N.Y. Comp. Codes R. & Regs. tit. 11, Appendices, app 12B
(c.f. Part 58)
Required disclosure statement for policies and certificates of Medicare supplement insurance meeting the standards of sections 52.11 and 52.14 of this Title and sections 58.1 and 58.4 of this Part issued with an effective date for coverage on or after June 1, 2010, including revisions effective January 1, 2020. The appendix contains the items that shall be included in the disclosure statement in the order prescribed therein. The disclosure statement shall consist of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The disclosure statement shall be in the language and format prescribed below in not less than 12-point type. All benefit plans "A" through "D", "F", high deductible "F+", "G", high deductible "G+", and "K" through "N" shall be shown on the cover page, and the plan(s) 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.
N.Y. Comp. Codes R. & Regs. tit. 11, Appendices, app 12B