(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 $[ ] each calendar year. The amounts that count toward your annual limit are noted with diamonds (⋄) in the chart below. Once you reach the annual limit, the policy plays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE COST-SHARING PART A – HOSPITAL SERVICES – PER BENEFIT PERIOD
Note: Issuers should include only the wording that applies to their policy’s “This Policy Pays” column and complete the “You Pay” column.
A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy’s “Core Benefits.”
MEDICARE COST-SHARING POLICIES - PART B BENEFITS
Note: Issuers should include only the wording which applies to their policy’s “This Policy Pays” column and complete the “You Pay” column.
*Once you have been billed [$ ] 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 - C
(COMPANY NAME)
OUTLINE OF MEDICARE COST INSURANCE
(The designation and caption required by sub. (7) (a))
MEDICARE COST 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 bracketed information that is appropriate for a Medicare cost policy with either basic or enhanced benefits.
* 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 COST 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 bracketed information that is appropriate for a Medicare cost policy with either basic or enhanced benefits.
*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 - D
(COMPANY NAME)
OUTLINE OF MEDICARE SELECT INSURANCE AND
MEDICARE SELECT 50% and 25% COST-SHARING PLANS
(The designation and caption required by sub. (30) (i) 8. and 9.,
or the designation required by subs. (30) (q) 1. and (r) 1.)
Note: Add the following text if the policy is a Medicare Select 50% or 25% Cost-Sharing Plan: You will pay [half or ⋄one quarter] the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[ ] each calendar year. The amounts that count toward your annual limit are noted with diamonds (⋄) in the chart below. Once you reach the annual limit, the policy plays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE SELECT PART A – HOSPITAL SERVICES – PER BENEFIT PERIOD
Note: Issuers should include only the wording that applies to their policy’s “This Policy Pays” column and complete the “You Pay” column.
A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy’s “Core Benefits.”
MEDICARE SELECT POLICIES - PART B BENEFITS
Note: Issuers should include only the wording that applies to their policy’s “This Policy Pays” column and complete the “You Pay” column.
*Once you have been billed [$ ] 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.
** NOTE: Insurers should include in the outline of coverage the appropriate preventive benefit based upon whether or not the policy is a cost-sharing policy.
Ins 3.39 APPENDIX 2m
For policies issued to persons first eligible for Medicare on or after June 1, 2010, and prior to January 1, 2020, the following information shall be inserted prior to each outline of coverage provided to an insured and include the information specific to the plan type.
PREMIUM INFORMATION
We can only raise your premium if we raise the premium for all policies like yours in this state. [Include information specifying when premiums will change.]
If your policy was issued as an under age 65 policy due to disability, when you turn 65 premiums will remain at the disabled rates. [Include this statement within premium information when issuer does not change premium to age 65 rate.]
DISCLOSURES
Use this outline to compare benefits and premiums among policies.
