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(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)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 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 June 1, 2010, remain subject
to the laws and rules in effect when the policy or certificate was
delivered or issued for delivery. These are minimum standards and
do not prevent the inclusion of other provisions or benefits that
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, Insurance Code Chapter
1652, and any other applicable law.
(A)A Medicare supplement policy or certificate must
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 waive any time applicable to preexisting condition waiting
periods, elimination periods, and probationary periods in the new
Medicare supplement policy or certificate to the extent the time was
spent under the original policy.
(ii)If a Medicare supplement policy or certificate
replaces another Medicare supplement policy or certificate that has
been in effect for at least six months, the replacing policy or certificate
must 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 (relating to Guaranteed Issue for Eligible Persons)
or §3.3324(a) of this title (relating to Open Enrollment), the
issuer must reduce the period of any preexisting condition exclusion
as required by §3.3312(a)(2) of this title and §3.3324(c)
and (d) of this title.
(B)A Medicare supplement policy or certificate may
not indemnify against losses resulting from sickness on a different
basis than losses resulting from accidents.
(C)A Medicare supplement policy or certificate must
provide that benefits designed to cover 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 Medicare supplement policy or certificate may
not:
(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 or nonrenewed by the insurer solely
on the grounds of deterioration of health.
(E)Each Medicare supplement policy must be guaranteed
renewable and must comply with the provisions of clauses (i) - (vi)
of this subparagraph.
(i)The issuer may not cancel or nonrenew the policy
solely on the ground of health status of the individual.
(ii)The issuer may 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) of this subparagraph, the issuer must offer certificate holders
an individual Medicare supplement policy that, 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:
(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 offer coverage
to all persons covered under the old group policy on its date of termination.
Coverage under the new policy may 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 be without prejudice to any continuous loss that
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 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
comply with clauses (i) - (iv) of this subparagraph:
(i)A Medicare supplement policy or certificate must
provide that benefits and premiums under the policy or certificate
will 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 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 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.
Cont'd...
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