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.
Ins 3.39(8)(a)5.
5. May exclude coverage for the treatment of service related conditions for members or ex-members of the armed forces by any military or veterans hospital or soldier home or any hospital contracted for or operated by any national government or agency.
Ins 3.39(8)(b)
(b) If the insured chooses not to enroll in Medicare Part B, the issuer may exclude from coverage the expenses which Medicare Part B would have covered if the insured were enrolled in Medicare Part B. An issuer may not exclude Medicare Part B eligible expenses incurred beyond what Medicare Part B would cover.
Ins 3.39(8)(c)
(c) The coverages set out in subs.
(5),
(5m),
(5t),
(7),
(30),
(30m), and
(30t) may not exclude, limit, or reduce coverage for specifically named or described preexisting diseases or physical conditions, except as provided in par.
(a) 3. Ins 3.39(8)(e)
(e) A Medicare cost policy, Medicare supplement policy or certificate and Medicare select policy or certificate may include other exclusions and limitations that are not otherwise prohibited and are not more restrictive than exclusions and limitations contained in Medicare.
Ins 3.39(9)
(9) Individual policies providing nursing home, hospital confinement indemnity, specified disease and other coverages. Ins 3.39(9)(a)(a)
Caption requirements. Captions required by this subsection shall be:
Ins 3.39(9)(a)1.
1. Printed and conspicuously placed on the first page of the Outline of Coverage,
Ins 3.39(9)(a)2.
2. Printed on a separate form attached to the first page of the policy, and
Ins 3.39(9)(b)
(b) Disclosure statements. The appropriate disclosure statement from Appendix 10 shall be used on the application or together with the application for each coverage in pars.
(c) to
(e). The disclosure statement may not vary from the text or format including bold characters, line spacing, and the use of boxes around text contained in Appendix 10 and shall use a type size of at least 12 points. The issuer may use either (a) or (aL), (b) or (bL), (c) or (cL) or (g) or (gL) providing the issuer uses the same disclosure statement for all policies of the type covered by the disclosure.
Ins 3.39(9)(c)
(c) Hospital confinement indemnity coverage. An individual policy form providing hospital confinement indemnity coverage sold to a Medicare eligible person:
Ins 3.39(9)(c)1.
1. Shall not include benefits for nursing home confinement unless the nursing home coverage meets the standards set forth in s.
Ins 3.46;
Ins 3.39(9)(c)2.
2. Shall bear the caption, if the policy provides no other types of coverage: “This policy is not designed to fill the gaps in Medicare. It will pay you only a fixed dollar amount per day when you are confined to a hospital. For more information, see “Wisconsin Guide to Health Insurance for People with Medicare', given to you when you applied for this policy."
Ins 3.39(9)(c)3.
3. Shall bear the caption set forth in par.
(e), if the policy provides other types of coverage in addition to the hospital confinement indemnity coverage.
Ins 3.39(9)(d)
(d) Specified disease coverage. An individual policy form providing benefits only for one or more specified diseases sold to a Medicare eligible person shall bear:
Ins 3.39(9)(d)1.
1. The designation: SPECIFIED OR RARE DISEASE LIMITED POLICY, and
Ins 3.39(9)(d)2.
2. The caption: “This policy covers only one or more specified or rare illnesses. It is not a substitute for a broader policy which would generally cover any illness or injury. For more information, see `Wisconsin Guide to Health Insurance for People with Medicare', given to you when you applied for this policy."
Ins 3.39(9)(e)
(e) Other coverage. An individual disability policy sold to a Medicare eligible person, other than a form subject to sub.
(5) or
(7) or otherwise subject to the caption requirements in this subsection or exempted by sub.
(2) (d) or
(e), shall bear the caption: “This policy is not a Medicare supplement. For more information, see “Wisconsin Guide to Health Insurance for People with Medicare', given to you when you applied for this policy."
Ins 3.39(10)(a)(a)
Conversion requirements. An insured under individual, family, or group hospital or medical coverage who will become eligible for Medicare and is offered a conversion policy which is not subject to subs.
(4),
(4m),
(4t),
(5),
(5m),
(5t) or
(7) shall be furnished by the issuer, at the time the conversion application is furnished in the case of individual or family coverage or within 14 days of a request in the case of group coverage.
Ins 3.39(10)(b)
(b)
Continuation requirements. An insured under individual, family, or group hospital or medical coverage who will become eligible for Medicare and whose coverage will continue with changed benefits (e.g., “carve-out" or reduced benefits) shall be furnished by the issuer, within 14 days of a request:
Ins 3.39(10)(b)1.
1. A comprehensive written explanation of the coverage to be provided after Medicare eligibility, and
Ins 3.39(10)(c)
(c)
Notice to group policyholder. An issuer which provides group hospital or medical coverage shall furnish to each group policyholder:
Ins 3.39(10)(c)1.
1. Annual written notice of the availability of the materials described in pars.
(a) and
(b), where applicable, and
Ins 3.39(10)(c)2.
2. Within 14 days of a request, sufficient copies of the same or a similar notice to be distributed to the group members affected.
