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 unless it complies
with these benefit standards. No issuer may offer any 1990 Standardized benefit
plan for sale on or after June 1, 2010. Benefit standards applicable to
policies and certificates issued with an effective date for coverage prior to
June 1, 2010 remain in effect. (3-31-22)
01.
General Standards. The
following standards apply to Medicare supplement policies and certificates and
are in addition to all other requirements of this regulation. (3-31-22)
a. A Medicare supplement policy or
certificate cannot exclude or limit benefits for losses incurred more than six
(6) months from the effective date of coverage because it involved a
preexisting condition. The policy or certificate will 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. (3-31-22)
b. A Medicare supplement policy or
certificate will not indemnify against losses resulting from sickness on a
different basis than losses resulting from accidents. (3-31-22)
c. A Medicare supplement policy or
certificate provides that benefits designed to cover cost sharing amounts under
Medicare will be changed automatically to coincide with any changes in the
applicable Medicare deductible, copayment, or coinsurance amounts. Premiums may
be modified to correspond with such changes. (3-31-22)
d. No Medicare supplement policy or
certificate may 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. (3-31-22)
e. Each Medicare supplement policy is
guaranteed renewable. (3-31-22)
i. The issuer
cannot cancel or nonrenew the policy solely on the ground of health status of
the individual. (3-31-22)
ii. The
issuer cannot cancel or nonrenew the policy for any reasons other than
nonpayment of premium or material representation. (3-31-22)
iii. If the Medicare supplement policy is
terminated by the group policyholder and is not replaced as provided under
Subparagraph 022.01.e.v., the issuer offers certificateholders an individual
Medicare supplement policy which (at the option of the certificateholder):
(3-31-22)
(1) Provides for continuation of the
benefits contained in the group policy; or (3-31-22)
(2) Provides for benefits that meet the
requirements of this Subsection. (3-31-22)
iv. If an individual is a certificateholder
in a group Medicare supplement policy and the individual terminates membership
in the group, the issuer: (3-31-22)
(1) Offers
the certificateholder the conversion opportunity described in Subparagraph
022.01.e.iii.; or (3-31-22)
(2) At
the option of the group policyholder, offers the certificate holder
continuation of coverage under the group policy. (3-31-22)
v. If a group Medicare supplement policy is
replaced by another group Medicare supplement policy purchased by the same
policyholder, the issuer of the replacement policy offers coverage to all
persons covered under the old group policy on its date of termination. Coverage
under the new policy cannot exclude preexisting conditions that would have been
covered under the group policy being replaced. (3-31-22)
f. Terminations of a Medicare supplement
policy or certificate need to be without prejudice to any continuous loss that
commenced while the policy was in force. Such extension of benefits beyond the
period during which the policy was in force may be conditioned 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. Receipt of
Medicare Part D benefits will not be considered in determining a continuous
loss. (3-31-22)
g. A Medicare
supplement policy or certificate provides that benefits and premiums under the
policy or certificate may be suspended at the request of the policyholder or
certificateholder for the period (not to exceed twenty-four (24) months) in
which the policyholder or certificateholder has applied for and is determined
to be entitled to medical assistance under Title XIX of the Social Security
Act, but only if the policyholder or certificateholder notifies the issuer of
the policy or certificate within ninety (90) days after the date the individual
becomes entitled to assistance. (3-31-22)
i.
If suspension occurs and if the policyholder or certificateholder loses
entitlement to medical assistance, the policy or certificate is automatically
reinstituted (effective as of the date of termination of entitlement) as of the
termination of entitlement if the policyholder or certificateholder provides
notice of loss of entitlement within ninety (90) days after the date of loss
and pays the premium attributable to the period, effective as of the date of
termination of entitlement. (3-31-22)
ii. Each Medicare supplement policy provides
that benefits and premiums under the policy may be suspended (for any period
that may be provided by federal regulation) at the request of the policyholder
if the policyholder is entitled to benefits under Section
226(b) of the
Social Security Act and is covered under a group health plan (as defined in
Section 1862(b)(1)(A)(v)
of the Social Security Act). If suspension
occurs and if the policyholder or certificateholder loses coverage under the
group health plan, the policy is automatically reinstituted (effective as of
the date of loss of coverage) if the policyholder provides notice of loss of
coverage within (90) days after the date of the loss and pays the premium
attributed to the period, effective as of the date of termination of enrollment
in the group health plan. (3-31-22)
iii. Reinstitution of coverages as described
in Subparagraphs 022.01.g.i. and 022.01.g.ii.; (3-31-22)
(1) Does not provide for any waiting period
with respect to treatment of preexisting conditions; (3-31-22)
(2) Provides for resumption of coverage that
is substantially equivalent to coverage in effect before the date of
suspension; and (3-31-22)
(3)
Provides for classification of premiums on terms at least as favorable to the
policyholder or certificateholder as the premium classification terms that
would have applied to the policyholder or certificateholder had the coverage
not been suspended. (3-31-22)
h. An issuer makes available to each
prospective policyholder and certificateholder a policy form or certificate
form containing only the basic (core) benefits, as defined in Subsection
022.02. (3-31-22)
i. If an issuer makes available any of the
additional benefits described in Subsection
022.03, or offers standardized
benefit Plans K or L (as described in Paragraphs 022.04.h. and 022.04.i.), then
the issuer makes available to each prospective policyholder and
certificateholder, in addition to a policy form or certificate form with only
the basic (core) benefits as described in Paragraph 022.01.h., a policy form or
certificate form containing either standardized benefit Plan C (as described in
Paragraph 022.04.c.) or standardized benefit Plan F (as described in Paragraph
022.04.e.). (3-31-22)
j. No groups,
packages or combinations of Medicare supplement benefits other than those
listed in this section are offered for sale in this state, except as may be
permitted in Subsection
022.05 and in Section
031. (3-31-22)
k. Benefit plans are uniform in structure,
language, designation and format to the standard benefit plans listed in this
Subsection and conform to the definitions in Section
010. Each benefit is structured in
accordance with the format provided in Subsections
022.02 and
022.03; or, in the case of plans
K or L, in Paragraphs 022.04.h. and 022.04.i. and list the benefits in the
order shown. For purposes of this section, "structure, language, and format"
means style, arrangement and overall content of benefit. (3-31-22)
l. In addition to the benefit plan
designations prescribed in Paragraph 022.01.k., an issuer may use other
designations to the extent permitted by law. (3-31-22)
02.
Standards for Basic (Core) Benefits
Common to Medicare Supplement Insurance Benefit Plans A, B, C, D, F, F with
High Deductible, G, M, and N. Every issuer of Medicare supplement
insurance benefit plans makes available a policy or certificate including only
the following basic "core" package of benefits to each prospective insured. An
issuer may make available to prospective insureds any of the other Medicare
Supplement Insurance Benefit Plans in addition to the basic core package, but
not in lieu of it. (3-31-22)
a. Coverage of
Part A Medicare eligible expenses for hospitalization to the extent not covered
by Medicare from the sixty-first day through the ninetieth day in any Medicare
benefit period; (3-31-22)
b.
Coverage of Part A Medicare eligible expenses incurred for hospitalization to
the extent not covered by Medicare for each Medicare lifetime inpatient reserve
day used; (3-31-22)
c. Upon
exhaustion of the Medicare hospital inpatient coverage including the lifetime
reserve days, coverage of one hundred percent (100%) 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 three hundred sixty-five
(365) days. The provider will accept the issuer's payment as payment in full
and will not bill the insured for any balance; (3-31-22)
d. Coverage under Medicare Parts A and 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; (3-31-22)
e. Coverage for the coinsurance amount, or in
the case of hospital outpatient department services paid under a prospective
payment system, the copayment amount, of Medicare eligible expenses under Part
B regardless of hospital confinement, subject to the Medicare Part B
deductible; (3-31-22)
f. Hospice
Care. Coverage of cost sharing for all Part A Medicare eligible hospice care
and respite care expenses. (3-31-22)
03.
Standards for Additional
Benefits. The following additional benefits are included in Medicare
supplement benefit Plans B, C, D, F, F with High Deductible, G, M, and N as
provided by Section 024.
(3-31-22)
a. Medicare Part A Deductible.
Coverage for one hundred percent (100%) of the Medicare Part A inpatient
hospital deductible amount per benefit period. (3-31-22)
b. Medicare Part A Deductible. Coverage for
fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount
per benefit period. (3-31-22)
c.
Skilled Nursing Facility Care. Coverage for the actual billed charges up to the
coinsurance amount from the twenty-first day through the one hundredth day in a
Medicare benefit period for post-hospital skilled nursing facility care
eligible under Medicare Part A. (3-31-22)
d. Medicare Part B Deductible. Coverage for
one hundred percent (100%) of the Medicare Part B deductible amount per
calendar year regardless of hospital confinement. (3-31-22)
e. One Hundred Percent (100%) of the Medicare
Part B Excess Charges. Coverage for all the difference between the actual
Medicare Part B charges as billed, not to exceed any charge limitation
established by the Medicare program or state law, and the Medicare-approved
Part B charge. (3-31-22)
f.
Medically Necessary Emergency Care in a Foreign Country. Coverage to the extent
not covered by Medicare for eighty percent (80%) of the billed charges for
Medicare-eligible expenses for medically necessary emergency hospital,
physician and medical care received in a foreign country, which care would have
been covered by Medicare if provided in the United States and which care began
during the first sixty (60) consecutive days of each trip outside the United
States, subject to a calendar year deductible of two hundred fifty dollars
($250), and a lifetime maximum benefit of fifty thousand dollars ($50,000). For
purposes of this benefit, "emergency care" means care needed immediately
because of an injury or an illness of sudden and unexpected onset.
(3-31-22)
04.
Make-up of 2010 Standardized Benefit Plans. (3-31-22)
a. Standardized benefit Plan A includes only
the following: The basic (core) benefits as defined in Subsection
022.02. (3-31-22)
b. Standardized benefit Plan B includes only
the following: The basic (core) benefit as defined in Subsection
022.02, plus one hundred percent
(100%) of the Medicare Part A deductible as defined in Paragraph 022.03.a.
(3-31-22)
c. Standardized benefit
Plan C includes only the following: The basic (core) benefit as defined in
Subsection 022.02, plus one hundred percent
(100%) of the Medicare Part A deductible, skilled nursing facility care, one
hundred percent (100%) of the Medicare Part B deductible, and medically
necessary emergency care in a foreign country as defined in Paragraphs
022.03.a., 022.03.c., 022.03.d., and 022.03.f., respectively.
(3-31-22)
d. Standardized benefit
Plan D includes only the following: The basic (core) benefit (as defined in
Subsection 022.02), plus one hundred
percent (100%) of the Medicare Part A deductible, skilled nursing facility
care, and medically necessary emergency care in a foreign country as defined in
Paragraphs 022.03.a., 022.03.c., and 022.03.f., respectively.
(3-31-22)
e. Standardized [regular]
Plan F includes only the following: The basic (core) benefit as defined in
Subsection 022.02, plus one hundred percent
(100%) of the Medicare Part A deductible, the skilled nursing facility care,
one hundred percent (100%) of the Medicare Part B deductible, one hundred
percent (100%) of the Medicare Part B excess charges, and medically necessary
emergency care in a foreign country as defined in Paragraphs 022.03.a., and
022.03.c., through 022.03.f., respectively. (3-31-22)
f. Standardized Plan F with High Deductible
includes only the following: One hundred percent (100%) of covered expenses
following the payment of the annual deductible set forth in Subparagraph
022.04.f.ii. (3-31-22)
i. The basic (core)
benefit as defined in Subsection
022.02, plus one hundred percent
(100%) of the Medicare Part A deductible, skilled nursing facility care, one
hundred percent (100%) of the Medicare Part B deductible, one hundred percent
(100%) of the Medicare Part B excess charges, and medically necessary emergency
care in a foreign country as defined in Paragraphs 022.03.a., and 022.03.c.,
through 022.03.f., respectively. (3-31-22)
ii. The annual deductible in Plan F with High
Deductible consists of out-of-pocket expenses, other than premiums, for
services covered by [regular] Plan F, and is in addition to any other specific
benefit deductibles. The basis for the deductible is one thousand five hundred
dollars ($1,500) and is 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 ($10). (3-31-22)
g. Standardized benefit Plan G includes only
the following: The basic (core) benefit as defined in Subsection
022.02, plus one hundred percent
(100%) of the Medicare Part A deductible, skilled nursing facility care, one
hundred percent (100%) of the Medicare Part B excess charges, and medically
necessary emergency care in a foreign country as defined in Paragraphs
022.03.a., 022.03.c., 022.03.e., and 022.03.f., respectively. Effective January
1, 2020, the standardized benefit plans described in Paragraph 025.01.d.
(Redesignated Plan G High Deductible) may be offered to any individual who was
eligible for Medicare prior to January 1, 2020. (3-31-22)
h. Standardized Plan K is mandated by the
Medicare Prescription Drug, Improvement and Modernization Act of 2003, and
includes only the following: (3-31-22)
i.
Part A Hospital Coinsurance sixty-first through ninetieth days: Coverage of one
hundred percent (100%) of the Part A hospital coinsurance amount for each day
used from the sixty-first through the ninetieth day in any Medicare benefit
period. (3-31-22)
ii. Part A
Hospital Coinsurance ninety-first through one hundred fiftieth day: Coverage of
one hundred percent (100%) of the Part A hospital coinsurance amount for each
Medicare lifetime inpatient reserve day used from the ninety-first through the
one hundred fiftieth day in any Medicare benefit period; (3-31-22)
iii. Part A Hospitalization After One Hundred
Fiftieth Day: Upon exhaustion of the Medicare hospital inpatient coverage,
including the lifetime reserve days, coverage of one hundred percent (100%) 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
three hundred sixty-five (365) days. The provider accepts the issuer's payment
as payment in full and will not bill the insured for any balance;
(3-31-22)
iv. Medicare Part A
Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient
hospital deductible amount per benefit period until the out-of-pocket
limitation is met as described in Subparagraph 022.04.h.x. (3-31-22)
v. Skilled Nursing Facility Care: Coverage
for fifty percent (50%) of the coinsurance amount for each day used from the
twenty-first day through the one hundredth 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 described in Subparagraph
022.04.h.x. (3-31-22)
vi. Hospice
Care: Coverage for fifty percent (50%) of cost sharing for all Part A Medicare
eligible expenses and respite care until the out-of-pocket limitation is met as
described in Subparagraph 022.04.h.x. (3-31-22)
vii. Blood: Coverage for fifty percent (50%),
under Medicare Part A or B, of 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
until the out-of-pocket limitation is met as described in Subparagraph
022.04.h.x. (3-31-22)
viii. Part B
Cost Sharing: Except for coverage provided in Subparagraph 022.04.h.ix.,
coverage for fifty percent (50%) 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 described in Subparagraph 022.04.h.x.
(3-31-22)
ix. Part B Preventive
Services: Coverage of one hundred percent (100%) of the cost sharing for
Medicare Part B preventive services after the policyholder pays the Part B
deductible; and (3-31-22)
x. Cost
Sharing After Out-of-Pocket Limits: Coverage of one hundred percent (100%) 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 four thousand dollars ($4,000) in
2006, indexed each year by the appropriate inflation adjustment specified by
the Secretary. (3-31-22)
i. Standardized Medicare supplement Plan L is
mandated by the Medicare Prescription Drug, Improvement and Modernization Act
of 2003, and includes only the following: (3-31-22)
i. The benefits described in Subparagraphs
022.04.h.i. through 022.04.h.iii., and 022.04.h.ix. (3-31-22)
ii. The benefits described in Subparagraphs
022.04.h.iv. through 022.04.h.viii. but substituting seventy-five percent (75%)
for fifty percent (50%); and (3-31-22)
iii. The benefit described in Subparagraph
022.04.h.x. but substituting two thousand dollars ($2,000) for four thousand
dollars ($4,000). (3-31-22)
j. Standardized Medicare supplement Plan M
includes only the following: The basic (core) benefit as defined in Subsection
022.02, plus fifty percent (50%)
of the Medicare Part A deductible, skilled nursing facility care, and medically
necessary emergency care in a foreign country as defined in Paragraphs
022.03.b., 022.03.c., and 022.03.f., respectively. (3-31-22)
k. Standardized Medicare supplement Plan N
includes only the following: The basic (core) benefit as defined in Subsection
022.02, plus one hundred percent
(100%) of the Medicare Part A deductible, skilled nursing facility care, and
medically necessary emergency care in foreign country as defined in Paragraphs
022.03.a., 022.03.c., and 022.03.f., respectively, with copayments in the
following amounts: (3-31-22)
i. The lesser of
twenty dollars ($20) or the Medicare Part B coinsurance or copayment for each
covered health care provider office visit (including visits to medical
specialists); and (3-31-22)
ii. The
lesser of fifty dollars ($50) or the Medicare Part B coinsurance or copayment
for each covered emergency room visit, however, this copayment is waived if the
insured is admitted to any hospital and the emergency visit is subsequently
covered as a Medicare Part A expense. (3-31-22)
05.
New or Innovative Benefits.
An issuer may, with the prior approval of the director, offer policies or
certificates with 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 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 cannot adversely impact the goal of Medicare supplement
simplification. New or innovative benefits cannot include an outpatient
prescription drug benefit. New or innovative benefits cannot be used to change
or reduce benefits, including a change of any cost-sharing provision, in any
standardized plan. (3-31-22)