Ins 3.39(5t)(d)3.
3. Coverage for all Medicare Part A eligible expenses for the first 3 pints of blood or equivalent quantities of packed red blood cells to the extent not covered by Medicare.
Ins 3.39(5t)(d)4.
4. Coverage of coinsurance or copayments for all Medicare Part A eligible expenses for hospice and respite care.
Ins 3.39(5t)(d)5.
5. Coverage of coinsurance or copayment for Medicare Part B eligible expenses to the extent not paid by Medicare or, in the case of hospital outpatient department services paid under a prospective payment system including outpatient psychiatric care, regardless of hospital confinement, subject to the Medicare Part B calendar year deductible.
Ins 3.39(5t)(d)7.
7. Coverage for skilled nursing care and kidney disease treatment as required under s.
632.895 (3) and
(4), Stats. Coverage for skilled nursing care shall be in addition to the required coverage under subd.
1. Payment of coinsurance or copayment for Medicare Part A eligible skilled nursing care may not count as satisfying the coverage requirement of at least 30 days of non-Medicare eligible skilled nursing care under s.
632.895 (3), Stats.
Ins 3.39(5t)(d)8.
8. In group policies, coverage for nervous and mental disorders and alcoholism and other drug abuse coverage as required under s.
632.89, Stats.
Ins 3.39(5t)(d)9.
9. Coverage in full for all usual and customary expenses for chiropractic services consistent with s.
632.87 (3), Stats. Issuers are not required to duplicate benefits paid by Medicare.
Ins 3.39(5t)(d)10.
10. Coverage of the first 3 pints of blood payable under Medicare Part B.
Ins 3.39(5t)(d)11.
11. Coverage of Medicare Part A eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period.
Ins 3.39(5t)(d)12.
12. Coverage of Medicare Part A eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days.
Ins 3.39(5t)(d)13.
13. Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of all Medicare Part A eligible expenses for hospitalization not covered by Medicare for an additional 365 days to the extent the hospital is permitted to charge Medicare by federal law and regulation and subject to the Medicare reimbursement rate and a lifetime maximum benefit. The provider shall accept the issuer's payment as payment in full and may not balance bill the insured.
Ins 3.39(5t)(d)14.
14. Coverage in accordance with s.
632.895 (6), Stats., for treatment of diabetes including non-prescription insulin or any other non-prescription equipment and supplies for the treatment of diabetes, but not including any other outpatient prescription medications. Issuers are not required to duplicate expenses paid by Medicare.
Ins 3.39(5t)(d)15.
15. Coverage for preventive health care services not covered by Medicare and as determined to be medically appropriate by an attending physician. These benefits shall be included in the basic policy or certificate. Reimbursement shall be for the actual charges up to 100% of the Medicare approved amount for each service, as if Medicare were to cover the service, as identified in the American Medical Association Current Procedural Terminology codes, to a minimum of $120 annually under this benefit. This benefit may not include payment for any procedure covered by Medicare.
Ins 3.39(5t)(d)16.
16. Coverage in full for all usual and customary expenses of hospital and ambulatory surgery center charges and anesthetics for dental care required by s.
632.895 (12), Stats. Issuers are not required to duplicate benefits paid by Medicare.
Ins 3.39(5t)(d)17.
17. Coverage in full for all usual and customary expenses for breast reconstruction required by s.
632.895 (13), Stats. Issuers are not required to duplicate benefits paid by Medicare.
Ins 3.39(5t)(e)
(e) Permissible coverage options may only be added to the policy or certificate as separate riders. The issuer shall issue a separate rider for each option offered. Issuers shall ensure that the riders offered are compliant with MACRA and each rider is priced separately, available for purchase separately at any time, subject to underwriting and the preexisting limitation allowed in sub.
(4t) (a) 2. The issuer shall not issue to the same insured for the same period of coverage both the Medicare Part A deductible rider and the Medicare 50% Part A deductible rider. If separate riders are offered, the separate riders shall only consist of any of the following riders:
Ins 3.39(5t)(e)1.
1. Coverage of 100% of the Medicare Part A hospital deductible. The rider shall be designated as: MEDICARE PART A DEDUCTIBLE RIDER.
Ins 3.39(5t)(e)2.
2. Coverage of 50% of the Medicare Part A hospital deductible per benefit period with no out-of-pocket maximum. The rider shall be designated as: MEDICARE 50% PART A DEDUCTIBLE RIDER.
Ins 3.39(5t)(e)3.
3. Coverage of home health care for an aggregate of 365 visits per policy or certificate year as required by s.
632.895 (2) (e), Stats. The rider shall be designated as: ADDITIONAL HOME HEALTH CARE RIDER.
Ins 3.39(5t)(e)4.
4. Coverage of Medicare Part B Copayment or Coinsurance Rider. Under this rider, the insured's copayment or coinsurance will be the lesser of $20 per office visit or the Medicare Part B coinsurance and the lesser of $50 per emergency room visit or the Medicare Part B coinsurance that is in addition to the Medicare Part B medical deductible. 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. The rider shall be designated as: MEDICARE PART B COPAYMENT OR COINSURANCE RIDER.
Ins 3.39(5t)(e)5.
5. Coverage of the difference between Medicare Part B eligible charges and the amount charged by the provider that shall be no greater than the actual charge or the limiting charge allowed by Medicare. The rider shall be designated as: MEDICARE PART B EXCESS CHARGES RIDER.
Ins 3.39(5t)(e)6.
6. Coverage for services obtained outside the United States. An issuer that offers this rider may not limit coverage to Medicare deductibles, coinsurance and copayments. Coverage may contain a deductible of up to $250. Coverage shall pay at least 80% of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country; care that would have been covered by Medicare if provided in the United States; and when the care began during the first 60 consecutive days of each trip outside the United States for up to a lifetime maximum benefit of at least $50,000. For purposes of this rider, “emergency hospital, physicians and medical care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset. The rider shall be designated as: FOREIGN TRAVEL EMERGENCY RIDER.
Ins 3.39(5t)(f)
(f) For HMO Medicare select policies, only the benefits specified in sub.
(30t) (p),
(r) and
(s) may be offered in addition to Medicare benefits.
Ins 3.39(5t)(g)
(g) For Medicare supplement 50% Cost-Sharing plans, all of the following shall be included:
Ins 3.39(5t)(g)2.
2. Coverage of coinsurance or copayment for Medicare Part A hospital amount for each day used from the 61st through the 90th day in any Medicare benefit period.
Ins 3.39(5t)(g)3.
3. Coverage of coinsurance or copayment of Medicare Part A hospital amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period.
Ins 3.39(5t)(g)4.
4. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage for 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system rate, or other appropriate Medicare standard of payment, subject to a lifetime limitation benefit of an additional 365 days.
Ins 3.39(5t)(g)5.
5. Coverage for 50% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation as described in subd.
12. is met.
Ins 3.39(5t)(g)6.
6. Coverage for 50% of the coinsurance or copayment amount for each day used from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation as described in subd.
12. is met.
Ins 3.39(5t)(g)7.
7. Coverage for 50% of coinsurance or copayments for all Medicare Part A eligible expenses and respite care until the out-of-pocket limitation as described in subd.
12. is met.
Ins 3.39(5t)(g)8.
8. Coverage for 50%, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations until the out-of-pocket limitation as described in subd.
12. is met.
Ins 3.39(5t)(g)9.
9. Except for coverage provided in subd.
11., coverage for 50% of the coinsurance or copayment otherwise applicable under Medicare Part B after the policyholder or certificateholder pays the Medicare Part B deductible until the out-of-pocket limitation as described in subd.
12. is met.
Ins 3.39(5t)(g)10.
10. Coverage for 100% of the coinsurance or copayments for the benefits described in pars.
(d) 1.,
6.,
7.,
9.,
14.,
16., and
17. and
(e) 3., to the extent the benefits do not duplicate benefits paid by Medicare and after the policyholder or certificateholder pays the Medicare Part A and B deductibles and the out-of-pocket limitation described in subd.
12. is met.
Ins 3.39(5t)(g)11.
11. Coverage for 100% of the coinsurance or copayments for Medicare Part B preventive services after the policyholder or certificateholder pays the Medicare Part B deductible.
Ins 3.39(5t)(g)12.
12. Coverage for 100% of all cost sharing under Medicare Part A or B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B indexed each year by the appropriate inflation adjustment specified by the secretary.
Ins 3.39(5t)(h)
(h) For Medicare Supplement 25% Cost-Sharing plans, all of the following shall be included:
Ins 3.39(5t)(h)2.
2. Coverage for 100% of the Medicare Part A hospital coinsurance or copayment amount for each day used from the 61st through the 90th day in any Medicare benefit period.
Ins 3.39(5t)(h)3.
3. Coverage for 100% of the Medicare Part A hospital coinsurance or copayment amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period.
Ins 3.39(5t)(h)4.
4. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage for 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system rate, or other appropriate Medicare standard of payment, subject to a lifetime limitation benefit of an additional 365 days.
Ins 3.39(5t)(h)5.
5. Coverage for 75% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation as described in subd.
12. is met.
Ins 3.39(5t)(h)6.
6. Coverage for 75% of the coinsurance or copayment amount for each day used from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation as described in subd.
12. is met.
Ins 3.39(5t)(h)7.
7. Coverage for 75% of cost sharing for all Medicare Part A eligible expenses and respite care until the out-of-pocket limitation as described in subd.
12. is met.
Ins 3.39(5t)(h)8.
8. Coverage for 75%, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations until the out-of-pocket limitation as described in subd.
12. is met.
Ins 3.39(5t)(h)9.
9. Except for coverage provided in subd.
11., coverage for 75% of the cost sharing otherwise applicable under Medicare Part B, after the policyholder or certificateholder pays the Medicare Part B deductible until the out-of-pocket limitation as described in subd.
12. is met.
Ins 3.39(5t)(h)10.
10. Coverage for 100% of the cost sharing for the benefits described in pars.
(d) 1.,
6.,
7.,
9.,
14.,
16., and
17. and
(e) 3., to the extent the benefits do not duplicate benefits paid by Medicare and after the policyholder or certificateholder pays the Medicare Part A and B deductible and the out-of-pocket limitation described in subd.
12. is met.
Ins 3.39(5t)(h)11.
11. Coverage for 100% of the cost sharing for Medicare Part B preventive services after the policyholder or certificateholder pays the Medicare Part B deductible.
Ins 3.39(5t)(h)12.
12. Coverage for 100% of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B indexed each year by the appropriate inflation adjustment specified by the secretary.
Ins 3.39(5t)(k)
(k) For the Medicare supplement high deductible plan, all of the following shall be included:
Ins 3.39(5t)(k)1.
1. The designation:
MEDICARE SUPPLEMENT INSURANCE-HIGH DEDUCTIBLE PLAN.
Ins 3.39(5t)(k)3.
3. The annual high deductible shall consist of out-of-pocket expenses, other than premiums, for services covered in subd. 2 and shall be in addition to any other specific benefit deductibles.
Ins 3.39(5t)(k)4.
4. The annual high deductible shall be $2,000 and shall be adjusted annually by the secretary to reflect the change in the Consumer Price Index for all urban consumers for the 12-month period ending with August of the preceding year, and rounded to the nearest multiple of $10.
Ins 3.39(5t)(L)
(L) Nothing in this section shall be construed to prohibit an insurer from discontinuing the marketing of policies offered under sub.
(5m),
(5t),
(7),
(30m), or
(30t).
Ins 3.39(6)
(6)
Usual, customary and reasonable charges. An issuer can only include a policy or certificate provision limiting benefits to the usual, customary and reasonable charge as determined by the issuer for coverages described in sub.
(5) (c) 5.,
8. and
13.,
(5m) (d) 6.,
9., and
14., or
(5t) (d) 6.,
9., and
14. If the issuer includes such a provision, the issuer shall:
Ins 3.39(6)(a)
(a) Define those terms in the policy or rider and disclose to the policyholder that the UCR charge may not equal the actual charge, if this is true.
Ins 3.39(6)(b)
(b) Have reasonable written standards based on similar services rendered in the locality of the provider to support benefit determination which shall be made available to the commissioner on request.
Ins 3.39(7)
(7)
Authorized Medicare cost policy designation, captions and required minimum coverages. Ins 3.39(7)(a)
(a) A Medicare cost policy that is issued by an issuer that has a cost contract with CMS for Medicare benefits shall meet the standards and requirements of sub.
(4) and shall contain all of the following required coverages, to be referred to as “Basic Medicare cost coverage" for a policy issued to persons first eligible for Medicare after January 1, 2005, and prior to June 1, 2010:
Ins 3.39(7)(a)2.
2. The caption, except that the word “certificate" may be used instead of “policy," if appropriate: “The Wisconsin Insurance Commissioner has set minimum standards for Medicare cost insurance. This policy meets these standards. For an explanation of these standards and other important information, see `Wisconsin Guide to health Insurance for People with Medicare,' given to you when you bought this policy. Do not buy this policy if you did not get this guide;"
Ins 3.39(7)(a)3.
3. Upon exhaustion of Medicare hospital inpatient psychiatric coverage, at least 175 days per lifetime for inpatient psychiatric hospital care;
Ins 3.39(7)(a)4.
4. Medicare Part A eligible expenses in a skilled nursing facility for the copayments for the 21
st through the 100
th day;
Ins 3.39(7)(a)5.
5. All Medicare Part A eligible expenses for blood to the extent not covered by Medicare;
Ins 3.39(7)(a)6.
6. All Medicare Part B eligible expenses to the extent not paid by Medicare, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, including outpatient psychiatric care, subject to Medicare Part B calendar year deductible;
Ins 3.39(7)(a)7.
7. Coverage for the first three pints of blood payable under Medicare Part B;
Ins 3.39(7)(a)8.
8. Coverage of Medicare Part A eligible expenses for hospitalization to the extent not covered by Medicare from the 61
st day through the 90
th day in any Medicare benefit period;
Ins 3.39(7)(a)9.
9. Coverage of Medicare Part A eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days;
Ins 3.39(7)(a)10.
10. Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of all Medicare Part A expenses for hospitalization not covered by Medicare and to the extent the hospital is permitted to charge by federal law and regulation or at the Medicare reimbursement rate; and
Ins 3.39(7)(a)11.
11. Coverage for preventive health care services not covered by Medicare and as determined to be medically appropriate by an attending physician. If offered, these benefits shall be included in the basic policy. Reimbursement shall be for the actual charges up to 100% of the Medicare approved amount for each service, as if Medicare were to cover the service, as identified in the American Medical Association Current Procedural Terminology (AMA CPT) codes, to a minimum of $120 annually under this benefit. This benefit shall not include payment for any procedure covered by Medicare.
Ins 3.39(7)(b)
(b) Medicare cost policies are exempt from the provisions of s.
632.73 (2m), Stats., and are subject to all of the following:
Ins 3.39(7)(b)1.
1. Medicare cost policies shall permit members to disenroll at any time for any reason. Premiums paid for any period of the policy beyond the date of disenrollment shall be refunded to the member on a pro rata basis. A Medicare cost policy shall include a written provision providing for the right to disenroll that shall contain all of the following:
Ins 3.39(7)(b)1.b.
b. Have the following caption or title:
“RIGHT TO DISENROLL FROM PLAN."
Ins 3.39(7)(b)1.c.
c. Include the following language or substantially similar language approved by the commissioner. “You may disenroll from the plan at any time for any reason. However, it may take up to 60 days to return you to the regular Medicare program. Your disenrollment will become effective on the day you return to regular Medicare. You will be notified by the plan of the date that your disenrollment becomes effective. The plan will return any unused premium to you on a pro rata basis."
Ins 3.39(7)(b)2.
2. The Medicare cost policy may require requests for disenrollment to be in writing. Enrollees may not be required to give their reasons for disenrolling, or to consult with an agent or other representative of the issuer before disenrolling.
Ins 3.39(7)(c)
(c) For Medicare cost policies issued to persons first eligible for Medicare prior to June 1, 2010, each issuer offering Medicare cost policies may offer an enhanced Medicare cost policy that contains the coverage described in sub.
(5) (c) 5.,
6.,
7.,
8.,
13.,
15.,
16.,
17., and the riders described in sub.
(5) (i).
Ins 3.39(7)(cm)
(cm) For Medicare cost policies issued to persons first eligible for Medicare on or after June 1, 2010, and prior to January 1, 2020, each issuer offering Medicare cost policies may offer an enhanced Medicare cost policy that contains the coverage described in sub.
(5m) (d) 6.,
7.,
8.,
10.,
14.,
16.,
17., and the riders described in sub.
(5m) (e).
Ins 3.39(7)(ct)
(ct) For Medicare cost policies issued to individuals newly eligible for Medicare on or after January 1, 2020, each issuer offering Medicare cost policies may offer an enhanced Medicare cost policy that contains the coverage described in sub.
(5t) (d) 6.,
7.,
8.,
10.,
14.,
16. and
17., and the riders described in sub.
(5t) (e).
Ins 3.39(7)(d)
(d) In addition to all other subsections that are applicable to Medicare cost policies, the marketing of Medicare cost policies shall comply with the requirements of Medicare supplement policies contained in subs.
(15),
(21),
(24), and
(25). The outline of coverage listed in Appendix 1 and the replacement form specified in Appendix 7 shall be modified to accurately reflect the benefit, exclusions and other requirements that differ from Medicare supplement policies approved under sub.
(5).
Ins 3.39(7)(dm)
(dm) For Medicare cost policies issued to persons first eligible for Medicare on or after June 1, 2010, and prior to January 1, 2020, in addition to all other subsections that are applicable to Medicare cost policies, the marketing of Medicare cost policies shall comply with the requirements of Medicare supplement policies contained in subs.
(15),
(21),
(24), and
(25). The outline of coverage listed in Appendix 2m and the replacement form specified in Appendix 7 shall be modified to accurately reflect the benefits, exclusions and other requirements that differ from Medicare supplement policies approved under sub.
(5m).
Ins 3.39(7)(dt)
(dt) For Medicare cost policies issued to persons newly eligible for Medicare on or after January 1, 2020, in addition to all other subsections that are applicable to Medicare cost policies, the marketing of Medicare cost policies shall comply with the requirements of Medicare supplement policies contained in subs.
(15),
(21),
(24), and
(25). The outline of coverage listed in Appendix 2t and the replacement form specified in Appendix 7 shall be modified to accurately reflect the benefits, exclusions and other requirements that differ from Medicare supplement policies approved under sub.
(5t).
Ins 3.39(8)
(8)
Permissible Medicare supplement policy and certificate, Medicare select policy and certificate, and Medicare cost policy exclusions and limitations. Ins 3.39(8)(a)1.
1. Shall exclude expenses for which the insured is compensated by Medicare;
Ins 3.39(8)(a)2.
2. May contain an appropriate provision relating to the effect of other insurance on claims;
Ins 3.39(8)(a)3.
3. May contain a pre-existing condition waiting period provision as provided in sub.
(4) (a) 2., which shall appear as a separate paragraph on the first page of the policy and shall be captioned or titled “Pre-existing Condition Limitations;" and
Ins 3.39(8)(a)4.
4. May, if issued by a health maintenance organization as defined by s.
609.01 (2), Stats., include territorial limitations which are generally applicable to all coverage issued by the plan.
