Connecticut Administrative Code › Title 38a - Insurance Department › 495a - Medicare Supplement Insurance › Appendix C

Current through July 10, 2024
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 prohibits
				the sale of a health insurance policy (the term policy or policies includes
				certificates) to Medicare beneficiaries that duplicate 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).
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.
(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 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
* (outpatient prescription drugs if you are enrolled in
				Medicare Part D)
* other approved items and services Before You Buy This
				Insurance
[TICK] Check the coverage in
all
health insurance
				policies you already have.
[TICK] For more information about Medicare and Medicare
				Supplement insurance, review the
Guide to Health Insurance for People
				with Medicare
, available from the insurance company.
[TICK] For help in understanding your health insurance, contact
				your state insurance department or state health insurance assistance program
				(SHIP).
(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
[TICK]
Check the coverage in all
health insurance
				policies you already have.
[TICK] For more information about Medicare and Medicare
				Supplement insurance, review the
Guide to Health Insurance for People
				with Medicare
, available from the insurance company.
[TICK] For help in understanding your health insurance, contact
				your state insurance department or state health insurance assistance program
				(SHIP).
(Original disclosure statement for policies that reimburse
				expenses incurred for specified disease(s) or other specified impairment(s).
				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 care
* (outpatient prescription drugs if you are enrolled in
				Medicare Part D)
* other approved items and services Before You Buy This
				Insurance
[TICK] Check the coverage in
all
health insurance
				policies you already have.
[TICK] For more information about Medicare and Medicare
				Supplement insurance, review the
Guide to Health Insurance for People
				with Medicare,
available from the insurance company.
[TICK] For help in understanding your health insurance, contact
				your state insurance department or state health insurance assistance program
				(SHIP).
(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 care
* (outpatient prescription drugs if you are enrolled in
				Medicare Part D)
* other approved items and services Before You Buy This
				Insurance
[TICK] Check the coverage in
all
health insurance
				policies you already have.
[TICK] For more information about Medicare and Medicare
				Supplement insurance, review the
Guide to Health Insurance for People
				with Medicare,
available from the insurance company.
[TICK] For help in understanding your health insurance, contact
				your state insurance department or state health insurance assistance program
				(SHIP).
(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
* (outpatient prescription drugs if you are enrolled in
				Medicare Part D)
* hospice care
* other approved items and services Before You Buy This
				Insurance
[TICK] Check the coverage in
all
health insurance
				policies you already have.
[TICK] For more information about Medicare and Medicare
				Supplement insurance, review the
Guide to Health Insurance for People
				with Medicare,
available from the insurance company.
[TICK] For help in understanding your health insurance, contact
				your state insurance department or state health insurance assistance program
				(SHIP).
(Original disclosure statement for policies that provide
				benefits upon both an expense-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
[TICK] Check the coverage in
all
health insurance
				policies you already have.
[TICK] For more information about Medicare and Medicare
				Supplement insurance, review the
Guide to Health Insurance for People
				with Medicare,
available from the insurance company.
[TICK] For help in understanding your health insurance, contact
				your state insurance department or state health insurance assistance program
				(SHIP).
(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 care
* (outpatient prescription drugs if you are enrolled in
				Medicare Part D)
* other approved items and services Before You Buy This
				Insurance
[TICK] Check the coverage in
all
health insurance
				policies you already have.
[TICK] For more information about Medicare and Medicare
				Supplement insurance, review the
Guide to Health Insurance for People
				with Medicare,
available from the insurance company.
[TICK] For help in understanding your health insurance, contact
				your state insurance department or state health insurance assistance program
				(SHIP).
(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
[TICK] Check the coverage in
all
health insurance
				policies you already have.
[TICK] For more information about Medicare and Medicare
				Supplement insurance, review the
Guide to Health Insurance for People
				with Medicare,
available from the insurance company.
[TICK] For help in understanding your health insurance, contact
				your state insurance department or state health insurance assistance program
				(SHIP).
(Alternative 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
[TICK] Check the coverage in
all
health insurance
				policies you already have.
[TICK] For more information about Medicare and Medicare
				Supplement insurance, review the
Guide to Health Insurance for People
				with Medicare,
available from the insurance company.
[TICK] For help in understanding your health insurance, contact
				your state insurance department or state health insurance assistance program
				(SHIP).
(Alternative disclosure statement for policies that reimburse
				expenses incurred for specified disease(s) or other specified impairment(s).
				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 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
[TICK] Check the coverage in
all
health insurance
				policies you already have.
[TICK] For more information about Medicare and Medicare
				Supplement insurance, review the
Guide to Health Insurance for People
				with Medicare,
available from the insurance company.
[TICK] For help in understanding your health insurance, contact
				your state insurance department or state health insurance assistance program
				(SHIP).
(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 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
[TICK] Check the coverage in
all
health insurance
				policies you already have.
[TICK] For more information about Medicare and Medicare
				Supplement insurance, review the
Guide to Health Insurance for People
				with Medicare,
available from the insurance company.
[TICK] For help in understanding your health insurance, contact
				your state insurance department or state health insurance assistance program
				(SHIP).
(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 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.
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
[TICK] Check the coverage in
all
health insurance
				policies you already have.
[TICK] For more information about Medicare and Medicare
				Supplement insurance, review the
Guide to Health Insurance for People
				with Medicare,
available from the insurance company.
[TICK] For help in understanding your health insurance, contact
				your state insurance department or state health insurance assistance program
				(SHIP).
(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
[TICK] Check the coverage in
all
health insurance
				policies you already have.
[TICK] For more information about Medicare and Medicare
				Supplement insurance, review the
Guide to Health Insurance for People
				with Medicare,
available from the insurance company.
[TICK] For help in understanding your health insurance, contact
				your state insurance department or state health insurance assistance program
				(SHIP).
(Alternative disclosure statement for other health insurance
				policies not specifically identified in the previous 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 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
[TICK] Check the coverage in
all
health insurance
				policies you already have.
[TICK] For more information about Medicare and Medicare
				Supplement insurance, review the
Guide to Health Insurance for People
				with Medicare,
available from the insurance company.
[TICK] For help in understanding your health insurance, contact
				your state insurance department or state health insurance assistance program
				(SHIP).