Current through Register Vol. 48, No. 12, March 22, 2024
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
Medicare supplement benefit plan for sale on or after June 1, 2010. Benefit
standards applicable to Medicare supplement policies and certificates issued
with an effective date for coverage before June 1, 2010 remain subject to the
requirements of Section
2008.70
for Pre-Standardized Plans or Section
2008.71
for 1990 Plans.
a) General Standards.
The following standards apply to Medicare supplement policies and certificates
and are in addition to all other requirements of this Part.
1) A Medicare supplement policy or
certificate shall not exclude or limit benefits for losses incurred more than 6
months from the effective date of coverage because it involved a preexisting
condition. The policy or certificate 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 6 months
before the effective date of coverage.
2) A Medicare supplement policy or
certificate shall not indemnify against losses resulting from sickness on a
different basis than losses resulting from accidents.
3) A Medicare supplement policy or
certificate 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, copayment, or coinsurance amounts. Premiums
may be modified to correspond with such changes.
4) No Medicare supplement policy or
certificate shall 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.
5) Each Medicare supplement policy shall be
guaranteed renewable.
A) The issuer shall not
cancel or nonrenew the policy solely on the ground of health status of the
individual.
B) The issuer shall not
cancel or nonrenew the policy for any reason other than nonpayment of premium
or material misrepresentation.
C)
If the Medicare supplement policy is terminated by the group policyholder and
is not replaced as provided under subsection (a)(5)(E), the issuer shall offer
certificateholders an individual Medicare supplement policy which, at the
option of the certificateholder:
i) Provides
for continuation of the benefits contained in the group policy; or
ii) Provides for benefits that otherwise meet
the requirements of this subsection.
D) If an individual is a certificateholder in
a group Medicare supplement policy and the individual terminates membership in
the group, the issuer shall:
i) Offer the
certificateholder the conversion opportunity described in subsection (a)(5)(C);
or
ii) At the option of the group
policyholder, offer the certificateholder continuation of coverage under the
group policy.
E) 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 shall offer coverage to all persons covered under the old
group policy on its date of termination. Coverage under the new 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 or certificate 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 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.
7) A Medicare supplement
policy or certificate shall provide that benefits and premiums under the policy
or certificate shall be suspended at the request of the policyholder or
certificateholder for the period 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 ( 42 USC 1901-1941 ), but only if the
policyholder or certificateholder notifies the issuer of the policy or
certificate within 90 days after the date the individual becomes entitled to
assistance. In no case shall the suspension exceed 24 months.
A) If suspension occurs and if the
policyholder or certificateholder loses entitlement to medical assistance, the
policy or certificate shall be automatically reinstituted, effective as of the
date of termination of entitlement, if the policyholder or certificateholder
provides notice of loss of entitlement within 90 days after the date of loss
and pays the premium attributable to the period, effective as of the date of
termination of entitlement.
B) Each
Medicare supplement policy shall provide that benefits and premiums under the
policy shall 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 (
42 USC
426(b) ) and is covered
under a group health plan (as defined in section 1862(b)(1)(A)(v) of the Social
Security Act (
42 USC
1395y(b)(1)(A)(v) ). If
suspension occurs and if the policyholder or certificate holder loses coverage
under the group health plan, the policy shall be 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 attributable to the period, effective as of the date of termination
of enrollment in the group health plan.
C) Reinstitution of coverages as described in
subsections (a)(7)(A) and (B):
i) Shall not
provide for any waiting period with respect to treatment of preexisting
conditions;
ii) Shall provide for
resumption of coverage that is substantially equivalent to coverage in effect
before the date of suspension; and
iii) Shall provide 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.
b) 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 shall make 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.
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 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) Upon exhaustion of the Medicare hospital
inpatient coverage, including the lifetime reserve days, coverage of 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 365
days. The provider shall accept the issuer's payment as payment in full and may
not bill the insured for any balance;
4) Coverage under Medicare Parts A and B for
the reasonable cost of the first 3 pints of blood (or equivalent quantities of
packed red blood cells, as defined under federal regulations) unless replaced
in accordance with federal regulations;
5) 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;
6) Hospice Care:
Coverage of cost sharing for all Part A Medicare eligible hospice care and
respite care expenses.
c) Standards for Additional Benefits. The
following additional benefits shall be included in Medicare supplement benefit
Plans B, C, D, F, F with High Deductible, G, M and N as provided by Section
2008.67.
1) Medicare Part A Deductible: Coverage for
100% of the Medicare Part A inpatient hospital deductible amount per benefit
period.
2) Medicare Part A
Deductible: Coverage for 50% of the Medicare Part A inpatient hospital
deductible amount per benefit period.
3) Skilled Nursing Facility Care: Coverage
for the actual billed charges up to the coinsurance amount 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.
4) Medicare Part B Deductible:
Coverage for 100% of the Medicare Part B deductible amount per calendar year
regardless of hospital confinement.
5) One Hundred Percent of the Medicare Part B
Excess Charges: Coverage for all of 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.
6) Medically Necessary
Emergency Care in a Foreign Country: Coverage to the extent not covered by
Medicare for 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 60 consecutive days of
each trip outside the United States, subject to a calendar year deductible of
$250, and a lifetime maximum benefit of $50,000. For purposes of this benefit,
"emergency care" shall mean care needed immediately because of an injury or an
illness of sudden and unexpected onset.