Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter M - Reserved › Appendix I - DISCLOSURE STATEMENTS

Current through Register Vol. 54, No. 28, July 13, 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 (
					 42 U.S.C.A. §
											1395ss ) prohibits the sale of health
					 insurance policies (the term policy or policies includes certificates) that
					 duplicate Medicare benefits unless it will pay benefits without regard to 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.
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 policies are 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 Social Security Act was amended in
					 subsection (d)(3)(A) to allow for alternative disclosure statements. The
					 disclosure statements already in Appendix I 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 MEDICARE BENEFITS DUPLICATES
								SOME
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
* other approved items and services
Before You Buy This
								Insurance
Click to view image
Check the coverage in
all
health insurance policies you already
					 have.
Click to view image
For more information about Medicare and Medicare Supplement insurance, review
					 the
Guide to Health Insurance for People with Medicare
,
					 available from the insurance company.
Click to view image
For help in understanding your health insurance, contact your state insurance
					 department or state senior insurance counseling program.
(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
* other approved items and services
Before You Buy This
								Insurance
Click to view image
Check the coverage in
all
health insurance policies you already
					 have.
Click to view image
For more information about Medicare and Medicare Supplement insurance, review
					 the
Guide to Health Insurance for People with Medicare
,
					 available from the insurance company.
Click to view image
For help in understanding your health insurance, contact your state insurance
					 department or state senior insurance counseling program.
(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
* other approved items and services
Before You Buy This
								Insurance
Click to view image
Check the coverage in
all
health insurance policies you already
					 have.
Click to view image
For more information about Medicare and Medicare Supplement insurance, review
					 the
Guide to Health Insurance for People with Medicare
,
					 available from the insurance company.
Click to view image
For help in understanding your health insurance, contact your state insurance
					 department or state senior insurance counseling program.
(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
* other approved items and services
Before You Buy This
								Insurance
Click to view image
Check the coverage in
all
health insurance policies you already
					 have.
Click to view image
For more information about Medicare and Medicare Supplement insurance, review
					 the
Guide to Health Insurance for People with Medicare
,
					 available from the insurance company.
Click to view image
For help in understanding your health insurance, contact your state insurance
					 department or state senior insurance counseling program.
(Original disclosure statement for indemnity policies and
					 other policies that pay a fixed dollar amount per day, excluding long-term care
					 policies.)
Important Notice to Persons on Medicare
THIS INSURANCE DUPLICATES SOME MEDICARE
								BENEFITS
This is not Medicare Supplement
					 Insurance
This insurance pays a fixed dollar amount, regardless of
					 your expenses, for each day you meet the policy conditions. It does not pay
					 your Medicare deductibles or coinsurance and is not a substitute for Medicare
					 Supplement insurance.
This insurance duplicates Medicare benefits
					 when:
* any expenses or services covered by the policy are also
					 covered by Medicare
Medicare generally pays for most or all of these
					 expenses.
Medicare pays extensive benefits for medically
					 necessary services regardless of the reason you need them. These
					 include:
* hospitalization
* physician services
* hospice
* other approved items and services
Before You Buy This
								Insurance
Click to view image
Check the coverage in
all
health insurance policies you already
					 have.
Click to view image
For more information about Medicare and Medicare Supplement insurance, review
					 the
Guide to Health Insurance for People with Medicare
,
					 available from the insurance company.
Click to view image
For help in understanding your health insurance, contact your state insurance
					 department or state senior insurance counseling program.
(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
* other approved items & services
Before You Buy This
								Insurance
Click to view image
Check the coverage in
all
health insurance policies you already
					 have.
Click to view image
For more information about Medicare and Medicare Supplement insurance, review
					 the
Guide to Health Insurance for People with Medicare
,
					 available from the insurance company.
Click to view image
For help in understanding your health insurance, contact your state insurance
					 department or state senior insurance counseling program.
(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
* other approved items and services
Before You Buy This
								Insurance
Click to view image
Check the coverage in
all
health insurance policies you already
					 have.
Click to view image
For more information about Medicare and Medicare Supplement insurance, review
					 the
Guide to Health Insurance for People with Medicare
,
					 available from the insurance company.
Click to view image
For help in understanding your health insurance, contact your state insurance
					 department or state senior insurance counseling program.
(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
* 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
Click to view image
Check the coverage in
all
health insurance policies you already
					 have.
Click to view image
For more information about Medicare and Medicare Supplement insurance, review
					 the
Guide to Health Insurance for People with Medicare
,
					 available from the insurance company.
Click to view image
For help in understanding your health insurance, contact your state insurance
					 department or state senior insurance counseling program.
(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
* 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
Click to view image
Check the coverage in
all
health insurance policies you already
					 have.
Click to view image
For more information about Medicare and Medicare Supplement insurance, review
					 the
Guide to Health Insurance for People with Medicare
,
					 available from the insurance company.
Click to view image
For help in understanding your health insurance, contact your state insurance
					 department or state senior insurance counseling program.
(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
* 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
Click to view image
Check the coverage in
all
health insurance policies you already
					 have.
Click to view image
For more information about Medicare and Medicare Supplement insurance, review
					 the
Guide to Health Insurance for People with Medicare
,
					 available from the insurance company.
Click to view image
For help in understanding your health insurance, contact your state insurance
					 department or state senior insurance counseling program.
(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
* 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
Click to view image
Check the coverage in
all
health insurance policies you already
					 have.
Click to view image
For more information about Medicare and Medicare Supplement insurance, review
					 the
Guide to Health Insurance for People with Medicare
,
					 available from the insurance company.
Click to view image
For help in understanding your health insurance, contact your state insurance
					 department or state senior insurance counseling program.
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
* 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
Click to view image
Check the coverage in
all
health insurance policies you already
					 have.
Click to view image
For more information about Medicare and Medicare Supplement insurance, review
					 the
Guide to Health Insurance for People with Medicare
,
					 available from the insurance company.
Click to view image
For help in understanding your health insurance, contact your state insurance
					 department or state senior insurance counseling program.
(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
* other approved items & 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
Click to view image
Check the coverage in
all
health insurance policies you already
					 have.
Click to view image
For more information about Medicare and Medicare Supplement insurance, review
					 the
Guide to Health Insurance for People with Medicare
,
					 available from the insurance company.
Click to view image
For help in understanding your health insurance, contact your state insurance
					 department or state senior insurance counseling program.
(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
* 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
Click to view image
Check the coverage in
all
health insurance policies you already
					 have.
Click to view image
For more information about Medicare and Medicare Supplement insurance, review
					 the
Guide to Health Insurance for People with Medicare
,
					 available from the insurance company.
Click to view image
For help in understanding your health insurance, contact your state insurance
					 department or state senior insurance counseling program.