760 Ind. Admin. Code 3-14-1
Authority: IC 27-8-13
Affected: IC 27-8-13-1
Sec. 1.
Delivery of the Guide shall be made whether or not the policies or certificates are advertised, solicited, or issued as Medicare supplement policies or certificates as defined in this article. Except in the case of direct response issuers, delivery of the Guide shall be made to the applicant at the time of application and acknowledgement of receipt of the Guide shall be obtained by the issuer. Direct response issuers shall deliver the Guide to the applicant upon request, but not later than at the time the policy is delivered.
As used in this section, "form" means the language, format, type size, type proportional spacing, bold character, and line spacing.
The outline of coverage shall be in the language and format prescribed in subsections (f) through (h) in not smaller than 12-point type. All plans shall be shown on the cover page, and the plans that are offered by the issuer shall be prominently identified. Premium information for plans that are offered shall be shown on the cover page or immediately following the cover page and shall be prominently displayed. The premium and mode shall be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant shall be illustrated.
"THIS [POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT [POLICY OR CONTRACT]. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company.".
DISCLOSURE STATEMENTS
Instructions for Use of the Disclosure Statements for
Health Insurance Policies Sold to Medicare Beneficiaries that Duplicate Medicare
*****
[Original disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.]
| IMPORTANT NOTICE TO PERSONS ON MEDICARE. THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS |
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. 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:
* hospital or medical expenses up to the maximum stated in the policy
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
* other approved items and services
| BEFORE YOU BUY THIS INSURANCE |
[TICK] Check the coverage in all health insurance policies you already have.
[TICK] For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
[TICK] For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
[Original disclosure statement for policies that reimburse expenses incurred for specified disease(s) or other specified impairment(s). This includes expense incurred cancer, specified disease, and other types of health insurance policies that limit reimbursement to named medical conditions.]
| IMPORTANT NOTICE TO PERSONS ON MEDICARE. THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS |
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one (1) of the specific diseases or health 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:
* hospital or medical expenses up to the maximum stated in the policy
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
* other approved items and services
| BEFORE YOU BUY THIS INSURANCE |
[TICK] Check the coverage in all health insurance policies you already have.
[TICK] For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
[TICK] For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
*****
[Original disclosure statement for policies that provide benefits for specified limited services.]
| IMPORTANT NOTICE TO PERSONS ON MEDICARE. THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS |
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services 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:
* any of the services covered by the policy are also covered by Medicare
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* hospitalization
* physician services
* other approved items and services
| BEFORE YOU BUY THIS INSURANCE |
[TICK] Check the coverage in all health insurance policies you already have.
[TICK] For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
[TICK] For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
*****
[Original disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.]
| IMPORTANT NOTICE TO PERSONS ON MEDICARE. THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS |
This is not Medicare Supplement Insurance
This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one (1) of the specific diseases or health conditions named 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 because Medicare generally pays for most of the expenses for the diagnosis and treatment of the specific conditions or diagnoses named in the policy.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* hospitalization
* physician services
* hospice
* other approved items and services
| BEFORE YOU BUY THIS INSURANCE |
[TICK] Check the coverage in all health insurance policies you already have.
[TICK] For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
[TICK] For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
*****
[Original disclosure statement for policies that provide benefits for both expenses incurred and fixed indemnity basis.]
| IMPORTANT NOTICE TO PERSONS ON MEDICARE. THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS |
This is not Medicare Supplement Insurance
This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
* any expenses or services covered by the policy are also covered by Medicare; or
* it pays the fixed dollar amount stated in the policy and Medicare covers the same event
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 care
* other approved items and services
| BEFORE YOU BUY THIS INSURANCE |
[TICK] Check the coverage in all health insurance policies you already have.
[TICK] For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
[TICK] For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
*****
[Original disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long term care policies.]
| IMPORTANT NOTICE TO PERSONS ON MEDICARE. THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS |
This is not Medicare Supplement Insurance
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductible or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
* any expenses or services covered by the policy are also covered 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 care
* other approved items and services
| BEFORE YOU BUY THIS INSURANCE |
[TICK] Check the coverage in all health insurance policies you already have.
[TICK] For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
[TICK] For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
*****
[Original disclosure statement for other health insurance policies not specifically identified in the previous statements.]
| IMPORTANT NOTICE TO PERSONS ON MEDICARE. THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS |
This is not Medicare Supplement Insurance
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
* other approved items and services
| BEFORE YOU BUY THIS INSURANCE |
[TICK] Check the coverage in all health insurance policies you already have.
[TICK] For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
[TICK] For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
*****
[Alternative disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.]
| IMPORTANT NOTICE TO PERSONS ON MEDICARE. THIS IS NOT MEDICARE SUPPLEMENT INSURANCE |
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 policy conditions, for hospital or medical expenses that result from accidental injury. 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
* 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.
| BEFORE YOU BUY THIS INSURANCE |
[TICK] Check the coverage in all health insurance policies you already have.
[TICK] For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
[TICK] For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
*****
[Alternative disclosure statement for policies that provide benefits for specified limited services.]
| IMPORTANT NOTICE TO PERSONS ON MEDICARE. THIS IS NOT MEDICARE SUPPLEMENT INSURANCE |
Some health care services paid for by Medicare may also trigger the payment of benefits under this policy.
This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* hospitalization
* physician services
* 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.
| BEFORE YOU BUY THIS INSURANCE |
[TICK] Check the coverage in all health insurance policies you already have.
[TICK] For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
[TICK] For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
*****
[Alternative disclosure statement for policies that reimburse expenses incurred for specified diseases or other specified impairments. This includes expense incurred cancer, specified disease, and other types of health insurance policies that limit reimbursement to named medical conditions.]
| IMPORTANT NOTICE TO PERSONS ON MEDICARE. THIS IS NOT MEDICARE SUPPLEMENT INSURANCE |
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy. Medicare generally pays for most or all of these expenses.
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one (1) of the specific diseases or health 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
* 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.
| BEFORE YOU BUY THIS INSURANCE |
[TICK] Check the coverage in all health insurance policies you already have.
[TICK] For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
[TICK] For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
*****
[Alternative disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.]
| IMPORTANT NOTICE TO PERSONS ON MEDICARE. THIS IS NOT MEDICARE SUPPLEMENT INSURANCE |
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one (1) of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
* hospitalization
* physician services
* hospice
* 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.
| BEFORE YOU BUY THIS INSURANCE |
[TICK] Check the coverage in all health insurance policies you already have.
[TICK] For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
[TICK] For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
*****
[Alternative disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long term care policies.]
| IMPORTANT NOTICE TO PERSONS ON MEDICARE. THIS IS NOT MEDICARE SUPPLEMENT INSURANCE |
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. 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
* 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.
| BEFORE YOU BUY THIS INSURANCE |
[TICK] Check the coverage in all health insurance policies you already have.
[TICK] For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
[TICK] For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
*****
[Alternative disclosure statement for policies that provide benefits upon both an expense incurred and fixed indemnity basis.]
| IMPORTANT NOTICE TO PERSONS ON MEDICARE. THIS IS NOT MEDICARE SUPPLEMENT INSURANCE |
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. 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 care
* 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.
| BEFORE YOU BUY THIS INSURANCE |
[TICK] Check the coverage in all health insurance policies you already have.
[TICK] For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
[TICK] For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
*****
[Alternative disclosure statement for other health insurance policies not specifically identified in the preceding statements.]
| IMPORTANT NOTICE TO PERSONS ON MEDICARE. THIS IS NOT MEDICARE SUPPLEMENT INSURANCE |
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
* 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.
| BEFORE YOU BUY THIS INSURANCE |
[TICK] Check the coverage in all health insurance policies you already have.
[TICK] For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
[TICK] For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
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 the premiums will change.] DISCLOSURES [Boldface Type]
Use this outline to compare benefits and premiums among policies.
READ YOUR POLICY VERY CAREFULLY [Boldface Type]
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]
The policy may not fully cover all of your medical costs.
[for agents:]
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 "The Medicare Handbook" 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.
760 IAC 3-14-1