C.M.R. 02, 031, ch. 270, app 031-270-A
[COMPANY NAME]
NOTICE OF CHANGES IN MEDICARE
AND YOUR MEDICARE SUPPLEMENT COVERAGE -- 1990
THE FOLLOWING CHART BRIEFLY DESCRIBES THE MODIFICATIONS IN MEDICARE AND IN YOUR MEDICARE SUPPLEMENT COVERAGE. PLEASE READ THIS CAREFULLY!
[A BRIEF DESCRIPTION, IN SUBSTANTIALLY THE FOLLOWING FORMAT, OF THE REVISIONS TO MEDICARE PARTS A & B, WITH A PARALLEL DESCRIPTION OF BENEFITS PROVIDED BY THE MEDICARE SUPPLEMENT COVERAGE AND SUBSEQUENT CHANGES, INCLUDING DOLLAR AMOUNTS.]
| SERVICES | MEDICARE BENEFITS | YOUR MEDICARE SUPPLEMENT COVERAGE | ||
| In 1989 Medicare Pays per calendar Year | Effective January 1, 1990, Medicare Will pay | In 1989 Your Coverage Pays | Effective January 1, 19990, Your Coverage Will Pay | |
| MEDICARE PART A SERVICES SUPPLIES | ||||
| In patient Hospital Services | Unlimited number of hospital days after $560 deductible | All but $592 for first 60 days/benefit period | ||
| Semi-private Room & Board | All but $148 a day for 61st-90th days/benefit period | |||
| Misc. Hospital Services & Supplies, such as Drugs, X-Rays, Lab Tests & Operating Room | All but $ 296 a day for 91st-10th days(if individual chooses to use 60 non renewable lifetime reserve days) | |||
| BLOOD | Pays all cost except payment of deductible(equal to costs for first 3 pints) each calendar year. Part A blood deductible reduced to the extent paid under Part B | Pays all cost except nonreplacement fees(blood deductible for first 3 pints in each calendar year | ||
| SKILLED NURSING FACILITY CARE | There is no prior confinement requirement for this benefit | 100% or cost for 1st 20 days (after a 3 day prior hospital confinement)/benefit period | ||
| First 8 days - All but 25.50 a day | All but $74.00 a day for 21st -100th days/benefit period | |||
| In 1989 Medicare Pays per Calendar Year | Effective January 1, 1990, Medicare Will Pay | In 1989 Your Coverage Pays | Effective January, 1 1990 Your Coverage Will Pay | |
| 9th thorough 150th day - 100% of costs | Beyond 100 days - Nothing/Benefit period | |||
| Beyond 150 days -- Nothing | ||||
| Medicare B Services And Supplies | 80% Of Allowable Charges (After $ 75 Deductible/calendar year | |||
| Prescription Drugs | Inpatient prescription drugs. 80% of allowable charges for immuno - suppressive drugs during the first year following covered transplant (after $74 deductible/calendar | |||
| BLOOD | 80% of all costs except not - replacement fees (blood deductible for first 3 pints in each benefit period (after $75 deductible / calendar year | 80% of all cost as except nonreplacement fees (blood deductible) for first 3 pints (after $ 75 deductible/calendar year) | ||
[Any other policy benefits not mentioned in this chart should be added to the chart in the order prescribed by the outline of coverage. If there are corresponding Medicare benefits, they should be shown.]
Describe any coverage provisions changing due to Medicare modifications.] [Include information about premium adjustments that may be necessary due to changes in Medicare benefits will be effective.]
THIS CHART SUMMARIZING THE CHANGES IN YOUR MEDICARE BENEFITS, AND IN YOUR MEDICARE SUPPLEMENT PROVIDED BY [COMPANY], ONLY BRIEFLY DESCRIBES SUCH BENEFITS. FOR INFORMATION ON YOUR MEDICARE BENEFITS CONTACT YOUR SOCIAL SECURITY OFFICE OR THE HEALTH CARE FINANCING ADMINISTRATION. FOR INFORMATION ON YOUR MEDICARE SUPPLEMENT [POLICY] CONTACT:
[COMPANY -- OR FOR AN INDIVIDUAL POLICY NAME OF AGENT] [ADDRESS/PHONE NUMBER]
C.M.R. 02, 031, ch. 270, app 031-270-A