Ill. Admin. Code tit. 50, pt. 2008, subpt. G, app B
[COMPANY NAME]
Outline of Medicare Supplement Coverage - Cover Page: 1 of 2
Benefit Plans ______ [insert letters of plans being offered]
These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan "A". Some plans may not be available in Illinois.
See Outlines of Coverage sections for details about all plans.
BASIC BENEFITS FOR PLANS A-J:
Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses), or copayments for hospital outpatient services.
Blood: First 3 pints of blood each year.
A | B | C | D | E |
Basic Benefits | Basic Benefits | Basic Benefits | Basic Benefits | Basic Benefits |
Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | ||
Part A Deductible | Part A Deductible | Part A Deductible | Part A Deductible | |
Part B Deductible | ||||
Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | ||
At-Home Recovery | ||||
Preventive Care NOT Covered by Medicare |
F F* | G | H | I | J J* |
Basic Benefits | Basic Benefits | Basic Benefits | Basic Benefits | Basic Benefits |
Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance |
Part A Deductible | Part A Deductible | Part A Deductible | Part A Deductible | Part A Deductible |
Part B Deductible | Part B Deductible | |||
Part B Excess (100%) | Part B Excess (80%) | Part B Excess (100%) | Part B Excess (100%) | |
Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency |
At-Home Recovery | At-Home Recovery | At-Home Recovery | ||
Preventive Care NOT Covered by Medicare |
Plans F and J also have an option called a high deductible Plan F and a high deductible Plan J. These high deductible plans pay the same benefits as Plans F and J after one has paid a calendar year [$_____] deductible. Benefits from high deductible Plans F and J will not begin until out-of-pocket expenses are [$_____]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.
NOTE:
Companies must add the current fixed dollar amount authorized by Medicare where the brackets appear above. The dollar amount is updated periodically by Medicare and companies must reflect these changes to their outlines of coverage in a timely manner.
[COMPANY NAME]
Outline of Medicare Supplement Coverage - Cover Page 2
Basic Benefits for Plans K and L include similar services as Plans A-J, but cost-sharing for the basic benefits is at different levels.
J | K** | L** |
Basic Benefits | 100% of Part A Hospitalization Coinsurance plus coverage for 365 days after Medicare benefits end 50% Hospice cost-sharing 50% of Medicare-eligible expenses for the first 3 pints of blood 50% Part B Coinsurance, except 100% coinsurance for Part B Preventive Services | 100% of Part A Hospitalization Coinsurance plus coverage for 365 days after Medicare benefits end 75% Hospice cost-sharing 75% of Medicare-eligible expenses for the first 3 pints of blood 75% Part B Coinsurance, except 100% coinsurance for Part B Preventive Services |
Skilled Nursing Coinsurance | 50% Skilled Nursing Facility Coinsurance | 75% Skilled Nursing Facility Coinsurance |
Part A Deductible | 50% Part A Deductible | 75% Part A Deductible |
Part B Deductible | ||
Part B Excess (100%) | ||
Foreign Travel Emergency | ||
At-Home Recovery | ||
Preventive Care NOT Covered by Medicare | ||
$[ ] Out of Pocket Annual Limit*** | $[ ] Out of Pocket Annual Limit*** |
** Plans K and L provide for different cost-sharing for items and services than Plans A-J.
Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance, and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called "excess charges". You will be responsible for paying excess charges.
***The out-of-pocket annual limit will increase each year for inflation.
See Outlines of Coverage for details and exceptions.
PREMIUM INFORMATION [Boldface Type]
We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this State. [If the premium is based on the increasing age of the insured, include information specifying when premiums will change.]
DISCLOSURES [Boldface Type]
Use this outline to compare benefits and premiums among policies.
This outline shows benefits and premiums of policies sold for effective dates prior to June 1, 2010.
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 [Boldface Type]
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 of your payments.
POLICY REPLACEMENT [Boldface Type]
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 [Boldface Type]
This policy may not fully cover all of your medical costs.
(for producers:)
Neither (insert company's name) nor its agents are connected with Medicare.
(for direct response:)
(insert company's name) is not connected with Medicare.
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security office or consult "Medicare & You" for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT [Boldface Type]
When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. [If the policy or certificate is guaranteed issue, this paragraph need not appear.]
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
[Include for each plan prominently identified on the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in Appendices C through N of this Part. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this Appendix. An issuer may use additional benefit plan designations on these charts pursuant to Section 2008.72(d) of this Part.]
[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the Director.]
Ill. Admin. Code tit. 50, pt. 2008, subpt. G, app B