Nebraska Administrative Code
Topic - INSURANCE, DEPARTMENT OF
Title 210 - NEBRASKA DEPARTMENT OF INSURANCE
Chapter 54 - REGULATION TO IMPLEMENT TRANSITIONAL REQUIREMENTS FOR THE CONVERSION OF MEDICARE SUPPLEMENT INSURANCE BENEFITS AND PREMIUMS TO CONFORM TO REPEAL OF MEDICARE CATASTROPHIC COVERAGE ACT
Appendix A
[COMPANY NAME]
NOTICE OF CHANGES IN MEDICARE AND YOUR MEDICARE SUPPLEMENT INSURANCE -- 1990
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.]
| SERVICES | MEDICARE BENEFITS | YOUR MEDICARE SUPPLEMENT COVERAGE | ||
| Effective | ||||
| January 1 | ||||
| Your | 1989 Your | |||
| Effective | 1988 | Coverage | ||
| January 1, 1989 | Coverage | Will Pay | ||
| Medicare Now | Medicare Will | Per | Per | |
| Pays Per Benefit | Pay Per Calendar | Benefit | Calendar | |
| Period | Year | Period | Year | |
|
MEDICARE PART A SERVICES AND SUPPLIES |
||||
| Inpatient | Unlimited number of | All but $592 for | ||
| Hospital | Hospital days after | First 60 | ||
| Services | $560 deductible | days/benefit period | ||
| Semi-Private | All but $148 a day | |||
| Room & Board | for 61st - 90th days/benefit period | |||
| Misc. Hospital | All but $296 a day | |||
| Services & | for 91st - 150th | |||
| Supplies, such | days (if individual | |||
| as Drugs, X-Rays, | chooses to use 60 | |||
| Lab Tests & | Nonrenewable | |||
| Operating Room | lifetime reserve days) | |||
| SERVICES | MEDICARE BENEFITS | YOUR MEDICARE SUPPLEMENT COVERAGE | |
| BLOOD | Pays all costs | Pays all costs except | |
| except payment of | nonreplacement fees | ||
| deductible (equal | (blood deductible) | ||
| to costs for first | for first 3 pints in | ||
| 3 pints) each | each benefit period. | ||
| calendar year. Part | |||
| A blood deductible | |||
| period reduced to | |||
| the extent paid under Part B | |||
| SKILLED NURSING | There is no prior | 100% of costs | |
| FACILITY CARE | confinement | for 1st 20 days (after | |
| requirement for | a 3 day prior | ||
| this benefit | hospital | ||
| confinement)/ | |||
| benefit period | |||
| First 8 days--All | All but $ 74.00 a | ||
| but $ 25.50 a day | day for 21st - 100 th | ||
| days/benefit period | |||
| 9th through 150th | Beyond 100 days | ||
| day -- 100% of costs period | --Nothing/benefit | ||
| Beyond 150 days --Nothing | |||
| MEDICARE PART B | 80% of allowable | 80% of allowable | |
| SERVICES AND | charges (after $75 | charges (after $75 | |
| SUPPLIES | deductible) | deductible/calendar year) | |
| PRESCRIPTION | Inpatient | Inpatient | |
| DRUGS | prescription drugs. | prescription drugs. | |
| 80% of allowable | 80% of allowable | ||
| charges for | charges for | ||
| immunosuppressive | immunosuppressive | ||
| drugs during the | drugs during the | ||
| first year following | first year following | ||
| a covered transplant | a covered transplant | ||
| (after $75 deductible calendar year) | (after $75 deductible calendar year) | ||
| SERVICES | MEDICARE BENEFITS | YOUR MEDICARE SUPPLEMENT COVERAGE | |
| BLOOD | 80% of all costs for | 80% of all costs for | |
| except non- | except | ||
| replacement fees | nonreplacement fees | ||
| (blood deductible) | (blood deductible) | ||
| first 3 pints | first 3 pints | ||
| after $75 deductible | after $75 deductible | ||
| calendar year | calendar year | ||
[ANY OTHER POLICY BENEFITS NOT MENTIONED IN THIS CHART SHOULD BE ADDED TO THE CHART IN THE ORDER PRESCRIBED BY THE OUTLINE OF COVERAGE BENEFITS. IF THERE ARE CORRESPONDING MEDICARE BENEFITS, THEY SHOULD BE SHOWN.]
[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 SUMMARIZING THE CHANGES IN YOUR MEDICARE BENEFITS AND IN YOUR MEDICARE SUPPLEMENT PROVIDED BY [COMPANY] ONLY BRIEFLY DESCRIBE SUCH BENEFITS. FOR INFORMATION ON YOUR MEDICARE BENEFITS CONTACT YOUR SOCIAL SECURITY OFFICE OR THE HEALTH CARE FINANCING ADMINISTRATION. FOR INFORMATION ON YOUR MEDICARE SUPPLEMENT [Policy] CONTACT:
[COMPANY OR FOR AN INDIVIDUAL POLICY -- NAME OF AGENT]
[ADDRESS/PHONE NUMBER]
