(company name)

outline of medicare

supplement coverage

1. (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. (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. (3) (a) (for agents:)

   Neither (Insert company's name) nor its agentsare connected with medicare.

4. (b) (for direct responses:)

   (Insert company's name) is not connected withmedicare.

5. (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:)

   . . . .
   service	thispolicypays	youpay
   I. Part A
   a. inpatient hospital services:
   Semi-private room & board
   	Miscellaneous hospitalservices & supplies, such asdrugs, X-rays, lab tests &operating room
   b. skilled nursing care
   c. blood
   II. Part B
   a. medical expense:
   Services of a physician/ outpatient services
   Medical supplies other than prescribed drugs
   b. blood
   c. mammography screening
   d. out-of-pocket maximum
   e. prescription drugs
   III. Parts A & B
   Home health services
   IV. Miscellaneous
   A. Home intravenous (IV) therapy drugs
   B. Immunosuppresive drugs
   C. Respite care benefits
   in addition to this outline of coverage, (insurance company name) will send an annual notice to you thirty days prior to the effective date of medicare changed which will describe these changes and the changes in your medicare supplement coverage.
   . . . .

6. (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

   - - - -
   Service	1988	1989	1990	1991
   part a
   Inpatient HospitalServices	All but $540 forfirst 60 days/benefitperiod	All but $560deductible for anunlimited numberof days/calendaryear	All but Part Adeductible for anunlimited numberof days/calendaryear	All but Part Adeductible for anunlimited numberof days/calendaryear
   Semi-PrivateRoom & Board	All but $135 a dayfor 61st - 90thday/benefit period
   MiscellaneousHospital Services& Supplies, suchas Drugs, X-Rays,Lab Tests &Operating Room	All but $270 a dayfor 91st - 150th days(if individualchooses to use 60nonrenewablelifetime reservedays) per benefitperiod
   - - - -
   Skilled NursingFacility Care	100% of costs for for 1st 20 days (after3-day prior hospitalconfinement)	80% of medicarereasonable costs forfirst 8 days percalendar yearwithout priorhospitalizationrequirement	80% for 1st 8days/calendar year	80% for 1st 8days/calendar year
   All but $67.50 a dayfor 21st - 100th days
   	Nothing beyond 100days	100% of coststhereafter up to 150days/calendar year	100% for 9th-150thday/calendar year	100% for 9th-150thday/calendar year
   - - - -
   Blood	Pays all costs exceptnonreplacement fees(blood deductible)for first 3 pints ineach benefit period	Pays all costsexcept payment ofdeductible (equal tocosts for first 3pints) each calendaryear.	All but blooddeductible (equal tocosts for first 3pints)	All but blooddeductible (equal tocosts for first 3pints)
   		Part A blood deductible reduced to the extent paid under Part B.

   Part B

   MEDICARE BENEFITS IN

   - - - -
   Service	1988	1989	1990	1991
   Parts A & B:
   Home HealthServices	Intermittent skilled nursing home care and other services in the home (daily skilled nursing care for up to 21 days or longer in some cases) — 100% of covered services and 80% of durable medical equipment under both Parts A & B	Intermittent skilled nursing care for up to 7 days a week for up to 38 days allowing for continuation of services under unusual circumstances — other services, — 100% of covered services and 80% of durable medical equipment under both Parts A & B (same 1990 & 1991)
   	(same 1988 and 1989)
   - - - -
   part b
   Medical Expense: Services of aPhysician/Outpatient Services —Medical Supplies Other than Prescribed Drugs	80% of reasonable charges after an annual $75 deductible	80% after $75 deductible	80% of reasonable charges after $75 deductible until out-of-pocket maximum is reached. 100% of reasonable charges are covered for the remainder of the calendar year. (same 1990 and 1991)
   - - - -
   Blood	80% of costs except non-replacement fees (blood deductible) for 1st 3 pints in each benefit period after $75 deductible	Pays 80% of all costs except payment of deductible (equal to costs for first 3 pints) each calendar year (same 1989, 1990, 1991)
   - - - -
   Mammography Screening			80% of approved charge for elderly and disabled medicare beneficiaries — exams available every other year for women age 65 and older (same 1990 and 1991)
   - - - -
   Out-of-PocketMaximum			$1,370 consisting of Part B $75 deductible, Part B blood deductible and 20% co-insurance (same 1990 & 1991, except $1,370 will be adjusted annually by Sec. Health & Human Services)
   - - - -
   OutpatientPrescription Drugs			There is a $550 total deductible for home IV drug and immunosuppressive drug therapies as noted below	Covered after $600 deductible subject to 50% co-insurance
   - - - -
   Home IV Drug Therapy			80% of IV therapy drugs subject to $550 deductible (deductible waived if home therapy is a continuation of therapy initiated in a hospital)	80% of IV therapy drugs subject to standard drug deductible (deductible waived if home therapy is a continuation of therapy initiated in a hospital)
   - - - -
   Immunosuppressive Drug Therapy	80% of costs during 1st year following a covered organ transplant (no special drug deductible — only the regular Part B deductible) (same benefit 1988 and 1989)	Same as 1988 & 1989 for 1st year following covered transplant; then 50% of costs during 2nd and following years (subject to $550 deductible in 1990, $600 in 1991)
   - - - -
   Respite CareBenefit		In-home care for chronically dependent individual covered for up to 80 hours after either the out-of-pocket limit or the outpatient drug deductible has been met (same in 1990 and 1991)
   - - - -
   - - - -

7. (6) (Statement that the policy does or does not cover the following:)

   1. (a) Private duty nursing,
   2. (b) Skilled nursing home care costs (beyond what is covered by medicare),
   3. (c) Custodial nursing home care costs,
   4. (d) Intermediate nursing home care costs,
   5. (e) Home health care above number of visits covered by medicare,
   6. (f) Physician charges (above medicare's reasonable charge),
   7. (g) Drugs and insulin (other than prescription drugs furnished during a hospital or skilled nursing facility stay),
   8. (h) Care received outside of U.S.A. (and its territories),
   9. (i) Dental care or dentures, checkups, routine immunizations, cosmetic surgery, routine foot care, examinations for, or the cost of, eyeglasses or hearing aids.
8. (7) (An explanation of such terms as "usual and customary," "reasonable and customary," or words of similar import, if used in the policy.)

9. (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:

   1. (a) That the chart summarizing medicare benefits only briefly describes such benefits.
   2. (b) That the Health Care Financing Administration or its medicare publications should be consulted for further details and limitations.
10. (9) A description of policy provisions respecting renewability or continuation of coverage, including any reservation of rights to change premium.

11. (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.]