New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 4 - ACTUARIAL SERVICES
Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE
Section 11:4-23.6 - General minimum benefit standards for all Medicare supplement policies and certificates
Universal Citation: NJ Admin Code 11:4-23.6
Current through Register Vol. 56, No. 6, March 18, 2024
(a) No policy or certificate shall be advertised, solicited, or issued for delivery in this State as a Medicare supplement policy if it does not meet the minimum standards contained in this section.
(b) The following general standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this subchapter.
1. A Medicare supplement policy or
certificate shall not exclude or limit benefits for losses incurred as a result
of a preexisting condition after six months from the effective date of
coverage, nor shall a preexisting condition be defined more restrictively than
as set forth at
11:4-23.4(a)9.
2. A Medicare supplement policy or
certificate shall not indemnify against losses resulting from sickness on a
different basis than losses resulting from accidents.
3. 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, copayment, or coinsurance amounts. Premiums
may be correspondingly modified subject to the requirements of
11:4-23.1 1.
4. A Medicare supplement policy or
certificate shall not:
i. Provide for
termination of coverage of an eligible spouse because of termination of
coverage of the insured other than for nonpayment of premium; or
ii. Provide for termination of a covered
persons' coverage by the carrier solely on the grounds of age or deterioration
of health.
5.
Termination of a Medicare supplement policy or certificate shall be without
prejudice to any continuous loss which commenced while the policy or
certificate 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 covered person 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 continuous
loss.
6. Existing Medicare
supplement policies and certificates shall be appropriately amended or endorsed
to eliminate benefit duplications with Medicare which are caused by Medicare
benefit changes. Any riders or endorsements shall specify the benefits deleted,
or shall otherwise result in a clear description of the Medicare supplement
benefits provided by the policy. Such riders or endorsements shall be submitted
for filing by the Commissioner.
7.
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,
Pub. L.
108-173, the modified policy shall be deemed to
satisfy the guaranteed renewal requirements of this subchapter.
(c) A carrier shall neither cancel nor nonrenew a Medicare supplement policy or certificate for any reason other than nonpayment of premium or material misrepresentation. With respect to terminations of group policies, or membership in a group, the following standards shall apply:
1. If a group
policyholder terminates the group Medicare supplement policy without replacing
that policy as provided in (c)3 below, the carrier shall offer individuals
covered under group policies at least the following two coverage choices:
i. An individual guaranteed renewable
Medicare supplement policy which provides for continuation of the benefits
contained in the group policy; and
ii. An individual Medicare supplement policy
which provides only benefits that otherwise are required to meet
11:4-23.8 if offered with an
effective date for coverage prior to June 1, 2010 and
11:4-23.8A(d) if
offered with an effective date for coverage on or after June 1, 2010.
2. If membership in a group is
terminated, the carrier shall:
i. Offer the
individual whose membership is terminated the conversion opportunities
described in (c)1 above; or
ii.
Offer the individual whose membership is terminated continuation of coverage
under the group policy, but only at the option of the group
policyholder.
3. If a
group policyholder replaces one group Medicare supplement policy by another
group Medicare supplement policy, the carrier issuing the replacement coverage
shall offer coverage to all persons who were covered under the old group policy
on its date of termination. Coverage under the new group policy shall not
result in any exclusions for preexisting conditions that would have been
covered under the group policy which was replaced.
Disclaimer: These regulations may not be the most recent version. New Jersey 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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