Connecticut Administrative Code
Title 38a - Insurance Department
495 - Medicare Supplement Insurance Minimum Standards
Appendix A
[Company Name]
Notice of Changes in Medicare and your Medicare
Supplement Coverage-199X
The following chart 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.]
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SERVICES |
MEDICARE BENEFITS Effective January 1, 199X, Medicare Will Pay |
YOUR MEDICARE SUPPLEMENT COVERAGE Effective January 1, 199X, Your Coverage Will Pay |
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MEDICARE PART A SERVICE AND SUPPLIES |
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Inpatient Hospital Services |
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Semi-Private Room & Board |
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Misc. Hospital Servivces & Supplies, such as Drugs, X-Rays, Lab Tests & Operating Rooom |
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BLOOD |
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SKILLED NURSING FACILITY CARE |
