PLEASE READ THIS CAREFULLY!
[Note: A brief description of the revisions to Medicare Parts A and B with a parallel description of supplemental benefits with subsequent changes, including dollar amounts, provided by the Medicare supplement or Medicare cost coverage in substantially the following format.]
[Note: Describe any coverage provisions changing due to Medicare modifications. Include information about when premium adjustments that may be necessary due to changes in Medicare benefits will be effective.]
THIS CHART SUMMARIZES THE CHANGES IN YOUR MEDICARE BENEFITS AND IN YOUR MEDICARE SUPPLEMENT OR MEDICARE REPLACEMENT] COVERAGE PROVIDED BY (COMPANY) ONLY BRIEFLY DESCRIBES SUCH BENEFITS. FOR INFORMATION ON YOUR MEDICARE BENEFITS CONTACT YOUR SOCIAL SECURITY OFFICE OR THE CENTERS FOR MEDICARE & MEDICAID SERVICES. FOR INFORMATION ON YOUR [MEDICARE SUPPLEMENT OR MEDICARE REPLACEMENT] POLICY CONTACT:
[COMPANY OR FOR AN INDIVIDUAL POLICY - NAME OF AGENT]
[ADDRESS/PHONE NUMBER]
INS 3.39 APPENDIX 6m
[NOTICE OF CHANGE FOR OUTLINE OF COVERAGE]
[FOR APPLICANTS FIRST ELIGIBLE FOR MEDICARE AFTER JUNE 1, 2010 AND PRIOR TO JANUARY 1, 2020.]
(COMPANY NAME)
NOTICE OF CHANGES IN MEDICARE AND YOUR [MEDICARE
SUPPLEMENT OR MEDICARE COST] COVERAGE – 2_____
THE FOLLOWING CHART BRIEFLY DESCRIBES THE MODIFICATIONS IN MEDICARE AND IN YOUR [MEDICARE SUPPLEMENT OR MEDICARE COST] COVERAGE.
PLEASE READ THIS CAREFULLY!
[Note: A brief description of the revisions to Medicare Parts A and B with a parallel description of supplemental benefits with subsequent changes, including dollar amounts, provided by the Medicare supplement or Medicare cost coverage in substantially the following format.]
[Note: Describe any coverage provisions changing due to Medicare modifications. Include information about when premium adjustments that may be necessary due to changes in Medicare benefits will be effective.]
THIS CHART SUMMARIZES THE CHANGES IN YOUR MEDICARE BENEFITS AND IN YOUR MEDICARE SUPPLEMENT OR MEDICARE COST] COVERAGE PROVIDED BY (COMPANY) ONLY BRIEFLY DESCRIBES SUCH BENEFITS. FOR INFORMATION ON YOUR MEDICARE BENEFITS CONTACT YOUR SOCIAL SECURITY OFFICE OR THE CENTERS FOR MEDICARE & MEDICAID SERVICES. FOR INFORMATION ON YOUR [MEDICARE SUPPLEMENT OR MEDICARE COST] POLICY CONTACT:
[COMPANY OR FOR AN INDIVIDUAL POLICY - NAME OF AGENT]
[ADDRESS/PHONE NUMBER]
INS 3.39 APPENDIX 6t
[NOTICE OF CHANGE FOR OUTLINE OF COVERAGE]
[FOR APPLICANTS NEWLY ELIGIBLE FOR MEDICARE ON OR AFTER JANUARY 1, 2020.]
(COMPANY NAME)
NOTICE OF CHANGES IN MEDICARE AND YOUR [MEDICARE
SUPPLEMENT OR MEDICARE COST] COVERAGE – 2_____
THE FOLLOWING CHART BRIEFLY DESCRIBES THE MODIFICATIONS IN MEDICARE AND IN YOUR [MEDICARE SUPPLEMENT OR MEDICARE COST] COVERAGE.
PLEASE READ THIS CAREFULLY!
