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

(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.

(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

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.”