OPTIONAL BENEFITS FOR MEDICARE SUPPLEMENT OR MEDICARE SELECT POLICY
Each of these riders may be purchased separately.
(Note: Only optional coverages provided by rider shall be listed here.)
$ ( ) 1. 100% of the Medicare Part A hospital deductible
$ ( ) 2. 50% of the Medicare Part A hospital deductible per benefit period with no out-of-pocket maximum
$ ( ) 3. Additional home health care
An aggregate of 365 visits per year including those covered by Medicare
$ ( ) 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.
SECTION 87. INS 3.39 Appendix 3 is renumbered INS 3.39 Appendix 3m and INS 3.39 Appendix 3m (title) and (subtitle), as renumbered, are amended to read:
INS 3.39 APPENDIX 33m (title)
OUTLINE OF COVERAGE
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT INSURANCE
(The designation and caption required by sub. (4s)(4m) (b) 4.)
SECTION 88. INS 3.39 Appendix 3t is created to read:
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.
SERVICES | PER BENEFIT PERIOD | MEDICARE PAYS | [AFTER YOU PAY A
$[ ] DEDUCTIBLE]
THIS POLICY PAYS | YOU PAY |
HOSPITALIZATION Semiprivate room and board, general nursing and miscellaneous hospital services and supplies. | First 60 days | All but $ [current deductible] | $0 or [V OPTIONAL PART A DEDUCTIBLE RIDER* (for non-high deductible plans)] [V PART A DEDUCTIBLE RIDER* (for high deductible plans)] V OPTIONAL MEDICARE 50% PART A DEDUCTIBLE RIDER*** | |
| 61st to 90th days | All but $ [current amount] per day | $ [current amount] per day | |
| 91st day and after while using 60 lifetime reserve days | All but $ [current amount] per day | $ [current amount] per day | |
| Once lifetime reserve days are used:
Additional 365 days | $0 | 100% of Medicare
eligible expenses** | |
| Beyond the additional 365 days | $0 | $0 | |
SKILLED NURSING FACILITY CARE You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital | First 20 days | All approved amounts | $0 | |
| 21st through 100th day | All but $ [current amount] per day | Up to $[ ] a day | |
| 101st day and after | $[0] | $0 | |
INPATIENT
PSYCHIATRIC CARE Inpatient psychiatric care in a participating psychiatric hospital | | 190 days per lifetime | 175 days per lifetime | |
BLOOD | First 3 pints | $0 | First 3 pints | |
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services. | | All but very limited coinsurance or
copayment for
outpatient drugs and inpatient respite care | $0 or [ ]% of coinsurance or copayments | |
* 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.
MEDICARE PART B BENEFITS | PER CALENDAR YEAR | MEDICARE PAYS | [AFTER YOU PAY A
$[ ] DEDUCTIBLE]
THIS POLICY PAYS | YOU PAY |
MEDICAL EXPENSES Eligible expense for
physician’s services,
in-patient and out-patient medical services and
supplies, physical and speech therapy, diagnostic tests, durable medical
equipment | First $[ ] of Medicare approved amounts* | $0 | $0 | |
| Remainder of Medicare approved amounts | Generally 80% | Generally 20% [V OPTIONAL MEDICARE PART B EXCESS CHARGES RIDER** (for non-high deductible plans)] [V MEDICARE PART B EXCESS CHARGES RIDER** (for high deductible plans)] [V OPTIONAL FOREIGN TRAVEL EMERGENCY RIDER** (non-high deductible plans)] [V FOREIGN TRAVEL EMERGENCY RIDER** (for high-deductible plans)] | |
BLOOD | First 3 pints | $0 | All costs | |
| Next $[ ] of Medicare approved amounts* | $0 | [$] | |
| Remainder of Medicare approved amounts | 80% | 20% | |
CLINICAL LABORATORY SERVICES Tests for diagnostic services | | 100% | $0 | |
HOME HEALTH CARE | | 100% of charges for visits considered medically necessary by Medicare | 40 visits or V OPTIONAL
ADDITIONAL HOME HEALTH CARE RIDER** | |
FOREIGN TRAVEL—
NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA | First $250 each calendar year | [$0] | $250 | 20% and amounts over the $50,000 lifetime maximum |
| Remainder of charges | | 80% to a lifetime maximum benefit of $50,000 | |
[PREVENTIVE MEDICAL CARE BENEFIT—
NOT COVERED BY MEDICARE Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare.]* | [First $120 each
calendar year] | [$0] | [$120] | |
| [Additional charges] | [$0] | [$0] or $[dollar amount] | |
* Once you have been billed [$ ] 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.
SECTION 89. INS 3.39 Appendix 4 is renumbered INS 3.39 Appendix 4m and INS 3.39 Appendix 4m (title), as renumbered, is amended to read:
INS 3.39 APPENDIX 44m (title)
OUTLINE OF COVERAGE
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT INSURANCE
(The designation and caption required by sub. (5m) (g) 1. and (h) 1.)
SECTION 90. INS 3.39 Appendix 4t is created to read:
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.
SERVICES | PER BENEFIT PERIOD | MEDICARE PAYS | [AFTER YOU PAY A
$[ ] DEDUCTIBLE]
THIS POLICY PAYS | YOU PAY |
HOSPITALIZATION Semiprivate room and board, general nursing and miscellaneous hospital services and supplies. | First 60 days | All but $ [current deductible] | $[ ] (50% or 75% of Medicare Part A
deductible.) | |
| 61st to 90th days | All but $ [current amount] per day | $ [current amount] per day | |
| 91st day and after while using 60 lifetime reserve days | All but $ [current amount] per day | $ [current amount] per day | |
| Once lifetime reserve days are used:
Additional 365 days | $0 | 100% of Medicare
eligible expenses** | |
| Beyond the additional 365 days | $0 | $0 | |
SKILLED NURSING FACILITY CARE You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital | First 20 days | All approved amounts | $0 | |
| 21st through 100th day | All but $ [current amount] per day | Up to $[ ] a day | |
INPATIENT
PSYCHIATRIC CARE Inpatient psychiatric care in a participating psychiatric hospital | | 190 days per lifetime | 175 days per lifetime | |
BLOOD | First 3 pints | $0 | [50% or 75%] | |
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services. | | All but very limited coinsurance or
copayment for
outpatient drugs and inpatient respite care | [50% or 75%] of
coinsurance or
copayments | |
** 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.
MEDICARE PART B BENEFITS | PER CALENDAR YEAR | MEDICARE PAYS | [AFTER YOU PAY A
$[ ] DEDUCTIBLE]
THIS POLICY PAYS | YOU PAY |
MEDICAL EXPENSES Eligible expense for
physician’s services,
in-patient and out-patient medical services and
supplies, physical and speech therapy, diagnostic tests, durable medical
equipment | First $[ ] of Medicare approved amounts* | $0 | $0 | |
| Preventive Benefits for Medicare covered services | Generally 75% or more of Medicare approved amounts | Remainder of Medicare approved amounts | |
| Remainder of Medicare approved amounts | Generally 80% | Generally [10% or 15%] | |
BLOOD | First 3 pints | $0 | [50% or 75%] | |
| Next $[ ] of Medicare approved amounts* | $0 | $0 | |
| Remainder of Medicare approved amounts | Generally 80% | Generally [10% or 15%] | |
CLINICAL LABORATORY SERVICES Tests for diagnostic services | | 100% | $0 | |
HOME HEALTH CARE | | 100% of charges for visits considered medically necessary by Medicare | 40 visits or V OPTIONAL
ADDITIONAL HOME HEALTH CARE RIDER** | |
[PREVENTIVE MEDICAL CARE BENEFIT –
NOT COVERED BY MEDICARE Some annual physical and preventive tests and services administered or ordered by your doctor when not
covered by Medicare.]* | [First $120 each
calendar year] | [$0] | [$120] | |
| [Additional charges]** | [$0]** | [$0] or $[dollar amount]** | |
* Once you have been billed [$ ] 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.
SECTION 91. INS 3.39 Appendix 5 is renumbered INS 3.39 Appendix 5m and INS 3.39 Appendix 5m (title), as renumbered, is amended to read:
