the “Wisconsin Guide to Health Insurance for People with Medicare", available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
Ins 3.40
Ins 3.40
Coordination of benefits provisions in group and blanket disability insurance policies. Ins 3.40(1)(a)(a) This section establishes authorized coordination of benefits provisions for group and blanket disability insurance policies pursuant to s.
631.23, Stats. It has been found that these clauses are necessary to provide certainty of meaning. Regulation of contract forms will be more effective, and litigation will be substantially reduced if there is uniformity regarding coordination of benefits provisions in health insurance policies.
Ins 3.40(1)(b)
(b) A Coordination of benefits (COB) provision as defined in sub.
(3) (e) avoids claim payment delays be establishing an order in which Plans pay their claims and by providing the authority for the orderly transfer of information needed to pay claims promptly. It avoids duplication of benefits by permitting a reduction of the benefits of a Plan when, by the rules established by this section, a Plan does not have to pay its benefits first.
Ins 3.40(1)(c)
(c) Coordinating health benefits has been found to be an effective tool in containing health care costs. However, minimum standards of protection and uniformity are needed to protect the insured's and the public's interest.
Ins 3.40(2)
(2) Scope. This section applies to all group and blanket disability insurance policies subject to s.
631.01 (1), Stats., that provide 24-hour continuous coverage for medical or dental care, treatment or expenses due to either injury or sickness that contain a coordination of benefits provision, an “excess,"“anti-duplication," “non-profit" or “other insurance" exclusion by whatever name designated under which benefits are reduced because of other insurance, other than an exclusion for expenses covered by worker's compensation, employer's liability insurance, or individual traditional automobile “fault" contracts. Except as permitted under s.
632.32 (4) (a) 2., Stats., this section applies to the medical benefits provisions in an automobile “no fault" type or group or group-type “fault" policy. A policy subject to this section may reduce benefits because of Medicare only to the extent permitted by federal law and shall comply with s.
632.755, Stats., when reducing benefits because of coverage by or eligibility for medical assistance.
Ins 3.40(3)(a)
(a) “Allowable expense" means the necessary, reasonable, and customary item of expense for health care, when the item of expense is covered at least in part by one or more Plans covering the person for whom the claim is made, except as provided in sub.
(4).
Ins 3.40(3)(b)
(b) “Claim" means a request that benefits of a Plan be provided or paid. The benefits claimed may be in the form of any of the following:
Ins 3.40(3)(c)
(c) “Claim determination period" means the period of time over which allowable expenses are compared with total benefits payable in the absence of COB to determine whether overinsurance exists and how much each Plan will pay or provide. However, it does not include any part of a year before the date this COB provision or a similar provision takes effect.
Ins 3.40(3)(d)
(d) “Complying Plan" means a Plan with order of benefit determination rules which comply with this section.
Ins 3.40(3)(e)
(e) A “Coordination of benefits (COB) provision" means an insurance contract provision intended to avoid claims payment delays and duplication of benefits when a person is covered by 2 or more plans providing benefits or services for medical, dental or other care or treatment.
Ins 3.40(3)(f)
(f) “Group-type contracts" means contracts which are not available to the general public and may be obtained and maintained only because of membership in or connection with a particular organization or group. Group-type contracts answering this description may be included in the definition of Plan at the option of the insurer issuing group-type plans or the service provider and its contract-client, whether or not uninsured arrangements or individual contract forms are used and regardless of how the group-type coverage is designated (for example, “franchise" or “blanket"). The use of payroll deductions by the employee, subscriber or member to pay for the coverage is not sufficient, of itself, to make an individual contract part of a group-type plan. Group-type contracts do not include individually underwritten and issued, guaranteed renewable policies that may be purchased through payroll deduction at a premium savings to the insured.
Ins 3.40(3)(g)
(g) “Hospital indemnity benefits" means benefits for hospital confinement which are not related to expenses incurred but does not include plans that reimburse a person for actual hospital expenses incurred even if the plans are designed or administered to give the insured the right to elect indemnity-type benefits at the time of claim.
Ins 3.40(3)(h)
(h) “Noncomplying Plan" means a Plan that declares its benefits to be “excess" or “always secondary" or that uses order of benefit determination rules inconsistent with those contained in this section.
Ins 3.40(3)(i)
(i) “Plan" means a form of coverage providing benefits for medical or dental care, except as limited under sub.
(6), with which coordination is allowed.
Ins 3.40(3)(j)
(j) “Primary Plan" means a health care plan, determined by the order of benefit determination rules, whose benefits shall be determined before those of the other Plan and without taking the existence of any other Plan into consideration.
Ins 3.40(3)(k)
(k) “Secondary Plan" means a plan which is not a Primary Plan according to the order of benefit determination rules and whose benefits are determined after those of another Plan and may be reduced because of the other plan's benefits.
Ins 3.40(3)(L)
(L) “This Plan" means the part of the group contract that provides the health care benefits to which the COB provision applies and which may be reduced because of the benefits of other Plans. Any other part of the group contract providing health care benefits is separate from This Plan.
Ins 3.40(4)
(4) Allowable expense uses and limitations. Ins 3.40(4)(a)(a) Items of expense under dental care, vision care, prescription drug or hearing aid programs may be excluded from the definition of allowable expense. A Plan which provides benefits only for these items may limit its definition of allowable expense to these items of expense.
Ins 3.40(4)(b)
(b) When a Plan provides benefits in the form of services, the reasonable cash value of each service rendered shall be considered as both an allowable expense and a benefit paid.
Ins 3.40(4)(c)
(c) The difference between the cost of a private hospital room and the cost of a semi-private hospital room is not considered an allowable expense under the above definition unless the patient's stay in a private hospital room is medically necessary in terms of generally accepted medical practice or as specifically defined in the Plan.
Ins 3.40(4)(d)
(d) When COB is restricted in its use to a specific coverage in a contract, for example, major medical or dental, the definition of allowable expense shall include the corresponding expenses or services to which COB applies.
Ins 3.40(5)
(5) Claim determination period uses and limitations. Ins 3.40(5)(a)(a) A claim determination period may not be less than 12 months and usually is a calendar year, but a Plan may use some other period of time that fits the coverage of the group contract. A person may be covered by a Plan during a portion of a claim determination period if that person's coverage starts or ends during that claim determination period.
Ins 3.40(5)(b)
(b) As each claim is submitted, each Plan shall determine its liability and pay or provide benefits based upon allowable expenses incurred to that point in the claim determination period. However, that determination is subject to adjustment as later allowable expenses are incurred in the same claim determination period.
