(c) Standard Medicare
supplement benefit plans for 2010 Standardized Medicare supplement benefit plan
policies or certificates issued or issued for delivery with an effective date
for coverage on or after June 1, 2010. The following standards are applicable
to all Medicare supplement policies or certificates issued or issued for
delivery in this state with an effective date for coverage on or after June 1,
2010. No insurance policy, subscriber contract, certificate, or evidence of
coverage may be advertised, solicited, or issued for delivery in this state as
a Medicare supplement policy unless the policy, contract, certificate, or
evidence of coverage complies with these benefit plan standards. Benefit plan
standards applicable to Medicare supplement policies and certificates issued or
issued for delivery with an effective date for coverage before June 1, 2010,
remain subject to the laws and rules in effect when the policy or certificate
was delivered, or issued for delivery.
(1) An
issuer of a Medicare supplement policy or certificate must comply with
subparagraphs (A) and (B) of this paragraph:
(A) An issuer must 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 (b)(2)
of this section.
(B) If an issuer
makes available any of the additional benefits described in subsection (b)(3)
of this section, or offers standardized benefit Plans K or L (as described in
paragraph (5)(I) and (J) of this subsection), then the issuer must make
available to each prospective policyholder and certificate holder who first
became eligible for Medicare before January 1, 2020, in addition to a policy
form or certificate form with only the basic (core) benefits as described in
subparagraph (A) of this paragraph, a policy form or certificate form
containing either:
(i) standardized benefit
Plan C (as described in paragraph (5)(C) of this subsection); or
(ii) standardized benefit Plan F (as
described in paragraph (5)(E) of this subsection).
(2) No groups, packages, or
combinations of Medicare supplement benefits other than those listed in this
subsection may be offered for sale in this state, except as may be permitted in
paragraph (6) of this subsection and in §
3.3325 of this title (relating to
Medicare Select Policies, Certificates, and Plans of Operation).
(3) Benefit plans must be uniform in
structure, language, and format, as well as designation, to the standard
benefit plans listed in this paragraph and conform to the definitions in §
3.3303 of this title (relating to
Definitions). Each benefit plan must be structured in accordance with the
format provided in subsection (b)(2) and (b)(3) of this section or, in the case
of Plans K or L, in accordance with the format provided in paragraph (5)(I) or
(J) of this subsection, and list the benefits in the order shown. For purposes
of this subsection, "structure, language, and format" means style, arrangement,
and overall content of a benefit.
(4) In addition to the benefit plan
designations required in paragraph (3) of this subsection, an issuer may use
other designations to the extent permitted by law.
(5) The make-up of 2010 Standardized Benefit
Plans is as specified in subparagraphs (A) - (L) of this paragraph.
(A) Standardized Medicare supplement benefit
Plan A must include only the following: The basic (core) benefits as defined in
subsection (b)(2) of this section.
(B) Standardized Medicare supplement benefit
Plan B must include only the following: The basic (core) benefits as defined in
subsection (b)(2) of this section, plus 100 percent of the Medicare Part A
deductible as defined in subsection (b)(3)(A)(i) of this section.
(C) Standardized Medicare supplement benefit
Plan C must include only the following: The basic (core) benefits as defined in
subsection (b)(2) of this section, 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 as
defined in subsection (b)(3)(A)(i), (B), (C), and (E) of this section,
respectively.
(D) Standardized
Medicare supplement benefit Plan D must include only: The basic (core) benefits
(as defined in subsection (b)(2) of this section), plus 100 percent of the
Medicare Part A deductible, skilled nursing facility care, and medically
necessary emergency care in a foreign country as defined in subsection
(b)(3)(A)(i), (B), and (E) of this section, respectively.
(E) Standardized Medicare supplement
(regular) Plan F must include only the following: The basic (core) benefits as
defined in subsection (b)(2) of this section, 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 as defined in
subsection (b)(3)(A)(i), (B), (C), (D), and (E) of this section,
respectively.
(F) Standardized
Medicare supplement Plan F with High Deductible must include 100 percent of
covered expenses following the payment of the annual deductible set forth in
clause (ii) of this subparagraph.
(i) The
basic (core) benefits as defined in subsection (b)(2) of this section, 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 as
defined in subsection (b)(3)(A)(i), (B), (C), (D), and (E) of this section,
respectively.
(ii) The annual
deductible in Plan F with High Deductible must consist of out-of-pocket
expenses, other than premiums, for services covered by regular Plan F, and must
be in addition to any other specific benefit deductibles. The basis for the
deductible is $2,240 for 2018, and will be adjusted annually by the Secretary
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.
(G) Standardized Medicare supplement benefit
Plan G must include only the following: The basic (core) benefits as defined in
subsection (b)(2) of this section, 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 as
defined in subsection (b)(3)(A)(i), (B), (D), and (E), respectively. Effective
January 1, 2020, Plan G with a High Deductible, as described in subsection
(c)(5)(H), may be offered to any individual who is eligible for Medicare before
January 1, 2020.
(H) Standardized
Medicare supplement Plan G with High Deductible must include 100 percent of the
covered expenses following the payment of the annual deductible set forth in
clause (ii) of this subparagraph, but will not provide coverage for any portion
of the Medicare Part B deductible. The Medicare Part B deductible paid by the
beneficiary will be considered an out-of-pocket expense in meeting the annual
high cost deductible.
(i) The basic (core)
benefits as defined in subsection (b)(2) of this section, 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 as defined in subsection (b)(3)(A)(i), (B), (D), and (E),
respectively.
(ii) The annual
deductible in Plan G with High Deductible must consist of out-of-pocket
expenses, other than premiums, for services covered by regular Plan G, and must
be in addition to any other specific benefit deductibles. The basis for the
deductible is $2,240 for 2018, and will be adjusted annually by the Secretary
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.
(I) Standardized Medicare supplement Plan K
must include only the following:
(i) Part A
hospital coinsurance, 61st through 90th days: 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) Part A hospital coinsurance, 91st
through 150th days: 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;
(iii) Part A hospitalization after 150 days:
On 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 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;
(iv) 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 clause
(x) of this subparagraph;
(v)
Skilled nursing facility care: Coverage for 50 percent of the coinsurance
amount for each day used from the 21st day through the 100th day in a Medicare
benefit period for posthospital skilled nursing facility care eligible under
Medicare Part A until the out-of-pocket limitation is met as described in
clause (x) of this subparagraph;
(vi) 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 clause (x) of this
subparagraph;
(vii) 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 clause
(x) of this subparagraph;
(viii)
Part B cost sharing: Except for coverage provided in clause (ix) of this
subparagraph, 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 clause (x) of this
subparagraph;
(ix) Part B
preventive services: Coverage of 100 percent of the cost sharing for Medicare
Part B preventive services after the policyholder pays the Part B deductible;
and
(x) Cost sharing after
out-of-pocket limits: 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 $5,240 in 2018, indexed each year by the
appropriate inflation adjustment specified by the Secretary.
(J) Standardized Medicare
supplement Plan L must include only the following:
(i) the benefits described in subparagraph
(I)(i), (ii), (iii), and (ix) of this paragraph;
(ii) the benefit described in subparagraph
(I)(iv), (v), (vi), (vii), and (viii) of this paragraph, but substituting 75
percent for 50 percent; and
(iii)
the benefit described in subparagraph (I)(x) of this subsection, but
substituting $2,620 for $5,240.
(K) Standardized Medicare supplement Plan M
must include only the following: The basic (core) benefit as defined in
subsection (b)(2) of this section, plus 50 percent of the Medicare Part A
deductible, skilled nursing facility care, and medically necessary emergency
care in a foreign country as defined in subsection (b)(3)(A)(ii), (B), and (E)
of this section, respectively.
(L)
Standardized Medicare supplement Plan N must include only the following: The
basic (core) benefit as defined in subsection (b)(2) of this section, plus 100
percent of the Medicare Part A deductible, skilled nursing facility care, and
medically necessary emergency care in a foreign country as defined in
subsection (b)(3)(A)(i), (B), and (E) of this section, respectively, with
copayments in the following amounts:
(i) 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
(ii) the lesser of $50 or the
Medicare Part B coinsurance or copayment for each covered emergency room visit;
however, this copayment must be waived if the insured is admitted to any
hospital and the emergency visit is subsequently covered as a Medicare Part A
expense.
(6) An
issuer may, with the prior approval of the Commissioner, 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 may 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 may not include an outpatient
prescription drug benefit. New or innovative benefits may not be used to change
or reduce benefits, including a change of any cost-sharing provision, in any
standardized plan.