Wisconsin Administrative Code, Chapter Ins 3, Section Ins 3.39 - Standards for disability insurance sold to the Medicare eligible | Wisconsin Administrative Code

(1) PURPOSE.

(a) This section establishes requirements for health and other disability insurance policies primarily sold to Medicare eligible persons. Disclosure provisions are required for other disability policies sold to Medicare eligible person because such policies frequently are represented to, and purchased by, the Medicare eligible as supplements to Medicare products.

(b) This section seeks to reduce abuses and confusion associated with the sale of disability insurance to Medicare eligible persons by providing reasonable standards. The disclosure requirements and established benefit standards are intended to provide to Medicare eligible persons guidelines that they can use to compare disability insurance policies and certificates as described in s. Ins 6.75(1) (c), and to aid them in the purchase of policies and certificates intended to supplement Medicare policies that are suitable for their needs. This section is designed not only to improve the ability of the Medicare eligible consumer to make an informed choice when purchasing disability insurance, but also to assure the Medicare eligible persons of this state that the commissioner will not approve a policy or certificate as "Medicare supplement" or as "Medicare cost" unless it meets the requirements of this section.

(d) Wisconsin statutes interpreted and implemented by this rule are ss. 185.983(1m), 600.03, 601.01(2), 601.42, 609.01(1g) (b), 625.16, 628.34(12), 628.38, 631.20(2), 632.73(2m), 632.76(2) (b), 632.81, 632.895(2), (3), (4) and (6), Stats.

(2) SCOPE. This section applies to individual and group disability policies sold, delivered or issued for delivery in Wisconsin to Medicare eligible persons as follows:

(a) Except as provided in pars. (d) and (e), this section applies to any group or individual Medicare supplement policy or certificate, or Medicare select policy or certificate as described in s. 600.03(28r), Stats., or any Medicare cost policy as described in s. 600.03(28p) (a) and (c), Stats., including all of the following:

1. Any Medicare supplement policy, Medicare select policy, or Medicare cost policy issued by a voluntary sickness care plan subject to ch. 185, Stats.

2. Any certificate issued under a group Medicare supplement policy or group Medicare select policy.

3. Any individual or group policy sold in Wisconsin predominantly to individuals or groups of individuals who are 65 years of age or older that offers hospital, medical, surgical, or other disability coverage, except for a policy that offers solely nursing home, hospital confinement indemnity, or specified disease coverage.

5. Any individual or group policy or certificate sold in Wisconsin to persons under 65 years of age and eligible for Medicare by reason of disability that offers hospital, medical, surgical or other disability coverage, except for a policy or certificate that offers solely nursing home, hospital confinement indemnity or specified disease coverage.

(b) Except as provided in pars. (d) and (e), subs. (9) and (11) apply to any individual disability policy sold to a person eligible for Medicare that is not a Medicare supplement, Medicare select, or a Medicare cost policy as described in par. (a).

(c) Except as provided in par. (e), sub. (10) applies to any individual or group hospital or medical policy that continues with changed benefits after the insured becomes eligible for Medicare.

(d) Except as provided in subs. (10) and (13), this section does not apply to any of the following:

1. A group policy issued to one or more employers or labor organizations, to the trustees of a fund established by one or more employers or labor organizations, or a combination of both, for employees or former employees or both, or for members or former members or both of the labor organizations;

3. Individual or group hospital, surgical, medical, major medical, or comprehensive medical expense coverage which continues after an insured becomes eligible for Medicare; or

(e) This section does not apply to either of the following:

1. A policy providing solely accident, dental, vision, disability income, or credit disability income coverage.

2. A single premium, non-renewable policy.

(f) This section may be enforced under ss. 601.41, 601.64, 601.65, Stats., or ch. 645, Stats., or any other enforcement provision of chs. 600 to 646, Stats., or Wisconsin Administrative Code Insurance chapters.

(3) DEFINITIONS. In this section and for use in policies or certificates:

(a) "Accident," " Accidental Injury," or "Accidental Means" shall be defined to employ "result" language and shall not include words that establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization.

1. The definition shall not be more restrictive than the following: "Injury or injuries for which benefits are provided" means accidental bodily injury sustained by the insured person that is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while insurance coverage is in force."

2. The definition may provide that injuries shall not include injuries for which benefits are provided or available under any workers' compensation, employer's liability or similar law or motor vehicle no-fault plan, unless prohibited by law.

(b) "Advertisement" has the meaning set forth in s. Ins 3.27(5) (a).

(c) "Applicant" means either of the following:

1. In the case of an individual Medicare supplement, Medicare select, or Medicare cost policy, the person who seeks to contract for insurance benefits.

2. In the case of a group Medicare supplement policy, the proposed certificateholder.

(ce) "Balance bill" means seeking: to bill, charge, or collect a deposit, remuneration or compensation from; to file or threaten to file with a credit reporting agency; or to have any recourse against an insured or any person acting on the insured's behalf for health care costs for which the insured is not liable. The prohibition on recovery does not affect the liability of an insured for any deductibles, coinsurance or copayments, or for premiums owed under the policy or certificate.

(cs) "Bankruptcy" means when a Medicare Advantage organization that is not an issuer has filed, or has had filed against it, a petition for declaration of bankruptcy and has ceased doing business in the state.

(d) "Benefit period," or "Medicare benefit period" shall not be defined more restrictively than as defined in the Medicare program.

(e) "CMS" means the Centers for Medicare & Medicaid Services within the U.S. department of health and human services.

(f) "Certificate" means a certificate delivered or issued for delivery in this state under a Medicare supplement policy or under a Medicare select policy that is issued on a group basis, i.e. employer retiree group.

(g) "Certificate form" means the form on which the certificate is delivered or issued for delivery by the issuer to a group that receives insurance coverage through a group Medicare supplement policy, or a group Medicare select policy.

(gg) "Certificateholder" means an individual member of a group that is receives a certificate that identifies the individual as a participant in the group Medicare supplement policy or the group Medicare select policy issued in this state.

(gr) "Complaint" means any dissatisfaction expressed by an individual concerning a Medicare select issuer or its network providers.

(h) "Continuous period of creditable coverage" means the period during which an individual was covered by creditable coverage, if during the period of the coverage the individual had no breaks in coverage greater than 63 days.

(i)

1. "Creditable coverage" means with respect to an individual, coverage of the individual provided under any of the following:

a. A group health plan;

b. Health insurance coverage;

c. Part A or Part B of Title XVIII of the social security act (Medicare);

d. Title XIX of the social security act (Medicaid), other than coverage consisting solely of benefits under section 1928;

e. Chapter 55 of Title 10 United States Code, commonly referred to as TRICARE (formerly known as CHAMPUS);

f. A medical care program of the Indian Health Service or of a tribal organization;

g. A state health benefits risk pool;

h. A health plan offered under chapter 89 of Title 5 United States Code commonly referred to as the Federal Employees Health Benefits Program;

i. A public health plan as defined in federal regulation; and

j. A health benefit plan under Section 5 (e) of the Peace Corps Act (22 United States Code 2504(e)).

2. "Creditable coverage" does not include any of the following:

a. Coverage only for accident or disability income insurance, or any combination thereof;

b. Coverage issued as a supplement to liability insurance;

c. Liability insurance, including general liability insurance and automobile liability insurance;

d. Worker's compensation or similar insurance;

e. Automobile medical payment insurance;

f. Credit-only insurance;

g. Coverage for on-site medical clinics; and

h. Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

3. "Creditable coverage" shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:

a. Limited scope dental or vision benefits;

b. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination; and

c. Such other similar, limited benefits as are specified in federal regulations.

4. "Creditable coverage" shall not include the following benefits if offered as independent, non-coordinated benefits:

a. Coverage only for a specified disease or illness; and

b. Hospital indemnity or other fixed indemnity insurance.

5. "Creditable coverage" shall not include the following if it is offered as a separate policy, certificate or contract of insurance:

a. Medicare supplemental health insurance as defined under section 1882 (g) (1) of the social security act;

b. Coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code; and

c. Similar supplemental coverage provided to coverage under a group health plan.

(j) "Employee welfare benefit plan" means a plan, fund or program of employee benefits as defined in 29 USC 1002 (Employee Retirement Income Security Act).

(jm) "Grievance" means dissatisfaction with the administration, claims practices or provision of services concerning a Medicare select issuer or its network providers that is expressed in writing by a policyholder or certificateholder under a Medicare select policy or certificate.

(k) "Health care expense" means, for purposes of sub. (16), expense of health maintenance organizations associated with the delivery of health care services that are analogous to incurred losses of insurers.

(l) "Health maintenance organization (HMO)" means an insurer as defined in s. 609.01(2), Stats.

(m) "Hospital" may be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals, but not more restrictively than as defined in the Medicare program.

(n) "Hospital confinement indemnity coverage" means coverage as defined in s. Ins 3.27(4) (b) 6.

(o) "Insolvency" is defined in s. 600.03(24), Stats., and means when an issuer, licensed to transact the business of insurance in this state, has had a final order of liquidation entered against it by a court of competent jurisdiction in the issuer's state of domicile.

(p) "Issuer" includes insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations and any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates.

(pm) "MACRA" means the Medicare Access and CHIP Reauthorization Act of 2015, PL 114-10, signed April 16, 2015.

(q) "Medicare" shall be defined in the policy or certificate. "Medicare" may be substantially defined as "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended," or "Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof, or words of similar import.

(r) "Medicare Advantage plan" means a plan of coverage for health benefits under Medicare Part C as defined in 42 USC 1395w-28(b) (1), as amended.

(rm) "Medicare cost policy" means a Medicare replacement policy that is offered by an issuer that has a contract with CMS to provide coverage when services are provided within the issuer's geographic service area and through network medical providers selected by the issuer. A "Medicare cost policy" is issued to an individual who is the policyholder.

(s) "Medicare eligible expenses" means health care expenses that are covered by Medicare Parts A and B, recognized as medically necessary and reasonable by Medicare, and that may or may not be fully reimbursed by Medicare.

(t) "Medicare eligible person" mean a person who qualifies for Medicare.

(v) "Medicare replacement policy" or "Medicare replacement insurance policy" means a policy that is described in s. 600.03(28p) (a) or (c), Stats., as interpreted by sub. (2) (a), and that provides coverage that conforms to subs. (4), (4m), (4t), and (7). "Medicare replacement policy" includes Medicare cost policies.

(ve) "Medicare select certificate" means a policy that is issued to a group that provides Medicare supplement coverage to the group's members when services are obtained through network medical providers selected by the issuer. Individuals that receive coverage through the group Medicare select policy receive a Medicare select certificate that demonstrates participation in the group coverage.

(vm) "Medicare select policy" means a policy that is issued to an individual or policyholder that provides Medicare supplement coverage when services are obtained by the policyholder through a network of medical providers selected by the issuer.

(vs) "Medicare supplement certificate" means a policy that is issued to a group that provides Medicare supplement coverage to the group's members. Individuals that receive coverage through the group Medicare supplement policy receive a Medicare supplement certificate that demonstrates participation in the group coverage.

(w) "Medicare supplement coverage" or "Medicare supplement insurance" means coverage that meets the definition in s. 600.03(28r), Stats., as interpreted by sub. (2) (a), and that conforms to subs. (4), (4m), (4t), (5), (5m), (5t), (6), (30), (30m), and (30t). "Medicare supplement coverage" is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expense of persons eligible for Medicare. "Medicare supplement coverage" includes group and individual Medicare supplement and group and individual Medicare select policies and certificates but does not include coverage under Medicare Advantage plans established under Medicare Part C or Outpatient Prescription Drug plans established under Medicare Part D.

(we) "Medicare supplement policy" means a policy that is issued to an individual or policyholder that provides Medicare supplement coverage.

(wg) "MMA" means the Medicare Prescription Drugs, Improvement and Modernization Act of 2003, Public Law 108-173, signed into law on December 8, 2003.

(wm) "Network provider," means a provider of health care, or a group of providers of health care, that have entered into a written agreement with the issuer to provide health care benefits to an insured under a Medicare select policy or Medicare select certificate.

(ws) "Newly eligible" means a person who meets one of the following criteria:

1. The person has attained age 65 on or after January 1, 2020.

2. The person is entitled to benefits under Medicare Part A pursuant to section 226 (b) or 226A of the social security act, or is deemed to be eligible for benefits under section 226 (a) of the social security act on or after January 1, 2020.

(x) "Nursing home coverage" means coverage for care that is convalescent or custodial care or care for a chronic condition or terminal illness and provided in an institutional or community-based setting.

(y) "Outline of coverage" means a printed statement as defined by s. Ins 3.27(5) (L), that meets the requirements of sub. (4) (b), (4m) (b), or (4t) (b), as applicable.

(z) "Policy form" means the form on which the policy is delivered or issued for delivery by the issuer.

(za) "PACE" means Program of All-Inclusive Care for the Elderly (PACE) under section 1894 of the social security act 42 USC 1302 and 1395.

(zag) "Policyholder" has the meaning provided at s. 600.03(37), Stat.

(zar) "Policy or certificate forms of the same type" means, for purposes of calculating loss ratios, rates, refunds or premium credits, each type of form filed with the commissioner including individual Medicare supplement policy forms, individual Medicare select policy forms, individual Medicare cost policy forms, group Medicare select certificate forms, and group Medicare supplement certificate forms.

(zb) "Replacement" means any transaction, other than when used to refer to an authorized Medicare Advantage policy, where new individual or group Medicare supplement or individual Medicare cost insurance is to be purchased, and it is known to the agent or issuer at the time of application that, as part of the transaction, existing accident and sickness insurance has been or is to be lapsed, cancelled or terminated or the benefits are substantially reduced. "Replacement" includes transactions replacing a Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy within the same insurer or affiliates of the insurer.

(zbm) "Restricted network provision," means any provision that conditions the payment of benefits, in whole or in part, on the use of network providers.

(zc) "Secretary" means the secretary of the United States department of health and human services.

(zcm) "Service area" means the geographic area approved by the commissioner within which an issuer is authorized to offer a Medicare select policy or certificate.

(zd)

1. "Sickness" shall not be defined to be more restrictive than illness or disease of an insured person that first manifests itself after the effective date of insurance and while the insurance is in force.

2. The definition of "sickness" may be further modified to exclude any illness or disease for which benefits are provided under any workers' compensation, occupational disease, employer's liability or similar law.

(ze) "Specified disease coverage" means coverage that is limited to named or defined sickness conditions. The term does not include dental or vision care coverage.

(3g) MEDICARE ELIGIBLE PERSON.

(a) Generally, an individual who attains age 65 or older, an individual under the age of 65 with certain disabilities, or an individual with end-stage renal disease is eligible to enroll in Medicare. The date a person is first eligible for Medicare Part B or first elected Medicare Part A establishes the benefits available regardless of the date of election provided the benefit is offered in the market. In addition to the provisions that apply to all Medicare supplement and Medicare cost policies, the following identify the benefits and coverage subsections that have provisions tied to the date and year when a person is first eligible for Medicare Parts A and B:

1. For persons first eligible for Medicare Part A and B before June 1, 2010, subs. (4), (5), (7) (a), and (30) describe benefits and coverage available as contained in Appendix 1, and are applicable in addition to any provision in this section that generally pertains to Medicare eligible persons.

2. For persons first eligible for Medicare Part A and B on or after June 1, 2010, and prior to January 1, 2020, subs. (4m), (5m), (7) (dm), (14m), and (30m) describe benefits and coverage available as contained in Appendices 2m, 3m, 4m, 5m and 6m and are applicable in addition to any provision in this section that generally pertains to Medicare eligible persons.

3. For persons first eligible for Medicare Part A and B on or after January 1, 2020, MACRA designated Medicare eligible persons as "newly eligible" to distinguish them from a person eligible prior to January 1, 2020. For these newly eligible persons, subs. (4t), (5t), (7) (dt), (14t), and (30t) describe benefits and coverage available as contained in Appendices 2t, 3t, 4t, 5t, and 6t and are applicable in addition to any provision in this section that generally pertains to Medicare eligible persons.

(b) Medicare supplement policies and certificates and Medicare select policies and certificates are guaranteed renewable for life. Therefore, a Medicare eligible person can, at his or her choice, elect to receive benefits and coverage under a policy that may have fewer riders available. An insurer may not require the Medicare eligible person to replace existing coverage with coverage reflecting recent changes, including changes due to MACRA. This means insurers may no longer actively market the Medicare Part B medical deductible rider to persons who are newly eligible for Medicare on or after January 1, 2020. A Medicare eligible person who is first eligible for Medicare prior to January 1, 2020, may elect the Medicare Part B medical deductible rider coverage at any time, provided an insurer is offering that coverage. If an insured was eligible for Medicare prior to January 1, 2020 and elected the Medicare Part B medical deductible rider coverage, upon renewal of the policy or certificate that person shall be eligible to continue to receive benefits provided by the Medicare Part B medical deductible rider in accordance with the terms of the Medicare supplement policy or certificate or Medicare select policy or certificate.

(3r) OPEN ENROLLMENT.

(a) An issuer may not deny nor condition the issuance or effectiveness of, or discriminate in the pricing of, basic Medicare supplement policies or certificates, Medicare cost policy, or Medicare select policies or certificates permitted, as applicable, under subs. (5), (5m), (5t), (7), (30), (30m), and (30t), or riders permitted under sub. (5) (i), (5m) (e), or (5t) (e), for which an application is submitted prior to or during the 6-month period beginning with the first month that an individual first enrolled for benefits under Medicare Part B or the month that an individual turns age 65 for any individual who was first enrolled in Medicare Part B when under the age of 65 on any of the following grounds:

1. Health status.

2. Claims experience.

3. Receipt of health care.

4. Medical condition.

(b) Except as provided in pars. (c) and (d), and sub. (34), this section shall not prevent the application of any preexisting condition limitation that is in compliance with sub. (4) (a) 2.

(c) If an applicant qualifies under par. (a) and submits an application during the time period referenced in par. (a) and, as of the date of application, has had a continuous period of creditable coverage of at least 6 months, the issuer may not exclude benefits based on a preexisting condition.

(d) If the applicant qualifies under par. (a) and submits an application during the time period referenced in par. (a) and, as of the date of application, has had a continuous period of creditable coverage that is less than 6 months, the issuer shall reduce the period of any preexisting condition exclusion by the aggregate of the period of creditable coverage applicable to the applicant as of the enrollment date. The secretary shall specify the manner of the reduction under this paragraph.

(4) MEDICARE SUPPLEMENT POLICY AND CERTIFICATE, MEDICARE SELECT POLICY AND CERTIFICATE AND MEDICARE COST POLICY REQUIREMENTS FOR POLICIES AND CERTIFICATES OFFERED TO PERSONS FIRST ELIGIBLE FOR MEDICARE PRIOR TO JUNE 1, 2010.. Except as explicitly allowed by subs. (5), (7), and (30), no disability insurance policy or certificate shall relate its coverage to Medicare or be structured, advertised, solicited, delivered or issued for delivery in this state after December 31, 1990, for policies or certificates issued to persons who were first eligible for Medicare prior to June 1, 2010, as a Medicare supplement policy or certificate, as a Medicare select policy or certificate, or as a Medicare cost policy unless the policy or certificate complies, as applicable, with all of the following:

(a) The Medicare supplement policy and certificate, Medicare select policy or certificate, or the Medicare cost policy complies, as applicable, with all the following requirements:

1. Provides only the coverage set out in sub. (5), (7), or (30) and applicable statutes and contains no exclusions or limitations other than those permitted by sub. (8). No issuer may issue a Medicare cost policy, Medicare supplement policy or certificate, or Medicare select policy or certificate without prior approval from the commissioner and compliance with subs. (5), (7) and (30), respectively.

2. Discloses on the first page any applicable preexisting conditions limitation, contains no preexisting condition waiting period longer than 6 months and does not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.

3. Contains no definitions of terms such as "Medicare eligible expenses." "accident," "sickness," "mental or nervous disorders," "skilled nursing facility," "hospital," "nurse," " physician," "benefit period," "convalescent nursing home," or "outpatient prescription drugs" that are worded less favorably to the insured person than the corresponding Medicare definition or the definitions contained in sub. (3), and defines "Medicare" as in accordance with sub. (3) (q).

4. Does not indemnify against losses resulting from sickness on a different basis from losses resulting from accident.

5. Is "guaranteed renewable" and does not provide for termination of coverage of a spouse solely because of an event specified for termination of coverage of the insured, other than the nonpayment of premium. The Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall not be cancelled or nonrenewed by the insurer on the grounds of deterioration of health. The Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy may be cancelled only for nonpayment of premium or material misrepresentation. If the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy is issued by a health maintenance organization, as defined by s. 609.01(2), Stats., the policy or certificate may, in addition to the above reasons, be cancelled or nonrenewed by the issuer if the insured moves out of the service area.

6. Provides that termination of a Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall be without prejudice to a continuous loss that commenced while the policy or certificate was in force, although the extension of benefits may be predicated upon the continuous total disability of the policyholder, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits. Receipt of Medicare Part D benefits shall not be considered in determining a continuous loss.

7. Contains statements on the first page and elsewhere in the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy that satisfy the requirements of s. Ins 3.13(2) (c), (d) or (e), and clearly states on the first page or schedule page the duration of the term of coverage for which the policy or certificate is issued and for which it may be renewed. The renewal period cannot be less than the greatest of the following: 3 months, the period the insured has paid the premium, or the period specified in the policy or certificate.

8. Changes benefits automatically to coincide with any changes in the applicable Medicare deductible amount, coinsurance, and copayment percentage factors, although there may be a corresponding modification of premiums in accordance with the policy or certificate provisions and ch. 625, Stats.

9. Prominently discloses any limitations on the choice of providers or geographical area of service.

10. Contains on the first page the designation, printed in 18-point type, and in close conjunction the caption printed in 12-point type, prescribed in sub. (5), (7), or (30).

11. Contains text that is plainly printed in black or blue ink and has a font size that is uniform and not less than 10-point with a lower-case unspaced alphabet length not less than 120-point.

12. Contains a provision describing any grievance rights as required by s. 632.83, Stats., applicable to Medicare supplement policy and certificate, Medicare select policy and certificate, and Medicare cost policies.

13. Is approved by the commissioner.

14. Contains no exclusion, limitation, or reduction of coverage for a specifically named or described condition after the policy effective date.

15. Provides for midterm cancellation at the request of the insured and that, if an insured cancels a policy midterm or the policy terminates midterm because of the insured's death, the issuer shall issue a pro rata refund to the insured or the insured's estate.

16. Except for permitted preexisting condition clauses as described in subd. 2., no Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate, Medicare select policy or certificate or Medicare cost policy if such policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.

17. No Medicare supplement policy or certificate in force in this state shall contain benefits that duplicate benefits provided by Medicare.

18. A Medicare supplement policy or certificate, Medicare select policy or certificate or Medicare cost policy shall provide that benefits and premiums under the policy or certificate shall be suspended at the request of the policyholder or certificateholder for the period not to exceed 24 months in which the policyholder or certificateholder has applied for and is determined to be entitled to medical assistance under Title XIX of the social security act, but only if the policyholder or certificateholder notifies the issuer of the policy or certificate within 90 days after the date the individual becomes entitled to the assistance.

18m. If the suspension in subd. 18. occurs and if the policyholder or certificateholder loses entitlement to medical assistance, the policy or certificate shall be automatically reinstituted (effective as of the date of termination of the entitlement) as of the termination of the entitlement if the policyholder or certificateholder provides notice of loss of the entitlement within 90 days after the date of the loss and pays the premium attributable to the period, effective as of the date of termination of the entitlement.

18p. Each Medicare supplement policy or certificate, Medicare select policy or certificate or Medicare cost policy shall provide, and contain within the policy, that benefits and premiums under the policy or certificate shall be suspended for any period that may be provided by federal regulation, at the request of the policyholder or certificateholder if the policyholder or certificateholder is entitled to benefits under section 226 (b) of the social security act and is covered under a group health plan, as defined in section 1862 (b) (1) (A) (v) of the social security act. If suspension occurs and if the policyholder or certificateholder loses coverage under the group health plan, the policy or certificate shall be automatically reinstituted, effective as of the date of loss of coverage, if the policyholder or certificateholder provides notice of loss of coverage within 90 days after the date of such loss and pays the premium attributable to the period, effective as of the date of termination of enrollment in the group health plan.

18s. No Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy may provide for any waiting period for resumption of coverage that was in effect before the date of suspension under subd. 18. with respect to treatment of preexisting conditions.

18u. Each Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall provide for resumption of coverage that was in effect before the date of suspension in subd. 18. If the suspended Medicare supplement policy or certificate, Medicare select policy or certificate or Medicare cost policy provided coverage for outpatient prescription drugs, resumption of the policy shall be without coverage for outpatient prescription drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension. If the suspended Medicare supplement policy or certificate, Medicare select policy or certificate or Medicare cost policy provided coverage of Medicare Part B medical deductible coverage or if the insured was enrolled or Medicare eligible prior to January 1, 2020, and the insurer offers a plan with Medicare Part B medical deductible coverage, then the policyholder or certificateholder may elect or renew coverage with the Medicare Part B medical deductible coverage. If the insurer no longer offers a plan with the Medicare Part B medical deductible coverage, then the insurer shall provide the policyholder or certificateholder with substantially equivalent coverage to the coverage in effect prior to the date of suspension.

18x. Each Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall provide that, upon the resumption of coverage that was in effect before the date of suspension in subd. 18., classification of premiums shall be on terms at least as favorable to the policyholder or certificateholder as the premium classification terms that would have applied to the policyholder or certificateholder had the coverage not been suspended.

19. Shall not use an underwriting standard for under age 65 that is more restrictive than that used for age 65 and above.

20.

a. A policy with benefits for outpatient prescription drugs in existence prior to January 1, 2006, shall be renewed for current policyholders who do not enroll in Medicare Part D at the option of the policyholder.

b. A policy with benefits for outpatient prescription drugs shall not be issued after December 31, 2005.

c. After December 31, 2005, a policy with benefits for outpatient prescription drugs may not be renewed after the policyholder enrolls in Medicare Part D unless the policy is modified to eliminate outpatient prescription drug coverage for expenses of outpatient prescription drugs incurred after the effective date of the individual's coverage under a Medicare Part D plan and the premiums are adjusted appropriately to reflect elimination of that coverage.

21. If a policy that provides Medicare supplement or Medicare cost coverage eliminates an outpatient prescription drug benefit as a result of requirements imposed by the MMA, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of subd. 5.

(b) The outline of coverage for the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy or certificate shall comply with all of the following:

1. Is provided to all applicants at the time application is made and, except in the case of direct response insurance, the issuer obtains written acknowledgement from the applicant that the outline was received.

2. Complies with s. Ins 3.27, including s. Ins 3.27(5) (L) and (9).

3. Is substituted to properly describe the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy or certificate as issued, if the outline provided at the time of application did not properly describe the coverage which was issued. The substituted outline shall accompany the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy or certificate when it is delivered and shall contain the following statement in no less than 12-point type and 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."

4. Contains in close conjunction on its first page the designation, printed in a distinctly contrasting color in 24-point type, and the caption, printed in a distinctly contrasting color in 18-point type prescribed in sub. (5), (7) or (30).

5. Is substantially in the format prescribed in Appendix 1 for the appropriate category and printed in no less than 12-point type.

6. Summarizes or refers to the coverage set out in applicable statutes.

7. Contains a listing of the required coverage as set out in sub. (5) (c) and the optional coverages as set out in sub. (5) (i), and the annual premiums for each selected coverage, substantially in the format of sub. (11) of Appendix 1.

8. Is approved by the commissioner along with the policy or certificate form.

(c) Any rider or endorsement added to the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy or certificate shall comply with all of the following:

1. Shall be contained in the policy or certificate and, if a separate, additional premium is charged in connection with the rider or endorsement, the premium charge shall be stated in the policy or certificate.

2. Shall be agreed to in writing signed by the insured if, after the date of the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy or certificate issue, the rider or endorsement increases benefits or coverage and there is an accompanying increase in premium during the term of the policy or certificate, unless the increase in benefits or coverage is required by law.

3. Shall only provide coverage as described in sub. (5) (i) or provide coverage to meet Wisconsin mandated provisions.

(d) The schedule of benefits page or the first page of the policy or certificate contains a listing giving the coverages and both the annual premium in the format shown in sub. (11) of Appendix 1 and modal premium selected by the applicant.

(e) The anticipated loss ratio for any new Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy form, or the expected percentage of the aggregate amount of premiums earned that will be returned to insureds in the form of aggregate benefits, not including anticipated refunds or credits, that is provided under the policy or certificate form:

1. Is computed on the basis of anticipated incurred claims or incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis and earned premiums for the entire period for which the policy form provides coverage, in accordance with accepted actuarial principles and practices; and

2. Is submitted to the commissioner along with the policy or certificate form and is accompanied by rates and an actuarial demonstration that expected claims in relationship to premiums comply with the loss ratio standards under sub. (16) (d). The policy or certificate form will not be approved by the commissioner unless the anticipated loss ratio along with the rates and actuarial demonstration show compliance with sub. (16) (d).

(g) For subsequent rate changes to the policy or certificate form, the insurer shall do all of the following:

1. File the rate changes in a format specified by the commissioner.

2. Include in the filing under subd.1. an actuarially sound demonstration that the rate change will not result in a loss ratio over the life of the policy or certificate that would violate the requirements under sub. (16) (d).

(h)

1. Medicare supplement policies written prior to January 1, 1992, shall comply with the standards then in effect, except that the appropriate loss ratios specified in sub. (16) (d) shall be used to demonstrate compliance with minimum loss ratio requirements and refund calculations for policies and certificates renewed after December 31, 1995, and with sub. (14) (c).

2. For purposes of loss ratio and refund calculations, policies and certificates renewed after December 31, 1995, shall be treated as if they were issued in 1996.

(4m) MEDICARE SUPPLEMENT POLICY AND CERTIFICATE, MEDICARE SELECT POLICY AND CERTIFICATE, AND MEDICARE COST POLICY REQUIREMENTS FOR POLICIES AND CERTIFICATES OFFERED TO PERSONS FIRST ELIGIBLE FOR MEDICARE ON OR AFTER JUNE 1, 2010, AND PRIOR TO JANUARY 1, 2020. Except as explicitly allowed by subs. (5m) and (30m), no disability insurance policy or certificate shall relate its coverage to Medicare or be structured, advertised, marketed or issued to persons first eligible for Medicare on or after June 1, 2010, and prior to January 1, 2020, as a Medicare supplement policy or certificate, as a Medicare select policy or certificate, or as a Medicare cost policy unless the policy or certificate complies with all of the following:

(a) The policy or certificate shall comply with all of the following requirements:

1. Provides only the coverage set out in sub. (5m), (7), or (30m) and applicable statutes and contains no exclusions or limitations other than those permitted by sub. (8). No issuer may issue a Medicare cost policy or Medicare select policy or certificate without prior approval from the commissioner and compliance with sub. (30m).

2. Discloses on the first page any applicable preexisting conditions limitation, contains no preexisting condition waiting period longer than 6 months and does not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.

3. Contains no definitions of terms such as "Medicare eligible expenses," "accident," "sickness," "mental or nervous disorders," skilled nursing facility," "hospital," "nurse," "physician," " benefit period," "convalescent nursing home," or "outpatient prescription drugs" that are worded less favorably to the insured person than the corresponding Medicare definition or the definitions contained in sub. (3), and defines "Medicare" as in accordance with sub. (3) (q).

4. Does not indemnify against losses resulting from sickness on a different basis from losses resulting from accident.

5. Is guaranteed renewable and does not provide for termination of coverage of a spouse solely because of an event specified for termination of coverage of the insured, other than the non-payment of premium. The policy or certificate may not be cancelled or nonrenewed by the issuer on the grounds of deterioration of health. The policy or certificate may be cancelled only for nonpayment of premium or material misrepresentation. If the policy or certificate is issued by a health maintenance organization, the policy or certificate may, in addition to the above reasons, be cancelled or nonrenewed by the issuer if the insured moves out of the service area.

6. Provides that termination of a Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall be without prejudice to a continuous loss that commenced while the policy or certificate was in force, although the extension of benefits may be predicated upon the continuous total disability of the insured, limited to the duration of the policy or certificate benefit period, if any, or payment of the maximum benefits. Receipt of the Medicare Part D benefits may not be considered in determining a continuous loss.

7. Contains statements on the first page and elsewhere in the policy or certificate that satisfy the requirements of s. Ins 3.13(2) (c), (d) and (e), and clearly states on the first page or schedule page the duration of the term of coverage for which the policy or certificate is issued and for which it may be renewed. The renewal period cannot be less than the greatest of the following: 3 months, the period for which the insured has paid the premium, or the period specified in the policy or certificate.

8. Changes benefits automatically to coincide with any changes in the applicable Medicare deductible amount, coinsurance and copayment percentage factors, although there may be a corresponding modification of premiums in accordance with the policy or certificate provisions and ch. 625, Stats.

9. Prominently discloses any limitations on the choice of providers or geographical area of service.

10. Contains on the first page the designation, printed in 18-point type, and in close conjunction the caption printed in 12-point type, prescribed in sub. (5m) or (30m).

11. Contains text that is plainly printed in black or blue ink and has a font size that is uniform and not less than 10-point type with a lower-case unspaced alphabet length not less than 120-point type.

12. Contains a provision describing any grievance rights as required by s. 632.83, Stats., applicable to Medicare supplement policies and certificates and Medicare cost policies.

13. Is approved by the commissioner.

14. Contains no exclusion, limitation, or reduction of coverage for a specifically named or described condition after the policy or certificate effective date.

15. Provides for midterm cancellation at the request of the insured and provides that, if an insured cancels a policy or certificate midterm or the policy or certificate terminates midterm because of the insured's death, the issuer shall issue a pro rata refund to the insured or the insured's estate.

16. Except for permitted preexisting condition clauses as described in subd. 2., no policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate if such policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.

17. No Medicare supplement policy or certificate in force in this state shall contain benefits that duplicate benefits provided by Medicare.

18. A Medicare supplement policy or certificate shall provide that benefits and premiums under the policy or certificate shall be suspended at the request of the policyholder or certificateholder for the period not to exceed 24 months in which the policyholder or certificateholder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act, but only if the policyholder or certificateholder notifies the issuer of the policy or certificate within 90 days after the date the individual becomes entitled to the assistance.

19. If the suspension in subd. 18. occurs and if the policyholder or certificateholder loses entitlement to medical assistance, the policy or certificate shall be automatically reinstituted, effective as of the date of termination of the entitlement, if the policyholder or certificateholder provides notice of loss of the entitlement within 90 days after the date of the loss and pays the premium attributable to the period.

20. Each Medicare supplement policy or certificate shall provide, and contain within the policy or certificate, that benefits and premiums under the policy or certificate shall be suspended for any period that may be provided by federal regulation, at the request of the policyholder or certificateholder if the policyholder or certificateholder is entitled to benefits under section 226 (b) of the Social Security Act and is covered under a group health plan, as defined in section 1862 (b) (1) (A)(v) of the Social Security Act. If suspension occurs and if the policyholder or certificateholder loses coverage under the group health plan, the policy or certificate shall be automatically reinstituted, effective as of the date of loss of coverage, if the policyholder or certificateholder provides notice of loss of coverage within 90 days after the date of such loss and pays the premium attributable to the period, effective as of the date of termination of enrollment in the group health plan.

21e. No Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy may provide for any waiting period for resumption of coverage that was in effect before the date of suspension under subd. 18. with respect to treatment of preexisting conditions.

21m. Each Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall provide for resumption of coverage that is substantially equivalent to coverage that was in effect before the date of suspension in subd. 18. If the suspended Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy provided coverage of Medicare Part B medical deductible coverage or if the insured was enrolled or Medicare eligible prior to January 1, 2020, and the insurer offers a plan with Medicare Part B medical deductible coverage, then resumption of the policy shall be with Medicare Part B medical deductible coverage. If the insurer no longer offers a plan with the Medicare Part B medical deductible coverage, then the insurer shall provide the insured with substantially equivalent coverage to the coverage in effect prior to the date of suspension.

21s. Each Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall provide that, upon the resumption of coverage that was in effect before the date of suspension in subd. 18., classification of premiums shall be on terms at least as favorable to the policyholder or certificateholder as the premium classification terms that would have applied to the policyholder or certificateholder had the coverage not been suspended.

22. May not use an underwriting standard during open enrollment for persons who are under age 65 that is more restrictive than the underwriting standards that are used for persons age 65 and older.

(b) The outline of coverage for the policy or certificate shall comply with all of the following:

1. Is provided to all applicants at the same time application is made, and except in the case of direct response insurance, the issuer obtains written acknowledgement from the applicant that the outline was received.

2. Complies with s. Ins 3.27.

3. Is substituted to describe properly the policy or certificate as issued, if the outline provided at the time of application did not properly describe the coverage that was issued. The substituted outline shall accompany the policy or certificate when it is delivered and shall contain the following statement in no less than 12-point type and 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."

4. Contains in close conjunction on its first page the designation, printed in a distinctly contrasting color or bold print in 24-point type, and the caption, printed in a distinctly contrasting color or bold print in 18-point type prescribed in sub. (5m), (7) or (30m).

5. Is substantially in the format prescribed in Appendices 3m, 4m, 5m, and 6m for the appropriate category and printed in a font size that is not less than 12-point type.

6. Summarizes or refers to the coverage set out in applicable statutes.

7. Contains a listing of the required coverage as set out in sub. (5m) (d) and the optional coverage as set out in sub. (5m) (e), and the annual premiums for each selected coverage, substantially in the format of sub. (11) in Appendix 2m.

8. Is approved by the commissioner along with the policy or certificate form.

(c) Any rider or endorsement added to the policy or certificate shall comply with the following:

1. Shall be contained in the policy or certificate and if a separate, additional premium is charged in connection with the rider or endorsement, the premium charge shall be stated in the policy or certificate.

2. Shall be agreed to in writing signed by the insured if, after the date of the policy or certificate issue, the rider or endorsement increases benefits or coverage and there is an accompanying increase in premium during the term of the policy or certificate, unless the increase in benefits or coverage is required by law.

3. Shall only provide coverage as defined in sub. (5m) (e) or provide coverage to meet Wisconsin mandated benefits.

(d) The schedule of benefits page or the first page of the policy or certificate contains a listing giving the coverages and both the annual premium in the format shown in sub. (11) of Appendix 2m and modal premium selected by the applicant.

(e) The anticipated loss ratio for any new policy or certificate form, or the expected percentage of the aggregate amount of premiums earned that will be returned to insureds in the form of aggregate benefits, not including anticipated refunds or credits, that is provided under the policy or certificate form:

1. Is computed on the basis of anticipated incurred claims or incurred health care expenses where coverage is provided by a health maintenance organizations on a service rather than reimbursement basis and earned premiums for the entire period for which the policy form provides coverage, in accordance with accepted actuarial principles and practices; and

2. Is submitted to the commissioner along with the policy or certificate form and is accompanied by rates and an actuarial demonstration that expected claims in relationship to premiums comply with the loss ratio standards under sub. (16) (d). The policy or certificate form will not be approved by the commissioner unless the anticipated loss ratio along with the rates and actuarial demonstration show compliance with sub. (16) (d).

(f) For subsequent rate changes to the policy or certificate form, the insurer shall do all of the following:

1. File the rate changes on a rate change transmittal form in a format specified by the commissioner.

2. Include in the filing under subd.1. an actuarially sound demonstration that the rate change will not result in a loss ratio over the life of the policy or certificate that would violate the requirements under sub. (16) (d).

(4t) MEDICARE SUPPLEMENT POLICY AND CERTIFICATE, MEDICARE SELECT POLICY AND CERTIFICATE, AND MEDICARE COST POLICY REQUIREMENTS FOR POLICIES AND CERTIFICATES OFFERED TO PERSONS FIRST ELIGIBLE FOR MEDICARE ON OR AFTER JANUARY 1, 2020.

(a) Except as explicitly allowed by subs. (5t), (7), and (30t), no disability insurance policy or certificate shall relate its coverage to Medicare or be structured, advertised, solicited, marketed or issued to persons newly eligible for Medicare on or after January 1, 2020, as a Medicare supplement policy or certificate, as a Medicare select policy or certificate, or as a Medicare cost policy unless the policy or certificate is in compliance with the following:

1. Provides only the coverage set out in sub. (5t), (7) or (30t), and applicable statutes, and contains no exclusions or limitations other than those permitted by sub. (8). No issuer may issue a Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy without prior approval from the commissioner and compliance with sub. (30t).

2. Discloses on the first page any applicable preexisting conditions limitation, contains no preexisting condition waiting period longer than 6 months and does not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.

3. Contains no definitions of terms such as "Medicare eligible expenses," "accident," "sickness," "mental or nervous disorders," skilled nursing facility," "hospital," "nurse," "physician," " benefit period," "convalescent nursing home," or "outpatient prescription drugs" that are worded less favorably to the insured person than the corresponding Medicare definition or the definitions contained in sub. (3), and defines "Medicare" as in accordance with sub. (3) (q).

4. Does not indemnify against losses resulting from sickness on a different basis from losses resulting from accident.

5. Is guaranteed renewable and does not provide for termination of coverage of a spouse solely because of an event specified for termination of coverage of the insured, other than the non-payment of premium. The policy or certificate may not be cancelled or nonrenewed by the issuer on the grounds of deterioration of health. The policy or certificate may be cancelled only for nonpayment of premium or material misrepresentation. If the policy or certificate is issued by a health maintenance organization, the policy or certificate may, in addition to the above reasons, be cancelled or nonrenewed by the issuer if the insured moves out of the service area.

6. Provides that termination of a Medicare supplement policy or certificate or Medicare cost policy shall be without prejudice to a continuous loss that commenced while the policy or certificate was in force, although the extension of benefits may be predicated upon the continuous total disability of the insured, limited to the duration of the policy or certificate benefit period, if any, or payment of the maximum benefits. Receipt of the Medicare Part D benefits may not be considered in determining a continuous loss.

7. Contains statements on the first page and elsewhere in the policy or certificate that satisfy the requirements of s. Ins 3.13(2) (c), (d) and (e), and clearly states on the first page or schedule page the duration of the term of coverage for which the policy or certificate is issued and for which it may be renewed. The renewal period cannot be less than the greatest of the following: 3 months, the period the insured has paid the premium, or the period specified in the policy or certificate.

8. Changes benefits automatically to coincide with any changes in the applicable Medicare deductible amount, coinsurance, and copayment percentage factors, although there may be a corresponding modification of premiums in accordance with the policy or certificate provisions and ch. 625, Stats.

9. Prominently discloses any limitations on the choice of providers or geographical area of service.

10. Contains on the first page the designation, printed in 18-point type, and in close conjunction the caption printed in 12-point type, prescribed in sub. (5t) or (30t).

11. Contains text that is plainly printed in black or blue ink and has a font size that is uniform and not less than 10-point type with a lower-case unspaced alphabet length not less than 120-point type.

12. Contains a provision describing any grievance rights as required by s. 632.83, Stats., applicable to Medicare supplement policies and certificates and Medicare cost policies.

13. Is approved by the commissioner.

14. Contains no exclusion, limitation, or reduction of coverage for a specifically named or described condition after the policy or certificate effective date.

15. Provides for midterm cancellation at the request of the insured and provides that, if an insured cancels a policy or certificate midterm or the policy or certificate terminates midterm because of the insured's death, the issuer shall issue a pro rata refund to the insured or the insured's estate.

16. Except for permitted preexisting condition clauses as described in subd. 2., no policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate if such policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.

17. No Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy in force in this state shall contain benefits that duplicate benefits provided by Medicare.

18. A Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall provide that benefits and premiums under the policy or certificate shall be suspended at the request of the policyholder or certificateholder for the period not to exceed 24 months in which the policyholder or certificateholder has applied for and is determined to be entitled to medical assistance under Title XIX of the social security act, but only if the policyholder or certificateholder notifies the issuer of the policy or certificate within 90 days after the date the individual becomes entitled to the assistance.

19. If the suspension in subd. 18. occurs and if the policyholder or certificateholder loses entitlement to medical assistance, the policy or certificate shall be automatically reinstituted, effective as of the date of termination of the entitlement, if the policyholder or certificateholder provides notice of loss of the entitlement within 90 days after the date of the loss and pays the premium attributable to the period.

20. Each Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall provide, and contain within the policy or certificate, that benefits and premiums under the policy or certificate shall be suspended for any period that may be provided by federal regulation, at the request of the policyholder or certificateholder if the policyholder or certificateholder is entitled to benefits under section 226 (b) of the social security act and is covered under a group health plan, as defined in section 1862 (b) (1) (A) (v) of the social security act. If suspension occurs and if the policyholder or certificateholder loses coverage under the group health plan, the policy or certificate shall be automatically reinstituted, effective as of the date of loss of coverage, if the policyholder or certificateholder provides notice of loss of coverage within 90 days after the date of such loss and pays the premium attributable to the period, effective as of the date of termination of enrollment in the group health plan.

21e. No Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy may provide for any waiting period for resumption of coverage that was in effect before the date of suspension under subd. 18. with respect to treatment of preexisting conditions.

21m. Each Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall provide for resumption of coverage that is substantially equivalent to coverage that was in effect before the date of suspension in subd. 18. If the suspended Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy provided coverage of Medicare Part B medical deductible coverage or if the insured was enrolled or Medicare eligible prior to January 1, 2020, and the insurer offers a plan with Medicare Part B medical deductible coverage, then resumption of the policy shall be with Medicare Part B medical deductible coverage. If the insurer no longer offers a plan with the Medicare Part B medical deductible coverage, then the insurer shall provide the insured with substantially equivalent coverage to the coverage in effect prior to the date of suspension.

21s. Each Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy shall provide that, upon the resumption of coverage that was in effect before the date of suspension in subd. 18., classification of premiums shall be on terms at least as favorable to the policyholder or certificateholder as the premium classification terms that would have applied to the policyholder or certificateholder had the coverage not been suspended.

22. May not use an underwriting standard during open enrollment for persons who are under age 65 that is more restrictive than the underwriting standards that are used for persons age 65 and older.

(b) The outline of coverage for the policy or certificate shall comply with all of the following:

1. Is provided to all applicants at the same time application is made and, except in the case of direct response insurance, the issuer obtains written acknowledgement from the applicant that the outline was received.

2. Complies with s. Ins 3.27.

3. Is substituted to describe properly the policy or certificate as issued, if the outline provided at the time of application did not properly describe the coverage that was issued. The substituted outline shall accompany the policy or certificate when it is delivered and shall contain the following statement in no less than 12-point type and 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."

4. Contains in close conjunction on its first page the designation, printed in a distinctly contrasting color or bold print in 24-point type, and the caption, printed in a distinctly contrasting color or bold print in 18-point type, prescribed in sub. (5t), (7), or (30t).

5. Is substantially in the format prescribed in Appendices 3t, 4t, 5t, and 6t, for the appropriate category and printed in a font size that is not less than 12-point type.

6. Summarizes or refers to the coverage set out in applicable statutes.

7. Contains a listing of the required coverage as set out in sub. (5t) (d), and the optional coverage as set out in sub. (5t) (e), and the annual premiums for each selected coverage, substantially in the format of sub. (11) in Appendix 2t.

8. Is approved by the commissioner along with the policy or certificate form.

(c) Any rider or endorsement added to the policy or certificate shall comply with all of the following:

1. Shall be contained in the policy or certificate and, if a separate, additional premium is charged in connection with the rider or endorsement, the premium charge shall be stated in the policy or certificate.

2. Shall be agreed to in writing signed by the insured if, after the date of the policy or certificate issue, the rider or endorsement increases benefits or coverages and there is an accompanying increase in premium during the term of the policy or certificate, unless the increase in benefits or coverage is required by law.

3. Shall only provide coverage as described in sub. (5t) (e), or provide coverage to meet Wisconsin mandated benefits.

(d) The schedule of benefits page or the first page of the policy or certificate shall contain a listing giving the coverages and both the annual premium in the format shown in sub. (11) of Appendix 2t and modal premium selected by the applicant.

(e) The anticipated loss ratio for any new policy or certificate form, or the expected percentage of the aggregate amount of premiums earned that will be returned to insureds in the form of aggregate benefits, not including anticipated refunds or credits, that is provided under the policy or certificate form:

1. Is computed on the basis of anticipated incurred claims or incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis and earned premiums for the entire period that the policy or certificate form provides coverage, in accordance with accepted actuarial principles and practices; and

2. Is submitted to the commissioner along with the policy or certificate form and is accompanied by rates and an actuarial demonstration that expected claims in relationship to premiums comply with the loss ratio standards under sub. (16) (d). The policy or certificate form will not be approved by the commissioner unless the anticipated loss ratio along with the rates and actuarial demonstration show compliance with sub. (16) (d).

(f) For subsequent rate changes to the policy or certificate form, the issuer shall do all of the following:

1. File the rate changes on a rate change transmittal form in a format specified by the commissioner.

2. Include in the filing under subd.1. an actuarially sound demonstration that the rate change will not result in a loss ratio over the life of the policy or certificate that would violate the requirements under sub. (16) (d).

(5) AUTHORIZED MEDICARE SUPPLEMENT POLICY AND CERTIFICATE DESIGNATION, CAPTIONS, REQUIRED COVERAGES, AND PERMISSIBLE ADDITIONAL BENEFITS FOR POLICIES OR CERTIFICATES OFFERED TO PERSONS FIRST ELIGIBLE FOR MEDICARE PRIOR TO JUNE 1, 2010. This subsection applies only to a Medicare supplement policy or certificate that meets the requirements of sub. (4), that is issued or effective after December 31, 1990, and prior to June 1, 2010, and that shall contain the authorized designation, caption and required coverage. A health maintenance organization shall place the letters HMO in front of the required designation on any approved Medicare supplement policy or certificate. A Medicare supplement policy or certificate shall include all of the following:

(a) The designation: MEDICARE SUPPLEMENT INSURANCE.

(b) The caption, except that the word "certificate" may be used instead of "policy," if appropriate: "The Wisconsin Insurance Commissioner has set standards for Medicare supplement insurance. This policy meets these standards. It, along with Medicare, may not cover all of your medical costs. You should review carefully all policy limitations. For an explanation of these standards and other important information, see `Wisconsin Guide to Health Insurance for People with Medicare,' given to you when you applied for this policy. Do not buy this policy if you did not get this guide."

(c) The following required coverages, to be referred to as "Basic Medicare Supplement coverage" for a policy issued to persons first eligible for Medicare after December 31, 1990 and prior to June 1, 2010, shall comply with all the following:

1. Upon exhaustion of Medicare hospital inpatient psychiatric coverage, at least 175 days per lifetime for inpatient psychiatric hospital care;

2. Medicare Part A eligible expenses in a skilled nursing facility for the copayments for the 21st through the 100th day;

3. All Medicare Part A eligible expenses for blood to the extent not covered by Medicare;

4. All Medicare Part B eligible expenses to the extent not paid by Medicare, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, including outpatient psychiatric care, subject to the Medicare Part B calendar year deductible;

5. Payment of the usual and customary home care expenses to a minimum of 40 visits per 12-month period as required under s. 632.895(1) and (2), Stats., and s. Ins 3.54;

6. Skilled nursing care and kidney disease treatment as required under s. 632.895(3) and (4), Stats. Coverage for skilled nursing care shall be in addition to the required coverage under subd. 2. and payment of the Medicare Part A copayment for Medicare eligible skilled nursing care shall not count as satisfying the coverage requirement of at least 30 days of non-Medicare eligible skilled nursing care under s. 632.895(3), Stats.;

7. In group policies, nervous and mental disorder and alcoholism and other drug abuse coverage as required under s. 632.89, Stats.;

8. Payment in full for all usual and customary expenses for chiropractic services required by s. 632.87(3), Stats. Issuers are not required to duplicate benefits paid by Medicare;

9. Coverage for the first 3 pints of blood payable under Part B;

10. Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period;

11. Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days;

12. Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of all Medicare Part A expenses for hospitalization not covered by Medicare to the extent the hospital is permitted to charge by federal law and regulation and subject to the Medicare reimbursement rate;

13. Prior to January 1, 2006, payment in full for all usual and customary expenses for treatment of diabetes required by s. 632.895(6), Stats. After December 31, 2005, payment in accordance with s. 632.895(6), Stats., including non-prescription insulin or any other non-prescription equipment and supplies for the treatment of diabetes, but not including any other outpatient prescription medications. Issuers are not required to duplicate expenses paid by Medicare.

14. Coverage for preventive health care services not covered by Medicare and as determined to be medically appropriate by an attending physician. These benefits shall be included in the basic policy. Reimbursement shall be for the actual charges up to 100% of the Medicare approved amount for each service, as if Medicare were to cover the service, as identified in the American Medical Association Current Procedural Terminology (AMA CPT) codes, to a minimum of $120 annually under this benefit. This benefit shall not include payment for any procedure covered by Medicare.

15. Coverage for at least 80% of the charges for outpatient prescription drugs after a drug deductible of no more than $6,250 per calendar year. Subject to sub. (4) (a) 20., this coverage may only be included in a Medicare supplement policy issued before January 1, 2006.

16. Payment in full for all usual and customary expenses of hospital and ambulatory surgery center charges and anesthetics for dental care required by s. 632.895(12), Stats. Issuers are not required to duplicate benefits paid by Medicare.

17. Payment in full for all usual and customary expenses for breast reconstruction required by s. 632.895(13), Stats. Issuers are not required to duplicate benefits paid by Medicare.

(i) Permissible additional coverage only added to the policy as separate riders. The issuer shall issue a separate rider for each coverage the issuer chooses to offer. Issuers shall ensure that the riders offered are compliant with MMA, that each rider is priced separately, available for purchase separately at any time, subject to underwriting and the pre-existing limitation allowed in sub. (4) (a) 2., and may consist of the following:

1. Coverage for the Medicare Part A hospital deductible. The rider shall be designated: MEDICARE PART A DEDUCTIBLE RIDER;

2. Coverage for home health care for an aggregate of 365 visits per policy year as required by s. 632.895(1) and (2), Stats. The rider shall be designated as: ADDITIONAL HOME HEALTH CARE RIDER;

3. Coverage for the Medicare Part B medical deductible. The rider shall be designated as: MEDICARE PART B DEDUCTIBLE RIDER;

4. Coverage for the difference between Medicare's Part B eligible charges and the amount charged by the provider which shall be no greater than the actual charge or the limiting charge allowed by Medicare. The rider shall be designated as: MEDICARE PART B EXCESS CHARGES RIDER;

5. Coverage for benefits obtained outside the United States. An issuer which offers this benefit shall not limit coverage to Medicare deductibles and copayments. Coverage may contain a deductible of up to $250. Coverage shall pay at least 80% of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during at least the first 60 consecutive days of each trip outside the United States and a lifetime maximum benefit of at least $50,000. For purposes of this benefit, "emergency hospital, physicians and medical care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset. The rider shall be designated as: FOREIGN TRAVEL RIDER.

7. At least 50% of the charges for outpatient prescription drugs after a deductible of no greater than $250 per year to a maximum of at least $3,000 in benefits received by the insured per year. The rider shall be designated as: OUTPATIENT PRESCRIPTION DRUG RIDER. This rider may only be offered for issuance or sale until January 1, 2006 in accordance with MMA.

(j) For HMO Medicare select policies, only the benefits specified in sub. (30) (p), (r) and (s), in addition to Medicare benefits.

(k) For the Medicare supplement high deductible plan that may be issued only prior to December 31, 2005 or renewed thereafter in accordance with sub. (29) (b) 1., the following:

1. The designation: MEDICARE SUPPLEMENT INSURANCE - HIGH DEDUCTIBLE PLAN.

2. 100% of the covered benefits described in pars. (c) and (i) 1., 2., 3., 4. and 5. following the payment of the annual high deductible.

3. The annual high deductible shall consist of out-of-pocket expenses, other than premiums, for services covered in subd. 2. and shall be in addition to any other specific benefit deductibles.

4. The annual high deductible shall be $1500 for 1999, and shall be based on the calendar year. It shall be adjusted annually thereafter by the secretary 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.

(m) For the Medicare supplement high deductible drug plan that may be issued only prior to December 31, 2005 or renewed thereafter in accordance with sub. (4) (a) 20., the following:

1. The designation: MEDICARE SUPPLEMENT INSURANCE - HIGH DEDUCTIBLE DRUG PLAN.

2. 100% of the covered benefits described in pars. (c) and (i) 1., 2., 3., 4., 5. and 7. following the payment of the annual high deductible.

3. The annual high deductible shall consist of out-of-pocket expenses, other than premiums, for services covered in subd. 2. and shall be in addition to any other specific benefit deductibles.

4. The annual high deductible shall be $1500 for 1999, and shall be based on the calendar year. It shall be adjusted annually thereafter by the secretary 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.

(n) For the Medicare Supplement 50% Cost-Sharing plans, only the following:

1. The designation: MEDICARE SUPPLEMENT 50% COST-SHARING PLAN;

2. Coverage of 100% of the Medicare Part A hospital coinsurance amount for each day used from the 61st through the 90 th day in any Medicare benefit period;

3. Coverage for 100% of the Medicare 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;

4. 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 rate, or other appropriate Medicare standard of payment, subject to a lifetime limitation benefit of an additional 365 days;

5. 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 subd. 12.;

6. Skilled Nursing Facility Care: Coverage for 50% of the coinsurance amount for each day used from the 21 st day through the 100 th 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 subd. 12.;

7. 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 subd. 12.;

8. 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 subd. 12.;

9. Except for coverage provided in subd. 11., coverage for 50% of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Medicare Part B deductible until the out-of-pocket limitation is met as described under subd. 12.;

10. Coverage of 100% of the cost sharing for the benefits described in pars. (c) 1., 5., 6., 8., 13., 16., and 17., and (i) 2., to the extent the benefits do not duplicate benefits paid by Medicare and after the policyholder pays the Medicare Part A and Part B deductible and meets the out-of-pocket limitation described under subd. 12.;

11. Coverage of 100% of the cost sharing for Medicare Part B preventive services after the policyholder pays the Medicare B deductible; and

12. Coverage of 100% of all cost sharing under Medicare Part A or 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 $4,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the secretary.

(o) For the Medicare Supplement 25% Cost-Sharing plans, only the following:

1. The designation: MEDICARE SUPPLEMENT 25% COST-SHARING PLAN;

2. Coverage of 100% of the Medicare Part A hospital coinsurance amount for each day used from the 61 st through the 90 th day in any Medicare benefit period;

3. Coverage for 100% of the Medicare Part A hospital co-insurance amount for each Medicare lifetime inpatient reserve day used from the 91 st through the 150 th day in any Medicare benefit period;

4. 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 rate, or other appropriate Medicare standard of payment, subject to a lifetime limitation benefit of an additional 365 days;

5. Medicare Part A Deductible: Coverage for 75% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subd. 12.;

6. Skilled Nursing Facility Care: Coverage for 75% of the coinsurance amount for each day used from the 21 st day through the 100 th 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 subd. 12.;

7. Hospice Care: Coverage for 75% of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subd. 12.;

8. Coverage of 75%, 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 subd. 12.;

9. Except for coverage provided in subd. 11., coverage for 75% of the cost sharing otherwise applicable under Medicare Part B, after the policyholder pays the Medicare Part B deductible until the out-of-pocket limitation is met as described in subd. 12.;

10. Coverage of 100% of the cost sharing for the benefits described in pars. (c) 1., 5., 6., 8., 13., 16., and 17., and (i) 2., to the extent the benefits do not duplicate benefits paid by Medicare and after the policyholder pays the Medicare Part A and Part B deductible and meets the out-of-pocket limitation described under subd. 12.;

11. Coverage for 100% of the cost sharing for Medicare Part B preventive services after the policyholder pays the Medicare Part B deductible; and

12. Coverage of 100% of all cost sharing under Medicare Part A or 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 $2,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the secretary.

(5m) AUTHORIZED MEDICARE SUPPLEMENT POLICY AND CERTIFICATE DESIGNATION, CAPTIONS, REQUIRED COVERAGES, AND PERMISSIBLE ADDITIONAL BENEFITS FOR POLICIES OR CERTIFICATES OFFERED TO PERSONS FIRST ELIGIBLE FOR MEDICARE ON OR AFTER JUNE 1, 2010 AND PRIOR TO JANUARY 1, 2020.

(a) All of the following standards are applicable to a Medicare supplement policy or certificate that is delivered or issued to persons first eligible for Medicare on or after June 1, 2010, and prior to January 1, 2020:

1. No policy or certificate may be advertised, solicited, delivered, or issued to persons first eligible for Medicare on or after June 1, 2010, and prior to January 1, 2020, as a Medicare supplement policy or certificate unless it complies with the benefit standards. All of the following standards are applicable to Medicare supplement policies or certificates, delivered or issued in this state:

b. Benefit standards applicable to Medicare supplement policies and certificates, issued to a person first eligible for Medicare prior to June 1, 2010, remain subject to the applicable requirements contained in sub. (5).

2. For a policy or certificate to meet the requirements of sub. (4m), it shall contain the authorized designation, caption and required coverage. A Medicare supplement policy or certificate shall include all of the following:

a. The designation: MEDICARE SUPPLEMENT INSURANCE.

b. The following caption, except that the word "certificate" may be used instead of "policy," if appropriate: "The Wisconsin Insurance Commissioner has set standards for Medicare supplement insurance. This policy meets these standards. It, along with Medicare, may not cover all of your medical costs. You should review carefully all policy limitations. For an explanation of these standards and other important information, see "Wisconsin Guide to Health Insurance for People with Medicare," given to you when you applied for this policy. Do not buy this policy if you did not get this guide."

(d) The following required coverages shall be referred to as "Basic Medicare Supplement Coverage:"

1. Coverage of at least 175 days per lifetime for inpatient psychiatric hospital care upon exhaustion of Medicare hospital inpatient psychiatric coverage.

2. Coverage of coinsurance or copayments for Medicare Part A eligible expenses in a skilled nursing facility from the 21st through the 100th day in a benefit period.

3. Coverage for all Medicare Part A eligible expenses for the first 3 pints of blood or equivalent quantities of packed red blood cells to the extent not covered by Medicare.

4. Coverage of coinsurance or copayments for all Medicare Part A eligible expenses for hospice and respite care.

5. Coverage of coinsurance or copayment for Medicare Part B eligible expenses to the extent not paid by Medicare, or in the case of hospital outpatient department services paid under a prospective payment system including outpatient psychiatric care, regardless of hospital confinement, subject to the Medicare Part B calendar year deductible.

6. Coverage for the usual and customary home care expenses to a minimum of 40 visits per 12-month period as required under s. 632.895(1) and (2), Stats., and s. Ins 3.54.

7. Coverage for skilled nursing care and kidney disease treatment as required under s. 632.895(3) and (4), Stats. Coverage for skilled nursing care shall be in addition to the required coverage under subd. 1., payment of coinsurance or copayment for Medicare Part A eligible skilled nursing care may not count as satisfying the coverage requirement of at least 30 days of non-Medicare eligible skilled nursing care under s. 632.895(3), Stats.

8. In group policies, coverage for nervous and mental disorder and alcoholism and other drug abuse coverage as required under s. 632.89, Stats.

9. Coverage in full for all usual and customary expenses for chiropractic services required by s. 632.87(3), Stats. Issuers are not required to duplicate benefits paid by Medicare.

10. Coverage of the first 3 pints of blood payable under Medicare Part B.

11. Coverage of Medicare Part A eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period.

12. Coverage of Medicare Part A eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days.

13. Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of all Medicare Part A eligible expenses for hospitalization not covered by Medicare for an additional 365 days to the extent the hospital is permitted to charge Medicare by federal law and regulation and subject to the Medicare reimbursement rate and a lifetime maximum benefit. The provider shall accept the issuer's payment as payment in full and may not balance bill the insured.

14. Coverage in accordance with s. 632.895(6), Stats., for treatment of diabetes including non-prescription insulin or any other non-prescription equipment and supplies for the treatment of diabetes, but not including any other outpatient prescription medications. Issuers are not required to duplicate expenses paid by Medicare.

15. Coverage for preventive health care services not covered by Medicare and as determined to be medically appropriate by an attending physician. These benefits shall be included in the basic policy or certificate. Reimbursement shall be for the actual charges up to 100% of the Medicare approved amount for each service, as if Medicare were to cover the service, as identified in the American Medical Association Current Procedural Terminology codes, to a minimum of $120 annually under this benefit. This benefit may not include payment for any procedure covered by Medicare.

16. Coverage in full for all usual and customary expenses of hospital and ambulatory surgery center charges and anesthetics for dental care required by s. 632.895(12), Stats. Issuers are not required to duplicate benefits paid by Medicare.

17. Coverage in full for all usual and customary expenses for breast reconstruction required by s. 632.895(13), Stats. Issuers are not required to duplicate benefits paid by Medicare.

(e) Permissible coverage options may only be added to the policy or certificate as separate riders. The issuer shall issue a separate rider for each option offered. Issuers shall ensure that the riders offered are compliant with MMA, each rider is priced separately, available for purchase separately at any time, subject to underwriting and the preexisting limitation allowed in sub. (4m) (a) 2. The issuer shall not issue to the same insured for the same period of coverage both the Medicare Part A Deductible rider and the Medicare 50% Part A Deductible rider. The issuer shall not issue to the same insured for the same period of coverage both the Medicare Part B Deductible rider and the Medicare Part B Copayment or Coinsurance rider. Separate riders, if offered, shall consist of the following:

1. Coverage of 100% of the Medicare Part A hospital deductible. The rider shall be designated: MEDICARE PART A DEDUCTIBLE RIDER.

2. Coverage of 50% of the Medicare Part A hospital deductible per benefit period with no out-of-pocket maximum. The rider shall be designated: MEDICARE 50% PART A DEDUCTIBLE RIDER.

3. Coverage of home health care for an aggregate of 365 visits per policy or certificate year as required by s. 632.895(1) and (2), Stats. The rider shall be designated as: ADDITIONAL HOME HEALTH CARE RIDER.

4. Coverage of 100% of the Medicare Part B medical deductible. The rider shall be designated as: MEDICARE PART B DEDUCTIBLE RIDER.

5. Medicare Part B Copayment or Coinsurance Rider. Under this option, the insured's copayment or coinsurance will be the lesser of $20 per office visit or the Medicare Part B coinsurance and the lesser of $50 per emergency room visit or the Medicare Part B coinsurance that is in addition to the Medicare Part B medical deductible. The emergency room copayment or coinsurance fee shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense. The rider shall be designated as: MEDICARE PART B COPAYMENT OR COINSURANCE RIDER.

6. Coverage of the difference between Medicare Part B eligible charges and the amount charged by the provider that shall be no greater than the actual charge or the limiting charge allowed by Medicare. The rider shall be designated as: MEDICARE PART B EXCESS CHARGES RIDER.

7. Coverage for services obtained outside the United States. An issuer that offers this benefit may not limit coverage to Medicare deductibles, coinsurance and copayments. Coverage may contain a deductible of up to $250. Coverage shall pay at least 80% of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country; which care would have been covered by Medicare if provided in the United States and which care began during the first 60 consecutive days of each trip outside the United States for up to a lifetime maximum benefit of at least $50,000. For purposes of this benefit, "emergency hospital, physicians and medical care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset. The rider shall be designated as: FOREIGN TRAVEL EMERGENCY RIDER.

(f) For HMO Medicare select policies, only the benefits specified in sub. (30m) (p), (r) and (s), may be offered in addition to Medicare benefits.

(g) For the Medicare supplement 50% Cost-Sharing plans, only the following:

1. The designation: MEDICARE SUPPLEMENT 50% COST-SHARING PLAN.

2. Coverage of coinsurance or copayment for Medicare Part A hospital amount for each day used from the 61st through the 90th day in any Medicare benefit period.

3. Coverage of coinsurance or copayment of Medicare Part A hospital amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period.

4. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage for 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system rate, or other appropriate Medicare standard of payment, subject to a lifetime limitation benefit of an additional 365 days.

5. 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 subd. 12.

6. Coverage for 50% of the coinsurance or copayment 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 subd. 12.

7. Coverage for 50% of coinsurance or copayments for all Medicare Part A eligible expenses and respite care until the out-of-pocket limitation is met as described in subd. 12.

8. 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 subd. 12.

9. Except for coverage provided in subd. 11., coverage for 50% of the coinsurance or copayment otherwise applicable under Medicare Part B after the policyholder or certificateholder pays the Medicare Part B deductible until the out-of-pocket limitation is met as described in subd. 12.

10. Coverage for 100% of the coinsurance or copayments for the benefits described in pars. (d) 1., 6., 7., 9., 14., 16., and 17., and (e) 3., to the extent the benefits do not duplicate benefits paid by Medicare and after the policyholder or certificateholder pays the Medicare Part A and B deductibles and meets the out-of-pocket limitation described in subd. 12.

11. Coverage for 100% of the coinsurance or copayments for Medicare Part B preventive services after the policyholder or certificateholder pays the Medicare Part B deductible.

12. Coverage for 100% of all cost sharing under Medicare Part A or 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 [$4,440], indexed each year by the appropriate inflation adjustment specified by the secretary.

(h) For the Medicare Supplement 25% Cost-Sharing plans, only the following:

1. The designation: MEDICARE SUPPLEMENT 25% COST-SHARING PLAN.

2. Coverage for 100% of the Medicare Part A hospital coinsurance or copayment amount for each day used from the 61st through the 90th day in any Medicare benefit period.

3. Coverage for 100% of the Medicare Part A hospital coinsurance or copayment amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period.

4. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage for 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system rate, or other appropriate Medicare standard of payment, subject to a lifetime limitation benefit of an additional 365 days.

5. Coverage for 75% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subd. 12.

6. Coverage for 75% of the coinsurance or copayment 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 subd. 12.

7. Coverage for 75% of cost sharing for all Medicare Part A eligible expenses and respite care until the out-of-pocket limitation is met as described in subd. 12.

8. Coverage for 75%, 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 subd. 12.

9. Except for coverage provided in subd. 11., coverage for 75% of the cost sharing otherwise applicable under Medicare Part B, after the policyholder or certificateholder pays the Medicare Part B deductible until the out-of-pocket limitation is met as described in subd. 12.

10. Coverage for 100% of the cost sharing for the benefits described in pars. (d) 1., 6., 7., 9., 14., 16., and 17., and (e) 3., to the extent the benefits do not duplicate benefits paid by Medicare and after the policyholder or certificateholder pays the Medicare Part A and B deductible and meets the out-of-pocket limitation described in subd. 12.

11. Coverage for 100% of the cost sharing for Medicare Part B preventive services after the policyholder or certificateholder pays the Medicare Part B deductible.

12. Coverage for 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 [$2,220], indexed each year by the appropriate inflation adjustment specified by the secretary.

(k) For the Medicare supplement high deductible plan, the following:

1. The designation: MEDICARE SUPPLEMENT INSURANCE-HIGH DEDUCTIBLE PLAN.

2. Coverage for 100% of benefits described in pars. (d) and (e) 1., 3., 4., 6., and 7., following the payment of the annual high deductible.

3. The annual high deductible shall consist of out-of-pocket expenses, other than premiums, for services covered in subd. 2 and shall be in addition to any other specific benefit deductibles.

4. The annual high deductible shall be $2000 and shall be adjusted annually by the secretary 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.

(5t) AUTHORIZED MEDICARE SUPPLEMENT POLICY AND CERTIFICATE DESIGNATION, CAPTIONS, REQUIRED COVERAGES, AND PERMISSIBLE ADDITIONAL BENEFITS FOR POLICIES OR CERTIFICATES OFFERED TO PERSONS FIRST ELIGIBLE FOR MEDICARE ON OR AFTER JANUARY 1, 2020.

(a) All of the following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state to individuals newly eligible for Medicare on or after January 1, 2020:

1. Policies or certificates issued to persons newly eligible for Medicare on or after January 1, 2020, shall not provide an option to elect coverage of the Medicare Part B medical deductible rider.

2. Insurers may continue to sell and renew policies and certificates that contain the Medicare Part B medical deductible benefit or rider to Medicare eligible persons who were first eligible for Medicare prior to January 1, 2020.

(b)

1. No Medicare supplement 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. All of the following standards are applicable to Medicare supplement policies or certificates delivered or issued in this state:

a. Benefit standards applicable to Medicare supplement policies and certificates issued to persons first eligible for Medicare prior to June 1, 2010, remain subject to the applicable requirements contained in sub. (5).

b. Benefit standards applicable to Medicare supplement policies and certificates issued to persons first eligible for Medicare on or after June 1, 2010, and prior to January 1, 2020, remain subject to the applicable requirements contained in sub. (5m).

2. Policies or certificates shall contain the authorized designation, caption and required coverage in order to meet the requirements of sub. (4t). A Medicare supplement policy or certificate shall include all of the following:

a. The designation: MEDICARE SUPPLEMENT INSURANCE.

b. The following caption, except that the word "certificate" may be used instead of "policy," if appropriate: "The Wisconsin Insurance Commissioner has set standards for Medicare supplement insurance. This policy meets these standards. It, along with Medicare, may not cover all of your medical costs. You should review carefully all policy limitations. For an explanation of these standards and other important information, see "Wisconsin Guide to Health Insurance for People with Medicare," given to you when you applied for this policy. Do not buy this policy if you did not get this guide."

(d) All of the following required coverages shall be referred to as "Basic Medicare Supplement Coverage:"

1. Coverage of at least 175 days per lifetime for inpatient psychiatric hospital care upon exhaustion of Medicare hospital inpatient psychiatric coverage.

2. Coverage of coinsurance or copayments for Medicare Part A eligible expenses in a skilled nursing facility from the 21st through the 100th day in a benefit period.

3. Coverage for all Medicare Part A eligible expenses for the first 3 pints of blood or equivalent quantities of packed red blood cells to the extent not covered by Medicare.

4. Coverage of coinsurance or copayments for all Medicare Part A eligible expenses for hospice and respite care.

5. Coverage of coinsurance or copayment for Medicare Part B eligible expenses to the extent not paid by Medicare or, in the case of hospital outpatient department services paid under a prospective payment system including outpatient psychiatric care, regardless of hospital confinement, subject to the Medicare Part B calendar year deductible.

6. Coverage for the usual and customary home care expenses to a minimum of 40 visits per 12-month period as required under s. 632.895(2) (d), Stats., and s. Ins 3.54.

7. Coverage for skilled nursing care and kidney disease treatment as required under s. 632.895(3) and (4), Stats. Coverage for skilled nursing care shall be in addition to the required coverage under subd. 1. Payment of coinsurance or copayment for Medicare Part A eligible skilled nursing care may not count as satisfying the coverage requirement of at least 30 days of non-Medicare eligible skilled nursing care under s. 632.895(3), Stats.

8. In group policies, coverage for nervous and mental disorders and alcoholism and other drug abuse coverage as required under s. 632.89, Stats.

9. Coverage in full for all usual and customary expenses for chiropractic services consistent with s. 632.87(3), Stats. Issuers are not required to duplicate benefits paid by Medicare.