West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-24 - Medicare Supplement Insurance
Section 114-24-7A - Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date for Coverage on or After June 1, 2010
Universal Citation: 114 WV Code of State Rules 114-24-7A
Current through Register Vol. XLI, No. 38, September 20, 2024
7A.1. 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. 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 issued with an effective date of coverage before June 1, 2010 remain subject to the requirements of sections 6 and 7 of this rule.
7A.2.
7A.2.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 subsection 6A.3 of this rule.
7A.2.b.
If an issuer makes available any of the additional benefits described in subsection
6A.4, or offers standardized benefit Plans K or L (as described in subdivisions h
and i, subsection 7A.6 of this section), 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 subdivision a
of this subsection, a policy form or certificate form containing either standardized
benefit Plan C (as described in subdivision c, subsection 7A.6 of this section) or
standardized benefit Plan F (as described in subdivision e, subsection 7A.6 of this
section).
7A.3. No groups, packages or combinations of Medicare supplement benefits other than those listed in this section shall be offered for sale in this state, except as may be permitted in subsections 7A.7 of this section and section 8 of this rule.
7A.4. Benefit plans 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 2 of this rule. Each benefit shall be structured in accordance with the format provided in subsections 6A.3 and 6A.4 of this rule; or in the case of plans K or L in subdivisions h and i, subsection 7A.6 of this section and list the benefits in the order shown. For purposes of this section, "structure, language and format" means style, arrangement and overall content of a benefit.
7A.5. In addition to the benefit plan designations required in subsection 7A.4 of this section, an issuer may use other designations to the extent permitted by law.
7A.6. Make-up of 2010 Standardized Benefit Plans:
7A.6.a. Standardized Medicare
supplement benefit Plan A shall include only the following: The basic core benefits
as defined in subsection 6A.3 of this rule.
7A.6.b. Standardized Medicare supplement benefit
Plan B shall include only the following: The basic core benefits as defined in
subsection 6A.3 of this rule, plus one hundred percent (100%) of the Medicare Part A
deductible as defined in subdivision a, subsection 6A.4 of this rule.
7A.6.c. Standardized Medicare supplement benefit
Plan C shall include only the following: The basic core benefit as defined in
subsection 6A.3 of this rule, plus one hundred percent (100%) of the Medicare Part A
deductible, skilled nursing facility care, one hundred percent (100%) of the
Medicare Part B deductible and medically necessary emergency care in a foreign
country as defined in subdivisions a, c, d and f of subsection 6A.4, respectively,
of this rule.
7A.6.d. Standardized
Medicare supplement benefit Plan D shall include only the following: The basic core
benefit as defined in subsection 6A.3 of this rule, plus one hundred percent (100%)
of the Medicare Part A deductible, skilled nursing facility care and medically
necessary emergency care in a foreign country as defined in subdivisions a, c and f
of subsection 6A.4, respectively, of this rule.
7A.6.e. Standardized Medicare supplement Plan F
shall include shall include only the following: The basic core benefit as defined in
subsection 6A.3 of this rule, plus one hundred percent (100%) of the Medicare Part A
deductible, the skilled nursing facility care, one hundred percent (100%) of the
Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess
charges and medically necessary emergency care in a foreign country as defined in
subdivisions a, c, d, e and f of subsection 6A.4, respectively, of this
rule.
7A.6.f. Standardized Medicare
supplement Plan F With High Deductible shall include only the following: one hundred
percent (100%) of covered expenses following the payment of the annual deductible
set forth in paragraph 2 of this subdivision.
7A.6.f.1. The basic core benefit as defined in
subsection 6A.3 of this rule, plus one hundred percent (100%) of the Medicare Part A
deductible, skilled nursing facility care, one hundred percent (100%) of the
Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess
charges and medically necessary emergency care in a foreign country as defined in
subdivisions a, c, d, e and f of subsection 6A.4, respectively, of this
rule.
7A.6.f.2. 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 (as described in subdivision e of this
subsection), and shall be in addition to any other specific benefit deductibles. The
basis for the deductible shall be one thousand five hundred dollars ($1,500) 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 twelve-month period ending with August of the preceding
year, and rounded to the nearest multiple of ten dollars ($10).
7A.6.g. Standardized Medicare supplement benefit
Plan G shall include only the following: The basic core benefit as defined in
subsection 6A.3 of this rule, plus one hundred percent (100%) of the Medicare Part A
deductible, skilled nursing facility care, one hundred percent (100%) of the
Medicare Part B excess charges and medically necessary emergency care in a foreign
country as defined in subdivisions a, c, e and f of subsection 6A.4, respectively.
Effective January 1, 2020, the standardized benefit plans described in subdivision
d, subsection 7B.2 of this rule (Redesignated Plan G With High Deductible) may be
offered to any individual who was eligible for Medicare prior to January 1,
2020.
7A.6.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:
7A.6.h.1. Part A Hospital Coinsurance 61st through
90th days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance
amount for each day used from the 61st day through the 90th day in any Medicare
benefit period;
7A.6.h.2. Part A
Hospital Coinsurance 91st day through 150th days: Coverage of one hundred percent
(100%) of the Part A hospital coinsurance amount for each Medicare lifetime
inpatient reserve day used from the 91st day through the 150th day in any Medicare
benefit period;
7A.6.h.3. Part A
Hospitalization After Lifetime Reserve Days are Exhausted: Upon exhaustion of the
Medicare hospital inpatient coverage, including the lifetime reserve days, coverage
of one hundred percent (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;
7A.6.h.4. Medicare Part A Deductible: Coverage for
fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per
benefit period until the out-of-pocket limitation is met as described in paragraph
10 of this subdivision;
7A.6.h.5.
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
10 of this subdivision;
7A.6.h.6.
Hospice Care: Coverage for fifty percent (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 paragraph 10 of this subdivision;
7A.6.h.7. Blood: Coverage for fifty percent (50%),
under Medicare Part A or B, of the reasonable cost of the first three (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 paragraph 10 of this
subdivision;
7A.6.h.8. Part B Cost
Sharing: Except for coverage provided in paragraph 9 of this subdivision, coverage
for fifty percent (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 paragraph 10 of this subdivision;
7A.6.h.9. Part B Preventive Services: Coverage of
one hundred percent (100%) of the cost sharing for Medicare Part B preventive
services after the policyholder pays the Part B deductible; and
7A.6.h.10. Cost Sharing After Out-of-Pocket
Limits: Coverage of one hundred percent (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
four thousand dollars ($4,000) in 2006, indexed each year by the appropriate
inflation adjustment specified by the Secretary of the U.S. Department of Health and
Human Services.
7A.6.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:
7A.6.i.1. The benefits described in
paragraphs 1, 2, 3 and 9, subdivision h of this subsection;
7A.6.i.2. The benefits described in paragraphs 4,
5, 6, 7 and 8, subdivision h of this subsection, but substitution seventy-five
percent (75%) for fifty percent (50%); and
7A.6.i.3. The benefit described in paragraph 10,
subdivision h of this subsection, but substituting two thousand dollars ($2,000) for
four thousand dollars ($4,000).
7A.6.j. Standardized Medicare supplement Plan M
shall include only the following: The basic core benefit as defined in subsection
6A.3 of this rule, plus fifty percent (50%) of the Medicare Part A deductible,
skilled nursing facility care and medically necessary emergency care in a foreign
country as defined in subdivision b, c and f of subsection 6A.4,
respectively:
7A.6.k. Standardized
Medicare supplement Plan N shall include only the following: The basic core benefit
as defined in subsection 6A.3 of this rule, plus one hundred percent (100%) of the
Medicare Part A deductible, skilled nursing facility care and medically necessary
emergency care in a foreign country as defined in subdivision a, c and f of
subsection 6A.4, respectively, of this rule, with co-payments in the following
amounts:
7A.6.k.1. The lesser of twenty dollars
($20) or the Medicare Part B coinsurance or co-payment for each covered health care
provider office visit (including visits to medical specialists); and
7A.6.k.2. The lesser of fifty dollars ($50) or the
Medicare Part B coinsurance or co-payment for each covered emergency room visit,
however, this co-payment shall be waived if the insured is admitted to any hospital
and the emergency visit is subsequently covered as a Medicare Part A
expense.
7A.7. 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 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.
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