* These are optional riders. You purchased this benefit if the box is checked and you paid the premium
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy's “Core Benefits."
MEDICARE SUPPLEMENT POLICIES - PART B BENEFITS
Note: Issuers should include only the wording that applies to their policy's “This Policy Pays" column and complete the “You Pay" column.
Note: Add the following text in a bold or contrasting color if the policy is a Medicare Supplement High Deductible Plan as defined in sub. (5) (k) or (m) only until December 31, 2005: This high deductible plan pays the same as a non-high deductible plan after one has paid a calendar year [$ ] deductible. Benefits will not begin until out-of-pocket expenses are $[ ]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include [the plan's separate foreign travel emergency deductible].
-
See PDF for table 
*Once you have been billed [$ ] of Medicare approved amounts for covered services (which are noted with an asterisk), your Medicare Part B deductible will have been met for the calendar year.
**These are optional riders. You purchased this benefit if the box is checked and you paid the premium.
OUTLINE OF COVERAGE - B
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT 50% and 25% COST-SHARING PLANS
(The designation required by sub. (5) (n) 1. and (o) 1.)
You will pay [half or one quarter] the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[ ] each calendar year. The amounts that count toward your annual limit are noted with diamonds (◇) in the chart below. Once you reach the annual limit, the policy plays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare approved amounts (these are called “Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE COST-SHARING PART A – HOSPITAL SERVICES – PER BENEFIT PERIOD
Note: Issuers should include only the wording that applies to their policy's “This Policy Pays" column and complete the “You Pay" column.
A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
-
See PDF for table
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy's “Core Benefits."
MEDICARE COST-SHARING POLICIES - PART B BENEFITS
Note: Issuers should include only the wording which applies to their policy's “This Policy Pays" column and complete the “You Pay" column.
-
See PDF for table
*Once you have been billed [$ ] of Medicare approved amounts for covered services (which are noted with an asterisk), your Medicare Part B deductible will have been met for the calendar year.
**These are optional riders. You purchased this benefit if the box is checked and you paid the premium.
OUTLINE OF COVERAGE - C
(COMPANY NAME)
OUTLINE OF MEDICARE COST INSURANCE
(The designation and caption required by sub. (7) (a))
MEDICARE COST PART A – HOSPITAL SERVICES – PER BENEFIT PERIOD
Note: Issuers should include only the wording that applies to their policy's “This Policy Pays" column and complete the “You Pay" column.
A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Note: Add the following bracketed information that is appropriate for a Medicare cost policy with either basic or enhanced benefits.
-
See PDF for table
* These are optional riders. You purchased this benefit if the box is checked and you paid the premium
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy's “Core Benefits."
MEDICARE COST POLICIES - PART B BENEFITS
Note: Issuers should include only the wording that applies to their policy's “This Policy Pays" column and complete the “You Pay" column.
Note: Add the following bracketed information that is appropriate for a Medicare cost policy with either basic or enhanced benefits.
-
See PDF for table
*Once you have been billed [$ ] of Medicare approved amounts for covered services (which are noted with an asterisk), your Medicare Part B deductible will have been met for the calendar year.
**These are optional riders. You purchased this benefit if the box is checked and you paid the premium.
OUTLINE OF COVERAGE - D
(COMPANY NAME)
OUTLINE OF MEDICARE SELECT INSURANCE AND
MEDICARE SELECT 50% and 25% COST-SHARING PLANS
(The designation and caption required by sub. (30) (i) 8. and 9.,
or the designation required by subs. (30) (q) 1. and (r) 1.)
Note: Add the following text if the policy is a Medicare Select 50% or 25% Cost-Sharing Plan: You will pay [half or ◇one quarter] the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[ ] each calendar year. The amounts that count toward your annual limit are noted with diamonds (◇) in the chart below. Once you reach the annual limit, the policy plays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare approved amounts (these are called “Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE SELECT PART A – HOSPITAL SERVICES – PER BENEFIT PERIOD
Note: Issuers should include only the wording that applies to their policy's “This Policy Pays" column and complete the “You Pay" column.
A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
-
See PDF for table
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy's “Core Benefits."
MEDICARE SELECT POLICIES - PART B BENEFITS
Note: Issuers should include only the wording that applies to their policy's “This Policy Pays" column and complete the “You Pay" column.
-
See PDF for table
*Once you have been billed [$ ] of Medicare approved amounts for covered services (which are noted with an asterisk), your Medicare Part B deductible will have been met for the calendar year.
** NOTE: Insurers should include in the outline of coverage the appropriate preventive benefit based upon whether or not the policy is a cost-sharing policy.
Ins 3.39 APPENDIX 2m
For policies issued to persons first eligible for Medicare on or after June 1, 2010, and prior to January 1, 2020, the following information shall be inserted prior to each outline of coverage provided to an insured and include the information specific to the plan type.
PREMIUM INFORMATION
We can only raise your premium if we raise the premium for all policies like yours in this state. [Include information specifying when premiums will change.]
If your policy was issued as an under age 65 policy due to disability, when you turn 65 premiums will remain at the disabled rates. [Include this statement within premium information when issuer does not change premium to age 65 rate.]
DISCLOSURES
Use this outline to compare benefits and premiums among policies.
READ YOUR POLICY VERY CAREFULLY
This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.
RIGHT TO RETURN POLICY
If you find that you are not satisfied with your policy, you may return it to (insert issuer's address). If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all your payments directly to you.
POLICY REPLACEMENT
If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
NOTICE
This policy may not fully cover all of your medical costs.
(1) The outline of coverage for a Medicare cost insurance policy as described in s.
600.03 (28p) (a) and
(c), Stats., shall contain the following language: Medicare cost insurance policy: This policy provides basic Medicare hospital and physician benefits. It also includes benefits beyond those provided by Medicare. This policy is a replacement for Medicare and is subject to certain limitations in choice of providers and area of service. The policy does not provide benefits for custodial care such as help in walking, getting in and out of bed, eating, dressing, bathing, and taking medicine.
(2) (a) In 24–point type: For Medicare supplement policies marketed by intermediaries:
Neither (insert company's name) nor its agents are connected with Medicare.
(b) In 24–point type: For Medicare supplement policies marketed by direct response:
(insert company's name) is not connected with Medicare.
(c) For Medicare cost policies as described in s.
600.03 (28p) a. and c., Stats.:
(insert company's name) has contracted with Medicare to provide Medicare benefits. Except for emergency care anywhere or urgently needed care when you are temporarily out of the service area, all services, including all Medicare services, must be provided or authorized by (insert company's name).
(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 reflect accurately 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.
The following information shall be inserted AFTER the specific plan type outline of coverage that is provided to all insureds. The information shall include the information specific to the plan type.
(4) 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 preexisting 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.
(5) 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.
(6) A description of policy provisions respecting renewability or continuation of coverage, including any reservation of rights to change premium.
(7) 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.
