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 for coverage 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 standards. No issuer may offer any 1990 Standardized
Medicare supplement benefit plan for sale with an effective date for coverage
on or after June 1, 2010. Benefit standards applicable to Medicare supplement
policies and certificates with an effective date for coverage before June 1,
2010 remain subject to the requirements of OAR
836-052-0133.
(1)
(a) 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 OAR
836-052-0132(2).
(b) If an issuer makes available any of the
additional benefits described in OAR
836-052-0132(3)
or offers standardized benefit Plans K or L as described subsections (5)(h) and
(i) of this rule, 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 subsection
(a) of this section, a policy form or certificate form containing either
standardized benefit Plan C as described in subsection (5)(c) of this rule or
standardized benefit Plan F as described in subsection (5)(e) of
this.
(2) No groups,
packages or combinations of Medicare supplement benefits other than those
listed in this rule shall be offered for sale in this state, except as may be
permitted in subsection (6) of this rule and OAR
836-052-0139.
(3) Benefit plans shall be uniform in
structure, language, designation and format to the standard benefit plans
listed in this rule and conform to the definitions in OAR
836-052-0119. Each benefit plan
must be structured in accordance with the format provided in
836-052-0132(2) and
(3); or, in the case of plans K or L, in
subsections (5)(h) and (i) of this rule and list the benefits in the order
shown. For purposes of this rule, "structure, language, and format" means
style, arrangement and overall content of a benefit.
(4) In addition to the benefit plan
designations required in section (3) of this rule, an issuer may use other
designations to the extent permitted by law.
(5) The content of the 2010 Standardized
Medicare supplement benefit plans must be as follows:
(a) Standardized Medicare supplement benefit
Plan A shall include only the basic core benefits as defined in OAR
836-052-0132
(2).
(b) Standardized Medicare supplement benefit
Plan B shall include only the following: The basic core benefit as defined in
OAR 836-052-0132(2);
plus 100 percent of the Medicare Part A deductible as defined in
836-052-0132(3)(a).
(c) Standardized Medicare supplement benefit
Plan C shall include only the following: The basic (core) benefit as defined
OAR 836-052-0132(2);
plus 100 percent of the Medicare Part A deductible, skilled nursing facility
care, 100 percent of the Medicare Part B deductible, and Medically necessary
emergency care in a foreign country, each as defined in OAR
836-052-0132(3)(a), (c), (d) and
(f).
(d) Standardized Medicare supplement benefit
Plan D shall include only the following: The basic core benefit as defined in
OAR 836-052-0142(2),
plus 100 percent of the Medicare Part A deductible skilled nursing facility
care, and medically necessary emergency care in an foreign country each as
defined in 836-052-0132(3)(a)(c) and
(f).
(e) Standardized Medicare supplement regular
Plan F shall include only the following: The basic core benefit as defined in
OAR 836-052-0132(2),
plus 100 percent of the Medicare Part A deductible, the skilled nursing
facility care, 100 percent of the Medicare Part B deductible, 100 percent of
the Medicare Part B excess charges, and medically necessary emergency care in a
foreign country each as defined in 836-052-132(3)(a), (c), (d), (e) and
(f).
(f) Standardized Medicare
supplement Plan F with high deductible shall include only the following: 100
percent of covered expenses following the payment of the annual deductible set
forth in paragraph (B) of this subsection.
(A) The basic core benefit as defined in OAR
836-052-0132(2),
plus 100 percent of the Medicare Part A deductible, skilled nursing facility
care, 100 percent of the Medicare Part B deductible, 100 percent of the
Medicare Part B excess charges, and medically necessary emergency care in a
foreign country each as defined in
836-052-0132(3)(a), (c), (d), (e) and
(f).
(B) The annual deductible in Plan F with high
deductible shall consist of out-of-pocket expenses, other than premiums, for
services covered by the standardized Medicare supplement regular 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
according to the method prescribed 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.
(g) Standardized Medicare supplement benefit
Plan G shall include only the following: The basic core benefit as defined in
OAR 836-052-0132(2)
of this regulation, plus 100 percent of the Medicare Part A deductible, skilled
nursing facility care, 100 percent of the Medicare Part B excess charges, and
medically necessary emergency care in a foreign country each as defined in
836-052-0132(3)(a), (c), (e) and
(f). Effective January 1, 2020, the
standardized benefit plans described in OAR
836-052-0144(1)(d)
(Redesignated Plan G High Deductible) may be offered to any individual who was
eligible for Medicare prior to January 1, 2020.
(h) Standardized Medicare supplement Plan K
is mandated by The Medicare Prescription Drug, Improvement and Modernization
Act of 2003, and shall include only the following:
(A) 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;
(B) Coverage of 100 percent of the Part A
hospital coinsurance amount for each Medicare lifetime inpatient reserve day
used from the 91st through the 150th day in any Medicare benefit
period;
(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 shall accept the
issuer's payment as payment in full and may not bill the insured for any
balance;
(D) Medicare Part A
Deductible: Coverage for 50 percent of the Medicare Part A inpatient hospital
deductible amount per benefit period until the out-of-pocket limitation is met
as described in paragraph (J) of this subsection;
(E) Skilled Nursing Facility Care: Coverage
for fifty percent (50%) of the coinsurance amount for each day used 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 paragraph (J) of this
subsection;
(F) Hospice Care:
Coverage for 50 percent of cost sharing for all Part A Medicare eligible
expenses and respite care until the out-of-pocket limitation is met as
described in paragraph (J) of this subsection;
(G) Blood: Coverage for 50 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 paragraph (J) of this
subsection;
(H) Except for coverage
provided in paragraph (I) of this subsection, 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 paragraph (J) of this subsection;
(I) Coverage of 100 percent of the cost
sharing for Medicare Part B preventive services after the policyholder pays the
Part B deductible; and
(J) 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 $4000 in
2006, indexed each year by the appropriate inflation adjustment specified by
the Secretary of the U.S. Department of Health and Human Services.
(i) Standardized Medicare
supplement Plan L is mandated by The Medicare Prescription Drug, Improvement
and Modernization Act of 2003, and shall include only the following:
(A) The benefits described in section
(5)(h)(A)(B)(C) and (I) of this rule;
(B) The benefit described in section (5)
(h)(D)(E)(F)(G) and (H) of this rule, but substituting 75 percent for 50
percent; and
(C) The benefit
described in section (5)(h)(J) of this rule, but substituting $2000 for
$4000.
(j) Standardized
Medicare supplement Plan M shall include only the following: The basic core
benefit as defined in OAR
836-052-0132(2),
plus 50 percent of the Medicare Part A deductible, skilled nursing facility
care, and medically necessary emergency care in a foreign country each as
defined in 836-052-0132(3)(b), (c) and
(f).
(k) Standardized Medicare supplement Plan N
shall include only the following: The basic core benefit as defined in OAR
836-052-0132(2),
plus 100 percent of the Medicare Part A deductible, skilled nursing facility
care, and medically necessary emergency care in a foreign country each as
defined in 836-052-0132(3)(a), (c) and
(f), with copayments in the following
amounts:
(A) The lesser of $20 or the Medicare
Part B coinsurance or copayment 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 copayment for each covered emergency room visit; however, this
copayment shall be waived if the insured is admitted to any hospital and the
emergency visit is subsequently covered as a Medicare Part A
expense.
(6)
With the prior approval of the Director of the Department of Consumer and
Business Services, an issuer may 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.
