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 cost policy designation, captions and required minimum coverages. Ins 3.39(7)(a)(a) A Medicare cost policy that is 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 issued to persons first eligible for Medicare after January 1, 2005, and prior to June 1, 2010: 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 100th 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 cost policies are exempt from the provisions of s. 632.73 (2m), Stats., and are subject to all of the following: Ins 3.39(7)(b)1.1. Medicare cost 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 cost policy shall include a written provision providing for the right to disenroll that shall contain all of the following: Ins 3.39(7)(b)1.c.c. Include the following language or substantially similar language approved by the commissioner. “You may disenroll from 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 that 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 cost 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) For Medicare cost policies issued to persons first eligible for Medicare prior to June 1, 2010, each issuer offering Medicare cost policies may offer an enhanced Medicare cost policy that contains the coverage described in sub. (5) (c) 5., 6., 7., 8., 13., 15., 16., 17., and the riders described in sub. (5) (i). Ins 3.39(7)(cm)(cm) For Medicare cost policies issued to persons first eligible for Medicare on or after June 1, 2010, and prior to January 1, 2020, each issuer offering Medicare cost policies may offer an enhanced Medicare cost policy that contains the coverage described in sub. (5m) (d) 6., 7., 8., 10., 14., 16., 17., and the riders described in sub. (5m) (e). Ins 3.39(7)(ct)(ct) For Medicare cost policies issued to individuals newly eligible for Medicare on or after January 1, 2020, each issuer offering Medicare cost policies may offer an enhanced Medicare cost policy that contains the coverage described in sub. (5t) (d) 6., 7., 8., 10., 14., 16. and 17., and the riders described in sub. (5t) (e). 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 to persons first eligible for Medicare on or after June 1, 2010, and prior to January 1, 2020, 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 2m 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(7)(dt)(dt) For Medicare cost policies issued to persons newly eligible for Medicare on or after January 1, 2020, 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 2t 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. (5t). Ins 3.39(8)(8) Permissible Medicare supplement policy and certificate, Medicare select policy and certificate, and Medicare cost policy exclusions and limitations. 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), (5t), (7), (30), (30m), and (30t) 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 cost policy, Medicare supplement policy or certificate and Medicare select policy or certificate may include other exclusions and limitations that 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)(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)(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), (4m), (4t), (5), (5m), (5t) 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)(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)(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(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 described in sub. (2) (d), even if they are Medicare supplement and Medicare select policies as described in s. 600.03 (28r), Stats., or Medicare cost policies as described in s. 600.03 (28p) (a) and (c), Stats., shall not be subject to either of the following: Ins 3.39(13)(b)(b) The special preexisting disease provisions for Medicare supplement, Medicare select, or Medicare cost 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 to persons first eligible for Medicare 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 cost policy form, one group Medicare select certificate form and one group Medicare supplement certificate 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 complying with all of the following: Ins 3.39(14)(c)1.1. Accepting a notice from a Medicare issuer 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)4.4. Furnishing, at the time of enrollment, each insured with a card listing the policy name, number and a central mailing address to which notices from a Medicare issuer 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 issuers. 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 Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost 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 Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost 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 discontinued policy form or certificate for in this state. Ins 3.39(14)(d)2.2. An issuer that discontinues the availability of a Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy form or certificate form pursuant to subd. 1., shall not file for approval a new policy form or certificate form for a period of 5 years after the issuer provides notice to the commissioner of the discontinuance. The period of discontinuance may be reduced if the commissioner determines that a shorter period is appropriate. Ins 3.39(14)(e)(e) The sale or other transfer of Medicare supplement business to another issuer shall be considered a discontinuance for the purposes of this subsection. Ins 3.39(14)(f)(f) A change in the rating structure or methodology shall be considered a discontinuance under par. (d) 1. unless the issuer complies with the following requirements: Ins 3.39(14)(f)1.1. The issuer provides an actuarial memorandum, in a form and manner prescribed by the commissioner, describing the manner in which the revised rating methodology and resultant rates differ from the existing rating methodology and resultant rates. Ins 3.39(14)(f)2.2. The issuer does not subsequently put into effect a change of rates or rating factors that would cause the percentage differential between the discontinued and subsequent rates as described in the actuarial memorandum to change. The commissioner may approve a change to the differential which is in the public interest. Ins 3.39(14)(g)(g) Except as provided in par. (h) the experience of all policy forms or certificate forms of the same type in a standard Medicare supplement benefit plan shall be combined for purposes of the refund or credit calculation prescribed in sub. (31).
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