N.H. Admin. Code Ins, ch. Ins 1900, pt. Ins 1905, app C
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
* [outpatient prescription drugs if you are enrolled in Medicare Part D]
* other approved items and services
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[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
* [outpatient prescription drugs if you are enrolled in Medicare Part D]
* other approved items and services
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Original 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 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 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
* [outpatient prescription drugs if you are enrolled in Medicare Part D]
* other approved items and services
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[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 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
* [outpatient prescription drugs if you are enrolled in Medicare Part D]
* other approved items and services
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[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 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
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
* [outpatient prescription drugs if you are enrolled in Medicare Part D]
* hospice
* other approved items and services
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Original disclosure statement for policies that provide benefits upon both an expense-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
* [outpatient prescription drugs if you are enrolled in Medicare Part D]
* other approved items & services
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Original disclosure statement for other health insurance policies not specifically identified in the preceding 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
* [outpatient prescription drugs if you are enrolled in Medicare Part D]
* other approved items and services
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[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
* [outpatient prescription drugs if you are enrolled in Medicare Part D]
* 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
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[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
* [outpatient prescription drugs if you are enrolled in Medicare Part D]
* 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
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[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 P ersons 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 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
* [outpatient prescription drugs if you are enrolled in Medicare Part D]
* 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
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[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 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
* [outpatient prescription drugs if you are enrolled in Medicare Part D]
* 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
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[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
* [outpatient prescription drugs if you are enrolled in Medicare Part D]
* 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
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[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
* [outpatient prescription drugs if you are enrolled in Medicare Part D]
* other approved items & 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
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[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
* [outpatient prescription drugs if you are enrolled in Medicare Part D]
* 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
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
________________
N.H. Admin. Code Ins, ch. Ins 1900, pt. Ins 1905, app C
The amended version of this appendix by New Hampshire Register Volume 37, Number 37, eff. 10/13/2017 is not yet available.