Nebraska Administrative Code › Topic - INSURANCE, DEPARTMENT OF › Title 210 - NEBRASKA DEPARTMENT OF INSURANCE › Chapter 54 - REGULATION TO IMPLEMENT TRANSITIONAL REQUIREMENTS FOR THE CONVERSION OF MEDICARE SUPPLEMENT INSURANCE BENEFITS AND PREMIUMS TO CONFORM TO REPEAL OF MEDICARE CATASTROPHIC COVERAGE ACT › Appendix A

Current through June 17, 2024
[COMPANY NAME]
NOTICE OF CHANGES IN MEDICARE AND YOUR MEDICARE SUPPLEMENT
				  INSURANCE -- 1990
THE FOLLOWING CHART BRIEFLY DESCRIBES THE MODIFICATIONS IN
				  MEDICARE AND IN YOUR MEDICARE SUPPLEMENT COVERAGE. PLEASE READ THIS
				  CAREFULLY!
[A BRIEF DESCRIPTION OF THE REVISIONS TO MEDICARE PARTS A
				  & B WITH A PARALLEL DESCRIPTION OF SUPPLEMENTAL BENEFITS WITH SUBSEQUENT
				  CHANGES, INCLUDING DOLLAR AMOUNTS, PROVIDED BY THE MEDICARE SUPPLEMENT COVERAGE
				  IN SUBSTANTIALLY THE FOLLOWING FORMAT.]
SERVICES
MEDICARE BENEFITS
YOUR MEDICARE SUPPLEMENT COVERAGE
Effective
January 1
Your
1989 Your
Effective
1988
Coverage
January 1, 1989
Coverage
Will Pay
Medicare Now
Medicare Will
Per
Per
Pays Per Benefit
Pay Per Calendar
Benefit
Calendar
Period
Year
Period
Year
MEDICARE PART
A
SERVICES AND
SUPPLIES
Inpatient
Unlimited number of
All but $592 for
Hospital
Hospital days after
First 60
Services
$560 deductible
days/benefit period
Semi-Private
All but $148 a day
Room & Board
for 61st - 90th days/benefit
						  period
Misc. Hospital
All but $296 a day
Services &
for 91st - 150th
Supplies, such
days (if individual
as Drugs, X-Rays,
chooses to use 60
Lab Tests &
Nonrenewable
Operating Room
lifetime reserve days)
SERVICES
MEDICARE BENEFITS
YOUR MEDICARE SUPPLEMENT COVERAGE
BLOOD
Pays all costs
Pays all costs except
except payment of
nonreplacement fees
deductible (equal
(blood deductible)
to costs for first
for first 3 pints in
3 pints) each
each benefit period.
calendar year. Part
A blood deductible
period reduced to
the extent paid under Part B
SKILLED NURSING
There is no prior
100% of costs
FACILITY CARE
confinement
for 1st 20 days (after
requirement for
a 3 day prior
this benefit
hospital
confinement)/
benefit period
First 8 days--All
All but $ 74.00 a
but $ 25.50 a day
day for 21st - 100 
						  th
days/benefit period
9th through 150th
Beyond 100 days
day -- 100% of costs period
--Nothing/benefit
Beyond 150 days --Nothing
MEDICARE PART B
80% of allowable
80% of allowable
SERVICES AND
charges (after $75
charges (after $75
SUPPLIES
deductible)
deductible/calendar year)
PRESCRIPTION
Inpatient
Inpatient
DRUGS
prescription drugs.
prescription drugs.
80% of allowable
80% of allowable
charges for
charges for
immunosuppressive
immunosuppressive
drugs during the
drugs during the
first year following
first year following
a covered transplant
a covered transplant
(after $75 deductible calendar year)
(after $75 deductible calendar year)
SERVICES
MEDICARE BENEFITS
YOUR MEDICARE SUPPLEMENT COVERAGE
BLOOD
80% of all costs for
80% of all costs for
except non-
except
replacement fees
nonreplacement fees
(blood deductible)
(blood deductible)
first 3 pints
first 3 pints
after $75 deductible
after $75 deductible
calendar year
calendar year
[ANY OTHER POLICY BENEFITS NOT MENTIONED IN THIS CHART SHOULD
				  BE ADDED TO THE CHART IN THE ORDER PRESCRIBED BY THE OUTLINE OF COVERAGE
				  BENEFITS. IF THERE ARE CORRESPONDING MEDICARE BENEFITS, THEY SHOULD BE
				  SHOWN.]
[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 SUMMARIZING THE CHANGES IN YOUR MEDICARE BENEFITS
				  AND IN YOUR MEDICARE SUPPLEMENT PROVIDED BY [COMPANY] ONLY BRIEFLY DESCRIBE
				  SUCH BENEFITS. FOR INFORMATION ON YOUR MEDICARE BENEFITS CONTACT YOUR SOCIAL
				  SECURITY OFFICE OR THE HEALTH CARE FINANCING ADMINISTRATION. FOR INFORMATION ON
				  YOUR MEDICARE SUPPLEMENT [Policy] CONTACT:
[COMPANY OR FOR AN INDIVIDUAL POLICY -- NAME OF AGENT]
[ADDRESS/PHONE NUMBER]