Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart G - MISCELLANEOUS PROVISIONS › Appendix V - Disclosure Statements

Current through Register Vol. 48, No. 28, July 12, 2024
Companies shall provide one of the following disclosures as
				  prescribed by the directions contained in paragraph (o).
a) Original disclosure statement for policies that
				  provide benefits for expenses incurred for an accidental injury only:
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS
							 INSURANCE DUPLICATES SOME MEDICARE BENEFITS
This is not Medicare Supplement
				  Insurance
This insurance provides limited benefits, if you
				  meet the policy conditions, for hospital or medical expenses that result from
				  accidental injury. It does not pay your Medicare deductibles or coinsurance and
				  is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits
				  when it pays hospital medical expenses up to the maximum stated in the
				  policy.
Medicare generally pays for most or all of
				  these expenses.
Medicare pays extensive benefits for
				  medically necessary services regardless of the reason you need them. These
				  include:
- hospitalization,
- physician services,
- [outpatient prescription drugs if you are
				  enrolled in Medicare Part D],
- other approved items and services.
Before You Buy This Insurance
- Check the coverage in all health insurance
				  policies you already have.
- For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
- For help in understanding your health insurance,
				  contact your state insurance department or state [senior] [health] insurance
				  [counseling] [assistance] program [SHIP].
b) Original disclosure statement for policies that
				  provide benefits for specified limited services:
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS
							 INSURANCE DUPLICATES SOME MEDICARE BENEFITS
This is not Medicare Supplement
				  Insurance
This insurance provides limited benefits, if
				  you meet the policy conditions, for expenses relating to the specific services
				  listed in the policy. It does not pay your Medicare deductibles or coinsurance
				  and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits
				  when any of the services covered by the policy are also covered by
				  Medicare.
Medicare pays extensive benefits for
				  medically necessary services regardless of the reason you need them. These
				  include:
- hospitalization,
- physician services,
- [outpatient prescription drugs if you are
				  enrolled in Medicare Part D],
- other approved items and services.
Before You Buy This Insurance
- Check the coverage in all health insurance
				  policies you already have.
- For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
- For help in understanding your health insurance,
				  contact your state insurance department or state [senior] [health] insurance
				  [counseling] [assistance] program [SHIP].
c) Original disclosure statement for policies that
				  reimburse expenses for specified disease(s) or other specified impairments.
				  This includes expense incurred cancer, specified disease and other types of
				  health insurance policies that limit reimbursement to named medical
				  conditions:
IMPORTANT NOTICE TO PERSONS ON
							 MEDICARE
THIS INSURANCE DUPLICATES SOME MEDICARE
							 BENEFITS
This is not Medicare Supplement
				  Insurance
This insurance provides limited benefits, if you
				  meet the policy conditions, for hospital or medical expenses only when you are
				  treated for one of the specific diseases or health conditions listed in the
				  policy. It does not pay your Medicare deductibles or coinsurance and is not a
				  substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits
				  when it pays hospital or medical expenses up to the maximum stated in the
				  policy.
Medicare generally pays for most or all of
				  these expenses.
Medicare pays extensive benefits for
				  medically necessary services regardless of the reason you need them. These
				  include:
- hospitalization,
- physician services,
- hospice,
- [outpatient prescription drugs if you are
				  enrolled in Medicare Part D],
- other approved items and services.
Before You Buy This Insurance
- Check the coverage in all health insurance
				  policies you already have.
- For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
- For help in understanding your health insurance,
				  contact your state insurance department or state [senior] [health] insurance
				  [counseling] [assistance] program [SHIP].
d) Original disclosure statement for policies that
				  pay fixed dollar amounts for specified diseases or other specified impairments.
				  This includes cancer, specified disease, and other health insurance policies
				  that pay a scheduled benefit or specific payment based on diagnosis of the
				  conditions named in the policy:
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS
							 INSURANCE DUPLICATES SOME MEDICARE BENEFITS
This is not Medicare Supplement
				  Insurance
This insurance pays a fixed amount, regardless of
				  your expenses, if you meet the policy conditions, for one of the specific
				  diseases or health conditions named in the policy. It does not pay your
				  Medicare deductibles or coinsurance and is not a substitute for Medicare
				  Supplement insurance.
This insurance duplicates Medicare benefits
				  because Medicare generally pays for most of the expenses for the diagnosis and
				  treatment of the specific conditions or diagnoses named in the
				  policy.
Medicare pays extensive benefits for
				  medically necessary services regardless of the reason you need them. These
				  include:
- hospitalization,
- physician services,
- hospice,
- [outpatient prescription drugs if you are
				  enrolled in Medicare Part D],
- other approved items and services.
Before You Buy This Insurance
- Check the coverage in all health insurance
				  policies you already have.
- For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
- For help in understanding your health insurance,
				  contact your state insurance department or state [senior] [health] insurance
				  [counseling] [assistance] program [SHIP].
e) Original disclosure statement for indemnity
				  policies and other policies that pay a fixed dollar amount per day, excluding
				  long-term care policies:
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS
							 INSURANCE DUPLICATES SOME MEDICARE BENEFITS
This is not Medicare Supplement
				  Insurance
This insurance pays a fixed dollar amount,
				  regardless of your expenses, for each day you meet the policy conditions. It
				  does not pay your Medicare deductibles or coinsurance and is not a substitute
				  for Medicare Supplement insurance.
This insurance duplicates Medicare benefits
				  when any expenses or services covered by the policy are also covered by
				  Medicare.
Medicare generally pays for most or all of
				  these expenses.
Medicare pays extensive benefits for
				  medically necessary services regardless of the reason you need them. These
				  include:
- hospitalization,
- physician services,
- hospice,
- [outpatient prescription drugs if you are
				  enrolled in Medicare Part D],
- other approved items and services.
Before You Buy This Insurance
- Check the coverage in all health insurance
				  policies you already have.
- For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
- For help in understanding your health insurance,
				  contact your state insurance department or state [senior] [health] insurance
				  [counseling] [assistance] program [SHIP].
f) Original disclosure statement for policies that
				  provide benefits for both expenses incurred and fixed indemnity basis:
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS
							 INSURANCE DUPLICATES SOME MEDICARE BENEFITS
This is not Medicare Supplement
				  Insurance
This insurance pays limited reimbursement for
				  expenses if you meet the conditions listed in the policy. It also pays a fixed
				  amount, regardless of your expenses, if you meet other policy conditions. It
				  does not pay your Medicare deductibles or coinsurance and is not a substitute
				  for Medicare Supplement insurance.
This insurance duplicates Medicare benefits
				  when:
- any expenses or services covered by the policy
				  are also covered by Medicare; or
- it pays the fixed dollar amount stated in the
				  policy and Medicare covers the same event.
Medicare generally pays for most or all of
				  these expenses.
Medicare pays extensive benefits for
				  medically necessary services regardless of the reason you need them. These
				  include:
- hospitalization,
- physician services,
- hospice care,
- [outpatient prescription drugs if you are
				  enrolled in Medicare Part D],
- other approved items and services.
Before You Buy This Insurance
- Check the coverage in all health insurance
				  policies you already have.
- For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
- For help in understanding your health insurance,
				  contact your state insurance department or state [senior] [health] insurance
				  [counseling] [assistance] program [SHIP].
g) Original disclosure statement for other health
				  insurance policies not specifically identified in the previous
				  statements:
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS
							 INSURANCE DUPLICATES SOME MEDICARE BENEFITS
This is not Medicare Supplement
				  Insurance
This insurance provides limited benefits if you
				  meet the conditions listed in the policy. It does not pay your Medicare
				  deductibles or coinsurance and is not a substitute for Medicare Supplement
				  insurance.
This insurance duplicates Medicare benefits
				  when it pays the benefits stated in the policy and coverage for the same event
				  is provided by Medicare.
Medicare generally pays for most or all of
				  these expenses.
Medicare pays extensive benefits for
				  medically necessary services regardless of the reason you need them. These
				  include:
- hospitalization,
- physician services,
- hospice,
- [outpatient prescription drugs if you are
				  enrolled in Medicare Part D],
- other approved items and services.
Before You Buy This Insurance
- Check the coverage in all health insurance
				  policies you already have.
- For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
- For help in understanding your health insurance,
				  contact your state insurance department or state [senior] [health] insurance
				  [counseling] [assistance] program [SHIP].
h) Alternative disclosure statement for policies
				  that provide benefits for expenses incurred for an accidental injury
				  only.
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS
							 NOT MEDICARE SUPPLEMENT INSURANCE
Some health care services paid for by
				  Medicare may also trigger the payment of benefits from this
				  policy.
This insurance provides limited benefits, if you
				  meet the policy conditions, for hospital or medical expenses that result from
				  accidental injury. It does not pay your Medicare deductibles or coinsurance and
				  is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of
				  these expenses.
Medicare pays extensive benefits for
				  medically necessary services regardless of the reason you need them. These
				  include:
- hospitalization,
- physician services,
- [outpatient prescription drugs if you are
				  enrolled in Medicare Part D],
- other approved items and services.
This policy must pay benefits without regard
				  to other health benefit coverage to which you may be entitled under Medicare or
				  other insurance.
Before You Buy This Insurance
- Check the coverage in
all
health
				  insurance policies you already have.
- For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
- For help in understanding your health insurance,
				  contact your state insurance department or state [senior] [health] insurance
				  [counseling] [assistance] program [SHIP].
i) Alternate disclosure statement for policies
				  that provide benefits for specified limited services:
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS
							 NOT MEDICARE SUPPLEMENT INSURANCE
Some health care services paid for by
				  Medicare may also trigger the payment of benefits from this
				  policy.
This insurance provides limited benefits, if you
				  meet the policy conditions, for expenses relating to the specific services
				  listed in the policy. It does not pay your Medicare deductibles or coinsurance
				  and is not a substitute for Medicare Supplement insurance.
Medicare pays extensive benefits for
				  medically necessary services regardless of the reason you need them. These
				  include:
- hospitalization,
- physician services,
- [outpatient prescription drugs if you are
				  enrolled in Medicare Part D],
- other approved items and services.
This policy must pay benefits without regard
				  to other health benefit coverage to which you may be entitled under Medicare or
				  other insurance.
Before You Buy This Insurance
- Check the coverage in
all
health
				  insurance policies you already have.
- For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
- For help in understanding your health insurance,
				  contract your state insurance department or state [senior] [health] insurance
				  [counseling] [assistance] program [SHIP].
j) Alternative disclosure statement for policies
				  that reimburse expenses incurred for specified diseases or other specified
				  impairments. This includes expense-incurred cancer, specified disease and other
				  types of health insurance policies that limit reimbursement to named medical
				  conditions.
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS
							 NOT MEDICARE SUPPLEMENT INSURANCE
Some health care services paid for by
				  Medicare may also trigger the payment of benefits from this policy. Medicare
				  generally pays for most or all of these expenses.
This insurance provides limited benefits, if you
				  meet the policy conditions, for hospital or medical expenses only when you are
				  treated for one of the specific diseases or health conditions listed in the
				  policy. It does not pay your Medicare deductibles or coinsurance and is not a
				  substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of
				  these expenses.
Medicare pays extensive benefits for
				  medically necessary services regardless of the reason you need them. These
				  include:
- hospitalization,
- physician services,
- hospice,
- [outpatient prescription drugs if you are
				  enrolled in Medicare Part D],
- other approved items and services.
This policy must pay benefits without regard
				  to other health benefit coverage to which you may be entitled under Medicare or
				  other insurance.
Before You Buy This Insurance
- Check the coverage in
all
health
				  insurance policies you already have.
- For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
- For help in understanding your health insurance,
				  contract your state insurance department or state [senior] [health] insurance
				  [counseling] [assistance] program [SHIP].
k) Alternative disclosure statement for policies
				  that pay fixed dollar amounts for specified diseases or other specified
				  impairments. This includes cancer, specified disease and other health insurance
				  policies that pay a scheduled benefit or specific payment based on diagnosis of
				  the conditions named in the policy.
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS
							 NOT MEDICARE SUPPLEMENT INSURANCE
Some health care services paid for by
				  Medicare may also trigger the payment of benefits from this
				  policy.
This insurance pays a fixed amount, regardless of
				  your expenses, if you meet the policy conditions, for one of the specific
				  diseases or health conditions named in the policy. It does not pay your
				  Medicare deductibles or coinsurance and is not a substitute for Medicare
				  Supplement insurance.
Medicare pays extensive benefits for
				  medically necessary services regardless of the reason you need them. These
				  include:
- hospitalization,
- physician services,
- hospice,
- [outpatient prescription drugs if you are
				  enrolled in Medicare Part D],
- other approved items and services.
This policy must pay benefits without regard
				  to other health benefit coverage to which you may be entitled under Medicare or
				  other insurance.
Before You Buy This Insurance
- Check the coverage in
all
health
				  insurance policies you already have.
- For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
- For help in understanding your health insurance,
				  contract your state insurance department or state [senior] [health] insurance
				  [counseling] [assistance] program [SHIP].
l) Alternative disclosure statement for indemnity
				  policies and other policies that pay a fixed dollar amount per day, excluding
				  long-term care policies.
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS
							 NOT MEDICARE SUPPLEMENT INSURANCE
Some health care services paid for by
				  Medicare may also trigger the payment of benefits from this
				  policy.
This insurance pays a fixed amount, regardless of
				  your expenses, for each day you meet the policy conditions. It does not pay
				  your Medicare deductibles or coinsurance and is not a substitute for Medicare
				  Supplement insurance.
Medicare generally pays for most or all of
				  these expenses.
Medicare pays extensive benefits for
				  medically necessary services regardless of the reason you need them. These
				  include:
- hospitalization,
- physician services,
- hospice,
- [outpatient prescription drugs if you are
				  enrolled in Medicare Part D],
- other approved items and services.
This policy must pay benefits without regard
				  to other health benefit coverage to which you may be entitled under Medicare or
				  other insurance.
Before You Buy This Insurance
- Check the coverage in
all
health
				  insurance policies you already have.
- For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
- For help in understanding your health insurance,
				  contract your state insurance department or state [senior] [health] insurance
				  [counseling] [assistance] program [SHIP].
m) Alternative disclosure statement for policies
				  that provide benefits upon both an expense-incurred and fixed indemnity
				  basis.
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS
							 NOT MEDICARE SUPPLEMENT INSURANCE
Some health care services paid for by
				  Medicare may also trigger the payment of benefits from this
				  policy.
This insurance pays limited reimbursement for
				  expenses if you meet the conditions listed in the policy. It also pays a fixed
				  amount, regardless of your expenses, if you meet other policy conditions. It
				  does not pay your Medicare deductibles or coinsurance and is not a substitute
				  for Medicare Supplement insurance.
Medicare generally pays for most or all of
				  these expenses.
Medicare pays extensive benefits for
				  medically necessary services regardless of the reason you need them. These
				  include:
- hospitalization,
- physician services,
- hospice care,
- [outpatient prescription drugs if you are
				  enrolled in Medicare Part D],
- other approved items and services.
This policy must pay benefits without regard
				  to other health benefit coverage to which you may be entitled under Medicare or
				  other insurance.
Before You Buy This Insurance
- Check the coverage in
all
health
				  insurance policies you already have.
- For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
- For help in understanding your health insurance,
				  contract your state insurance department or state [senior] [health] insurance
				  [counseling] [assistance] program [SHIP].
n) Alternative disclosure statement for other
				  health insurance policies not specifically identified in the preceding
				  statements.
IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS
							 NOT MEDICARE SUPPLEMENT INSURANCE
Some health care services paid for by
				  Medicare may also trigger the payment of benefits from this
				  policy.
This insurance provides limited benefits if you
				  meet the conditions listed in the policy. It does not pay your Medicare
				  deductibles or coinsurance and is not a substitute for Medicare Supplement
				  insurance.
Medicare generally pays for most or all of
				  these expenses.
Medicare pays extensive benefits for
				  medically necessary services regardless of the reason you need them. These
				  include:
- hospitalization,
- physician services,
- hospice,
- [outpatient prescription drugs if you are
				  enrolled in Medicare Part D],
- other approved items and services.
This policy must pay benefits without regard
				  to other health benefit coverage to which you may be entitled under Medicare or
				  other insurance.
Before You Buy This Insurance
- Check the coverage in
all
health
				  insurance policies you already have.
- For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
- For help in understanding your health insurance,
				  contract your state insurance department or state [senior] [health] insurance
				  [counseling] [assistance] program [SHIP].
o) Instructions for use of the disclosure
				  statements for health insurance policies sold to Medicare beneficiaries that
				  duplicate Medicare.
1) Section 1882(d) of the federal Social Security
				  Act ( 42 USC 1395 ss ) prohibits the sale of a health insurance policy (the
				  term policy includes certificate) to Medicare beneficiaries that duplicates
				  Medicare benefits unless it will pay benefits without regard to a beneficiary's
				  other health coverage and it includes the prescribed disclosure statement on or
				  together with the application for the policy.
2) All types of health insurance policies that
				  duplicate Medicare shall include one of the attached disclosure statements,
				  according to the particular policy type involved, on the application or
				  together with the application. The disclosure statement may not vary from the
				  attached statements in terms of language or format type size, type proportional
				  spacing, bold character, line spacing, and usage of boxes around text from
				  those presented in the disclosure statements.
3) State and federal law prohibits insurers from
				  selling a Medicare supplement policy to a person that already has a Medicare
				  supplement policy except as a replacement policy.
4) Property/casualty and life insurance policies
				  are not considered health insurance.
5) Disability income policies are not considered
				  to provide benefits that duplicate Medicare.
6) Long-term care insurance policies that
				  coordinate with Medicare and other health insurance are not considered to
				  provide benefits that duplicate Medicare.
7) The federal law does not preempt state laws
				  that are more stringent than the federal requirements.
8) The federal law does not preempt existing state
				  form filing requirements.
9) Section 1882 of the federal Social Security Act
				  was amended in subsection (d)(3)(A) to allow for alternative disclosure
				  statements. The disclosure statements already in Appendix C remain. Carriers
				  may use either disclosure statement with the requisite insurance product.
				  However, carriers should use either the original disclosure statements or the
				  alternative disclosure statements and not use both simultaneously.
10) In the disclosure language included under the
				  heading
Before You Buy This Insurance
, that reads: "For help in
				  understanding your health insurance, contact your state insurance department or
				  state [senior] [health] insurance [counseling] [assistance] program [SHIP],"
				  insurers are to insert reference to the state health insurance assistance
				  program (SHIP) above when new notices need to be printed after December 31,
				  2005.