Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 6
[NOTICE OF CHANGE FOR OUTLINE OF COVERAGE]
(COMPANY NAME)
NOTICE OF CHANGES IN MEDICARE AND YOUR [MEDICARE
SUPPLEMENT OR MEDICARE REPLACEMENT] COVERAGE - 2_____
THE FOLLOWING CHART BRIEFLY DESCRIBES THE MODIFICATIONS IN MEDICARE AND IN YOUR [MEDICARE SUPPLEMENT OR MEDICARE REPLACEMENT] COVERAGE.
PLEASE READ THIS CAREFULLY!
[Note: A brief description of the revisions to Medicare Parts A and B with a parallel description of supplemental benefits with subsequent changes, including dollar amounts, provided by the Medicare supplement or Medicare replacement coverage in substantially the following format.]
SERVICES | MEDICARE BENEFITS | YOUR [MEDICARE SUPPLEMENT OR MEDICARE REPLACEMENT] COVERAGE | ||
In 2____, Medicare Pays Per Benefit Period | Effective January 1, 2____, Medicare will Pay | In 2____, Your Coverage Pays | Effective January 1, 2____, Your Coverage will Pay Per Calendar Year | |
MEDICARE PART A SERVICES AND SUPPLIES | ||||
HOSPITALIZATION Inpatient Hospital Services, Semi-Private Room & Board, Misc. Hospital Services & Supplies, such as Drugs, X-Rays, Lab Tests & Operating Room | All but $___ for the first 60 days/benefit period All but $___ a day for 61st-90th days/benefit period All but $___ a day for 91st day and after while using 60 lifetime reserve days $0 once lifetime reserve days are used: Additional 365 days $0 beyond additional 365 days. | All but $___ for the first 60 days/benefit period All but $___ a day for 61st-90th days/benefit period All but $ [current amount] per day $0 once lifetime reserve days are used: Additional 365 days $0 beyond the additional 365 days. | ||
SKILLED NURSING FACILITY CARE Skilled nursing care in a facility approved by Medicare. Confinement must meet Medicare standards. You must have been in a hospital for at least 3 days and enter the facility within 30 days after discharge. | First 20 days 100% of costs All but $___ (current amount per day) for the 21st - 100th day $[0] of the 101st day and thereafter. | First 20 days 100% of costs All but $___ (current amount per day) for the 21st - 100th day $[0] of the 101st day and thereafter. | ||
BLOOD | Pays all costs except payment of deductible (equal to costs for first 3 pints) each calendar year. Part A blood deductible reduced to the extent paid under Part B | $0 for first 3 pints. 100% of additional amounts | ||
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 | All but very limited coinsurance or copayment for outpatient drugs and inpatient respite care $0 or [ ]% of coinsurance or copayments | & | |
MEDICARE PART B SERVICES AND SUPPLIES | ||||
MEDICAL EXPENSES Eligible expense for physician's services, medical services in and out patient, physical and speech therapy, diagnostic tests, and durable medical equipment. | After $[ ] deductible, generally 80% of remainder of Medicare approved amounts | After $[ ] deductible, generally 80% of remainder of Medicare approved amounts | ||
HOME HEALTH CARE | 100% of charges for visits considered medically necessary by Medicare | 40 visits | ||
PREVENTIVE MEDICAL CARE BENEFIT Some annual physical and preventive tests and services administered or ordered by your doctor when NOT covered by Medicare | $0 | $0 | $120 | |
[Note: 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 SUMMARIZES THE CHANGES IN YOUR MEDICARE BENEFITS AND IN YOUR MEDICARE SUPPLEMENT OR MEDICARE REPLACEMENT] COVERAGE PROVIDED BY (COMPANY) ONLY BRIEFLY DESCRIBES SUCH BENEFITS. FOR INFORMATION ON YOUR MEDICARE BENEFITS CONTACT YOUR SOCIAL SECURITY OFFICE OR THE CENTERS FOR MEDICARE & MEDICAID SERVICES. FOR INFORMATION ON YOUR [MEDICARE SUPPLEMENT OR MEDICARE REPLACEMENT] POLICY CONTACT:
[COMPANY OR FOR AN INDIVIDUAL POLICY - NAME OF AGENT]
[ADDRESS/PHONE NUMBER]
Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 6