Ins 3.39(5m)(h)10. 10. Coverage for 100% of the cost sharing for the benefits described in pars. (d) 1., 6., 7., 9., 14., 16., and 17., and (e) 3., to the extent the benefits do not duplicate benefits paid by Medicare and after the policyholder or certificateholder pays the Medicare Part A and B deductible and meets the out-of-pocket limitation described in subd. 12.
Ins 3.39(5m)(h)11. 11. Coverage for 100% of the cost sharing for Medicare Part B preventive services after the policyholder or certificateholder pays the Medicare Part B deductible.
Ins 3.39(5m)(h)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 [$2,220], indexed each year by the appropriate inflation adjustment specified by the Secretary.
Ins 3.39(5m)(k) (k) For the Medicare supplement high deductible plan, the following:
Ins 3.39(5m)(k)1. 1. The designation: MEDICARE SUPPLEMENT INSURANCE-HIGH DEDUCTIBLE PLAN.
Ins 3.39(5m)(k)2. 2. Coverage for 100% of benefits described in pars. (d) and (e) 1., 3., 4., 6., and 7., following the payment of the annual high deductible.
Ins 3.39(5m)(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(5m)(k)4. 4. The annual high deductible shall be $2000 and shall be adjusted annually by the Secretary of the U.S. Department of Health and Human Services 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(6) (6)Usual, customary and reasonable charges. An issuer can only include a policy or certificate provision limiting benefits to the usual, customary and reasonable charge as determined by the issuer for coverages described in subs. (5) (c) 5., 8. and 13., or (5m) (d) 6., 9., and 14. If the issuer includes such a provision, the issuer shall:
Ins 3.39(6)(a) (a) Define those terms in the policy or rider and disclose to the policyholder that the UCR charge may not equal the actual charge, if this is true.
Ins 3.39(6)(b) (b) Have reasonable written standards based on similar services rendered in the locality of the provider to support benefit determination which shall be made available to the commissioner on request.
Ins 3.39(7) (7)Authorized Medicare replacement policy and certificate designation, captions and required minimum coverages.
Ins 3.39(7)(a)(a) A Medicare cost policy or certificate issued by an issuer that has a cost contract with CMS for Medicare benefits shall meet the standards and requirements of sub. (4) and shall contain all of the following required coverages, to be referred to as "Basic Medicare cost coverage" for a policy or certificate issued after January 1, 2005.
Ins 3.39(7)(a)1. 1. The designation: MEDICARE COST INSURANCE;
Ins 3.39(7)(a)2. 2. The caption, except that the word "certificate" may be used instead of "policy," if appropriate: "The Wisconsin Insurance Commissioner has set minimum standards for Medicare cost insurance. This policy meets these standards. 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 bought this policy. Do not buy this policy if you did not get this guide;"
Ins 3.39(7)(a)3. 3. Upon exhaustion of Medicare hospital inpatient psychiatric coverage, at least 175 days per lifetime for inpatient psychiatric hospital care;
Ins 3.39(7)(a)4. 4. Medicare Part A eligible expenses in a skilled nursing facility for the copayments for the 21st through the 100 th day;
Ins 3.39(7)(a)5. 5. All Medicare Part A eligible expenses for blood to the extent not covered by Medicare;
Ins 3.39(7)(a)6. 6. 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 Medicare Part B calendar year deductible;
Ins 3.39(7)(a)7. 7. Coverage for the first three pints of blood payable under Medicare Part B;
Ins 3.39(7)(a)8. 8. Coverage of Medicare Part A 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(7)(a)9. 9. Coverage of Medicare Part A eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days;
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 replacement policies, as defined in s. 600.03 (28p) (a) and (c), Stats., are exempt from the provisions of s. 632.73 (2m), Stats., and are subject to the following:
Ins 3.39(7)(b)1. 1. Medicare replacement 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 replacement policy shall include a written provision providing for the right to disenrolls which 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 disenrolls form 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 on which 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 replacement 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) Each Medicare cost issuer, as defined in s. 600.03 (28p) (a) and (c), Stats., may offer an enhanced Medicare cost plan that contain the coverage contained in sub. (5) (c) 5., 6., 7., 8., 13., 15., 16., 17., and the riders described in sub. (5) (i) and other coverages as authorized by CMS.
Ins 3.39(7)(cm) (cm) For Medicare cost policies issued on or after June 1, 2010, each Medicare cost issuer, as defined in s. 600.03 (28p) (a) and (c), Stats., may offer an enhanced Medicare cost plan that contain the coverage contained in sub. (5m) (d) 6., 7., 8., 10., 14., 16., and 17., and the riders described in sub. (5m) and other coverages as authorized by CMS.
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 on or after June 1, 2010, 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 2 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(8) (8)Permissible Medicare supplement and Medicare replacement policy or certificate exclusions and limitations.
Ins 3.39(8)(a)(a) The coverage set out in subs. (5), (5m), (7), (30) and (30m), 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), (7), (30), and (30m) 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 replacement policy and Medicare supplement policy may include other exclusions and limitations which 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.
Ins 3.39(9)(b) (b) Disclosure statements. The appropriate disclosure statement from Appendix 10 shall be used on the application or together with the application for each coverage in pars. (c) to (e). The disclosure statement may not vary from the text or format including bold characters, line spacing, and the use of boxes around text contained in Appendix 10 and shall use a type size of at least 12 points. The issuer may use either (a) or (aL), (b) or (bL), (c) or (cL) or (g) or (gL) providing the issuer uses the same disclosure statement for all policies of the type covered by the disclosure.
Ins 3.39(9)(c) (c) Hospital confinement indemnity coverage. An individual policy form providing hospital confinement indemnity coverage sold to a Medicare eligible person:
Ins 3.39(9)(c)1. 1. Shall not include benefits for nursing home confinement unless the nursing home coverage meets the standards set forth in s. Ins 3.46;
Ins 3.39(9)(c)2. 2. Shall bear the caption, if the policy provides no other types of coverage: "This policy is not designed to fill the gaps in Medicare. It will pay you only a fixed dollar amount per day when you are confined to a hospital. For more information, see "Wisconsin Guide to Health Insurance for People with Medicare', given to you when you applied for this policy."
Ins 3.39(9)(c)3. 3. Shall bear the caption set forth in par. (e), if the policy provides other types of coverage in addition to the hospital confinement indemnity coverage.
Ins 3.39(9)(d) (d) Specified disease coverage. An individual policy form providing benefits only for one or more specified diseases sold to a Medicare eligible person shall bear:
Ins 3.39(9)(d)1. 1. The designation: SPECIFIED OR RARE DISEASE LIMITED POLICY, and
Ins 3.39(9)(d)2. 2. The caption: "This policy covers only one or more specified or rare illnesses. It is not a substitute for a broader policy which would generally cover any illness or injury. For more information, see `Wisconsin Guide to Health Insurance for People with Medicare', given to you when you applied for this policy."
Ins 3.39(9)(e) (e) Other coverage. An individual disability policy sold to a Medicare eligible person, other than a form subject to sub. (5) or (7) or otherwise subject to the caption requirements in this subsection or exempted by sub. (2) (d) or (e), shall bear the caption: "This policy is not a Medicare supplement. For more information, see "Wisconsin Guide to Health Insurance for People with Medicare', given to you when you applied for this policy."
Ins 3.39(10) (10)Conversion or continuation of coverage.
Ins 3.39(10)(a)(a) Conversion requirements. An insured under individual, family, or group hospital or medical coverage who will become eligible for Medicare and is offered a conversion policy which is not subject to subs. (4) and (5) or (7) shall be furnished by the issuer, at the time the conversion application is furnished in the case of individual or family coverage or within 14 days of a request in the case of group coverage:
Ins 3.39(10)(a)1. 1. An outline of coverage as described in par. (d) and
Ins 3.39(10)(a)2. 2. A copy of the current edition of the pamphlet described in sub. (11).
Ins 3.39(10)(b) (b) Continuation requirements. An insured under individual, family, or group hospital or medical coverage who will become eligible for Medicare and whose coverage will continue with changed benefits (e.g., "carve-out" or reduced benefits) shall be furnished by the issuer, within 14 days of a request:
Ins 3.39(10)(b)1. 1. A comprehensive written explanation of the coverage to be provided after Medicare eligibility, and
Ins 3.39(10)(b)2. 2. A copy of the current edition of the pamphlet described in sub. (11).
Ins 3.39(10)(c) (c) Notice to group policyholder. An issuer which provides group hospital or medical coverage shall furnish to each group policyholder:
Ins 3.39(10)(c)1. 1. Annual written notice of the availability of the materials described in pars. (a) and (b), where applicable, and
Ins 3.39(10)(c)2. 2. Within 14 days of a request, sufficient copies of the same or a similar notice to be distributed to the group members affected.
Ins 3.39(10)(d) (d) Outline of coverage. The outline of coverage:
Ins 3.39(10)(d)1. 1. For a conversion policy which relates its benefits to or complements Medicare, shall comply with sub. (4) (b) 2., 5. and 7. of this section and shall be submitted to the commissioner; and
Ins 3.39(10)(d)2. 2. For a conversion policy not subject to subd. 1., shall comply with sub. (9), where applicable, and s. Ins 3.27 (5) (L).
Ins 3.39(11) (11)"Wisconsin Guide to Health Insurance for People with Medicare" pamphlet. Every prospective Medicare eligible purchaser of any policy or certificate subject to this section which provides hospital or medical coverage, other than incidentally, or of any coverage added to an existing Medicare supplement policy or certificate, except any policy subject to s. Ins 3.46, shall receive a copy of the current edition of the commissioner's pamphlet "Wisconsin Guide to Health Insurance for People with Medicare" in a type size no smaller than 12 point type at the time the prospect is contacted by an intermediary or issuer with an invitation to apply as defined in s. Ins 3.27 (5) (g). Except in the case of direct response insurance, written acknowledgement of receipt of this pamphlet shall be obtained by the issuer. This pamphlet provides information on Medicare and advice to people on Medicare on the purchase of Medicare supplement insurance and other health insurance. Issuers may obtain information from the commissioner's office on how to obtain copies or may reproduce this pamphlet themselves. This pamphlet may be periodically revised to reflect changes in Medicare and any other appropriate changes. No issuer shall be responsible for providing applicants the revised pamphlet until 30 days after the issuer has been given notice that the revised pamphlet is available.
Ins 3.39(12) (12)Approval not a recommendation. While the commissioner may authorize the use of a particular designation on a policy or certificate in accordance with this section, that authorization is not to be construed or advertised as a recommendation of any particular policy or certificate by the commissioner or the state of Wisconsin.
Ins 3.39(13) (13)Exemption of certain policies and certificates from certain statutory Medicare supplement requirements. Policies and certificates defined in sub. (2) (d), even if they are Medicare supplement policies as defined in s. 600.03 (28r), Stats., or Medicare replacement policies as defined in s. 600.03 (28p) (a) and (c), Stats., shall not be subject to either of the following:
Ins 3.39(13)(a) (a) The special right of return provision for Medicare supplement policies set forth in s. 632.73 (2m), Stats., and s. Ins 3.13 (2) (j) 3.
Ins 3.39(13)(b) (b) The special pre-existing diseases provisions for Medicare supplement policies set forth in s. 632.76 (2) (b), Stats.
Ins 3.39(14) (14)Other requirements for policies or certificates with effective dates prior to June 1, 2010.
Ins 3.39(14)(a)(a) Each issuer issuing policies or certificates with effective dates prior to June 1, 2010, may file and utilize only one individual Medicare supplement policy form, one individual Medicare select policy form, one individual Medicare replacement policy form and one group Medicare supplement policy form with any of the accompanying riders permitted in sub. (5) (i), unless the commissioner approves the use of additional forms and the issuer agrees to aggregate experience for the various forms in calculating rates and loss ratios.
Ins 3.39(14)(b) (b) An issuer shall mail any refund or return of premium directly to the insured and may not require or permit delivery by an agent or other representative.
Ins 3.39(14)(c) (c) An issuer shall comply with section 1882 (c) (3) of the Social Security Act, as enacted by section 4081 (b) (2) (C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Pub. L. No. 100-203, by:
Ins 3.39(14)(c)1. 1. Accepting a notice from a Medicare carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of any other claim form otherwise required and making a payment determination on the basis of the information contained in that notice;
Ins 3.39(14)(c)2. 2. Notifying the participating physician or supplier and the beneficiary of the payment determination;
Ins 3.39(14)(c)3. 3. Paying the participating physician or supplier directly;
Ins 3.39(14)(c)4. 4. Furnishing, at the time of enrollment, each enrollee with a card listing the policy name, number and a central mailing address to which notices from a Medicare carrier may be sent;
Ins 3.39(14)(c)5. 5. Paying user fees for claim notices that are transmitted electronically or otherwise;
Ins 3.39(14)(c)6. 6. Providing to the Secretary, at least annually, a central mailing address to which all claims may be sent by Medicare carriers; and
Ins 3.39(14)(c)7. 7. Certifying compliance with the requirements set forth in this subsection on the Medicare supplement insurance experience reporting form.
Ins 3.39(14)(d) (d) Except as provided in subd. 1., an issuer shall continue to make available for purchase any policy form or certificate form issued after August 1, 1992 that has been approved by the commissioner. A policy form or certificate form shall not be considered to be available for purchase unless the issuer has actively offered it for sale in the previous 12 months.
Ins 3.39(14)(d)1. 1. An issuer may discontinue the availability of a policy form or certificate form if the issuer provides to the commissioner in writing its decision at least 30 days prior to discontinuing the availability of the form of the policy or certificate. After receipt of the notice by the commissioner, the issuer shall no longer offer for sale the policy form or certificate form in this state.
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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.