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 [
requirements of subsections (c) and (d) of this section].
(1)An issuer of a Medicare supplement policy or certificate
must [shall] comply with subparagraphs (A) and (B)
of this paragraph:
(A)An issuer must [shall] make
available to each prospective policyholder and certificate holder
a policy form or certificate form containing only the basic (core)
benefits, as defined in subsection (b) [(a)](2)
of this section.
(B)If an issuer makes available any of the additional
benefits described in subsection (b)[(a)](3)
of this section, or offers standardized benefit Plans K or L (as described
in paragraph (5)(I)[(H)] and (J)[(I)
] of this subsection), then the issuer must [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 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), for any individual who
first became eligible for Medicare before January 1, 2020.
(2)No groups, packages, or combinations
of Medicare supplement benefits other than those listed in this subsection
may [shall] 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 [subchapter] (relating to Medicare
Select Policies, Certificates, and Plans of Operation).
(3)Benefit plans must [shall]
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 [subchapter
] (relating to Definitions). Each benefit plan must [
shall] be structured in accordance with the format provided
in subsection (b)[(a)](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)[(H)
] or (J)[(I)] 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) [(K)]
of this paragraph.
(A)Standardized Medicare supplement benefit Plan A must
[shall] include only the following: The basic (core)
benefits as defined in subsection (b)[(a)](2)
of this section.
(B)Standardized Medicare supplement benefit Plan B must
[shall] include only the following: The basic (core)
benefits as defined in subsection (b)[(a)](2)
of this section, plus 100 percent of the Medicare Part A deductible
as defined in subsection (b)[(a)](3)(A)(i) of
this section.
(C)Standardized Medicare supplement benefit Plan C must
[shall] include only the following: The basic (core)
benefits as defined in subsection (b)[(a)](2)
of this section, plus 100 percent of the Medicare Part A deductible,
skilled nursing facility care, 100 percent of the Medicare Part B
deductible, and medically necessary emergency care in a foreign country
as defined in subsection (b)[(a)](3)(A)(i),
(B), (C), and (E) of this section, respectively.
(D)Standardized Medicare supplement benefit Plan D must
[shall] include only [the following]:
The basic (core) benefits (as defined in subsection (b)[(a)
](2) of this section), plus 100 percent of the Medicare Part
A deductible, skilled nursing facility care, and medically necessary
emergency care in a [an] foreign country as
defined in subsection (b)[(a)](3)(A)(i), (B),
and (E) of this section, respectively.
(E)Standardized Medicare supplement (regular) Plan
F must [shall] include only the following: The
basic (core) benefits as defined in subsection (b) [(a)](2)
of this section, plus 100 percent of the Medicare Part A deductible,
the skilled nursing facility care, 100 percent of the Medicare Part
B deductible, 100 percent of the Medicare Part B excess charges, and
medically necessary emergency care in a foreign country as defined
in subsection (b)[(a)](3)(A)(i), (B), (C), (D),
and (E) of this section, respectively.
(F)Standardized Medicare supplement Plan F with [
With] High Deductible must [shall] include
100 percent of covered expenses following the payment of the annual
deductible set forth in clause (ii) of this subparagraph.
(i)The basic (core) benefits as defined in subsection
(b)[(a)](2) of this section, plus 100 percent of
the Medicare Part A deductible, skilled nursing facility care, 100
percent of the Medicare Part B deductible, 100 percent of the Medicare
Part B excess charges, and medically necessary emergency care in a
foreign country as defined in subsection (b)[(a)](3)(A)(i),
(B), (C), (D), and (E) of this section, respectively.
(ii)The annual deductible in Plan F with [
With] High Deductible must [shall] consist
of out-of-pocket expenses, other than premiums, for services covered
by regular Plan F, and must [shall] be in addition
to any other specific benefit deductibles. The basis for the deductible
is $2,200 for 2017, and will [shall be $1,500 and shall]
be adjusted annually 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 12-month period ending
with August of the preceding year, and rounded to the nearest multiple
of $10.
(G)Standardized Medicare supplement benefit Plan G must
[shall] include only the following: The basic (core)
benefits as defined in subsection (b)[(a)](2)
of this section, plus 100 percent of the Medicare Part A deductible,
skilled nursing facility care, 100 percent of the Medicare Part B
excess charges, and medically necessary emergency care in a foreign
country as defined in subsection (b)[(a)](3)(A)(i),
(B), (D), and (E), respectively. Effective January 1, 2020, Plan
G with a High Deductible, as described in subsection (c)(5)(H), may
be offered to any individual who is eligible for Medicare before January
1, 2020.
(H)Standardized Medicare supplement
Plan G with High Deductible must include 100 percent of the covered
expenses following the payment of the annual deductible set forth
in clause (ii) of this subparagraph.
(i)The basic (core) benefits as defined in subsection
(b)(2) of this section, plus 100 percent of the Medicare Part A deductible,
skilled nursing facility care, 100 percent of the Medicare Part B
excess charges, and medically necessary emergency care in a foreign
country as defined in subsection (b)(3)(A)(i), (B), (D), and (E),
respectively.
(ii)The annual deductible in Plan G with High Deductible
must consist of out-of-pocket expenses, other than premiums, for services
covered by regular Plan G, and must be in addition to any other specific
benefit deductibles. The basis for the deductible is $2,200 for 2017,
and will be adjusted annually by the Secretary to reflect the change
in the Consumer Price Index for all urban consumers for the 12-month
period ending with August of the preceding year, and rounded to the
nearest multiple of $10.
(I)[(H)] Standardized Medicare
supplement Plan K [is mandated by the Medicare Prescription Drug,
Improvement and Modernization Act of 2003, and] must [
shall] include only the following:
(i)Part A hospital coinsurance [Hospital
Coinsurance], 61st through 90th days: Coverage of 100 percent
of the Part A hospital coinsurance amount for each day used from the
61st through the 90th day in any Medicare benefit period;
(ii)Part A hospital coinsurance [Hospital
Coinsurance], 91st through 150th days: Coverage of 100 percent
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;
(iii)Part A hospitalization after [Hospitalization
After] 150 days [Days]: On [Upon
] 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
PPS [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 [shall
] accept the issuer's payment as payment in full and may not
bill the insured for any balance;
(iv)Medicare Part A deductible [Deductible
]: Coverage for 50 percent of the Medicare Part A inpatient
hospital deductible amount per benefit period until the out-of-pocket
limitation is met as described in clause (x) of this subparagraph;
(v)Skilled nursing facility care [Nursing
Facility Care]: Coverage for 50 percent of the coinsurance amount
for each day used from the 21st day through the 100th day in a Medicare
benefit period for posthospital [post-hospital]
skilled nursing facility care eligible under Medicare Part A until
the out-of-pocket limitation is met as described in clause (x) of
this subparagraph;
(vi)Hospice care [Care]: Coverage
for 50 percent of cost sharing for all Part A Medicare eligible expenses
and respite care until the out-of-pocket limitation is met as described
in clause (x) of this subparagraph;
(vii)Blood: Coverage for 50 percent, under Medicare
Part A or B, of 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
until the out-of-pocket limitation is met as described in clause (x)
of this subparagraph;
(viii)Part B cost sharing [Cost Sharing]:
Except for coverage provided in clause (ix) of this subparagraph,
coverage for 50 percent 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 clause (x)
of this subparagraph;
(ix)Part B preventive services [Preventive
Services]: Coverage of 100 percent of the cost sharing for Medicare
Part B preventive services after the policyholder pays the Part B
deductible; and
(x)Cost sharing after out-of-pocket limits [
Sharing After Out-of-Pocket Limits]: Coverage of 100 percent
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 $5,120
in 2017 [$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].
(J)[(I)] Standardized Medicare
supplement Plan L must [is mandated by The Medicare
Prescription Drug, Improvement and Modernization Act of 2003, and
shall] include only the following:
(i)the benefits described in subparagraph (I)[
(H)](i), (ii), (iii), and (ix) of this paragraph;
(ii)the benefit described in subparagraph (I)[
(H)](iv), (v), (vi), (vii), and (viii) of this paragraph, but
substituting 75 percent for 50 percent; and
(iii)the benefit described in subparagraph (I)[
(H)](x) of this subsection, but substituting $2,560 for
$5,120 [$2000 for $4000].
(K)[(J)] Standardized Medicare
supplement Plan M must [shall] include only
the following: The basic (core) benefit as defined in subsection (b)
[(a)](2) of this section, plus 50 percent of the
Medicare Part A deductible, skilled nursing facility care, and medically
necessary emergency care in a foreign country as defined in subsection
(b)[(a)](3)(A)(ii), (B), and (E) of this section,
respectively.
(L)[(K)] Standardized Medicare
supplement Plan N must [shall] include only
the following: The basic (core) benefit as defined in subsection (b)
[(a)](2) of this section, plus 100 percent of the
Medicare Part A deductible, skilled nursing facility care, and medically
necessary emergency care in a foreign country as defined in subsection
(b)[(a)](3)(A)(i), (B), and (E) of this section,
respectively, with copayments in the following amounts:
(i)the lesser of $20 or the Medicare Part B coinsurance
or copayment for each covered health care provider office visit (including
visits to medical specialists); and
(ii)the lesser of $50 or the Medicare Part B coinsurance
or copayment for each covered emergency room visit; however, this
copayment must [shall] be waived if the insured
is admitted to any hospital and the emergency visit is subsequently
covered as a Medicare Part A expense.
(6)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 may [shall] include only
benefits that are appropriate to Medicare supplement insurance, are
new or innovative, are not otherwise available, and are cost
effective [cost-effective]. Approval of new or innovative
benefits must not adversely impact the goal of Medicare supplement
simplification. New or innovative benefits may [shall]
not include an outpatient prescription drug benefit. New or innovative
benefits may [shall] not be used to change or
reduce benefits, including a change of any cost-sharing provision,
in any standardized plan.
[(c)Benefit Standards for 1990 Standardized
Medicare Supplement Benefit Plan Policies or Certificates Issued or
Issued for Delivery on or After March 1, 1992, and with an Effective
Date for Coverage Prior to 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
meets the applicable standards in paragraphs (1) - (3) of this subsection.
These are minimum standards and do not preclude the inclusion of other
provisions or benefits which are not inconsistent with these standards.]
[(1)General standards. The following standards apply
to Medicare supplement policies and are in addition to all other requirements
of this subchapter, the Insurance Code Chapter 1652, and any other
applicable law.]
[(A)A Medicare supplement policy shall not exclude
or limit benefits for losses incurred more than six months from the
effective date of coverage because they involved a preexisting condition.
The policy or certificate may 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
six months before the effective date of coverage.]
[(i)If a Medicare supplement policy or certificate
replaces another Medicare supplement policy or certificate, the replacing
issuer shall waive any time periods applicable to preexisting condition
waiting periods, elimination periods, and probationary periods in
the new Medicare supplement policy or certificate to the extent such
time was spent under the original policy.]
[(ii)If a Medicare supplement policy or certificate
replaces another Medicare supplement policy or certificate which has
been in effect for at least six months, the replacing policy or certificate
shall not provide any time period applicable to preexisting conditions,
waiting periods, elimination periods and probationary periods for
benefits.]
Cont'd...
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