Wis. Admin. Code Office of the Commissioner of InsuranceIns 3.39 app 6

Current through November 29, 2021

[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]

Notes

Wis. Admin. Code Office of the Commissioner of InsuranceIns 3.39 app 6

The following state regulations pages link to this page.



State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.