Ill. Admin. Code tit. 50, pt. 2008, subpt. G, app T
(Company Name)
NOTICE ON CHANGES IN MEDICARE AND YOUR MEDICARE SUPPLEMENT INSURANCE
The following outline briefly describes the modifications in Medicare and in your Medicare supplement coverage. Please read carefully!
(A) brief description of the revisions to Medicare Parts A & B with a parallel description of supplemental benefits with subsequent changes, including dollar amounts, provided by the Medicare supplement coverage in substantially the following format).
Services | Medicare Benefits | Your Medicare Supplement Coverage |
Effective (insert current calendar year) Medicare Will Pay | Effective (insert current calendar year) Your Coverage Will Pay | |
MEDICARE PART A SERVICES AND SUPPLIES | ||
Inpatient Hospital Services | All but _______ for first 60 days/benefit period | |
Semi-Private Room & Board | All but _______ a day for 61st-90th days/benefit period | |
Miscellaneous Hospital Service & Supplies, such as Drugs, X-Rays, Lab Tests & Operating Room | All but _____ a day for 91st-150th days (if individual chooses to use 60 nonrenewable lifetime reserve days) | |
BLOOD | Pays all costs except nonreplacement fees (blood deductible) for first 3 pints in each calendar year | |
SKILLED NURSING FACILITY CARE | 100% of costs for first 20 days (after a 3 day prior hospital/ confinement/ benefit period) | |
All but ______ a day for 21st-100th days /benefit period | ||
Beyond 100 days - Nothing /benefit period | ||
MEDICARE PART B SERVICES AND SUPPLIES | 80% of allowable charges (after ____ deductible/calendar year) | |
PRESCRIPTION DRUGS | Inpatient prescription drugs 80% of allowable charges for immunosuppressive drugs during the first year following a covered transplant (after ____ deductible/ calendar year) | |
BLOOD | 80% of costs except nonreplacement fees (blood deductible) for first 3 pints (after ___ deductible/calendar year |
(Any other policy benefits not mentioned in this chart should be added to the chart in the order prescribed by the outline of coverage. If there are corresponding Medicare benefits, they should be shown.)
(Describe any coverage provisions changing due to Medicare modifications.)
(Include information about when premium adjustments that may be necessary due to changes in Medicare benefits will be effective.)
THIS CHART SUMMARIZING THE CHANGES IN YOUR MEDICARE BENEFITS AND IN YOUR MEDICARE SUPPLEMENT PROVIDED BY (COMPANY) ONLY BRIEFLY DESCRIBES SUCH BENEFITS. FOR INFORMATION ON YOUR MEDICARE BENEFITS CONTACT YOUR SOCIAL SECURITY OFFICE OR THE HEALTH CARE FINANCING ADMINISTRATION. FOR INFORMATION ON YOUR MEDICARE SUPPLEMENT (POLICY) CONTACT: (COMPANY AND FOR AN INDIVIDUAL POLICY-NAME OF AGENT) (ADDRESS/PHONE NUMBER).
Ill. Admin. Code tit. 50, pt. 2008, subpt. G, app T