Wisconsin Administrative Code
Office of the Commissioner of Insurance
Chapter Ins 3 - Casualty Insurance
Appendix 3
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 |
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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 |
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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 |
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INPATIENT PSYCHIATRIC CARE Inpatient psychiatric care in a participating psychiatric hospital |
190 days per lifetime |
175 days per lifetime |
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BLOOD |
First 3 pints Additional amounts |
$0 100% |
First 3 pints $0 |
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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.
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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)] |
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BLOOD |
First 3 pints Next $[ ] of Medicare approved amounts* Remainder of Medicare approved amounts |
$0 $0 80% |
All costs [$[ ] (Part B deductible)] 20% |
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CLINICAL LABORATORY SERVICES Tests for diagnostic services |
100% |
$0 |
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HOME HEALTH CARE |
100% of charges for visits considered medically necessary by Medicare |
40 visits or [ [] OPTIONAL ADDITIONAL HOME HEALTH CARE RIDER** |
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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 |
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[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.
