(3) (a) For Medicare supplement policies, provide a brief summary of the major benefits and gaps in Medicare Parts A and B with a parallel description of supplemental benefits, including dollar amounts, as outlined in these charts.
(b) For Medicare cost policies, as described in s. 600.03 (28p) a. and c., Stats., provide a brief summary of both the basic Medicare benefits in the policy and additional benefits using the basic format as outlined in these charts and modified to accurately reflect the benefits. (c) If the coverage is provided by a health maintenance organization as defined in s. 609.01 (2), Stats., provide a brief summary of the coverage for emergency care anywhere and urgent care received outside the service area if this care is treated differently than other covered benefits. (4) If the plan is a Medicare Supplement High Deductible Plan as described in sub. (5) (n) or (o), add the following text in a bold or contrasting color: You will pay [half (for plans described in sub. (5) (n))] [one quarter (for plans described in sub. (5) (o))] of the cost-sharing of some covered services until you reach the annual out-of-pocket maximum of [$4,000 (for plans described in sub. (5) (n))] [$2,000 (for plan described in sub. (5) (o))] each calendar year. The amounts you must pay are noted in the chart below. Once you reach the annual limit, the plan pays for 100% for the items or services noted in the chart.
The following information shall be inserted AFTER the specific plan type, Medicare supplement, Medicare supplement cost-sharing, Medicare cost, or Medicare select outline of coverage that is provided to all insureds. The information shall include the information specific to the plan type.
(5) All limitations and exclusions, including each of the following, must be listed under the caption “LIMITATIONS AND EXCLUSIONS” if benefits are not provided:
(a) Nursing home care costs beyond what is covered by Medicare and the additional 30–day skilled nursing mandated by s. 632.895 (3), Stats. (b) Home health care above the number of visits covered by Medicare and the 365 visits mandated by s. 632.895 (2), Stats. [For Medicare select policies only.] (c) Physician charges above Medicare’s approved charge.
(d) Outpatient prescription drugs.
(e) Most care received outside of U.S.A.
(f) Dental care, dentures, checkups, routine immunizations, cosmetic surgery, routine foot care, examinations for and the cost of eyeglasses or hearing aids, unless eligible under Medicare.
(g) Coverage for emergency care anywhere or for care received outside the service area if this care is treated differently than other covered benefits.
(h) Waiting period for pre–existing conditions.
(i) Limitations on the choice of providers or the geographical area served (if applicable for Medicare select policies only).
(j) Usual, customary, and reasonable limitations.
(6) CONSPICUOUS STATEMENTS AS FOLLOWS:
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult “Medicare & You” for more details.
(7) A description of policy provisions respecting renewability or continuation of coverage, including any reservation of rights to change premium.
(8) Information on how to file a claim for services received from non–participating providers because of an emergency within or outside of the service area shall be prominently disclosed.
(9) If there are restrictions on the choice of providers, a list of providers available to enrollees shall be included with the outline of coverage.
(10) The definition of grievance as contained in s. Ins 18.01 (4). (11) The premium for the policy and riders, if any, in the following format:
MEDICARE SUPPLEMENT, MEDICARE SELECT AND MEDICARE COST PREMIUM INFORMATION
Annual Premium
$ ( ) BASIC MEDICARE SUPPLEMENT, MEDICARE SELECT, OR MEDICARE COST COVERAGE
OPTIONAL BENEFITS FOR MEDICARE SUPPLEMENT, MEDICARE SELECT, OR MEDICARE COST
POLICY
Each of these riders may be purchased separately.
(Note: Only optional coverages provided by rider shall be listed here.)