(a) The following
standards are applicable to all Medicare supplement policies or certificates
delivered or issued for delivery in this state with an effective date for
coverage on or after June 1, 2010. No policy or certificate may be advertised,
solicited, delivered or issued for delivery in this state as a Medicare
supplement policy or certificate on or after June 1, 2010 unless it complies
with these benefit plan standards. Benefit plan standards applicable to
Medicare supplement policies and certificates with an effective date for
coverage on or after July 30, 1992, and before June 1, 2010, remain subject to
the requirements of sections
38a-495a-5
and
38a-495a-6
of the Regulations of Connecticut State Agencies.
(1)
(A) An
issuer shall make available to each prospective policyholder and
certificateholder a policy form or certificate form containing only the basic
core benefits, as defined in section
38a-495a-5
a of the Regulations of Connecticut State Agencies.
(B) If an issuer makes available any of the
additional benefits set forth in section
38a-495a-5
a(c) of the Regulations of Connecticut State Agencies or offers standardized
benefit plan K or L as set forth in this section, the issuer shall also make
available to each prospective policyholder and certificateholder standardized
benefit plan C or F, as set forth in this section, in addition to the basic
core benefit plan required under subparagraph (A) of this
subdivision.
(b) No groups, packages or combinations of
Medicare supplement benefits other than those listed in this section and
section
38a-495a-7
of the Regulations of Connecticut State Agencies shall be offered for sale in
this state.
(c) Benefit plans shall
be uniform in structure, language, designation and format to the standard
benefit plans listed in this section and conform to the definitions in section
38a-495a-2 of the
Regulations of Connecticut State Agencies. Each benefit shall be structured in
accordance with section
38a-495a-5
a of the Regulations of Connecticut State Agencies, or, in the case of plans K
or L, this section, and list the benefits in the order shown. For purposes of
this section, "structure", "language", "designation" and "format" means style,
arrangement and overall content of a benefit.
(d) In addition to the benefit plan
designation required in subsection (c) of this section, an issuer may use other
designations to the extent permitted by law
(e)
Make-up of 2010 standardized
benefit plans:
(1) Standardized
Medicare supplement benefit plan A shall include only the following: The basic
core benefit as set forth in section
38a-495a-5
a(b) of the Regulations of Connecticut State Agencies.
(2) Standardized Medicare supplement benefit
plan B shall include only the following: The basic core benefit as set forth in
section
38a-495a-5
a(b) of the Regulations of Connecticut State Agencies, plus one hundred percent
of the Medicare Part A deductible, as set forth in section
38a-495a-5
a(c)(1) of the Regulations of Connecticut State Agencies.
(3) Standardized Medicare supplement benefit
plan C shall include only the following: The basic core benefit as set forth in
section
38a-495a-5
a(b) of the Regulations of Connecticut State Agencies, plus one hundred percent
of the Medicare Part A deductible, skilled nursing facility care, one hundred
percent of the Medicare Part B deductible, and medically necessary emergency
care in a foreign country, as set forth in section
38a-495a-5
a(c) of the Regulations of Connecticut State Agencies.
(4) Standardized Medicare supplement benefit
plan D shall include only the following: The basic core benefit as set forth in
section
38a-495a-5
a(b) of the Regulations of Connecticut State Agencies, plus one hundred percent
of the Medicare Part A deductible, skilled nursing facility care, and medically
necessary emergency care in a foreign country, as set forth in section
38a-495a-5
a(c) of the Regulations of Connecticut State Agencies.
(5) Standardized Medicare supplement plan F
shall include only the following: The basic core benefits as set forth in
section
38a-495a-5
a(b) of the Regulations of Connecticut State Agencies, plus one hundred percent
of the Medicare Part A deductible, the skilled nursing facility care, one
hundred percent of the Medicare Part B deductible, one hundred percent of the
Medicare Part B excess charges, and medically necessary emergency care in a
foreign country, as set forth in section
38a-495a-5
a(c) of the Regulations of Connecticut State Agencies.
(6) Standardized Medicare supplement plan F
with High Deductible shall include only the following:
(A) The basic core benefit as set forth in
section
38a-495a-5
a(b) of the Regulations of Connecticut State Agencies, plus one hundred percent
of the Medicare Part A deductible, skilled nursing facility care, one hundred
percent of the Medicare Part B deductible, one hundred percent of the Medicare
Part B excess charges, and medically necessary emergency care in a foreign
country, as set forth in section
38a-495a-5
a(c) of the Regulations of Connecticut State Agencies, plus one hundred percent
of covered expenses following payment of the annual deductible set forth in
subparagraph (B) of this subdivision.
(B) The annual deductible in plan F with High
Deductible shall consist of out-of-pocket expenses, other than premiums, for
services covered by plan F, and shall be in addition to any other specific
benefit deductibles. The basis for the deductible shall be $1500 and shall be
adjusted annually from 1999 by the secretary to reflect the change in the
Consumer Price Index for all urban consumers for the twelve month period ending
with August of the preceding year, and rounded to the nearest multiple of ten
dollars.
(7)
Standardized Medicare supplement plan G shall include only the following: The
basic core benefit as set forth in section
38a-495a-5
a(b) of the Regulations of Connecticut State Agencies, plus one hundred percent
of the Medicare Part A deductible, skilled nursing facility care, one hundred
percent of the Medicare Part B excess charges, and medically necessary
emergency care in a foreign country, as set forth in section
38a-495a-5
a(c) of the Regulations of Connecticut State Agencies. Effective January 1,
2020, the standardized benefit plans described in section
38a-495a-6
b of the Regulations of Connecticut State Agencies may be offered to any
individual who was eligible for Medicare prior to January 1, 2020.
(8) Standardized Medicare supplement plan K
shall include only the following:
(A) Part A
hospital coinsurance 61st through
90th days: Coverage of one hundred percent of the
Part A hospital coinsurance amount for each day used from the
61st through the 90th day
in any Medicare benefit period;
(B)
Part A hospital coinsurance, 91st through
150th days: Coverage of one hundred percent of the
Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve
day used from the 91st through the
150th day in any Medicare benefit period;
(C) Part A hospitalization after 150 days:
Upon exhaustion of the Medicare hospital inpatient coverage, including the
lifetime reserve days, coverage of one hundred percent of the Medicare Part A
eligible expenses for hospitalization paid at the applicable prospective
payment system (PPS) rate, or other appropriate Medicare standard of payment,
subject to a lifetime maximum benefit of an additional 365 days. The provider
shall accept issuer's payment as payment in full and may not bill the insured
for any balance;
(D) Medicare Part
A deductible: Coverage for fifty percent of the Medicare Part A inpatient
hospital deductible amount per benefit period until the out-of-pocket
limitation is met as set forth in subparagraph (J) of this
subdivision;
(E) Skilled Nursing
Facility Care: Coverage for fifty percent of the coinsurance amount for each
day used from the 21st day through the
100th day in a Medicare benefit period for
post-hospital skilled nursing facility care eligible under Medicare Part A
until the out-of-pocket limitation is met as set forth in subparagraph (J) of
this subdivision;
(F) Hospice
Coverage: Coverage for fifty percent of cost sharing for all Part A Medicare
eligible expenses and respite care until the out-of-pocket limitation is met as
set forth in subparagraph (J) of this subdivision;
(G) Blood: Coverage for fifty percent under
Medicare Part A or B, of the reasonable cost of the first three pints of blood,
or equivalent quantities of packed red blood cells, as defined under federal
regulations, unless replaced in accordance with federal regulations until the
out-of-pocket limitation is met as set forth in subparagraph (J) of this
subdivision;
(H) Part B Cost
Sharing: Except for coverage provided in subparagraph (I) of this subdivision,
coverage for fifty percent of the cost sharing otherwise applicable under
Medicare Part B after the policyholder pays the Part B deductible until the
out-of-pocket limitation is met as set forth in subparagraph (J) of this
subdivision:
(I) Part B Preventive
Services: Coverage of one hundred percent of the cost sharing for Medicare Part
B preventive services after the policyholder pays the Part B deductible;
and
(J) Cost Sharing After
Out-Of-Pocket Limits: Coverage of one hundred percent of all cost sharing under
Medicare Parts A and B for the balance of the calendar year after the
individual has reached the out-of-pocket limitation on annual expenditures
under Medicare Parts A and B of $5,240 in 2018, indexed each year by the
appropriate inflation adjustment specified by the secretary.
(9) Standardized Medicare
supplement plan L shall include only the following:
(A) The benefits set forth in subparagraphs
(A), (B), (C) and (I) of subdivision (8) of this subsection;
(B) The benefits set forth in subparagraphs
(D), (E), (F) and (G) of subdivision (8) of this subsection, but substituting
seventy-five percent for fifty percent, and
(C) The benefit set forth in subparagraph (J)
of subdivision (8) of this subsection, but substituting $2,620 for
$5,240.
(10)
Standardized Medicare supplement plan M shall include only the following: The
basic core benefits as set forth in section
38a-495a-5
a(b) of the Regulations of Connecticut State Agencies, plus fifty percent of
the Medicare Part A deductible, skilled nursing facility care, and medically
necessary emergency care in a foreign country, as set forth in section
38a-495a-5
a(c) of the Regulations of Connecticut State Agencies.
(II) Standardized Medicare supplement plan N
shall include only the following: The basic core benefits as set forth in
section
38a-495a-5
a(b) of the Regulations of Connecticut State Agencies, plus one hundred percent
of the Medicare Part A deductible, skilled nursing facility care, and medically
necessary emergency care in a foreign country, as set forth in section
38a-495a-5
a(c) of the Regulations of Connecticut State Agencies with copayments in the
following amounts:
(A) the lesser of twenty
dollars or the Medicare Part B coinsurance or copayment for each covered health
care provider office visit, including visits to medical specialists;
and
(B) the lesser of fifty dollars
or the Medicare Part B coinsurance or copayment for each covered emergency room
visit, however, this copayment shall be waived if the insured is admitted to
any hospital and the emergency visit is subsequently covered as a Medicare Part
A expense.
(f) New or Innovative Benefits: An issuer
may, with the prior approval of the commissioner, offer new or innovative
benefits in addition to the standardized benefits provided in a policy or
certificate that otherwise complies with the applicable standards. The new or
innovative benefits shall include only benefits that are appropriate to
Medicare supplement insurance, are new or innovative, are not otherwise
available, and are cost-effective. Approval of new or innovative benefits shall
not adversely impact the goal of Medicare supplement simplification. New or
innovative benefits shall not include an outpatient prescription drug benefit.
New or innovative benefits shall not be used to change or reduce benefits,
including a change of any cost-sharing provision, in any standardized plan.
