(a)Benefit standards for standardized
Medicare supplement benefit plan policies or certificates issued to
2020 newly eligible individuals. The Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA) provides that no policy or certificate that provides
coverage of the Medicare Part B deductible may be advertised, solicited,
delivered, or issued for delivery in this state as a Medicare supplement
policy or certificate to individuals newly eligible for Medicare on
or after January 1, 2020. Benefit standards applicable to Medicare
supplement policies and certificates issued to individuals eligible
for Medicare before January 1, 2020, remain subject to the requirements
of subsections (b) and (c) of this section. All policies issued to
a 2020 newly eligible individual, as defined in this subchapter, must
comply with the following benefit standards:
(1)Benefit requirements. The standards and requirements
of subsections (b) and (c) of this section apply to all Medicare supplement
policies or certificates delivered or issued for delivery to 2020
newly eligible individuals, with the exception of subsections (b)(3)(C),
(c)(5)(C), (c)(5)(E), and (c)(5)(F) of this section.
(2)Eligibility to purchase. A 2020 newly eligible
individual is only eligible to purchase standardized Medicare supplement
benefit plans A, B, D, G, High Deductible G, K, L, M, and N. Standardized
Medicare supplement benefit plans C, F, and High Deductible F may
not be offered to 2020 newly eligible individuals.
(b)[(a)] Benefit standards
for 2010 standardized Medicare supplement benefit plan policies or
certificates issued or issued for delivery with an effective date
for coverage on or after [Standards 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. This section specifies the minimum standards 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 meets the applicable
standards in paragraphs (1) - (3) of this subsection. No issuer may
offer or issue any 1990 Standardized Medicare supplement benefit plan
for sale on or after June 1, 2010. Benefit standards applicable to
Medicare supplement policies and certificates issued or issued for
delivery with an effective date before [prior to]
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]. These
are minimum standards and do not prevent [preclude]
the inclusion of other provisions or benefits that [which
] are not inconsistent with these standards.
(1)General standards. The following standards apply
to Medicare supplement policies and certificates 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 or certificate must [
shall] not exclude or limit benefits for losses incurred more
than six months from the effective date of coverage because it 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 must [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 the [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
must [shall] not provide any time period applicable
to preexisting conditions, waiting periods, elimination periods, and
probationary periods for benefits.
(iii)If a Medicare supplement policy or certificate
is issued or issued for delivery to an applicant who qualifies under §3.3312(b)
of this title [subchapter] (relating to Guaranteed
Issue for Eligible Persons) or §3.3324(a) of this title [
subchapter] (relating to Open Enrollment), the issuer must [
shall] reduce the period of any preexisting condition exclusion
as required by §3.3312(a)(2) of this subchapter and §3.3324(c)
and (d) of this title [subchapter].
(B)A Medicare supplement policy or certificate may [
shall] not indemnify against losses resulting from sickness
on a different basis than losses resulting from accidents.
(C)A Medicare supplement policy or certificate must [
shall] provide that benefits designed to cover cost-sharing [
cost sharing] amounts under Medicare will be changed automatically
to coincide with any changes in the applicable Medicare deductible,
copayment, or coinsurance amounts. Premiums may be modified to correspond
with such changes.
(D)A [No] Medicare supplement
policy or certificate may not: [shall]
(i)provide for termination of coverage
of a spouse solely because of the occurrence of an event specified
for termination of coverage of the insured, other than the nonpayment
of premium;[,] or
(ii)be canceled [cancelled]
or nonrenewed by the insurer solely on the grounds of deterioration
of health.
(E)Each Medicare supplement policy must [
shall] be guaranteed renewable and must [shall]
comply with the provisions of clauses (i) - (vi) [(v)]
of this subparagraph.
(i)The issuer may [shall] not
cancel or nonrenew the policy solely on the ground of health status
of the individual.
(ii)The issuer may [shall] not
cancel or nonrenew the policy for any reason other than nonpayment
of premium or material misrepresentation.
(iii)If the Medicare supplement policy is terminated
by the group policyholder and is not replaced as provided in clause
(v) [(iv)] of this subparagraph, the issuer must [
shall] offer certificate holders an individual Medicare supplement
policy that, [which] at the option of the certificate
holder:
(I)provides for continuation of the benefits contained
in the group policy; or
(II)provides for benefits that otherwise meet the
requirements of this subparagraph.
(iv)If an individual is a certificate holder in a
group Medicare supplement policy and the individual terminates membership
in the group, the issuer must [shall]:
(I)offer the certificate holder the conversion opportunity
described in clause (iii) of this subparagraph; or
(II)at the option of the group policyholder, offer
the certificate holder continuation of coverage under the group policy.
(v)If a group Medicare supplement policy is replaced
by another group Medicare supplement policy purchased by the same
policyholder, the issuer of the replacement policy must [
shall] offer coverage to all persons covered under the old group
policy on its date of termination. Coverage under the new policy may
[shall] not result in any exclusion for preexisting
conditions that would have been covered under the group policy being
replaced.
(vi)If an individual is issued a
certificate in Texas in a group Medicare supplement policy and the
individual moves out of the state, the issuer may replace the Texas
certificate with a certificate of the same standardized benefit plan
type, approved by the new state of residence, if the issuer acts uniformly
in its treatment of certificate holders who move out of Texas.
(F)Termination of a Medicare supplement policy or
certificate must [shall] be without prejudice
to any continuous loss that [which] commenced
while the policy was in force, but the extension of benefits beyond
the period during which the policy was in force may be conditioned on
[upon] the continuous total disability of the insured,
limited to the duration of the policy benefit period, if any, or payment
of the maximum benefits. Receipt of Medicare Part D benefits must
not be considered in determining a continuous loss.
(G)A Medicare supplement policy or certificate must [
shall] comply with clauses (i) - (iv) of this subparagraph:
(i)A Medicare supplement policy or certificate must [
shall] provide that benefits and premiums under the policy or
certificate will [shall] be suspended at the
request of the policyholder or certificate holder for the period, not
to exceed 24 months, in which the policyholder or certificate
holder 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 certificate holder notifies the issuer of the
policy or certificate within 90 days after the date the individual
becomes entitled to that assistance.
(ii)If suspension occurs and if the policyholder or
certificate holder loses entitlement to medical assistance, the policy
or certificate must [shall] be automatically
reinstituted effective as of the date of termination of entitlement
if the policyholder or certificate holder provides notice of loss
of entitlement within 90 days after the date of loss and pays the
premium attributable to the period, effective as of the date of termination
of entitlement.
(iii)Each Medicare supplement policy must [
shall] provide that benefits and premiums under the policy will
[shall] 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 [shall] 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 [shall
] comply with subclauses (I) - (III) of this clause.
(I)Reinstitution of coverage must [shall]
not provide for any waiting period with respect to treatment of preexisting
conditions.
(II)Reinstitution of coverage must [shall
] provide for resumption of coverage that is substantially equivalent
to coverage in effect before the date of suspension.
(III)Reinstitution of coverage must [shall
] 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 [
Basic (Core) Benefits Common] to Medicare supplement insurance
benefit plans [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 [shall] 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 [in
lieu] 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 [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 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;
(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
[Medicare eligible] hospice care and respite care
expenses.
(3)Standards for additional benefits [Additional
Benefits]. The following additional benefits must [
shall] 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) [(b)] 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 [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 [Deductible]:
coverage for 100 percent of the Medicare Part B deductible amount
per calendar year regardless of hospital confinement.
(D)One hundred percent [Hundred Percent]
of the Medicare Part B excess charges [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 [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 [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" means [shall mean] care needed immediately
because of an injury or an illness of sudden and unexpected onset.
(c)[(b)] 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 [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 Cont'd...
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