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

Current through June 24, 2024
OUTLINE OF COVERAGE
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT INSURANCE
(The designation and caption required by sub. (4s) (b)
				4.)
MEDICARE SUPPLEMENT PART A - HOSPITAL SERVICES - PER BENEFIT
				PERIOD
Note: Issuers should include only the wording that applies to
				their policy's "This Policy Pays" column and complete the "You Pay"
				column.
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.
Note: This includes the Medicare deductibles for Part A and
				Part B, but does not include [the plan's separate riders deductible.]
Note: Add the following text in a bold or contrasting color if
				the plan is a Medicare supplement insurance - high deductible plan as defined
				at sub. (5m) (k): This high deductible plan offers benefits after one has paid
				a calendar year [$2000] deductible. This deductible consists of 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.
SERVICES
PER BENEFIT PERIOD
MEDICARE PAYS
[AFTER YOU PAY A
$[ ] DEDUCTIBLE]
							 THIS POLICY PAYS
YOU PAY
HOSPITALIZATION
Semiprivate room and board, general nursing and
							 miscellaneous hospital services and supplies.
First 60 days
61st to 90th days
91st day and after while using 60 lifetime reserve
							 days
Once lifetime reserve days are used:
Additional 365 days
Beyond the additional 365 days
All but $ [current
deductible]
All but $ [current amount] per day All but $
							 [current
amount] per day
$0
$0
$0 or
[ []OPTIONAL PART A DEDUCTIBLE RIDER* (for non-high
							 deductible plans)]
[ [] PART A DEDUCTIBLE RIDER* (for high deductible
							 plans)]
[ []OPTIONAL MEDICARE 50% PART A DEDUCTIBLE
							 RIDER***
$ [current amount] per day
$ [current amount] per day
100% of Medicare eligible expenses**
$0
SKILLED NURSING FACILITY CARE
You must meet Medicare's requirements, including
							 having been in a hospital for at least 3 days and entered a Medicare-approved
							 facility within 30 days after leaving the hospital
First 20 days
21st through 100th day
101st day and after
All approved amounts
All but $ [current amount] per day
$[0]
$0
Up to $[ ] a day
$0
INPATIENT PSYCHIATRIC CARE Inpatient psychiatric care
							 in a participating psychiatric hospital
190 days per lifetime
175 days per lifetime
BLOOD
First 3 pints Additional amounts
$0
100%
First 3 pints
$0
HOSPICE CARE Available as long as your doctor
							 certifies you are terminally ill and you elect to receive these
							 services.
All but very limited coinsurance or copayment for
							 outpatient drugs and inpatient respite care
$0 or [ ]% of coinsurance or copayments
* These are optional riders. You purchased this benefit if the
				box is checked and you paid the premium.
** NOTICE: When your Medicare Part A hospital benefits are
				exhausted, the issuer stands in the place of Medicare and will pay whatever
				amount Medicare would have paid as provided in the policy's "Core
				Benefits."
*** This optional rider may reduce your premium when you pay
				50% of Medicare Part A deductible.
MEDICARE SUPPLEMENT POLICIES - PART B BENEFITS
Note: Issuers should include only the wording that applies to
				their policy's "This Policy Pays" column and complete the "You Pay"
				column.
Note: Add the following text in a bold or contrasting color if
				the plan is a Medicare supplement insurance-high deductible plan as defined at
				sub. (5m) (k): This high deductible plan offers benefits after one has paid a
				calendar year [$2000] deductible. This deductible consists of 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.
MEDICARE PART B BENEFITS
PER CALENDAR YEAR
MEDICARE PAYS
[AFTER YOU PAY A $[ ] DEDUCTIBLE] THIS POLICY
							 PAYS
YOU PAY
MEDICAL EXPENSES
Eligible expense for physician's services, in-patient
							 and out-patient medical services and supplies, physical and speech therapy,
							 diagnostic tests, durable medical equipment
First $[ ] of Medicare approved amounts*
Remainder of Medicare approved amounts
$0
Generally 80%
$0 or
[ [] OPTIONAL PART B DEDUCTIBLE RIDER** (for non-high
							 deductible plans)]
[ [] PART B DEDUCTIBLE RIDER** (for high deductible
							 plans)]
[ [] OPTIONAL PART B COPAYMENT OR COINSURANCE
							 RIDER***
Generally 20%
[ []OPTIONAL MEDICARE PART B EXCESS CHARGES RIDER**
							 (for non-high deductible plans)]
[ [] MEDICARE PART B EXCESS CHARGES RIDER** (for high
							 deductible plans)]
[ []OPTIONAL FOREIGN TRAVEL EMERGENCY RIDER**
							 (non-high deductible plans)]
[ []FOREIGN TRAVEL EMERGENCY RIDER** (for
							 high-deductible plans)]
BLOOD
First 3 pints
Next $[ ] of Medicare approved amounts*
Remainder of Medicare approved amounts
$0
$0
80%
All costs
[$[ ] (Part B deductible)]
20%
CLINICAL LABORATORY SERVICES
Tests for diagnostic services
100%
$0
HOME HEALTH CARE
100% of charges for visits considered medically
							 necessary by Medicare
40 visits
or [ [] OPTIONAL ADDITIONAL HOME HEALTH CARE
							 RIDER**
FOREIGN TRAVEL- NOT COVERED BY MEDICARE Medically
							 necessary emergency care services beginning during the first 60 days of each
							 trip outside the USA
First $250 each calendar year
Remainder of charges
[$0]
$250
80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
[PREVENTIVE MEDICAL CARE BENEFIT- NOT COVERED BY
							 MEDICARE
Some annual physical and preventive tests and
							 services administered or ordered by your doctor when not covered by
							 Medicare.]*
[First $120 each calendar year]
[Additional charges]
[$0]
[$0]
[$120]
[$0] or $[dollar amount]
* Once you have been billed [$ ] of Medicare approved amounts
				for covered services (that are noted with an asterisk), your Medicare Part B
				deductible will have been met for the calendar year.
** These are optional riders. You purchased this benefit if the
				box is checked and you paid the premium.
*** This is an optional rider that may decrease your premium
				when you pay copayments for medical and emergency room visits.