Louisiana Administrative Code
Title 37 - INSURANCE Part
Part XIII - Regulations
Chapter 5 - Regulation 33-Medicare Supplement Insurance Minimum Standards
Section XIII-521 - Standard Medicare Supplement Benefit Plans 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-521
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 plan standards. Benefit plan 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 §510, §515, §520, and §525
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
§516. A.2 of this
regulation.
b. If an issuer makes
available any of the additional benefits described in
§516. A 3, or offers
standardized benefit Plans K or L (as described
§521. A.5.h and i of
this regulation), then the issuer shall make 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 Subsection A.1.a.
above, a policy form or certificate form containing either standardized benefit
Plan C (as described in
§521. A.5.c of this
regulation) or standardized benefit Plan F (as described in
§521. A.5.e of this
regulation).
2. No
groups, packages or combinations of Medicare supplement benefits other than
those listed in this Section shall be offered for sale in this state, except as
may be permitted in
§521. A.6 and in
§525 of this regulation.
3. Benefit plans shall be uniform in
structure, language, designation and format to the standard benefit plans
listed in this Subsection and conform to the definitions in
§503 of this regulation. Each benefit
shall be structured in accordance with the format provided in
§516. A.2 and
§516. A.3 of this
regulation; or, in the case of plans K or L, in
§521. A.5.h or i of
this regulation and list the benefits in the order shown. For purposes of this
Section, "structure, language, and format" means style, arrangement and overall
content of a benefit.
4. In
addition to the benefit plan designations required in
§521. A.3 of this
Section, an issuer may use other designations to the extent permitted by
law.
5. Make-up of 2010
Standardized Benefit Plans:
a. Standardized
Medicare supplement benefit Plan A shall include only the following: The basic
(core) benefits as defined in
§516. A.2 of this
regulation.
b. Standardized
Medicare supplement benefit Plan B shall include only the following: The basic
(core) benefit as defined in
§516. A.2 of this
regulation, plus 100 percent of the Medicare Part A deductible as defined in
§516. A.3.a of this
regulation.
c. Standardized
Medicare supplement benefit Plan C shall include only the following: The basic
(core) benefit as defined in
§516. A.2 of this
regulation, plus 100 percent of the Medicare Part A deductible, skilled nursing
facility care, 100 percent of the Medicare Part B deductible, and medically
necessary emergency care in a foreign country as defined in
§516. A .3 a, c, d, and
f of this regulation, respectively.
d. Standardized Medicare supplement benefit
Plan D shall include only the following: The basic (core) benefit (as defined
in §516.
A.2 of this regulation), plus 100 percent of
the Medicare Part A deductible, skilled nursing facility care, and medically
necessary emergency care in a foreign country as defined in
§516. A.3 a, c, and f
of this regulation, respectively.
e. Standardized Medicare supplement regular
Plan F shall include only the following: The basic (core) benefit as defined in
§516. A.2 of this
regulation, plus 100 percent of the Medicare Part A deductible, the skilled
nursing facility care, 100 percent of the Medicare Part B deductible, 100
percent of the Medicare Part B excess charges, and medically necessary
emergency care in a foreign country as defined in
§516. A.3 a, c, d, e,
and f, respectively.
f.
Standardized Medicare supplement Plan F With High Deductible shall include only
the following: 100 percent of covered expenses following the payment of the
annual deductible set forth in Subparagraph ii.
i. The basic (core) benefit as defined in
§516. A.2 of this
regulation, plus 100 percent of the Medicare Part A deductible, skilled nursing
facility care, 100 percent of the Medicare Part B deductible, 100 percent of
the Medicare Part B excess charges, and medically necessary emergency care in a
foreign country as defined in
§516. A.3 a, c, d, e,
and f of this regulation, respectively.
ii. The annual deductible in Plan F With High
Deductible shall consist of out-of-pocket expenses, other than premiums, for
services covered by regular Plan F, and shall be in addition to any other
specific benefit deductibles. The basis for the deductible shall be $1,500 and
shall be adjusted annually from 1999 by the Secretary of the U.S. Department of
Health and Human Services to reflect the change in the Consumer Price Index for
all urban consumers for the 12-month period ending with August of the preceding
year, and rounded to the nearest multiple of $10.
g. Standardized Medicare supplement benefit
Plan G shall include only the following: the basic (core) benefit as defined in
§516.A.2 of this
regulation, plus 100 percent of the Medicare Part A deductible, skilled nursing
facility care, 100 percent of the Medicare Part B excess charges, and medically
necessary emergency care in a foreign country as defined in
§516.A.3 a, c, e, and
f, respectively. Effective January 1, 2020, the standardized benefit plans
described in
§522.A.1.d of this
regulation (Redesignated Plan G High Deductible) may be offered to any
individual who was eligible for Medicare prior to January 1, 2020.
h. Standardized Medicare supplement Plan K is
mandated by The Medicare Prescription Drug, Improvement and Modernization Act
of 2003, and shall include only the following:
i. Part A Hospital Coinsurance Sixty-first
through the Ninetieth Day: Coverage of 100 percent of the Part A hospital
coinsurance amount for each day used from the sixty-first through the ninetieth
day in any Medicare benefit period;
ii. Part A Hospital Coinsurance, Ninety-first
through the One Hundredth Fiftieth Day: Coverage of 100 percent 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;
iii. Part A
Hospitalization After One Hundred Fifty Days: 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;
iv. Medicare Part A Deductible: Coverage for
50 percent of the Medicare Part A inpatient hospital deductible amount per
benefit period until the out-of-pocket limitation is met as described in
Subparagraph x.;
v. Skilled Nursing
Facility Care: Coverage for 50 percent 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 x.;
vi. Hospice Care:
Coverage for 50 percent 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 x.;
vii.
Blood: Coverage for 50 percent, under Medicare Part A or B, of 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 until the out-of-pocket limitation is met
as described in Subparagraph x.;
viii. Part B Cost Sharing: Except for
coverage provided in Subparagraph (ix), coverage for 50 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 described in
Subparagraph x.;
ix. Part B
Preventive Services: Coverage of 100 percent of the cost sharing for Medicare
Part B preventive services after the policyholder pays the Part B deductible;
and
x. Cost Sharing After
Out-of-Pocket Limits: Coverage of 100 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 $4000 in 2006, indexed each year by the
appropriate inflation adjustment specified by the Secretary of the U.S.
Department of Health and Human Services.
i. Standardized Medicare supplement Plan L is
mandated by The Medicare Prescription Drug, Improvement and Modernization Act
of 2003, and shall include only the following:
i. the benefits described in Paragraphs
§521. A.5.h.i, ii, iii
and ix;
ii. the benefits described
in Paragraphs
§521. A.5.h iv., v, vi,
vii and viii, but substituting 75 percent for 50 percent; and
iii. the benefit described in Paragraph
§521. A.5.h x, but
substituting $2000 for $4000.
j. Standardized Medicare supplement Plan M
shall include only the following: The basic (core) benefit as defined in
§516. A.2 of this
regulation, plus 50 percent of the Medicare Part A deductible, skilled nursing
facility care, and medically necessary emergency care in a foreign country as
defined in
§516. A.3 b, c and f of
this regulation, respectively.
k.
Standardized Medicare supplement Plan N shall include only the following: The
basic (core) benefit as defined in
§516. A.2 of this
regulation, plus 100 percent of the Medicare Part A deductible, skilled nursing
facility care, and medically necessary emergency care in a foreign country as
defined in
§516. A.3 a, c and f.
of this regulation, respectively, with co-payments in the following amounts:
i. the lesser of $20 or the Medicare Part B
coinsurance or co-payment for each covered health care provider office visit
(including visits to medical specialists); and
ii. the lesser of $50 or the Medicare Part B
coinsurance or co-payment 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.
6. New or Innovative
Benefits: An issuer may, with the prior approval of the commissioner, 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 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 must 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.
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.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
