Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES
Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES
Section 3.3308 - Required Disclosure Provisions
Universal Citation: 28 TX Admin Code § 3.3308
Current through Reg. 50, No. 13; March 28, 2025
(a) General rules.
(1) Medicare supplement
policies and certificates must include a renewal or continuation provision. The
language or specifications of the renewal or continuation provision must be
consistent with the type of contract issued. The provision must be
appropriately captioned, appear on the first page of the policy, and include
any reservation by the issuer of the right to change premiums and any automatic
renewal premium increases based on the age of the policyholder.
(2) Except for riders or endorsements by
which the issuer effectuates a request made in writing by the policyholder, or
by which the issuer exercises a specifically reserved right under a Medicare
supplement policy, or by which the issuer is required to reduce or eliminate
benefits to avoid duplication of Medicare benefits, all riders or endorsements
added to a Medicare supplement policy after the date of issue or at
reinstatement or renewal that reduce or eliminate benefits or coverage in the
policy must require signed acceptance by the policyholder. After the date of
issue of the policy or certificate, any rider or endorsement that increases
benefits or coverage with concomitant increase in premium during the policy
term must be agreed to in writing and signed by the policyholder unless the
benefits are required by the minimum standards for Medicare supplement
insurance policies, or unless the increased benefits or coverage is required by
law. Where a separate additional premium is charged for benefits provided in
connection with riders or endorsements, the additional premium charge must be
set forth in the policy.
(3)
Medicare supplement policies may not provide for the payment of benefits based
on standards described as "usual and customary," "reasonable and customary," or
similar words and phrases.
(4) If a
Medicare supplement policy or certificate contains any limitations with respect
to preexisting conditions:
(A) the limitations
must appear as a separate paragraph of the policy or certificate and be labeled
as "Preexisting Condition Limitations;"
(B) the policy or certificate must define the
term "preexisting condition" and must provide an explanation of the term in its
accompanying outline of coverage; and
(C) the policy or certificate must include a
provision explaining the reduction of the preexisting condition limitation for
individuals who qualify under §
3.3306(b)(1)(A)
of this title (relating to Minimum Benefit Standards), §
3.3312(a)(2) of
this title (relating to Guaranteed Issue for Eligible Persons), or §
3.3324(c) and (d)
of this title (relating to Open Enrollment).
(5) Medicare supplement policies and
certificates must have a notice prominently printed on the first page or
attached to the first page stating in substance that the policyholder or
certificate holder has the right to return the policy or certificate within 30
days of its delivery and to have the premium refunded if, after examination,
the insured person is not satisfied for any reason.
(6) Issuers of accident and sickness
policies, certificates, or subscriber contracts that provide hospital or
medical-expense coverage on an expense-incurred or indemnity basis, to persons
eligible for Medicare must provide to those applicants a Guide to Health
Insurance for People with Medicare (Guide) in the form developed jointly by the
National Association of Insurance Commissioners and the Centers for Medicare
and Medicaid Services of the United States Department of Health and Human
Services in no smaller than 12-point type.
(A) For purposes of this section, "form"
means the language, format, style, type size, type proportional spacing, bold
character, and line spacing.
(B) If
a Guide incorporating the latest statutory changes is not available from a
government agency, companies may comply with this provision by modifying the
latest available Guide to the extent required by applicable law.
(C) Except as provided in this section,
delivery of the Guide must be made whether or not any policies, certificates,
subscriber contracts, or evidences of coverage are advertised, solicited, or
issued as Medicare supplement policies or certificates as defined in this
regulation.
(D) Except in the case
of direct response issuers, delivery of the Guide must be made to the applicant
at the time of application, and acknowledgment of receipt of the Guide must be
obtained from the applicant by the issuer. Issuers must deliver the Guide to
the applicant for a direct response Medicare supplement policy on request, but
not later than at the time the policy is delivered.
(7) Except as otherwise provided in this
section, the terms "Medicare Supplement," "Medigap," "Medicare Wrap-Around,"
and similar words or phrases may not be used unless the policy is issued in
compliance with §
3.3306 of this
title.
(b) Outline of coverage requirements for Medicare supplement policies.
(1) Issuers of Medicare supplement coverage
in this state must provide an outline of coverage to all applicants, including
certificate holders under group policies, at the time application is presented
to the prospective applicant and, except for direct-response policies, must
obtain an acknowledgment of receipt of the outline from the
applicant.
(2) If a Medicare
supplement policy or certificate is issued on a basis that would require
revision of the outline of coverage delivered at the time of application, a
substitute outline of coverage properly describing the policy or certificate
actually issued must accompany the policy or certificate when it is delivered.
The outline of coverage must contain the following statement in no less than
12-point type, immediately above the company name: "Notice: Read this outline
of coverage carefully. It is not identical to the outline of coverage provided
upon application and the coverage originally applied for has not been
issued."
(c) Form for outline of coverage. In providing outlines of coverage to applicants under the requirements of subsection (b)(1) of this section, insurers must use a form that complies with the requirements of this subsection. The outline of coverage must contain each of the following four parts in the following order: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage must be in the language and format prescribed in paragraphs (1) and (2) of this subsection in no less than 12-point type.
(1) All plans
must be shown on the cover page, and the plans that are offered by the issuer
must be prominently identified. Premium information for plans that are offered
must be shown on the cover page or immediately following the cover page and
must be prominently displayed. The premium and mode must be stated for all
plans that are offered to the prospective applicant. All possible premiums for
the prospective applicant must be illustrated.
(2) The items in subparagraphs (A) - (C) of
this paragraph must be included in the outline of coverage in addition to the
items specified in the plan-specific outline-of-coverage forms.
(A) Dollar amounts that are shown in
parentheses for each of the plan-specific charts on the following pages are for
the calendar year in which the charts were published. Issuers must, for each
plan offered, appropriately complete outline-of-coverage-chart statements about
amounts to be paid by Medicare, the plan, and the covered person by replacing
the amount in parentheses with the dollar amount corresponding to each covered
service for the applicable calendar year benefit period.
(B) The outline of coverage must include an
explanation of any limitations and exclusions. Those limitations and exclusions
resulting from Medicare program provisions may be disclosed by reference and
need not be explained in their entirety. All limitations and exclusions related
to preexisting conditions and all other limitations and exclusions not
resulting from Medicare regulations must be fully explained in the outline of
coverage.
(C) The outline of
coverage must include a statement that the policy either does or does not
contain provisions providing for a refund or partial refund of premium on the
death of an insured or on the surrender of the policy or certificate. If the
policy contains these provisions, a description of the provisions must be
included.
(D) The outline of
coverage for Medicare Select policies or certificates must include information
regarding grievance procedures that meet the requirements of §
3.3325(m) of
this title (relating to Medicare Select Policies, Certificates, and Plans of
Operation).
(E) The Commissioner
adopts the Outline of Coverage form, LHL 050 Rev. 06/18. This form contains a
chart of benefits for each of the standard Medicare supplement plans and
required disclosures applicable to policies sold with an effective date for
coverage of June 1, 2010, or later. Issuers must begin using form LHL 050 Rev.
06/18 no later than July 1, 2019.
(d) Notice requirements.
(1) As soon as practicable, but no later than
30 days before the annual effective date of any Medicare benefit changes, every
issuer providing Medicare supplement coverage to a resident of this state must
notify its policyholders, contract holders, and certificate holders of
modifications it has made to Medicare supplement insurance policies, contracts,
or certificates. The notice must:
(A) include
a description of revisions to the Medicare program and a description of each
modification made to the coverage provided under the Medicare supplement
insurance policy, contract, or certificate; and
(B) inform each covered person as to when any
premium adjustment is to be made due to changes in Medicare.
(2) The notice of benefit
modifications and any premium adjustments must be in outline form and in clear
and simple terms so as to facilitate comprehension.
(3) The notice may not contain or be
accompanied by any solicitation.
(4) Issuers must comply with any notice
requirements of the MMA.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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