WAC 284-55-165. Form of annual adjustment notice—Policy changes effective January 1, 1989

(COMPANY NAME) NOTICE OF CHANGES IN MEDICARE AND YOUR MEDICARE SUPPLEMENT INSURANCE — 1989 Your health care benefits provided by the federal medicare program will change beginning January 1, 1989. Additional change will occur on medical benefits in following years. The major changes are summarized below. These changes will affect hospital, medical and other services and supplies provided under medicare. Because of these changes your medicare supplement coverage provided by (company name) will change, also. The following outline briefly describes the modifications in medicare and in your medicare supplement coverage. Please read 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.) Your health care benefits provided by the federal medicare program will change beginning January 1, 1989. Additional change will occur on medical benefits in following years. The major changes are summarized below. These changes will affect hospital, medical and other services and supplies provided under medicare. Because of these changes your medicare supplement coverage provided by (company name) will change, also. The following outline briefly describes the modifications in medicare and in your medicare supplement coverage. Please read 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.) MEDICARE BENEFITS YOUR MEDICARE SUPPLEMENT COVERAGE Medicare Now Pays Per Benefit Period Effective January 1, 1989 medicare Will Pay Per Calendar Year Your 1988 Coverage Per Benefit Period Effective Jan. 1, 1989 Your Coverage Will Pay Per Calendar Year MEDICARE PART A: SERVICES AND SUPPLIES First 60 days - all but $540 Unlimited number of hospital days after $564 deductible 61st to 90th day - all but $135/day 91st to 150th day - all but $270/day (if individual chooses to use 60 nonrenewable lifetime days) Beyond 150th day - nothing SKILLED NURSING FACILITY CARE Requires a 3-day prior stay and enter the facility generally within 30 days after hospital discharge There is no prior confinement requirement for this benefit First 20 days - 100% of costs First 8 days - All but $(_22.00_) a day 21st through 100th day - all but $67.50 a day 9th through 150th 100% of costs Beyond 100 days - Nothing Beyond 150 days - Nothing MEDICARE PART B: SERVICES AND SUPPLIES 80% of allowable charges (after $75.00 deductible) In 1989 medicare Part B pays the same as in 1989 note : Medicare benefits changes on January 1, 1990 as follows: 80% of allowable charges (after $75.00 deductible) until an annual medicare catastrophic limit is met. 100% of allowable charges for the remainder of the calendar year. The limit in 1990 is $1370* and will be adjusted on an annual basis. *Expenses that count toward the Part B medicare catastrophic limit include: The Part B deductible and copayment charges and the Part B blood deductible charges. PRESCRIPTION DRUGS Inpatient prescription drugs only In 1989 medicare covers inpatient prescription drugs only note : Effective January 1, 1990, per calendar year — 80% of allowable charges for home intravenous (IV) therapy drugs and 50% of allowable charges for immunosuppressive drugs after calendar year deductible is met ($550 in 1990). Effective January 1, 1991, per calendar year — Inpatient prescription drugs: 50% of allowable charges for all other outpatient prescription drugs after a $600 calendar year deductible is met. (The deductible will change.) Coverage will increase to 60% of allowable charges in 1992 and to 80% of allowable charges from 1993 on. (ANY ADDITIONAL BENEFITS) (Describe any coverage provisions changing due to medicare modifications.) (Include information about premium adjustments that may be necessary due to changes in medicare benefits or when premium information will be sent.) MEDICARE BENEFITS YOUR MEDICARE SUPPLEMENT COVERAGE Medicare Now Pays Per Benefit Period Effective January 1, 1989 medicare Will Pay Per Calendar Year Your 1988 Coverage Per Benefit Period Effective Jan. 1, 1989 Your Coverage Will Pay Per Calendar Year MEDICARE PART A: SERVICES AND SUPPLIES First 60 days - all but $540 Unlimited number of hospital days after $564 deductible 61st to 90th day - all but $135/day 91st to 150th day - all but $270/day (if individual chooses to use 60 nonrenewable lifetime days) Beyond 150th day - nothing SKILLED NURSING FACILITY CARE Requires a 3-day prior stay and enter the facility generally within 30 days after hospital discharge There is no prior confinement requirement for this benefit First 20 days - 100% of costs First 8 days - All but $(_22.00_) a day 21st through 100th day - all but $67.50 a day 9th through 150th 100% of costs Beyond 100 days - Nothing Beyond 150 days - Nothing MEDICARE PART B: SERVICES AND SUPPLIES 80% of allowable charges (after $75.00 deductible) In 1989 medicare Part B pays the same as in 1989 note : Medicare benefits changes on January 1, 1990 as follows: 80% of allowable charges (after $75.00 deductible) until an annual medicare catastrophic limit is met. 100% of allowable charges for the remainder of the calendar year. The limit in 1990 is $1370* and will be adjusted on an annual basis. *Expenses that count toward the Part B medicare catastrophic limit include: The Part B deductible and copayment charges and the Part B blood deductible charges. PRESCRIPTION DRUGS Inpatient prescription drugs only In 1989 medicare covers inpatient prescription drugs only note : Effective January 1, 1990, per calendar year — 80% of allowable charges for home intravenous (IV) therapy drugs and 50% of allowable charges for immunosuppressive drugs after calendar year deductible is met ($550 in 1990). Effective January 1, 1991, per calendar year — Inpatient prescription drugs: 50% of allowable charges for all other outpatient prescription drugs after a $600 calendar year deductible is met. (The deductible will change.) Coverage will increase to 60% of allowable charges in 1992 and to 80% of allowable charges from 1993 on. (ANY ADDITIONAL BENEFITS) (Describe any coverage provisions changing due to medicare modifications.) (Include information about premium adjustments that may be necessary due to changes in medicare benefits or when premium information will be sent.) This chart summarizing the changes in your medicare benefits and in your medicare supplement insurance provided by (company) , only briefly describes 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 name — or name of agent) (address) (phone number). This chart summarizing the changes in your medicare benefits and in your medicare supplement insurance provided by (company) , only briefly describes 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 name — or name of agent) (address) (phone number).