Ins 3.39(4s)(c)2. 2. After the date of policy or certificate issue, any rider or endorsement added to the policy or certificate shall be agreed to in writing signed by the insured if the rider or endorsement increases benefits or coverages and there is an accompanying increase in premium during the term of the policy or certificate, unless the increase in benefits or coverage is required by law.
Ins 3.39(4s)(c)3. 3. Shall only provide coverage as defined in sub. (5m) (e) or provide coverage to meet Wisconsin mandated benefits.
Ins 3.39(4s)(d) (d) The schedule of benefits page or the first page of the policy or certificate contains a listing giving the coverages and both the annual premium in the format shown in sub. (11) of Appendix 2 to this section and modal premium selected by the applicant.
Ins 3.39(4s)(e) (e) The anticipated loss ratio for any new policy or certificate form, that is, the expected percentage of the aggregate amount of premiums earned that will be returned to insureds in the form of aggregate benefits, not including anticipated refunds or credits, provided under the policy or certificate form:
Ins 3.39(4s)(e)1. 1. Is computed on the basis of anticipated incurred claims or incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis and earned premiums for the entire period for which the policy or certificate form provides coverage, in accordance with accepted actuarial principles and practices.
Ins 3.39(4s)(e)2. 2. Is submitted to the commissioner along with the policy or certificate form and is accompanied by rates and an actuarial demonstration that expected claims in relationship to premiums comply with the loss ratio standards in sub. (16) (d). The policy or certificate form will not be approved unless the anticipated loss ratio along with the rates and actuarial demonstration show compliance.
Ins 3.39(4s)(f) (f) As regards subsequent rate changes to the policy or certificate form, the issuer:
Ins 3.39(4s)(f)1. 1. Files such changes on a rate change transmittal form in a format specified by the commissioner.
Ins 3.39(4s)(f)2. 2. Includes in its filing an actuarially sound demonstration that the rate change will not result in a loss ratio over the life of the policy or certificate that would violate sub. (16) (d).
Ins 3.39(5) (5)Authorized Medicare supplement policy and certificate designation, captions, required coverages, and permissible additional benefits for policies or certificates effective prior to June 1, 2010. For a policy or certificate to meet the requirements of sub. (4), that is issued or effective after December 31, 1990, and prior to June 1, 2010, it shall contain the authorized designation, caption and required coverage. A health maintenance organization shall place the letters HMO in front of the required designation on any approved Medicare supplement policy or certificate. A Medicare supplement policy or certificate shall include all of the following:
Ins 3.39(5)(a) (a) The designation: MEDICARE SUPPLEMENT INSURANCE.
Ins 3.39(5)(b) (b) The 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(5)(c) (c) The following required coverages, to be referred to as "Basic Medicare Supplement coverage" for a policy issued after December 31, 1990:
Ins 3.39(5)(c)1. 1. Upon exhaustion of Medicare hospital inpatient psychiatric coverage, at least 175 days per lifetime for inpatient psychiatric hospital care;
Ins 3.39(5)(c)2. 2. Medicare Part A eligible expenses in a skilled nursing facility for the copayments for the 21st through the 100th day;
Ins 3.39(5)(c)3. 3. All Medicare Part A eligible expenses for blood to the extent not covered by Medicare;
Ins 3.39(5)(c)4. 4. All 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, the copayment amount, including outpatient psychiatric care, subject to the Medicare Part B calendar year deductible;
Ins 3.39(5)(c)5. 5. Payment of the usual and customary home care expenses to a minimum of 40 visits per 12-month period as required under s. 632.895 (1) and (2), Stats., and s. Ins 3.54;
Ins 3.39(5)(c)6. 6. 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. 2. and payment of the Medicare Part A copayment for Medicare eligible skilled nursing care shall 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(5)(c)7. 7. In group policies, nervous and mental disorder and alcoholism and other drug abuse coverage as required under s. 632.89, Stats.;
Ins 3.39(5)(c)8. 8. Payment in full for all usual and customary expenses for chiropractic services required by s. 632.87 (3), Stats. Issuers are not required to duplicate benefits paid by Medicare;
Ins 3.39(5)(c)9. 9. Coverage for the first 3 pints of blood payable under Part B;
Ins 3.39(5)(c)10. 10. Coverage of Part A Medicare 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(5)(c)11. 11. Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days;
Ins 3.39(5)(c)12. 12. 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 to the extent the hospital is permitted to charge by federal law and regulation and subject to the Medicare reimbursement rate;
Ins 3.39(5)(c)13. 13. Prior to January 1, 2006, payment in full for all usual and customary expenses for treatment of diabetes required by s. 632.895 (6), Stats. After December 31, 2005, payment in accordance with s. 632.895 (6), Stats., 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(5)(c)14. 14. 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. 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(5)(c)15. 15. Coverage for at least 80% of the charges for outpatient prescription drugs after a drug deductible of no more than $6,250 per calendar year. Subject to sub. (4) (a) 20., this coverage may only be included in a Medicare supplement policy issued before January 1, 2006.
Ins 3.39(5)(c)16. 16. Payment 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(5)(c)17. 17. Payment 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(5)(i) (i) Permissible additional coverage only added to the policy as separate riders. The issuer shall issue a separate rider for each coverage the issuer chooses to offer. Issuers shall ensure that the riders offered are compliant with MMA, that each rider is priced separately, available for purchase separately at any time, subject to underwriting and the pre-existing limitation allowed in sub. (4) (a) 2., and may consist of the following:
Ins 3.39(5)(i)1. 1. Coverage for the Medicare Part A hospital deductible. The rider shall be designated: MEDICARE PART A DEDUCTIBLE RIDER;
Ins 3.39(5)(i)2. 2. Coverage for home health care for an aggregate of 365 visits per policy year as required by s. 632.895 (1) and (2), Stats. The rider shall be designated as: ADDITIONAL HOME HEALTH CARE RIDER;
Ins 3.39(5)(i)3. 3. Coverage for the Medicare Part B medical deductible. The rider shall be designated as: MEDICARE PART B DEDUCTIBLE RIDER;
Ins 3.39(5)(i)4. 4. Coverage for the difference between Medicare's Part B eligible charges and the amount charged by the provider which 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(5)(i)5. 5. Coverage for benefits obtained outside the United States. An issuer which offers this benefit shall not limit coverage to Medicare deductibles 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, which care would have been covered by Medicare if provided in the United States and which care began during at least the first 60 consecutive days of each trip outside the United States and a lifetime maximum benefit of at least $50,000. For purposes of this benefit, "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 RIDER.
Ins 3.39(5)(i)7. 7. At least 50% of the charges for outpatient prescription drugs after a deductible of no greater than $250 per year to a maximum of at least $3,000 in benefits received by the insured per year. The rider shall be designated as: OUTPATIENT PRESCRIPTION DRUG RIDER. This rider may only be offered for issuance or sale until January 1, 2006 in accordance with MMA.
Ins 3.39(5)(j) (j) For HMO Medicare select policies, only the benefits specified in sub. (30) (p), (r) and (s), in addition to Medicare benefits.
Ins 3.39(5)(k) (k) For the Medicare supplement high deductible plan that may be issued only prior to December 31, 2005 or renewed thereafter in accordance with sub. (29) (b) 1., the following:
Ins 3.39(5)(k)1. 1. The designation: MEDICARE SUPPLEMENT INSURANCE - HIGH DEDUCTIBLE PLAN.
Ins 3.39(5)(k)2. 2. 100% of the covered benefits described in pars. (c) and (i) 1., 2., 3., 4. and 5. following the payment of the annual high deductible.
Ins 3.39(5)(k)3. 3. The annual high deductible shall consist of out-of-pocket expenses, other than premiums, for services covered in subd. 2. and shall be in addition to any other specific benefit deductibles.
Ins 3.39(5)(k)4. 4. The annual high deductible shall be $1500 for 1999, and shall be based on the calendar year. It shall be adjusted annually thereafter by the secretary to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of $10.
Ins 3.39(5)(m) (m) For the Medicare supplement high deductible drug plan that may be issued only prior to December 31, 2005 or renewed thereafter in accordance with sub. (4) (a) 20., the following:
Ins 3.39(5)(m)1. 1. The designation: MEDICARE SUPPLEMENT INSURANCE - HIGH DEDUCTIBLE DRUG PLAN.
Ins 3.39(5)(m)2. 2. 100% of the covered benefits described in pars. (c) and (i) 1., 2., 3., 4., 5. and 7. following the payment of the annual high deductible.
Ins 3.39(5)(m)3. 3. The annual high deductible shall consist of out-of-pocket expenses, other than premiums, for services covered in subd. 2. and shall be in addition to any other specific benefit deductibles.
Ins 3.39(5)(m)4. 4. The annual high deductible shall be $1500 for 1999, and shall be based on the calendar year. It shall be adjusted annually thereafter by the secretary to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of $10.
Ins 3.39(5)(n) (n) For the Medicare Supplement 50% Cost-Sharing plans, only the following:
Ins 3.39(5)(n)1. 1. The designation: Medicare Supplement 50% cost-sharing plan;
Ins 3.39(5)(n)2. 2. Coverage of 100% of the Medicare Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;
Ins 3.39(5)(n)3. 3. Coverage for 100% of the Medicare Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;
Ins 3.39(5)(n)4. 4. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system rate, or other appropriate Medicare standard of payment, subject to a lifetime limitation benefit of an additional 365 days;
Ins 3.39(5)(n)5. 5. Medicare Part A Deductible: Coverage for 50% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subd. 12.;
Ins 3.39(5)(n)6. 6. Skilled Nursing Facility Care: Coverage for 50% of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subd. 12.;
Ins 3.39(5)(n)7. 7. Hospice Care: Coverage for 50% of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subd. 12.;
Ins 3.39(5)(n)8. 8. Coverage for 50%, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations until the out-of-pocket limitation is met as described in subd. 12.;
Ins 3.39(5)(n)9. 9. Except for coverage provided in subd. 11., coverage for 50% of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Medicare Part B deductible until the out-of-pocket limitation is met as described under subd. 12.;
Ins 3.39(5)(n)10. 10. Coverage of 100% of the cost sharing for the benefits described in pars. (c) 1., 5., 6., 8., 13., 16., and 17., and (i) 2., to the extent the benefits do not duplicate benefits paid by Medicare and after the policyholder pays the Medicare Part A and Part B deductible and meets the out-of-pocket limitation described under subd. 12.;
Ins 3.39(5)(n)11. 11. Coverage of 100% of the cost sharing for Medicare Part B preventive services after the policyholder pays the Medicare B deductible; and
Ins 3.39(5)(n)12. 12. Coverage of 100% of all cost sharing under Medicare Part A or B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $4,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary.
Ins 3.39(5)(o) (o) For the Medicare Supplement 25% Cost-Sharing plans, only the following:
Ins 3.39(5)(o)1. 1. The designation: Medicare Supplement 25% cost-sharing plan;
Ins 3.39(5)(o)2. 2. Coverage of 100% of the Medicare Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;
Ins 3.39(5)(o)3. 3. Coverage for 100% of the Medicare Part A hospital co-insurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;
Ins 3.39(5)(o)4. 4. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system rate, or other appropriate Medicare standard of payment, subject to a lifetime limitation benefit of an additional 365 days;
Ins 3.39(5)(o)5. 5. Medicare Part A Deductible: Coverage for 75% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subd. 12.;
Ins 3.39(5)(o)6. 6. Skilled Nursing Facility Care: Coverage for 75% of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subd. 12.;
Ins 3.39(5)(o)7. 7. Hospice Care: Coverage for 75% of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subd. 12.;
Ins 3.39(5)(o)8. 8. Coverage of 75%, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations until the out-of-pocket limitation is met as described in subd. 12.;
Ins 3.39(5)(o)9. 9. Except for coverage provided in subd. 11., coverage for 75% of the cost sharing otherwise applicable under Medicare Part B, after the policyholder pays the Medicare Part B deductible until the out-of-pocket limitation is met as described in subd. 12.;
Ins 3.39(5)(o)10. 10. Coverage of 100% of the cost sharing for the benefits described in pars. (c) 1., 5., 6., 8., 13., 16., and 17., and (i) 2., to the extent the benefits do not duplicate benefits paid by Medicare and after the policyholder pays the Medicare Part A and Part B deductible and meets the out-of-pocket limitation described under subd. 12.;
Ins 3.39(5)(o)11. 11. Coverage for 100% of the cost sharing for Medicare Part B preventive services after the policyholder pays the Medicare Part B deductible; and
Ins 3.39(5)(o)12. 12. Coverage for 100% of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $2,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary.
Ins 3.39(5m) (5m)Authorized Medicare supplement policy and certificate designation, captions, required coverages, and permissible additional benefits for policies or certificates with effective dates on or after June 1, 2010.
Ins 3.39(5m)(a)1.1. The following standards are applicable to all Medicare supplement policies or certificates delivered or issued in this state. No policy or certificate may be advertised, solicited, delivered, or issued for delivery in this state as a Medicare supplement policy or certificate unless it complies with these benefit standards. Benefit standards applicable to Medicare supplement policies and certificates with effective dates prior to June 1, 2010 remain subject to the applicable requirements contained in sub. (5).
Ins 3.39(5m)(a)2. 2. For a policy or certificate to meet the requirements of sub. (4s), it shall contain the authorized designation, caption and required coverage. A health maintenance organization shall place the letters HMO in front of the required designation on any approved Medicare supplement policy or certificate. A Medicare supplement policy or certificate shall include all of the following:
Ins 3.39(5m)(b) (b) The designation: MEDICARE SUPPLEMENT INSURANCE.
Ins 3.39(5m)(c) (c) The 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(5m)(d) (d) The following required coverages shall be referred to as "Basic Medicare Supplement Coverage:"
Ins 3.39(5m)(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(5m)(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(5m)(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(5m)(d)4. 4. Coverage of coinsurance or copayments for all Medicare Part A eligible expenses for hospice and respite care.
Ins 3.39(5m)(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(5m)(d)6. 6. Coverage for the usual and customary home care expenses to a minimum of 40 visits per 12-month period as required under s. 632.895 (1) and (2), Stats., and s. Ins 3.54.
Ins 3.39(5m)(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(5m)(d)8. 8. In group policies, coverage for nervous and mental disorder and alcoholism and other drug abuse coverage as required under s. 632.89, Stats.
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Published under authority of s. 35.93, Stats. Updated on the first day of each month. Entire code is alwaycurrent. The date shown on each chapter is the date the chapter was last published.