The following standards are applicable to all Medicare
supplement policies or certificates delivered or issued for delivery in this
state with an effective date for coverage on or after June 1, 2010. No policy
or certificate may be advertised, solicited, delivered or issued for delivery
in this state as a Medicare supplement policy or certificate unless it complies
with these benefit plan standards Benefit plan standards applicable to Medicare
supplement policies and certificates issued with an effective date for coverage
before June 1, 2010 remain subject to the requirements of Section
8.
(a) Policy or Certificate Form.
(i) An issuer shall make available to each
prospective policyholder and certificate holder a policy form or certificate
form containing only the basic (core) benefits, as defined in Section 8.1(b) of
this regulation.
(ii) If an issuer
makes available any of the additional benefits described in Section 8.1(c), or
offers standardized benefit Plans K or L (as described in Sections 9.1(e)
(viii) and (ix) of this regulation), then the issuer shall make available to
each prospective policyholder and certificate holder, in addition to a policy
form or certificate form with only the basic (core) benefits as described in
subsection (a)(i) above, a policy form or certificate form containing either
standardized benefit Plan C (as described in Section 9.1(e)(iii) of this
regulation) or standardized benefit Plan F (as described in 9.1(e)(v) of this
regulation).
(b) No
groups, packages or combinations of Medicare supplement benefits other than
those listed in this Section shall be offered for sale in this state, except as
may be permitted in Section 9.1(f) and in Section
10 of this regulation.
(c) Benefit plans shall be uniform in
structure, language, designation and format to the standard benefit plans
listed in this Subsection and conform to the definitions in Section
4 of this
regulation. Each benefit shall be structured in accordance with the format
provided in Sections 8.1(b) and 8.1(c) of this regulation; or, in the case of
plans K or L, in Sections 9.1(e) (viii) or (ix) of this regulation and list the
benefits in the order shown. For purposes of this Section, "structure,
language, and format" means style, arrangement and overall content of a
benefit.
(d) In addition to the
benefit plan designations required in Subsection (c) of this section, an issuer
may use other designations to the extent permitted by law.
(e) Make-up of 2010 Standardized Benefit
Plans:
(i) Standardized Medicare supplement
benefit Plan A shall include only the following: The basic (core) benefits as
defined in Section 8.1(b) of this regulation.
(ii) Standardized Medicare supplement benefit
Plan B shall include only the following: The basic (core) benefit as defined in
Section 8.1(b) of this regulation, plus one hundred percent (100%) of the
Medicare Part A deductible as defined in Section 8.1(c)(i) of this
regulation.
(iii) Standardized
Medicare supplement benefit Plan C shall include only the following: The basic
(core) benefit as defined in Section 8.1(b) of this regulation, plus one
hundred percent (100%) of the Medicare Part A deductible, skilled nursing
facility care, one hundred percent (100%) of the Medicare Part B deductible,
and medically necessary emergency care in a foreign country as defined in
Sections 8.1(c)(i), (iii), (iv) and (vi) of this regulation,
respectively.
(iv) Standardized
Medicare supplement benefit Plan D shall include only the following: The basic
(core) benefit (as defined in Section 8.1(b) of this regulation), plus one
hundred percent (100%) of the Medicare Part A deductible, skilled nursing
facility care, and medically necessary emergency care in a foreign country as
defined in Sections 8.1(c)(i), (iii) and (vi) of this regulation,
respectively.
(v) Standardized
Medicare supplement [regular] Plan F shall include only the following: The
basic (core) benefit as defined in Section 8.1(b) of this regulation, plus one
hundred percent (100%) of the Medicare Part A deductible, the skilled nursing
facility care, one hundred percent (100%) of the Medicare Part B deductible,
one hundred percent (100%) of the Medicare Part B excess charges, and medically
necessary emergency care in a foreign country as defined in Sections 8.1(c)(i),
(iii), (iv), (v), and (vi), respectively.
(vi) Standardized Medicare supplement Plan F
with High Deductible shall include only the following: one hundred percent
(100%) of covered expenses following the payment of the annual deductible set
forth in Subparagraph (B).
(A) The basic
(core) benefit as defined in Section 8.1(b) of this regulation, plus one
hundred percent (100%) of the Medicare Part A deductible, skilled nursing
facility care, one hundred percent (100%) of the Medicare Part B deductible,
one hundred percent (100%) of the Medicare Part B excess charges, and medically
necessary emergency care in a foreign country as defined in Sections 8.1(c)(i),
(iii), (iv), (v), and (vi) of this regulation, respectively.
(B) The annual deductible in Plan F With High
Deductible shall consist of out-of-pocket expenses, other than premiums, for
services covered by [regular] Plan F, and shall be in addition to any other
specific benefit deductibles. The basis for the deductible shall be $1,500 and
shall be adjusted annually from 1999 by the Secretary of the U.S. Department of
Health and Human Services to reflect the change in the Consumer Price Index for
all urban consumers for the twelve-month period ending with August of the
preceding year, and rounded to the nearest multiple of ten dollars
($10).
(vii)
Standardized Medicare supplement benefit Plan G shall include only the
following: The basic (core) benefit as defined in Section 8.1(b) of this
regulation, plus one hundred percent (100%) of the Medicare Part A deductible,
skilled nursing facility care, one hundred percent (100%) of the Medicare Part
B excess charges, and medically necessary emergency care in a foreign country
as defined in Sections 8.1(c)(i), (iii), (v), and (vi), respectively. Effective
January 1, 2020, the standardized benefit plans described in Section 9.2(a)(iv)
of this regulation (Redesignated Plan G High Deductible) may be offered to any
individual who was eligible for Medicare prior to January 1, 2020.
(viii) Standardized Medicare supplement Plan
K is mandated by The Medicare Prescription Drug, Improvement and Modernization
Act of 2003, and shall include only the following:
(A) Part A Hospital Coinsurance 61st through
90th days: Coverage of one hundred percent (100%) of the Part A hospital
coinsurance amount for each day used from the 61st through the 90th day in any
Medicare benefit period;
(B) Part A
Hospital Coinsurance, 91st through 150th days: Coverage of one hundred percent
(100%) of the Part A hospital coinsurance amount for each Medicare lifetime
inpatient reserve day used from the 91st through the 150th day in any Medicare
benefit period;
(C) Part A
Hospitalization After 150 Days: Upon exhaustion of the Medicare hospital
inpatient coverage, including the lifetime reserve days, coverage of one
hundred percent (100%) of the Medicare Part A eligible expenses for
hospitalization paid at the applicable prospective payment system (PPS) rate,
or other appropriate Medicare standard of payment, subject to a lifetime
maximum benefit of an additional 365 days. The provider shall accept the
issuer's payment as payment in full and may not bill the insured for any
balance;
(D) Medicare Part A
Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient
hospital deductible amount per benefit period until the out-of-pocket
limitation is met as described in Subparagraph (J);
(E) Skilled Nursing Facility Care: Coverage
for fifty percent (50%) of the coinsurance amount for each day used from the
21st day through the 100th day in a Medicare benefit period for post-hospital
skilled nursing facility care eligible under Medicare Part A until the
out-of-pocket limitation is met as described in Subparagraph (J);
(F) Hospice Care: Coverage for fifty percent
(50%) of cost sharing for all Part A Medicare eligible expenses and respite
care until the out-of-pocket limitation is met as described in Subparagraph
(J);
(G) Blood: Coverage for fifty
percent (50%), under Medicare Part A or B, of the reasonable cost of the first
three (3) pints of blood (or equivalent quantities of packed red blood cells,
as defined under federal regulations) unless replaced in accordance with
federal regulations until the out-of-pocket limitation is met as described in
Subparagraph (J);
(H) Part B Cost
Sharing: Except for coverage provided in Subparagraph (I), coverage for fifty
percent (50%) of the cost sharing otherwise applicable under Medicare Part B
after the policyholder pays the Part B deductible until the out-of-pocket
limitation is met as described in Subparagraph (J);
(I) Part B Preventive Services: Coverage of
one hundred percent (100%) of the cost sharing for Medicare Part B preventive
services after the policyholder pays the Part B deductible; and
(J) Cost Sharing After Out-of-Pocket Limits:
Coverage of one hundred percent (100%) of all cost sharing under Medicare Parts
A and B for the balance of the calendar year after the individual has reached
the out-of-pocket limitation on annual expenditures under Medicare Parts A and
B of $4000 in 2006, indexed each year by the appropriate inflation adjustment
specified by the Secretary of the U.S. Department of Health and Human
Services.
(ix)
Standardized Medicare supplement Plan L is mandated by The Medicare
Prescription Drug, Improvement and Modernization Act of 2003, and shall include
only the following:
(A) The benefits described
in Paragraphs 9.1(e)(viii)(A), (B), (C) and (I);
(B) The benefit described in Paragraphs
9.1(e)(viii)(D), (E), (F), (G) and (H), but substituting seventy-five percent
(75%) for fifty percent (50%); and
(C) The benefit described in Paragraph
9.1(e)(viii)(J), but substituting $2000 for $4000.
(x) Standardized Medicare supplement Plan M
shall include only the following: The basic (core) benefit as defined in
Section 8.1(b) of this regulation, plus fifty percent (50%) of the Medicare
Part A deductible, skilled nursing facility care, and medically necessary
emergency care in a foreign country as defined in Sections 8.1(c)(ii), (iii)
and (vi) of this regulation, respectively.
(xi) Standardized Medicare supplement Plan N
shall include only the following: The basic (core) benefit as defined in
Section 8.1(b) of this regulation, plus one hundred percent (100%) of the
Medicare Part A deductible, skilled nursing facility care, and medically
necessary emergency care in a foreign country as defined in Sections 8.1(c)(i),
(iii) and (vi) of this regulation, respectively, with co-payments in the
following amounts:
(A) the lesser of twenty
dollars ($20) or the Medicare Part B coinsurance or co-payment for each covered
health care provider office visit (including visits to medical specialists);
and
(B) the lesser of fifty dollars
($50) or the Medicare Part B coinsurance or co-payment for each covered
emergency room visit, however, this co-payment shall be waived if the insured
is admitted to any hospital and the emergency visit is subsequently covered as
a Medicare Part A expense.
(f) New or Innovative Benefits. An issuer
may, with the prior approval of the commissioner, offer policies or
certificates with new or innovative benefits, in addition to the standardized
benefits provided in a policy or certificate that otherwise complies with the
applicable standards. The new or innovative benefits shall include only
benefits that are appropriate to Medicare supplement insurance, are new or
innovative, are not otherwise available, and are cost-effective. Approval of
new or innovative benefits must not adversely impact the goal of Medicare
supplement simplification. New or innovative benefits shall not include an
outpatient prescription drug benefit. New or innovative benefits shall not be
used to change or reduce benefits, including a change of any cost-sharing
provision, in any standardized plan.
