Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 2

Current through June 24, 2024
For policies with an effective date on or after June 1,
				2010, the following information shall be inserted prior to each outline of
				coverage provided to an insured and include the information specific to the
				plan type.
PREMIUM INFORMATION
We can only raise your premium if we raise the premium for all
				policies like yours in this state. [Include information specifying when
				premiums will change.]
If your policy was issued as an under age 65 policy due to
				disability, when you turn 65 premiums will remain at the disabled rates.
				[Include this statement within premium information when issuer does not change
				premium to age 65 rate.]
DISCLOSURES
Use this outline to compare benefits and premiums among
				policies.
READ YOUR POLICY VERY CAREFULLY
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
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 your payments directly to you.
POLICY REPLACEMENT
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
This policy may not fully cover all of your medical
				costs.
(1) The outline of coverage for a Medicare replacement
				insurance policy as defined in s.
				600.03(28p) (a)
				and (c), Stats., shall contain the following
				language: Medicare replacement insurance policy: This policy provides basic
				Medicare hospital and physician benefits. It also includes benefits beyond
				those provided by Medicare. This policy is a replacement for Medicare and is
				subject to certain limitations in choice of providers and area of service. The
				policy does not provide benefits for custodial care such as help in walking,
				getting in and out of bed, eating, dressing, bathing, and taking
				medicine.
(2)
(a) In 24-point type: For Medicare supplement policies marketed
				by intermediaries:
Neither (insert company's name) nor its agents are connected
				with Medicare.
(b) In 24-point type: For Medicare supplement policies marketed
				by direct response:
(insert company's name) is not connected with Medicare.
(c) For Medicare replacement policies as defined in s.
				600.03(28p)
				a and c., Stats.:
(insert company's name) has contracted with Medicare to provide
				Medicare benefits. Except for emergency care anywhere or urgently needed care
				when you are temporarily out of the service area, all services, including all
				Medicare services, must be provided or authorized by (insert company's
				name).
(3)
(a) For Medicare supplement policies, provide a brief summary
				of the major benefits and gaps in Medicare Parts A and B with a parallel
				description of supplemental benefits, including dollar amounts, as outlined in
				these charts.
(b) For Medicare replacement policies, as defined in s.
				600.03(28p)
				a and c., Stats., provide a brief summary of
				both the basic Medicare benefits in the policy and additional benefits using
				the basic format as outlined in these charts and modified to reflect accurately
				the benefits.
(c) If the coverage is provided by a health maintenance
				organization as defined in s.
				609.01(2),
				Stats., provide a brief summary of the coverage for emergency care anywhere and
				urgent care received outside the service area if this care is treated
				differently than other covered benefits.
The following information shall be inserted AFTER the
				specific plan type outline of coverage that is provided to all insureds. The
				information shall include the information specific to the plan
				type.
(4) All limitations and exclusions, including each of the
				following, must be listed under the caption "
LIMITATIONS AND
				EXCLUSIONS
" if benefits are not provided:
(a) Nursing home care costs beyond what is covered by Medicare
				and the additional 30-day skilled nursing mandated by s.
				632.895(3),
				Stats.
(b) Home health care above the number of visits covered by
				Medicare and the 365 visits mandated by s.
				632.895(2),
				Stats. [For Medicare select policies only.]
(c) Physician charges above Medicare's approved charge.
(d) Outpatient prescription drugs.
(e) Most care received outside of U.S.A.
(f) Dental care, dentures, checkups, routine immunizations,
				cosmetic surgery, routine foot care, examinations for and the cost of
				eyeglasses or hearing aids, unless eligible under Medicare.
(g) Coverage for emergency care anywhere or for care received
				outside the service area if this care is treated differently than other covered
				benefits.
(h) Waiting period for pre-existing conditions.
(i) Limitations on the choice of providers or the geographical
				area served (if applicable for Medicare select policies only).
(j) Usual, customary, and reasonable limitations.
(5) CONSPICUOUS STATEMENTS AS FOLLOWS:
This outline of coverage does not give all the details of
				Medicare coverage. Contact your local Social Security Office or consult
				"Medicare & You" for more details.
(6) A description of policy provisions respecting renewability
				or continuation of coverage, including any reservation of rights to change
				premium.
(7) Information on how to file a claim for services received
				from non-participating providers because of an emergency within or outside of
				the service area shall be prominently disclosed.
(8) If there are restrictions on the choice of providers, a
				list of providers available to enrollees shall be included with the outline of
				coverage.
(9) A description of the review and appeal procedure for denied
				claims.
(10) The premium for the policy and riders, if any, in the
				following format:
MEDICARE SUPPLEMENT AND MEDICARE SELECT PREMIUM
				INFORMATION
Annual Premium
$ ( ) BASIC MEDICARE SUPPLEMENT OR MEDICARE SELECT
				COVERAGE
OPTIONAL BENEFITS FOR MEDICARE SUPPLEMENT OR MEDICARE SELECT
				POLICY
Each of these riders may be purchased separately.
(Note: Only optional coverages provided by rider shall be
				listed here.)
$ ( ) 1. 100% of the Medicare Part A hospital deductible
$ ( ) 2. 50% of the Medicare Part A hospital deductible per
				benefit period with no out-of-pocket maximum
$ ( ) 3. Additional home health care
An aggregate of 365 visits per year including those covered by
				Medicare
$ ( ) 4. 100% of Medicare Part B deductible
$ ( ) 5. 100% of the Medicare Part B medical deductible subject
				to copayment or coinsurance of no more than $20 per office visit and no more
				than $50 per emergency room visit in addition to the Medicare Part B deductible
				and in addition to out-of-pocket maximums. The emergency room copayment or
				coinsurance fee shall be waived if the insured is admitted to any hospital and
				the emergency visit is subsequently covered as a Medicare Part A
				expense.
$ ( ) 6. Medicare Part B excess charges
Difference between the Medicare eligible charge and the amount
				charged by the provider which shall be no greater than the actual charge or the
				limited charge allowed by Medicare, whichever is less
$ ( ) 7. Foreign travel emergency rider
After a deductible not greater than $250, covers at least 80%
				of expenses associated with emergency medical care received outside the U.S.A.
				during the first 60 days of a trip with a lifetime maximum of at least
				$50,000
__________
$ ( ) TOTAL FOR BASIC POLICY AND SELECTED OPTIONAL
				BENEFITS
(Note: The soliciting agent shall enter the appropriate premium
				amounts and the total at the time this outline is given to the applicant.
				Medicare select policies and the Medicare Supplement 50% and 25% Cost-Sharing
				plans and Medicare Select 50% and 25% Cost-Sharing plans shall modify the
				outline to reflect the benefits that are contained in the policy or certificate
				and the optional or included riders.)
IN ADDITION TO THIS OUTLINE OF COVERAGE, [ISSUER] WILL SEND AN
				ANNUAL NOTICE TO YOU 30 DAYS PRIOR TO THE EFFECTIVE DATE OF MEDICARE CHANGES
				THAT WILL DESCRIBE THESE CHANGES AND THE CHANGES IN YOUR MEDICARE SUPPLEMENT
				COVERAGE.
(11) If premiums for each rating classification are not listed
				in the outline of coverage under subsection (10), then the issuer shall give a
				separate schedule of premiums for each rating classification with the outline
				of coverage.
(12) Include a summary of or reference to the coverage required
				by applicable statutes.
(13) The term "certificate" should be substituted for the word
				"policy" throughout the outline of coverage where appropriate.