| (C) upon exhaustion of all Medicare hospital inpatient coverage
including the lifetime reserve days, coverage of the Medicare Part A eligible
expenses for hospitalization paid at the diagnostic related group (DRG) day
outlier per diem or other appropriate standard of payment, subject to a lifetime
maximum benefit of an additional 365 days;
(D) coverage under Medicare Parts A and B for the reasonable
cost of the first three pints of blood (or equivalent quantities of packed
red blood cells, as defined under federal regulation) unless replaced in accordance
with federal regulation; and
(E) coverage for the coinsurance amount (or in the case of
hospital outpatient department services paid under a prospective payment system,
the copayment amount) of Medicare eligible expenses under Part B regardless
of hospital confinement, subject to the Medicare Part B deductible.
(3) Standards for Additional Benefits. The additional benefits
as uniformly defined in subparagraphs (A) - (K) of this paragraph shall be
included in Medicare Supplement Benefit Plans "B" through "J" only as provided
in paragraph (5)(A) - (I) of this section.
(A) Medicare Part A Deductible--Coverage for all of the Medicare
Part A inpatient hospital deductible amount per benefit period.
(B) Skilled Nursing Facility Care--Coverage for the actual
billed charges up to the coinsurance amount 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.
(C) Medicare Part B Deductible--Coverage for all of the Medicare
Part B deductible amount per calendar year regardless of hospital confinement.
(D) Eighty Percent of the Medicare Part B Excess Charges--Coverage
for 80% of the difference between the actual Medicare Part B charge as billed
and the Medicare-approved Part B charge, not to exceed any charge limitation
established by the Medicare program or state law.
(E) One Hundred Percent of the Medicare Part B Excess Charges--Coverage
for all of the difference between the actual Medicare Part B charge as billed
and the Medicare-approved Part B charge, not to exceed any charge limitation
established by the Medicare program or state law.
(F) Basic Outpatient Prescription Drug Benefit--Coverage for
50% of outpatient prescription drug charges, after a $250 calendar year deductible,
to a maximum of $1,250 in benefits received by the insured per calendar year,
to the extent not covered by Medicare.
(G) Extended Outpatient Prescription Drug Benefit--Coverage
for 50% of outpatient prescription drug charges, after a $250 calendar year
deductible to a maximum of $3,000 in benefits received by the insured per
calendar year, to the extent not covered by Medicare.
(H) Medically Necessary Emergency Care in a Foreign Country--Coverage
to the extent not covered by Medicare for 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, subject
to a calendar year deductible of $250, and a lifetime maximum benefit of $50,000.
For purposes of this benefit, "emergency care" shall mean care needed immediately
because of an injury or an illness of sudden and unexpected onset.
(I) Preventive Medical Care Benefit or Services--Coverage for
the preventive health services described in clauses (i) - (iv) of this subparagraph.
Coverage for preventive medical care benefits or services 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 American Medical
Association Current Procedural Terminology (AMA CPT) codes, to a maximum of
$120 annually under this benefit. This benefit shall not include payment for
any procedure covered by Medicare:
(i) an annual clinical preventive medical history and physical
examination that may include tests and services from clause (ii) of this subparagraph
and patient education to address preventive health care measures;
(ii) any one or a combination of the following preventive screening
tests or preventive services, the frequency of which is considered medically
appropriate:
(I) digital rectal examination;
(II) dipstick urinalysis for hematuria, bacteriuria, and proteinuria;
(III) pure tone (air only) hearing screening test, administered
or ordered by a physician;
(IV) serum cholesterol screening (every five years);
(V) thyroid function test; or
(VI) diabetes screening;
(iii) tetanus and diphtheria booster (every 10 years);
(iv) any other tests or preventive measures determined appropriate
by the attending physician.
(J) At-Home Recovery Benefit--Coverage for services to provide
short-term, at-home assistance with activities of daily living for those recovering
from an illness, injury, or surgery.
(i) For purposes of this benefit, the following definitions
in subclauses (I) - (IV) of this clause shall apply.
(I) Activities of daily living include, but are not limited
to, bathing, dressing, personal hygiene, transferring, eating, ambulating,
assistance with drugs that are normally self-administered, and changing bandages
or other dressings.
(II) Care provider means a duly qualified or licensed home
health aide or homemaker, personal care aide, or nurse provided through a
licensed home health care agency or referred by a licensed referral agency
or licensed nurses registry.
(III) Home shall mean any place used by the insured as a place
of residence, provided that such place would qualify as a residence for home
health care services covered by Medicare. A hospital or skilled nursing facility
shall not be considered the insured's place of residence.
(IV) At-home recovery visit means the period of a visit required
to provide at-home recovery care, without limit on the duration of the visit,
except each consecutive four hours in a 24-hour period of services provided
by a care provider is one visit.
(ii) Coverage requirements and limitations.
(I) At-home recovery services provided must be primarily services
which assist in activities of daily living.
(II) The insured's attending physician must certify that the
specific type and frequency of at-home recovery services are necessary because
of a condition for which a home care plan of treatment was approved by Medicare.
(III) Coverage is limited to:
(-a-) no more than the number and type of at-home recovery
visits certified as necessary by the insured's attending physician. The total
number of at-home recovery visits shall not exceed the number of Medicare
approved home health care visits under a Medicare approved home care plan
of treatment;
(-b-) the actual charges for each visit up to maximum coverage
of $40 per visit;
(-c-) $1,600 per calendar year;
(-d-) seven visits in any one week;
(-e-) care furnished on a visiting basis in the insured's home;
(-f-) services provided by a care provider as defined in this
section;
(-g-) at-home recovery visits while the insured is covered
under the policy or certificate and not otherwise excluded;
(-h-) at-home recovery visits received during the period the
insured is receiving Medicare approved home care services or no more than
eight weeks after the service date of the last Medicare approved home health
care visit.
(iii) Coverage is excluded for:
(I) home care visits paid for by Medicare or other government
programs; and
(II) care provided by family members, unpaid volunteers, or
providers who are not care providers.
(K) New or Innovative Benefits--Any benefit which an issuer
may, with the prior approval of the commissioner, offer in addition to the
benefits provided in a policy or certificate that otherwise complies with
the applicable standards. The new or innovative benefits may include benefits
that are appropriate to Medicare supplement insurance, new or innovative,
not otherwise available, cost-effective, and offered in a manner which is
consistent with the goal of simplification of Medicare supplement policies.
Cont'd... |
