Neb. Admin. Code INSURANCE, DEPARTMENT OF, tit. 210, ch. 54, app A

Current through September 17, 2024

Appendix A

[COMPANY NAME]

NOTICE OF CHANGES IN MEDICARE AND YOUR MEDICARE SUPPLEMENT INSURANCE -- 1990

THE FOLLOWING CHART BRIEFLY DESCRIBES THE MODIFICATIONS IN MEDICARE AND IN YOUR MEDICARE SUPPLEMENT COVERAGE. PLEASE READ THIS 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
				January 1
			Your	1989 Your
		Effective	1988	Coverage
		January 1, 1989	Coverage	Will Pay
	Medicare Now	Medicare Will	Per	Per
	Pays Per Benefit	Pay Per Calendar	Benefit	Calendar
	Period	Year	Period	Year
MEDICARE PART A SERVICES AND SUPPLIES
Inpatient	Unlimited number of	All but $592 for
Hospital	Hospital days after	First 60
Services	$560 deductible	days/benefit period
Semi-Private		All but $148 a day
Room & Board		for 61st - 90th days/benefit period
Misc. Hospital		All but $296 a day
Services &		for 91st - 150th
Supplies, such		days (if individual
as Drugs, X-Rays,		chooses to use 60
Lab Tests &		Nonrenewable
Operating Room		lifetime reserve days)

SERVICES	MEDICARE BENEFITS		YOUR MEDICARE SUPPLEMENT COVERAGE
BLOOD	Pays all costs	Pays all costs except
	except payment of	nonreplacement fees
	deductible (equal	(blood deductible)
	to costs for first	for first 3 pints in
	3 pints) each	each benefit period.
	calendar year. Part
	A blood deductible
	period reduced to
	the extent paid under Part B
SKILLED NURSING	There is no prior	100% of costs
FACILITY CARE	confinement	for 1st 20 days (after
	requirement for	a 3 day prior
	this benefit	hospital
		confinement)/
		benefit period
	First 8 days--All	All but $ 74.00 a
	but $ 25.50 a day	day for 21st - 100 th
		days/benefit period
	9th through 150th	Beyond 100 days
	day -- 100% of costs period	--Nothing/benefit
	Beyond 150 days --Nothing
MEDICARE PART B	80% of allowable	80% of allowable
SERVICES AND	charges (after $75	charges (after $75
SUPPLIES	deductible)	deductible/calendar year)
PRESCRIPTION	Inpatient	Inpatient
DRUGS	prescription drugs.	prescription drugs.
	80% of allowable	80% of allowable
	charges for	charges for
	immunosuppressive	immunosuppressive
	drugs during the	drugs during the
	first year following	first year following
	a covered transplant	a covered transplant
	(after $75 deductible calendar year)	(after $75 deductible calendar year)

SERVICES	MEDICARE BENEFITS		YOUR MEDICARE SUPPLEMENT COVERAGE
BLOOD	80% of all costs for	80% of all costs for
	except non-	except
	replacement fees	nonreplacement fees
	(blood deductible)	(blood deductible)
	first 3 pints	first 3 pints
	after $75 deductible	after $75 deductible
	calendar year	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 BENEFITS. 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 DESCRIBE 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 OR FOR AN INDIVIDUAL POLICY -- NAME OF AGENT]

[ADDRESS/PHONE NUMBER]

Neb. Admin. Code INSURANCE, DEPARTMENT OF, tit. 210, ch. 54, app A