Section 284-55-060. Form for "outline of coverage."

(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:)

(b) (for direct responses:)

(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:)

(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

Part B

MEDICARE BENEFITS IN

(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),

(c) Custodial nursing home care costs,

(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.)

[Statutory Authority: RCW 48.02.060 (3)(a) and 48.66.050. WSR 89-11-096 (Order R 89-7), § 284-55-060, filed 5/24/89. Statutory Authority: RCW 48.02.060 (3)(a) and 48.30.010(2). WSR 88-22-061 (Order R 88-9), § 284-55-060, filed 11/1/88. Statutory Authority: RCW 48.02.060, 48.44.050 and 48.46.200. WSR 82-01-016 (Order R 81-6), § 284-55-060, filed 12/9/81.]

RCW 48.02.060 (3)(a) and 48.66.050. WSR 89-11-096 (Order R 89-7), § 284-55-060, filed 5/24/89. Statutory Authority: RCW 48.02.060 (3)(a) and 48.30.010(2). WSR 88-22-061 (Order R 88-9), § 284-55-060, filed 11/1/88. Statutory Authority: RCW 48.02.060, 48.44.050 and 48.46.200. WSR 82-01-016 (Order R 81-6), § 284-55-060, filed 12/9/81.