Louisiana Administrative Code
Title 37 - INSURANCE Part
Part XIII - Regulations
Chapter 5 - Regulation 33-Medicare Supplement Insurance Minimum Standards
Section XIII-516 - Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date For Coverage on or after June 1, 2010
Universal Citation: LA Admin Code XIII-516
Current through Register Vol. 50, No. 9, September 20, 2024
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 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 prior to June 1, 2010 remain subject to the requirements of §510, §515, §520, and §525
1. General Standards. The following standards
apply to Medicare supplement policies and certificates and are in addition to
all other requirements of this regulation.
a.
A Medicare supplement policy or certificate shall not exclude or limit benefits
for losses incurred more than six 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 six months before the effective date of coverage.
b. A Medicare supplement policy or
certificate shall not indemnify against losses resulting from sickness on a
different basis than losses resulting from accidents.
c. 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, co-payment, or coinsurance amounts.
Premiums may be modified to correspond with such changes.
d. 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.
e. Each Medicare supplement policy shall be
guaranteed renewable.
i. The issuer shall not
cancel or non-renew the policy solely on the ground of health status of the
individual.
ii. The issuer shall
not cancel or non-renew the policy for any reason other than nonpayment of
premium or material misrepresentation.
iii. If the Medicare supplement policy is
terminated by the group policyholder and is not replaced as provided under
§516. A.1.e.v of this
regulation, the issuer shall offer certificateholders an individual Medicare
supplement policy which (at the option of the certificateholder):
(a). provides for continuation of the
benefits contained in the group policy; or
(b). provides for benefits that otherwise
meet the requirements of this Subsection.
iv. If an individual is a certificateholder
in a group Medicare supplement policy and the individual terminates membership
in the group, the issuer shall:
(a). offer the
certificateholder the conversion opportunity described in
§516. A.1.e iii. of
this regulation; or
(b). at the
option of the group policyholder, offer the certificateholder continuation of
coverage under the group policy.
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 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.
f. 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.
g.i.
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 (not to exceed 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 90 days after the date the
individual becomes entitled to assistance.
ii.
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) 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.
iii. 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 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 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.
iv. Reinstitution of coverages as described
in Subparagraphs (ii) and (iii):
(a). shall
not provide for any waiting period with respect to treatment of preexisting
conditions;
(b). shall provide for
resumption of coverage that is substantially equivalent to coverage in effect
before the date of suspension; and
(c). 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.
2. 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.
a. Coverage of Part A Medicare eligible
expenses for hospitalization to the extent not covered by Medicare from the
sixty-first through the ninetieth day in any Medicare benefit period;
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;
c. Upon exhaustion of the Medicare hospital
inpatient coverage, including the lifetime reserve days, coverage of 100
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 the issuer's payment as payment
in full and may not bill the insured for any balance;
d. 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;
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;
f. Hospice Care:
Coverage of cost sharing for all Part A Medicare eligible hospice care and
respite care expenses.
3. 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
§521 of this regulation.
a. Medicare Part A Deductible: Coverage for
100 percent of the Medicare Part A inpatient hospital deductible amount per
benefit period.
b. Medicare Part A
Deductible: Coverage for 50 percent of the Medicare Part A inpatient hospital
deductible amount per benefit period.
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.
d. Medicare Part B Deductible:
Coverage for 100 percent of the Medicare Part B deductible amount per calendar
year regardless of hospital confinement.
e. 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.
f. Medically Necessary
Emergency Care in a Foreign Country: Coverage to the extent not covered by
Medicare for 80 percent 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 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.
AUTHORITY NOTE: Promulgated in accordance with R.S. 22:1111 (re-designated from LSA-R.S. 22:224 pursuant to Acts 2008, No. 415, effective January 1, 2009) and 42 U.S.C. 1395 et seq.
Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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