Ill. Admin. Code tit. 50, pt. 2008, subpt. G, app A

Current through Register Vol. 48, No. 43, October 25, 2024

Appendix A - Policy Checklist

Applicant's Name ________________________________________________________

Policy Number ___________________________________________________________

Name of Existing Insurer ___________________________________________________

Expiration Date of Existing Insurance __________________________________________

SERVICE	BENEFIT		MEDICARE PAYS	EXISTING COVERAGE	SUPPLEMENT PAYS	YOU PAY
Hospital Inpatient	First 60 Days		All But ($)
61^st to 90^th Day		All But ($) a Day
91^st to 150^th Day (Lifetime Reserve)		($) a Day
Beyond 150 Days		Nothing
Skilled Nursing Home Care	First 20 Days Additional 80 Days		100% of Cost All But ($) A Day
Beyond 100 Days		Nothing
Medical Expense	Physician's Services in hospital, office or home, inpatient and out-patient medical services and supplies at a hospital, physical and speech therapy and ambulance		80% of Medicare Determined allowable charges after ($) Deductible
Prescription Drugs			Inpatient Prescription Drugs. 80% of allowable charges for immunosuppressive drugs during the first year following a covered transplant.

This policy does/does not comply with the minimum standards set forth in Section 363 of the Illinois Insurance Code.

DATE __________________ SIGNATURE OF APPLICANT _________________________

SIGNATURE OF INSURANCE PRODUCER

Ill. Admin. Code tit. 50, pt. 2008, subpt. G, app A

Amended at 16 Ill. Reg. 2766, effective February 11, 1992; corrected at 16 Ill. Reg. 3590