Wis. Admin. Code Office of the Commissioner of InsuranceIns 3.39 app 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
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
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%	First 3 pints $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	$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.

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)]
BLOOD	First 3 pints Next $[ ] of Medicare approved amounts* Remainder of Medicare approved amounts	$0 $0 80%	All costs [$[ ] (Part B deductible)] 20%
CLINICAL LABORATORY SERVICES Tests for diagnostic services	100%	$0
HOME HEALTH CARE	100% of charges for visits considered medically necessary by Medicare	40 visits or [ [] OPTIONAL ADDITIONAL HOME HEALTH CARE RIDER**
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
[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.

Notes

Wis. Admin. Code Office of the Commissioner of InsuranceIns 3.39 app 3