(company name)

outline of medicare

supplement coverage

(1) Read your policy carefully - This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you read your policy carefully!

(2) Medicare supplement coverage - Policies of this category are designed to supplement medicare by covering some hospital, medical, and surgical services which are partially covered by medicare. Coverage is provided for hospital inpatient charges and some physician charges, subject to any deductibles and copayment provisions which may be in addition to those provided by medicare, and subject to other limitations which may be set forth in the policy. 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 (delete if such coverage is provided).

(3)(a) (for agents:)

Neither (Insert company's name) nor its agents

are connected with medicare.

(b) (for direct responses:)

(Insert company's name) is not connected with

medicare.

(4) (A brief summary of the major benefit gaps in medicare Parts A and B with a description of supplemental benefits, including dollar amounts, provided by the medicare supplement coverage in the following order:)

. . . .
service		this policy pays	you pay
I. Part A
a. inpatient hospital services:
Semi-private room & board
	Miscellaneous hospital services & supplies, such as drugs, X-rays, lab tests & operating room
b. skilled nursing care
c. blood
II. Part B
a. medical expense:
Services of a physician/ outpatient services
Medical supplies other than prescribed drugs
b. blood
c. mammography screening
d. out-of-pocket maximum
e. prescription drugs
III. Parts A & B
Home health services
IV. Miscellaneous
A. Home intravenous (IV) therapy drugs
B. Immunosuppresive drugs
C. Respite care benefits
in addition to this outline of coverage, (insurance company name) will send an annual notice to you thirty days prior to the effective date of medicare changed which will describe these changes and the changes in your medicare supplement coverage.
. . . .

(5) (The following chart shall accompany the outline of coverage and the form thereof shall be filed with the commissioner prior to use in this state:)

Part A

MEDICARE BENEFITS IN

- - - -
Service	1988	1989	1990	1991

part a

Inpatient Hospital Services	All but $540 for first 60 days/benefit period	All but $560 deductible for an unlimited number of days/calendar year	All but Part A deductible for an unlimited number of days/calendar year	All but Part A deductible for an unlimited number of days/calendar year

Semi-Private Room & Board	All but $135 a day for 61st - 90th day/benefit period

Miscellaneous Hospital Services & Supplies, such as Drugs, X-Rays, Lab Tests & Operating Room	All but $270 a day for 91st - 150th days (if individual chooses to use 60 nonrenewable lifetime reserve days) per benefit period
- - - -
Skilled Nursing Facility Care	100% of costs for for 1st 20 days (after 3-day prior hospital confinement)	80% of medicare reasonable costs for first 8 days per calendar year without prior hospitalization requirement	80% for 1st 8 days/calendar year	80% for 1st 8 days/calendar year
Skilled Nursing Facility Care	All but $67.50 a day for 21st - 100th days		80% for 1st 8 days/calendar year	80% for 1st 8 days/calendar year
	Nothing beyond 100 days	100% of costs thereafter up to 150 days/calendar year	100% for 9th-150th day/calendar year	100% for 9th-150th day/calendar year
- - - -
Blood	Pays all costs except nonreplacement fees (blood deductible) for first 3 pints in each benefit period	Pays all costs except payment of deductible (equal to costs for first 3 pints) each calendar year.	All but blood deductible (equal to costs for first 3 pints)	All but blood deductible (equal to costs for first 3 pints)

		Part A blood deductible reduced to the extent paid under Part B.

Part B

MEDICARE BENEFITS IN

- - - -
Service	1988	1989	1990	1991

Parts A & B:

Home Health Services	Intermittent skilled nursing home care and other services in the home (daily skilled nursing care for up to 21 days or longer in some cases) — 100% of covered services and 80% of durable medical equipment under both Parts A & B		Intermittent skilled nursing care for up to 7 days a week for up to 38 days allowing for continuation of services under unusual circumstances — other services, — 100% of covered services and 80% of durable medical equipment under both Parts A & B (same 1990 & 1991)
	(same 1988 and 1989)
- - - -

part b

Medical Expense: Services of a Physician/ Outpatient Services —Medical Supplies Other than Prescribed Drugs	80% of reasonable charges after an annual $75 deductible	80% after $75 deductible	80% of reasonable charges after $75 deductible until out-of-pocket maximum is reached. 100% of reasonable charges are covered for the remainder of the calendar year. (same 1990 and 1991)
- - - -

Blood	80% of costs except non-replacement fees (blood deductible) for 1st 3 pints in each benefit period after $75 deductible	Pays 80% of all costs except payment of deductible (equal to costs for first 3 pints) each calendar year (same 1989, 1990, 1991)
- - - -
Mammography Screening			80% of approved charge for elderly and disabled medicare beneficiaries — exams available every other year for women age 65 and older (same 1990 and 1991)
- - - -
Out-of-Pocket Maximum			$1,370 consisting of Part B $75 deductible, Part B blood deductible and 20% co-insurance (same 1990 & 1991, except $1,370 will be adjusted annually by Sec. Health & Human Services)
- - - -
Outpatient Prescription Drugs			There is a $550 total deductible for home IV drug and immunosuppressive drug therapies as noted below	Covered after $600 deductible subject to 50% co-insurance
- - - -
Home IV Drug Therapy			80% of IV therapy drugs subject to $550 deductible (deductible waived if home therapy is a continuation of therapy initiated in a hospital)	80% of IV therapy drugs subject to standard drug deductible (deductible waived if home therapy is a continuation of therapy initiated in a hospital)
- - - -
Immunosuppressive Drug Therapy	80% of costs during 1st year following a covered organ transplant (no special drug deductible — only the regular Part B deductible) (same benefit 1988 and 1989)		Same as 1988 & 1989 for 1st year following covered transplant; then 50% of costs during 2nd and following years (subject to $550 deductible in 1990, $600 in 1991)
- - - -
Respite Care Benefit			In-home care for chronically dependent individual covered for up to 80 hours after either the out-of-pocket limit or the outpatient drug deductible has been met (same in 1990 and 1991)
- - - -
- - - -

(6) (Statement that the policy does or does not cover the following:)

(a) Private duty nursing,

(b) Skilled nursing home care costs (beyond what is covered by medicare),

(d) Intermediate nursing home care costs,

(e) Home health care above number of visits covered by medicare,

(f) Physician charges (above medicare's reasonable charge),

(g) Drugs and insulin (other than prescription drugs furnished during a hospital or skilled nursing facility stay),

(h) Care received outside of U.S.A. (and its territories),

(i) Dental care or dentures, checkups, routine immunizations, cosmetic surgery, routine foot care, examinations for, or the cost of, eyeglasses or hearing aids.

(7) (An explanation of such terms as "usual and customary," "reasonable and customary," or words of similar import, if used in the policy.)

(8) A description of any policy provisions which exclude, eliminate, resist, reduce, limit, delay, or in any other manner operate to qualify payments of the benefits described in subsection (4) of this section, including conspicuous statements:

(a) That the chart summarizing medicare benefits only briefly describes such benefits.

(b) That the Health Care Financing Administration or its medicare publications should be consulted for further details and limitations.

(9) A description of policy provisions respecting renewability or continuation of coverage, including any reservation of rights to change premium.

(10) The amount of premium for this policy.

	. . . . (Insurer's Name)
	By	Date
	. . . . (Agent's or Officer's Signature)

(Drafting note. Where inappropriate terms are used, such as "insurance," "policy," or "insurance company," a fraternal benefit society, health care service contractor or health maintenance organization shall substitute appropriate terminology.)

PDFWAC 284-55-060

Form for "outline of coverage."