(a) No insurance
policy or subscriber contract which provides benefits to any resident of this
State may be advertised, solicited or issued for delivery in this State who is
eligible for Medicare which does not meet the following minimum standards.
These are minimum standards and do not preclude the inclusion of other
provisions or benefits which are not inconsistent with these
standards.
(b)
General
Standards. The following standards apply to Medicare supplement policies
and are in addition to all other requirements of Sections
38a-495-1
to
38a-495-17,
inclusive.
(1) A Medicare supplement policy
may not deny a claim for losses incurred more than six (6) months from the
effective date of coverage for a preexisting condition. The policy may not
define a preexisting condition more restrictively than a condition for which
medical advice was given or treatment was recommended by or received from a
physician within six (6) months before the effective date of
coverage.
(2) A Medicare supplement
policy may not indemnify against losses resulting from sickness on a different
basis than losses resulting from accidents.
(3) A Medicare supplement policy shall
provide that benefits designed to cover cost sharing amounts under Medicare
will be changed automatically to coincide with any changes in the applicable
Medicare deductible amount and copayment percentage factors. Premiums may be
modified to correspond with such changes only with the prior approval of the
Commissioner.
(4) A
"noncancellable," "guaranteed renewable," or "noncancellable and guaranteed
renewable" Medicare supplement policy shall not:
(A) provide for termination of coverage of a
spouse solely because of the occurrence of an event specified for termination
of coverage of the insured, other than the nonpayment of premium; or
(B) be cancelled or nonrenewed by the insurer
solely on the grounds of deterioration of health.
(5)
(A)
Except as authorized by the Commissioner, an insurer shall neither cancel nor
nonrenew a Medicare supplement policy or certificate for any reason other than
nonpayment of premium or material misrepresentation.
(B) If a group Medicare supplement insurance
policy is terminated by the group policyholder and not replaced as provided in
paragraph (D) of this subdivision, the insurer shall offer certificateholders
an individual Medicare supplement policy. The insurer shall offer the
certificateholder at least the following choices:
(i) an individual Medicare supplement policy
which provides for continuation of the benefits contained in the group policy;
and
(ii) an individual Medicare
supplement policy which provides only such benefits as are required to meet the
minimum standards.
(C)
If membership in a group is terminated, the insurer shall:
(i) offer the certificateholder such
conversion opportunities as are described in paragraph (B); or
(ii) at the option of the group policyholder,
offer the certificateholder continuation of coverage under the group
policy.
(D) If a group
Medicare supplement policy is replaced by another group Medicare supplement
policy purchased by the same policyholder, the succeeding insurer shall offer
coverage to all persons covered under the old group policy on its date of
termination. Coverage under the new group policy shall not result in any
exclusion for preexisting conditions that would have been covered under the
group policy being replaced.
(6) Termination of a Medicare supplement
policy shall be without prejudice to any continuous loss which commenced while
the policy was in force, but the extension of benefits beyond the period during
which the policy was in force may be predicated upon the continuous total
disability of the insured, limited to the duration of the policy benefit
period, if any, or payment of the maximum benefits.
(c)
Minimum Benefit Standards.
The following standards apply to Medigap policies and are in addition to all
other requirements of this regulation.
(1)
Coverage of Part A Medicare eligible expenses for hospitalization to the extent
not covered by Medicare from the 61st day through the 90th day in any Medicare
benefit period.
(2) Coverage for
either all or none of the Medicare Part A inpatient hospital deductible
amount.
(3) Coverage of Part A
Medicare eligible expenses incurred as daily hospital charges during use of
Medicare's lifetime hospital inpatient reserve days.
(4) Upon exhaustion of all Medicare hospital
inpatient coverage including the lifetime reserve days, coverage of ninety
percent (90%) of all Medicare Part A eligible expenses for hospitalization not
covered by Medicare subject to a lifetime maximum benefit of an additional 365
days.
(5) Coverage for the daily
copayment amount of Medicare Part A eligible expenses for skilled nursing
facility care.
(6) Coverage under
Medicare Part A for the reasonable cost of the first three (3) pints of blood
(or equivalent quantities of packed red blood cells, as defined under federal
regulations) unless replaced in accordance with federal regulations or already
paid for under Part B.
(7) Coverage
for either all or none of the Medicare Part B deductible amount.
(8) No Medicare supplement policy shall
provide coverage for amounts which exceed the co-payment for Medicare eligible
expenses under Part B, unless such additional coverage will provide for
reimbursement of 100 percent of the usual and prevailing charges for Medical
care. This 100 percent reimbursement shall not be made subject to any
additional deductibles.
(9)
Coverage for the coinsurance amount of Medicare eligible expenses under Part B
regardless of hospital confinement, subject to a maximum calendar year
out-of-pocket amount equal to the Medicare Part B deductible.
(10) Effective January 1, 1990, coverage
under Medicare Part B for the reasonable cost of the first three (3) pints of
blood (or equivalent quantities of packed red blood cells, as defined under
federal regulations), unless replaced in accordance with federal regulations or
already paid for under Part A, subject to the Medicare deductible
amount.
(d)
Medicare Eligible Expenses. Medicare eligible expenses shall mean
health care expenses of the kinds covered by Medicare, to the extent recognized
as reasonable by Medicare. Payment of benefits by insurers for Medicare
eligible expenses may be conditioned upon the same or less restrictive payment
conditions, including determinations of medical necessity as are applicable to
Medicare claims.
(e) Any Medicare
supplement policy which is not a Medigap policy shall be disapproved by the
Commissioner if it contains a provision or provisions which are unfair or
deceptive or which encourage misrepresentation of the policy.
