Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 1

Current through June 24, 2024
For policies with an effective date prior to 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 accurately reflect
				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.
(4) If the plan is a Medicare Supplement High Deductible Plan
				as defined in sub. (5) (n) or (o), add the following text in a bold or
				contrasting color: You will pay [half (for plans defined in sub. (5) (n))] [one
				quarter (for plans defined in sub. (5) (o))] of the cost-sharing of some
				covered services until you reach the annual out-of-pocket maximum of [$4,000
				(for plans defined in sub. (5) (n))] [$2,000 (for plan defined in sub. (5)
				(o))] each calendar year. The amounts you must pay are noted in the chart
				below. Once you reach the annual limit, the plan pays for 100% for the items or
				services noted in the chart.
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.
(5) 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.
(6) 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.
(7) A description of policy provisions respecting renewability
				or continuation of coverage, including any reservation of rights to change
				premium.
(8) 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.
(9) If there are restrictions on the choice of providers, a
				list of providers available to enrollees shall be included with the outline of
				coverage.
(10) A description of the review and appeal procedure for
				denied claims.
(11) The premium for the policy and riders, if any, in the
				following format:
MEDICARE SUPPLEMENT AND MEDICARE COST PREMIUM
				INFORMATION
Annual Premium
$ ( ) BASIC MEDICARE SUPPLEMENT OR MEDICARE COST
				COVERAGE
OPTIONAL BENEFITS FOR MEDICARE SUPPLEMENT OR MEDICARE COST
				POLICY
Each of these riders may be purchased separately.
(Note: Only optional coverages provided by rider shall be
				listed here.)
$ ( ) 1. Medicare Part A deductible
100% of Medicare Part A deductible
$ ( ) 2. Additional home health care
An aggregate of 365 visits per year including those covered by
				Medicare
$ ( ) 3. Medicare Part B deductible
100% of Medicare Part B deductible
$ ( ) 4. 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
$ ( ) 5. Foreign travel 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.
				beginning 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 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
				WITH WILL DESCRIBE THESE CHANGES AND THE CHANGES IN YOUR MEDICARE SUPPLEMENT
				COVERAGE.
(12) If premiums for each rating classification are not listed
				in the outline of coverage under subsection (11), then the issuer shall give a
				separate schedule of premiums for each rating classification with the outline
				of coverage.
(13) Include a summary of or reference to the coverage required
				by applicable statutes.
(14) The term "certificate" should be substituted for the word
				"policy" throughout the outline of coverage where appropriate.
Issuers shall select the appropriate outline of coverage
				specific to the plan being presented from among the following Outlines of
				Coverage A through D.
OUTLINE OF COVERAGE - A
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT INSURANCE
(The designation and caption required by sub. (4) (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: Add the following text in a bold or contrasting color if
				the policy is a Medicare Supplement High Deductible Plan as defined in sub. (5)
				(k) or (m), only until December 31, 2005: This high deductible plan pays the
				same as a non-high deductible plan after one has paid a calendar year [$ ]
				deductible. Benefits will not begin until out-of-pocket expenses are [$].
				Out-of-pocket expenses for this deductible are 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 to
							 150th days Beyond 150 days
All but $ [current deductible]
All but $ [current amount] per day
All but $ [current amount] per day
$0
$0 or
D
Optional Part A Deductible
							 Rider*
$ [current amount] per day
$ [current amount] per day
100% of Medicare eligible expenses**
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 $0
* These are optional riders. You purchased this benefit if the
				box is checked and you paid the premium
** NOTICE: When your Medicare Part A hospital benefits are
				exhausted, the insurer stands in the place of Medicare and will pay whatever
				amount Medicare would have paid as provided in the policy's "Core
				Benefits."
MEDICARE SUPPLEMENT POLICIES - PART B BENEFITS
Note: Issuers should include only the wording that applies to
				their policy's "This Policy Pays" column and complete the "You Pay"
				column.
Note: Add the following text in a bold or contrasting color if
				the policy is a Medicare Supplement High Deductible Plan as defined in sub. (5)
				(k) or (m) only until December 31, 2005: This high deductible plan pays the
				same as a non-high deductible plan after one has paid a calendar year [$ ]
				deductible. Benefits will not begin until out-of-pocket expenses are $[ ].
				Out-of-pocket expenses for this deductible are 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
D
Optional Part B Deductible
							 Rider**
Generally 20%
D
Optional Medicare Part B
Excess Charges Rider**
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
D
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 (which 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.
OUTLINE OF COVERAGE - B
(COMPANY NAME)
OUTLINE OF MEDICARE SUPPLEMENT 50% and 25% COST-SHARING
				PLANS
(The designation required by sub. (5) (n) 1. and (o) 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 limit are noted with
				diamonds ([DIAMOND]) in the chart below. Once you reach the annual 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 to
							 150th days Beyond 150 days
All but $
[current deductible]
All but $ [current amount] per day
All but $ [current amount] per day
$0
$[ ] (50% or 75% of Part A deductible)
$ [current amount] per day
$ [current amount] per day
100% Medicare eligible expenses**
&
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.
Generally, most Medicare eligible expenses 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 insurer 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 which 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*
Remainder of Medicare approved amounts
$0
$0
Generally 80%
[50% or 75%]
$0
$Generally [10% or 15%]
&
&
&
CLINICAL LABORATORY SERVICES
Tests for diagnostic Services
100%
$0
HOME HEALTH CARE
100% of charges for visits considered medically
							 necessary by Medicare
40 visits or [] Optional Additional Home Health Care
							 Rider**
*Once you have been billed [$ ] of Medicare approved amounts
				for covered services (which 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.
OUTLINE OF COVERAGE - C
(COMPANY NAME)
OUTLINE OF MEDICARE COST INSURANCE
(The designation and caption required by sub. (7) (a))
MEDICARE COST 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: Add the following bracketed information that is
				appropriate for a Medicare cost policy with either basic or enhanced benefits.
SERVICES
PER BENEFIT PERIOD
MEDICARE PAYS
THIS POLICY PAYS
YOU PAY
HOSPITALIZATION Semiprivate room and board, General
							 nursing and miscellaneous hospital services and supplies.
First 60 days
61st to 90
							 th
days 91st to 150
							 th days
Beyond 150 days
All but $
(current deductible]
All but $ [current amount] per day
All but $ [current amount] per day
$0
$0 or
[]
Optional Part A Deductible
							 Rider*
$[current amount] per day
$[current amount] per day
100% of Medicare eligible expenses**
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
$0
$0
INPATIENT PSYCHIATRIC CARE Inpatient psychiatric care
							 in a participating psychiatric hospital
190 days per lifetime
[$0 or 175 days per lifetime]
BLOOD
First 3 pints Additional amounts
$0
100%
First 3 pints
$0
* These are optional riders. You purchased this benefit if the
				box is checked and you paid the premium
** NOTICE: When your Medicare Part A hospital benefits are
				exhausted, the insurer stands in the place of Medicare and will pay whatever
				amount Medicare would have paid as provided in the policy's "Core
				Benefits."
MEDICARE COST POLICIES - PART B BENEFITS
Note: Issuers should include only the wording that applies to
				their policy's "This Policy Pays" column and complete the "You Pay"
				column.
Note: Add the following bracketed information that is
				appropriate for a Medicare cost policy with either basic or enhanced
				benefits.
MEDICARE PART B BENEFITS
PER CALENDAR YEAR
MEDICARE PAYS
THIS POLICY PAYS
YOU PAY
MEDICAL EXPENSES. Eligible expense for physician's
							 services, in-patient and out-patient medical services and supplies, physical
							 and speech therapy, diagnostic tests, durable medical equipment
First [$ ] of Medicare approved amounts*
Remainder of Medicare approved amounts
$ 0
Generally 80%
$0 or
[]
Optional Part B Deductible
							 Rider**
Generally 20%
BLOOD
First 3 pints
Next $[ ] of Medicare approved amounts*
Remainder of Medicare approved amounts
$0
$0
80%
All
[$[ ] (Part B deductible)]
20%
CLINICAL LABORATORY
SERVICES
Tests for diagnostic services
100%
$0
HOME HEALTH CARE
100% of charges for visits considered medically
							 necessary by Medicare
40 visits
[]
Optional Additional Home Health Care
							 Rider**
*Once you have been billed [$ ] of Medicare approved amounts
				for covered services (which 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.
OUTLINE OF COVERAGE - D
(COMPANY NAME)
OUTLINE OF MEDICARE SELECT INSURANCE AND MEDICARE SELECT
				50% and 25% COST-SHARING PLANS
(The designation and caption required by sub. (30) (i) 8. and
				9., or the designation required by subs. (30) (q) 1. and (r) 1.)
Note: Add the following text if the policy is a Medicare Select
				50% or 25% Cost-Sharing Plan: You will pay [half or ([DIAMOND]) 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 limit are noted with diamonds ([DIAMOND]) in the chart below. Once
				you reach the annual 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 SELECT 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 to
							 150th days
Beyond 150 days
All but $[current deductible]
All but $[current amount] per day
All but $[current amount] per day
$0
$[ ] or [ ]% of Medicare Part A deductible
$[current amount] per day
$[current amount] per day
100% of Medicare eligible expenses **
&
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%
[3 pints] or [ %]
$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 for outpatient drugs
							 and inpatient respite care
$0 or [ ]% of coinsurance or copayments
&
** NOTICE: When your Medicare Part A hospital benefits are
				exhausted, the insurer stands in the place of Medicare and will pay whatever
				amount Medicare would have paid as provided in the policy's "Core
				Benefits."
MEDICARE SELECT 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 In or out of the hospital and
							 outpatient hospital treatment, such as Physician's services, inpatient and
							 outpatient medical and surgical 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
$0
[Generally [ ]% or more of Medicare approved
							 amounts**]
Generally 80%
[$[ ] (Part B deductible)] or $0
[Remainder of Medicare approved amounts**]
Generally [10% or 15%]
&
&
BLOOD
First 3 pints
Next $ [ ] of Medicare approved amounts*
Remainder of Medicare approved amounts
$0
$0
Generally 80%
[ ]% $0
Generally [10% or 15%]
&
&
&
CLINICAL LABORATORY SERVICES
Tests for diagnostic services
100%
$0
[HOME HEALTH CARE]
100% of charges for visits considered medically
							 necessary by Medicare
365 necessary visits for medically necessary
							 services
[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 (which are noted with an asterisk), your Medicare Part B
				deductible will have been met for the calendar year.
** NOTE: Insurers should include in the outline of coverage the
				appropriate preventive benefit based upon whether or not the policy is a
				cost-sharing policy.