Conn. Agencies Regs. § APPENDIXA
[Company Name]
Notice of Changes in Medicare and your Medicare
Supplement Coverage–199X
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 Effective January 1, 199X, Medicare Will Pay | YOUR MEDICARE SUPPLEMENT COVERAGE Effective January 1, 199X, Your Coverage Will Pay |
| MEDICARE PART A SERVICE AND SUPPLIES | ||
| Inpatient Hospital Services | ||
| Semi-Private Room & Board | ||
| Misc. Hospital Servivces & Supplies, such as Drugs, X-Rays, Lab Tests & Operating Rooom | ||
| BLOOD | ||
| SKILLED NURSING FACILITY CARE |
(Effective September 25, 1992)