Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 71.00 - Medicare Supplement Insurance To Facilitate The Implementation Of M.G.L. c. 176k And Section 1882 Of The Federal Social Security Act
Section 71.09 - New or Innovative Benefits
Current through Register 1531, September 27, 2024
An Issuer of Medicare Supplement Insurance may, with the prior approval of the Commissioner, offer Medicare Supplement Insurance Policies with new or innovative benefits described in 211 CMR 71.09 in addition to the benefits provided in a Policy that otherwise complies with the applicable standards set forth in 211 CMR 71.00. The new or innovative benefits may include benefits that are appropriate to Medicare Supplement Insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner which is consistent with the goal of simplification of Medicare Supplement Insurance Policies. Only those new and innovative benefits specified in 211 CMR 71.09 and any other new or innovative benefits approved by the Commissioner may be so offered. Nothing in 211 CMR 71.09 prohibits an Issuer offering a Policy with new or innovative benefits consistent with 211 CMR 71.09 from also providing a Policy of the same Medicare Supplement option type without the new or innovative benefit. Notwithstanding the provisions of any other section, a Medicare Supplement Insurance Policy with benefits for outpatient prescription drugs, including such benefits provided through Alternate Innovative Benefits Riders shall not be issued after December 31, 2005, but coverage in effect on December 31, 2005 shall be renewed, except as identified in 211 CMR 71.07(5).
(1) Individual Case Management. Issuers providing Medicare Supplement Insurance may provide coverage for services in addition to the benefits required by the Commissioner for the applicable Medicare Supplement Core Policy, Medicare Supplement 1 Policy, Medicare Supplement 1A Policy, or Medicare Supplement 2 Policy as part of an individual case management program. Such program must be approved by the Commissioner in advance. Such individual case management program may be established by the Issuer pursuant to a plan of care agreed to by the Insured and the attending physician and approved under the Issuer's individual case management program.
(2) Outpatient Prescription Drug Benefits. In providing the Outpatient Prescription Drug benefits in a Medicare Supplement 2 Insurance Policy, an Issuer may limit benefits to those received from providers with which it has an agreement, provided that such limitation does not significantly reduce the availability of benefits under the Policy; and provided further, that any limitation or exclusion of a provider, and any such agreement, are in accordance with M.G.L. c. 176D, § 3B. For the purposes of 211 CMR 71.09(2), "Outpatient Prescription Drugs" includes insulin, as well as the needles, syringes, pumps and pump supplies necessary for the administration of insulin and blood sugar level testing equipment and supplies for use at home; drugs provided by a home infusion therapy provider; and drugs used on an off-label basis for the treatment of cancer or HIV/AIDS and medically necessary services associated with the administration of such drugs as required by M.G.L. c. 175, § 47K; M.G.L. c. 175, § 47L; M.G.L. c. 176A, § 8N; or M.G.L. c. 176B, § 4N, or by M.G.L. c. 175, § 47O; M.G.L. c. 175, § 47P; M.G.L. c. 176A, § 8Q (as added by St. 1996, c. 450, § 222); or by M.G.L. c. 176B, § 4P (as added by St. 1994, c. 60, § 146), and drugs and devices for hormone replacement therapy for peri- and post-menopausal women and for outpatient prescription contraceptive drugs or devices as required by M.G.L. c. 175, § 47W; M.G.L. c. 176A, § 8W or M.G.L. c. 176B, § 4W (as added by St. 2002, c. 49).
(3) Mail Service Prescription Drug Program. Issuers providing Medicare Supplement Insurance Policies may provide coverage for a mail service prescription drug program for Outpatient Prescription Drugs for which federal law requires a prescription in addition to the benefits required by the Commissioner for a Medicare Supplement 2 Insurance Policy. The benefit must be approved by the Commissioner in advance; provided however, that the Insured shall only be charged a copayment and the Insured's copayments for Outpatient Prescription Drugs shall be either:
Nothing in 211 CMR 71.09(3) shall be construed to prevent such an Issuer from basing payment on allowed charges rather than on charges or limiting benefits to those received from providers with whom they have an agreement; provided that such limitation does not significantly reduce the availability of benefits under the Policy; and provided further, that any limitation or exclusion of a provider, and any such agreement, are in accordance with M.G.L. c. 176D, § 3B. For the purposes of 211 CMR 71.09(3), "Outpatient Prescription Drugs" includes insulin, as well as the needles, syringes, pumps and pump supplies necessary for the administration of insulin and blood sugar level testing equipment and supplies for use at home; drugs provided by a home infusion therapy provider; and drugs used on an off-label basis for the treatment of cancer or HIV/AIDS and medically necessary services associated with the administration of such drugs as required by M.G.L. c. 175, § 47K; M.G.L. c. 175, § 47L; M.G.L. c. 176A, § 8N; or M.G.L. c. 176B, § 4N; or by M.G.L. c. 175, § 47O; M.G.L. c. 175, § 47P; M.G.L. c. 176A, § 8Q (as added by St. 1996, c. 450, § 222); or by M.G.L. c. 176B, § 4P (as added by St. 1994, c. 60, § 146); and drugs and devices for hormone replacement therapy for peri- and post-menopausal women and for outpatient prescription contraceptive drugs or devices as required by M.G.L. c. 175, § 47W; M.G.L. c. 176A, § 8W or M.G.L. c. 176B, § 4W (as added by St. 2002, c. 49, §§ 4 and 5).
(4) Alternate Innovative Benefits. Issuers providing Medicare Supplement Insurance may provide alternate innovative benefits consisting of the innovative preventive care benefit described in 211 CMR 71.09(4)(a) or the innovative foreign travel care benefit described in 211 CMR 71.09(4)(b), in addition to the benefits required for a Medicare Supplement Core Insurance Policy, a Medicare Supplement 1 Insurance Policy or a Medicare Supplement 1A Insurance Policy, as applicable, subject to the prior approval of the Commissioner of Insurance. Alternate innovative benefits may be provided within a Medicare Supplement Insurance Policy or by an Alternate Innovative Benefit Rider to a Medicare Supplement Policy, provided, that each Issuer may offer only one combination of the benefits described in 211 CMR 71.09(4)(a) and (b) for each type of Medicare Supplement Insurance Policy. An Alternate Innovative Benefit Rider may be offered only in addition to the applicable Medicare Supplement Insurance Policy form required for a Medicare Supplement Core Insurance Policy, a Medicare Supplement 1 Insurance Policy or a Medicare Supplement 1A Insurance Policy, as applicable.
