Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 6

Current through June 24, 2024
[NOTICE OF CHANGE FOR OUTLINE OF COVERAGE]
(COMPANY NAME)
NOTICE OF CHANGES IN MEDICARE AND YOUR [MEDICARE
SUPPLEMENT OR MEDICARE REPLACEMENT] COVERAGE - 2_____
THE FOLLOWING CHART BRIEFLY DESCRIBES THE MODIFICATIONS IN
				MEDICARE AND IN YOUR [MEDICARE SUPPLEMENT OR MEDICARE REPLACEMENT]
				COVERAGE.
PLEASE READ THIS CAREFULLY!
[Note: A brief description of the revisions to Medicare Parts A
				and B with a parallel description of supplemental benefits with subsequent
				changes, including dollar amounts, provided by the Medicare supplement or
				Medicare replacement coverage in substantially the following format.]
SERVICES
MEDICARE BENEFITS
YOUR [MEDICARE SUPPLEMENT OR MEDICARE
							 REPLACEMENT] COVERAGE
In 2____, Medicare Pays Per Benefit
							 Period
Effective January 1, 2____, Medicare will
							 Pay
In 2____, Your Coverage Pays
Effective January 1, 2____, Your Coverage will
							 Pay Per Calendar Year
MEDICARE PART A SERVICES AND
							 SUPPLIES
HOSPITALIZATION Inpatient Hospital Services,
							 Semi-Private Room & Board, Misc. Hospital Services & Supplies, such as
							 Drugs, X-Rays, Lab Tests & Operating Room
All but $___ for the first 60 days/benefit
							 period
All but $___ a day for 61st-90th days/benefit
							 period
All but $___ a day for 91st day and after while using
							 60 lifetime reserve days
$0 once lifetime reserve days are used: Additional
							 365 days
$0 beyond additional 365 days.
All but $___ for the first 60 days/benefit
							 period
All but $___ a day for
							 61st-90th days/benefit period
All but $ [current amount] per day
$0 once lifetime reserve days are used: Additional
							 365 days
$0 beyond the additional 365 days.
SKILLED NURSING FACILITY CARE Skilled nursing care in
							 a facility approved by Medicare. Confinement must meet Medicare standards. You
							 must have been in a hospital for at least 3 days and enter the facility within
							 30 days after discharge.
First 20 days 100% of costs
All but $___ (current amount per day) for the 21st -
							 100th day
$[0] of the 101st day and
							 thereafter.
First 20 days 100% of costs
All but $___ (current amount per day) for the 21st -
							 100th day
$[0] of the 101st day and
							 thereafter.
BLOOD
Pays all costs except payment of deductible (equal to
							 costs for first 3 pints) each calendar year. Part A blood deductible reduced to
							 the extent paid under Part B
$0 for first 3 pints.
100% of additional amounts
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
All but very limited coinsurance or copayment for
							 outpatient drugs and inpatient respite care
$0 or [ ]% of coinsurance or copayments
&
MEDICARE PART B SERVICES AND
							 SUPPLIES
MEDICAL EXPENSES Eligible expense for physician's
							 services, medical services in and out patient, physical and speech therapy,
							 diagnostic tests, and durable medical equipment.
After $[ ] deductible, generally 80% of remainder of
							 Medicare approved amounts
After $[ ] deductible, generally 80% of remainder of
							 Medicare approved amounts
HOME HEALTH CARE
100% of charges for visits considered medically
							 necessary by Medicare
40 visits
PREVENTIVE MEDICAL CARE BENEFIT Some annual physical
							 and preventive tests and services administered or ordered by your doctor when
							 NOT covered by Medicare
$0
$0
$120
[Note: Describe any coverage provisions changing due to
				Medicare modifications. Include information about when premium adjustments that
				may be necessary due to changes in Medicare benefits will be effective.]
THIS CHART SUMMARIZES THE CHANGES IN YOUR MEDICARE BENEFITS AND
				IN YOUR MEDICARE SUPPLEMENT OR MEDICARE REPLACEMENT] COVERAGE PROVIDED BY
				(COMPANY) ONLY BRIEFLY DESCRIBES SUCH BENEFITS. FOR INFORMATION ON YOUR
				MEDICARE BENEFITS CONTACT YOUR SOCIAL SECURITY OFFICE OR THE CENTERS FOR
				MEDICARE & MEDICAID SERVICES. FOR INFORMATION ON YOUR [MEDICARE SUPPLEMENT
				OR MEDICARE REPLACEMENT] POLICY CONTACT:
[COMPANY OR FOR AN INDIVIDUAL POLICY - NAME OF AGENT]
[ADDRESS/PHONE NUMBER]