Ins 3.39(4t)(c)1.1. Shall be contained in the policy or certificate and, if a separate, additional premium is charged in connection with the rider or endorsement, the premium charge shall be stated in the policy or certificate.
Ins 3.39(4t)(c)2.2. Shall be agreed to in writing signed by the insured if, after the date of the policy or certificate issue, the rider or endorsement increases benefits or coverages and there is an accompanying increase in premium during the term of the policy or certificate, unless the increase in benefits or coverage is required by law.
Ins 3.39(4t)(c)3.3. Shall only provide coverage as described in sub. (5t) (e), or provide coverage to meet Wisconsin mandated benefits.
Ins 3.39(4t)(d)(d) The schedule of benefits page or the first page of the policy or certificate shall contain a listing giving the coverages and both the annual premium in the format shown in sub. (11) of Appendix 2t and modal premium selected by the applicant.
Ins 3.39(4t)(e)(e) The anticipated loss ratio for any new policy or certificate form, or the expected percentage of the aggregate amount of premiums earned that will be returned to insureds in the form of aggregate benefits, not including anticipated refunds or credits, that is provided under the policy or certificate form:
Ins 3.39(4t)(e)1.1. Is computed on the basis of anticipated incurred claims or incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis and earned premiums for the entire period that the policy or certificate form provides coverage, in accordance with accepted actuarial principles and practices; and
Ins 3.39(4t)(e)2.2. Is submitted to the commissioner along with the policy or certificate form and is accompanied by rates and an actuarial demonstration that expected claims in relationship to premiums comply with the loss ratio standards under sub. (16) (d). The policy or certificate form will not be approved by the commissioner unless the anticipated loss ratio along with the rates and actuarial demonstration show compliance with sub. (16) (d).
Ins 3.39(4t)(f)(f) For subsequent rate changes to the policy or certificate form, the issuer shall do all of the following:
Ins 3.39(4t)(f)1.1. File the rate changes on a rate change transmittal form in a format specified by the commissioner.
Ins 3.39(4t)(f)2.2. Include in the filing under subd.1. an actuarially sound demonstration that the rate change will not result in a loss ratio over the life of the policy or certificate that would violate the requirements under sub. (16) (d).
Ins 3.39(5)(5)Authorized Medicare supplement policy and certificate designation, captions, required coverages, and permissible additional benefits for policies or certificates offered to persons first eligible for Medicare prior to June 1, 2010. This subsection applies only to a Medicare supplement policy or certificate that meets the requirements of sub. (4), that is issued or effective after December 31, 1990, and prior to June 1, 2010, and that shall contain the authorized designation, caption and required coverage. A health maintenance organization shall place the letters HMO in front of the required designation on any approved Medicare supplement policy or certificate. A Medicare supplement policy or certificate shall include all of the following:
Ins 3.39(5)(a)(a) The designation: MEDICARE SUPPLEMENT INSURANCE.
Ins 3.39(5)(b)(b) The caption, except that the word “certificate” may be used instead of “policy,” if appropriate: “The Wisconsin Insurance Commissioner has set standards for Medicare supplement insurance. This policy meets these standards. It, along with Medicare, may not cover all of your medical costs. You should review carefully all policy limitations. 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 applied for this policy. Do not buy this policy if you did not get this guide.”
Ins 3.39(5)(c)(c) The following required coverages, to be referred to as “Basic Medicare Supplement coverage” for a policy issued to persons first eligible for Medicare after December 31, 1990 and prior to June 1, 2010, shall comply with all the following:
Ins 3.39(5)(c)1.1. Upon exhaustion of Medicare hospital inpatient psychiatric coverage, at least 175 days per lifetime for inpatient psychiatric hospital care;
Ins 3.39(5)(c)2.2. Medicare Part A eligible expenses in a skilled nursing facility for the copayments for the 21st through the 100th day;
Ins 3.39(5)(c)3.3. All Medicare Part A eligible expenses for blood to the extent not covered by Medicare;
Ins 3.39(5)(c)4.4. 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 the Medicare Part B calendar year deductible;
Ins 3.39(5)(c)5.5. Payment of the usual and customary home care expenses to a minimum of 40 visits per 12-month period as required under s. 632.895 (1) and (2), Stats., and s. Ins 3.54;
Ins 3.39(5)(c)6.6. 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. 2. and payment of the Medicare Part A copayment for Medicare eligible skilled nursing care shall 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(5)(c)7.7. In group policies, nervous and mental disorder and alcoholism and other drug abuse coverage as required under s. 632.89, Stats.;
Ins 3.39(5)(c)8.8. Payment in full for all usual and customary expenses for chiropractic services required by s. 632.87 (3), Stats. Issuers are not required to duplicate benefits paid by Medicare;
Ins 3.39(5)(c)9.9. Coverage for the first 3 pints of blood payable under Part B;
Ins 3.39(5)(c)10.10. Coverage of Part A Medicare 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(5)(c)11.11. Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare’s lifetime hospital inpatient reserve days;
Ins 3.39(5)(c)12.12. 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 to the extent the hospital is permitted to charge by federal law and regulation and subject to the Medicare reimbursement rate;
Ins 3.39(5)(c)13.13. Prior to January 1, 2006, payment in full for all usual and customary expenses for treatment of diabetes required by s. 632.895 (6), Stats. After December 31, 2005, payment in accordance with s. 632.895 (6), Stats., 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(5)(c)14.14. 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. 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(5)(c)15.15. Coverage for at least 80% of the charges for outpatient prescription drugs after a drug deductible of no more than $6,250 per calendar year. Subject to sub. (4) (a) 20., this coverage may only be included in a Medicare supplement policy issued before January 1, 2006.