New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Appendix TO SUBCHAPTER 23

Current through Register Vol. 56, No. 14, July 15, 2024
EXHIBIT D
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[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.
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** 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.
*** Deductible amounts and out-of-pocket limits announced annually by CMS.
**** 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.
READ YOUR POLICY VERY CAREFULLY
[Boldface Type]
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 agents:]
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 and 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 in 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 the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this regulation. An issuer may use additional benefit plan designations on these charts pursuant to Section 9D of this regulation.]
[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the commissioner.]
PLAN A
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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** NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
***Deductible amounts announced annually by CMS.
PLAN A
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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PARTS A & B
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*** Deductible amounts announced annually by CMS.
PLAN B
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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** NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's *Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
*** Deductible amounts announced annually by CMS.
PLAN B
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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PARTS A & B
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***Deductible amounts announced annually by CMS.
PLAN C
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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** NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
*** Deductible amounts announced annually by CMS.
PLAN C
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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PARTS A & B
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OTHER BENEFITS--NOT COVERED BY MEDICARE
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***Deductible amounts announced annually by CMS.
PLAN D
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
***Deductible amounts announced annually by CMS.
PLAN D
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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PARTS A & B
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PLAN D
OTHER BENEFITS--NOT COVERED BY MEDICARE
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***Deductible amounts announced annually by CMS.
PLAN E
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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** NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits" During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
***Deductible amounts announced annually by CMS.
PLAN E
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk) your Part B deductible will have been met for the calendar year.
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PARTS A & B
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PLAN E
OTHER BENEFITS--NOT COVERED BY MEDICARE
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* Medicare benefits are subject to change. Please consult the latest
Guide to Health Insurance for People with Medicare.
***Deductible amounts announced annually by CMS.
PLAN F or HIGH DEDUCTIBLE PLAN F
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
[** This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $ [***] deductible. Benefits from the high deductible Plan F 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. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible]
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**** NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
***Deductible amounts announced annually by CMS.
PLAN F or HIGH DEDUCTIBLE PLAN F
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
[** This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $ [***] deductible. Benefits from the high deductible Plan F 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. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.]
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PARTS A & B
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PLAN F or HIGH DEDUCTIBLE PLAN F
OTHER BENEFITS--NOT COVERED BY MEDICARE
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***Deductible amounts and out-of-pocket expenses announced annually by CMS.
PLAN G
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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** NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
***Deductible amounts announced annually by CMS.
PLAN G
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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PARTS A & B
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PLAN G
OTHER BENEFITS--NOT COVERED BY MEDICARE
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***Deductible amounts announced annually by CMS.
PLAN H
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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** NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
***Deductible amounts announced annually by CMS.
PLAN H
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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PARTS A & B
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OTHER BENEFITS-NOT COVERED BY MEDICARE
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***Deductible amounts announced annually by CMS.
PLAN I
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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** NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
***Deductible amounts announced annually by CMS.
PLAN I
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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PARTS A & B
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PLAN I
OTHER BENEFITS--NOT COVERED BY MEDICARE
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***Deductible amounts announced annually by CMS.
PLAN J or HIGH DEDUCTIBLE PLAN J
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
[** This high deductible plan pays the same benefits as Plan J after one has paid a calendar year $ [***] deductible. Benefits from high deductible plan 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. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.]
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****NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
*** Deductible amounts and out-of-pocket expenses announced annually by CMS.
PLAN J or HIGH DEDUCTIBLE PLAN J
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
[**This high deductible plan pays the same benefits as Plan J after one has paid a calendar year$ [***] deductible. Benefits from high deductible plan 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. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.]
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PLAN J or HIGH DEDUCTIBLE PLAN J
PARTS A & B
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OTHER BENEFITS--NOT COVERED BY MEDICARE
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**** Medicare benefits are subject to change. Please consult the latest
Guide to Health Insurance for People with Medicare
.
*** Deductible amounts and out-of-pocket expenses announced annually by CMS.
PLAN K
* You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $ [***] each calendar year. The amounts that count toward your annual limit are noted with diamonds ([diamond]) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year.
However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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**** NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN K
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
****Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $ [***] per year.
However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
PARTS A & B
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***** Medicare benefits are subject to change. Please consult the latest
Guide to Health Insurance for People with Medicare
.
*** Deductible amounts and out-of-pocket limits announced annually by CMS.
PLAN L
* You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $ [***] each calendar year. The amounts that count toward your annual limit are noted with diamonds ([diamond]) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year.
However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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**** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits," During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN L
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $ [***] per year.
However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
PARTS A & B
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***** Medicare benefits are subject to change. Please consult the latest
Guide to Health Insurance for People with Medicare.
*** Deductible amounts and out-of-pocket limits announced annually by CMS
EXHIBIT D1
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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 on or after June 1, 2010. Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums. Plans E, H, I, and J are no longer available for sale.
[This paragraph shall not appear after June 1, 2011.]
READ YOUR POLICY VERY CAREFULLY
[Boldface Type]
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 agents:]
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 and 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 in 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 the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this regulation. An issuer may use additional benefit plan designations on these charts pursuant to Section 9.1D of this regulation.]
[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the commissioner.]
PLAN A
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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**
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
***Deductible amounts announced annually by CMS.
PLAN A
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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***Deductible amounts announced annually by CMS.
PARTS A & B
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***Deductible amounts announced annually by CMS.
PLAN B
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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**
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
***Deductible amounts announced annually by CMS.
PLAN B
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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PARTS A & B
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***Deductible amounts announced annually by CMS.
PLAN C
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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**
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
***Deductible amounts announced annually by CMS.
PLAN C
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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***Deductible amounts announced annually by CMS.
PARTS A & B
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OTHER BENEFITS--NOT COVERED BY MEDICARE
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***Deductible amounts announced annually by CMS.
PLAN D
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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**
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
***Deductible amounts announced annually by CMS.
PLAN D
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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***Deductible amounts announced annually by CMS.
PLAN D
PARTS A & B
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***Deductible amounts announced annually by CMS.
OTHER BENEFITS--NOT COVERED BY MEDICARE
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PLAN F or HIGH DEDUCTIBLE PLAN F
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
[**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [**] deductible. Benefits from the high deductible plan F 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. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.]
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***Deductible and out-of-pocket amounts announced annually by CMS.
****
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN F or HIGH DEDUCTIBLE PLAN F
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
*Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
[**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [**] deductible. Benefits from the high deductible plan F 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. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.]
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***Deductible amounts announced annually by CMS.
PLAN F or HIGH DEDUCTIBLE PLAN F
PARTS A & B
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OTHER BENEFITS - NOT COVERED BY MEDICARE
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***Deductible amounts announced annually by CMS.
PLAN G
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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**
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
***Deductible amounts announced annually by CMS.
PLAN G
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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***Deductible amounts announced annually by CMS.
PLAN G
PARTS A & B
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OTHER BENEFITS--NOT COVERED BY MEDICARE
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***Deductible amounts announced annually by CMS.
PLAN K
* You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $ [***] each calendar year. The amounts that count toward your annual limit are noted with diamonds ([diamond]) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year.
However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
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***Deductible and out-of-pocket amounts announced annually by CMS.
****
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN K
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
***** Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $ [***] per year.
However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
***Deductible and out-of-pocket amounts announced annually by CMS.
PLAN K
PARTS A & B
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***Deductible amounts announced annually by CMS.
******Medicare benefits are subject to change. Please consult the latest
Guide to Health Insurance for People with Medicare
.
PLAN L
* You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $ [***] each calendar year. The amounts that count toward your annual limit are noted with diamonds ([diamond]) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year.
However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Data in image
***Deductible and out-of-pocket amounts announced annually by CMS.
****
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN L
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
***** Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Data in image
* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $ [***] per year.
However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
***Deductible and out-of-pocket amounts announced annually by CMS.
PLAN L
PARTS A & B
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***Deductible amounts announced annually by CMS.
******Medicare benefits are subject to change. Please consult the latest
Guide to Health Insurance for People with Medicare
.
PLAN M
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Data in image
**
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
***Deductible amounts announced annually by CMS.
PLAN M
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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PARTS A & B
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OTHER BENEFITS--NOT COVERED BY MEDICARE
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***Deductible amounts announced annually by CMS.
PLAN N
MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Data in image
**
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
***Deductible amounts announced annually by CMS.
PLAN N
MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR
* Once you have been billed $ [***] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
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PARTS A & B
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OTHER BENEFITS--NOT COVERED BY MEDICARE
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***Deductible amounts announced annually by CMS.
EXHIBIT E
NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE
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EXHIBIT F
MEDICARE SUPPLEMENT REFUND CALCULATION FORM
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<1> Individual, Group, Individual Medicare Select, or Group Medicare Select Only.
<2> "SMSBP" = Standardized Medicare Supplement Benefit Plan--Use "P" for prestandardized plans.
<3> Includes Modal Loadings and Fees Charged
<4> Excludes Active Life Reserves
<5> This is to be used as "Issue Year Earned Premium" for Year 1 of next year's "Worksheet for Calculation of Benchmark Ratios"
MEDICARE SUPPLEMENT REFUND CALCULATION FORM
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REPORTING FORM FOR THE CALCULATION OF BENCHMARK
RATIO SINCE INCEPTION FOR GROUP POLICIES
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REPORTING FORM FOR THE CALCULATION OF BENCHMARK
RATIO SINCE INCEPTION FOR GROUP POLICIES
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EXHIBIT G
FORM FOR REPORTING
MEDICARE SUPPLEMENT POLICIES
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EXHIBIT H
DISCLOSURE STATEMENTS
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.
[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
[checkmark] Check the coverage in
all
health insurance policies you already have.
[checkmark] For more information about Medicare and Medicare Supplement insurance, review the
Guide to Health Insurance for People with Medicare
, available from the insurance company.
[checkmark] For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].*
* Drafting Note:
Insurers insert reference to: outpatient prescription drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
[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
[checkmark] Check the coverage in
all
health insurance policies you already have.
[checkmark] For more information about Medicare and Medicare Supplement insurance, review the
Guide to Health Insurance for People with Medicare
, available from the insurance company.
[checkmark] For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].*
* Drafting Note:
Insurers insert reference to: outpatient prescription drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
[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.
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 insurance benefit coverage to which you may be entitled under Medicare or other insurance.
Before You Buy This Insurance
[checkmark] Check the coverage in
all
health insurance policies you already have.
[checkmark] For more information about Medicare and Medicare Supplement insurance, review the
Guide to Health Insurance for People with Medicare
, available from the insurance company.
[checkmark] For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].*
* Drafting Note:
Insurers insert reference to: outpatient prescription drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
[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
[checkmark] Check the coverage in
all
health insurance policies you already have.
[checkmark] For more information about Medicare and Medicare Supplement insurance, review the
Guide to Health Insurance for People with Medicare
, available from the insurance company.
[checkmark] For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].*
* Drafting Note:
Insurers insert reference to: outpatient prescription drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
[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
[checkmark] Check the coverage in
all
health insurance policies you already have.
[checkmark] For more information about Medicare and Medicare Supplement insurance, review the
Guide to Health Insurance for People with Medicare
, available from the insurance company.
[checkmark] For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].*
* Drafting Note:
Insurers insert reference to: outpatient prescription drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
[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
[checkmark] Check the coverage in
all
health insurance policies you already have.
[checkmark] For more information about Medicare and Medicare Supplement insurance, review the
Guide to Health Insurance for People with Medicare
, available from the insurance company.
[checkmark] For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].*
* Drafting Note:
Insurers insert reference to: outpatient prescription drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.
[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
[checkmark] Check the coverage in
all
health insurance policies you already have.
[checkmark] For more information about Medicare and Medicare Supplement insurance, review the
Guide to Health Insurance for People with Medicare
, available from the insurance company.
[checkmark] For help in understanding your health insurance, contact your state insurance department or your state [health] insurance [assistance] program [SHIP].*
* Drafting Note: Insurers insert reference to: outpatient prescription drugs and state health insurance assistance program (SHIP) above when new notices need to be printed after December 31, 2005.