Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 4

Current through June 24, 2024
OUTLINE OF COVERAGE
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT 50% and 25% COST-SHARING
				PLANS
(The designation required by sub. (5m) (g) 1. and (h)
				1.)
You will pay [half or one quarter] the cost-sharing of some
				covered services until you reach the annual out-of-pocket limit of $[ ] each
				calendar year. The amounts that count toward your annual out-of-pocket limit
				are noted with diamonds (?) in the chart below. Once you reach the annual
				out-of-pocket limit, the policy plays 100% of your Medicare copayment and
				coinsurance for the rest of the calendar year.
However, this limit does
				NOT include charges from your provider that exceed Medicare approved amounts
				(these are called "Excess Charges") and you will be responsible for paying this
				difference in the amount charged by your provider and the amount paid by
				Medicare for the item or service.
MEDICARE COST-SHARING 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.
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
$[ ] (50% or 75% of Medicare Part A
							 deductible.)
$ [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%
[50% or 75%] $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
[50% or 75%] of coinsurance or copayments
&
** 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."
MEDICARE COST-SHARING 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.
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*
Preventive Benefits for Medicare covered
							 services
Remainder of Medicare approved amounts
$0
Generally 75% or more of Medicare approved
							 amounts
Generally 80%
$0
Remainder of Medicare approved amounts
Generally [10% or 15%]
&
&
BLOOD
First 3 pints Next $[ ] of Medicare approved
							 amounts*
$0
$0
Generally 80%
[50% or 75%]
$0
Generally [10% or 15%]
&
&
&
CLINICAL LABORATORY SERVICES
Tests for diagnostic services
Remainder of Medicare approved amounts
100%
$0
HOME HEALTH CARE
100% of charges for visits considered medically
							 necessary by Medicare
40 visits or [ []OPTIONAL ADDITIONAL HOME HEALTH CARE
							 RIDER**
[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.