Ins 3.39(5t)(b)2.b.b. The following 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(5t)(d)(d) All of the following required coverages shall be referred to as “Basic Medicare Supplement Coverage:” Ins 3.39(5t)(d)1.1. Coverage of at least 175 days per lifetime for inpatient psychiatric hospital care upon exhaustion of Medicare hospital inpatient psychiatric coverage. Ins 3.39(5t)(d)2.2. Coverage of coinsurance or copayments for Medicare Part A eligible expenses in a skilled nursing facility from the 21st through the 100th day in a benefit period. 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: