Conn. Agencies Regs. tit. 38a, 495, app A
[Company Name]
Notice of Changes in Medicare and your Medicare
Supplement Coverage-199X
The following chart briefly describes the modifications in Medicare and in your medicare supplement coverage. PLEASE READ THIS CAREFULLY!
[A brief description of the revisions to Medicare Parts A & B with a parallel description of supplemental benefits with subsequent changes, including dollar amounts, provided by the Medicare supplement coverage in substantially the following format.]
SERVICES | MEDICARE BENEFITS Effective January 1, 199X, Medicare Will Pay | YOUR MEDICARE SUPPLEMENT COVERAGE Effective January 1, 199X, Your Coverage Will Pay |
MEDICARE PART A SERVICE AND SUPPLIES | ||
Inpatient Hospital Services | ||
Semi-Private Room & Board | ||
Misc. Hospital Servivces & Supplies, such as Drugs, X-Rays, Lab Tests & Operating Rooom | ||
BLOOD | ||
SKILLED NURSING FACILITY CARE |
Conn. Agencies Regs. tit. 38a, 495, app A