Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-220:3 - APPENDIX C. DISCLOSURE STATEMENTS

Current through Register Vol. 40, No. 24, July 15, 2024
Rev. 8/05
APPENDIX C
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 of 1935 ( 42
				USC 1395 ss ) prohibits the sale of a health
				insurance policy (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.
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 who 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 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 pre-empt state
				laws that are more stringent than the federal requirements.
8. The federal law does not pre-empt existing
				state form filing requirements.
9.
				Section 1882 of the federal Social Security Act was amended in subsection (d)
				(3) (A) thereof 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.
Rev. 8/05
APPENDIX C
[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
[RIGHT] Check the coverage in
all
health
				  insurance policies you already have.
[RIGHT] For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
[RIGHT] For help in understanding your health insurance,
				  contact your state insurance department or state health insurance assistance
				  program (Virginia Insurance Counseling and Assistance Program).
Rev. 8/05
APPENDIX C
[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
[RIGHT] Check the coverage in
all
health
				  insurance policies you already have.
[RIGHT] For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
[RIGHT] For help in understanding your health insurance,
				  contact your state insurance department or state health insurance assistance
				  program (Virginia Insurance Counseling and Assistance Program).
Rev. 8/05
APPENDIX C
[Original disclosure statement for policies that reimburse
				  expenses incurred for specified disease(s) or other specified impairment(s).
				  This includes expense incurred cancer, specified disease, and other types of
				  health insurance policies that limit reimbursement to named medical
				  conditions.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE
THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the
				  policy conditions, for hospital or medical expenses only when you are treated
				  for one of the specific diseases or health conditions listed in the policy. It
				  does not pay your Medicare deductibles or coinsurance and is not a substitute
				  for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it
				  pays:
. hospital or medical expenses up to the maximum stated in
				  the policy
Medicare generally pays for most or all of these
				  expenses.
Medicare pays extensive benefits for medically
				  necessary services regardless of the reason you need them. These include:
. hospitalization
. physician services
. hospice care
. outpatient prescription drugs if you are enrolled in
				  Medicare Part D
. other approved items and services
Before You Buy This Insurance
[RIGHT] Check the coverage in
all
health
				  insurance policies you already have.
[RIGHT] For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
[RIGHT] For help in understanding your health insurance,
				  contact your state insurance department or state health insurance assistance
				  program (Virginia Insurance Counseling and Assistance Program).
Rev. 8/05
APPENDIX C
[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 diagnosis named in the policy.
Medicare pays extensive benefits for medically
				  necessary services regardless of the reason you need them. These include:
. hospitalization
. physician services
. hospice care
. outpatient prescription drugs if you are enrolled in
				  Medicare Part D
. other approved items and services
Before You Buy This Insurance
[RIGHT] Check the coverage in
all
health
				  insurance policies you already have.
[RIGHT] For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
[RIGHT] For help in understanding your health insurance,
				  contact your state insurance department or state health insurance assistance
				  program (Virginia Insurance Counseling and Assistance Program).
Rev. 8/05
APPENDIX C
[Original disclosure statement for policies that provide
				  benefits for both expenses 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
[RIGHT] Check the coverage in
all
health
				  insurance policies you already have.
[RIGHT] For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
[RIGHT] For help in understanding your health insurance,
				  contact your state insurance department or state health insurance assistance
				  program (Virginia Insurance Counseling and Assistance Program).
Rev. 8/05
APPENDIX C
[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 care
. outpatient prescription drugs if you are enrolled in
				  Medicare Part D
. other approved items and services
Before You Buy This Insurance
[RIGHT] Check the coverage in
all
health
				  insurance policies you already have.
[RIGHT] For more information about Medicare and Medicare
				  Supplement Insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
[RIGHT] For help in understanding your health insurance,
				  contact your state insurance department or state health insurance assistance
				  program (Virginia Insurance Counseling and Assistance Program).
Rev. 8/05
APPENDIX C
[Original disclosure statement for other health insurance
				  policies not specifically identified in the previous statements.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE
THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS
This is not Medicare Supplement Insurance
This insurance provides limited benefits if you meet the
				  conditions listed in the policy. It does not pay your Medicare deductibles or
				  coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it
				  pays:
. the benefits stated in the policy and coverage for the same
				  event is provided by Medicare
Medicare generally pays for most or all of these
				  expenses.
Medicare pays extensive benefits for medically
				  necessary services regardless of the reason you need them. These include:
. hospitalization
. physician services
. hospice care
. outpatient prescription drugs if you are enrolled in
				  Medicare Part D
. other approved items and services
Before You Buy This Insurance
[RIGHT] Check the coverage in
all
health
				  insurance policies you already have.
[RIGHT] For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
[RIGHT] For help in understanding your health insurance,
				  contact your state insurance department or state health insurance assistance
				  program (Virginia Insurance Counseling and Assistance Program).
Rev. 8/05
APPENDIX C
[Alternative disclosure statement for policies that provide
				  benefits for expenses incurred for an accidental injury only.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE
THIS IS NOT MEDICARE SUPPLEMENT INSURANCE
Some health care services paid for by Medicare may also
				  trigger the payment of benefits from this policy.
This insurance provides limited benefits, if you meet the
				  policy conditions, for hospital or medical expenses that result from accidental
				  injury. It does not pay your Medicare deductibles or coinsurance and is not a
				  substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these
				  expenses.
Medicare pays extensive benefits for medically
				  necessary services regardless of the reason you need them. These include:
. hospitalization
. physician services
. outpatient prescription drugs if you are enrolled in
				  Medicare Part D
. other approved items and services
This policy must pay benefits without regard to other
				  health benefit coverage to which you may be entitled under Medicare or other
				  insurance.
Before You Buy This Insurance
[RIGHT] Check the coverage in
all
health
				  insurance policies you already have.
[RIGHT] For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
[RIGHT] For help in understanding your health insurance,
				  contact your state insurance department or state health insurance assistance
				  program (Virginia Insurance Counseling and Assistance Program).
Rev. 8/05
APPENDIX C
[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
[RIGHT] Check the coverage in
all
health
				  insurance policies you already have.
[RIGHT] For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
[RIGHT] For help in understanding your health insurance,
				  contact your state insurance department or state health insurance assistance
				  program (Virginia Insurance Counseling and Assistance Program).
Rev. 8/05
APPENDIX C
[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 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
[RIGHT] Check the coverage in
all
health
				  insurance policies you already have.
[RIGHT] For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
[RIGHT] For help in understanding your health insurance,
				  contact your state insurance department or state health insurance assistance
				  program (Virginia Insurance Counseling and Assistance Program).
Rev. 8/05
APPENDIX C
[Alternative disclosure statement for policies that pay fixed
				  dollar amounts for specified diseases or other specified impairments. This
				  includes cancer, specified disease, and other health insurance policies that
				  pay a scheduled benefit or specific payment based on diagnosis of the
				  conditions named in the policy.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE
THIS IS NOT MEDICARE SUPPLEMENT INSURANCE
Some health care services paid for by Medicare may also
				  trigger the payment of benefits from this policy.
This insurance pays a fixed amount, regardless of your
				  expenses, if you meet the policy conditions, for one of the specific diseases
				  or health conditions named in the policy. It does not pay your Medicare
				  deductibles or coinsurance and is not a substitute for Medicare Supplement
				  insurance.
Medicare pays extensive benefits for medically
				  necessary services regardless of the reason you need them. These include:
. hospitalization
. physician services
. hospice care
. outpatient prescription drugs if you are enrolled in
				  Medicare Part D
. other approved items and services
This policy must pay benefits without regard to other
				  health benefit coverage to which you may be entitled under Medicare or other
				  insurance.
Before You Buy This Insurance
[RIGHT] Check the coverage in
all
health
				  insurance policies you already have.
[RIGHT] For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
[RIGHT] For help in understanding your health insurance,
				  contact your state insurance department or state health insurance assistance
				  program (Virginia Insurance Counseling and Assistance Program).
Rev. 8/05
APPENDIX C
[Alternative disclosure statement for indemnity policies and
				  other policies that pay a fixed dollar amount per day, excluding long-term care
				  policies.]
IMPORTANT NOTICE TO PERSONS ON MEDICARE
THIS IS NOT MEDICARE SUPPLEMENT INSURANCE
Some health care services paid for by Medicare may also
				  trigger the payment of benefits from this policy.
This insurance pays a fixed dollar amount, regardless of your
				  expenses, for each day you meet the policy conditions. It does not pay your
				  Medicare deductibles or coinsurance and is not a substitute for Medicare
				  Supplement insurance.
Medicare generally pays for most or all of these
				  expenses.
Medicare pays extensive benefits for medically
				  necessary services regardless of the reason you need them. These include:
. hospitalization
. physician services
. hospice care
. outpatient prescription drugs if you are enrolled in
				  Medicare Part D
. other approved items and services
This policy must pay benefits without regard to other
				  health benefit coverage to which you may be entitled under Medicare or other
				  insurance.
Before You Buy This Insurance
[RIGHT] Check the coverage in
all
health
				  insurance policies you already have.
[RIGHT] For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
[RIGHT] For help in understanding your health insurance,
				  contact your state insurance department or state health insurance assistance
				  program (Virginia Insurance Counseling and Assistance Program).
Rev. 8/05
APPENDIX C
[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
[RIGHT] Check the coverage in
all
health
				  insurance policies you already have.
[RIGHT] For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
[RIGHT] For help in understanding your health insurance,
				  contact your state insurance department or state health insurance assistance
				  program (Virginia Insurance Counseling and Assistance Program).
Rev. 8/05
APPENDIX C
[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 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
[RIGHT] Check the coverage in
all
health
				  insurance policies you already have.
[RIGHT] For more information about Medicare and Medicare
				  Supplement insurance, review the Guide to Health Insurance for People with
				  Medicare, available from the insurance company.
[RIGHT] For help in understanding your health insurance,
				  contact your state insurance department or state health insurance assistance
				  program (Virginia Insurance Counseling and Assistance
				  Program).
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of Virginia.