Administrative Rules of Montana › Department 6 - STATE AUDITOR › Chapter 6.6 - INSURANCE DEPARTMENT › Subchapter 6.6.5 - Medicare Supplements › Rule 6.6.526 - APPENDIX C DISCLOSURE STATEMENTS

Current through Register Vol. 13, July 5, 2024
(1) This
				is the appendix referred to in ARM 6.6.509(6).
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
				U.S.C. 1395ss ) 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) .
(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.
(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 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
* Check for 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 [health] insurance [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 [health] insurance [assistance]
				  program [SHIP].
(c)
				[Original 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
							 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 [health] insurance [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
				  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 [health] insurance [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 of the 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
* 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 [health] insurance [assistance]
				  program [SHIP].
(f)
				[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
* 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 [health] insurance [assistance]
				  program [SHIP].
(g)
				[Original disclosure statement for other health insurance policies not
				specifically identified in the preceding 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 [health] insurance [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 INSURANCE
Some health care service 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 [health] insurance [assistance]
				  program [SHIP].
(i)
				[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 under 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, contact
				  your state insurance department or state [health] insurance [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, contact
				  your state insurance department or state [health] insurance [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, contact
				  your state insurance department or state [health] insurance [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 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
* [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 [health] insurance [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, contact
				  your state insurance department or state [health] insurance [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 pays 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
* 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 [health] insurance [assistance]
				  program [SHIP].