Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 5

Current through June 24, 2024
OUTLINE OF COVERAGE
(COMPANY NAME)
OUTLINE OF MEDICARE SELECT INSURANCE AND MEDICARE SELECT
				50% and 25% COST-SHARING PLANS
(The designation and caption required by sub. (30m) (i) 8. and
				9., or the designation required by sub. (30m) (r) 1. and (s) 1.)
Note: Add the following text if the policy is a Medicare Select
				50% or 25% Cost-Sharing Plan: 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 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 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 [ ]% 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%
[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 or copayment for
							 outpatient drugs and inpatient respite care
$0
or [ ]% 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 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
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 [ ]% 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
365 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 (that are noted with an asterisk), your Medicare Part B
				deductible will have been met for the calendar year.
** NOTE: Issuers should include in the outline of coverage the
				appropriate preventive benefit based upon whether or not the policy is a
				cost-sharing policy.