Current through Register No. 12, March 21, 2024
(a) No policy or certificate shall be
advertised, solicited, or issued for delivery in this state as a Medicare
supplement policy or certificate unless it meets or exceeds the minimum
standards set forth in this section. These are minimum standards and do not
preclude the inclusion of other provisions or benefits which are not
inconsistent with these standards.
(b) General Standards. The following
standards shall 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;
(2) The policy or
certificate shall 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;
(3) A Medicare supplement
policy or certificate shall not indemnify against losses resulting from
sickness on a different basis than losses resulting from accidents;
(4) 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;
(5) A "noncancellable," "guaranteed
renewable," or "noncancellable and guaranteed renewal" Medicare supplement
policy shall not:
a. 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; or
b. Be cancelled or
non-renewed by the issuer solely on the grounds of deterioration of
health;
(6) Except as
authorized by the commissioner of this state, an issuer shall neither cancel
nor nonrenew a Medicare supplement policy or certificate for any reason other
than nonpayment of premium or material misrepresentation.
a. If a group Medicare supplement insurance
policy is terminated by the group policyholder and not replaced as provided in
Ins 1905.06(b)(6)c., the issuer shall offer certificate holders an individual
Medicare supplement policy. The issuer shall offer the certificate holder at
least the following choices:
1. An individual
Medicare supplement policy currently offered by the issuer having comparable
benefits to those contained in the terminated group Medicare supplement policy;
or
2. An individual Medicare
supplement policy which provides only such benefits as are required to meet the
minimum standards as defined in Ins 1905.08(b) of this rule;
b. If membership in a group is
terminated, the issuer shall:
1. Offer the
certificate holder the conversion opportunities described in subparagraph
(6)(a); or
2. At the option of the
group policyholder, offer the certificate holder continuation of coverage under
the group policy; and
c.
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 group policy
shall not result in any exclusion for preexisting conditions that would have
been covered under the group policy being replaced;
(7) 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 predicated upon the
continuous total disability of the insured, limited to the duration of the
policy benefit period, if any, or to payment of the maximum benefits. Receipt
of Medicare Part D benefits will not be considered in determining a continuous
loss; and
(8) If a Medicare
supplement policy eliminates an outpatient prescription drug benefit as a
result of requirements imposed by the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003, the modified policy shall be deemed to satisfy
the guaranteed renewal requirements of this subsection.
(c) Minimum Benefit Standards:
(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 for
either all or none of the Medicare Part A inpatient hospital deductible
amount;
(3) Coverage of Part A
Medicare eligible expenses incurred as daily hospital charges during use of
Medicare's lifetime hospital inpatient reserve days;
(4) Upon exhaustion of all Medicare hospital
inpatient coverage including the lifetime reserve days, coverage of 90% of all
Medicare Part A eligible expenses for hospitalization not covered by Medicare
subject to a lifetime maximum benefit of an additional 365 days;
(5) Coverage under Medicare Part A 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 or already paid for under Medicare Part
B;
(6) 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 Medicare Part B regardless of hospital confinement, subject to a maximum
calendar year out-of-pocket amount equal to the Medicare Part B deductible
($147); and
(7) Effective January
1, 1990, coverage under Medicare Part 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 or already paid for under Medicare Part A, subject to the Medicare
deductible amount.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406,
eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363,
eff 9-8-05; ss by #9559, eff 10-13-09