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.a.a. Be printed on, or attached to, the first page of the policy.
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)(a) The coverage set out in subs. (5), (5m), (5t), (7), (30), (30m), and (30t), as applicable:
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)(a)3.3. Printed in 18-point bold letters.