| (iii) Each Medicare supplement policy must provide
that benefits and premiums under the policy will be suspended (for
any period that may be provided by federal regulation) at the request
of the policyholder or certificate holder if the policyholder or certificate
holder 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 certificate holder loses coverage
under the group health plan, the policy must be automatically reinstituted,
effective as of the date of loss of coverage, if the policyholder
or certificate holder provides notice of loss of coverage within 90
days after the date of the loss.
(iv) Reinstitution of coverages must comply with subclauses
(I) - (III) of this clause.
(I) Reinstitution of coverage must not provide for
any waiting period with respect to treatment of preexisting conditions.
(II) Reinstitution of coverage must provide for resumption
of coverage that is substantially equivalent to coverage in effect
before the date of suspension.
(III) Reinstitution of coverage must provide for classification
of premiums on terms at least as favorable to the policyholder or
certificate holder as the premium classification terms that would
have applied to the policyholder or certificate holder had the coverage
not been suspended.
(2) Standards for basic (core) benefits common to Medicare
supplement insurance benefit plans A, B, C, D, F, F with High Deductible,
G, G with High Deductible, M, and N. Every issuer of Medicare supplement
insurance benefit plans must make available a policy or certificate
including only the following basic "core" package of benefits to each
prospective insured. An issuer may make available to prospective insureds
any of the other Medicare Supplement Insurance Benefit Plans in addition
to the basic core package, but not instead of it. These plans include:
(A) 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;
(B) coverage of Part A Medicare eligible expenses incurred
for hospitalization to the extent not covered by Medicare for each
Medicare lifetime inpatient reserve day used;
(C) on exhaustion of the Medicare hospital inpatient
coverage, including the lifetime reserve days, coverage of 100 percent
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 must accept the issuer's
payment as payment in full and may not bill the insured for any balance;
(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 regulations, unless
replaced in accordance with federal regulations;
(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;
(F) coverage of cost sharing for all Part A Medicare-eligible
hospice care and respite care expenses.
(3) Standards for additional benefits. The following
additional benefits must be included in Medicare supplement benefit
Plans B, C, D, F, F with High Deductible, G, G with High Deductible,
M, and N as provided by subsection (c) of this section.
(A) Medicare Part A deductible:
(i) coverage for 100 percent of the Medicare Part A
inpatient hospital deductible amount per benefit period; or
(ii) coverage for 50 percent 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 100 percent
of the Medicare Part B deductible amount per calendar year regardless
of hospital confinement.
(D) One hundred percent of the Medicare Part B excess
charges: coverage for all of the difference between the actual Medicare
Part B charges as billed, not to exceed any charge limitation established
by the Medicare program or state law, and the Medicare-approved Part
B charge.
(E) Medically necessary emergency care in a foreign
country: coverage to the extent not covered by Medicare for 80 percent
of the billed charges for Medicare-eligible expenses for medically
necessary emergency hospital, physician, and medical care received
in a foreign country, which 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" means care
needed immediately because of an injury or an illness of sudden and
unexpected onset.
(c) Standard Medicare supplement benefit plans for
2010 Standardized Medicare supplement benefit plan policies or certificates
issued or issued for delivery with an effective date for coverage
on or after June 1, 2010. The following standards are applicable to
all Medicare supplement policies or certificates issued or issued
for delivery in this state with an effective date for coverage on
or after June 1, 2010. No insurance policy, subscriber contract, certificate,
or evidence of coverage may be advertised, solicited, or issued for
delivery in this state as a Medicare supplement policy unless the
policy, contract, certificate, or evidence of coverage complies with
these benefit plan standards. Benefit plan standards applicable to
Medicare supplement policies and certificates issued or issued for
delivery with an effective date for coverage before June 1, 2010,
remain subject to the laws and rules in effect when the policy or
certificate was delivered, or issued for delivery.
(1) An issuer of a Medicare supplement policy or certificate
must comply with subparagraphs (A) and (B) of this paragraph:
(A) An issuer must make available to each prospective
policyholder and certificate holder a policy form or certificate form
containing only the basic (core) benefits, as defined in subsection
(b)(2) of this section.
(B) If an issuer makes available any of the additional
benefits described in subsection (b)(3) of this section, or offers
standardized benefit Plans K or L (as described in paragraph (5)(I)
and (J) of this subsection), then the issuer must make available to
each prospective policyholder and certificate holder who first became
eligible for Medicare before January 1, 2020, in addition to a policy
form or certificate form with only the basic (core) benefits as described
in subparagraph (A) of this paragraph, a policy form or certificate
form containing either:
(i) standardized benefit Plan C (as described in paragraph
(5)(C) of this subsection); or
(ii) standardized benefit Plan F (as described in paragraph
(5)(E) of this subsection).
(2) No groups, packages, or combinations of Medicare
supplement benefits other than those listed in this subsection may
be offered for sale in this state, except as may be permitted in paragraph
(6) of this subsection and in §3.3325 of this title (relating
to Medicare Select Policies, Certificates, and Plans of Operation).
(3) Benefit plans must be uniform in structure, language,
and format, as well as designation, to the standard benefit plans
listed in this paragraph and conform to the definitions in §3.3303
of this title (relating to Definitions). Each benefit plan must be
structured in accordance with the format provided in subsection (b)(2)
and (b)(3) of this section or, in the case of Plans K or L, in accordance
with the format provided in paragraph (5)(I) or (J) of this subsection,
and list the benefits in the order shown. For purposes of this subsection,
"structure, language, and format" means style, arrangement, and overall
content of a benefit.
(4) In addition to the benefit plan designations required
in paragraph (3) of this subsection, an issuer may use other designations
to the extent permitted by law.
(5) The make-up of 2010 Standardized Benefit Plans
is as specified in subparagraphs (A) - (L) of this paragraph.
(A) Standardized Medicare supplement benefit Plan A
must include only the following: The basic (core) benefits as defined
in subsection (b)(2) of this section.
Cont'd... |
