$ ( ) 4. 100% of the Medicare Part B medical coinsurance that is subject to copayment or coinsurance of no more than $20 per office visit and no more than $50 per emergency room visit in addition to the Medicare Part B coinsurance and in addition to out-of-pocket maximums. The emergency room copayment or coinsurance fee shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.
$ ( ) 5. Medicare Part B excess charges
Difference between the Medicare eligible charge and the amount charged by the provider that shall be no greater than the actual charge or the limited charge allowed by Medicare, whichever is less
$ ( ) 6. Foreign travel emergency rider
After a deductible not greater than $250, covers at least 80% of expenses associated with emergency medical care received outside the U.S.A. during the first 60 days of a trip with a lifetime maximum of at least $50,000
__________
$ ( ) TOTAL FOR BASIC POLICY AND SELECTED OPTIONAL BENEFITS
(Note: The soliciting agent shall enter the appropriate premium amounts and the total at the time this outline is given to the applicant. Medicare select policies and the Medicare Supplement 50% and 25% Cost-Sharing plans and Medicare Select 50% and 25% Cost-Sharing plans shall modify the outline to reflect the benefits that are contained in the policy or certificate and the optional or included riders.)
IN ADDITION TO THIS OUTLINE OF COVERAGE, [ISSUER] WILL SEND AN ANNUAL NOTICE TO YOU 30 DAYS PRIOR TO THE EFFECTIVE DATE OF MEDICARE CHANGES THAT WILL DESCRIBE THESE CHANGES AND THE CHANGES IN YOUR MEDICARE SUPPLEMENT COVERAGE.
(11) If premiums for each rating classification are not listed in the outline of coverage under subsection (10), then the issuer shall give a separate schedule of premiums for each rating classification with the outline of coverage.
(12) Include a summary of or reference to the coverage required by applicable statutes.
(13) The term “certificate" should be substituted for the word “policy" throughout the outline of coverage where appropriate.
Ins 3.39 APPENDIX 3m
OUTLINE OF COVERAGE
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT INSURANCE
(The designation and caption required by sub. (4m) (b) 4.)
MEDICARE SUPPLEMENT 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: This includes the Medicare deductibles for Part A and Part B, but does not include [the plan's separate riders deductible.]
Note: Add the following text in a bold or contrasting color if the plan is a Medicare supplement insurance - high deductible plan as defined at sub. (5m) (k): This high deductible plan offers benefits after one has paid a calendar year [$2000] deductible. This deductible consists of 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 
* 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 issuer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy's “Core Benefits."
*** This optional rider may reduce your premium when you pay 50% of Medicare Part A deductible.
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 plan is a Medicare supplement insurance-high deductible plan as defined at sub. (5m) (k): This high deductible plan offers benefits after one has paid a calendar year [$2000] deductible. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.
-
See PDF for table
* Once you have been billed [$ ] of Medicare approved amounts for covered services (that 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.
*** This is an optional rider that may decrease your premium when you pay copayments for medical and emergency room visits.
INS 3.39 APPENDIX 3t
OUTLINE OF COVERAGE
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT INSURANCE
(The designation and caption required by sub. (4t) (b) 4.)
MEDICARE SUPPLEMENT 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: This includes the Medicare deductibles for Part A and Part B but does not include [the plan's separate riders deductible.]
Note: Add the following text in a bold or contrasting color if the plan is a Medicare supplement insurance - high deductible plan as described at sub. (5t) (k): This high deductible plan offers benefits after one has paid a calendar year [$2000] deductible. This deductible consists of 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
* 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 issuer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy's “Core Benefits."
*** This optional rider may reduce your premium when you pay 50% of Medicare Part A deductible.
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 plan is a Medicare supplement insurance-high deductible plan as described at sub. (5t) (k): This high deductible plan offers benefits after one has paid a calendar year [$2000] deductible. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the plan's separate foreign travel emergency deductible.
-
See PDF for table
* Once you have been billed [$ ] of Medicare approved amounts for covered services (that 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.
*** This is an optional rider that may decrease your premium when you pay copayments for medical and emergency room visits.
Ins 3.39 APPENDIX 4m
OUTLINE OF COVERAGE
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT 50% and 25% COST-SHARING PLANS
(The designation required by sub. (5m) (g) 1. and (h) 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 $[ ] each calendar year. The amounts that count toward your annual out-of-pocket limit are noted with diamonds (◇) in the chart below. Once you reach the annual out-of-pocket limit, the policy plays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare approved amounts (these are called “Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE COST-SHARING PART A – HOSPITAL SERVICES – PER BENEFIT PERIOD
Note: Issuers should include only the wording that applies to their policy's “This Policy Pays" column and complete the “You Pay" column.
A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
-
See PDF for table
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the issuer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy's “Core Benefits."
MEDICARE COST-SHARING POLICIES – PART B BENEFITS
Note: Issuers should include only the wording that applies to their policy's “This Policy Pays" column and complete the “You Pay" column.
-
See PDF for table
* Once you have been billed [$ ] of Medicare approved amounts for covered services (that 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.
INS 3.39 APPENDIX 4t
OUTLINE OF COVERAGE
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT 50% and 25% COST-SHARING PLANS
(The designation required by sub. (5t) (g) 1. and (h) 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 $[ ] each calendar year. The amounts that count toward your annual out-of-pocket limit are noted with diamonds (◇) in the chart below. Once you reach the annual out-of-pocket limit, the policy plays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare approved amounts (these are called “Excess Charges"). You will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE COST-SHARING PART A – HOSPITAL SERVICES – PER BENEFIT PERIOD
Note: Issuers should include only the wording that applies to their policy's “This Policy Pays" column and complete the “You Pay" column.
A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
-
See PDF for table
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the issuer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy's “Core Benefits."
MEDICARE COST-SHARING POLICIES – PART B BENEFITS
Note: Issuers should include only the wording that applies to their policy's “This Policy Pays" column and complete the “You Pay" column.
-
See PDF for table
* Once you have been billed [$ ] of Medicare approved amounts for covered services (that 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.
Ins 3.39 APPENDIX 5m
OUTLINE OF COVERAGE
(COMPANY NAME)
OUTLINE OF MEDICARE SELECT INSURANCE AND
MEDICARE SELECT 50% and 25% COST-SHARING PLANS
(The designation and caption required by sub. (30m) (i) 8. and 9., or the designation required by sub. (30m) (r) 1. and (s) 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 out-of-pocket 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 issuer 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
