14 Va. Admin. Code § 5-160-110:1
NOTICE OF CHANGES IN MEDICARE AND YOUR MEDICARE SUPPLEMENT COVERAGE-1990
THE FOLLOWING OUTLINE BRIEFLY DESCRIBES THE MODIFICATIONS IN MEDICARE AND IN YOUR MEDICARE SUPPLEMENT COVERAGE. PLEASE READ THIS CAREFULLY!
[A BRIEF DESCRIPTION OF THE REVISIONS TO MEDICARE PARTS A & B WITH A PARALLEL DESCRIPTION OF SUPPLEMENTAL BENEFITS WITH SUBSEQUENT CHANGES, INCLUDING DOLLAR AMOUNTS, PROVIDED BY THE MEDICARE SUPPLEMENT COVERAGE IN SUBSTANTIALLY THE FOLLOWING FORMAT.]
| SERVICES | MEDICARE BENEFITS | YOUR MEDICARE SUPPLEMENT COVERAGE | ||
| In 1989 Medicare Per Calendar Year | Effective January 1, 1990, Medicare Will Pay | In 1989 Your Coverage Pays | Effective January 1, 1990, Your Coverage Will Pay Per Calendar Year | |
| MEDICARE PART A SERVICES AND SUPPLIES | ||||
| Inpatient 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-90 days/benefit period | |||
| Misc. Hospital Services & Supplies, such as Ddrugs, X-Rays, Lab Tests & Operating Room | All but $296 a day for 91st-150 days (if individual chooses to use 60 nonrenewable days) | |||
| BLOOD | Pays all costs except payment of deductible (equal to costs for first three pints) each calendar year. Part A blood deductible reduced to the extent paid under Part B | Pays all costs except nonreplacement fees (blood deductible) for first three pints in each benefit period | ||
| SKILLED NURSING FACILITY CARE | There is no prior confinement requirement for this benefit | 100% of costs for 1st 20 days (after a three-day prior hospital confinement)/benefit period | ||
| First eight days - all but $25.50 a day | All but $74 a day for 21st-100th days/benefit period | |||
| 9th through 150th day - 100% of costs | Beyond 100 days Nothing/benefit period | |||
| Beyond 150 days - Nothing | ||||
| MEDICARE PART B SERVICES AND SUPPLIES | 80% of allowable charges (after $75 deductible/calendar year) | 80% of allowable charges (after $75 deductible) | ||
| PRESCRIPTION | Inpatient prescription drugs. 80% of allowable charges for immuno-suppressive drugs during the first year following a covered transplant (after $75 deductible/calendar year) | Inpatient prescription drugs. 80% of allowable charges for immuno-suppressive drugs during the first year following a covered transplant (after $75 deductible/calendar year) | ||
| BLOOD | 80% of all costs except nonreplacement fees (blood deductible) for first three pints in each benefit period (after $75 deductible/calendar year) | 80% of costs except nonreplacement fees (blood deductible) for first three pints in each benefit period (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 benefits. If there are corresponding Medicare benefits, they should be shown.]
[Describe any coverage provisions changing due to Medicare modifications.]
[Include information about when 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]
14 Va. Admin. Code § 5-160-110:1