Conn. Agencies Regs. tit. 38a, 495, app A

[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

Notes

Conn. Agencies Regs. tit. 38a, 495, app A

Effective September 25, 1992