Current through Register Vol. 35, No. 18, September 24, 2024
The following standards are applicable to all Medicare
Supplement policies or certificates delivered or issued for delivery in this
state 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 before June 1, 2010 remain subject to the requirements
of
13.10.25.12
NMAC.
A.
Benefit
requirements:
(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
Subsection D of
13.10.25.13
NMAC of this regulation.
(2) If an
issuer makes available any of the additional benefits described in Subsection E
of
13.10.25.13
NMAC, or offers standardized benefit Plans K or L (as described in Paragraphs
(8) and (9) of Subsection E of this section), then the issuer shall make
available to each prospective policyholder and certificate holder, in addition
to a policy form or certificate form with only the basic (core) benefits as
described in Paragraph (1) of this subsection, a policy form or certificate
form containing either standardized benefit Plan C (as described in Paragraph
(3) of Subsection of E of this section) or standardized benefit Plan F (as
described in Paragraph (5) of Subsection E of this
section).
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 Subsection F of this section and
13.10.25.16
NMAC.
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
13.10.25.7
NMAC. Each benefit shall be structured in accordance with the format provided
in Subsections D and E of
13.10.25.13
NMAC; or, in the case of Plans K or L, in Paragraphs (8) and (9) of Subsection
E of this section 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.
D. In
addition to the benefit plan designations required in Subsection C of this
section, an issuer may use other designations to the extent permitted by
law.
E.
Make-up of 2010
standardized benefit plans:
(1)
Plan A. Standardized Medicare Supplement Benefit Plan A shall
include only the following: The basic (core) benefits as defined in Subsection
D of
13.10.25.13
NMAC.
(2)
Plan B.
Standardized Medicare Supplement Benefit Plan B shall include only the
following: The basic (core) benefit as defined in Subsection d of
13.10.25.13
NMAC, plus one-hundred percent of the Medicare Part A deductible as defined in
Paragraph (1) of Subsection E of
13.10.25.13
NMAC.
(3)
Plan C.
Standardized Medicare Supplement Benefit Plan C shall include only the
following: The basic (core) benefit as defined in Subsection D of
13.10.25.13
NMAC, plus one-hundred percent of the Medicare Part A deductible, skilled
nursing facility care, one-hundred percent of the Medicare Part B deductible,
and medically necessary emergency care in a foreign country as defined in
Paragraphs (1), (3), (4), and (6) respectively of Subsection E of
13.10.25.13
NMAC.
(4)
Plan D.
Standardized Medicare Supplement Benefit Plan D shall include only the
following: The basic (core) benefit as defined in Subsection D of
13.10.25.13
NMAC, plus one-hundred percent of the Medicare Part A deductible, skilled
nursing facility care, and medically necessary emergency care in an foreign
country as defined in Paragraphs (1), (3) and (6) respectively of Subsection E
of
13.10.25.13
NMAC.
(5)
Plan F.
Standardized Medicare Supplement Benefit Plan F shall include only the
following: The basic (core) benefit as defined in Subsection D of
13.10.25.13
NMAC, plus one-hundred percent of the Medicare Part A deductible, the skilled
nursing facility care, one-hundred percent of the Medicare Part B deductible,
one-hundred percent of the Medicare Part B excess charges, and medically
necessary emergency care in a foreign country as defined in Paragraphs (1),
(3), (4), (5) and (6) respectively of Subsection E of
13.10.25.13
NMAC.
(6)
High Deductible
Plan F. Standardized Medicare Supplement Benefit Plan F with High
Deductible shall include only the following: one-hundred percent of covered
expenses following the payment of the annual deductible set forth in
Subparagraph (b) of this paragraph.
(a) The
basic (core) benefit as defined in Subsection D of
13.10.25.13
NMAC, plus one-hundred percent of the Medicare Part A deductible, skilled
nursing facility care, one-hundred percent of the Medicare Part B deductible,
one-hundred percent of the Medicare Part B excess charges, and medically
necessary emergency care in a foreign country as defined in Paragraphs (1),
(3), (4), (5) and (6) respectively of Subsection E of
13.10.25.13
NMAC.
(b) The annual deductible in
Plan F with High Deductible shall consist of out-of-pocket expenses, other than
premiums, for services covered by 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)
Plan
G. Standardized Medicare Supplement Benefit Plan G shall include only
the following: The basic (core) benefit as defined in Subsection D of
13.10.25.13
NMAC, plus one-hundred percent of the Medicare Part A deductible, skilled
nursing facility care, one-hundred percent of the Medicare Part B excess
charges, and medically necessary emergency care in a foreign country as defined
in Paragraphs (1), (3), (5) and (6) respectively of Subsection E of
13.10.25.13
NMAC. Effective January 1, 2020, the standardized benefit plans described in
Paragraph (4) of Subsection A of
13.10.25.15
NMAC (Redesignated Plan G With High Deductible) may be offered to any
individual who was eligible for Medicare prior to January 1, 2020.
(8)
Plan K. Standardized
Medicare Supplement Benefit Plan K shall consist of only those benefits
described in Paragraph (1) of Subsection F of
13.10.25.13
NMAC.
(9)
Plan L.
Standardized Medicare Supplement Benefit Plan L shall consist of only those
benefits described in Paragraph (2) of Subsection F of
13.10.25.13
NMAC.
(10)
Plan M.
Standardized Medicare Supplement Benefit Plan M shall include only the
following: The basic (core) benefit as defined in Subsection B of
13.10.25.13
NMAC, plus fifty percent of the Medicare Part A deductible, skilled nursing
facility care, and medically necessary emergency care in a foreign country as
defined in Paragraphs (2), (3) and (6) of Subsection C of
13.10.25.13
NMAC, respectively.
(11)
Plan
N. Standardized Medicare Supplement Benefit Plan N shall include only
the following: The basic (core) benefit as defined in Subsection B of
13.10.25.13
NMAC, plus one-hundred percent of the Medicare Part A deductible, skilled
nursing facility care, and medically necessary emergency care in a foreign
country as defined in Paragraphs (1), (3) and (6) Subsection C of
13.10.25.13
NMAC, respectively, with co-payments in the following amounts:
(a) the lesser of $20 or the Medicare Part B
coinsurance or co-payment for each covered health care provider office visit
(including visits to medical specialists); and
(b) the lesser of $50 or the Medicare Part B
coinsurance or co-payment for each covered emergency room visit, however, this
co-payment 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. Approval of 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.
