Oregon Administrative Rules
Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION
Division 52 - INSURANCE POLICIES
Section 836-052-0132 - Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date of Coverage on or After June 1, 2010
Universal Citation: OR Admin Rules 836-052-0132
Current through Register Vol. 63, No. 9, September 1, 2024
The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state with an effective date of coverage on or after June 1, 2010. A policy or certificate may not be advertised, solicited, delivered, or issued for delivery in this state as a Medicare supplement policy or certificate unless it complies with or exceeds the benefit standards set forth in this rule. No issuer may offer a 1990 Standardized Medicare supplement benefit plan for sale on or after June 1, 2010. Benefit standards applicable to Medicare supplement policies and certificates issued with an effective date of coverage before June 1, 2010 remain subject to the requirements of OAR 836-052-0133, 836-052-0134 and 836-052-0136.
(1) The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of OAR 836-052-0103 to 836-052-0194:
(a) Regarding preexisting conditions, a
Medicare supplement policy or certificate shall not:
(A) Exclude or limit benefits for loss
incurred more than six months after the effective date of coverage because the
loss involved a preexisting condition; or
(B) 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 six months before the
effective date of coverage.
(b) A Medicare supplement policy or
certificate shall not cover losses resulting from sickness on a different basis
than losses resulting from accidents.
(c) 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 modified to correspond with such changes.
(d) A Medicare supplement policy or
certificate shall not 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.
(e) Each Medicare supplement policy shall be
guaranteed renewable. In addition:
(A) The
insurer shall not cancel or nonrenew the policy solely on the ground of health
status of the individual.
(B) The
insurer shall not cancel or nonrenew the policy for any reason other than
nonpayment of premium or material misrepresentation.
(C) If the Medicare supplement policy is
terminated by the group policyholder and is not replaced as provided under
paragraph (E) of this subsection, the issuer shall offer certificate holders an
individual Medicare supplement policy that, at the option of the certificate
holder:
(i) Provides for continuation of the
benefits contained in the group policy; or
(ii) Provides for benefits that otherwise
meet the requirements of this subsection.
(D) If an individual is a certificate holder
in a group Medicare supplement policy and the individual terminates membership
in the group, the issuer shall:
(i) Offer the
certificate holder the conversion opportunity described in paragraph (e)(C) of
this subsection; or
(ii) At the
option of the group policyholder, offer the certificate holder continuation of
coverage under the group policy.
(E) 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 policy shall not result in any exclusion for preexisting
conditions that would have been covered under the group policy being replaced.
(f) 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 conditioned upon the continuous total disability of the insured, 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 a continuous loss.
(g)
(A) 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
certificate holder for the period, not to exceed 24 months, in which the
policyholder or certificate holder has applied for and is determined to be
entitled to medical assistance under Title XIX of the Social Security Act, but
only if the policyholder or certificate holder notifies the issuer of the
policy or certificate within 90 days after the date the individual becomes
entitled to the assistance.
(B) If
suspension occurs and if the insured loses entitlement to medical assistance,
the policy or certificate shall be automatically reinstituted, effective as of
the date of termination of entitlement, as of the termination of entitlement if
the insured provides notice of loss of entitlement within 90 days after the
date of loss and pays the premium attributable to the period, effective as of
the date of termination of entitlement.
(C) 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 and is covered under a group health plan as defined
in Section 1862 (b)(1)(A)(v) of the Social Security Act. If suspension occurs
and if the policyholder or certificate holder 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.
(D) Reinstitution of coverages as described
in paragraphs (B) and (C):
(i) Shall not
provide for any waiting period with respect to treatment of preexisting
conditions;
(ii) Shall provide for
resumption of coverage that is substantially equivalent to coverage in effect
before the date of the suspension; and
(iii) Shall provide for classification of
premiums on terms at least as favorable to the insured as the premium
classification terms that would have applied to the insured had the coverage
not been suspended.
(2) This section establishes standards for basic or core benefits common to Medicare Supplement Insurance Benefit Plans A, B, C, D, F, F with High Deductible, G, M and N. Each issuer of Medicare supplement insurance benefit plans shall make available each prospective insured a policy or certificate including only the basic core package of benefits established in this section. An issuer may make available to prospective insureds any of the other Medicare supplement insurance benefit plans in addition to the basic core package, but not in lieu of it. The basic core package includes the following:
(a)
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;
(b) Coverage of
Part A Medicare eligible expenses incurred for hospitalization to the extent
not covered by Medicare for each Medicare lifetime inpatient reserve day
used;
(c) 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 must accept the
issuer's payment as payment in full and may not bill the insured for any
balance. Billing the insured for any such balance is an unfair practice in the
transaction of insurance that is injurious to the insurance-buying public, and
is a violation of ORS
746.240.
(d) Coverage under Medicare Parts A and B for
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;
(e) 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 Part
B regardless of hospital confinement, subject to the Medicare Part B
deductible;
(f) Coverage of cost
sharing for all Part A Medicare eligible hospice care and respite care
expenses.
(3) This section establishes standards for additional benefits. The following additional benefits shall be included in Medicare supplement benefit Plans B, C, D, F, F with High Deductible, G, M, and N as provided by OAR 836-052-0141.
(a) Medicare Part A deductible benefit,
providing coverage for 100 percent of the Medicare Part A inpatient hospital
deductible amount per benefit period.
(b) Medicare Part A deductible benefit,
providing coverage for 50 percent of the Medicare Part A inpatient hospital
deductible amount per benefit period.
(c) Skilled Nursing Facility Care benefit,
providing coverage for the actual billed charges up to the 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.
(d) Medicare Part B Deductible
benefit, providing coverage for 100 percent of the Medicare Part B deductible
amount per calendar year regardless of hospital confinement.
(e) 100 percent of the Medicare Part B Excess
Charges benefit, providing coverage for 100 percent of the difference between
the actual Medicare Part B charges as billed, not to exceed any charge
limitation established by the Medicare program or state law, and the
Medicare-approved Part B charge.
(f) Medically Necessary Emergency Care in a
Foreign Country, providing coverage to the extent not covered by Medicare for
80 percent of the billed charges for Medicare-eligible expenses for medically
necessary emergency hospital, physician and medical care received in a foreign
country, when the care would have been covered by Medicare if provided in the
United States and when the care began during the first 60 consecutive days of
each trip outside the United States, subject to a calendar year deductible of
$250, and a lifetime maximum benefit of $50,000. For purposes of this benefit,
"emergency care" means care needed immediately because of an injury or an
illness of sudden and unexpected onset.
Stat. Auth.: ORS 743.683
Stats. Implemented: ORS 743.010 & 743.683
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