Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart G - MISCELLANEOUS PROVISIONS › Appendix B - Outline of Medicare Supplement Coverage - Cover Page for Medicare Supplement Plans Sold Prior to June 1, 2010

Current through Register Vol. 48, No. 28, July 12, 2024
[COMPANY NAME]
Outline of Medicare Supplement Coverage -
				  Cover Page: 1 of 2
Benefit Plans ______ [insert letters of plans
				  being offered]
These charts show the benefits included in each of the
				  standard Medicare supplement plans. Every company must make available Plan "A".
				  Some plans may not be available in Illinois.
See Outlines of Coverage sections for details
				  about all plans.
BASIC BENEFITS FOR PLANS A-J:
Hospitalization: Part A coinsurance plus coverage for 365
				  additional days after Medicare benefits end.
Medical Expenses: Part B coinsurance (generally 20% of
				  Medicare-approved expenses), or copayments for hospital outpatient
				  services.
Blood: First 3 pints of blood each year.
A
B
C
D
E
Basic Benefits
Basic Benefits
Basic Benefits
Basic Benefits
Basic Benefits
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Part A Deductible
Part A Deductible
Part A Deductible
Part A Deductible
Part B Deductible
Foreign Travel Emergency
Foreign Travel Emergency
Foreign Travel Emergency
At-Home Recovery
Preventive Care NOT Covered by Medicare
F F*
G
H
I
J J*
Basic Benefits
Basic Benefits
Basic Benefits
Basic Benefits
Basic Benefits
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Part A Deductible
Part A Deductible
Part A Deductible
Part A Deductible
Part A Deductible
Part B Deductible
Part B Deductible
Part B Excess (100%)
Part B Excess (80%)
Part B Excess (100%)
Part B Excess (100%)
Foreign Travel Emergency
Foreign Travel Emergency
Foreign Travel Emergency
Foreign Travel Emergency
Foreign Travel Emergency
At-Home Recovery
At-Home Recovery
At-Home Recovery
Preventive Care NOT Covered by Medicare
Plans F and J also have an option called a high deductible
				  Plan F and a high deductible Plan J. These high deductible plans pay the same
				  benefits as Plans F and J after one has paid a calendar year [$_____]
				  deductible. Benefits from high deductible Plans F and J will not begin until
				  out-of-pocket expenses are [$_____]. Out-of-pocket expenses for this deductible
				  are expenses that would ordinarily be paid by the policy. These expenses
				  include the Medicare deductibles for Part A and Part B, but do not include the
				  plan's separate foreign travel emergency deductible.
NOTE:
Companies must add the current fixed dollar amount authorized
				  by Medicare where the brackets appear above. The dollar amount is updated
				  periodically by Medicare and companies must reflect these changes to their
				  outlines of coverage in a timely manner.
[COMPANY NAME]
Outline of Medicare Supplement Coverage -
				  Cover Page 2
Basic Benefits for Plans K and L include similar services as
				  Plans A-J, but cost-sharing for the basic benefits is at different
				  levels.
J
K**
L**
Basic Benefits
100% of Part A Hospitalization Coinsurance plus
							 coverage for 365 days after Medicare benefits end
50% Hospice cost-sharing
50% of Medicare-eligible expenses for the first 3
							 pints of blood
50% Part B Coinsurance, except 100% coinsurance for
							 Part B Preventive Services
100% of Part A Hospitalization Coinsurance plus
							 coverage for 365 days after Medicare benefits end
75% Hospice cost-sharing
75% of Medicare-eligible expenses for the first 3
							 pints of blood
75% Part B Coinsurance, except 100% coinsurance for
							 Part B Preventive Services
Skilled Nursing Coinsurance
50% Skilled Nursing Facility Coinsurance
75% Skilled Nursing Facility Coinsurance
Part A Deductible
50% Part A Deductible
75% Part A Deductible
Part B Deductible
Part B Excess (100%)
Foreign Travel Emergency
At-Home Recovery
Preventive Care NOT Covered by Medicare
$[ ] Out of Pocket Annual Limit***
$[ ] Out of Pocket Annual Limit***
** Plans K and L provide for different cost-sharing for items
				  and services than Plans A-J.
Once you reach the annual limit, the plan pays 100% of the
				  Medicare copayments, coinsurance, and deductibles for the rest of the calendar
				  year. The out-of-pocket annual limit does NOT include charges from your
				  provider that exceed Medicare-approved amounts, called "excess charges". You
				  will be responsible for paying excess charges
.
***The out-of-pocket annual limit will increase each year for
				  inflation.
See Outlines of Coverage for details and exceptions.
PREMIUM INFORMATION [Boldface
				  Type]
We [insert issuer's name] can only raise your premium if we
				  raise the premium for all policies like yours in this State. [If the premium is
				  based on the increasing age of the insured, include information specifying when
				  premiums will change.]
DISCLOSURES [Boldface
				  Type]
Use this outline to compare benefits and premiums among
				  policies.
This outline shows benefits and premiums of policies
				  sold for effective dates prior to June 1, 2010.
READ YOUR POLICY VERY CAREFULLY
This is only an outline, describing your policy's most
				  important features. The policy is your insurance contract. You must read the
				  policy itself to understand all of the rights and duties of both you and your
				  insurance company.
RIGHT TO RETURN POLICY [Boldface
				  Type]
If you find that you are not satisfied with your policy, you
				  may return it to [insert issuer's address]. If you send the policy back to us
				  within 30 days after you receive it, we will treat the policy as if it had
				  never been issued and return all of your payments.
POLICY REPLACEMENT [Boldface
				  Type]
If you are replacing another health insurance policy, do NOT
				  cancel it until you have actually received your new policy and are sure you
				  want to keep it.
NOTICE [Boldface Type]
This policy may not fully cover all of your medical
				  costs.
(for producers:)
Neither (insert company's name) nor its agents are
				  connected with Medicare.
(for direct response:)
(insert company's name) is not connected with
				  Medicare.
This outline of coverage does not give all the details of
				  Medicare coverage. Contact your local Social Security office or consult
				  "Medicare & You" for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT
				  [Boldface Type]
When you fill out the application for the new policy, be sure
				  to answer truthfully and completely all questions about your medical and health
				  history. The company may cancel your policy and refuse to pay any claims if you
				  leave out or falsify important medical information. [If the policy or
				  certificate is guaranteed issue, this paragraph need not appear.]
Review the application carefully before you sign it. Be
				  certain that all information has been properly recorded.
[Include for each plan prominently identified on the cover
				  page, a chart showing the services, Medicare payments, plan payments and
				  insured payments for each plan, using the same language, in the same order,
				  using uniform layout and format as shown in Appendices C through N of this
				  Part. No more than four plans may be shown on one chart. For purposes of
				  illustration, charts for each plan are included in this Appendix. An issuer may
				  use additional benefit plan designations on these charts pursuant to Section
				  2008.72(d)
				  of this Part.]
[Include an explanation of any innovative benefits on the
				  cover page and in the chart, in a manner approved by the
				  Director.]