The following standards are applicable to all Medicare
supplement policies or certificates delivered or issued for delivery in this
State with an effective date of 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 of
coverage before June 1, 2010 remain subject to the requirements of Section
9.
A.
(1) An
issuer shall make available to each prospective policyholder and certificate
holder a policy form or certificate form containing only the basic (core)
benefits, as defined in Section
8.1(B) of this
Rule.
(2) If an issuer makes
available any of the additional benefits described in Section
8.1(C), or offers
standardized benefit Plans K or L (as described in Sections 9.1(E)(8) and (9)
of this Rule), 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) above,
a policy form or certificate form containing either standardized benefit Plan C
(as described in Section 9.1(E)(3) of this Rule) or standardized benefit Plan F
(as described in 9.1(E)(5) of this Rule).
B. 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 Section 9.1(F)
and in Section
10 of this Rule.
C. 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 Section
4 of this Rule. Each benefit shall be
structured in accordance with the format provided in Sections
8.1(B) and
8.1(C) of this
Rule; or, in the case of plans K or L, in Sections 9.1(E)(8) or (9) of this
Rule 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.
E. Make-up of 2010 Standardized Benefit
Plans:
(1) Standardized Medicare supplement
benefit Plan A shall include only the following:
The basic (core) benefits as defined in Section
8.1(B) of this
Rule.
(2) Standardized
Medicare supplement benefit Plan B shall include only the following:
The basic (core) benefit as defined in Section
8.1(B) of this
Rule, plus one hundred percent (100%) of the Medicare Part A deductible as
defined in Section
8.1(C)(1) of this
Rule.
(3) Standardized
Medicare supplement benefit Plan C shall include only the following: The basic
(core) benefit as defined in Section
8.1(B) of this
Rule, 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 Sections
8.1(C)(1), (3), (4), and
(6) of this Rule, respectively.
(4) Standardized Medicare supplement benefit
Plan D shall include only the following: The basic (core) benefit (as defined
in Section
8.1(B) of this
Rule), 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 Sections
8.1(C)(1), (3), and
(6) of this Rule, respectively.
(5) Standardized Medicare supplement
[regular] benefit Plan F shall include only the following: The basic (core)
benefit as defined in Section
8.1(B) of this
Rule, 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
Sections
8.1(C)(1), (3), (4), (5), and
(6) respectively.
(6) Standardized Medicare supplement benefit
Plan F with High Deductible shall include only the following: one hundred
percent (100%) of covered expenses following the payment of the annual
deductible set forth in Subparagraph (b).
a.
The covered expenses (after the deductible) are: the basic (core) benefit as
defined in Section
8.1(B) of this
Rule, 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
Sections
8.1(C)(1), (3), (4), (5), and
(6) of this Rule, respectively.
b. 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 twelve-month period ending with August of the
preceding year, and rounded to the nearest multiple of ten dollars
($10).
(7) Standardized
Medicare supplement benefit Plan G shall include only the following: The basic
(core) benefit as defined in Section
8.1(B) of this
Rule, 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 Sections
8.1(C)(1), (3), (5), and
(6), respectively. Effective January 1, 2020,
the standardized benefit plans described in Section 9.2(A)(4) of this Rule
(Redesignated Plan G High Deductible) may be offered to any individual who was
eligible for Medicare prior to January 1, 2020.
(8) Standardized Medicare supplement benefit
Plan K is mandated by The Medicare Prescription Drug, Improvement and
Modernization Act of 2003, and shall include only the following:
a. Part A Hospital Coinsurance 61st through
90th days: Coverage of one hundred percent (100%) 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
(100%) 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 (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;
d. 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 (j);
e. Skilled Nursing Facility Care: Coverage
for fifty percent (50%) 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 described in Subparagraph (j);
f. 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
(j);
g. 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 (j);
h. Part B Cost
Sharing: Except for coverage provided in Subparagraph (i), 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 (j);
i. 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
j. 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, which was $4000 in 2006 and is indexed each year by the appropriate
inflation adjustment specified by the Secretary of the U.S. Department of
Health and Human Services.
(9) Standardized Medicare supplement benefit
Plan L is mandated by The Medicare Prescription Drug, Improvement, and
Modernization Act of 2003, and shall include only the following:
a. The benefits described in Paragraphs
9.1(E)(8)(a), (b), (c), and (i);
b.
The benefit described in Paragraphs 9.1(E)(8)(d), (e), (f), (g), and (h), but
substituting seventy-five percent (75%) for fifty percent (50%); and
c. The benefit described in Paragraph
9.1(E)(8)(j), but substituting $2000 for $4000.
(10) Standardized Medicare supplement benefit
Plan M shall include only the following: The basic (core) benefit as defined in
Section
8.1(B) of this
Rule, 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 Sections
8.1(C)(2), (3), and
(6) of this Rule, respectively.
(11) Standardized Medicare supplement benefit
Plan N shall include only the following: The basic (core) benefit as defined in
Section
8.1(B) of this
Rule, 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 Sections
8.1(C)(1), (3), and
(6) of this Rule, respectively, with
copayments in the following amounts:
a. 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
b. The lesser of
fifty dollars ($50) 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 Superintendent, 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. 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.
