This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
○ the benefits stated in the policy and coverage for the same event is provided by Medicare
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
○ hospitalization
○ physician services
○ hospice
○ [outpatient prescription drugs if you are enrolled in Medicare
Part D]
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the “Wisconsin Guide to Health Insurance for People with Medicare," available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
(h) [Alternative disclosure statement for other health insurance policies not specifically identified in the preceding statements.]
-
See PDF for table 
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
○ hospitalization
○ physician services
○ hospice
○ [outpatient prescription drugs if you are enrolled in Medicare
Part D]
○ other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
- See PDF for table
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the “Wisconsin Guide to Health Insurance for People with Medicare", available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
Ins 3.40
Ins 3.40 Coordination of benefits provisions in group and blanket disability insurance policies. Ins 3.40(1)(a)(a) This section establishes authorized coordination of benefits provisions for group and blanket disability insurance policies pursuant to s.
631.23, Stats. It has been found that these clauses are necessary to provide certainty of meaning. Regulation of contract forms will be more effective, and litigation will be substantially reduced if there is uniformity regarding coordination of benefits provisions in health insurance policies.
Ins 3.40(1)(b)
(b) A Coordination of benefits (COB) provision as defined in sub.
(3) (e) avoids claim payment delays be establishing an order in which Plans pay their claims and by providing the authority for the orderly transfer of information needed to pay claims promptly. It avoids duplication of benefits by permitting a reduction of the benefits of a Plan when, by the rules established by this section, a Plan does not have to pay its benefits first.
Ins 3.40(1)(c)
(c) Coordinating health benefits has been found to be an effective tool in containing health care costs. However, minimum standards of protection and uniformity are needed to protect the insured's and the public's interest.
Ins 3.40(2)
(2)
Scope. This section applies to all group and blanket disability insurance policies subject to s.
631.01 (1), Stats., that provide 24-hour continuous coverage for medical or dental care, treatment or expenses due to either injury or sickness that contain a coordination of benefits provision, an “excess,"“anti-duplication," “non-profit" or “other insurance" exclusion by whatever name designated under which benefits are reduced because of other insurance, other than an exclusion for expenses covered by worker's compensation, employer's liability insurance, or individual traditional automobile “fault" contracts. Except as permitted under s.
632.32 (4) (a) 2., Stats., this section applies to the medical benefits provisions in an automobile “no fault" type or group or group-type “fault" policy. A policy subject to this section may reduce benefits because of Medicare only to the extent permitted by federal law and shall comply with s.
632.755, Stats., when reducing benefits because of coverage by or eligibility for medical assistance.
Ins 3.40(3)(a)
(a) “Allowable expense" means the necessary, reasonable, and customary item of expense for health care, when the item of expense is covered at least in part by one or more Plans covering the person for whom the claim is made, except as provided in sub.
(4).
Ins 3.40(3)(b)
(b) “Claim" means a request that benefits of a Plan be provided or paid. The benefits claimed may be in the form of any of the following:
Ins 3.40(3)(c)
(c) “Claim determination period" means the period of time over which allowable expenses are compared with total benefits payable in the absence of COB to determine whether overinsurance exists and how much each Plan will pay or provide. However, it does not include any part of a year before the date this COB provision or a similar provision takes effect.
Ins 3.40(3)(d)
(d) “Complying Plan" means a Plan with order of benefit determination rules which comply with this section.
Ins 3.40(3)(e)
(e) A “Coordination of benefits (COB) provision" means an insurance contract provision intended to avoid claims payment delays and duplication of benefits when a person is covered by 2 or more plans providing benefits or services for medical, dental or other care or treatment.
Ins 3.40(3)(f)
(f) “Group-type contracts" means contracts which are not available to the general public and may be obtained and maintained only because of membership in or connection with a particular organization or group. Group-type contracts answering this description may be included in the definition of Plan at the option of the insurer issuing group-type plans or the service provider and its contract-client, whether or not uninsured arrangements or individual contract forms are used and regardless of how the group-type coverage is designated (for example, “franchise" or “blanket"). The use of payroll deductions by the employee, subscriber or member to pay for the coverage is not sufficient, of itself, to make an individual contract part of a group-type plan. Group-type contracts do not include individually underwritten and issued, guaranteed renewable policies that may be purchased through payroll deduction at a premium savings to the insured.
Ins 3.40(3)(g)
(g) “Hospital indemnity benefits" means benefits for hospital confinement which are not related to expenses incurred but does not include plans that reimburse a person for actual hospital expenses incurred even if the plans are designed or administered to give the insured the right to elect indemnity-type benefits at the time of claim.
Ins 3.40(3)(h)
(h) “Noncomplying Plan" means a Plan that declares its benefits to be “excess" or “always secondary" or that uses order of benefit determination rules inconsistent with those contained in this section.
Ins 3.40(3)(i)
(i) “Plan" means a form of coverage providing benefits for medical or dental care, except as limited under sub.
(6), with which coordination is allowed.
Ins 3.40(3)(j)
(j) “Primary Plan" means a health care plan, determined by the order of benefit determination rules, whose benefits shall be determined before those of the other Plan and without taking the existence of any other Plan into consideration.
Ins 3.40(3)(k)
(k) “Secondary Plan" means a plan which is not a Primary Plan according to the order of benefit determination rules and whose benefits are determined after those of another Plan and may be reduced because of the other plan's benefits.
Ins 3.40(3)(L)
(L) “This Plan" means the part of the group contract that provides the health care benefits to which the COB provision applies and which may be reduced because of the benefits of other Plans. Any other part of the group contract providing health care benefits is separate from This Plan.
Ins 3.40(4)
(4)
Allowable expense uses and limitations. Ins 3.40(4)(a)
(a) Items of expense under dental care, vision care, prescription drug or hearing aid programs may be excluded from the definition of allowable expense. A Plan which provides benefits only for these items may limit its definition of allowable expense to these items of expense.
Ins 3.40(4)(b)
(b) When a Plan provides benefits in the form of services, the reasonable cash value of each service rendered shall be considered as both an allowable expense and a benefit paid.
Ins 3.40(4)(c)
(c) The difference between the cost of a private hospital room and the cost of a semi-private hospital room is not considered an allowable expense under the above definition unless the patient's stay in a private hospital room is medically necessary in terms of generally accepted medical practice or as specifically defined in the Plan.
Ins 3.40(4)(d)
(d) When COB is restricted in its use to a specific coverage in a contract, for example, major medical or dental, the definition of allowable expense shall include the corresponding expenses or services to which COB applies.
Ins 3.40(5)
(5)
Claim determination period uses and limitations. Ins 3.40(5)(a)
(a) A claim determination period may not be less than 12 months and usually is a calendar year, but a Plan may use some other period of time that fits the coverage of the group contract. A person may be covered by a Plan during a portion of a claim determination period if that person's coverage starts or ends during that claim determination period.
Ins 3.40(5)(b)
(b) As each claim is submitted, each Plan shall determine its liability and pay or provide benefits based upon allowable expenses incurred to that point in the claim determination period. However, that determination is subject to adjustment as later allowable expenses are incurred in the same claim determination period.
Ins 3.40(6)(a)
(a) The definition of Plan in the group contract shall state the types of coverage which shall be considered in applying the COB provision of that contract. The right to include a type of coverage is limited by the rest of this subsection.
Ins 3.40(6)(b)
(b) The definition of Plan shown in the model COB provision in APPENDIX A is an example of what may be used. Any definition that satisfies sub.
(3) (i) and this subsection may be used.
Ins 3.40(6)(c)
(c) Notwithstanding the fact that this section uses the term “Plan," a group contract may instead use “Program" or some other term.
Ins 3.40(6)(d)
(d) “Plan" shall not include individual or family insurance or subscriber contracts or individual or family coverage through health maintenance organizations (HMOs), limited service health organizations (LSHOs), or any other prepayment, group practice or individual practice plan except as provided in pars.
(e) and
(f).
Ins 3.40(6)(e)
(e) “Plan" may include: group insurance and group subscriber contracts; uninsured arrangements of group or group-type coverage; group or group-type coverage through HMOs, LSHOs and other prepayment, group practice and individual practice plans; and group-type contracts.
Ins 3.40(6)(f)
(f) “Plan" may include the medical benefits coverage in group, group-type, and individual automobile “no-fault" contracts; but, as to the traditional automobile “fault" contracts, only the medical benefits written on a group or group-type basis may be included.
Ins 3.40(6)(g)
(g) If “Plan" includes Medicare or other governmental benefits, that part of the definition of “Plan" may be limited to the hospital, medical and surgical benefits of the governmental program. However, “Plan" shall not include a state plan under Medicaid (Title XIX, Grants to State for Medical Assistance Programs, of the United States Social Security Act as amended from time to time) and shall not include a law or plan whose benefits, by law, are excess to those of any private insurance plan or other non-government plan.
Ins 3.40(6)(h)
(h) “Plan" shall not include group or group-type hospital indemnity benefits of $100 per day or less but may include the amount by which group or group-type hospital indemnity benefits exceed $100 per day.
Ins 3.40(6)(i)
(i) “Plan" shall not include school accident-type coverages that cover grammar, high school, and college students for accidents only, including athletic injuries, either on a 24-hour basis or on a “to and from school" basis.
Ins 3.40(6)(j)
(j) Each contract or other arrangement for coverage is a separate Plan. If an arrangement has 2 parts and COB rules apply only to one of the 2, each of the parts is a separate Plan.
Ins 3.40(7)
(7)
Primary plan and secondary plan uses and limitations. Ins 3.40(7)(a)(a) The order of benefit determination rules state whether This Plan is a Primary Plan or Secondary Plan as to another plan covering the person.
Ins 3.40(7)(b)
(b) There may be more than one Primary Plan. A Plan is a Primary Plan if either subd.
1. or
2. is true:
Ins 3.40(7)(b)1.
1. The Plan either has no order of benefit determination rules, or it has rules that differ from sub.
(11).
Ins 3.40(7)(b)2.
2. All plans that cover the person are complying plans and, under sub.
(11), the Plan determines its benefits first.
Ins 3.40(7)(c)
(c) When there are more than 2 plans covering the person, This Plan may be a Primary Plan as to one or more other Plans and may be a Secondary Plan as to a different Plan or Plans.
Ins 3.40(7)(d)
(d) If a person is covered by more than one Secondary Plan, the order of benefit determination rules of this section decide the order in which the benefits are determined in relation to each other. The benefits of each Secondary Plan may take into consideration the benefits of the Primary Plan or Plans and the benefits of any other Plan which, under the rules of this section, has its benefits determined before those of that Secondary Plan.
Ins 3.40(8)(a)(a) This coordination of benefits (COB) provision applies to This Plan when an employee or the employee's covered dependent has health care coverage under more than one Plan.
Ins 3.40(8)(b)
(b) If this COB provision applies, the order of benefit determination rules shall be looked at first. Those rules determine whether the benefits of This Plan are determined before or after those of another Plan.
Ins 3.40(8)(c)
(c) The benefits of This Plan shall not be reduced when, under the order of benefit determination rules, This Plan is primary and determines its benefits before another Plan.
Ins 3.40(8)(d)
(d) The benefits of This Plan may be reduced when, under the order of benefit determination rules, another Plan determines its benefits first.
Ins 3.40(9)
(9)
Flexibility and consistency with this section. Ins 3.40(9)(a)
(a) APPENDIX A shall be considered authorized clauses pursuant to s.
631.23, Stats., for use in policy forms subject to this section and shall only be changed as provided in this section.
Ins 3.40(9)(b)
(b) This section permits but does not require the use of COB or “other insurance" provisions. However, if such provisions are used, they must conform with this section and substantially conform to the clauses contained in APPENDIX A. Liberalization of the prescribed language in APPENDIX A, including rearrangement of the order of the clauses, is permitted provided that the modified language is not less favorable to the insured person.
Ins 3.40(9)(c)
(c) Policy language which reduces benefits because of other insurance and which is inconsistent with this section violates the criteria of s.
631.20, Stats., and shall not be used.
Ins 3.40(9)(d)
(d) A Plan that includes a COB provision inconsistent with this section shall not take the benefits of another Plan into account when it determines its benefits. There is one exception: a contract holder's coverage that is designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the Plan provided by the contract holder.
Ins 3.40(9)(e)
(e) A group contract's COB provision does not have to use the words and format contained in APPENDIX A. Changes may be made to fit the language and style of the rest of the group contract or to reflect the differences among Plans which provide services, which pay benefits for expenses incurred, and which indemnify. Substantive changes are allowed only as set forth in this section.
Ins 3.40(9)(f)
(f) A term such as “usual and customary," “usual and prevailing," or “reasonable and customary" may be substituted for the term “necessary, reasonable and customary." Terms such as “medical care" or “dental care" may be substituted for “health care" to describe the coverages to which the COB provisions apply.
Ins 3.40(9)(g)
(g) A group contract may apply one COB provision to certain of its benefits (such as dental benefits), coordinating only with like benefits, and may apply other separate COB provisions to coordinate other benefits.
