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 plan standards. Benefit plan standards applicable to
Medicare supplement policies and certificates with an effective date of
coverage before June 1, 2010 remain subject to the requirements of Sections 8a
and 9 of this rule.
A.
(1) An issuer shall make available to each
prospective policyholder and certificateholder a policy form or certificate
form containing only the basic core benefits, as defined in Subsection 8a.B. of
this rule.
(2) If an issuer makes
available any of the additional benefits described in Subsection 8a.C., or
offers standardized benefit Plan K or L, as described in Subsections 9a.E.(8)
and (9) of this rule, then the issuer shall make available to each prospective
policyholder and certificateholder, in addition to a policy form or certificate
form with only the basic core benefits as described in Subsection (1), a policy
form or certificate form containing either standardized benefit Plan C, as
described in Subsection 9a.E.(3) of this rule, or standardized benefit Plan F,
as described in Subsection 9a.E.(5) of this rule.
B. No groups, packages or combinations of
Medicare supplement benefits other than those listed in this Subsection shall
be offered for sale in this state, except as may be permitted in Subsection
9a.F. and in Section 10 of this rule.
C. Benefit plan shall be uniform in
structure, language, designation and format to the standard benefit plans
listed in this subsection and conform to the definitions in Section 4 of this
rule. Each benefit shall be structured in accordance with the format provide in
Subsections 8a.B. and C. of this rule; or, in the case of plans K or L, in
Subsections 9a.E.(8) or (9) of this rule 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.
E.
Make-up of 2010 Standardized Benefit Plans:
(1) Standardized Medicare supplement benefit
Plan A shall include only the following: The basic core benefits as defined in
Subsection 8a.B. of this rule.
(2)
Standardized Medicare supplement benefit Plan B shall include only the
following: the basic core benefit as defined in Subsection 8a.B. of this rule,
plus 100% of the Medicare Part A deductible as defined in Subsection 8a.C.(1)
of this rule.
(3) Standardized
Medicare supplement benefit Plan C shall include only the following: The basic
core benefit as defined in Subsection 8a.B. of this rule, plus 100% of the
Medicare Part A deductible, skilled nursing facility care, 100% of the Medicare
Part B deductible, and medically necessary emergency care in a foreign country
as defined in Subsections 8a.C.(1), (3), (4), and (6) of this rule,
respectively.
(4) Standardized
Medicare supplement benefit Plan D shall include only the following: The basic
core benefit as defined in Subsection 8a.B. of this rule, plus 100% of the
Medicare Part A deductible, skilled nursing facility care, and medically
necessary emergency care in a foreign country as defined in Subsections 8a.C.
(1), (3), and (6) of this rule, respectively.
(5) Standardized Medicare supplement benefit
Plan F shall include only the following: The basic core benefit as defined in
Subsection 8a.B. of this rule, plus 100% of the Medicare Part A deductible,
skilled nursing facility care, 100% of the Medicare Part B deductible, 100% of
the Medicare Part B excess charges, and medically necessary emergency care in a
foreign country as defined in Subsections 8a.C.(1), (3), (4), (5), and (6) of
this rule, respectively.
(6)
Standardized Medicare supplement benefit Plan F With High Deductible shall
include only the following: 100% of covered expenses following the payment of
the annual deductible set forth in Subsection (b).
(a) The basic core benefit as defined in
Subsection 8a.B. of this rule, 100% of the Medicare Part A deductible, skilled
nursing facility care, 100% of the Medicare Part B deductible, 100% of the
Medicare Part B excess charges, and medically necessary emergency care in a
foreign country as defined in Subsections 8a.C.(1), (3), (4), (5), and (6) of
this rule, respectively.
(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 $1500 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 12-month
period ending with August of the preceding year, and rounded to the nearest
multiple of ten dollars.
(7) Standardized Medicare supplement benefit
Plan G shall include only the following: The basic core benefit as defined in
Subsection 8a.B. of this rule, plus 100% of the Medicare Part A deductible,
skilled nursing facility care, 100% of the Medicare Part B excess charges, and
medically necessary emergency care in a foreign country as defined in
Subsections 8a.C.(1), (3), (5), and (6) of this rule, respectively. Effective
January 1, 2020, the standardized benefit plans described in Section 9b.A.(4)
of this rule, Redesignated Plan G High Deductible, may be offered to any
individual who was eligible for Medicare prior to January 1, 2020.
(8) Standardized Medicare supplement benefit
Plan K is mandated by The Medicare Prescription Drug, Improvement and
Modernization Act of 2003, and shall include only the following:
(a) Part A Hospital Coinsurance
61st through 90th days:
Coverage of 100% of the Part A hospital coinsurance amount for each day used
from the 61st through the
90th day in any Medicare benefit period:
(b) Part A Hospital Coinsurance,
91st through 150th days:
Coverage of 100% 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) Part A Hospitalization
After 150 Days: Upon exhaustion of the Medicare hospital inpatient coverage,
including the lifetime reserve days, coverage of 100% 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% of the Medicare Part A inpatient
hospital deductible amount per benefit period until the out-of-pocket
limitation is met as described in Subsection (j):
(e) Skilled Nursing Facility Care: Coverage
for 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 Subsection
(j):
(f) Hospice Care: Coverage for
50% of cost sharing for all Part A Medicare eligible expenses and respite care
until the out-of-pocket limitation is met as described in
Subsection(j):
(g) Blood: Coverage
for 50%, under Medicare Part A or B, of the reasonable cost of the first 3
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
Subsection (j):
(h) Part B Cost
Sharing: Except for coverage provided in Subsection (i), coverage of 50% 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 Subsection (j):
(i)
Part B Preventive Services: Coverage of 100% of the cost sharing for Medicare
Part B preventive services after the policyholder pays the Part B deductible;
and
(j) Cost Sharing After
Out-of-Pocket Limits: Coverage of 100% 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.
(9)
Standardized Medicare supplement benefit 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 Subsections (8)(a), (b), (c) and (i);
(b) The benefit described in Subsections
(8)(d), (e), (f), (g) and (h), but substituting 75% for 50%; and
(c) The benefit described in Subsection
(8)(j), but substituting $2000 for $4000.
(10) Standardized Medicare supplement benefit
Plan M shall include only the following:
The basic core benefit as defined in Subsection 8a.B. of this
rule, plus 50% of the Medicare Part A deductible, skilled nursing facility
care, and medically necessary emergency care in a foreign county as defined in
Subsections 8a.C.(2), (3) and (6) of this rule, respectively.
(11) Standardized Medicare supplement benefit
Plan N shall include only the following: The basic core benefit as defined in
Subsection 8a.B. of this rule, plus 100% of the Medicare Part A deductible,
skilled nursing facility care, and medically necessary emergency care in a
foreign country as defined in Subsections 8a.C. (1), (3) and (6) of this rule,
respectively, 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.
F. New or Innovative
Benefits. 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 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 shall 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.
