Wis. Admin. Code Office of the Commissioner of Insurance § 1

Current through May 28, 2024

Appendix 1

For policies with an effective date prior to June 1, 2010 the following information shall be inserted prior to each outline of coverage provided to an insured and include the information specific to the plan type.

PREMIUM INFORMATION

We can only raise your premium if we raise the premium for all policies like yours in this state. [Include information specifying when premiums will change.]

If your policy was issued as an under age 65 policy due to disability, when you turn 65 premiums will remain at the disabled rates. [Include this statement within premium information when issuer does not change premium to age 65 rate.]

DISCLOSURES

Use this outline to compare benefits and premiums among policies.

READ YOUR POLICY VERY CAREFULLY

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

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 your payments directly to you.

POLICY REPLACEMENT

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

This policy may not fully cover all of your medical costs.

(1) The outline of coverage for a Medicare replacement insurance policy as defined in s. 600.03(28p) a and c., Stats., shall contain the following language: Medicare replacement insurance policy: This policy provides basic Medicare hospital and physician benefits. It also includes benefits beyond those provided by Medicare. This policy is a replacement for Medicare and is subject to certain limitations in choice of providers and area of service. The policy does not provide benefits for custodial care such as help in walking, getting in and out of bed, eating, dressing, bathing, and taking medicine.

(2)

(a) In 24-point type: For Medicare supplement policies marketed by intermediaries:

Neither (insert company's name) nor its agents are connected with Medicare.

(b) In 24-point type: For Medicare supplement policies marketed by direct response:

(insert company's name) is not connected with Medicare.

(insert company's name) has contracted with Medicare to provide Medicare benefits. Except for emergency care anywhere or urgently needed care when you are temporarily out of the service area, all services, including all Medicare services, must be provided or authorized by (insert company's name).

(3)

(a) For Medicare supplement policies, provide a brief summary of the major benefits and gaps in Medicare Parts A and B with a parallel description of supplemental benefits, including dollar amounts, as outlined in these charts.

(b) For Medicare replacement policies, as defined in s. 600.03(28p) a and c., Stats., provide a brief summary of both the basic Medicare benefits in the policy and additional benefits using the basic format as outlined in these charts and modified to accurately reflect the benefits.

(c) If the coverage is provided by a health maintenance organization as defined in s. 609.01(2), Stats., provide a brief summary of the coverage for emergency care anywhere and urgent care received outside the service area if this care is treated differently than other covered benefits.

(4) If the plan is a Medicare Supplement High Deductible Plan as defined in sub. (5) (n) or (o), add the following text in a bold or contrasting color: You will pay [half (for plans defined in sub. (5) (n))] [one quarter (for plans defined in sub. (5) (o))] of the cost-sharing of some covered services until you reach the annual out-of-pocket maximum of [$4,000 (for plans defined in sub. (5) (n))] [$2,000 (for plan defined in sub. (5) (o))] each calendar year. The amounts you must pay are noted in the chart below. Once you reach the annual limit, the plan pays for 100% for the items or services noted in the chart.

The following information shall be inserted AFTER the specific plan type outline of coverage that is provided to all insureds. The information shall include the information specific to the plan type.

(5) All limitations and exclusions, including each of the following, must be listed under the caption "LIMITATIONS AND EXCLUSIONS" if benefits are not provided:

(a) Nursing home care costs beyond what is covered by Medicare and the additional 30-day skilled nursing mandated by s. 632.895(3), Stats.

(b) Home health care above the number of visits covered by Medicare and the 365 visits mandated by s. 632.895(2), Stats. [For Medicare select policies only.]

(d) Outpatient prescription drugs.

(e) Most care received outside of U.S.A.

(f) Dental care, dentures, checkups, routine immunizations, cosmetic surgery, routine foot care, examinations for and the cost of eyeglasses or hearing aids, unless eligible under Medicare.

(g) Coverage for emergency care anywhere or for care received outside the service area if this care is treated differently than other covered benefits.

(h) Waiting period for pre-existing conditions.

(i) Limitations on the choice of providers or the geographical area served (if applicable for Medicare select policies only).

(j) Usual, customary, and reasonable limitations.

(6) CONSPICUOUS STATEMENTS AS FOLLOWS:

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult "Medicare & You" for more details.

(7) A description of policy provisions respecting renewability or continuation of coverage, including any reservation of rights to change premium.

(8) Information on how to file a claim for services received from non-participating providers because of an emergency within or outside of the service area shall be prominently disclosed.

(9) If there are restrictions on the choice of providers, a list of providers available to enrollees shall be included with the outline of coverage.

(10) A description of the review and appeal procedure for denied claims.

(11) The premium for the policy and riders, if any, in the following format:

MEDICARE SUPPLEMENT AND MEDICARE COST PREMIUM INFORMATION

Annual Premium

$ ( ) BASIC MEDICARE SUPPLEMENT OR MEDICARE COST COVERAGE

OPTIONAL BENEFITS FOR MEDICARE SUPPLEMENT OR MEDICARE COST POLICY

Each of these riders may be purchased separately.

(Note: Only optional coverages provided by rider shall be listed here.)

$ ( ) 1. Medicare Part A deductible

100% of Medicare Part A deductible

$ ( ) 2. Additional home health care

An aggregate of 365 visits per year including those covered by Medicare

$ ( ) 3. Medicare Part B deductible

100% of Medicare Part B deductible

$ ( ) 4. Medicare Part B excess charges

Difference between the Medicare eligible charge and the amount charged by the provider which shall be no greater than the actual charge or the limited charge allowed by Medicare, whichever is less

$ ( ) 5. Foreign travel rider

After a deductible not greater than $250, covers at least 80% of expenses associated with emergency medical care received outside the U.S.A. beginning the first 60 days of a trip with a lifetime maximum of at least $50,000

__________

$ ( ) TOTAL FOR BASIC POLICY AND SELECTED OPTIONAL BENEFITS

(Note: The soliciting agent shall enter the appropriate premium amounts and the total at the time this outline is given to the applicant. Medicare select policies and the Medicare Supplement 50% and 25% Cost-Sharing plans and Medicare Select 50% and 25% Cost-Sharing plans shall modify the outline to reflect the benefits that are contained in the policy and the optional or included riders.)

IN ADDITION TO THIS OUTLINE OF COVERAGE, [ISSUER] WILL SEND AN ANNUAL NOTICE TO YOU 30 DAYS PRIOR TO THE EFFECTIVE DATE OF MEDICARE CHANGES WITH WILL DESCRIBE THESE CHANGES AND THE CHANGES IN YOUR MEDICARE SUPPLEMENT COVERAGE.

(12) If premiums for each rating classification are not listed in the outline of coverage under subsection (11), then the issuer shall give a separate schedule of premiums for each rating classification with the outline of coverage.

(13) Include a summary of or reference to the coverage required by applicable statutes.

(14) The term "certificate" should be substituted for the word "policy" throughout the outline of coverage where appropriate.

Issuers shall select the appropriate outline of coverage specific to the plan being presented from among the following Outlines of Coverage A through D.

OUTLINE OF COVERAGE - A

(COMPANY NAME)

OUTLINE OF MEDICARE SUPPLEMENT INSURANCE

(The designation and caption required by sub. (4) (b) 4.)

MEDICARE SUPPLEMENT PART A - HOSPITAL SERVICES - PER BENEFIT PERIOD

Note: Issuers should include only the wording that applies to their policy's "This Policy Pays" column and complete the "You Pay" column.

A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

Note: Add the following text in a bold or contrasting color if the policy is a Medicare Supplement High Deductible Plan as defined in sub. (5) (k) or (m), only until December 31, 2005: This high deductible plan pays the same as a non-high deductible plan after one has paid a calendar year [$ ] deductible. Benefits will not begin until out-of-pocket expenses are [$]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include [the plan's separate foreign travel emergency deductible.]

SERVICES	PER BENEFIT PERIOD	MEDICARE PAYS	(AFTER YOU PAY A $[ ] DEDUCTIBLE) THIS POLICY PAYS	YOU PAY
HOSPITALIZATION Semiprivate room and board, General nursing and miscellaneous hospital services and supplies.	First 60 days 61^st to 90^th days 91^st to 150^th days Beyond 150 days	All but $ [current deductible] All but $ [current amount] per day All but $ [current amount] per day $0	$0 or D Optional Part A Deductible Rider* $ [current amount] per day $ [current amount] per day 100% of Medicare eligible expenses**
SKILLED NURSING FACILITY CARE You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital	First 20 days 21^st through 100^thday 101^st day and after	All approved amounts All but $ [current amount] per day $[0]	$0 Up to $[ ] a day $0
INPATIENT PSYCHIATRIC CARE Inpatient psychiatric care in a participating psychiatric hospital	190 days per lifetime	175 days per lifetime
BLOOD	First 3 pints Additional amounts	$0 100%	First 3 pints $0

* These are optional riders. You purchased this benefit if the box is checked and you paid the premium

** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy's "Core Benefits."

MEDICARE SUPPLEMENT POLICIES - PART B BENEFITS

Note: Issuers should include only the wording that applies to their policy's "This Policy Pays" column and complete the "You Pay" column.

Note: Add the following text in a bold or contrasting color if the policy is a Medicare Supplement High Deductible Plan as defined in sub. (5) (k) or (m) only until December 31, 2005: This high deductible plan pays the same as a non-high deductible plan after one has paid a calendar year [$ ] deductible. Benefits will not begin until out-of-pocket expenses are $[ ]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include [the plan's separate foreign travel emergency deductible].

MEDICARE PART B BENEFITS	PER CALENDAR YEAR	MEDICARE PAYS	[AFTER YOU PAY A $ [ ] DEDUCTIBLE] THIS POLICY PAYS	YOU PAY
MEDICAL EXPENSES. Eligible expense for physician's services, in-patient and out-patient medical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment.	First $[ ] of Medicare approved amounts* Remainder of Medicare approved amounts	$ 0 Generally 80%	$0 or D Optional Part B Deductible Rider Generally 20% D Optional Medicare Part B Excess Charges Rider
BLOOD	First 3 pints Next $[ ] of Medicare approved amounts* Remainder of Medicare approved amounts	$0 $0 80%	All costs [$[ ] (Part B deductible)] 20%
CLINICAL LABORATORY SERVICES Tests for diagnostic services	100%	$0
HOME HEALTH CARE	100% of charges for visits considered medically necessary by Medicare	40 visits or D Optional Additional Home Health Care Rider**
PREVENTIVE MEDICAL CARE BENEFIT - NOT COVERED BY MEDICARE. Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare.	First $120 each calendar year Additional charges	$0 $0	$120 [$0] or $[dollar amount]

*Once you have been billed [$ ] of Medicare approved amounts for covered services (which are noted with an asterisk), your Medicare Part B deductible will have been met for the calendar year.

**These are optional riders. You purchased this benefit if the box is checked and you paid the premium.

OUTLINE OF COVERAGE - B

(COMPANY NAME)

OUTLINE OF MEDICARE SUPPLEMENT 50% and 25% COST-SHARING PLANS

(The designation required by sub. (5) (n) 1. and (o) 1.)

You will pay [half or one quarter] the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[ ] each calendar year. The amounts that count toward your annual limit are noted with diamonds ([DIAMOND]) in the chart below. Once you reach the annual limit, the policy plays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

MEDICARE COST-SHARING PART A - HOSPITAL SERVICES - PER BENEFIT PERIOD

Note: Issuers should include only the wording that applies to their policy's "This Policy Pays" column and complete the "You Pay" column.

SERVICES	PER BENEFIT PERIOD	MEDICARE PAYS	AFTER YOU PAY A $[ ] DEDUCTIBLE THIS POLICY PAYS	YOU PAY
HOSPITALIZATION Semiprivate room and board, General nursing and miscellaneous hospital services and supplies.	First 60 days 61^st to 90^th days 91^st to 150^th days Beyond 150 days	All but $ [current deductible] All but $ [current amount] per day All but $ [current amount] per day $0	$[ ] (50% or 75% of Part A deductible) $ [current amount] per day $ [current amount] per day 100% Medicare eligible expenses**	&
SKILLED NURSING FACILITY CARE You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital	First 20 days 21^st through 100^th day 101^st day and after	All approved amounts All but $ [current amount] per day $0	$0 Up to $[ ] a day $0	&
INPATIENT PSYCHIATRIC CARE Inpatient psychiatric care in a participating psychiatric hospital	190 days per lifetime	175 days per lifetime
BLOOD	First 3 pints Additional amounts	$0 100%	[50% or 75%] $0	&
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services.	Generally, most Medicare eligible expenses for outpatient drugs and inpatient respite care	[50% or 75%] of coinsurance or copayments	&

MEDICARE COST-SHARING POLICIES - PART B BENEFITS

Note: Issuers should include only the wording which applies to their policy's "This Policy Pays" column and complete the "You Pay" column.

MEDICARE PART B BENEFITS

PER CALENDAR YEAR

MEDICARE PAYS

[AFTER YOU PAY A $[ ]

DEDUCTIBLE] THIS

POLICY PAYS

YOU PAY

MEDICAL EXPENSES.

Eligible expense for physician's services, in-patient and out-patient medical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment.

First $[ ] of Medicare approved amounts*

Preventive Benefits for Medicare covered services

Remainder of Medicare approved amounts.

$ 0

Generally 75% or

more of Medicare approved amounts

Generally 80%

Remainder of Medicare

approved amounts.

Generally [10% or 15%]

BLOOD

First 3 pints

Next $[ ] of Medicare approved amounts*

Remainder of Medicare approved amounts

Generally 80%

[50% or 75%]

$Generally [10% or 15%]

CLINICAL LABORATORY SERVICES

Tests for diagnostic Services

100%

HOME HEALTH CARE

100% of charges for visits considered medically necessary by Medicare

40 visits or [] Optional Additional Home Health Care Rider**

*Once you have been billed [$ ] of Medicare approved amounts for covered services (which are noted with an asterisk), your Medicare Part B deductible will have been met for the calendar year.

**These are optional riders. You purchased this benefit if the box is checked and you paid the premium.

OUTLINE OF COVERAGE - C

(COMPANY NAME)

OUTLINE OF MEDICARE COST INSURANCE

(The designation and caption required by sub. (7) (a))

MEDICARE COST PART A - HOSPITAL SERVICES - PER BENEFIT PERIOD

Note: Issuers should include only the wording that applies to their policy's "This Policy Pays" column and complete the "You Pay" column.

Note: Add the following bracketed information that is appropriate for a Medicare cost policy with either basic or enhanced benefits.

SERVICES	PER BENEFIT PERIOD	MEDICARE PAYS	THIS POLICY PAYS	YOU PAY
HOSPITALIZATION Semiprivate room and board, General nursing and miscellaneous hospital services and supplies.	First 60 days 61^st to 90 ^th days 91^st to 150 ^th days Beyond 150 days	All but $ (current deductible] All but $ [current amount] per day All but $ [current amount] per day $0	$0 or [] Optional Part A Deductible Rider* $[current amount] per day $[current amount] per day 100% of Medicare eligible expenses**
SKILLED NURSING FACILITY CARE You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital	First 20 days 21^st through 100^thday 101^st day and after	All approved amounts All but $[current amount] per day $0	$0 $0 $0
INPATIENT PSYCHIATRIC CARE Inpatient psychiatric care in a participating psychiatric hospital	190 days per lifetime	[$0 or 175 days per lifetime]
BLOOD	First 3 pints Additional amounts	$0 100%	First 3 pints $0

* These are optional riders. You purchased this benefit if the box is checked and you paid the premium

MEDICARE COST POLICIES - PART B BENEFITS

Note: Issuers should include only the wording that applies to their policy's "This Policy Pays" column and complete the "You Pay" column.

Note: Add the following bracketed information that is appropriate for a Medicare cost policy with either basic or enhanced benefits.

MEDICARE PART B BENEFITS	PER CALENDAR YEAR	MEDICARE PAYS	THIS POLICY PAYS	YOU PAY
MEDICAL EXPENSES. Eligible expense for physician's services, in-patient and out-patient medical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment	First [$ ] of Medicare approved amounts* Remainder of Medicare approved amounts	$ 0 Generally 80%	$0 or [] Optional Part B Deductible Rider** Generally 20%
BLOOD	First 3 pints Next $[ ] of Medicare approved amounts* Remainder of Medicare approved amounts	$0 $0 80%	All [$[ ] (Part B deductible)] 20%
CLINICAL LABORATORY SERVICES Tests for diagnostic services	100%	$0
HOME HEALTH CARE	100% of charges for visits considered medically necessary by Medicare	40 visits [] Optional Additional Home Health Care Rider**

*Once you have been billed [$ ] of Medicare approved amounts for covered services (which are noted with an asterisk), your Medicare Part B deductible will have been met for the calendar year.

**These are optional riders. You purchased this benefit if the box is checked and you paid the premium.

OUTLINE OF COVERAGE - D

(COMPANY NAME)

OUTLINE OF MEDICARE SELECT INSURANCE AND MEDICARE SELECT 50% and 25% COST-SHARING PLANS

(The designation and caption required by sub. (30) (i) 8. and 9., or the designation required by subs. (30) (q) 1. and (r) 1.)

Note: Add the following text if the policy is a Medicare Select 50% or 25% Cost-Sharing Plan: You will pay [half or ([DIAMOND]) one quarter] the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[ ] each calendar year. The amounts that count toward your annual limit are noted with diamonds ([DIAMOND]) in the chart below. Once you reach the annual limit, the policy plays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

MEDICARE SELECT PART A - HOSPITAL SERVICES - PER BENEFIT PERIOD

Note: Issuers should include only the wording that applies to their policy's "This Policy Pays" column and complete the "You Pay" column.

SERVICES	PER BENEFIT PERIOD	MEDICARE PAYS	AFTER YOU PAY A $[ ] DEDUCTIBLE THIS POLICY PAYS	YOU PAY
HOSPITALIZATION Semiprivate room and board, General nursing and miscellaneous hospital services and supplies.	First 60 days 61^st to 90^th days 91^st to 150^th days Beyond 150 days	All but $[current deductible] All but $[current amount] per day All but $[current amount] per day $0	$[ ] or [ ]% of Medicare Part A deductible $[current amount] per day $[current amount] per day 100% of Medicare eligible expenses **	&
SKILLED NURSING FACILITY CARE You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital	First 20 days 21^st through 100^th day 101^st day and after	All approved amounts All but $ [current amount] per day $0	$0 Up to $[ ] a day $0	&
INPATIENT PSYCHIATRIC CARE Inpatient psychiatric care in a participating psychiatric hospital	190 days per lifetime	175 days per lifetime
BLOOD	First 3 pints Additional amounts	$0 100%	[3 pints] or [ %] $0	&
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services.	All but very limited coinsurance for outpatient drugs and inpatient respite care	$0 or [ ]% of coinsurance or copayments	&

MEDICARE SELECT POLICIES - PART B BENEFITS

Note: Issuers should include only the wording that applies to their policy's "This Policy Pays" column and complete the "You Pay" column.

MEDICARE PART B BENEFITS

PER CALENDAR YEAR

MEDICARE PAYS

[AFTER YOU PAY A

$[ ] DEDUCTIBLE

THIS POLICY PAYS

YOU PAY

MEDICAL EXPENSES In or out of the hospital and outpatient hospital treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment:

First $[ ] of Medicare approved amounts

[Preventive Benefits for Medicare covered services**]

Remainder of Medicare approved amounts

[Generally [ ]% or more of Medicare approved amounts**]

Generally 80%

[$[ ] (Part B deductible)] or $0

[Remainder of Medicare approved amounts**]

Generally [10% or 15%]

BLOOD

First 3 pints

Next $ [ ] of Medicare approved amounts*

Remainder of Medicare approved amounts

Generally 80%

[ ]% $0

Generally [10% or 15%]

CLINICAL LABORATORY SERVICES

Tests for diagnostic services

100%

[HOME HEALTH CARE]

100% of charges for visits considered medically necessary by Medicare

365 necessary visits for medically necessary services

[PREVENTIVE MEDICAL CARE BENEFIT - NOT COVERED BY MEDICARE

Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare.]*

[First $120 each calendar year]

[Additional charges]**

[$0]

[$0]**

[$120]

[$0] or $[dollar amount]**

*Once you have been billed [$ ] of Medicare approved amounts for covered services (which are noted with an asterisk), your Medicare Part B deductible will have been met for the calendar year.

** NOTE: Insurers should include in the outline of coverage the appropriate preventive benefit based upon whether or not the policy is a cost-sharing policy.

Wis. Admin. Code Office of the Commissioner of Insurance § 1