Cal. Code Regs. tit. 10, § 2220.59
(g) The Notice of New or Innovative Benefits shall be in the following form; if the plan in question does not use a network of providers, the issuer shall omit the “YOUR OUT-OF-POCKET COSTS (In-Network Provider)” column, and shall omit “(Out-of-Network Provider)” from the heading of the remaining column, designated for out-of-pocket costs:
Notice of New or Innovative Benefits
The purpose of this form is to notify consumers of the availability of a Medicare supplement plan offered for sale by [INSERT ISSUER NAME] that includes new or innovative benefits, in addition to the standardized coverage offered by the plan.
For additional information, please contact [INSERT ISSUER CONTACT INFORMATION].
New or innovative benefits added to Medicare supplement plan [INSERT PLAN NAME].
Total annual premium for new or innovative benefits only: $[XX.XX] [see attached rate sheet].
NEW OR INNOVATIVE BENEFITS
YOUR OUT-OF-POCKET COSTS (In-Network Provider)
YOUR OUT-OF-POCKET COSTS (Out-of-Network Provider)
[New or innovative benefit, detailed description, and any limitations]
[Out-of-pocket cost]
[Out-of-pocket cost]
[New or innovative benefit, detailed description, and any limitations]
[Out-of-pocket cost]
[Out-of-pocket cost]
[New or innovative benefit, detailed description, and any limitations]
[Out-of-pocket cost]
[Out-of-pocket cost]
Note: Authority cited: Section 10192.91, Insurance Code. Reference: Section 10192.91, Insurance Code.
1. .New section filed 2-20-2024; operative 4-1-2024 (Register 2024, No. 8).