Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 4
OUTLINE OF COVERAGE
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT 50% and 25% COST-SHARING PLANS
(The designation required by sub. (5m) (g) 1. and (h) 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 out-of-pocket limit are noted with diamonds (?) in the chart below. Once you reach the annual out-of-pocket 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.
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.
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 | $[ ] (50% or 75% of Medicare Part A deductible.) $ [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% | [50% or 75%] $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 | [50% or 75%] of coinsurance or copayments | & |
** 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."
MEDICARE COST-SHARING 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 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% | $0 Remainder of Medicare approved amounts Generally [10% or 15%] | & & |
BLOOD | First 3 pints Next $[ ] of Medicare approved amounts* | $0 $0 Generally 80% | [50% or 75%] $0 Generally [10% or 15%] | & & & |
CLINICAL LABORATORY SERVICES Tests for diagnostic services | Remainder of Medicare approved amounts | 100% | $0 | |
HOME HEALTH CARE | 100% of charges for visits considered medically necessary by Medicare | 40 visits or [ []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 (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.
Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 4