Current through Register Vol. 56, No. 24, December 18, 2024
(a) No policy or
certificate shall be advertised, solicited, delivered or issued for delivery in
this State as a Medicare supplement policy on or after January 4, 1993 and with
an effective date for coverage prior to June 1, 2010 unless it complies with
the standards of
N.J.A.C. 11:4-23.6 and the benefit
standards set forth below.
(c) A Medicare supplement policy or
certificate shall provide that benefits and premiums under the policy or
certificate shall be suspended at the request of the policyholder or
certificateholder for the period (not to exceed 24 months) in which the
policyholder or certificateholder has applied for and is determined to be
entitled to medical assistance under Title XIX of the Social Security Act (42 U.S.C.
§
1396v through end), but only if the
policyholder or certificateholder notifies the issuer of the policy or
certificate within 90 days after the date that the individual becomes entitled
to that assistance.
1. If suspension occurs
and if the policyholder or certificateholder loses entitlement to Title XIX
medical assistance, the policy or certificate shall be automatically
reinstituted (effective as of the date of the termination of the entitlement)
if the policyholder or certificateholder provides notice of their loss of the
entitlement to the Title XIX assistance within 90 days after the date of that
loss and the policyholder or certificateholder pays the premium attributable to
the period subsequent to the date of the termination of the
entitlement.
2. Each Medicare
supplement policy shall provide that benefits and premiums under the policy
shall be suspended for any period that may be provided by Federal regulation at
the request of the policyholder if the policyholder is entitled to benefits
under Section 226(b) of the Social Security Act,
42 U.S.C. §
426(b), and is covered under
a group health plan (as defined in Section 1862(b)(1)(A)(v) of the Social
Security Act,
42 U.S.C.
§
1395y(b)(1)(A)(v)).
If suspension occurs and if the policyholder or certificateholder loses
coverage under the group health plan, the policy shall be automatically
reinstituted (effective as of the date of loss of coverage) if the policyholder
provides notice of loss of coverage within 90 days after the date of the loss
and pays the premium attributable to the period from the date of the
termination of their enrollment in the group health plan.
3. Reinstitution of coverage as described in
(c)1 and 2 above shall:
i. Not impose any
waiting period with respect to treatment of preexisting conditions;
ii. Provide for resumption of coverage that
is substantially equivalent to the coverage that was in effect before the date
of the suspension. If the suspended Medicare supplement policy provided
coverage for outpatient prescription drugs, reinstitution of the policy for
Medicare Part D enrollees shall be without coverage for outpatient prescription
drugs and shall otherwise provide substantially equivalent coverage to the
coverage in effect before the date of suspension; and
iii. Provide for classification of premiums
on terms at least as favorable to the policyholder or certificateholder as the
premium classification terms that would have applied to the policyholder or
certificateholder had the coverage not been suspended.
4. If a carrier makes a written offer to the
Medicare supplement policyholders or certificateholders of one or more of its
plans to exchange, during a specified period, from his or her 1990 Standardized
plan to a 2010 Standardized plan, the offer and subsequent exchange shall
comply with the following requirements:
i. A
carrier need not provide justification to the Commissioner if the insured
replaces a 1990 Standardized policy or certificate with an issue age rated 2010
Standardized policy or certificate at the insured's original issue age and
duration. If an insured's policy or certificate to be replaced is priced on an
issue age rate schedule at the time of such offer, the rate charged to the
insured for the new exchanged policy shall recognize the policy reserve
buildup, due to the pre-funding inherent in the use of an issue age rate basis,
for the benefit of the insured. The method proposed to be used by a carrier
must be filed with the Commissioner.
ii. The rating class of the new policy or
certificate shall be the class closest to the insured's class of the replaced
coverage.
iii. A carrier may not
apply new pre-existing condition limitations or a new incontestability period
to the new policy for those benefits contained in the exchanged 1990
Standardized policy or certificate of the insured, but may apply pre-existing
condition limitations of no more than six months to any added benefits
contained in the new 2010 Standardized policy or certificate that are not
contained in the exchanged policy.
iv. The new policy or certificate shall be
offered to all policyholders or certificateholders within a given plan, except
where the offer or issue would be in violation of state or Federal
law.
(e) Carriers may offer to all applicants
policies or certificates providing the core benefits and additional benefits
defined at (g) below. Only those additional benefits defined at (g) below may
be included in Medicare supplement policies or certificates delivered or issued
for delivery in this State. Policies or certificates providing additional
benefits shall be structured and designated as follows:
1. Standardized Medicare supplement benefit
plan B shall provide:
i. The Core Benefit;
and
ii. The Medicare Part A
Deductible benefit.
2.
Standardized Medicare supplement benefit plan C shall provide:
i. The Core Benefit;
ii. The Medicare Part A Deductible
benefit;
iii. The Skilled Nursing
Facility Care benefit;
iv. The
Medicare Part B Deductible benefit; and
v. The Medically Necessary Emergency Care in
a Foreign Country benefit.
3. Standardized Medicare supplement benefit
plan D shall provide:
i. The Core
Benefit;
ii. The Medicare Part A
Deductible benefit;
iii. The
Skilled Nursing Facility Care benefit;
iv. The Medically Necessary Emergency Care in
a Foreign Country benefit; and
v.
The At-Home Recovery Benefit.
4. Standardized Medicare supplement benefit
Plan E shall provide:
i. The Core
Benefit;
ii. The Medicare Part A
Deductible benefit;
iii. The
Skilled Nursing Facility Care benefit;
iv. The Medically Necessary Emergency Care in
a Foreign Country benefit; and
v.
The Preventive Medical Care benefit.
5. Standardized Medicare supplement benefit
Plan F shall provide:
i. The Core
Benefit;
ii. The Medicare Part A
Deductible benefit;
iii. The
Skilled Nursing Facility Care benefit;
iv. The Medicare Part B Deductible
benefit;
v. The One-Hundred Percent
(100%) of the Medicare Part B Excess Charges Benefit; and
vi. The Medically Necessary Emergency Care in
a Foreign Country benefit.
6. Standardized Medicare supplement benefit
high deductible plan F shall include 100 percent of covered expenses following
the payment of the annual high deductible plan "F" deductible, and shall
provide: the Core Benefit; the Medicare Part A Deductible benefit; the Skilled
Nursing Facility Care benefit; the Medicare Part B Deductible benefit; the One
Hundred Percent (100%) of the Medicare Part B Excess Charges benefit; and the
Medically Necessary Emergency Care in a Foreign Country benefit. The annual
high deductible plan F deductible shall consist of out-of-pocket expenses,
other than premiums, for services covered by the Medicare supplement plan F
policy, and shall be in addition to any other specific benefit deductibles. The
annual high deductible Plan F deductible shall be $ 1,500 for 1998 and 1999,
and shall be based on the calendar year. It shall be adjusted annually
thereafter 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 $ 10.00.
7.
Standardized Medicare supplement benefit plan G shall provide:
i. The Core Benefit;
ii. The Medicare Part A Deductible
benefit;
iii. The Skilled Nursing
Facility Care benefit;
iv. The
Eighty Percent (80%) of the Medicare Part B Excess Charges benefit;
v. The Medically Necessary Emergency Care in
a Foreign Country benefit; and
vi.
The At-Home Recovery Benefit.
8. Standardized Medicare supplement benefit
plan H shall provide:
i. The Core
Benefit;
ii. The Medicare Part A
Deductible benefit;
iii. The
Skilled Nursing Facility Care benefit;
iv. The Basic Outpatient Prescription Drug
Benefit. The Basic Outpatient Prescription Drug Benefit shall not be included
in a Medicare supplement plan sold after December 31, 2005; and
v. The Medically Necessary Emergency Care in
a Foreign Country benefit.
9. Standardized Medicare supplement benefit
plan I shall provide:
i. The Core
Benefit;
ii. The Medicare Part A
Deductible benefit;
iii. The
Skilled Nursing Facility Care benefit;
iv. The One-Hundred Percent (100%) of the
Medicare Part B Excess Charges Benefit;
v. The Basic Outpatient Prescription Drug
Benefit. The Basic Outpatient Prescription Drug Benefit shall not be included
in a Medicare supplement plan sold after December 31, 2005;
vi. The Medically Necessary Emergency Care in
a Foreign Country benefit; and
vii.
The At-Home Recovery Benefit.
10. Standardized Medicare supplement benefit
plan J shall provide:
i. The Core
Benefit;
ii. The Medicare Part A
Deductible benefit;
iii. The
Skilled Nursing Facility Care benefit;
iv. The Medicare Part B Deductible
benefit;
v. The One-Hundred Percent
(100%) of the Medicare Part B Excess Charges Benefit;
vi. The Extended Outpatient Prescription Drug
Benefit. The Extended Outpatient Prescription Drug Benefit shall not be
included in a Medicare supplement plan sold after December 31, 2005;
vii. The Medically Necessary Emergency Care
in a Foreign Country benefit;
viii.
The Preventive Medical Care benefit; and
ix. The At-Home Recovery Benefit.
11. Standardized Medicare
supplement benefit high deductible plan J shall provide 100 percent of covered
expenses following the payment of the annual high deductible plan J deductible,
and shall provide: the Core Benefit; the Medicare Part A Deductible benefit;
the Skilled Nursing Facility Care benefit; the Medicare Part B Deductible
benefit; the One Hundred Percent (100 percent) of the Medicare Part B Excess
Charges Benefit; the Extended Outpatient Prescription Drug Benefit; the
Medically Necessary Emergency Care in a Foreign Country benefit; the Preventive
Medical Care Benefit; and the At-Home Recovery Benefit. The Extended Outpatient
Prescription Drug Benefit shall not be included in a Medicare supplement plan
sold after December 31, 2005. The annual high deductible plan J deductible
shall consist of out-of-pocket expenses, other than premiums, for services
covered by the Medicare supplement plan J policy, and shall be in addition to
any other specific benefit deductibles. The annual deductible shall be $ 1,500
for 1998 and 1999, and shall be based on a calendar year. It shall be adjusted
annually thereafter 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 $ 10.00.
12. Standardized Medicare supplement benefit
plan K shall provide:
i. Coverage of 100
percent of the Part A hospital coinsurance amount for each day used from the
61st through the 90th day in any Medicare benefit period;
ii. Coverage of 100 percent of the Part A
hospital coinsurance for each Medicare lifetime inpatient reserve day used from
the 91st through the 150th day in any Medicare benefit period;
iii. 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 carrier's payment as payment
in full and may not bill the insured for the balance;
iv. Coverage of 50 percent of the Medicare
Part A Deductible until the out-of-pocket limitation is met as described in
(e)12x below;
v. Coverage for 50
percent of the coinsurance amount for each day 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 (e)12x below;
vi. Coverage for 50 percent of cost sharing
for all Part A Medicare eligible expenses for hospice and respite care until
the out-of-pocket limitation is met as described in (e)12x below;
vii. Coverage for 50 percent, under Medicare
A or B, of the reasonable cost of the first three 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 (e)12x below;
viii. Except for coverage provided in (e)12ix
below, 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 (e)12x below;
ix. Coverage of 100 percent of the cost
sharing for Medicare Part B preventive services after the policyholder pays the
Part B deductible;
x. 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 $ 4,000 in 2006, indexed
each year by the appropriate inflation adjustment specified by the Secretary of
the U.S. Department of Health and Human Services.
13. Standardized Medicare supplement benefit
plan L shall provide:
i. Coverage of 100
percent of the Part A hospital coinsurance amount for each day used from the
61st through the 90th day in any Medicare benefit period;
ii. Coverage of 100 percent of the Part A
hospital coinsurance for each Medicare lifetime inpatient reserve day used from
the 91st through the 150th day in any Medicare benefit period;
iii. 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 carrier's payment as payment
in full and may not bill the insured for the balance;
iv. Coverage of 75 percent of the Medicare
Part A Deductible until the out-of-pocket limitation is met as described in
(e)13x below;
v. Coverage for 75
percent of the coinsurance amount for each day 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 (e)13x below;
vi. Coverage for 75 percent of cost sharing
for all Part A Medicare eligible expenses for hospice and respite care until
the out-of-pocket limitation is met as described in (e)13x below;
vii. Coverage for 75 percent, under Medicare
Part A or B, of the reasonable cost of the first three 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 (e)13x below;
viii. Except for coverage provided in (e)13ix
below, coverage for 75 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 (e)13x below;
ix. Coverage of 100 percent of the cost
sharing for Medicare Part B preventive services after the policyholder pays the
Part B deductible;
x. 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 $ 2,000 in 2006, indexed
each year by the appropriate inflation adjustment specified by the Secretary of
the U.S. Department of Health and Human Services.
(f) No groupings, packages or
combinations of Medicare supplement benefits shall be offered which differ from
the standardized Medicare supplement benefit plans specified in (d) and (e)
above, except as an Innovative Benefit which may be approved by the
Commissioner. Benefit plans shall be uniform in structure, language,
designation and format to the standardized Medicare supplement benefit plans A,
B, C, D, E, F, G, H, I, J, K and L as set forth in (d) and (e) above. For
purposes of this section, "structure," "language," and "format" means style,
arrangement and overall content of a benefit.
(g) The following terms and phrases, as used
in this section, shall have the following meanings:
1. "At-Home Recovery Benefit" means coverage
for services to provide short term, at-home assistance with activities of daily
living for persons recovering from an illness, injury or surgery. At-home
recovery services shall be services which are designed primarily to assist with
activities of daily living.
i. The insured's
attending physician shall certify that the specific type and frequency of
at-home recovery services prescribed are necessary due to a condition for which
a home care plan of treatment was approved by Medicare.
ii. Coverage shall be limited to:
(1) The number and type of at-home recovery
visits certified as necessary by the insured's attending physician, received
during the period the insured is receiving Medicare-approved home care services
or no more than eight weeks after the service date of the last Medicare
approved home health care visit, the total number of which shall not exceed the
number of Medicare-approved home health care visits under a Medicare-approved
home care plan of treatment;
(2)
Care furnished on a visiting basis in the insured's home by a care provider as
defined at (g)1v below for up to seven visits in any one week; and
(3) Actual charges up to $ 40.00 per visit to
a maximum per calendar year benefit of $ 1,600.
iii. Coverage shall be excluded for home care
visits reimbursed by Medicare or other government programs and for care
provided by family members, unpaid volunteers, or providers who do not
otherwise meet the definition of a care provider, to the extent Medicare would
exclude coverage for care provided by such individuals.
iv. Activities of daily living shall include,
but not be limited to, bathing, dressing, personal hygiene, transferring,
eating, ambulating, assistance with drugs that are normally self-administered,
and changing of bandages or other dressings.
v. A care provider shall be a duly qualified
or licensed home health aide/homemaker, personal care aide or nurse provided
through a licensed home health care agency or referred by a licensed referral
agency or a licensed nurses registry.
vi. Any place used by the insured as a place
of residence shall be the insured's home, provided that such place would
qualify as a residence for home health care services under Medicare. A hospital
or skilled nursing facility shall not be considered the insureds' place of
residence.
vii. An at-home recovery
visit shall be that period of a visit required to provide at-home recovery
care. The duration of any such visit shall not be limited, but each consecutive
four hours in a 24 hour period of services provided by a care provider shall
constitute one visit for purposes of this section.
2. "Basic Outpatient Prescription Drug
Benefit" means coverage for 50 percent of outpatient prescription drug charges
to the extent not covered by Medicare, subject to a $ 250.00 calendar year
deductible and a maximum per calendar year benefit per insured of $ 1,250. The
basic outpatient prescription drug benefit may be included for sale or issuance
in a Medicare supplement policy until January 1, 2006.
3. "Core Benefit" means coverage of:
i. Medicare Part A eligible expenses for
hospitalization from the 61st day through the 90th day in any Medicare benefit
period, to the extent not covered by Medicare;
ii. Medicare Part A eligible expenses for
hospitalization for each Medicare lifetime inpatient reserve day used, to the
extent not covered by Medicare;
iii. One hundred percent of Medicare Part A
eligible expenses for hospitalization upon exhaustion of Medicare hospital
inpatient coverage, including lifetime reserve days, up to a maximum lifetime
benefit of 365 days, to be paid at the applicable prospective payment system
(PPS) rate, or other appropriate Medicare standard of payment. The provider
shall accept the carrier's payment as payment in full and may not bill the
insured for any balance;
iv. The
reasonable cost of the first three pints of blood (or equivalent quantities of
packed red blood cells, as defined by Federal regulations) under Medicare Parts
A and B, unless replaced in accordance with Federal regulation; and
v. The coinsurance amount or, in the case of
hospital outpatient department services paid under a prospective payment
system, the copayment amount of Medicare Part B eligible expenses (generally 20
percent of the approved amount; 50 percent of the approved charges for
outpatient psychiatric services), regardless of hospital confinement, subject
to the Medicare Part B deductible.
4. "Eighty Percent (80%) of the Medicare Part
B Excess Charges" means coverage for 80 percent of the difference between the
Medicare-approved Part B charge and the actual Medicare Part B charge billed,
up to but not exceeding any charge limitation established by the Medicare
program or this State's law, if any.
5. "Extended Outpatient Prescription Drug
Benefit" means coverage for 50 percent of outpatient prescription drug charges
to the extent not covered by Medicare, subject to a $ 250.00 deductible per
calendar year, and a maximum per calendar year per insured benefit of $ 3,000.
The extended outpatient prescription drug benefit may be included for sale or
issuance in a Medicare supplement policy until January 1, 2006.
6. "Innovative Benefits" means benefits that
are in addition to the benefits specified for standardized Medicare supplement
benefit plans A, B, C, D, E, F, G, H, I and J, that are appropriate to Medicare
supplement insurance and do not duplicate any benefit provided by Medicare, and
that are otherwise unavailable, cost effective, and offered in a manner
consistent with simplification of Medicare supplement policies. No carrier
shall include an Innovative Benefit in a policy or certificate offered for
delivery in this State without the prior approval of the
Commissioner.
7. "Medically
Necessary Emergency Care in a Foreign Country" means coverage of 80 percent of
the billed charges for Medicare-eligible expenses for medically necessary
emergency hospital, physician and medical care received in a foreign country,
which care would have been covered by Medicare if received in the United
States, and which care began during the first 60 consecutive days of each trip
outside the United States, to the extent billed charges are not covered by
Medicare, and subject to a calendar year deductible of $ 250.00 and a lifetime
maximum benefit of $ 50,000. For purposes of this benefit, "emergency care"
shall mean care needed immediately because of an injury or an illness of sudden
and unexpected onset.
8. "Medicare
Part A Deductible" means coverage of all of the Medicare Part A inpatient
hospital deductible amount per benefit period.
9. "Medicare Part B Deductible" means
coverage of all of the Medicare Part B deductible amount per calendar year
regardless of hospital confinement.
10. "One Hundred Percent (100%) of the
Medicare Part B Excess Charges" means coverage for all of the difference
between the Medicare Part B approved charge and the actual Medicare Part B
billed charge, up to but not exceeding any charge limitation established by the
Medicare program or this State's law, if any.
11. "Preventive Medical Care Benefit" means
coverage of the following services not otherwise covered by Medicare in the
calendar year for the actual charges up to 100 percent of the Medicare-approved
amount for each service (as if Medicare were to cover the service as identified
in the American Medical Association Current Procedural Terminology Codes),
subject to a maximum benefit of $ 120.00 per calendar year:
i. An annual clinical preventive medical
history and physical examination that shall include patient education to
address preventive health care measures and preventive screening tests and/or
preventive services, the selection and frequency of which is determined to be
medically appropriate by the attending physician.
12. "Skilled Nursing Facility Care" means
coverage for the actual billed charges up to the Medicare coinsurance amount
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.