OUTLINE OF COVERAGE
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT INSURANCE
(The designation and caption required by sub. (4s) (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: This includes the Medicare deductibles for Part A and Part B, but does not include [the plan's separate riders deductible.]
Note: Add the following text in a bold or contrasting color if the plan is a Medicare supplement insurance - high deductible plan as defined at sub. (5m) (k): This high deductible plan offers benefits after one has paid a calendar year [$2000] deductible. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.
SERVICES | PER BENEFIT PERIOD | MEDICARE PAYS | [AFTER YOU PAY A$[ ] DEDUCTIBLE] THIS POLICY PAYS | YOU PAY |
HOSPITALIZATION Semiprivate room and board, general nursing and miscellaneous hospital services and supplies. | First 60 days 61st to 90th days 91st day and after while using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days Beyond the additional 365 days | All but $ [current deductible] All but $ [current amount] per day All but $ [current amount] per day $0 $0 | $0 or [ []OPTIONAL PART A DEDUCTIBLE RIDER* (for non-high deductible plans)] [ [] PART A DEDUCTIBLE RIDER* (for high deductible plans)] [ []OPTIONAL MEDICARE 50% PART A DEDUCTIBLE RIDER*** $ [current amount] per day $ [current amount] per day 100% of Medicare eligible expenses** $0 | |
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 21st through 100th day 101st 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 | |
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 or copayment for outpatient drugs and inpatient respite care | $0 or [ ]% of coinsurance or copayments |
* 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 issuer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy's "Core Benefits."
*** This optional rider may reduce your premium when you pay 50% of Medicare Part A deductible.
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 plan is a Medicare supplement insurance-high deductible plan as defined at sub. (5m) (k): This high deductible plan offers benefits after one has paid a calendar year [$2000] deductible. This deductible consists of 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 [ [] OPTIONAL PART B DEDUCTIBLE RIDER** (for non-high deductible plans)] [ [] PART B DEDUCTIBLE RIDER** (for high deductible plans)] [ [] OPTIONAL PART B COPAYMENT OR COINSURANCE RIDER*** Generally 20% [ []OPTIONAL MEDICARE PART B EXCESS CHARGES RIDER** (for non-high deductible plans)] [ [] MEDICARE PART B EXCESS CHARGES RIDER** (for high deductible plans)] [ []OPTIONAL FOREIGN TRAVEL EMERGENCY RIDER** (non-high deductible plans)] [ []FOREIGN TRAVEL EMERGENCY RIDER** (for high-deductible plans)] | |
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 [ [] OPTIONAL ADDITIONAL HOME HEALTH CARE RIDER** | ||
FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA | First $250 each calendar year Remainder of charges | [$0] | $250 80% to a lifetime maximum benefit of $50,000 | 20% and amounts over the $50,000 lifetime maximum |
[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 (that 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.
*** This is an optional rider that may decrease your premium when you pay copayments for medical and emergency room visits.
Wis. Admin. Code Office of the Commissioner of Insurance § 3