$ ( ) 6. 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
$ ( ) 7. 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 2t
For policies issued to persons newly eligible for Medicare on or after 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.