CHAPTER Ins 1900 ACCIDENT AND HEALTH INSURANCE
PART Ins 1901 MINIMUM STANDARDS
FOR ACCIDENT AND HEALTH INSURANCE - EXPIRED
Source. (See Revision Note at chapter heading for Ins
6000)
PART Ins 1902 MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT
POLICIES ISSUED PRIOR TO ADOPTION OF INSURANCE REGULATION 1905
Statutory Authority: RSA 400-A:15 II
Ins
1902.01 Purpose. The purpose of this part is to provide for
the reasonable standardization of coverage and simplification of benefits of
medicare supplement accident and sickness insurance policies and medicare
supplement subscriber contracts in order to facilitate the public understanding
and comparison and to eliminate provisions contained in such policies or
contracts which may be misleading or confusing in connection either with the
purchase of such policies or with the settlement of claims and to provide for
full disclosures in the sale of such coverage.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5656, eff 7-1-93, EXPIRED: 7-1-99
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
Ins
1902.02 Applicability And Scope.
(a) Except as provided in paragraph (b) this part
shall apply to:
(1)
All medicare supplement policies and subscriber contracts advertised,
solicited, delivered or issued for delivery in this state prior to July 1,
1992; and
(2)
All certificates issued under group medicare supplement policies or
subscriber contracts, which policies or contracts have been advertised,
solicited, delivered, or issued for delivery in this state prior to July 1,
1992.
(b) This part shall not apply to policies or
contracts:
(1)
Of one or more employers or labor organizations;
(2)
Of the trustees of a fund established by one or more employers or labor
organizations, or a combination thereof;
(3)
For employees or former employees, or a combination thereof;
(4)
For members or former members, or a combination thereof, of the labor
organizations; or
(5)
Medicare supplement policies and certificates subject to Ins 1905.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
Ins
1902.03 Definitions.
(a) "Applicant" means:
(1)
In the case of an individual medicare supplement policy or subscriber
contract, the person who seeks to contract for insurance benefits; and
(2)
In the case of a group medicare supplement policy or subscriber
contract, the proposed certificateholder.
(b) "Certificate" means any certificate
issued under a group medicare supplement policy, which policy has been
advertised, solicited, delivered, or issued for delivery in this state.
(c) "Medicare supplement policy" means
a group or individual policy of accident and health insurance or a subscriber
contract of hospital service corporations, medical service corporations, or
health service corporations which is advertised, marketed, or designed
primarily as a supplement to reimbursements under medicare for the hospital,
medical, or surgical expenses of persons eligible for medicare and includes:
(1)
A policy or contract for one or more employers or labor organizations,
or of the trustees of a fund established by one or more employers or labor
organizations, or a combination thereof, for employees or former employees, or
combination thereof, or for members or former members, or combination thereof,
of the labor organizations; or
(2)
A policy or contract of any professional, trade, or occupational
association for its members or former or retired members, or a combination
thereof, if such association:
a.
Is composed of individuals all of whom are actively engaged in the same
profession, trade, or occupation;
b.
Has been maintained in good faith for purposes other than obtaining
insurance; and
c.
Has been in existence for at least 2 years prior to the date of its
initial offering of such policy or plan to its members.
(d) "Medicare" means the "Health Insurance
For The Aged Act," Title XVIII of the Social Security Amendments of 1965,
as then constituted or later amended.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5119, eff 4-25-91; amd by #5421, eff 7-1-92; ss by #5656, eff 7-1-93; ss
by #7017, INTERIM, eff 7-1-99, EXPIRED:10-29-99
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
Ins
1902.04 Policy Definitions And Terms. No medicare supplement policy subject to this
part shall contain definitions or terms respecting the matters set forth herein
unless such definitions or terms conform to the requirements of this section as
follows:
(a) "Accident, "accidental
injury," or "accidental means" shall be defined to employ
"result" language and shall not include words which establish an
accidental means test or use words such as "external, violent, visible
wounds," or similar words of description or characterization so that:
(1)
The definition shall not be more restrictive than the following: “injury or injuries, for which benefits are
provided, means accidental bodily injury sustained by the insured person which
is the direct result of an accident, independent of disease or bodily infirmity
or any other cause and occurrence while the insurance is in force;” and
(2) The definition may include coverage of injuries for which
benefits are provided under any workers' compensation, employer's liability or
similar law, motor vehicle no-fault plan, unless prohibited by law.
(b) "Benefit period" or "medicare
benefit period" shall not be defined as more restrictive than as that
defined in the medicare program.
(c) "Convalescent nursing home,"
"extended care facility," or "skilled nursing facility"
shall be defined in relation to its status, facilities, and available services
so that:
(1)
A definition of such home or facility shall not be more restrictive than
one requiring that it:
a.
Be operated pursuant to law;
b.
Be approved for payment of medicare benefits or be qualified to receive
such approval, if so requested;
c.
Be primarily engaged in providing, in addition to room and board
accommodations, skilled nursing care under the supervision of a duly licensed
physician;
d.
Provide continuous 24-hours-a-day nursing service by or under the
supervision of a registered graduate professional nurse R.N.; and
e.
Maintains a daily medical record of each patient ; and
(2)
The definition of such home or facility may provide that such term shall
not be inclusive of:
a.
Any home, facility, or part thereof used primarily for rest;
b.
A home or facility for the aged or for the care of drug addicts or
alcoholics; or
c.
A home or facility primarily used for the care and treatment of mental
diseases, or disorders, or custodial or educational care.
(d) "Hospital" may be defined in
relation to its status, facilities, and available services or to reflect its
accreditation by the Joint Commission on Accreditation of Hospitals so that:
(1)
The definition of the term "hospital" shall not be more
restrictive than one requiring that the hospital:
a.
Be an institution operated pursuant to law;
b.
Be primarily and continuously engaged in providing or operating, either
on its premises or in facilities available to the hospital on a prearranged
basis and under the supervision of a staff of duly licensed physicians,
medical, diagnostic, and major surgical facilities for the medical care and
treatment of sick or injured persons on an inpatient basis for which a charge
is made; and
c.
Provide 24-hour nursing service by or under the supervision of
registered graduate professional nurses; and
(2)
The definition of the term "hospital" may state that such term
shall not be inclusive of:
a.
Convalescent homes, convalescent, rest, or nursing facilities;
b.
Facilities primarily affording custodial, educational or rehabilitory
care;
c.
Facilities for the aged, drug addicts, or alcoholics; or
d.
Any military or veterans hospital or soldiers home or any hospital
contracted for or operated by any national government or agency thereof for the
treatment of members or ex-members of the armed forces, except for services
rendered on an emergency basis where a legal liability exists for charges made
to the individual for such services.
(e) "Medicare" shall be defined as "The Health Insurance For The
Aged Act, Title XVIII of the Social Security Amendments of 1965 as then
constituted or later amended," or "Title I, Part I of Public Laws of
89-97, as enacted by the Eighty-ninth Congress of the United States of America
and popularly known as The Health Insurance For The Aged Act, as then
constituted and any later amendments or substitutes thereof," or words of
similar import. Medicare consists of
Part A and Part B. Part A refers to
hospital benefits and Part B refers to Medicaid benefits.
(f) "Issuer" shall be defined as
including insurance companies, fraternal benefit societies, nonprofit health service
corporations, health maintenance organizations, and any other entity
advertising, soliciting, delivering or issuing for delivery in this state
medicare supplement policies or certificates.
(g) "Medicare eligible expenses" shall
be defined as health care expenses
of the kinds covered by medicare, to the extent recognized as reasonable by
medicare. Payment of benefits by
insurers for medicare eligible expenses may be conditioned upon the same or
less restrictive payment conditions, including determinations of medical
necessity as are applicable to medicare claims.
(h) "Mental or nervous disorders" shall
not be defined more restrictively than a definition including neurosis,
psychoneurosis, psychopathy, psychosis, or mental or emotional disease or
disorder of any kind.
(i) "Nurses" may be defined so that the
description of nurse is restricted to a type of nurse, such as a registered
graduate professional nurse, R.N., a licensed practical nurse, L.P.N. or a
licensed vocational nurse, L.V.N. If the
words "nurse," "trained nurse" or "registered
nurse" are used without specific instruction, then the insurer shall
recognize the services of any individual who qualified under such terminology
in accordance with the applicable statutes or administrative rules of the
licensing or registry board of the state.
(j) "Physician" may be defined by
including words such as "duly qualified physician" or "duly
licensed physician." The use of
such terms shall require an insurer to recognize and to accept, to the extent
of its obligation under the contract, all providers of medical care and
treatment when such services are within the scope of the provider's licensed
authority and are provided pursuant to applicable laws.
(k)
"Preexisting condition" shall be defined as a condition for which medical advice or treatment was recommended
by or received from a physician within the 6 month period preceding the
effective date of the coverage of the insured person.
(l) "Sickness" shall not be defined to
be more restrictive than the following:
(1)
Sickness means sickness or disease of an insured person which first
manifests itself after the effective date of insurance and while the insurance
is in force; and
(2)
The definition may be further modified to exclude sickness or disease
for which benefits are provided under any workers' compensation, occupational
disease, employer's liability, or similar law.
(m)
"Health care expenses" shall be defined as expenses of health maintenance organizations associated with the delivery
of health care services which are analogous to incurred losses of insurers, but the definition shall not include
the following expenses:
(1)
Home office and overhead costs;
(2)
Advertising costs;
(3)
Commissions and other acquisitional costs;
(4)
Taxes;
(5)
Capital costs;
(6)
Administrative costs; or
(7)
Claims processing cost.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss
by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff
7-1-99, EXPIRED: 10-29-99
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
Ins
1902.05 Prohibited Policy Provisions.
(a) No medicare supplement policy shall limit or
exclude coverage by type of illness, accident, treatment, or medical condition,
except as follows:
(1)
Foot care in connection with corns, calluses, flat feet, fallen arches,
weak feet, chronic foot strain, or symptomatic complaints of the feet;
(2)
Alcoholism, drug addiction,
and mental or emotional disorders except as provided in RSA 415:18-a; RSA
419:5-a; and RSA 420:5-a;
(3)
Illness, treatment, or medical condition arising out of:
a.
War or act of war, whether declared or undeclared;
b.
Participation in a felony, riot or insurrection;
c.
Service in the armed forces or units auxiliary thereto;
d.
Suicide, sane or insane, attempted suicide or intentionally
self-inflicted injury;
e.
Aviation;
(4)
Cosmetic surgery, except that "cosmetic surgery" shall not
include reconstructive surgery when such service is incidental to or follows
surgery resulting from trauma, infection, other diseases or disorders of the
involved part;
(5)
Care in connection with the detection and correction by manual or
mechanical means of structural imbalance, distortion, or subluxation in the
human body for purposes of removing nerve interference and the effects thereof,
where such interference is the result of or related to distortion, misalignment
or subluxation of, or in the vertebral column;
(6) Treatment provided in a governmental hospital, benefits provided under
governmental program, except Medicaid, any state or federal workers'
compensation, employers' liability or occupational disease law or any motor
vehicle no-fault law, services rendered by employees of hospitals, laboratories
or other institutions, services performed by a member of the covered person's
immediate family and services for which no charge is normally made in the
absence of insurance;
(7)
Dental care or treatment;
(8)
Eyeglasses, hearing aids, and examinations for the prescription or
fitting thereof;
(9)
Rest cures, custodial care, transportation, and routine physical
examinations; or
(10) Territorial limitations outside the
(b) No medicare supplement policy may use waivers
to exclude, limit, or reduce coverage or benefits for specifically named or
described preexisting diseases or physical conditions.
(c) No medicare supplement policy shall include
terms which provide that the policy may be cancelled or nonrenewed by the
insurer solely on the grounds of deteriorated health.
(d) The terms "medicare supplement,"
"medigap", and words of similar import shall not be used unless the
policy is issued in compliance with this part.
(e) No medicare supplement insurance policy,
contract, or certificate in force in this state shall contain benefits which
duplicate benefits provided by medicare.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5119, eff 4-25-91; amd by #5421, eff 7-1-92; ss by #5656, eff 7-1-93; ss
by #7017, INTERIM, eff 7-1-99, EXPIRED:10-29-99
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
Ins
1902.06 Minimum Standards For
Medicare Supplement Policies. No
policy or certificate shall be advertised, solicited, delivered, or issued for
delivery in this state as a medicare supplement policy or certificate unless it
meets or exceeds the following minimum standards:
(a) Medicare supplement policies and
certificates, advertised, solicited, delivered, or issued for delivery in this
state shall comply with the following:
(1)
A medicare supplement policy or certificate shall not exclude or limit
benefits for losses incurred more than 6 months from the effective date of
coverage because it involved a preexisting condition and shall not define a
preexisting condition more restrictively than the definition found in Ins
1902.04(k);
(2)
A medicare supplement policy or certificate shall not indemnify against
losses resulting from sickness on a different basis than losses resulting from
accidents;
(3)
A medicare supplement policy or certificate shall 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 amount and co-payment percentage factors. Premiums may be changed to correspond with
such benefit changes, but such changes in premiums may not be implemented prior
to their approval by the commissioner pursuant to RSA 415:1;
(4)
A "noncancellable," "guaranteed renewable," or
"noncancellable and guaranteed renewable" medicare supplement policy
or certificate shall not 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;
(5)
The rights of an insured with respect to or upon termination shall be as
follows:
a.
Except as authorized by the insurance commissioner an issuer shall
neither cancel nor nonrenew a medicare supplement policy or certificate for any
reason other than nonpayment of premium or material misrepresentation;
b.
If a group medicare supplement insurance policy is terminated by the
group policyholder and not replaced as provided in Ins 1902.06(a)(5)e., the
insurer shall give written notice to certificateholders and offer an individual
medicare supplement policy with at least the following choices:
1.
An individual medicare supplement policy currently offered by the issuer
having comparable benefits to those contained in the terminated group medicare
supplement policy; and
2.
An individual medicare supplement policy that provides only such
benefits as are required to meet the minimum standards as defined in Ins
1902.06(b);
c.
If membership in a group is terminated, the issuer shall give written
notice and:
1.
Offer the certificateholder such conversion opportunities as are
described in Ins 1902.06(a)(5)e.; or
2.
At the option of the group policyholders, offer the certificateholder
continuation of coverage under the group policy;
d.
The certificateholder shall have 30 days following receipt of written
notice to apply for any conversion policy offered pursuant to this section;
e. 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 shall offer coverage to all persons
covered under the old group policy on its date of termination; and
f.
Coverage under the replacement policy shall not result in any exclusion
for preexisting conditions that would have been covered under the group policy
that was replaced; and
(6)
The termination of a medicare supplement policy or certificate shall be
without prejudice to any continuous loss 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 predicated 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.
(b) Medicare supplement policies advertised,
solicited, delivered, or issued for delivery in this state shall meet or exceed
the following minimum benefit standards:
(1)
Coverage of part A medicare eligible expenses for hospitalization to the
extent not covered by medicare for the 61st day through the 90th day in any
medicare benefit period;
(2)
Coverage for either all or none of the medicare part A inpatient
hospital deductible amount;
(3)
Coverage of part A medicare eligible expenses incurred as daily hospital
charges during the use of Medicare’s lifetime hospital inpatient reserve days;
(4)
Upon exhaustion of all medicare hospital inpatient coverage including
the lifetime reserve days, coverage of 90 percent of all medicare part A
eligible expenses for hospitalization not covered by medicare subject to a
lifetime maximum benefit of an additional 365 days;
(5)
Coverage under medicare part A for the reasonable cost of the first 3
pints of blood or equivalent quantities of packed red blood cells, as defined
under 42 CFR Part 409.87 unless replaced in accordance with 42 CFR Part 409.87
or already paid for under part B;
(6)
Coverage for coinsurance amount of medicare eligible expenses under part
B regardless of hospital confinement subject to a maximum calendar year
out-of-pocket amount equal to the $100 medicare part B deductible; and
(7)
Coverage under medicare part B for the reasonable cost of the first 3
pints of blood or equivalent quantities of packed red blood cells, as defined
under 42 CFR Part 409.87 unless replaced in accordance with 42 CFR Part 409.87
or already paid under part A, subject to the medicare deductible amount.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss
by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff
7-1-99, EXPIRED: 10-29-99
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
Ins
1902.07 Required Disclosure
Provisions.
(a) All medicare supplement policies shall
include the following general rules:
(1)
Medicare supplement policies shall include a renewal or continuation
provision which shall be consistent with the type of contract issued,
captioned, and shall appear on the first page of the policy;
(2)
A medicare supplement policy which provides for the payment of benefits
based on standards described as "usual and customary,"
"reasonable and customary," or words of similar import, shall include
a definition of such terms and an explanation of such terms in its accompanying
outline of coverage;
(3) If a medicare supplement policy
contains any limitations with respect to preexisting conditions, such
limitations shall appear as a separate paragraph of the policy and be labeled
as "preexisting condition limitations";
(4)
All medicare supplement policies or certificates shall have a notice
prominently printed on the first page of the policy or certificate attached
thereto stating that the policyholder or certificateholder shall have the right
to return the policy or certificate within 30 days of its delivery and to have
the premium refunded if, after examination of the policy or certificate, the
insured person is not satisfied for any reason;
(5)
Except as otherwise provided in this part, the terms "medicare
supplement," "medigap" and words of similar import shall not be
used unless the policy is issued in compliance with Ins 1902.06; and
(6)
Except for riders or endorsements by which the insurer effectuates a
request made in writing by the insured, exercises a specifically reserved right
under a medicare supplement policy, or is required to reduce or eliminate
benefits to avoid duplication of medicare benefits, all riders or endorsements
added to a medicare supplement policy after date of issue or at reinstatement
or renewal which reduce or eliminate benefits or coverage in the policy shall
require signed acceptance by the insured.
After the date of policy issue, any rider or endorsement which increases
benefits or coverage with a concomitant increase in premium during the policy
term shall be agreed to in writing signed by the insured, unless the benefits
are required by the minimum standards for medicare supplement policies, or if
the increased benefits or coverage is required by law. Where a separate additional premium is
charged for benefits provided in connection with riders or endorsements, such
premium charge shall be set forth in the policy.
(b) The following notice requirements shall be
met:
(1)
As soon as practicable, but not later than 30 days prior to the annual
effective date of any medicare benefit changes, every insurer, health care
service plan, or other entity providing medicare supplement insurance or
benefits to a resident of this state shall notify its policyholders, contractholders
and certificateholders of modifications it has made to medicare insurance
policies or contracts;
(2)
The notice required by (1) above shall:
a.
Include a description of revisions to the medicare program and a
description of each modification made to the coverage provided under the
medicare supplement insurance policy or contract; and
b.
Inform each covered person as to when any premium adjustment is to be
made due to changes in medicare;
(3)
The notice of benefit modifications and any premium adjustments shall be
in outline form and in clear and simple terms so as to facilitate
comprehension; and
(4)
Such notices shall not contain or be accompanied by any solicitation.
(c)
Medicare supplement policies shall contain the following information:
(1)
Insurers issuing medicare supplement policies or certificates for
delivery in this state shall provide an outline of coverage to all applicants
at the time application is made and, except for direct response policies, shall
obtain an acknowledgment of receipt of such outline from the applicant; and
(2)
If an outline of coverage is provided at the time of application and the
medicare supplement policy or certificate is issued on a basis which would
require revision of the outline, a substitute outline of coverage properly
describing the policy or certificate shall accompany such policy or certificate
when it is delivered and contain the following statement, in no less than 12
point type, immediately above the company name: "It is not identical to
the outline of coverage provided upon application and the coverage originally
applied for has not been issued;" and
(3)
In addition to the requirements of subparagraphs (1) and (2), insurers
issuing medicare supplement policies or certificates shall provide an outline
of coverage for such medicare supplement policies or certificates to any
prospective purchaser upon request.
(d) Notice regarding policies or subscriber
contracts which are not medicare supplement policies shall include:
(1)
The following in no less than 12 point type, either printed or attached
to the first page of the outline of coverage delivered to insureds under the
policy or subscriber contract, or if no outline of coverage is delivered, to
the first page of the policy, certificate or subscriber contract delivered to
insureds: "This, policy, certificate or subscriber contract, is not a
medicare supplement policy or certificate.
If you are eligible for medicare, review the medicare supplement buyer's
guide available from the company" on the following policies issued for
delivery in this state to persons eligible for medicare:
a.
Any accident and sickness insurance policy or subscriber contract, other
than a medicare supplement policy;
b.
A policy issued pursuant to a contract under section 1876 of the Federal
Social Security Act 42 U.S.C. Section 1395 et seq., disability income policy;
c.
Basic, catastrophic, or major medical expense policy; and
d.
Single premium nonrenewable policy or other policy identified in Ins
1902.02(b) of this part.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5119, eff 4-25-91; amd by #5421, eff 7-1-92; ss by #5656, eff 7-1-93;
amd by #6405, eff 1-1-97; amd by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
Ins
1902.08 Requirements for Application
Forms and Replacement Coverage.
(a) Application forms shall include the following
questions designed to elicit information as to whether, as of the date of the
application, the applicant has another medicare supplement policy or certificate
in force or whether a medicare policy or certificate is intended to replace any
other accident and sickness policy or certificate presently in force:
(1)
"Do you have another medicare supplement insurance policy or
certificate in force, including either a health care service contract or a
health maintenance organization contract?";
(2)
"Did you have another medicare supplement policy or certificate in
force during the last 12 months?" with the following additional questions:
a.
"If so, with which company?"and
b.
"If that policy lapsed, when did it lapse?";
(3)
"Are you covered by Medicaid?"and
(4)
"Do you intend to replace any of your medical or health insurance
coverage with this policy, certificate?".
(b) A supplementary application or other form
signed by the applicant and agent, except where the coverage is sold without an
agent, containing the questions outlined in (a) may be used to satisfy the
requirements set forth in (a) above.
(c) Agents shall list on the applicant's
application form, supplementary application or other form, whichever is used,
any other health insurance policies they have sold to the applicant. In addition, the agent shall list those
policies sold which are still in force and those policies sold in the past 5
years which are no longer in force.
(d) Upon determining that a sale will involve
replacement, an insurer, other than a direct response insurer, or its agent,
shall furnish the applicant, prior to issuance or delivery of the medicare
supplement policy or certificate, a notice regarding replacement of medicare
supplement insurance. One copy of such
notice signed by the applicant and the agent, except where the coverage is sold
without an agent, shall be provided to the applicant and an additional signed
copy shall be retained by the insurer. A
direct response insurer shall deliver to the applicant at the time of the
issuance of the policy the notice regarding replacement of medicare supplement
insurance.
Source.
#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by
#5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
Ins
1902.09 Loss Ratio Standards and
Refund or Credit of Premiums.
(a) A group medicare supplement policy form or
certificate form shall not be advertised, solicited, delivered, or issued for
delivery unless the policy form or certificate form can be expected, as
estimated for the entire period for which rates are computed to provide
coverage, on the basis of:
(1)
Either:
a.
Incurred claims experience; or
b. Incurred health care expenses
where coverage is provided by a health maintenance organization on a service
rather than reimbursement basis; and
(2)
Earned premiums for such period in accordance with accepted actuarial
principals and practices, to return to policyholders and certificateholders in
the form of aggregate benefits, not including anticipated refunds or credits,
provided under the policy form at least 75 percent of the aggregate amount of
premiums earned.
(b) An individual medicare supplement policy
shall not be advertised, solicited, delivered, or issued for delivery unless
the policy form can be expected, as estimated for the entire period for which
rates are computed to provide coverage, on the basis of:
(1)
Incurred claims experience or incurred health care expenses where
coverage is provided by a health maintenance organization on a service rather
than reimbursement basis; and
(2) Earned premiums for such period
in accordance with accepted actuarial principles and practices, to return to
policyholders in the form of aggregate benefits, not including anticipated
refunds or credits, provided under the policy form at least 65 percent of the
aggregate amount of premiums earned.
(c) The return to policyholders and
certificateholders in the form of aggregate benefits of at least 75 percent of
the aggregate amount of premiums earned in the case of group policies and of at
least 65 percent of the aggregate amount of premiums earned in the case of
individual policies shall be deemed the loss ratio standards established by
this rule.
(d) All filings of rates and rating schedules
shall:
(1)
Demonstrate that expected claims in relation to premiums comply with the
requirements of this section when combined with actual experience to date; and
(2)
Demonstrate if the filing is for a rate revision, that the anticipated
loss ratio over the entire future period for which the revised premiums are
computed to provide coverage can be expected to meet the appropriate loss ratio
standard as determined by reference to Ins 1902.09 (a) in the case of a group
policy or to Ins 1902.09 (b) in the case of an individual policy.
(e) For policies issued prior to July 1, 1992,
expected claims in relation to premium shall meet:
(1)
The originally filed anticipated loss ratio when combined with the
actual experience since inception;
(2) The appropriate loss ratio
requirement from Ins 1902.09 (a) or Ins 1902.09 (b) when combined with actual
experience; and
(3) The appropriate loss ratio
requirement from Ins 1902.09 (a) or Ins 1902.09 (b) over the entire future
period for which the rates are computed to provide coverage.
(f) Rules applicable to refund or credit
calculation reporting shall be as follows:
(1)
With respect to Medicare supplement policies or certificates issued prior
to July 1, 1992, the issuer shall make one refund or credit calculation
combining the experience of all the issuer's individual policies beginning with
experience after 12/31/96 and one refund or credit calculation combining the
experience of all the issuer's group policies beginning with experience after
December 31, 1996;
(2)
Each issuer shall collect the data contained in the applicable reporting
form contained in Table 1900.03 and, using this reporting form, file the data
with the commissioner;
(3)
Reports shall be due on May 31 of each year;
(4) If, on the basis of the
experience as reported, the benchmark ratio since inception of the reporting
requirement, ratio 1 from line 7 of the reporting form contained in Table
1900.03, exceeds the adjusted experience ratio since inception of the same
reporting requirement, ratio 3 from line 11 of the reporting form contained in
Table 1900.03, then a refund or credit calculation shall be required. The refund calculation shall be done on a
statewide basis;
(5)
A refund or credit shall be made only when the benchmark loss ratio
exceeds the adjusted experience loss ratio and the amount to be refunded or
credited exceeds a de minimis level of $5.00 per individual policy or each
individual certificate;
(6)
The refund shall include interest pursuant to Ins 1905.13 (b)(4) from
the end of the calendar year to the date of the refund or credit at a rate
specified by the U.S. Secretary of Health and Human Services but in no event
shall it be less than the average rate of interest for 13-week Treasury notes;
and
(7) A refund or credit against
premiums due shall be made by September 30 following the experience year upon
which the refund or credit is based.
(g) An issuer of medicare supplement policies and
certificates in this state shall file annually its premium rates, rating
schedule, and supporting documentation including ratios of incurred to earned
premiums by policy duration.
(h) For the purpose of this section, policy forms
shall be deemed to comply with the loss ratio standards if:
(1)
For the most recent year, the ratio of the incurred losses to earned
premiums, for policies or certificates which have been in force for 3 years or
more is greater than or equal to the applicable percentages contained in this
section;
(2)
The expected losses in relation to premiums over the entire period for
which the policy is rated comply with the requirements of this section; and
(3)
An expected 3rd year loss ratio which is greater than or equal to the
applicable percentage shall be demonstrated for policies or certificates in
force less than 3 years.
(i) As soon as practicable, but prior to the effective
date of enhancements in medicare benefits, every issuer of medicare supplement
policies or certificates in this state shall file with the commissioner in
accordance with the applicable filing procedures of this state the following
items:
(1)
Appropriate premium adjustments necessary to produce loss ratios as
anticipated for the current premium for the applicable policies or
certificates;
(2)
Such supporting documents as necessary to justify the premium
adjustments; and
(3)
Any appropriate riders, endorsements or policy forms needed to
accomplish the medicare supplement policy or certificate modification necessary
to eliminate benefit duplications with medicare.
(j) An insurer shall make such premium
adjustments as are necessary to produce an expected loss ratio under such
policy or certificate as will conform with minimum loss ratio standards for
medicare supplement policies.
(k) Such premium adjustments shall be expected to
result in a loss ratio at least as great as that originally anticipated in the
rates used to produce current premiums by the issuer for such medicare policies
or certificates.
(l) No premium adjustment which would modify the loss
ratio experience under the policy other than the adjustments described herein
shall be made with respect to a policy or certificate at any time other than
upon its renewal date or anniversary date.
(m) Riders, endorsements, or policy forms filed pursuant to this section shall provide a clear
description of the medicare supplement benefits provided by the policy or
certificate.
(n) If presented with a request from an issuer
for an increase in a rate for a policy or certificate form for which the experience
under the form for the previous reporting period is not in compliance with the
applicable loss ratio standard, the commissioner, in order to gather
information, shall, prior to any approval or disapproval of the request,
conduct a public hearing in accordance with RSA 400-A:17 when:
(1)
The issuer requests a public hearing, or
(2)
At least 10 policyholders or certificate holders request a public
hearing.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff
7-1-99, EXPIRED: 10-29-99
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
Ins
1902.10 Standard for Claims Payment.
(a) An issuer shall comply with section
1882(c)(3) of the Social Security Act, as enacted by section 4081(b)(2)(c) of
the Omnibus Budget Reconciliation Act of 1987, OBRA, 1987, Public Law No.
100-203, by:
(1) Accepting a notice from a
medicare carrier on dually assigned claims submitted by participating
physicians and suppliers as a claim for benefits in place of any other claim
form otherwise required and making a payment determination on the basis of the
information contained in that notice;
(2) Notifying the participating
physicians or supplier and the beneficiary of the payment determination;
(3)
Paying the participating physician or supplier directly;
(4) Furnishing, at the time of
enrollment, each enrollee with a card listing the policy name, number and a
central mailing address to which notices from a medicare carrier may be sent;
(5)
Paying user fees for claim notices that are transmitted electronically
or otherwise; and
(6)
Providing to the Secretary of Health and Human Services, at least
annually, a central mailing address to which all claims may be sent by medicare
carriers.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5119, eff 4-25-91; amd by #5421, eff 7-1-92; ss by #5656, eff 7-1-93; ss
by #6405, eff 1-1-97, EXPIRED: 1-1-05
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
Ins
1902.11 Permitted Compensation
Arrangements.
(a) An insurer or other entity may provide
commission or other compensation to an agent or other representative for the
sale of a medicare supplement policy or certificate only if the first year
commission or other first year compensation is no more than 200 percent of the
commission or other compensation paid for selling or servicing the policy or
certificate in the second year or period.
(b) The commission or other compensation provided
in subsequent renewal years shall be the same as that provided in the second
year or period.
(c) No entity shall provide compensation to its
agents or other producers and no agent or producer shall receive compensation
greater than the renewal compensation payable by the replacing insurer on
renewal policies or certificates if an existing policy or certificate is
replaced unless benefits of the new policy or certificate are substantially
more favorable than the benefits under the replaced policy.
(d) For purposes of this section, "compensation" shall include pecuniary or
nonpecuniary remuneration of any kind relating to the sale or renewal of the
policy or certificate, including but not limited to bonuses, gifts, prizes,
awards, and finders' fees.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff
7-1-99, EXPIRED: 10-29-99
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
Ins
1902.12 Appropriations of Recommended
Purchase and Excessive Insurance.
(a) In recommending the purchase or replacement
of any medicare supplement policy or certificate an agent shall make reasonable
efforts to determine the appropriateness of a recommended purchase or replacement.
(b) Any sale of medicare supplement coverage
which will provide an individual more than one medicare supplement policy or
certificate shall be prohibited; provided, however, that additional medicare
supplement coverage may be sold if, when combined with that individual's health
coverage already in force, it would insure no more than 100 percent of the
individual's actual medical expenses covered under the combined policies.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff
7-1-99, EXPIRED: 10-29-99
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
Ins
1902.13 Reporting of Multiple
Policies.
(a) On or before March 1 of each year, every
insurer or other entity providing medicare supplement insurance coverage in
this state shall report the following information for every individual resident
of this state for which the insurer or entity has in force more than one
medicare supplement insurance policy or certificate:
(1)
Policy and certificate number; and
(2)
Date of issuance.
(b) The items set forth above shall be grouped by
individual policyholder.
Source.
#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by
#5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
Ins
1902.14 Prohibition Against
Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary
Periods in Replacement Policies or Certificates. If a medicare supplement policy or
certificate replaces another medicare supplement policy or certificate, the
replacing insurer shall waive any time periods applicable to preexisting
conditions, waiting periods, elimination periods, and probationary periods in
the new medicare supplement policy for similar benefits to the extent such time
was spent under the original policy.
Source. #5119, eff 4-25-91; ss by #5656, eff 7-1-93;
ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
Ins
1902.15 Benefit Conversion
Requirements During Transition.
(a) Benefits eliminated by operation of the
Medicare Catastrophic Coverage Act of 1988 transition provisions shall be
restored.
(b) For medicare supplement policies subject to
the minimum standards adopted by the states pursuant to Medicare Catastrophic
Coverage Act of 1988, the minimum benefits shall be:
(1)
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;
(2)
Coverage of either all or none of the medicare part A inpatient hospital
deductible amount;
(3)
Coverage of part A medicare eligible expenses incurred as daily hospital
charges during use of Medicare’s lifetime hospital inpatient reserve days;
(4)
Upon exhaustion of all medicare hospital inpatient coverage including
the lifetime reserve days, coverage of 90 percent of all medicare part A
eligible expenses for hospitalization not covered by medicare subject to a
lifetime maximum benefit for an additional 365 days; and
(5)
Coverage under medicare part A for the reasonable cost of the first 3
pints of blood or equivalent quantities of packed red blood cells, as defined
under 42 CFR Part 409.87 unless replaced in accordance with 42 CFR Part 409.87
or already paid for under part B.
Source. #5119, eff 4-25-91; ss by #5656, eff 7-1-93;
ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8555, eff 2-1-06, EXPIRED: 2-1-14
New. #11014, eff 1-8-16
PART Ins
1903 MEDICARE SUPPLEMENT INSURANCE
Statutory Authority: RSA 400-A:15 II.
Ins 1903.01 Purpose. The purpose of this part is to assure the
orderly implementation and conversion of medicare supplement insurance benefits
and premiums due to changes in the federal medicare program.
Source. #4553, eff 12-7-88; ss by #5656, eff 7-1-93;
ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8556, eff 2-1-06, EXPIRED: 2-1-14
Ins
1903.02 Applicability and Scope.
(a)
This part shall take precedence over other rules and requirements
relating to medicare supplement policies or contracts only to the extent
necessary to assure that benefits are not duplicated, that applicants receive
adequate notice and disclosure of changes in medicare supplement policies and
contracts, that appropriate premium adjustments are made in a timely manner,
and that premiums are reasonable in relation to benefits.
(b)
This part shall apply to:
(1) All medicare supplement policies and
subscriber contracts advertised, solicited, delivered or issued for delivery in
this state, or which are otherwise subject to the jurisdiction of this state
and issued prior to July 1, 1992; and
(2) All certificates issued under group medicare supplement
policies or subscriber contracts, which policies or contracts have been
advertised, solicited, delivered or issued for delivery in this state, or which
are otherwise subject to the jurisdiction of this state and issued prior to
July 1, 1992.
Source. #8556, eff 2-1-06,
EXPIRED: 2-1-14
Ins 1903.03 Definitions.
(a)
"Applicant" means:
(1) In the case of an individual medicare
supplement policy or subscriber contract, the person who seeks to contract for
insurance benefits; and
(2) In the case of group medicare supplement
policy or subscriber contract, the proposed certificateholder.
(b)
"Certificate" means any certificate issued under a group
medicare supplement policy, which policy has been advertised, solicited,
delivered, or issued for delivery in this state.
(c)
"Insurer" means an insurance company, hospital service
corporation, medical service corporation, health service corporation, health
maintenance organization or other entity subject to Title XXXVII of the
(d)
"Medicare supplement policy" means either a group or
individual policy of accident and health insurance or a subscriber contract of
an insurer that is designed primarily to supplement coverage for hospital,
medical or surgical expenses incurred by an insured person which are not
covered by medicare. Such term does not
include:
(1) A policy or contract of one or more employers
or labor organizations, or of the trustees of a fund established by one or more
employers or labor organizations, or combination thereof, or for members or
former members, or combination thereof, of the labor organizations; or
(2) A policy or contract of any professional,
trade or occupational association for its members or former or retired members,
or combination thereof, if such association:
a. Is composed of individuals all of whom are
actively engaged in the same profession, trade or occupation;
b. Has been maintained in good faith for
purposes other than obtaining insurance; and
c. Has been in existence for at least 2 years
prior to the date of its initial offering of such policy or plan to its
members.
Source. #8556, eff 2-1-06,
EXPIRED: 2-1-14
Ins 1903.04 Benefit Conversion Requirements.
(a)
No medicare supplement insurance policy, contract or certificate in
force in this state shall contain benefits which duplicate benefits
provided by medicare.
(b)
No later than 30 days prior to the annual effective date of medicare
benefit changes mandated by the Medicare Catastrophic Coverage Act of 1988,
every insurer providing medicare supplement insurance or benefits to a resident
of this state shall notify its policyholders, contractholders and
certificateholders of modifications it has made to medicare supplement
insurance policies or contracts.
(c)
The notice required in (b) above shall include a description of
revisions to the medicare program and a description of each modification made
to the coverage provided under the medicare supplement insurance policy or
contract. The notice shall inform each
covered person as to when any premium adjustment due to changes in medicare
benefits will be made. The notice of
benefit modifications and any premium adjustments shall be in outline form and
in clear and simple terms so as to facilitate comprehension. Such notice shall not contain or be
accompanied by any solicitation.
(d)
No modifications to an existing medicare supplement contract or policy
shall be made at the time of or in connection with the notice requirements of
this part except to the extent necessary to eliminate duplication of medicare
benefits and any modifications necessary under the policy or contract to
provide indexed benefit adjustment.
(e)
As soon as practicable, but no longer than 45 days after the effective
date of the medicare benefit changes, every insurer providing medicare
supplement insurance or contracts in this state shall file with the
commissioner, the following:
(1) The appropriate premium adjustments necessary
to produce loss ratios as originally anticipated for the applicable policies or
contracts. Such supporting documents as
necessary to justify the adjustment shall accompany the filing; and
(2) Any appropriate riders, endorsements or
policy forms needed to accomplish the medicare supplement insurance
modifications necessary to eliminate benefit duplications with medicare. Any such riders, endorsements or policy forms
shall provide a clear description of the medicare supplement benefits provided
by the policy or contract.
(f)
Every insurer providing medicare supplement insurance in this state
shall provide each covered person with any rider, endorsement or policy form
necessary to eliminate any benefit duplications under the policy or contract
with benefits provided by medicare.
(g)
No insurer shall require any person covered under a medicare supplement
policy or contract which was in force prior to January 1, 1989 to purchase
additional coverage under such policy or contract unless additional coverage
was provided for in the policy or contract.
(h)
Every insurer providing medicare supplement insurance or benefits to a
resident of this state shall make such premium adjustments as are necessary to
produce an expected loss ratio under such policy or contract as will conform with
minimum loss ratio standards for medicare supplement policies and which is
expected to result in a loss ratio at least as great as the originally
anticipated by the insurer for such medicare supplement insurance policies or
contracts. No premium adjustment which
would modify the loss ratio experience under the policy other than the
adjustments described herein shall be made with respect to a policy at any time
other than upon its renewal date.
Premium adjustments shall be in the form of refunds or premium credits
and shall be made no later than upon renewal if a credit is given, or within 60
days of the renewal date if a refund is provided to premium payer.
Source. #8556, eff 2-1-06,
EXPIRED: 2-1-14
Ins
1903.05 Requirements for New Policies and
Certificates.
(a)
No medicare supplement policy, contract or certificate shall be issued or
issued for delivery in this state which provides benefits which duplicate
benefits provided by medicare. No such
policy, contract or certificate shall provide less benefits than those required
under Ins 1902 except where duplication of medicare benefits would result.
(b)
Every applicant for a medicare supplement insurance policy or
certificate shall be provided with an outline of coverage which simplifies and
accurately describes benefits provided by medicare, the benefits provided by
the policy or contract being applied for, and the benefit limitations
applicable to the policy or contract for which application is being made.
Source. #8556, eff 2-1-06,
EXPIRED: 2-1-14
Ins
1903.06 Separability. If any provision of this part or the
application thereof to any person or circumstances
is for any reason held to be invalid, the remainder of this part and the
application of such provision to other persons or circumstances shall not be
affected thereby.
Source. #8556, eff 2-1-06,
EXPIRED: 2-1-14
PART Ins 1904 GROUP COORDINATION
OF BENEFITS
Statutory
Authority: RSA 400-A:15
Ins 1904.01 Scope.
This part applies to all group or blanket insurance plans subject to RSA
415, RSA 420-A and RSA 420-B.
Source.
#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by
#7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13
Ins 1904.02 Purpose.
The purpose of this rule is to:
(a) Establish a uniform order of benefit
determination under which plans pay claims;
(b) Reduce duplication of benefits by permitting
a reduction of the benefits to be paid by plans that, pursuant to rules
established by this rule, do not have to pay their benefits first; and
(c) Provide greater efficiency in the processing
of claims when a person is covered under more than one plan.
Source.
#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by
#7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13
Ins 1904.03 Definitions. As used in this rule, these words and terms
have the following meanings, unless the context clearly indicates otherwise:
(a) "Allowable Expense", except as set
forth below or where a statute requires a different definition, means:
(1) Any health care expense, including
coinsurance or copayments and without reduction for any applicable deductible,
that is covered in full or in part by any of the plans covering the person;
(2) If a plan is advised by a covered person that
all plans covering the person are high-deductible health plans and the person
intends to contribute to a health savings account established in accordance
with Section 223 of the Internal Revenue Code of 1986, the primary
high-deductible health plan's deductible is not an allowable expense, except
for any health care expense incurred that may not be subject to the deductible
as described in Section 223(c)(2)(C) of the Internal Revenue Code of 1986;
(3) An expense or a portion of an expense that is
not covered by any of the plans is not an allowable expense;
(4) Any expense that a provider by law or in
accordance with a contractual agreement is prohibited from charging a covered
person is not an allowable expense;
(5) The following are examples of expenses that
are not allowable expenses:
a. If a person is confined in a private hospital
room, the difference between the cost of a semi-private room in the hospital
and the private room is not an allowable expense, unless one of the plans
provides coverage for private hospital room expenses;
b. If a person is covered by 2 or more plans
that compute their benefit payments on the basis of usual and customary fees or
relative value schedule reimbursement or other similar reimbursement
methodology, any amount charged by the provider in excess of the highest
reimbursement amount for a specified benefit is not an allowable expense;
c. If a person is covered by 2 or more plans
that provide benefits or services on the basis of negotiated fees, any amount
in excess of the highest of the negotiated fees is not an allowable expense;
and
d. If a person is covered by one plan that
calculates its benefits or services on the basis of usual and customary fees or
relative value schedule reimbursement or other similar reimbursement
methodology and another plan that provides its benefits or services on the
basis of negotiated fees, the primary plan's payment arrangement shall be the
allowable expenses for all plans.
However, if the provider has contracted with the secondary plan to
provide the benefit or service for a specific negotiated fee or payment amount
that is different than the primary plan's payment arrangement and if the
provider's contract permits, that negotiated fee or payment shall be the
allowable expense used by the secondary plan to determine its benefits;
(6) The definition of "allowable
expense" may exclude certain types of coverage or benefits such as dental
care, vision care, prescription drug or hearing aids. A plan that limits the application of COB to
certain coverages or benefits may limit the definition of allowable expense in
its contract to expenses that are similar to the expenses that it
provides. When COB is restricted to
specific coverages or benefits in a contract, the definition of allowable
expense shall include similar expenses to which COB applies;
(7) When a plan provides benefits in the form of
services, the reasonable cash value of each service will be considered an
allowable expense and a benefit paid;
(8) The amount of the reduction may be excluded
from allowable expense when a covered person's benefits are reduced under a
primary plan:
a. Because the covered person does not comply with
the plan provisions concerning second surgical opinions or precertification of
admissions or services; or
b. Because the covered person has a lower
benefit because the covered person did not use a preferred provider.
(b)
"Birthday"
means only the month and day in a calendar year and does not include the year
in which the individual is born.
(c)
"Claim" means a request that benefits of a plan be provided or
paid. The benefits claimed may be in the
form of:
(1) Services (including supplies);
(2) Payment for all or a portion of the expenses
incurred;
(3) A combination of (1) and (2) above; or
(4) An indemnification.
(d)
"Closed panel plan" means a plan that provides health benefits
to covered persons primarily in the form of services through a panel of
providers that have contracted with or are employed by the plan, and that
excludes benefits for services provided by other
providers, except in cases of emergency or referral by a panel member.
(e)
"Consolidated Omnibus Budget Reconciliation Act of 1985" or
"COBRA" means coverage provided under a right of continuation
pursuant to federal law.
(f)
"Coordination of Benefits" or "COB" means a
provision establishing an order in which plans pay their claims, and permitting
secondary plans to reduce their benefits so that the combined benefits of all
plans do not exceed total allowable expenses.
(g)
"Custodial Parent" means:
(1) The parent awarded custody of a child by a
court decree; or
(2) In the absence of a court decree, the parent
with whom the child resides more than one half of the calendar year without
regard to any temporary visitation.
(h)
"Group-type Contract" means:
a. A contract that is not available to the
general public and is obtained and maintained only because of membership in or
a connection with a particular organization or group, including blanket
coverage; and
b.
"Group-type contract" does not include an individually underwritten
and issued guaranteed renewable policy even if the policy is purchased through
payroll deduction at a premium savings to the insured since the insured would
have the right to maintain or renew the policy independently of continued
employment with the employer.
(i)
"High-deductible Health Plan" means the meaning given the term
under Section 223 of the Internal Revenue Code of 1986, as amended by the
Medicare Prescription Drug, Improvement and Modernization Act of 2003.
(j)
"Hospital Indemnity Benefits" means:
a. Benefits not related to expenses incurred;
and
b. "Hospital indemnity benefits" does
not include reimbursement-type benefits even if they are designed or
administered to give the insured the right to elect indemnity-type benefits at
the time of claim.
(k)
"Plan" means:
a. A form of coverage with which coordination is
allowed. Separate parts of a plan for members
of a group that are provided through alternative contracts that are intended to
be part of a coordinated package of benefits are considered one plan and there
is not COB among the separate parts of the plan.
b. If a plan coordinates benefits, its contract
shall state the types of coverage that will be considered in applying the COB
provision of that contract. Whether the
contract uses the term "plan" or some other term such as
"program", the contractual definition may be no broader than the
definition of "plan" in this subsection. The definition of "plan" in the
model COB provision in Appendix A is an example.
c. "Plan" includes:
1. Group and nongroup insurance contracts and
subscriber contracts;
2. Uninsured arrangements of group or group-type
coverage;
3. Group and nongroup coverage through closed
panel plans;
4. Group-type contracts;
5. The medical care components of long-term care
contracts, such as skilled nursing care;
6. The medical benefits coverage in automobile
"no fault" or "personal injury protection" (PIP) type
contracts, not including medical payments coverage, also known as Part B in the
personal automobile policy or med pay; and
7. Medicare or other governmental benefits, as
permitted by law, except as provided in d. 8. below. That part of the definition of plan may be
limited to the hospital, medical and surgical benefits of the governmental
program; and
d. "Plan" does not include:
1. Hospital indemnity coverage or benefits or
other fixed indemnity coverage;
2. Accident only coverage;
3. Specified disease or specified accident
coverage;
4. Limited benefits health coverage, as defined
in Ins 1901.06 (l);
5. School accident-type coverages that cover
students for accidents only, including athletic injuries, either on a 24 hour
basis or on a "to and from school" basis;
6. Medical payments coverage in a personal
automobile policy, also known as Part B or med pay;
7. Benefits provided in long-term care insurance
policies for non-medical services, for example, personal care, adult day care,
homemaker services, assistance with activities of daily living, respite care
and custodial care or for contracts that pay a fixed daily benefit without
regard to expenses incurred or the receipt of services;
8. Medicare supplement policies;
9. A state plan under Medicaid; or
10. A governmental plan, which, by law, provides
benefits that are in excess of those of any private insurance plan or other
non-governmental plan.
(l)
"Policyholder" means the primary insured named in a nongroup
insurance policy.
(m)
"Primary plan" means a plan whose benefits for a person's
health care coverage must be determined without taking the existence of any other
plan into consideration. A plan is a
primary plan if:
(1) The plan either has no order of benefit
determination rules, or its rules differ from those permitted by this rule; or
(2) All plans that cover the person use the order
of benefit determination rules required by this rule, and under those rules the
plan determines its benefits first.
(n)
"Secondary plan" means a plan that is not a primary plan.
Source.
#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by
#7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13
Ins 1904.04 Use
of Model COB Contract Provision.
(a)
Appendix A contains a model COB provision for use in contracts. The use of this model COB provision is
subject to the provisions of (b), (c) and (d) below and the provisions of Ins
1904.05.
(b)
Appendix B is a plain language description of the COB process that
explains to the covered person how health plans will implement coordination of
benefits. It is not intended to replace
or change the provisions that are set forth in the contract. Its purpose is to explain the process by
which the 2 or more plans will pay for or provide benefits.
(c)
The COB provision contained in Appendix A and the plain language
explanation in Appendix B do not have to use the specific words and format
shown in Appendix A or Appendix B.
Changes may be made to fit the language and style of the rest of the
contract or to reflect differences among plans that provide services, that pay
benefits for expenses incurred and that indemnify. No substantive changes are permitted.
(d)
A COB provision may not be used that permits a plan to reduce its
benefits on the basis that:
(1) Another plan exists and the covered person
did not enroll in the plan;
(2) A person is or could have been covered under
another plan, except with respect to Part B of Medicare; or
(3) A person has elected an option under another
plan providing a lower level of benefits than another option that could have
been elected.
(e)
No plan may contain a
provision that its benefits are "always excess" or "always
secondary" except in accordance with the rules permitted by this rule.
(f)
Under the terms of a
closed panel plan, benefits are not payable if the covered person does not use
the services of a closed panel provider.
In most instances, COB does not occur if a covered person is enrolled in
2 or more closed panel plans and obtain services from a provider in one of the
closed panel plans because the other closed panel plan (the one whose providers
were not used) has no liability.
However, COB may occur during the plan year when the covered person
received emergency services that would have been covered by both plans. Then the secondary plan shall use the
provisions of Ins 1904.06 to determine the amount it should pay for the
benefit.
(g)
No plan may use a COB provision, or any other provision that allows it
to reduce its benefits with respect to any other coverage its insured may have
that does not meet the definition of plan under Ins 1904.03 (k).
Source.
#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by
#7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13
Ins 1904.05 Rules for Coordination of Benefits. When a person is covered by 2 or more plans:
(a)
The rules for determining the order of benefit payments are as follows:
(1) The primary plan shall pay or provide its
benefits as if the secondary plan or plans did not exist;
(2) If the primary plan is a closed panel plan
and the secondary plan is not a closed panel plan, the secondary plan shall pay
or provide benefits as if it were the primary plan when a covered person uses a
non-panel provider, except for emergency services or authorized referrals that
are paid or provided by the primary plan;
(3) When multiple contracts providing coordinated
coverage are treated as a single plan under this rule, this section applies
only to the plan as a whole, and coordination among the component contracts is
governed by the terms of the contracts.
If more than one carrier pays or provides benefits under the plan, the
carrier designated as primary within the plan shall be responsible for the
plan's compliance with this rule; and
(4) If a person is covered by more than one
secondary plan, the order of benefit determination rules of this rule decide
the order in which secondary plans benefits are determined in relation to each
other. Each secondary plan shall take
into consideration the benefits of the primary plan or plans and the benefits
of any other plan, which, under the rules of this rule, has its benefits
determined before those of that secondary plan.
(b)
Except as provided in paragraph (2) below:
(1) A plan that does not contain order of benefit
determination provisions that are consistent with this rule is always the
primary plan unless the provisions of both plans, regardless of the provisions
of this paragraph, state that the complying plan is primary; and
(2) Coverage that is obtained by virtue of
membership in a group and designed to supplement a part of a basic package of benefits
may provide that the supplementary coverage shall be excess to any other parts
of the plan provided by the contract holder.
Examples of these types of situations are major medical coverages that
are superimposed over base plan hospital and surgical benefits, and insurance
type coverages that are written in connection with a closed panel plan to
provide out-of-network benefits.
(c)
A plan may take into consideration the benefits paid or provided by
another plan only when, under the rules of this rule, it is secondary to that
other plan.
(d)
Order of Benefit Determination.
Each plan determines its order of benefits using the first of the
following rules that applies:
(1) Non-Dependent or Dependent.
a. Subject to subparagraph b. of this paragraph,
the plan that covers the person other than as a dependent, for example as an
employee, member, subscriber, policyholder or retiree, is the primary plan and
the plan that covers the person as a dependent is the secondary plan.
b. If the person is a Medicare beneficiary, and,
as a result of the provisions of Title XVIII of the Social Security Act and
implementing regulations, Medicare is:
1.
Secondary to the plan covering the person as a dependent; and
2. Primary to the plan covering the person as
other than a dependent (e.g. a retired employee). Then the order of benefits is reversed so
that the plan covering the person as an employee, member, subscriber,
policyholder or retiree is the secondary plan and the other plan covering the
person as a dependent is the primary plan.
(2) Dependent Child Covered Under More Than One
Plan. Unless there is a court decree
stating otherwise, plans covering a dependent child shall determine the order
of benefits as follows:
a. For a dependent child whose parents are
married or are living together, whether or not they have ever been married:
1.
The plan of the parent whose birthday falls earlier in the calendar year
is the primary plan; or
2.
If both parents have the same birthday, the plan that has covered the
parent longest is the primary plan.
b. For a dependent child whose parents are divorced
or separated or are not living together, whether or not they have ever been
married:
1.
If a court decree states that one of the parents is responsible for the
dependent child's health care expenses or health care coverage and the plan of
that parent has actual knowledge of those terms, that plan is primary. If the parent with responsibility has no
health care coverage for the dependent child's health care expenses, but that
parent's spouse does, that parent's spouse's plan is the primary plan. This item shall not apply with respect to any
plan year during which benefits are paid or provided before the entity has
actual knowledge of the court decree provision;
2.
If a court decree states that both parents are responsible for the
dependent child's health care expenses or health care coverage, the provisions
of subparagraph a. of this paragraph shall determine the order of benefits;
3.
If a court decree states that the parents have joint custody without
specifying that one parent has responsibility for the health care expenses or
health care coverage of the dependent child, the provisions of subparagraph a.
of this paragraph shall determine the order of benefits; or
4.
If there is no court decree allocating responsibility for the child's
health care expenses or health care coverage, the order of benefits for the
child are as follows:
(i) The plan covering the custodial parent;
(ii) The plan covering the custodial parent's
spouse;
(iii) The plan covering the non-custodial parent;
and then
(iv) The plan covering the non-custodial parent's
spouse; and
c. For a dependent child covered under more than
one plan of individuals who are not the parents of the child, the order of
benefits shall be determined, as applicable, under subparagraph a. or b. of
this paragraph as if those individuals were parents of the child.
(3) Active Employee or Retired or Laid-Off
Employee.
a. The plan that covers a person as an active
employee that is, an employee who is neither laid off nor retired or as a
dependent of an active employee is the primary plan. The plan covering that same person as a
retired or laid-off employee or as a dependent of a retired or laid-off
employee is the secondary plan.
b. If the other plan does not have this rule,
and as a result, the plans do not agree on the order of benefits, this rule is
ignored; and
c. This rule does not apply if the rule in
paragraph (1) can determine the order of benefits.
(4) COBRA or State Continuation Coverage.
a. If a person whose coverage is provided
pursuant to COBRA or under a right of continuation pursuant to state or other
federal law is covered under another plan, the plan covering the person as an
employee, member, subscriber or retiree or covering the person as a dependent
of an employee, member, subscriber or retiree is the primary plan and the plan
covering that same person pursuant to COBRA or under a right of continuation
pursuant to state or other federal law is the secondary plan.
b. If the other plan does not have this rule,
and if, as a result, the plans do not agree on the order of benefits, this rule
is ignored; and
c. This rule does not apply if the rule in
paragraph (1) can determine the order of benefits.
(5) Longer or Short Length of Coverage.
a. If the preceding rules do not determine the
order of benefits, the plan that covered the person for the longer period of
time is the primary plan and the plan that covered the person for the shorter
period of time is the secondary plan.
b. To determine the length of time a person has been
covered under a plan, two successive plans shall be treated as one if the
covered person was eligible under the second plan within 24 hours after
coverage under the first plan ended.
c. The start of a new plan does not include:
1. A change in the amount or scope of a plan's
benefits;
2. A change in the entity that pays, provides or
administers the plan's benefits; or
3. A change from one type of plan to another,
such as, from a single employer plan to a multiple employer plan; and
d. The person's length of time covered under a
plan is measured from the person's first date of coverage under that plan. If that date is not readily available for a
group plan, the date the person first became a member of the group shall be
used as the date from which to determine the length of time the person's
coverage under the present plan has been in force; and
(6) If none of the preceding rules determines the
order of benefits, the allowable expenses shall be shared equally between the
plans.
Source.
#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by
#7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13
Ins 1904.06 Procedure to be Followed by Secondary Plan to Calculate Benefits and Pay a Claim. In determine the amount to be paid by the
secondary plan on a claim, should the plan wish to coordinate benefits, the
secondary plan shall calculate the benefits it would have paid on the claim in
the absence of other health care coverage and apply that calculated amount to
any allowable expense under its plan that is unpaid by the primary plan. The secondary plan may reduce its payment by
the amount so that, when combined with the amount paid by the primary plan, the
total benefits paid or provided by all plans for the claim do not exceed 100
percent of the total allowable expense for that claim. In addition, the secondary plan shall credit
to its plan deductible any amounts it would have credited to its deductible in
the absence of other health care coverage.
Source.
#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by
#7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13
Ins 1904.07 Notice to Covered Persons. A plan shall, in its explanation of benefits
provided to covered persons, include the following language; "If you are
covered by more than one health benefit plan, you should file all your claims
with each plan."
Source.
#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by
#7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13
Ins 1904.08 Miscellaneous Provisions.
(a)
A secondary plan that provides benefits in the form of services may
recover the reasonable cash value of the services from the primary plan, to the
extent that benefits for the services are covered by the primary plan and have
not already been paid or provided by the primary plan. Nothing in this provision shall be interpreted
to require a plan to reimburse a covered person in cash for the value of
services provided by a plan that provides benefits in the form of services.
(b)
Order of Benefit Determination Rules.
(1) A plan with order of benefit determination
rules that comply with this rule (complying plan) may coordinate its benefits
with a plan that is "excess" or "always secondary" or that
uses order of benefit determination rules that are inconsistent with those
contained in this rule (noncomplying plan) on the following basis:
a. If the complying plan is the primary plan, it
shall pay or provide its benefits first;
b. If the complying plan is the secondary plan,
it shall pay or provide its benefits first, but the amount of the benefits
payable shall be determined as if the complying plan were the secondary
plan. In such a situation, the payment
shall be the limit of the complying plan's liability; and
c. If the noncomplying plan does not provide the
information needed by the complying plan to determine its benefits within a reasonable
time after it is requested to do so, the complying plan shall assume that the
benefits of the noncomplying plan are identical to its own, and shall pay its
benefits accordingly. If, within 2 years
of payment, the complying plan receives information as to the actual benefits
of the noncomplying plan, it shall adjust payments accordingly.
(2) If the noncomplying plan reduces its benefits
so that the covered person receives less in benefits than the covered person
would have received had the complying plan paid or provided its benefits as the
secondary plan and the noncomplying plan paid or provided its benefits as the
primary plan, and governing state law allows the right of subrogation set forth
below, then the complying plan shall advance to the covered person or on behalf
of the covered person an amount equal to the difference; and
(3) In no event shall the complying plan advance
more than the complying plan would have paid had it been the primary plan less
any amount it previously paid for the same expense or service. In conditions of the advance, the complying
plan shall be subrogated to all rights of the covered person against the
noncomplying plan. The advance by the
complying plan shall also be without prejudice to any claim it may have against
a noncomplying plan in the absence of subrogation.
(c)
COB differs from subrogation.
Provisions for one may be included in health care benefits contracts without compelling the inclusion or
exclusion of the other.
(d)
If the plans cannot agree on the order of benefits within 30 calendar
days after the plans have received all of the information needed to pay the
claim, the plans shall immediately pay the claim in equal shares and determine their relative liabilities
following payment, except that no plan shall be required to pay more than it
would have paid had it been the primary plan.
Source.
#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017,
INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13
Ins 1904.09 Effective Date for Existing Contracts.
(a)
A contract that provides health
care benefits and that was issued before the effective date of this rule shall
be brought into compliance with this rule by:
(1) The later of:
a. The next anniversary date or renewal date of
the contract; or
b. Twelve months following the effective date of
this rule; or
(2) The expiration of any applicable collectively
bargained contract pursuant to which it was written.
(b)
For the transition period between the adoption of this rule and the
timeframe for which plans are to be in compliance pursuant to Subsection A, a
plan that is subject to the prior COB requirements shall not be considered a
noncomplying plan by a plan subject to the new COB requirements if there is a
conflict between the prior COB requirements under the prior rule and the new
COB requirements under the amended rule, the prior COB requirements shall
apply.
Source.
#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by
#7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13
Ins 1904.10 Penalties. Any insurer, producer, or any person, firm,
association or corporation violating any provisions of this part shall be
subject to the provisions of RSA 400-A:15, III.
Source. #8402, eff 8-1-05; ss by #10371,
eff 8-1-13
APPENDIX A
MODEL COB CONTRACT
PROVISIONS
COORDINATION OF
THIS CONTRACT'S BENEFITS
WITH OTHER
BENEFITS
The Coordination
of Benefits (COB) provision applies when a person has health care coverage
under more than one Plan. Plan
is defined below.
The order of
benefit determination rules govern the order in which each Plan will pay
a claim for benefits. The Plan
that pays first is called the Primary plan. The Primary plan must pay benefits in
accordance with its policy terms without regard to the possibility that another
Plan may cover some expenses. The
Plan that pays after the Primary plan is the Secondary plan. The Secondary plan may reduce the
benefits it pays so that payments from all Plans does not exceed 100% of
the total Allowable expense.
DEFINITIONS
(a) A Plan is any of the following that
provides benefits or services for medical or dental care or treatment. If separate contracts are used to provide
coordinated coverage for members of a group, the separate contracts are considered
parts of the same plan and there is no COB among those separate contracts.
(1) Plan includes: group and nongroup insurance contracts, health
maintenance organization (HMO) contracts, closed panel plans or other forms of
group or group-type coverage (whether insured or uninsured); medical care
components of long-term care contracts, such as skilled nursing care; medical
benefits under "no-fault" or "personal injury protection"
(PIP) automobile contracts; and Medicare or any other federal governmental
plan, as permitted by law.
(2) Plan does not include: hospital indemnity coverage or other fixed
indemnity coverage; accident only coverage; specified disease or specified
accident coverage; limited benefit health coverage, as defined by state law;
school accident type coverage; medical payments coverage in a personal
automobile policy, also known as Part B or med pay coverage; benefits for non-medical
components of long-term care policies; Medicare supplement policies; Medicaid
policies; or coverage under other federal governmental plans, unless permitted
by law.
Each contract for
coverage under (1) or (2) is a separate Plan. If a Plan has two parts and COB rules
apply only to one of the 2, each of the parts is treated as a separate Plan.
(b) This plan means, in a COB
provision, the part of the contract providing the health care benefits to which
the COB provision applies and which may be reduced because of the
benefits to other plans. Any other part
of the contract providing health care benefits is separate from this plan. A contract may apply one COB provision
to certain benefits, such as dental benefits, coordinating only with similar
benefits, and may apply another COB provision to coordinate other
benefits.
(c) The order of benefit determination rules
determine whether This plan is a Primary plan or Secondary
plan when the person has health care coverage under more than one plan.
When This plan
is primary, it determines payment for its benefits first before those of any
other Plan without considering any other Plan's benefits. When This plan is secondary, it
determines its benefits after those of another Plan and may reduce the benefits
it pays so that all Plan benefits do not exceed 100% of the total Allowable
expense.
(d) Allowable expense is a health care
expense, including deductibles, coinsurance and copayments, that is covered at
least in part by a Plan covering the person. When a Plan provides benefits in the
form of services, the reasonable cash value of each service will be considered
an Allowable expense and a benefit paid.
An expense that is not covered by any Plan covering the person is
not an Allowable expense. In
addition, any expense that a provider by law or in accordance with a
contractual agreement is prohibited from charging a covered person is not an Allowable
expense.
The following are
examples of expenses that are not Allowable expenses:
(1) The difference between the cost of a
semi-private hospital room and a private hospital room is not an Allowable
expense, unless one of the Plans provides coverage for private
hospital room expenses.
(2) If a person is covered by 2 or more Plans that compute their benefit
payments on the basis of usual and customary fees or relative value schedule
reimbursement methodology or other similar reimbursement methodology, any
amount in excess of the highest reimbursement amount for a specific benefit is
not an Allowable expense.
(3) If a person is covered by 2 or more Plans that provide benefits or services
on the basis of negotiated fees, an amount in excess of the highest of the
negotiated fees is not an Allowable expense.
(4) If a person is covered by one Plan that calculates its benefits or
services on the basis of usual and customary fees or relative value schedule
reimbursement methodology or other similar reimbursement methodology and
another Plan that provides its
benefits or services on the basis of negotiated fees, the Primary plan's payment
arrangement shall be the Allowable expense for all Plans. However, if the
provider has contracted with the Secondary
plan to provide the benefit or service
for a specific negotiated fee or payment amount that is different than the Primary plan's payment arrangement and if the provider's contract permits,
the negotiated fee or payment shall be the Allowable
expense used by the Secondary plan to determine its benefits.
(5) The amount of any benefit reduction by the Primary plan because a covered person has failed to comply with the Plan provisions is not an Allowable expense. Examples of these
types of plan provisions include second surgical opinions, precertification of
admissions, and preferred provider arrangements.
(e) Closed panel plan is a Plan
that provides health care benefits to covered persons primarily in the form of
services through a panel or providers that have contracted with or are employed
by the Plan, and that excludes coverage for services provided by other
providers, except in cases of emergency or referral by a panel member.
(f) Custodial parent is the parent awarded
custody by a court decree or, in the absence of a court decree, is the parent
with whom the child resides more than one half of the calendar year excluding
any temporary visitation.
ORDER OF BENEFIT
DETERMINATION RULES
When a person is
covered by 2 or more Plans, the rules for determining the order of
benefit payments are as follows:
(a) The Primary plan pays or provides its
benefits according to its terms of coverage and without regard to the benefits
under any other Plan.
(b) Except as provided in paragraph (2),
(1) A Plan that does not contain a
coordination of benefits provision that is consistent with this rule is always
primary unless the provisions of both Plans state that the complying
plan is primary.
(2) Coverage that is obtained by virtue of
membership in a group that is designed to supplement a part of a basic package
of benefits and provides that this supplementary coverage shall be excess to
any other parts of the Plan provided by the contract holder. Examples of these types of situations are
major medical coverages that are superimposed over base plan hospital and
surgical benefits, and insurance type coverages that are written in connection
with a Closed panel plan to provide out-of-network benefits.
(c) A Plan may consider the benefits paid
or provided by another Plan in calculating payment of its benefits only
when it is secondary to that other Plan.
(d) Each
Plan determines its order of benefits using the first of the following
rules that apply:
(1) Non-Dependent or Dependent. The Plan that covers the person other
than as a dependent, for example as an employee, member, policyholder,
subscriber or retiree is the Primary plan and the Plan that
covers the person as a dependent is the Secondary plan. However, if the person is a Medicare beneficiary
and, as a result of federal law, Medicare is secondary to the Plan
covering the person as a dependent; and primary to the Plan covering the
person as other than a dependent (e.g. a retired employee); then the order of
benefits between the 2 Plans is reversed so that the Plan
covering the person as an employee, member, policyholder, subscriber or retiree
is the Secondary plan and the other Plan is the Primary plan.
(2) Dependent Child Covered Under More Than One
Plan. Unless there is a court decree
stating otherwise, when a dependent child is covered by more than one Plan
the order of benefits is determined as follows:
a. For a dependent child whose parents are
married or are living together, whether or not they have ever been married:
1. The Plan
of the parent whose birthday falls earlier in the calendar year is the Primary plan; or
2. If both parents have the same birthday, the Plan that has covered the parent the
longest is the Primary plan.
b. For a dependent child whose parents are
divorced or separated or not living together, whether or not they have ever
been married:
1. If a court decree states that one of the
parents is responsible for the dependent child's health care expenses or health
care coverage and the Plan of that parent has actual knowledge of those
terms, that Plan is primary. This
rule applies to plan years commencing after the Plan is given notice of
the court decree;
2. If a court decree states that both parents
are responsible for the dependent child's health care expenses or health care
coverage, the provisions of subparagraph (a) above shall determine the order of
benefits;
3. If a court decree states that the parents
have joint custody without specifying that one parent has responsibility for
the health care expenses or health care coverage of the dependent child, the
provisions of subparagraph (a) above shall determine the order of benefits; or
4. If there is no court decree allocating
responsibility for the dependent child's health care expenses or health care
coverage, the order of benefits for the child are as follows:
The Plan covering the Custodial parent;
The Plan covering the spouse of the Custodial parent;
The Plan covering the non-custodial parent;
and then
The Plan covering the spouse of the non-custodial parent.
c. For a dependent child covered under more than
one Plan of individuals who are the parents of the child, the provisions
of subparagraph (a) or (b) above shall determine the order of benefits as if
those individuals were the parents of the child.
(3) Active Employee or Retired or Laid-off
Employee. The Plan that covers a
person as an active employee, that is, an employee who is neither laid-off nor
retired, is the Primary plan. The
Plan covering that same person as a retired or laid-off employee is the Secondary
plan. The same would hold true if a
person is a dependent of an active employee and that same person is a dependent
of a retired or laid-off employee. If
the other Plan does not have this rule, and as a result, the Plans
do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule labeled
(d) (1) can determine the order of benefits.
(4) COBRA or State Continuation Coverage. If a person whose coverage is provided
pursuant to COBRA or under a right of continuation provided by state or other
federal law is covered under another Plan,
the Plan cover the person as an
employee, member, subscriber or retiree covering the person as a dependent of
an employee, member, subscriber or retiree is the Primary plan and the
COBRA or state or other federal continuation coverage is the Secondary plan. If the other Plan does not have this rule, and as a
result the Plans do not agree on the
order of benefits, this rule is ignored.
This rule does not apply if the rule labeled (d)(1) can determine the
order of benefits.
(5) Longer or Shorter Length of Coverage. The Plan
that covered the person as an employee, member, policyholder, subscriber or
retiree longer is the Primary plan and the Plan that covered the person the shorter period of time is the Secondary plan.
(6) If the preceding rules do not determine the
order of benefits, the Allowable expenses shall be shared equally
between the Plans meeting the definition
of Plan. In addition, This plan will not pay
more than it would have paid had it been the Primary plan.
EFFECT ON THE
BENEFITS OF THIS PLAN
(a) When This plan is secondary, it may
reduce its benefits so that the total benefits paid or provided by all Plans
during a plan year are not more than the total Allowable expenses. In determining the amount to be paid for any
claim, the Secondary plan will calculate the benefits it would have paid
in the absence of other health care coverage and apply that calculated amount
to any Allowable expense under its Plan that is unpaid by the Primary
plan. The Secondary plan may
then reduce its payment by the amount so that, when combined with the amount
paid by the Primary plan, the total benefits paid or provided by all Plans
for the claim do not exceed the total Allowable expense for that
claim. In addition, the Secondary
plan shall credit to its plan deductible any amounts it would have credited
to its deductible in the absence of other health care coverage.
(b) If a covered person is enrolled in two or
more Closed panel plans and if, for any reason, including the provision
of service by a non-panel provider, benefits are not payable by one Closed
panel plan, COB shall not apply between that Plan and other Closed
panel plans.
RIGHT TO RECEIVE
AND RELEASE NEEDED INFORMATION
Certain facts
about health care coverage and services are needed to apply these COB
rules and to determine benefits payable under This plan and other Plans. [Organization responsibility for COB
administration] may get the facts it needs from or give them to other
organizations or persons for the purpose of applying these rules and
determining benefits payable under This plan and other Plans covering
the person claiming benefits.
[Organization responsibility for COB administration] need not
tell, or get the consent of, any person to do this. Each person claiming benefits under This
plan must give [Organization responsibility for COB administration]
any facts it needs to apply those rules and determine benefits payable.
FACILITY OF
PAYMENT
A payment made
under another Plan may include an amount that should have been paid
under This plan. If it does,
[Organization responsibility for COB administration] may pay that amount
to the organization that made that payment.
That amount will then be treated as though it were a benefit paid under This
plan. [Organization responsibility
for COB administration] will not have to pay that amount again. The term "payment made" includes
providing benefits in the form of service, in which case "payment
made" means the reasonable cash value of the benefits provided in the form
of services.
RIGHT OF RECOVERY
If the amount of
the payments made by [Organization responsibility for COB
administration] is more than it should have paid under this COB
provision, it may recover the excess from one or more of the persons it has
paid or for whom it has paid; or any other person or organization that may be
responsible for the benefits or services provided for the covered person. The "amount of the payments made"
includes the reasonable cash value of any benefits provided in the form of
services.
APPENDIX B
CONSUMER
EXPLANATORY BOOKLET
COORDINATION OF
BENEFITS
This is a
summary of only a few of the provisions of your health plan to help you
understand coordination of benefits, which can be very complicated. This is not a complete description of all
of the coordination rules and procedures, and does not change or replace
the language contained in your insurance contract, which determines your
benefits.
IMPORTANT NOTICE
Double Coverage
It is common for
family members to be covered by more than one health care plan. This happens, for example, when a husband and
wife both work and choose to have family coverage through both employers.
When you are
covered by more than one health plan, state law permits your insurers to follow
a procedure called "coordination of benefits" to determine how much
each should pay when you have a claim.
The goal is to make sure that the combined payments of all plans do not
add up to more than your covered health care expenses.
Coordination of
benefits (COB) is complicated, and covers a wide variety of circumstances. This is only an outline of some of the most
common ones. If your situation is not
described, read your evidence of coverage or contact your state insurance
department.
Primary or
Secondary?
You will be asked
to identify all the plans that cover members of your family. We need this information to determine whether
we are the "primary" or "secondary" benefit payer. The primary plan always pays first when you
have a claim.
Any plan that does
not contain your state's COB rules will always be primary.
When This Plan is
Primary
If you or a family
member are covered under another plan in addition to this one, we will be
primary when:
Your Own Expenses
* The claim is for your own health care
expenses, unless you are covered by Medicare and both you and your spouse are
retired.
Your Spouse's
Expenses
* The claim is for your spouse, who is covered
by Medicare, and you are not both retired.
Your Child's
Expenses
* The claim is for the health care expenses of
your child who is covered by this plan and
* You are married and your birthday is earlier
in the year than your spouse's or you are living with another individual,
regardless of whether or not you have ever been married to that individual, and
your birthday is earlier than that other individual's birthday. This is known as the "birthday
rule";
or
* You are separated or divorced and you have
informed us of a court decree that makes you responsible for the child's health
care expenses;
or
* There is no court decree, but you have
custody of the child.
Other Situations
We will be primary
when any other provisions of state or federal law require us to be.
How We Pay Claims
When We Are Primary
When we are the
primary plan, we will pay the benefits in accordance with the terms of your
contract, just as if you had no other health care coverage under any other
plan.
How We Pay Claims
When We Are Secondary
We will be
secondary whenever the rules do not require us to be primary.
How We Pay Claims
When We Are Secondary
When we are the
secondary plan, we do not pay until after the primary plan has paid its
benefits. We will then pay part or all
of the allowable expenses left unpaid, as explained below. An "allowable expense" is a health
care expense covered by one of the plans, including copayments, coinsurance and
deductibles.
* If there is a
difference between the amount the plans allow, we will base our payment on the
higher amount. However, if the primary
plan has a contract with the provider, our combined payments will not be more
than the amount called for in our contract or the amount called for in the
contract of the primary plan, whichever is higher. Health maintenance organizations (HMOs) and
preferred provider organizations (PPOs) usually have contracts with their
providers.
* We will
determine our payment by subtracting the amount the primary plan paid from the
amount we would have paid if we had been primary. We may reduce our payment by any amount so
that, when combined with the amount paid by the primary plan, the total
benefits paid do not exceed the total allowable expense for your claim. We will credit any amount we would have paid
in the absence of your other health care coverage toward our own plan
deductible.
* If the primary
plan covers similar kinds of health care expenses, but allows expenses that we
do not cover, we may pay for those expenses.
* We will not pay
an amount the primary plan did not cover because you did not follow its rules
and procedures. For example, if your
plan has reduced its benefits because you did not obtain pre-certification, as
required by that plan, we will not pay the amount of the reduction, because it
is not an allowable expense.
Questions About
Coordination of Benefits?
Contact
Your State Insurance Department
Part Ins 1905
Minimum Standards for Medicare Supplement Policies
Statutory
Authority: RSA 400-A:15 I; RSA 415-F:3 III - VI; RSA 415-F:5 III - V
Ins
1905.01 Purpose. The purpose of this part is to provide for
the reasonable standardization of coverage and simplification of terms and
benefits of Medicare supplement policies, to facilitate public understanding
and comparison of such policies, to eliminate provisions contained in such
policies which may be misleading or confusing in connection with the purchase
of such policies or with the settlement of claims, and to provide for full
disclosures in the sale of accident and sickness insurance coverages to persons
eligible for Medicare.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99,
EXPIRED: 10-29-99
New.
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by
#9559, eff 10-13-09; ss by #12370, eff 10-13-17
Ins
1905.02 Applicability and Scope.
(a)
Except as otherwise specifically provided in Ins 1905.06, Ins
1905.15, Ins 1905.16, Ins 1905.19, and Ins 1905.24, this part shall apply to:
(1) All Medicare supplement policies delivered or
issued for delivery in this state on or after the effective date of this part;
and
(2) All certificates issued under group Medicare
supplement policies, which certificates have been delivered or issued for
delivery in this state.
(b)
This part shall not apply to a policy or contract of one or more
employers or labor organizations, or of the trustees of a fund established by
one or more employers or labor organizations, or combination thereof, for
employees or former employees, or a combination thereof, or for members or
former members, or a combination thereof, of the labor organizations.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559,
eff 10-13-09; ss by #12370, eff 10-13-17
Ins 1905.03 Definitions.
(a)
“Applicant” means:
(1) In the case of an individual Medicare supplement
policy, the person who seeks to contract for insurance benefits; and
(2) In the case of a group Medicare supplement
policy, the proposed certificate holder.
(b)
“Bankruptcy” means when a Medicare Advantage organization that is not an
issuer:
(1) Has filed, or has had filed against it, a
petition for declaration of bankruptcy; and
(2) Has ceased doing business in the state.
(c)
“Certificate” means any certificate delivered or issued for
delivery in this state under a group Medicare supplement policy.
(d)
“Certificate form” means the form on which the certificate is delivered
or issued for delivery by the issuer.
(e)
“Continuous period of creditable coverage” means the period during which
an individual was covered by creditable coverage, if during the period of the
coverage the individual had no breaks in coverage greater than 63 days.
(f)
“Creditable coverage” means, with respect to an individual, coverage of
the individual provided under any of the following:
(1) A group health plan;
(2) Health insurance coverage;
(3) Part A or Part B of Title XVIII of the Social
Security Act (Medicare);
(4) Title XIX of the Social Security Act
(Medicaid), other than coverage consisting solely of benefits under
section 1928;
(5) Chapter 55 of Title 10 United States Code
(CHAMPUS);
(6) A medical care program of the Indian Health
Service or of a tribal organization;
(7) A state health benefits risk pool;
(8) A health plan offered under Chapter 89 of
Title 5 United States Code (Federal Employees Health Benefits Program;
(9) A public health plan as defined in federal
regulation; or
(10) A health benefit plan under 22 United States
Code 2504 (e) (Peace Corps Act).
(g)
"Creditable coverage" shall not include:
(1) One or more, or any combination of, the
following:
a. Coverage only for accident or disability
income insurance, or any combination thereof;
b. Coverage issued as a supplement to liability
insurance;
c.
Liability insurance, including general liability insurance and automobile
liability insurance;
d. Workers' compensation or similar insurance;
e. Automobile medical payment insurance;
f. Credit-only insurance;
g. Coverage for on-site medical clinics; and
h. Other similar insurance coverage, specified
in federal regulations, under which benefits for medical care are secondary or
incidental to other insurance benefits;
(2) The following benefits, if they are provided
under a separate policy, certificate, or contract of insurance or are
otherwise not an integral part of the plan:
a. Limited scope dental or vision benefits;
b. Benefits for long-term care, nursing home
care, home health care, community-based care, or any combination thereof; and
c. Such other similar, limited benefits as are
specified in federal regulations;
(3) The following benefits if offered as
independent, non-coordinated benefits:
a. Coverage only for a specified disease or
illness; and
b. Hospital indemnity or other fixed indemnity
insurance; and
(4) The following, if it is offered as a
separate policy, certificate, or contract of insurance:
a. Medicare supplemental health insurance as
defined under section 1882 (g)(1) of the Social Security Act;
b. Coverage supplemental to the coverage
provided under chapter 55 of title 10, United States Code; and
c. Similar supplemental coverage provided to
coverage under a group health plan.
(h)
“Employee welfare benefit plan” means a plan, fund, or program of employee
benefits as defined in 29 U.S.C. Chapter 18 Section 1002 (Employee Retirement
Income Security Act).
(i)
“Insolvency” means when an issuer, licensed to transact the business of
insurance in this state, has had a final order of liquidation entered against
it with a finding of insolvency by a court of competent jurisdiction in the
issuer's state of domicile.
(j)
“Issuer” includes insurance companies, fraternal benefit societies,
health care service plans, health maintenance organizations, and any other
entity delivering or issuing for delivery in this state Medicare supplement
policies or certificates.
(k)
“Medicare” means the "Health Insurance for the Aged Act,"
Title XVIII of the Social Security Amendments of 1965, as then constituted or
later amended.
(l)
“Medicare Advantage plan” means a plan of coverage for health benefits
under Medicare Part C as defined in (refer to definition of Medicare Advantage
plan in 42 U.S.C. Chapter 7 Section 1395w-28(b)(1)), and includes:
(1) Coordinated care plans that provide health
care services, including but not limited to:
a. Health maintenance organization plans, with
or without a point-of-service option;
b. Plans offered by provider-sponsored
organizations; and
c. Preferred provider organization plans;
(2) Medical savings account plans coupled with a
contribution into a Medicare Advantage plan medical savings account; and
(3) Medicare Advantage private fee-for-service
plans.
(m)
“Medicare supplement policy” means a group or individual policy of
accident and sickness insurance or a subscriber contract of
hospital and medical service associations or health maintenance organizations,
other than a policy issued pursuant to a contract under Section 1876 of the
federal Social Security Act (42 U.S.C. Section 1395 et. seq.) or an issued
policy under a demonstration project specified in 42 U.S.C. Section 1395 ss
(g)(1), which is advertised, marketed or designed primarily as a supplement to
reimbursements under Medicare for the hospital, medical or surgical expenses of
persons eligible for Medicare.
"Medicare supplement policy" does not include Medicare
Advantage plans established under Medicare Part C, Outpatient Prescription Drug
plans established under Medicare Part D, or any Health Care Prepayment Plan
(HCPP) that provides benefits pursuant to an agreement under Section 1833
(a)(1)(A) of the Social Security Act.
(n)
"Pre-Standardized Medicare supplement benefit plan,"
"Pre-Standardized benefit plan" or "Pre-Standardized plan"
means a group or individual policy of Medicare supplement insurance issued
prior to July 1, 1992.
(o)
"1990 Standardized Medicare supplement benefit plan,"
"1990 Standardized benefit plan", or "1990 plan" means a
group or individual policy of Medicare supplement insurance issued on or after
July 1, 1992 and prior to June 1, 2010 and includes Medicare supplement
insurance policies and certificates renewed on or after that date which are not
replaced by the issuer at the request of the insured.
(p)
"2010 Standardized Medicare supplement benefit plan,"
"2010 Standardized benefit plan", or "2010 plan" means a
group or individual policy of Medicare supplement insurance issued on or after
June 1, 2010.
(q)
“Policy form” means the form on which the policy is delivered or issued
for delivery by the issuer.
(r)
“Secretary” means the secretary of the United States Department of
Health and Human Services.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by
#9559, eff 10-13-09; ss by #12370, eff 10-13-17
Ins
1905.04 Policy Definitions and Terms. No
policy or certificate may be advertised,
solicited or issued for delivery in this state as a Medicare supplement policy
or certificate unless the policy or
certificate contains definitions or terms that conform to the requirements of
this section as follows:
(a)
"Accident”, "accidental injury”, or “accidental means” shall
be defined to employ "result" language and shall not include words
that establish an accidental means test or use words such as "external,
violent, visible wounds" or similar words of description or
characterization and shall not be more restrictive than the following:
(1) "Injury or injuries for which benefits
are provided means accidental bodily injury sustained by the insured person
which is the direct result of an accident, independent of disease or bodily
infirmity or any other cause, and occurs while insurance coverage is in
force"; and
(2) The definition in (a) above may
provide that injuries shall not include injuries for which benefits are
provided or available under any workers' compensation, employer's liability or
similar law, or motor vehicle no-fault plan, unless prohibited by law.
(b)
“Benefit period” or “Medicare benefit period” shall not be defined more
restrictively than as defined in the Medicare program.
(c)
“Convalescent nursing home,” “extended care facility,” or “skilled
nursing facility” shall not be defined more restrictively than as defined in
the Medicare program.
(d) “Health care expenses” means, for purposes of
Ins 1905.16, expenses of health maintenance organizations associated with the
delivery of health care services, which expenses are analogous to incurred
losses of insurers.
(e)
“Hospital” may be defined in relation to its status, facilities and
available services or to reflect its accreditation by the joint commission on
accreditation of hospitals, but not more restrictively than as defined in the
Medicare program.
(f)
“Medicare” shall be defined in the policy and certificate. Medicare may be substantially defined as
"The Health Insurance for the Aged Act, Title XVIII of the Social Security
Amendments of 1965 as Then Constituted or Later Amended," or "Title
I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the
United States of America and popularly known as the Health Insurance for the
Aged Act, as then constituted and any later amendments or substitutes
thereof," or words of similar import.
(g)
“Medicare eligible expenses” shall mean expenses of the kinds covered by
Medicare Part A and B, to the extent recognized as reasonable and medically
necessary by Medicare.
(h)
“Physician” shall not be defined more restrictively than as defined in
the Medicare program.
(i)
“Sickness” shall not be defined to be more restrictive than the
following:
(1) "Sickness" means illness or disease
of an insured person which first manifests itself after the effective date of
insurance and while the insurance is in force; and
(2) The definition in (1) above may be further
modified to exclude sicknesses or diseases for which benefits are provided
under any workers' compensation, occupational disease, employer's liability or
similar law.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99,
EXPIRED: 10-29-99
New.
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by
#9559, eff 10-13-09; ss by #12370, eff 10-13-17
Ins
1905.05 Policy Provisions.
(a)
Except for permitted preexisting condition clauses as described in Ins
1905.06 (b)(1) and (2), Ins 1905.07 (b)(1), and Ins 1905.08 (a)(1) of this rule, no policy or certificate may be
advertised, solicited or issued for delivery in this state as a Medicare
supplement policy if the policy or certificate contains limitations or
exclusions on coverage that are more restrictive than those of Medicare.
(b)
No Medicare supplement
policy or certificate shall use waivers to exclude, limit, or reduce coverage or benefits
for specifically named or described preexisting diseases or physical
conditions.
(c)
No Medicare supplement policy or certificate in force in the state shall
contain benefits that duplicate benefits provided by Medicare.
(d)
Subject to Ins 1905.06
(b)(5), (6), and (8) and Ins 1905.07 (b)(4) and (5), a Medicare supplement
policy with benefits for outpatient prescription drugs in existence prior to
January 1, 2006 shall be renewed for current policyholders who do not enroll in
Part D at the option of the policyholder.
(e)
A Medicare supplement policy with benefits for outpatient prescription
drugs shall not be issued after December 31, 2005.
(f)
After December 31, 2005,
a Medicare supplement policy with benefits for outpatient prescription drugs
may not be renewed after the policyholder enrolls in Medicare Part D unless:
(1) The policy is modified to eliminate
outpatient prescription coverage for expenses of outpatient prescription drugs
incurred after the effective date of the individual's coverage under a Part D
plan; and
(2) Premiums are adjusted to reflect the
elimination of outpatient prescription drug coverage at the time of Medicare
Part D enrollment, accounting for any claims paid, if applicable.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99,
EXPIRED: 10-29-99
New.
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by
#9559, eff 10-13-09; ss by #12370, eff 10-13-17
Ins
1905.06 Minimum Benefit Standards for
Pre-Standardized Medicare Supplement Benefit Plan Policies or Certificates
Issued for Delivery Prior To July 1, 1992.
(a)
No policy or certificate shall be advertised, solicited,
or issued for delivery in this state as a Medicare supplement policy or
certificate unless it meets or exceeds the minimum standards set
forth in this section. These are minimum
standards and do not preclude the inclusion of other provisions or benefits
which are not inconsistent with these standards.
(b)
General Standards. The following
standards shall apply to Medicare supplement policies and certificates and are
in addition to all other requirements of this part:
(1) A Medicare supplement policy or certificate
shall not exclude or limit benefits for losses incurred more than 6 months from
the effective date of coverage because it involved a preexisting condition;
(2) The policy or certificate shall 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 6 months before the effective date of coverage;
(3) A Medicare supplement policy or certificate
shall not indemnify against losses resulting from sickness on a different basis
than losses resulting from accidents;
(4) A Medicare supplement policy or certificate
shall 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, co-payment, or coinsurance amounts. Premiums may be modified to correspond with
such changes;
(5) A "noncancellable,"
"guaranteed renewable," or "noncancellable and guaranteed
renewal" Medicare supplement policy shall not:
a. 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
b. Be cancelled or non-renewed by the issuer
solely on the grounds of deterioration of health;
(6) Except
as authorized by the commissioner of this state, an issuer shall neither cancel
nor nonrenew a Medicare supplement policy or certificate for any reason other
than nonpayment of premium or material misrepresentation.
a. If a group Medicare supplement insurance
policy is terminated by the group
policyholder and not replaced as provided in
Ins 1905.06(b)(6)c., the issuer shall
offer certificate holders an individual Medicare supplement policy. The issuer shall offer the certificate
holder at least the following choices:
1.
An individual Medicare supplement policy
currently offered by the issuer having comparable benefits to those contained
in the terminated group Medicare supplement policy; or
2. An individual Medicare supplement policy
which provides only such benefits as are required to meet the minimum standards
as defined in Ins 1905.08(b) of this rule;
b. If membership in a group is terminated, the
issuer shall:
1. Offer the certificate holder the conversion
opportunities described in subparagraph (6)(a); or
2. At the option of the group policyholder,
offer the certificate holder continuation of coverage under the group policy;
and
c. 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 shall offer coverage to all
persons covered under the old group policy on its date of termination. Coverage under the new group policy shall not
result in any exclusion for preexisting conditions that would have been covered
under the group policy being replaced;
(7) Termination of a Medicare supplement policy
or certificate shall be without prejudice to any continuous loss 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 predicated upon the
continuous total disability of the insured, limited to the duration of the
policy benefit period, if any, or to payment of the maximum benefits. Receipt
of Medicare Part D benefits will not be considered in determining a continuous
loss; and
(8) If a Medicare supplement policy eliminates an
outpatient prescription drug benefit as a result of requirements imposed by the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the
modified policy shall be deemed to satisfy the guaranteed renewal requirements
of this subsection.
(c)
Minimum Benefit Standards:
(1) 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;
(2) Coverage for either all or none of the Medicare
Part A inpatient hospital deductible amount;
(3) Coverage of Part A Medicare eligible expenses
incurred as daily hospital charges during use of Medicare's lifetime hospital
inpatient reserve days;
(4) Upon exhaustion of all Medicare hospital
inpatient coverage including the lifetime reserve days, coverage of 90% of all
Medicare Part A eligible expenses for hospitalization not covered by Medicare
subject to a lifetime maximum benefit of an additional 365 days;
(5) Coverage under Medicare Part A for the
reasonable cost of the first 3 pints of blood, or equivalent quantities of
packed red blood cells, as defined under federal regulations, unless
replaced in accordance with federal regulations or already paid for under
Medicare Part B;
(6) 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
Medicare Part B regardless of hospital confinement, subject to a maximum
calendar year out-of-pocket amount equal to the Medicare Part B deductible
($147); and
(7) Effective January 1, 1990, coverage under
Medicare Part B for the reasonable cost of the first 3 pints of blood or equivalent
quantities of packed red blood cells, as defined under federal regulations,
unless replaced in accordance with federal regulations or already paid for
under Medicare Part A, subject to the Medicare deductible amount.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by
#9559, eff 10-13-09; ss by #12370, eff 10-13-17
Ins
1905.07 Benefit Standards for 1990
Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued
or Delivered on or after July 1, 1992 and Prior to June 1, 2010.
(a) The standards set forth in this section are
applicable to all Medicare supplement policies or certificates delivered or
issued for delivery in this state on or after July 1, 1992 and prior to June 1,
2010. No policy or certificate may be
advertised, solicited, delivered, or issued for delivery in this
state as a Medicare supplement policy or certificate unless it complies with
these benefit standards.
(b) General Standards. The following standards apply to Medicare
supplement policies and certificates and are in addition to all other
requirements of this rule:
(1) A Medicare supplement policy or certificate
shall not exclude or limit benefits for losses incurred more than 6 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 6 months before the effective date of coverage;
(2) A Medicare supplement policy or certificate
shall not indemnify against losses resulting from sickness on a different basis
than losses resulting from accidents;
(3) A Medicare supplement policy or certificate
shall 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;
(4) No Medicare supplement policy or certificate
shall 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;
(5) Each Medicare supplement policy shall be
guaranteed renewable and:
a. The issuer shall not cancel or non-renew
the policy solely on the ground of health status of the individual;
b. The issuer shall not cancel or non-renew
the policy for any reason other than nonpayment of premium or material
misrepresentation;
c. If the Medicare supplement policy is
terminated by the group policyholder and is not replaced as provided under Ins
1905.07(b)(5)e., the issuer shall offer certificate holders an individual
Medicare supplement policy which, at the option of the certificate holder:
1. Provides for continuation of the benefits
contained in the group policy, or
2. Provides for benefits that otherwise meet the
requirements of this subsection;
d. If an individual is a certificate holder in a
group Medicare supplement policy and the individual terminates membership in
the group, the issuer shall:
1. Offer the certificate holder the conversion
opportunity described in Ins 1905.07(b)(5) c.; or
2. At the option of the group policyholder,
offer the certificate holder continuation of coverage under the group policy;
e. 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 shall offer coverage to all
persons covered under the old group policy on its date of termination. Coverage under the new policy shall not
result in any exclusion for preexisting conditions that would have been covered
under the group policy being replaced; and
f. If a Medicare supplement policy eliminates an
outpatient prescription drug benefit as a result of requirements imposed by the
Medicare Prescription Drug, Improvement and Modernization Act of 2003, the
modified policy shall be deemed to satisfy the guaranteed renewal requirements
of this paragraph;
(6) Termination of a Medicare supplement policy
or certificate shall be without prejudice to any continuous loss 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 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 will not
be considered in determining a continuous loss;
(7) A Medicare supplement policy or certificate
shall provide that benefits and premiums under the policy or certificate 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 assistance; and
a. If suspension occurs and if the policyholder
or certificate holder loses entitlement to medical assistance, the policy or
certificate shall be automatically reinstituted, effective as of the date of
termination of entitlement, as of the 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;
b. Each Medicare supplement policy shall provide
that benefits and premiums under the policy shall be suspended, for any period
that may be provided by federal regulation, at the request of the policyholder
if the policyholder 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 shall be automatically
reinstituted, effective as of the date of loss of coverage, if the policyholder
provides notice of loss of coverage within 90 days after the date of the loss;
and
c. Reinstitution of coverages as described in
subparagraphs a. and b. shall:
1. Not provide for any waiting period with
respect to treatment of preexisting conditions;
2. Provide for resumption of coverage that is substantially
equivalent to coverage in effect before the date of suspension. If the suspended Medicare supplement policy
provided coverage for outpatient prescription drugs, reinstitution of the
policy for Medicare Part D enrollees shall be without coverage for outpatient
prescription drugs and shall otherwise provide substantially equivalent
coverage to the coverage in effect before the date of suspension; and
3. 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;
(8) If an issuer makes a written offer to the
Medicare Supplement policyholders or certificate holders of one or more of its
plans to exchange during a specified period from his or her 1990 Standardized
plan,
as described in Ins 1905.07 of this part, to a 2010 Standardized plan,
as described in Ins 1905.08 of this part, the offer and subsequent exchange
shall comply with the following requirements:
a. An issuer need not provide justification to
the commissioner if the insured replaces a 1990 Standardized policy or
certificate with an issue age rated 2010 Standardized policy or certificate at
the insured's original issue age and duration.
If an insured's policy or certificate to be replaced is priced on an
issue age rate schedule at the time of such offer, the rate charged to the
insured for the new exchanged policy shall recognize the policy reserve
buildup, due to the prefunding inherent in the use of an issue age rate basis,
for the benefit of the insured. The
method proposed to be used by an issuer shall be filed with the commissioner
according to Ins 1905.17;
b. The rating class of the new policy or
certificate shall be the class closest to the insured's class of the replaced
coverage;
c. An issuer may not apply new preexisting
condition limitations or a new incontestability period to the new policy for
those benefits contained in the exchanged 1990 Standardized policy or
certificate of the insured, but may apply preexisting condition limitations of
no more than 6 months to any added benefits contained in the new 2010
Standardized policy or certificate not contained in the exchanged policy; and
d. The new policy or certificate shall be
offered to all policyholders or certificate holders within a given plan, except
where the offer or issue would be in violation of state or federal law.
(c) Standards for Basic Core Benefits Common to
All Benefit Plans A – J. Every issuer
shall make available a policy or certificate including only the following basic
"core" package of benefits to each prospective insured and may make
available to prospective insureds any of the other Medicare supplement
insurance benefit plans in addition to the basic core package, but not in lieu
of it:
(1) 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;
(2) 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;
(3) Upon exhaustion of the Medicare hospital
inpatient coverage, including the lifetime reserve days, coverage of 100% 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 shall
accept the issuer's payment as payment in full and may not bill the insured for
any balance;
(4) Coverage under Medicare Parts A and B for the
reasonable cost of the first 3 pints of blood, or equivalent quantities of
packed red blood cells, as defined under federal regulations, unless replaced
in accordance with federal regulations; and
(5) 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.
(d)
Standards for Additional Benefits. The following additional benefits
shall be included in Medicare supplement benefit plans “B” through “J” only as
provided by Ins 1905.09 of this rule:
(1) Medicare Part A deductible shall be coverage
for all of the Medicare Part A inpatient hospital deductible amount per benefit
period;
(2) Skilled nursing facility care shall be 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;
(3) Medicare Part B deductible shall be coverage
for all of the Medicare Part B deductible amount per calendar year regardless
of hospital confinement;
(4) Eighty percent of the Medicare Part B excess
charges shall be coverage for 80% of the difference between the actual Medicare
Part B charge as billed, not to exceed any charge limitation established by the
Medicare program or state law, and the Medicare-approved Part B charge;
(5) One hundred percent of the Medicare Part B
excess charges shall be coverage for all of the difference between the actual
Medicare Part B charge as billed, not to exceed any charge limitation
established by the Medicare program or state law, and the Medicare-approved
Part B charge;
(6) 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. The outpatient
prescription drug benefit may be included for sale or issuance in a Medicare
supplement policy until January 1,
2006;
(7) 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. The outpatient prescription
drug benefit may be included for sale or issuance in a Medicare supplement
policy until January 1, 2006;
(8) 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;
(9) Preventive medical care benefit: Coverage for the following preventive health
services not covered by Medicare:
a. An annual clinical preventive medical history
and physical examination that may include tests and services from subparagraph
b., below, and patient education to address preventive health care measures;
b. Preventive screening tests or preventive
services, the selection and frequency of which is determined to be medically
appropriate by the attending physician; and
c. Reimbursement 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; and
(10) 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:
a. For purposes of this benefit, the following
definitions shall apply:
1. “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;
2.
“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;
3. “Home” shall mean any place used by the
insured as a place of residence, provided that the 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; and
4. “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 4 hours in a 24-hour period of
services provided by a care provider is one visit;
b. Coverage requirements and limitations:
1. At-home recovery services provided shall be
primarily services which assist in activities of daily living;
2. The insured's attending physician shall
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;
3. Coverage shall be limited to:
(i) 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;
(ii) The actual charges for each visit up to a
maximum reimbursement of $40 per visit;
(iii) Sixteen hundred dollars ($1600) per calendar
year;
(iv) Seven visits in any one week;
(v) Care furnished on a visiting basis in the
insured's home;
(vi) Services provided by a care provider as
defined in (10) a. 2. above;
(vii) At-home recovery visits while the insured is
covered under the policy or certificate and not otherwise excluded; and
(viii) At-home recovery visits received during the
period the insured is receiving Medicare approved home care services or no more
than 8 weeks after the service date of the last Medicare approved home health
care visit; and
c. Coverage shall be excluded for:
1. Home care visits paid for by Medicare or
other government programs; and
2. Care provided by family members, unpaid
volunteers, or providers who are not care providers.
(e)
Standards for Plans K and L shall be as follows:
(1) Standardized Medicare supplement benefit plan
"K" shall consist of the following:
a. Coverage of 100% of the Part A hospital
coinsurance amount for each day used from the 61st through the 90th day in any
Medicare benefit period;
b. Coverage of 100% 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;
c. Upon exhaustion of the Medicare hospital
inpatient coverage, including the lifetime reserve days, coverage of 100% 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 shall accept the
issuer's payment as payment in full and may not bill the insured for any
balance;
d. Medicare Part A Deductible: Coverage for 50% of the Medicare Part A
inpatient hospital deductible amount per benefit period until the out-of-pocket
limitation is met as described in subparagraph j., below;
e. Skilled Nursing Facility Care: Coverage for 50% of the coinsurance amount
for each day used 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 until the out-of-pocket limitation is met as described in subparagraph
j., below;
f. Hospice Care:
Coverage for 50% of cost sharing for all Part A Medicare eligible
expenses and respite care until the out-of-pocket limitation is met as
described in subparagraph j., below;
g. Coverage for 50%, under Medicare Part A or B,
of the reasonable cost of the first 3 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 subparagraph j., below;
h. Except for coverage provided in subparagraph
i. below, coverage for 50% of the cost sharing otherwise applicable under
Medicare Part B after the policyholder pays the Medicare Part B deductible until
the out-of-pocket limitation is met as described in subparagraph j.,
below;
i. Coverage of 100% of the cost sharing for
Medicare Part B preventive services after the policyholder pays the Medicare
Part B deductible; and
j. Coverage of 100% 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 $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; and
(2) Standardized Medicare supplement benefit plan
"L" shall consist of the following:
a. The benefits described in paragraphs (1) a.,
b., c., and i.;
b. The benefits described in paragraphs (1) d.,
e., f., g., and h., but substituting 75% for 50%; and
c. The benefit described in paragraph (1) j.,
but substituting $2000 for $4000.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by
#9559, eff 10-13-09; ss by #12370, eff 10-13-17
Ins 1905.08 Benefit Standards for 2010 Standardized Medicare
Supplement Benefit Plan Policies or Certificates Issued for Delivery on or
After June 1, 2010. The following
standards are applicable to all Medicare supplement policies or certificates
delivered or issued for delivery in this state on or after June 1, 2010. No policy or certificate may be advertised,
solicited, delivered, or issued for delivery in this state as a Medicare
supplement policy or certificate unless it complies with these benefit
standards. No issuer may offer 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 before June 1, 2010 remain
subject to the requirements of Ins 1905.07.
(a)
General Standards. The following
standards apply to Medicare supplement policies and certificates and are in
addition to all other requirements of this part:
(1) A Medicare supplement policy or certificate
shall not exclude or limit benefits for losses incurred more than 6 months from
the effective date of coverage because it involved a preexisting
condition. The policy or certificate
shall 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 6 months before the effective date of coverage;
(2) A Medicare supplement policy or certificate
shall not indemnify against losses resulting from sickness on a different basis
than losses resulting from accidents;
(3) A Medicare supplement policy or certificate
shall 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;
(4) No Medicare supplement policy or certificate
shall 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;
(5) Each Medicare supplement policy shall be
guaranteed renewable and:
a. The issuer shall not cancel or non-renew
the policy solely on the ground of health status of the individual;
b.
The issuer shall not cancel or non-renew the policy for any reason
other than nonpayment of premium or material misrepresentation;
c. If the Medicare supplement policy is
terminated by the group policyholder and is not replaced as provided under Ins
1905.08(5)(e), the issuer shall offer certificate holders an individual
Medicare supplement policy which, at the option of the certificate holder:
1. Provides for continuation of the benefits
contained in the group policy; or
2. Provides for benefits that otherwise meet the
requirements of this subsection;
d. If an individual is a certificate holder in a
group Medicare supplement policy and the individual terminates membership in
the group, the issuer shall:
1. Offer the certificate holder the conversion
opportunity described in Ins 1905.08(a)(5)c.; or
2. At the option of the group policyholder,
offer the certificate holder continuation of coverage under the group policy;
and
e.
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 shall offer coverage to all
persons covered under the old group policy on its date of termination. Coverage under the new policy shall not
result in any exclusion for preexisting conditions that would have been covered
under the group policy being replaced;
(6) Termination of a Medicare supplement policy
or certificate shall be without prejudice to any continuous loss 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 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 will not
be considered in determining a continuous loss;
(7) a. A
Medicare supplement policy or certificate shall provide that benefits and
premiums under the policy or
certificate 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 assistance;
b. If
suspension occurs and if the policyholder or certificate holder loses
entitlement to medical assistance, the policy or certificate shall be
automatically reinstituted, effective as of the date of termination of entitlement,
as of the 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;
c. Each Medicare supplement policy shall provide
that benefits and premiums under the policy shall be suspended, for any period
that may be provided by federal regulation, at the request of the policyholder
if the policyholder 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 shall
be automatically reinstituted, effective as of the date of loss of coverage, if
the policyholder provides notice of loss of coverage within 90 days after the
date of loss; and
d. Reinstitution of coverages as described in
subparagraphs b. and c above:
1. Shall not provide for any waiting period with
respect to treatment of preexisting conditions;
2. Shall provide for resumption of coverage that
is substantially equivalent to coverage in effect before the date of
suspension; and
3. 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.
(b)
Standards for Basic Core Benefits Common to Medicare Supplement Insurance
Benefit Plans A, B, C, D, E, F, F with High Deductible, G, M,
and N. Every issuer of Medicare
supplement insurance benefit plans shall make available a policy or certificate
including only the following basic "core" package of benefits to each
prospective insured and may make available to prospective insureds any of the
other Medicare supplement insurance benefit plans in addition to the basic core
package, but not in lieu of it:
(1) 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;
(2) Coverage of Part A Medicare eligible expenses
for hospitalization to the extent not covered by Medicare for each Medicare
lifetime inpatient reserve day used;
(3) Upon exhaustion of the Medicare hospital
inpatient coverage, including the lifetime reserve days, coverage of 100% 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 shall accept the
issuer's payment as payment in full and may not bill the insured for any
balance;
(4) Coverage under Medicare Parts A and B for the
reasonable cost of the first 3 pints of blood, or equivalent quantities of
packed red blood cells, as defined under federal regulations, unless replaced
in accordance with federal regulations;
(5) 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
Medicare Part B regardless of hospital confinement, subject to the
Medicare Part B deductible; and
(6) Hospice Care:
Coverage of cost sharing for all Part A Medicare eligible hospice care
and respite care expenses.
(c)
Standards for Additional Benefits.
The following additional benefits shall be included in Medicare
supplement benefit plans B, C, D, E, F, F with High Deductible, G, M and N as
provided by Ins 1905.10:
(1) Medicare Part A Deductible: Coverage for 100% of the Medicare Part A
inpatient hospital deductible amount per benefit period;
(2) Medicare Part A Deductible: Coverage for 50% of the Medicare Part A
inpatient hospital deductible amount per benefit period;
(3) 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;
(4) Medicare Part B Deductible: Coverage for 100% of the Medicare Part B
deductible amount per calendar year regardless of hospital confinement;
(5) 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; and
(6) 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 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.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #6406, eff 1-1-97; ss by
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by
#9559, eff 10-13-09; ss by #12370, eff 10-13-17
Ins
1905.09 Standard Medicare Supplement
Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies
or Certificates Issued for Delivery on or After July 1, 1992 and Prior to June
1, 2010.
(a) An issuer 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 Ins
1905.07(c) of this rule.
(b)
No groups, packages or combinations
of Medicare supplement benefits other than those listed in this section shall
be offered for sale in this state, except as may be permitted in Ins
1905.09(f) and Ins 1905.12.
(c)
Benefit plans shall be
uniform in structure, language, designation, and format to the standard benefit
plans "A" through "L" listed in this subsection and conform
to the definitions in Ins 1905.03. Each benefit shall be structured in accordance with the format
provided in Ins 1905.07(c), (d), and (e) and list the benefits in the order
shown in this subsection. For purposes
of this section, "structure, language, and format" means style,
arrangement and overall content of a benefit.
(d)
An issuer may use, in addition to the benefit plan designations required
in paragraph (c) above, other designations to the extent permitted by law.
(e)
Make-up of benefit plans:
(1) Standardized Medicare supplement benefit plan
"A" shall be limited to the basic core benefits common to all benefit
plans, as defined in Ins 1905.07(c);
(2) Standardized Medicare supplement benefit plan
"B" shall include only the following:
a. The core benefit as specified in Ins
1905.07(c) of this rule; plus
b. The Medicare Part A deductible as defined in
Ins 1905.07(d)(1);
(3) Standardized Medicare supplement benefit plan
"C" shall include only the following:
a. The core benefit as defined in Ins
1905.07(c); plus
b. The Medicare Part A deductible as defined in
Ins 1905.07(d)(1);
c. Skilled nursing facility care as defined in
Ins 1905.07(d)(2);
d. Medicare Part B deductible as defined in Ins
1905.07(d)(3); and
e. Medically necessary emergency care in a
foreign country as defined in Ins 1905.07(d)(8);
(4) Standardized Medicare supplement benefit plan
"D" shall include only the following:
a. The core benefit as defined in Ins 1905.07(c) of
this rule; plus
b. The Medicare Part A deductible as defined in
Ins 1905.07(d)(1);
c. Skilled nursing facility care as defined in
Ins 1905.07(d)(2);
d. Medically necessary emergency care in a
foreign country as defined in Ins 1905.07(d)(8); and
e. The at-home recovery benefit as defined in
Ins 1905.07(d)(10);
(5) Standardized Medicare supplement benefit plan
"E" shall include only the following:
a. The core benefit as defined in Ins 1905.07(c)
of this rule; plus
b. The Medicare Part A deductible as defined in
Ins 1905.07(d)(1);
c. Skilled nursing facility care as defined in
Ins 1905.07(d)(2);
d. Medically necessary emergency care in a
foreign country as defined in Ins 1905.07 (d)(8); and
e. Preventive medical care as defined in Ins
1905.07(d)(9);
(6) Standardized Medicare supplement benefit plan
"F" shall include only the following:
a. The core benefit as defined in Ins 1905.07(c) of
this rule; plus
b. The Medicare Part A deductible as defined in
Ins 1905.07(d)(1);
c. The skilled nursing facility care as defined
in Ins 1905.07(d)(2);
d. The Part B deductible as defined in Ins
1905.07(d)(3);
e. One hundred percent of the Medicare Part B
excess charges as defined in Ins 1905.07(d)(5); and
f. Medically necessary emergency care in a
foreign country as defined in Ins 1905.07(d)(8);
(7) Standardized Medicare supplement benefit high
deductible plan "F" shall include only the following:
a. 100% of covered expenses following the
payment of the annual high deductible plan F deductible. The covered expenses include:
1. The core benefit as defined in Ins 1905.07(c)
of this rule; plus
2. The Medicare Part A deductible as defined in
Ins 1905.07(d)(1);
3. Skilled nursing facility care as defined in
Ins 1905.07(d)(2);
4. The Medicare Part B deductible as defined in
Ins 1905.07(d)(3);
5. One hundred percent of the Medicare Part B
excess charges as defined in Ins 1905.07(d)(5); and
6. Medically necessary emergency care in a
foreign country as defined in Ins
1905.07(d)(8);
b. The annual high deductible plan "F"
deductible shall consist of out-of-pocket expenses, other than premiums, for
services covered by the Medicare supplement plan F policy; and shall be in
addition to any other specific benefit deductibles;
c. The annual high deductible plan "F"
deductible shall be $1500 for 1998 and 1999,
and shall be based on the calendar year; and
d. It shall be adjusted annually thereafter 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;
(8)
Standardized Medicare supplement benefit
plan "G" shall include only the following:
a. The core benefit as defined in Ins
1905.07(c) of this rule; plus
b. The Medicare Part A deductible as defined in
Ins 1905.07(d)(1);
c. Skilled nursing facility care as defined in
Ins 1905.07(d)(2);
d. Eighty
percent of the Medicare Part B excess charges as defined in Ins
1905.07(d)(4);
e. Medically necessary emergency care in a foreign
country as defined in Ins 1905.07(d)(8); and
f. The at-home recovery benefit as defined in
Ins 1905.07(d)(10);
(9) Standardized Medicare supplement benefit plan
"H" shall consist of only the following:
a. The core benefit as defined in Ins 1905.07(c)
of this rule; plus
b. The Medicare Part A deductible as defined in
Ins 1905.07(d)(1);
c. Skilled nursing facility care as defined in
Ins 1905.07(d)(2);
d. Basic prescription drug benefit as defined in
Ins 1905.07(d)(6); and
e.
Medically necessary emergency care in a foreign country as defined in Ins
1905.07(d)(8); and
f. The outpatient prescription drug benefit
shall not be included in a Medicare supplement policy sold after December 31,
2005;
(10) Standardized Medicare supplement benefit plan
"I" shall consist of only
the following:
a. The core benefit as defined in Ins 1905.07(c) of
this rule; plus
b. The Medicare Part A deductible as defined in
Ins 1905.07(d)(1);
c. Skilled nursing facility care as defined in
Ins 1905.07(d)(2);
d. One hundred percent of the Medicare Part B
excess charges as defined in Ins 1905.07(d)(5);
e. Basic prescription drug benefit as defined in
Ins 1905.07(d)(6);
f.
Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8);
g. At-home recovery benefits as defined in Ins
1905.07 (d)(10); and
h. The outpatient prescription drug benefit
shall not be included in a Medicare supplement policy sold after December 31,
2005;
(11) Standardized Medicare supplement benefit plan
"J" shall consist of only the following:
a. The core benefit as defined in Ins
1905.07(c) of this rule; plus
b. The Medicare Part A deductible as defined in
Ins 1905.07(d)(1);
c. Skilled nursing facility care as defined in
Ins 1905.07(d)(2);
d. Medicare Part B deductible as defined in Ins
1905.07(d)(3);
e.
One hundred percent of the Medicare Part B excess charges as defined in Ins
1905.07(d)(5);
f. Extended prescription drug benefit as defined
in Ins 1905.07(d)(7);
g.
Medically necessary emergency care in a foreign country as defined in Ins
1905.07(d)(8);
h. Preventive medical care as defined in Ins
1905.07(d)(9);
i. At-home recovery benefit as defined in Ins
1905.07(d)(10); and
j. The outpatient prescription drug benefit
shall not be included in a Medicare supplement policy sold after December 31,
2005;
(12) Standardized Medicare supplement benefit high
deductible plan "J" shall consist of only the following:
a. One hundred percent of covered expenses,
following the payment of the annual high deductible plan “J” deductible. The covered expenses include:
1. The core benefit as defined in Ins 1905.07(c)
of this rule; plus
2. The Medicare Part A deductible as defined in
Ins 1905.07(d)(1);
3. Skilled nursing facility care as defined in
Ins 1905.07(d)(2);
4. Medicare Part B deductible as defined in Ins
1905.07(d)(3);
5. One hundred percent of the Medicare Part B
excess charges as defined in Ins 1905.07(d)(5);
6. Extended outpatient prescription drug benefit
as defined in Ins 1905.07(d)(7);
7. Medically necessary emergency care in a
foreign country as defined in Ins 1905.07(d)(8);
8. Preventive medical care benefit as defined in
Ins 1905.07(d)(9); and
9. At-home recovery benefit as defined in Ins
1905.07(d)(10);
b. The annual high deductible plan “J” deductible
shall consist of out-of-pocket expenses, other than premiums, for services
covered by the Medicare supplement plan “J” policy, and shall be in addition to
any other specific benefit deductibles;
c. The annual deductible shall be $1500 for 1998
and 1999, and shall be based on a calendar year;
d. It shall be adjusted annually thereafter 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; and
e. The outpatient prescription drug benefit
shall not be included in a Medicare supplement policy sold after December 31,
2005; and
(13) Make-up of two Medicare supplement plans
mandated by The Medicare Prescription Drug, Improvement and Modernization Act
of 2003 (MMA):
a. Standardized Medicare supplement benefit plan
"K" shall consist of only those benefits described in Ins
1905.07(e)(1); and
b. Standardized Medicare supplement benefit plan
"L" shall consist of only those benefits described in Ins
1905.07(e)(2).
(f)
New or Innovative Benefits. An
issuer may, with the prior approval of the commissioner, offer policies or
certificates with new or innovative benefits 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. After December 31,
2005, the innovative benefit shall not include an outpatient prescription drug
benefit.
Source. #5390, eff 7-1-92; ss by #5656, eff
7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #7174, eff 12-22-99; ss by #8051, eff
3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff
10-13-17
Ins
1905.10 Standard Medicare Supplement
Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies
or Certificates Issued for Delivery on or After June 1, 2010. The
following standards are applicable to all Medicare supplement policies or
certificates delivered or issued for delivery in this state on or after June 1,
2010. No policy or certificate may be
advertised, solicited, delivered or issued for delivery in this state as a
Medicare supplement policy or certificate unless it complies with these benefit
plan standards. Benefit plan standards
applicable to Medicare supplement policies and certificates issued before June
1, 2010 remain subject to the requirements of Ins 1905.07:
(a) (1) An
issuer 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 Ins 1905.08(b).
(2) If an issuer makes available any of the additional
benefits described in Ins 1905.08(c) or offers standardized benefit plans “K”
or “L”, as described in Ins 1905.10(e)(8) and (9), then the issuer 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 Ins 1905.10(a)(1) above, a policy form or certificate form
containing either standardized benefit plan “C”, as described in Ins
1905.10(e)(3) or standardized benefit plan
“F”, as described in Ins 1905.10(e)(5).
(b)
No groups, packages, or combinations of Medicare supplement benefits
other than those listed in this section shall be offered for sale in this
state, except as may be permitted in Ins 1905.10 (f) and Ins 1905.12.
(c)
Benefit plans shall be uniform in structure, language, designation, and
format to the standard benefit plans listed in this subsection and conform to
the definitions in Ins 1905.03. Each
benefit shall be structured in accordance with the format provided in Ins
1905.08(b); or, in the case of plans “K” or “L”, in Ins 1905.10(e)(8) or (9)
and list the benefits in the order shown.
For purposes of this section, "structure, language, and
format" means style, arrangement, and overall content of a benefit.
(d) In addition to the benefit plan designations
required in Ins 1905.10(c), an issuer may use other designations to the extent
permitted by law.
(e)
Make-up of 2010 Standardized Benefit Plans:
(1) Standardized Medicare supplement benefit plan
“A” shall include only the following:
a. The basic core benefits as defined in Ins
1905.08(b);
(2) Standardized Medicare supplement benefit plan
“B” shall include only the following:
a. The basic core benefit as defined in Ins
1905.08(b); plus
b. One hundred percent of the Medicare Part A
deductible as defined in Ins 1905.08(c)(1);
(3) Standardized Medicare supplement benefit plan
“C” shall include only the following:
a. The basic core benefit as defined in Ins
1905.08(b); plus
b. One hundred percent of the Medicare Part A
deductible as defined in Ins 1905.08(c)(1);
c. Skilled nursing facility care as defined in
Ins 1905.08(c)(3);
d. One hundred percent of the Medicare Part B
deductible as defined in Ins 1905.08(c)(4); and
e. Medically necessary emergency care in a
foreign country as defined in Ins 1905.08(c)(6);
(4) Standardized Medicare supplement benefit plan
“D” shall include only the following:
a. The basic core benefit as defined in Ins
1905.08(b); plus
b. One hundred percent of the Medicare Part A
deductible as defined in Ins 1905.08(c)(1);
c. Skilled nursing facility care as defined in
Ins 1905.08(c)(3); and
d. Medically necessary emergency care in a
foreign country as defined in Ins 1905.08(c)(6);
(5) Standardized Medicare supplement (regular)
plan “F” shall include only the following:
a. The basic core benefit as defined in Ins
1905.08(b); plus
b. One hundred percent of the Medicare Part A
deductible as defined in Ins 1905.08(c)(1);
c. The skilled nursing facility care as defined
in Ins 1905.08(c)(3);
d. One hundred percent of the Medicare Part B
deductible as defined in Ins 1905.08(c)(4);
e. One hundred percent of the Medicare Part B
excess charges as defined in Ins 1905.08(c)(5); and
f. Medically necessary care in a foreign country
as defined in Ins 1905.08(c)(6);
(6) Standardized Medicare supplement plan “F” with
high deductible shall include only the following:
a. One hundred percent of covered expenses
following the payment of the annual deductible set forth in subparagraph h;
b. The basic core benefit as defined in Ins
1905.08(b); plus
c. One hundred percent of the Medicare Part A
deductible as defined in Ins 1905.08(c)(1);
d. Skilled nursing facility care as defined in
Ins 1905.08(c)(3);
e. One hundred percent of the Medicare Part B
deductible as defined in Ins 1905.08(c)(4);
f.
One hundred percent of the Medicare Part B excess charges as defined in Ins
2905.08(c)(5);
g.
Medically necessary emergency care in a foreign country as defined in Ins
1905.08(c)(6); and
h. The annual deductible in plan “F” with high
deductible shall consist of out-of-pocket expenses, other than premiums, for
services covered by regular plan “F”, and shall be in addition to any other
specific benefit deductibles. The basis
for the deductible shall be $1,500 and shall be adjusted annually from 1999 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 dollars;
(7) Standardized Medicare supplement benefit plan
“G” shall include only the following:
a. The basic core benefit as defined in Ins
1905.08(b); plus
b. One hundred percent of the Medicare Part A deductible
as defined in Ins 1905.08(c)(1);
c. Skilled nursing facility care as defined in
Ins 1905.08(c)(3);
d.
One hundred percent of the Medicare Part B excess charges as defined in Ins
1905.08(c)(5);
e.
Medically necessary emergency care in a foreign country as defined in Ins
1905.08(c)(6); and
f. Effective January 1, 2020, the standardized
benefit plans describe in Ins 1905.11(a)(4) – redesignated Plan G High
Deductible – may be offered to any individual who was eligible for Medicare
prior to January 1, 2020.
(8) Standardized Medicare supplement plan “K” is
mandated by The Medicare Prescription Drug, Improvement and Modernization Act
of 2003, and shall include only the following:
a. Part A Hospital Coinsurance, 61st through
90th days: Coverage of 100% of the Part
A hospital coinsurance amount for each day from the 61st through the 90th day
in any Medicare benefit period;
b. Part A Hospital Coinsurance, 91st through
150th days: Coverage of 100% 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;
c. Part A Hospitalization After 150 Days: Upon exhaustion of the Medicare hospital
inpatient coverage, including the lifetime reserve days, coverage of 100% 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 shall accept the
issuer's payment as payment in full and may not bill the insured for any
balance;
d. Medicare Part A Deductible: Coverage for 50% of the Medicare Part A
inpatient hospital deductible amount per benefit period until the out-of-pocket
limitation is met as described in subparagraph j., below;
e. Skilled Nursing Facility Care: Coverage for 50% of the coinsurance amount for
each day used 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 until the out-of-pocket limitation is met as described in subparagraph
j., below;
f. Hospice Care:
Coverage for 50% of cost sharing for all Part A Medicare eligible
expenses and respite care until the out-of-pocket limitation is met as
described in subparagraph j., below;
g. Blood:
Coverage for 50%, under Medicare Part A or B, of the reasonable cost of
the first 3 pints of blood, or equivalent quantities of packed red blood cells,
and defined under federal regulations, unless replaced in accordance with
federal regulations until the out-of-pocket limitation is met as described in
subparagraph j., below;
h. Part B Cost Sharing: Except for coverage provided in subparagraph
i, coverage for 50% 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 subparagraph j., below;
i. Part B Preventive Services: Coverage of 100% of the cost sharing for
Medicare Part B preventive services after the policyholder pays the Part B
deductible; and
j. Cost Sharing After Out-of-Pocket Limits: Coverage of 100% 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 $4,000 in 2006, indexed each year by the
appropriate inflation adjustment specified by the Secretary of the U.S.
Department of Health and Human Services;
(9) Standardized Medicare supplement plan “L” is
mandated by The Medicare Prescription Drug, Improvement and Modernization Act
of 2003, and shall include only the following:
a. The benefits described in Ins
1905.10(e)(8)a., b., c., and i.;
b. The benefits described in Ins
1905.10(e)(8)d., e., f., g., and h., but substituting 75% for 50%; and
c. The benefits described in Ins 1905.10(e)(8)j.,
but substituting $2,000 for $4,000;
(10) Standardized Medicare supplement plan “M”
shall include only the following:
a. The basic core benefit as defined in Ins
1905.08(b); plus
b. Fifty percent of the Medicare Part A
deductible as defined in Ins 1905.08(c)(2);
c. Skilled nursing facility care as defined in
Ins 1905.08(c)(3); and
d.
Medically necessary emergency care in a foreign country as defined in Ins
1905.08(c)(6); and
(11)
Standardized Medicare supplement plan
“N” shall include only the following:
a. The basic core benefit as defined in Ins
1905.08(b); plus
b. One hundred percent of the Medicare Part A
deductible as defined in Ins 1905.08(c)(1);
c. Skilled nursing facility care as defined in
Ins 1905.08(c)(3); and
d.
Medically necessary emergency care in a foreign country as defined in Ins
1905.08(c)(6), with co-payments in the following amounts:
1. 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
2. The lesser of $50 or the Medicare Part B
coinsurance or copayment for each covered emergency room visit, however, this
copayment shall be waived if the insured is admitted to any hospital and the
emergency visit is subsequently covered as a Medicare Part A expense.
(f)
New or Innovative Benefits: An
insurer 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 shall include only benefits that are appropriate to
Medicare supplement insurance, are new or innovative, are not otherwise
available, and are cost-effective.
Approval of new or innovative benefits shall not adversely impact the
goal of Medicare supplement simplification.
New or innovative benefits shall not include an outpatient prescription
drug benefit. New or innovative benefits
shall not be used to change or reduce benefits, including a change of any
cost-sharing provision, in any standardized plan.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by
#9559, eff 10-13-09; ss by #12370, eff 10-13-17
Ins 1905.11 Standard Medicare
Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan
Policies or Certificates Issued for Delivery to Individuals Newly Eligible for
Medicare On or After January 1, 2020.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
requires that the following standards are applicable to all Medicare supplement
policies or certificates delivered, or issued for delivery in this state, to
individuals newly eligible for Medicare on or after January 1, 2020. 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. All policies must comply with the
following benefit standards. Benefit plan standards applicable to Medicare
supplement policies and certificates issued to individuals eligible for
Medicare before January 1, 2020, remain subject to the requirements of Ins
1905.10:
(a)
Benefit Requirements. The standards and requirements of Section Ins
1905.10 shall apply to all Medicare supplement policies or certificates
delivered or issued for delivery to individuals newly eligible for Medicare on
or after January 1, 2020, with the following exceptions:
(1) Standardized Medicare supplement benefit Plan
C is redesignated as Plan D and shall provide the benefits contained in Ins
1905.10(e)(3) but shall not provide coverage for one hundred percent (100%) or
any portion of the Medicare Part B deductible;
(2) Standardized Medicare supplement benefit Plan
F is redesignated as Plan G and shall provide the benefits contained in Ins
1905.10(e)(5) but shall not provide coverage for one hundred percent (100%) or
any portion of the Medicare Part B deductible;
(3) Standardized Medicare supplement benefit
plans C, F, and F with High Deductible may not be offered to individuals newly
eligible for Medicare on or after January 1, 2020;
(4) Standardized Medicare supplement benefit Plan
F With High Deductible is redesignated as Plan G With High Deductible and shall
provide the benefits contained in Ins 1905.10(e)(6) but shall not provide
coverage for one hundred percent (100%) or any portion of the Medicare Part B
deductible, provided further that the Medicare Part B deductible paid by the
beneficiary shall be considered an out-of-pocket expense in meeting the annual
high deductible; and
(5) The reference to Plans C or F contained in
Ins 1905.10(a)(2) is deemed a reference to Plans D or G for purposes of this
section.
(b)
Applicability to Certain Individuals. Ins 1905.11 applies to only
individuals that are newly eligible for Medicare on or after January 1, 2020:
(1) By reason of attaining age 65 on or after
January 1, 2020; or
(2) By reason of entitlement to benefits under
part A pursuant to Section 226(b) or 226A of the Social Security Act, available
as referenced in Appendix A, or who is deemed to be eligible for benefits under
Section 226(a) of the Social Security Act on or after January 1, 2020.
(c)
Guaranteed Issue for Eligible Persons. For purposes of Ins 1905.14(e),
in the case of any individual newly eligible for Medicare on or after January
1, 2020, any reference to a Medicare supplement policy C or F (including F With
High Deductible) shall be deemed to be a reference to Medicare supplement
policy D or G (including G With High Deductible), respectively, that meet the
requirements of Ins 1905.11(a).
(d)
Applicability to Waivered States. In the case of a state described in
Section 1882(p)(6) of the Social Security Act (“waivered” alternative
simplification states), MACRA prohibits the coverage of the Medicare Part B
deductible for any Medicare supplement policy sold or issued to an individual
that is newly eligible for Medicare on or after January 1, 2020.
(e)
Offer of Redesignated Plans to Individuals Other Than Newly Eligible. On
or after January 1, 2020, the standardized benefit plans described in
subparagraph Ins 1905.11(a)(4), above, may be offered to any individual who was
eligible for Medicare prior to January 1, 2020, in addition to the standardized
plans described in Ins 1905.10(e).
Source.
#12370, eff 10-13-17
Ins
1905.12 Medicare Select Policies and Certificates.
(a) This section shall apply to Medicare Select
policies and certificates, as defined in this section.
(b)
No policy or certificate may be advertised as a Medicare Select policy
or certificate unless it meets the requirements of this section.
(c)
For the purposes of this section:
(1) "Complaint" means any
dissatisfaction expressed by an individual concerning a Medicare Select issuer
or its network providers;
(2) "Grievance" means dissatisfaction
expressed in writing by an individual insured under a Medicare Select policy or
certificate with the administration, claims practices, or provision of services
concerning a Medicare Select issuer or its network providers;
(3) "Medicare Select issuer" means an
issuer offering, or seeking to offer, a Medicare Select policy or certificate;
(4) "Medicare Select policy" or
"Medicare Select certificate" means respectively a Medicare
supplement policy or certificate that contains restricted network provisions;
(5) "Network provider" means a provider
of health care, or a group of providers of health care, which has entered into
a written agreement with the issuer to provide benefits insured under a
Medicare Select policy;
(6)
"Restricted network provision" means any provision which conditions
the payment of benefits, in whole or in part, on the use of network providers;
and
(7) "Service area" means the geographic
area approved by the commissioner within which an issuer is authorized to offer
a Medicare Select policy.
(d)
The commissioner may authorize an issuer to offer a Medicare Select
policy or certificate, pursuant to this section and Section 4358 of the Omnibus
Budget Reconciliation Act (OBRA) of 1990 if the commissioner finds that the
issuer has satisfied all of the requirements of this rule.
(e) A Medicare Select issuer shall not issue a Medicare
Select policy or certificate in this state until its plan of operation has been
approved by the commissioner.
(f)
A Medicare Select issuer shall file a proposed plan of operation with
the commissioner in a format prescribed by the commissioner. The plan of operation shall contain at least
the following information:
(1) Evidence that all covered services that are
subject to restricted network provisions are available and accessible through
network providers, including a demonstration that:
a. Services can be provided by network providers
with reasonable promptness with respect to geographic location, hours of
operation and after-hour care. The hours
of operation and availability of after-hour care shall reflect usual practice
in the local area. Geographic
availability shall reflect the usual travel times within the community;
b. The number of network providers in the
service area is sufficient, with respect to current and expected policyholders,
either:
1.
To deliver adequately all services that are subject to a restricted network
provision; or
2. To make appropriate referrals;
c.
There are written agreements with network providers describing specific
responsibilities;
d. Emergency care is available 24 hours per day
and 7 days per week; and
e. In the case of covered services that are
subject to a restricted network provision and are provided on a prepaid basis,
there are written agreements with network providers prohibiting the providers
from billing or otherwise seeking reimbursement from or recourse against any
individual insured under a Medicare Select policy or certificate. This paragraph shall not apply to
supplemental charges or coinsurance amounts as stated in the Medicare Select
policy or certificate;
(2) A statement or map providing a clear
description of the service area;
(3) A description of the grievance procedure to
be utilized;
(4) A description of the quality assurance
program, including:
a. The formal organizational structure;
b. The written criteria for selection, retention
and removal of network providers; and
c. The procedures for evaluating quality of care
provided by network providers, and the process to initiate corrective action
when warranted;
(5) A list and description, by specialty, of the
network providers;
(6) Copies of the written information proposed to
be used by the issuer to comply with paragraph (k) below; and
(7) Any other information requested by the
commissioner.
(g) A Medicare Select issuer shall file any
proposed changes to the plan of operation, except for changes to the list of
network providers, with the commissioner prior to implementing the
changes. Changes shall be considered
approved by the commissioner after 30 days unless specifically disapproved.
(h)
An updated list of network providers shall be filed with the
commissioner at least quarterly.
(i)
A Medicare Select policy or certificate shall not restrict payment for
covered services provided by non-network providers if:
(1) The services are for symptoms requiring
emergency care or are immediately required for an unforeseen illness, injury or
a condition; and
(2) It is not reasonable to obtain services
through a network provider.
(j) A Medicare Select policy or certificate shall
provide payment for full coverage under the policy for covered services that
are not available through network providers.
(k)
A Medicare Select issuer shall make full and fair disclosure in writing
of the provisions, restrictions and limitations of the Medicare Select policy
or certificate to each applicant. This
disclosure shall include at least the following:
(1) An outline of coverage sufficient to permit
the applicant to compare the coverage and premiums of the Medicare Select
policy or certificate with:
a. Other Medicare supplement policies or
certificates offered by the issuer; and
b. Other Medicare Select policies or
certificates;
(2) A description, including address, phone
number and hours of operation, of the network providers, including primary care
physicians, specialty physicians, hospitals and other providers;
(3) A description of the restricted network
provisions, including payments for coinsurance and deductibles when providers
other than network providers are utilized.
Except to the extent specified in the policy or certificate, expenses
incurred when using out-of-network providers do not count toward the
out-of-pocket annual limit contained in plans “K” and “L”;
(4) A description of coverage for emergency and
urgently needed care and other out-of-service area coverage;
(5) A description of limitations on referrals to
restricted network providers and to other providers;
(6) A description of the policyholder's rights to
purchase any other Medicare supplement policy or certificate otherwise offered
by the issuer; and
(7) A description of the Medicare Select issuer's
quality assurance program and grievance procedure.
(l) Prior to the sale of a Medicare Select policy
or certificate, a Medicare Select issuer shall obtain from the applicant a
signed and dated form stating that the applicant has received the information
provided pursuant to subsection (k) of this section and that the applicant
understands the restrictions of the Medicare Select policy or certificate.
(m)
A Medicare Select issuer shall have and use procedures for hearing
complaints and resolving written grievances from the subscribers. The procedures shall be aimed at mutual
agreement for settlement may include arbitration procedures and:
(1) The grievance procedure shall be described in
the policy and certificates and in the outline of coverage;
(2) At the time the policy or certificate is
issued, the issuer shall provide detailed information to the policyholder
describing how a grievance may be registered with the issuer;
(3) Grievances shall be considered in a timely
manner and shall be transmitted to appropriate decision-makers who have
authority to fully investigate the issue and take correction action;
(4) If a grievance is found to be valid,
corrective action shall be taken promptly;
(5) All concerned parties shall be notified about
the results of a grievance; and
(6) The issuer shall report no later than each
March 31st to the commissioner regarding its grievance procedure. The report shall be in a format prescribed by
the commissioner and shall contain the number of grievances filed in the past
year and a summary of the subject, nature and resolution of such grievances.
(n)
At the time of initial purchase, a Medicare Select issuer shall make
available to each applicant for a Medicare Select policy or certificate the
opportunity to purchase any Medicare supplement policy or certificate otherwise
offered by the issuer.
(o)
At the request of an individual insured under a Medicare Select policy
or certificate, a Medicare Select issuer shall:
(1) Make available to the individual insured the
opportunity to purchase a Medicare supplement policy or certificate offered by
the issuer which has comparable or lesser benefits and which does not contain a
restricted network provision. The issuer
shall make the policies or certificates available without requiring evidence of
insurability after the Medicare Select policy or certificate has been in force
for 6 months; and
(2) For the purposes of this subsection, a
Medicare supplement policy or certificate will be considered to have comparable
or lesser benefits unless it contains one or more significant benefits not
included in the Medicare Select policy or certificate being replaced. For the purposes of this paragraph, a
significant benefit means coverage for the Medicare Part A deductible, coverage
for at-home recovery services, or coverage for Part B excess charges.
(p) Medicare Select policies and certificates
shall provide for continuation of coverage in the event the Secretary of Health
and Human Services determines that Medicare Select policies and certificates
issued pursuant to this section should be discontinued due to either the
failure of the Medicare Select Program to be reauthorized under law or its
substantial amendment.
(1) Each Medicare Select issuer shall make
available to each individual insured under a Medicare Select policy or
certificate the opportunity to purchase any Medicare supplement policy or
certificate offered by the issuer which has comparable or lesser benefits and
which does not contain a restricted network provision. The issuer shall make the policies and certificates
available without requiring evidence of insurability; and
(2) For the purposes of this subsection, a
Medicare supplement policy or certificate will be considered to have comparable
or lesser benefits unless it contains one or more significant benefits not
included in the Medicare Select policy or certificate being replaced. For the purposes of this paragraph, a
significant benefit means coverage for the Medicare Part A deductible, coverage
for at-home recovery services, or coverage for Part B excess charges.
(q) A Medicare Select issuer shall comply with
reasonable requests for data made by state or federal agencies, including the
United States Department of Health and Human Services, for the purpose of
evaluating the Medicare Select Program.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by
#9559, eff 10-13-09; ss by #12370, eff 10-13-17 (from Ins 1905.11)
Ins
1905.13 Open Enrollment.
(a) An issuer shall not deny or condition the
issuance or effectiveness of any Medicare supplement policy or certificate
available for sale in this state, nor discriminate in the pricing of a policy or
certificate because of the health status, claims experience, receipt of health
care, or medical condition of an applicant in the case of an application for a
policy or certificate that is submitted prior to or during the 6 month period
beginning with the first day of the first month in which an individual is
enrolled for benefits under Medicare Part B and when each Medicare supplement
policy and certificate currently available from an insurer shall be made
available to all applicants who qualify under this subsection without regard to
age.
(b) If an applicant qualifies under (a) and
submits an application during the time period referenced in (a) and, as of the
date of application, has had a continuous period of creditable coverage of at
least 6 months, the issuer shall not exclude benefits based on a preexisting
condition.
(c)
If the applicant
qualifies under (a) and submits an application during the time period referenced
in (a) and, as of the date of application, has had a continuous period of
creditable coverage that is less than 6 months, the issuer shall reduce the
period of any preexisting condition exclusion by the aggregate of the period of
creditable coverage applicable to the applicant as of the enrollment date. The Secretary shall specify the manner of the
reduction under this subsection.
(d)
Except as provided in (b) and Ins 1905.25, (a) shall not be
construed as preventing the exclusion of benefits under a policy, during the first 6 months, based on a
preexisting condition for which the policyholder or certificate holder received treatment or was otherwise diagnosed
during the 6 months before the coverage became effective.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99,
EXPIRED: 10-29-99
New.
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by
#9559, eff 10-13-09 (from Ins 1905.10); ss by #12370, eff 10-13-17 (from Ins
1905.12)
Ins 1905.14 Guaranteed Issue
for Eligible Persons.
(a) Guaranteed issue shall be for:
(1) Eligible persons are
those individuals described in (b) who:
a. Seek to enroll under the policy during
the period specified in Ins 1905.14(c); and
b. Submit evidence of the
date of termination or disenrollment, or Medicare Part D enrollment with the
application for a Medicare supplement policy;
(2) With respect to eligible
persons, an issuer shall not:
a. Deny or condition the
issuance or effectiveness of a Medicare supplement policy described below that
is offered and is available for issuance to new enrollees by the issuer;
b. Discriminate in the
pricing of such a Medicare supplement policy because of:
1. Health status;
2. Claims experience;
3. Receipt of health care;
or
4. Medical condition; and
c. Impose an exclusion of
benefits based on a preexisting condition under such a Medicare supplement
policy.
(b) An eligible person is an individual described
in any of the following subparagraphs:
(1) The individual is enrolled
under an employee welfare benefit plan that provides health benefits that
supplement the benefits under Medicare; and the plan terminates, or the plan
ceases to provide all such supplemental health benefits to the individual;
(2) The individual is
enrolled with a Medicare Advantage organization under a Medicare Advantage plan
under Part C of Medicare, and any of the following circumstances apply,
or the individual is 65 years of age or older and is enrolled with a Program of
All-Inclusive Care for the Elderly (PACE) provider under Section 1894 of the
Social Security Act, and there are circumstances similar to those described
below that would permit discontinuance of the individual's enrollment with such
provider if such individual were enrolled in a Medicare Advantage plan:
a. The certification of the
organization or plan has been terminated;
b. The organization has
terminated or otherwise discontinued providing the plan in the area in which
the individual resides;
c. The individual is no longer eligible to elect the plan because
of a change in the individual’s place of residence or other change in
circumstances specified by the secretary, but not including termination of the
individual’s enrollment on the basis described in section 1851(g)(3)(B) of the
federal Social Security Act, where the individual has not paid premiums on a
timely basis or has engaged in disruptive behavior as specified in standards
under section 1856, or the plan is terminated for all individuals within a
residence area;
d. The individual
demonstrates, in accordance with guidelines established by the secretary, that:
1. The organization
offering the plan substantially violated a material provision of the
organization’s contract under this part in relation to the individual,
including the failure to provide an enrollee on a timely basis medically
necessary care for which benefits are available under the plan or the failure
to provide such covered care in accordance with applicable quality standards;
or
2. The organization, or agent, or other entity acting on the organization’s
behalf, materially misrepresented the plan’s provisions in marketing the plan
to the individual; or
e. The individual meets
such other exceptional conditions as the Secretary may provide;
(3) The individual is
enrolled with:
a. An eligible organization
under a contract under Section 1876 of the Social Security Act (Medicare cost);
b. A similar organization operating
under demonstration project authority, effective for periods before April 1,
1999;
c. An organization under an
agreement under Section 1833 (a)(1)(A) of the Social Security Act (health care
prepayment plan); or
d. An organization under a
Medicare Select policy; and
e. The enrollment ceases
under the same circumstances that would permit discontinuance of an
individual's election of coverage under Ins 1905.14(b)(2);
(4) The individual is
enrolled under a Medicare supplement policy and the enrollment ceases because:
a.
Of the insolvency of the issuer or bankruptcy of the nonissuer
organization;
b.
Of other involuntary termination of coverage or enrollment under
the policy;
c.
The issuer of the policy substantially violated a material provision of the policy;
or
d.
The issuer, or an agent or other entity acting on the issuer's behalf,
materially misrepresented the policy's provisions in marketing the policy
to the individual;
(5)
The individual was enrolled under a Medicare supplement
policy and:
a.
Terminates enrollment and subsequently enrolls, for the first time, with
any Medicare Advantage organization under a Medicare Advantage plan under Part
C of Medicare, any eligible organization under a contract under Section 1876 of
the Social Security Act (Medicare cost), any similar organization operating
under demonstration project authority, any PACE provider under Section 1894 of
the Social Security Act,or a Medicare Select policy; and
b.
The subsequent enrollment under a. is terminated by the enrollee during
any period within the first 12 months of such subsequent enrollment during
which the enrollee is permitted to terminate such subsequent enrollment under
Section 1851 (e) of the federal Social Security Act;
(6)
The individual, upon first becoming eligible for benefits under Part A
of Medicare at age 65, enrolls in a Medicare Advantage plan under Part C of Medicare, or
with a PACE provider under Section 1894 of the Social Security Act and disenrolls from the plan or program by
not later than 12 months after the effective date of enrollment; or
(7)
The individual enrolls in a Medicare Part D plan during the initial
enrollment period and, at the time of enrollment in Part D, was enrolled under
a Medicare supplement policy that covers outpatient prescription drugs and the
individual terminates enrollment in the Medicare supplement policy and submits
evidence of enrollment in Medicare Part D along with the application for a
policy described in (e)(4) below.
(c) Guaranteed Issue Time Periods. In the case of an individual described in:
(1) Ins 1905.14(b)(1), the guaranteed issue period begins on the later
of:
a. The date the individual
receives a notice of termination or cessation of all supplemental health
benefits or, if a notice is not received, notice that a claim has been denied
because of such a termination or cessation; or
b. The date that the
applicable coverage terminates or ceases; and ends 63 days thereafter;
(2) Ins 1905.14(b)(2),(3),
(5), or (6) whose enrollment is terminated involuntarily, the guaranteed issue
period begins on the date that the individual receives a notice of termination
and ends 63 days after the date the applicable coverage is terminated;
(3) Ins 1905.14(b)(4) a. and
b., the guaranteed issue period begins on the earlier of:
a. The date that the individual
receives a notice of termination, a notice of the issuer's bankruptcy or insolvency, or other
such similar notice if any, and
b. The date that the
applicable coverage is terminated, and ends on the date that is 63 days after
the date the coverage is terminated;
(4) Ins 1905.14(b)(2), (4)
c. and d., (5), or (6) who disenrolls voluntarily, the guaranteed issue period
begins on the date that is 60 days before the effective date of the
disenrollment and ends on the date that is 63 days after the effective date;
(5) In the case of an
individual described in subsection (b) (7), the guaranteed issue period begins
on the date the individual receives notice pursuant to Section 1882 (v)(2)(B)
of the Social Security Act from the Medicare supplement issuer during the 60
day period immediately preceding the initial Part D enrollment period and ends
on the date that is 63 days after the effective date of the individual's
coverage under Medicare Part D; and
(6) Ins 1905.14(b) but not
described in the preceding provisions of this subsection, the guaranteed issue
period begins on the effective date of disenrollment and ends on the date that
is 63 days after the effective date;
(d)
Extended Medigap access for interrupted trial periods:
(1)
In the case of an individual described in Ins 1905.14(b)(5), or deemed to be so described,
pursuant to this paragraph,
whose enrollment with an organization or provider described in Ins 1905.14(b)(5)a. is involuntarily terminated within
the first 12 months of enrollment, and who, without an intervening enrollment,
enrolls with another such organization or provider, the subsequent enrollment
shall be deemed to be an initial enrollment described in Ins 1905.14(b)(5);
(2)
In the case of an individual described in Ins 1905.14(b)(6), or deemed to be
so described, pursuant to this paragraph, whose enrollment with a plan or in a
program described in Ins 1905.14(b)(6)
is involuntarily terminated within the first 12 months of enrollment, and who,
without an intervening enrollment, enrolls in another such plan or program, the
subsequent enrollment shall be deemed to be an initial enrollment described in
Ins 1905.14(b)(6); and
(3)
For purposes of Ins 1905.14(b)(5) and (6), no enrollment of an
individual with an organization or provider described in Ins 1905.14(b)(5) a., or with a plan or in a program
described in Ins 1905.14(b)(6), may be deemed to be an initial
enrollment under this paragraph after the two-year period beginning on the date on which the individual first
enrolled with such an organization, provider, plan or program.
(e) Products to which eligible persons are
entitled. The Medicare supplement policy
to which eligible persons are entitled under:
(1)
Ins 1905.14(b)(1), (2), (3), and (4) is
a Medicare supplement policy which has a benefit package classified as Plan A,
B, C, F (including F with a high deductible), K, or L offered by any issuer;
(2)
Ins 1905.14(b)(5) is the same Medicare supplement policy in which the individual was
most recently previously enrolled, if available from the same issuer, or, if
not so available, a policy described in Ins 1905.14(c)(1);
(3)
After December 31, 2005, if the individual was most recently enrolled in
a Medicare supplement policy with an outpatient prescription drug benefit, a
Medicare supplement policy described in this subparagraph is:
a.
The policy available from the same issuer but modified to remove
outpatient prescription drug coverage; or
b.
At the election of the policyholder, an A, B, C, F (including F with a
high deductible), K, or L policy that is offered by any issuer;
(4)
Ins 1905.14(b)(6) shall
include any Medicare supplement policy offered by any issuer; and
(5)
Ins 1905.14(b)(7) is a Medicare supplement policy that has a benefit
package classified as Plan A, B, C, F (including F with a high deductible), K
or L, and that is offered and is available for issuance to new enrollees by the
same issuer that issued the individual's Medicare supplement policy with
outpatient prescription drug coverage.
(f) Notification provisions at the
time of an event:
(1)
Described in Ins 1905.14(b) of this section because of which an
individual loses coverage or benefits due to the termination of a contract or
agreement, policy, or plan, the organization that:
a.
Terminates the contract or agreement, the issuer terminating the policy,
or the administrator of the plan being terminated, respectively, shall notify
the individual of his or her rights under this section, and of the obligations
of issuers of Medicare supplement policies under Ins 1905.14(a). Such notice shall be communicated
contemporaneously with the notification of termination; and
(2)
Described in Ins 1905.14(b) of this section because of which an
individual ceases enrollment under a contract or agreement, policy, or plan,
the organization that:
a.
Offers the contract or agreement, regardless of the basis for the cessation
of enrollment, the issuer offering the policy, or the administrator of the
plan, respectively, shall notify the individual of his or her rights under this
section, and of the obligations of issuers of Medicare supplement policies
under Ins 1905.14 (a). Such notice shall be
communicated within 10 working days of the issuer receiving notification of
disenrollment.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by
#9559, eff 10-13-09 (from Ins 1905.11) ); ss by #12370, eff 10-13-17 (from Ins
1905.13)
Ins
1905.15 Standards
for Claims Payment.
(a)
An issuer shall comply with Section 1882(c)(3) of the Social Security
Act, as enacted by Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987, OBRA, 1987, Public Law
No. 100-203 by:
(1) Accepting a notice from a Medicare carrier on
dually assigned claims submitted by participating physicians and suppliers as a
claim for benefits in place of any other claim form otherwise required and
making a payment determination on the basis of the information contained in
that notice;
(2) Notifying the participating physician or
supplier and the beneficiary of the payment determination;
(3) Paying the participating physician or
supplier directly;
(4) Furnishing, at the time of enrollment, each
enrollee with a card listing the policy name, number and a central mailing
address to which notices from a Medicare carrier may be sent;
(5) Paying user fees for claim notices that are
transmitted electronically or otherwise; and
(6) Providing to the secretary of Health and
Human Services, at least annually, a central mailing address to which all
claims may be sent by Medicare carriers.
(b)
Compliance with the requirements set forth in subsection (a) above shall
be certified on the Medicare supplement insurance experience reporting form.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by
#9559, eff 10-13-09 (from Ins 1905.12); ss by #12370, eff 10-13-17 (from Ins
1905.14)
Ins
1905.16 Loss Ratio Standards and Refund or Credit of
Premium.
(a) Loss ratio standards shall be as follows:
(1) A Medicare supplement policy or certificate form shall not be delivered or issued
for delivery unless the policy form or certificate form can be expected, as estimated for the entire period
for which rates are computed to provide coverage, to return to policyholders and
certificate holders in the form of aggregate benefits, not including
anticipated refunds or credits, provided under the policy form or certificate
form:
a. At least 75% of the aggregate
amount of premiums earned in the case of group policies; or
b. At least 65% of the aggregate
amount of premiums earned in the case of individual policies;
(2) Calculated on the basis of incurred claims experience or incurred
health care expenses where coverage is provided by a health maintenance
organization on a service rather than reimbursement basis and earned premiums
for the period and in accordance with accepted actuarial principles and
practices. Incurred health care expenses where coverage is provided by a health
maintenance organization shall not include:
a. Home office and overhead costs;
b. Advertising costs;
c. Commissions and other
acquisition costs;
d. Taxes;
e. Capital costs;
f. Administrative costs; and
g. Claims processing costs;
(3) All filings of rates and rating
schedules shall demonstrate that expected claims in relation to premiums comply
with the requirements of this section when combined with actual experience to
date. Filings of rate revisions shall also demonstrate that the anticipated
loss ratio over the entire future period for which the revised rates are
computed to provide coverage can be expected to meet the appropriate loss ratio
standards;
(4) For purposes of applying Ins 1905.16(a)(1) and (2) of this section and Ins 1905.17(d)(2) only, policies issued as
a result of solicitations of individuals through the mails or by mass media
advertising, including both print and broadcast advertising, shall be deemed to
be individual policies; and
(5) For policies issued prior to July 1, 1992 expected claims in relation to premiums
shall meet:
a. The originally filed
anticipated loss ratio when combined with the actual experience since
inception;
b. The appropriate loss ratio
requirement from Ins 1905.16(a)(1)a. and b. when combined with actual experience
beginning with the effective date of this rule to date; and
c. The appropriate loss ratio
requirement from Ins 1905.16(a)(1)a. and b. over the entire future period for which
the rates are computed to provide coverage.
(b) Refund or credit calculation requirements
shall be as follows:
(1) An issuer shall collect and
file with the commissioner by May 31 of each year the data contained in the
applicable reporting form contained
in Appendix A for each type in a standard Medicare supplement benefit plan;
(2) If on the basis of the experience
as reported the benchmark ratio since inception, ratio 1, exceeds the adjusted
experience ratio since inception, ratio 3, then a refund or credit calculation
is required. The refund calculation shall be done on a statewide basis for each type in a standard Medicare
supplement benefit plan. For purposes of the refund or credit
calculation, experience on policies issued within the reporting year shall be
excluded;
(3) For the purposes of this
section, policies or certificates issued prior to July 1, 1992, the
issuer shall make the refund or credit calculation separately for all
individual policies, including all group policies subject to an individual loss
ratio standard when issued, combined and all other group policies combined for
experience after July 1, 1992. The first report shall be due by May 31, 1994;
and
(4) A refund or credit shall be
made only when the benchmark loss ratio exceeds the adjusted experience loss
ratio and the amount to be refunded
or credited exceeds a de minimis level. The refund shall include
interest from the end of the calendar year to the date of the refund or credit
at a rate specified by the secretary of Health and Human Services, but in
no event shall it be less than the average rate of interest for 13-week Treasury
notes. A refund or credit against premiums due shall be made by
September 30 following the experience year upon which the refund or credit is
based.
(c) Annual Filing of Premium Rates:
(1) Issuers of Medicare supplement policies and
certificates advertised, solicited, delivered or issued in this state shall
file their rates, rating schedules, and supporting documentation with the
commissioner in accordance with the general filing requirements and procedures
described in Ins 4100;
(2) Carriers shall use the calendar year as the
rate effective period. Rates shall not
vary during the rate effective period based on either the policy's date of
issue or the policy's renewal date.
Rates shall be guaranteed to policyholders for the 12 month period
between policy anniversary or renewal dates.
The policy anniversary date or renewal date shall be the anniversary of
the policy's date of issue. Rates shall
be filed and approved according to the procedures set forth in Ins 1905.16 and
Ins 1905.17 before their intended effective
date. Carriers shall make the annual
required rate filing no later than August 15;
(3) All approved rates shall be available to the
public on October 15 preceding the rate effective period;
(4) The department shall not approve rates for
policyholders less than age 65 that are greater than the highest rate proposed
for a policyholder greater than age 65;
(5) The department shall not approve changes in premium
relativities between plans unless such changes are demonstrated to be
consistent with the NAIC Medicare Supplement Insurance Compliance Manual, dated
March 25, 2010 and available as referenced in Appendix 2, or are necessary to
prevent a policy from requiring refunds pursuant to this chapter;
(6) The supporting documentation provided
pursuant to (a) above shall include a one-page exhibit which:
a. Shows New Hampshire-specific monthly premium
rates, as would be billed to the policyholder or certificate holder, for each
form approved, pursuant to the requirements of Ins 1905.17;
b. Indicates the preexisting condition
limitation provisions applicable to each form;
c. Includes the name, address and telephone
number of the issuer;
d. Shows whether the forms are generally
available to all Medicare recipients in the state or whether availability is
restricted, and, if availability is restricted, lists and explains the restrictions
that apply; and
e. Rates shown in the one page exhibit shall be
only those rates applicable during open enrollment;
(7) An issuer of Medicare supplement policies and
certificates issued before or after the effective date of July 1, 1992 in this
state shall file annually its rates, rating schedule and supporting
documentation including ratios of incurred losses to earned premiums by policy
duration for approval by the commissioner in accordance with the filing
requirements and procedures prescribed by the commissioner. The supporting documentation shall also
demonstrate in accordance with actuarial standards of practice using reasonable
assumptions that the appropriate loss ratio standards can be expected to be met
over the entire period for which rates are computed. The demonstration shall exclude active life
reserves. An expected third-year loss
ratio which is greater than or equal to the applicable percentage shall be
demonstrated for policies or certificates in force less than 3 years;
(8) As soon as practicable, but prior to the
effective date of enhancements in Medicare benefits, every issuer of Medicare
supplement policies or certificates in this state shall file with the
commissioner, in accordance with the applicable filing procedures of this
state:
a. Appropriate premium adjustments necessary to
produce loss ratios as anticipated for the current premium for the applicable
policies or certificates. The supporting
documents necessary to justify the adjustment shall accompany the filing;
b. An issuer shall make premium adjustments
necessary to produce an expected loss ratio under the policy or certificate to
conform to minimum loss ratio standards for Medicare supplement policies and
which are expected to result in a loss ratio at least as great as that
originally anticipated in the rates used to produce current premiums by the
issuer for the Medicare supplement policies or certificates. No premium adjustment which would modify the
loss ratio experience under the policy other than the adjustments described
herein shall be made with respect to a policy at any time other than upon its
renewal date or anniversary date; and
c. If an issuer fails to make premium adjustments
acceptable to the commissioner, the commissioner may order premium adjustments,
refunds or premium credits deemed necessary to achieve the loss ratio required
by this section; and
(9) Any appropriate riders, endorsements or
policy forms needed to accomplish the Medicare supplement policy or certificate
modifications necessary to eliminate benefit duplications with Medicare. The riders, endorsements or policy forms
shall provide a clear description of the Medicare supplement benefits provided by
the policy or certificate.
(d)
Public Hearings. The commissioner may conduct a public hearing to
gather information concerning a request by an issuer for an increase in a rate
for a policy form or certificate form issued before or after the effective date
of Ins 1905 if the experience of the form for the previous reporting period is
not in compliance with the applicable loss ratio standard. The determination of compliance is made
without consideration of any refund or credit for the reporting period. Public
notice of the hearing shall be furnished in a manner deemed appropriate by the
commissioner.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99,
EXPIRED: 10-29-99
New.
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by
#9559, eff 10-13-09 (from Ins 1905.13); amd by #10559, eff 4-1-14; ss by
#12370, eff 10-13-17 (from Ins 1905.15)
Ins 1905.17 Filing and Approval of Policies and
Certificates and Premium Rates.
(a)
An issuer shall not deliver or issue for delivery a policy or
certificate to a resident of this state unless the policy form or certificate
form has been filed with and approved by
the commissioner in accordance with filing requirements and procedures
prescribed by the commissioner in Ins 4100.
(b)
An issuer shall file any riders or amendments to policy or certificate
forms to delete outpatient prescription drug benefits as required by the
Medicare Prescription Drug, Improvement and Modernization Act of 2003 only with
the commissioner in the state in which the policy or certificate was issued.
(c)
An issuer shall not use or change premium rates for a Medicare
supplement policy or certificate unless the rates, rating schedule and
supporting documentation have been filed with and approved by the commissioner in
accordance with the filing requirements and procedures prescribed by the
commissioner in Ins 4100.
(d)
Except as provided in (1) below, an issuer shall not file for approval
more than one form of a policy or certificate of each type for each standard
Medicare supplement benefit plan.
(1) An issuer may offer, with the approval of the
commissioner, up to 4 additional policy forms or certificate forms of the same
type for the same standard Medicare supplement benefit plan, one for each of
the following cases:
a. The inclusion of new or innovative benefits;
b. The addition of either direct response or
agent marketing methods;
c. The addition of either guaranteed issue or
underwritten coverage; and
d. The offering of coverage to individuals
eligible for Medicare by reason of disability; and
(2) For the purposes of this section, a
"type" means an individual policy, a group policy, an individual
Medicare Select policy, or a group Medicare Select policy.
(e)
Except as provided in (1) below, an issuer shall continue to make
available for purchase any policy form or certificate form issued after the
effective date of this part that has been approved by the commissioner. A policy form or certificate form shall not
be considered to be available for purchase unless the issuer has actively
offered it for sale in the previous 12 months.
(1) An issuer may discontinue the availability of
a policy form or certificate form if the issuer provides to the commissioner in
writing its decision at least 30 days prior to discontinuing the availability
of the form of the policy or certificate.
After receipt of the notice by the commissioner, the issuer shall
no longer offer for sale the policy form or certificate form in this state; and
(2) An issuer that discontinues the availability
of a policy form or certificate form pursuant to (1) shall not file for
approval a new policy form or certificate form of the same type for the same
standard Medicare supplement benefit plan as the discontinued form for a period
of 5 years after the issuer provides notice to the commissioner of the
discontinuance. The period of discontinuance may be reduced if the commissioner
determines that a shorter period is appropriate.
(f)
The sale or other transfer of Medicare supplement business to another
issuer shall be considered a discontinuance for the purposes of this section.
(g)
A change in the rating structure or methodology shall be considered a
discontinuance under (d) unless the issuer complies with the following
requirements:
(1) The issuer provides an actuarial memorandum,
in a form and manner prescribed by the commissioner, describing the manner in
which the revised rating methodology and resultant rates differ from the
existing rating methodology and existing rates; and
(2) The issuer does not subsequently put into
effect a change of rates or rating factors that would cause the percentage
differential between the discontinued and subsequent rates as described in the
actuarial memorandum to change. The
commissioner may approve a change to the differential which is in the public
interest.
(h)
Except as provided in (i) below, the experience of all policy forms or
certificate forms of the same type in a standard Medicare supplement benefit
plan shall be combined for purposes of the refund or credit calculation
prescribed in Ins 1905.16.
(i) Forms assumed under an assumption
reinsurance agreement shall not be combined with the experience of other forms
for purposes of the refund or credit calculation.
(j) An issuer shall present for filing or
approval a rate structure for its Medicare supplement policies or certificates
issued after the effective date of the amendment of this rule based upon issue
age only.
Source.
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99,
EXPIRED: 10-29-99
New.
#7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by
#9559, eff 10-13-09 (from Ins 1905.14); ss by #12370, eff 10-13-17 (from Ins
1905.16)
Ins 1905.18 Permitted
Compensation Arrangements.
(a)
An issuer or other entity may provide commission or other compensation
to an agent or other representative for the sale of a Medicare supplement
policy or certificate only if the first year commission or other first year
compensation is no more than 200% of the commission or other compensation paid
for selling or servicing the policy or certificate in the second year or
period.
(b)
The commission or other compensation provided in subsequent renewal
years shall be the same as that provided in the second year or period and shall
be provided for no fewer than 5 renewal years.
(c)
No issuer or other entity shall provide compensation to its agents or
other producers, and no agent or producer shall receive compensation greater
than the renewal compensation payable by the replacing issuer on renewal
policies or certificates if an existing policy or certificate is replaced.
(d)
For purposes of this section, "compensation" includes
pecuniary or non-pecuniary remuneration of any kind relating to the sale or
renewal of the policy or certificate, including but not limited to bonuses, gifts,
prizes, awards, and finders fees.
Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93;
ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #7174, eff 12-22-99; ss by #8051, eff 3-1-04;
ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.15); ss by
#12370, eff 10-13-17 (from Ins 1905.17)
Ins
1905.19 Required Disclosure
Provisions.
(a)
General rules shall be as
follows:
(1) Medicare
supplement policies and certificates shall include a renewal or continuation
provision. The language or
specifications of the provision shall be consistent with the type of contract
issued. The provision shall be appropriately
captioned and shall appear on the first page of the policy, and shall include
any reservation by the issuer of the right to change premiums and any automatic
renewal premium increases based on the policyholder's age;
(2) Except
for riders or endorsements by which the issuer effectuates a request made in
writing by the insured, exercises a specifically reserved right under a
Medicare supplement policy, or is required to reduce or eliminate benefits to
avoid duplication of Medicare benefits, all riders or endorsements added to a
Medicare supplement policy after date of issue or at reinstatement or renewal
which reduce or eliminate benefits or coverage in the policy shall require a
signed acceptance by the insured. After the date of policy or certificate
issue, any rider or endorsement which increases benefits or coverage with a
concomitant increase in premium during the policy term shall be agreed to in
writing signed by the insured, unless the benefits are required by the minimum
standards for Medicare supplement policies, or if the increased benefits or
coverage is required by law. Where a
separate additional premium is charged for benefits provided in connection with
riders or endorsements, the premium charge shall be set forth in the policy;
(3) Medicare supplement policies or certificates
shall not provide for the payment of benefits based on standards described as
"usual and customary," "reasonable and customary" or words
of similar import;
(4) If a Medicare supplement policy or certificate
contains any limitations with respect to preexisting conditions, such
limitations shall appear as a separate paragraph of the policy and be labeled
as "preexisting condition limitations”;
(5) Medicare supplement policies and certificates
shall have a notice prominently printed on the first page of the policy or
certificate or attached thereto stating in substance that the policyholder or
certificate holder shall have the right to return the policy or certificate
within 30 days of its delivery and to have the premium refunded if, after
examination of the policy or certificate, the insured person is not satisfied
for any reason; and
(6) Issuers of accident and sickness policies or
certificates which provide hospital or medical expense coverage on an expense
incurred or indemnity basis to persons eligible for Medicare shall provide to
those applicants a “Guide to Health Insurance for People with Medicare” in the
form developed jointly by the National Association of Insurance Commissioners
and CMS and in a type size no smaller than 12 point type:
a. Delivery of the Guide shall be made
whether or not the policies or certificates are advertised, solicited, or
issued as Medicare supplement policies or certificates as defined in this
rule. Except in the case of direct
response issuers, delivery of the Guide shall be made to the applicant
at the time of application and acknowledgement of receipt of the Guide shall be obtained by the issuer.
Direct response issuers shall deliver the Guide to the applicant
upon request but not later than at the time the policy is delivered; and
b. For the
purposes of this section, "form" means the language, format, type
size, type proportional spacing, bold character, and line spacing.
(b)
Notice Requirements shall be as follows:
(l) As soon as practicable, but no later than 30
days prior to the annual effective date of any Medicare benefit changes, an
issuer shall notify its policyholders and certificate holders of modifications
it has made to Medicare supplement insurance policies or certificates in a
format acceptable to the commissioner.
The notice shall:
a. Include
a description of revisions to the Medicare program and a description of each
modification made to the coverage provided under the Medicare supplement policy
or certificate; and
b. Inform
each policyholder or certificate holder as to when any premium adjustment is to
be made due to changes
in Medicare;
(2) The notice of benefit modifications and any
premium adjustments shall be in outline form and in clear and simple terms so
as to facilitate comprehension; and
(3) The notices shall not contain or be
accompanied by any solicitation.
(c)
MMA Notice Requirements. Issuers
shall comply with any notice requirements of the Medicare Prescription Drug,
Improvement and Modernization Act of 2003.
(d)
Outline of Coverage Requirements for Medicare Supplement Policies.
(1) Issuers shall provide an outline of coverage
to all applicants at the time application is presented to the prospective
applicant and, except for direct response policies, shall obtain an
acknowledgment of receipt of the outline from the applicant;
(2) If an outline of coverage is provided at the
time of application and the Medicare supplement policy or certificate is issued
on a basis which would require revision of the outline, a substitute outline of
coverage properly describing the policy or certificate shall accompany the
policy or certificate when it is delivered and contain the following statement,
in no less than 12-point type, immediately above the company name:
"NOTICE:
Read this outline of coverage carefully. It is not identical to the outline of
coverage provided upon application and the coverage originally applied for has
not been issued."
(3) The outline of coverage provided to
applicants pursuant to this section shall consist of 4 parts: a cover page,
premium information, disclosure pages, and charts displaying the features of
each benefit plan offered by the issuer.
The outline of coverage shall be in the language and format prescribed
below in no less than 12 point type. All
plans A-L shall be shown on the cover page, and the plans that are
offered by the issuer shall be prominently identified. Premium information for
plans that are offered shall be shown on the cover page or immediately
following the cover page and shall be prominently displayed. The premium and mode shall be stated for all
plans that are offered to the prospective applicant. All possible premiums for the prospective
applicant shall be illustrated; and
(4) The following items shall be included in the
outline of coverage in the order prescribed below:
Benefit Chart of Medicare Supplement
Plans Sold on or After June 1, 2010
This chart shows the benefits included
in each of the standard Medicare supplement plans. Every company shall make Plan “A”
available. Some plans may not be
available in your state.
Basic Benefits:
· Hospitalization - Part A coinsurance
plus coverage for 365 additional days after Medicare benefits end.
· Medical Expenses - Part B coinsurance
(generally 20% of Medicare-approved expenses) or co-payments for hospital
outpatient services. Plans K, L and N require
insureds to pay a portion of Part B coinsurance or co-payments.
· Blood - First three pints of blood each
year.
· Hospice - Part A coinsurance
A |
B |
C |
D |
F |
F* |
G |
K |
L |
M |
N |
Basic, incl. 100% Part B co- insurance |
Basic, incl. 100% Part B co-insurance |
Basic, incl. 100% Part B co- insurance |
Basic, incl. 100% Part B co-insurance |
Basic, incl. 100% Part B co-insurance |
Basic, incl. 100% Part B co-insurance |
Basic, incl. 100% Part B co-insurance |
Hospitalization and preventive
care paid at 100%; other basic benefits paid at 50% |
Hospitalization and
preventive care paid at 100%; other basic benefits paid at 75% |
Basic, incl. 100%
Part B co-insurance |
Basic, incl. 100%
Part B co-insurance, except up to $20 copayment for office visit, and up to
$50 copayment for ER |
|
|
Skilled Nursing
Facility Co-insurance |
Skilled Nursing
Facility Co-insurance |
Skilled Nursing
Facility Co-insurance |
Skilled Nursing
Facility Co-insurance |
Skilled Nursing
Facility Co-insurance |
50% Skilled Nursing Facility
Co-insurance |
75% Skilled Nursing
Facility Co-insurance |
Skilled Nursing
Facility Co-insurance |
Skilled Nursing
Facility Co-insurance |
|
Part A Deductible |
Part A Deductible |
Part A Deductible |
Part A Deductible |
Part A Deductible |
Part A Deductible |
50% Part A Deductible |
75% Part A Deductible |
50% Part A Deductible |
Part A Deductible |
|
|
Part B Deductible |
|
Part B Deductible |
|
|
|
|
|
|
|
|
|
|
Part B Excess (100%) |
Part B Excess (100%) |
Part B Excess (100%) |
|
|
|
|
|
|
Foreign Travel Emergency |
Foreign Travel Emergency |
Foreign Travel Emergency |
Foreign Travel
Emergency |
Foreign Travel Emergency |
|
|
Foreign Travel Emergency |
Foreign Travel
Emergency |
|
|
|
|
|
|
|
Out-of-Pocket limit $[5120]
paid at 100% after limit reached |
Out-of-Pocket limit
$[2560] paid at 100% after limit reached |
|
|
*Plan F also has an option called a high deductible
plan F. This high deductible plan pays
the same benefits as Plan F after one has paid a calendar year [$2200]
deductible. Benefits from high
deductible Plan F will not begin until out-of-pocket expenses exceed
[$2200]. Out-of-pocket expenses for this
deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare
deductibles for Part A and Part B, but do not include the plan's separate
foreign travel emergency deductible.
PREMIUM
INFORMATION
[Boldface Type]
We
[insert issuer's name] can only raise your premium if we raise the premium for
all policies like yours in this State.
[If the premium is based on the increasing age of the insured, include
information specifying when premiums will change.]
DISCLOSURES [Boldface Type]
Use
this outline to compare benefits and premiums among policies.
This
outline shows benefits and premiums of policies sold for effective dates on or
after June 1, 2010. Policies sold for
effective dates prior to June 1, 2010 have different benefits and
premiums. Plans E, H, I, and J are no
longer available for sale. [This
paragraph shall not appear after June 1, 2011.]
READ
YOUR POLICY VERY CAREFULLY
[Boldface Type]
This
is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand
all of the rights and duties of both you and your insurance company.
RIGHT
TO RETURN POLICY [Boldface Type]
If
you find that you are not satisfied with your policy, you may return it to
[insert issuer's address]. If you send
the policy back to us within 30 days after you receive it, we will treat the
policy as if it had never been issued and return all of your payments.
POLICY
REPLACEMENT [Boldface Type]
If
you are replacing another health insurance policy, do NOT cancel it until you
have actually received your new policy and are sure you want to keep it.
NOTICE
[Boldface Type]
This
policy may not fully cover all of your medical costs.
[for
agents:]
Neither
[insert company's name] nor its agents are connected with Medicare.
[for
direct response:]
[insert
company's name] is not connected with Medicare.
This
outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or
consult Medicare and You for more details.
COMPLETE
ANSWERS ARE VERY IMPORTANT [Boldface Type]
When
you fill out the application for the new policy, be sure to answer truthfully
and completely all questions about your medical and health history. The company may cancel your policy and refuse
to pay any claims if you leave out or falsify important medical
information. [If the policy or certificate
is guaranteed issue, this paragraph need not appear.]
Review
the application carefully before you sign it.
Be certain that all information has been properly recorded.
[Include
for each plan prominently identified in the cover page, a chart showing the
services, Medicare payments, plan payments and insured payments for each plan,
using the same language, in the same order, using uniform layout and format as
shown in the charts below. No more than
four plans may be shown on one chart.
For purposes of illustration, charts for each plan are included in this
rule. An issuer may use additional
benefit plan designations on these charts pursuant to Ins 1905.10(d) of this
rule.]
[Include
an explanation of any innovative benefits on the cover page and in the chart,
in a manner approved by the commissioner.]
Benefit Chart of Medicare Supplement Plans Sold on or
after January 1, 2020
This chart shows the benefits
included in each of the standard Medicare supplement plans. Some plans may not be available. Only applicants first eligible for Medicare
before 2020 may purchase Plans C, F, and high deductible F.
Note: A ü means 100% of the benefit is paid.
Benefits |
Plans Available to All
Applicants |
|
Medicare first eligible before |
||||||||
A |
B |
C |
G1 |
K |
L |
M |
N |
C |
F1 |
||
Medicare Part A coinsurance and hospital
coverage (up to an addition 365 days after Medicare benefits are used up) |
ü
|
ü |
ü |
ü |
ü |
ü |
ü |
ü |
ü |
ü |
|
Medicare Part B coinsurance or Copayment |
ü |
ü |
ü |
ü |
50% |
75% |
ü |
ü copays apply3 |
ü |
ü |
|
Blood (first three pints) |
ü |
ü |
ü |
ü |
50% |
75% |
ü |
ü |
ü |
ü |
|
Part A hospice care coinsurance or copayment |
ü |
ü |
ü |
ü |
50% |
75% |
ü |
ü |
ü |
ü |
|
Skilled nursing facility coinsurance |
|
|
ü |
ü |
50% |
75% |
ü |
ü |
ü |
ü |
|
Medicare Part A deductible |
|
ü |
ü |
ü |
50% |
75% |
50% |
ü |
ü |
ü |
|
Medicare Part B deductible |
|
|
|
|
|
|
|
|
ü |
ü |
|
Medicare Part B excess Charges |
|
|
|
ü |
|
|
|
|
|
ü |
|
Foreign travel emergency (up to plan limits) |
|
|
ü |
ü |
|
|
ü |
ü |
ü |
ü |
|
Out-of-pocket limit in [2017]2 |
|
[$5120]2 |
[$2560]2 |
|
1Plans F and G also have a high
deductible option which require first paying a plan deductible of [$2200]
before the plan begins to pay. Once the plan
deductible is met, the plan pays 100% of covered services for the rest of the
calendar year. High deductible plan G
does not cover the Medicare Part B deductible.
However, high deductible plans F and G count your payment of the
Medicare Part B deductible toward meeting the plan deductible.
2Plans K and L pay 100% of covered
services for the rest of the calendar year once you meet the out-of-pocket
yearly limit.
3Plan N pays 100% of the Part B
coinsurance, except for a co-payment of up to $20 for some office visits and up
to a $50 co-payment for emergency room visits that do not result in an
inpatient admission.
PLAN A
MEDICARE (PART
A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
* A benefit period
begins on the first day you receive service as an inpatient in a hospital and
ends after you have been out of the hospital and have not received skilled care
in any other facility for 60 days in a row.
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
HOSPITALIZATION* board, general
nursing and
miscellaneous services and
supplies First 60 days
—While using 60
lifetime reserve days
days are used:
additional 365 days |
All but $[658] a
day
|
100% of Medicare
eligible expenses $0 |
$0**
|
SKILLED NURSING
FACILITY CARE*
|
All approved
amounts All but
$[164.50] a day
|
|
|
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
BLOOD
|
|
|
|
HOSPICE CARE |
|
|
|
** NOTICE: When your Medicare Part A hospital benefits
are exhausted, the insurer stands in the place of Medicare and will pay
whatever amount Medicare would have paid for up to an additional 365 days as
provided in the policy's "Core Benefits." During this time the
hospital is prohibited from billing you for the balance based on any difference
between its billed charges and the amount Medicare would have paid.
MEDICARE (PART
B)—MEDICAL SERVICES—PER CALENDAR YEAR
* Once you have
been billed $[183] of Medicare-approved amounts for covered services (which are
noted with an asterisk), your Part B deductible will have been met for the
calendar year.
SERVICES |
MEDICARE PAYS |
PLAN PAYS |
YOU PAY |
MEDICAL
EXPENSES—
|
|
|
|
Part B Excess
Charges (Above Medicare
Approved Amounts) |
$0 |
$0 |
All costs |
BLOOD
|
|
|
|
CLINICAL
LABORATORY |
|
|
|
PLAN
A
PARTS
A & B
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
HOME
HEALTH CARE
- First $[183] of Medicare
|
|
|
$0 |
MEDICARE
(PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
*
A benefit period begins on the first day you receive service as an inpatient in
a hospital and ends after you have been out of the hospital and have not
received skilled care in any other facility for 60 days in a row.
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
HOSPITALIZATION* board,
general nursing and
miscellaneous services
and supplies
days are used:
365 days |
$0 $0 |
$[329]
a day
|
|
SKILLED
NURSING FACILITY CARE* having
been in a hospital for
at least 3 days and entered a
Medicare-approved facility within 30 days after leaving the
hospital
|
$0 |
$0 |
All
costs |
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
BLOOD
|
|
|
|
HOSPICE
CARE |
|
|
|
**
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer
stands in the place of Medicare and will pay whatever amount Medicare would
have paid for up to an additional 365 days as provided in the policy's
"Core Benefits." During this
time the hospital is prohibited from billing you for the balance based on any
difference between its billed charges and the amount Medicare would have paid.
PLAN
B
MEDICARE
(PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
*
Once you have been billed $[183] of Medicare-approved amounts for covered
services (which are noted with an asterisk), your Part B deductible will have
been met for the calendar year.
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
MEDICAL
EXPENSES— First
$[183] of Medicare Remainder of Medicare |
$0
|
|
|
Part
B Excess Charges (Above
Medicare Approved Amounts) |
$0 |
$0 |
All
costs |
BLOOD
|
|
|
|
CLINICAL
LABORATORY |
|
|
|
PLAN
B
PARTS
A & B
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
HOME
HEALTH CARE
-
First $[183] of Medicare
|
|
|
|
PLAN
C
MEDICARE
(PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
*
A benefit period begins on the first day you receive service as an inpatient in
a hospital and ends after you have been out of the hospital and have not
received skilled care in any other facility for 60 days in a row.
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
HOSPITALIZATION* and
miscellaneous services
and supplies
|
$0 |
$[329]
a day
|
$0
|
SKILLED
NURSING FACILITY CARE*
|
|
|
|
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
BLOOD
|
|
|
|
HOSPICE
CARE |
|
|
|
**
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer
stands in the place of Medicare and will pay whatever amount Medicare would
have paid for up to an additional 365 days as provided in the policy's
"Core Benefits." During this time the hospital is prohibited from
billing you for the balance based on any difference between its billed charges
and the amount Medicare would have paid.
PLAN C
MEDICARE
(PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
*
Once you have been billed $[183] of Medicare-approved amounts for covered
services (which are noted with an asterisk), your Part B deductible will have
been met for the calendar year.
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
MEDICAL
EXPENSES—
|
|
Generally
20% |
$0 |
Part
B Excess Charges (Above
Medicare Approved Amounts) |
$0 |
$0 |
All
Costs |
BLOOD
|
|
|
|
CLINICAL
LABORATORY |
|
|
|
PLAN C
PARTS
A & B
HOME
HEALTH CARE
-
First $[183] of Medicare - Remainder of Medicare |
$0
|
|
$0
|
PLAN
C
OTHER
BENEFITS - NOT COVERED BY MEDICARE
FOREIGN
TRAVEL—
|
|
|
|
PLAN D
MEDICARE
(PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
*
A benefit period begins on the first day you receive service as an inpatient in
a hospital and ends after you have been out of the hospital and have not
received skilled care in any other facility for 60 days in a row.
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
HOSPITALIZATION* board,
general nursing and
miscellaneous services
and supplies
days are used:
365 days |
|
$[329]
a day
|
|
SKILLED
NURSING FACILITY CARE* days
after leaving the hospital
|
All
approved amounts
$0 |
|
|
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
BLOOD
|
|
|
|
HOSPICE
CARE |
co-payment/ coinsurance
for out-patient drugs and inpatient respite care |
|
|
**
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer
stands in the place of Medicare and will pay whatever amount Medicare would
have paid for up to an additional 365 days as provided in the policy's
"Core Benefits." During this time the hospital is prohibited from
billing you for the balance based on any difference between its billed charges
and the amount Medicare would have paid.
PLAN
D
MEDICARE
(PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
*
Once you have been billed $[183] of Medicare-approved amounts for covered
services (which are noted with an asterisk), your Part B deductible will have
been met for the calendar year.
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
MEDICAL
EXPENSES— First
$[183] of Medicare
|
|
|
$0 |
Part
B Excess Charges (Above
Medicare Approved Amounts) |
$0 |
$0 |
All
costs |
BLOOD
|
$0
|
All
costs
|
$0 $0 |
CLINICAL
LABORATORY |
|
|
|
PLAN D
PARTS
A & B
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
HOME
HEALTH CARE
Durable
medical equipment
- Remainder of Medicare |
|
|
$0 |
PLAN
D
OTHER
BENEFITS - NOT COVERED BY MEDICARE
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
FOREIGN
TRAVEL—NOT COVERED BY MEDICARE
|
|
|
|
PLAN F or HIGH DEDUCTIBLE PLAN F
MEDICARE
(PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*
A benefit period begins on the first day you receive service as an inpatient in
a hospital and ends after you have been out of the hospital and have not
received skilled care in any other facility for 60 days in a row.
[**This high deductible plan pays the same benefits
as Plan F after one has paid a calendar year [$2200] deductible. Benefits from the high deductible plan F will
not begin until out-of-pocket expenses are [$2200]. Out-of-pocket expenses for this deductible
are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for
Part A and Part B, but does not include the plan's separate foreign travel
emergency deductible.]
SERVICES |
MEDICARE
PAYS |
[AFTER
YOU PAY |
[IN
ADDITION |
HOSPITALIZATION* board,
general nursing and
miscellaneous services
and supplies
- While using 60 Lifetime reserve days - Once lifetime reserve days
|
All
but $[1316]
|
$[329]
a day
|
|
SKILLED
NURSING
|
All
approved amounts All
but $[164.50] a day
|
|
|
BLOOD Additional
amounts |
$0 100% |
|
|
HOSPICE
CARE |
|
|
$0 |
***
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer
stands in the place of Medicare and will pay whatever amount Medicare would
have paid for up to an additional 365 days as provided in the policy's
"Core Benefits." During this time the hospital is prohibited from
billing you for the balance based on any difference between its billed charges
and the amount Medicare would have paid.
PLAN
F or HIGH DEDUCTIBLE PLAN F
MEDICARE
(PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
*Once
you have been billed $[183] of
Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.
[**This high deductible plan pays the same benefits
as Plan F after you have paid
a calendar year [$2200] deductible.
Benefits from the high deductible plan F will not begin until
out-of-pocket expenses are [$2200].
Out-of-pocket expenses for this deductible are expenses that would
ordinarily be paid by the policy. This
includes the Medicare deductibles for Part A and Part B, but does not include
the plan's separate foreign travel emergency deductible.]
|
|
[AFTER
YOU PAY |
[IN
ADDITION TO $[2200] DEDUCTIBLE,**] |
MEDICAL
EXPENSES - First
$[183] of Medicare
|
|
|
|
Part
B Excess Charges (Above Medicare Approved Amounts) |
$0 |
100% |
$0 |
|
|
[AFTER
YOU PAY |
[IN
ADDITION TO $[2200] DEDUCTIBLE,**] |
BLOOD
|
$0
|
|
|
CLINICAL
LABORATORY |
|
|
|
PLAN F or HIGH DEDUCTIBLE PLAN F
PARTS A & B
|
|
AFTER
YOU PAY |
IN
ADDITION TO $[2200] DEDUCTIBLE,** |
HOME
HEALTH CARE
Durable
medical equipment -
First $[183] of Medicare Approved Amounts*
|
|
|
|
PLAN
F or HIGH DEDUCTIBLE PLAN F
OTHER
BENEFITS - NOT COVERED BY MEDICARE
|
|
AFTER
YOU PAY |
IN
ADDITION TO $[2200] DEDUCTIBLE,** |
FOREIGN
TRAVEL - the
first 60 days of each trip outside the USA First
$250 each calendar year |
|
|
|
PLAN
G or HIGH DEDUCTIBLE PLAN G
MEDICARE
(PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
*
A benefit period begins on the first day you receive service as an inpatient in
a hospital and ends after you have been out of the hospital and have not
received skilled care in any other facility for 60 days in a row.
[**This
high deductible plan pays the same benefits as Plan G after you have paid a
calendar year [$2200] deductible.
Benefits from the high deductible Plan G will not begin until
out-of-pocket expenses are [$2200].
Out-of-pocket expenses for this deductible include expenses for the
Medicare Part B deductible, and expenses that would ordinarily be paid by the
policy. This does not include the plan’s
separate foreign travel emergency deductible.
SERVICES |
MEDICARE
PAYS |
[AFTER
YOU PAY |
[IN
ADDITION TO $[2200] DEDUCTIBLE,**] |
HOSPITALIZATION* board,
general nursing and miscellaneous services and supplies First
60 days 61st thru 90th day
days
are used:
|
All
but $[1316]
All
but $[658] a day $0
|
$[1316] (Part
A deductible) $[329]
a day $[658]
a day 100% of Medicare
eligible expenses
|
|
SKILLED
NURSING FACILITY CARE* 30
days after leaving the hospital
|
All
approved amounts
|
|
|
BLOOD
|
|
|
|
HOSPICE
CARE |
|
|
|
***
NOTICE:
When your Medicare Part A hospital benefits are exhausted, the insurer
stands in the place of Medicare and will pay whatever amount Medicare would
have paid for up to an additional 365 days as provided in the policy's
"Core Benefits." During this time the hospital is prohibited from
billing you for the balance based on any difference between its billed charges
and the amount Medicare would have paid.
PLAN G or HIGH DEDUCTIBLE PLAN G
MEDICARE
(PART B)—MEDICAL SERVICES—PER CALENDAR YEAR
*
Once you have been billed $[183] of Medicare-approved amounts for covered
services (which are noted with an asterisk), your Part B deductible will have
been met for the calendar year.
[**This
high deductible plan pays the same benefits as Plan G after you have paid a
calendar year [$2200] deductible.
Benefits from the high deductible Plan G will not begin until
out-of-pocket expenses are [$2200].
Out-of-pocket expenses for this deductible include expenses for the
Medicare Part B deductible, and expenses that would ordinarily be paid by the
policy. This does not include the plan’s
separate foreign travel emergency deductible.]
SERVICES |
MEDICARE
PAYS |
[AFTER
YOU PAY |
[IN
ADDITION TO $[2200] DEDUCTIBLE,**] |
MEDICAL
EXPENSES —IN
OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's
services, inpatient
and outpatient medical and surgical services and supplies, physical
and speech therapy,
diagnostic tests, durable medical equipment First
$[183] of Medicare Remainder
of Medicare |
|
|
$0 |
Part
B Excess Charges (Above
Medicare Approved Amounts) |
$0 |
100% |
$0 |
BLOOD
|
|
|
$0 |
SERVICES |
MEDICARE
PAYS |
[AFTER
YOU PAY |
[IN
ADDITION TO $[2200] DEDUCTIBLE,**] |
CLINICAL
LABORATORY |
|
|
|
PLAN G or HIGH DEDUCTIBLE PLAN G
PARTS
A & B
SERVICES |
MEDICARE
PAYS |
[AFTER
YOU PAY |
[IN
ADDITION TO $[2200] DEDUCTIBLE,**] |
HOME
HEALTH CARE skilled
care services and
medical supplies
|
80% |
|
|
PLAN
G or HIGH DEDUCTIBLE PLAN G
OTHER
BENEFITS - NOT COVERED BY MEDICARE
SERVICES |
MEDICARE
PAYS |
[AFTER
YOU PAY |
[IN
ADDITION TO $[2200] DEDUCTIBLE,**] |
FOREIGN
TRAVEL—
|
|
|
|
PLAN
K
*
You will pay half the cost-sharing of some covered services until you reach the
annual out-of-pocket limit of $[5120] each calendar year. The amounts that count toward your annual
limit are noted with diamonds (♦) in the chart below. Once you reach the annual limit, the plan
pays 100% of your Medicare copayment and coinsurance for the rest of the
calendar year. However, this limit
does NOT include charges from your provider that exceed Medicare-approved
amounts (these are called "Excess Charges") and you will be
responsible for paying this difference in the amount charged by your provider
and the amount paid by Medicare for the item or service.
MEDICARE
(PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
**
A benefit period begins on the first day you receive service as an inpatient in
a hospital and ends after you have been out of the hospital and have not
received skilled care in any other facility for 60 days in a row.
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
HOSPITALIZATION** Semiprivate
room and board,
general nursing and miscellaneous services and supplies First
60 days 61st
thru 90th day 91st
day and after: -
While using 60 lifetime
reserve days -
Once lifetime reserve days
are used: --
Additional 365 days --
Beyond the additional 365
days |
All
but $[1316] All
but $[329] a day All
but $[658] a day $0 $0 |
$[658](50%
of Part A deductible) $[329]
a day $[658]
a day 100%
of Medicare eligible expenses $0 |
$[658](50%
of Part A deductible)♦ $0 $0 $0*** All
costs |
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
SKILLED
NURSING FACILITY CARE** You
must meet Medicare's requirements, including having been in a hospital for at
least 3 days and entered a Medicare-approved facility within 30 days after
leaving the hospital First
20 days 21st
thru 100th day 101st
day and after |
All
approved amounts All
but $[164.50] a day $0 |
$0 Up
to $[82.25] a day (50% of Part A Coinsurance) $0 |
$0 Up
to $[82.25] a day (50% of Part A Coinsurance)♦ All
costs |
BLOOD First
3 pints Additional
amounts |
$0 100% |
50% $0 |
50%
♦ $0 |
HOSPICE
CARE You
must meet Medicare's requirements, including a doctor's certification of
terminal illness |
All
but very limited co-payment/coinsurance for outpatient drugs and inpatient
respite care |
50%
of co-payment/coinsurance |
50%
of Medicare co-payment/coinsurance
♦ |
***NOTICE: When your Medicare Part A hospital benefits
are exhausted, the insurer stands in the place of Medicare and will pay
whatever amount Medicare would have paid for up to an additional 365 days as
provided in the policy's "Core Benefits." During this time the hospital is prohibited
from billing you for the balance based on any difference between its billed
charges and the amount Medicare would have paid.
PLAN
K
MEDICARE
(PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once
you have been billed $[183] of Medicare-approved amounts for covered services
(which are noted with an asterisk), your Part B deductible will have been met
for the calendar year.
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
MEDICAL
EXPENSES – IN
OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's
services, inpatient and outpatient medical and surgical services and
supplies, physical and speech therapy, diagnostic tests, durable medical
equipment First
$[183] of Medicare Approved Amounts**** Preventive
Benefits for Medicare covered services Remainder
of Medicare Approved Amounts |
$0 Generally
80% or more of Medicare approved amounts Generally
80% |
$0 Remainder
of Medicare approved amounts Generally
10% |
$[183]
(Part B deductible)**** ♦ All
costs above Medicare approved amounts Generally
10% ♦ |
Part
B Excess Charges (Above
Medicare Approved Amounts) |
$0 |
$0 |
All
costs (and they do not count toward annual out-of-pocket limit of $[5120])* |
BLOOD First
3 pints Next
$[183] of Medicare Approved Amounts**** Remainder
of Medicare Approved Amounts |
$0 $0 Generally
80% |
50% $0 Generally
10% |
50%
♦ $[183]
(Part B deductible)**** ♦ Generally
10% ♦ |
CLINICAL
LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
*This
plan limits your annual out-of-pocket payments for Medicare-approved amounts to
$[5120] per year. However, this limit
does NOT include charges from your provider that exceed Medicare-approved
amounts (these are called "Excess Charges") and you will be responsible
for paying this difference in the amount charged by your provider and the
amount paid by Medicare for the item or service.
PLAN
K
PARTS
A & B
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
HOME
HEALTH CARE MEDICARE
APPROVED SERVICES -
Medically necessary skilled care services and medical supplies Durable
medical equipment - First $[183] of Medicare Approved
Amounts**** - Remainder of Medicare Approved Amounts |
100% $0 80% |
$0 $0 10% |
$0 $[183]
(Part B deductible) ♦ 10%
♦ |
*****Medicare
benefits are subject to change. Please
consult the latest Guide to Health Insurance for People with Medicare.
PLAN
L
*
You will pay one-fourth of the cost-sharing of some covered services until you
reach the annual out-of-pocket limit of $[2560] each calendar year. The amounts that count toward your annual
limit are notice with diamonds (♦) in the chart below. Once you reach the annual limit, the plan
pays 100% of your Medicare copayment and coinsurance for the rest of the
calendar year. However, this limit
does NOT include charges from your provider that exceed Medicare-approved
amounts (these are called "Excess Charges") and you will be
responsible for payment this difference in the amount charged by your provider
and the amount paid by Medicare for the item or service.
MEDICARE
(PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
**
A benefit period begins on the first day you receive service as an inpatient in
a hospital and ends after you have been out of the hospital and have not
received skilled care in any other facility for 60 days in a row.
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
HOSPITALIZATION** Semiprivate
room and board, general nursing and miscellaneous services and supplies First
60 days 61st
thru 90th day 91st
day and after: -
While using 60 lifetime reserve days -
Once lifetime reserve days are used: --
Additional 365 days --
Beyond the additional 365 days |
All
but $[1316] All
but $[329] a day All
but $[658] a day $0 $0 |
$[987]
(75% of Part A deductible) $[329]
a day $[658]
a day 100%
of Medicare eligible expenses $0 |
$[329]
(25% of Part A deductible) ♦ $0 $0 $0*** All
costs |
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
SKILLED
NURSING FACILITY CARE** You
must meet Medicare's requirements, including having been in a hospital for at
least 3 days and entered a Medicare-approved facility within 30 days after
leaving the hospital First
20 days 21st
thru 100th day 101st
day and after |
All
approved amounts All
but $[164.50] a day $0 |
$0 Up
to $[123.38] a
day (75% of Part A Coinsurance) $0 |
$0 Up
to $[41.13] a day (25% of Part A Coinsurance)♦ All
costs |
BLOOD First
3 pints Additional
amounts |
$0 100% |
75% $0 |
25%
♦ $0 |
HOSPICE
CARE You
must meet Medicare's requirements, including a doctor's certification of
terminal illness |
All
but very limited co-payment/coinsurance for out-patient drugs and inpatient
respite care |
75%
of co-payment/coinsurance |
25%
of co-payment/coinsurance ♦ |
***NOTICE: When your Medicare Part A hospital benefits
are exhausted, the insurer stands in the place of Medicare and will pay
whatever amount Medicare would have paid for up to an additional 365 days as
provided in the policy's "Core Benefits." During this time the hospital is prohibited
from billing you for the balance based on any difference between its billed
charges and the amount Medicare would have paid.
PLAN
L
MEDICARE
(PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
****Once
you have been billed $[183] of Medicare-approved amounts for covered services
(which are noted with an asterisk), your Part B deductible will have been met
for the calendar year.
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
MEDICAL
EXPENSES – IN
OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's
services, inpatient and outpatient medical and surgical services and
supplies, physical and speech therapy, diagnostic tests, durable medical
equipment First
$[183] of Medicare Approved Amounts Preventive
Benefits for Medicare covered services Remainder
of Medicare Approved Amounts |
$0 Generally
80% or more of Medicare approved amounts Generally
80% |
$0 Remainder
of Medicare approved amounts Generally
15% |
$[183]
(Part B deductible)**** ♦ All
costs above Medicare approved amounts Generally
5% ♦ |
Part
B Excess Charges (Above
Medicare Approved Amounts) |
$0 |
$0 |
All
costs (and they do not count toward annual out-of-pocket limit of [$2560])* |
BLOOD First
3 pints Next
$[183] of Medicare Approved Amounts**** Remainder
of Medicare Approved Amounts |
$0 $0 Generally
80% |
75% $0 Generally
15% |
25%
♦ $[183]
(Part B deductible) ♦ Generally
5% ♦ |
CLINICAL
LABORATORY SERVICES – TEST FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
*This
plan limits your annual out-of-pocket payments for Medicare-approved amounts to
$[2560] per year. However, this limit
does NOT include charges from your provider that exceed Medicare-approved
amounts (these are called "Excess Charges") and you will be responsible
for paying this difference in the amount charged by your provider and the
amount paid by Medicare for the item or service.
PLAN
L
PARTS
A & B
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
HOME
HEALTH CARE MEDICARE
APPROVED SERVICES Medically
necessary skilled care services and medical supplies Durable
medical equipment - First $[183] of Medicare Approval
Amounts***** - Remainder of Medicare Approved Amounts |
100% $0 80% |
$0 $0 15% |
$0 $[183]
(Part B deductible) ♦ 5%
♦ |
*****Medicare
benefits are subject to change. Please
consult the latest Guide to Health Insurance for People with Medicare.
PLAN M
MEDICARE
(PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*
A benefit period begins on the first day you receive service as an inpatient in
a hospital and ends after you have been out of the hospital and have not
received skilled care in any other facility for 60 days in a row.
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
HOSPITALIZATION* Semiprivate
room and board, general nursing and miscellaneous services and supplies First
60 days 61st
thru 90th day 91st
day and after: -
While using 60 lifetime reserve days -
Once lifetime reserve days are used: --
Additional 365 days --
Beyond the additional 365 days |
All
but $[1316] All
but $[329] a day All
but $[658] a day $0 $0 |
$[658]
(50% of Part A deductible) $[329]
a day $[658]
a day 100%
of Medicare eligible expenses $0 |
$[658]
(50% of Part A deductible) $0 $0 $0** All
costs |
SKILLED
NURSING FACILITY CARE* You
must meet Medicare's requirements, including having been in a hospital for at
least 3 days and entered a Medicare-approved facility within 30 days after
leaving the hospital First
20 days 21st
thru 100th day 101st
day and after |
All
approved amount All
but $[164.50] a day $0 |
$0 Up
to $[164.50] a day $0 |
$0 $0 All
costs |
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
BLOOD First
3 pints Additional
amounts |
$0 100% |
3
Pints $0 |
$0 $0 |
HOSPICE
CARE You
must meet Medicare's requirements, including a doctor's certification of
terminal illness |
All
but very limited co-payment/coinsurance for out-patient drugs and inpatient
respite care |
Medicare
co-payment/coinsurance |
$0 |
**NOTICE:
When your Medicare Part A hospital
benefits are exhausted, the insurer stands in the place of Medicare and will
pay whatever amount Medicare would have paid for up to an additional 365 days
as provided in the policy's "Core Benefits." During this time the hospital is prohibited
from billing you for the balance based on any difference between its billed
charges and the amount Medicare would have paid.
PLAN
M
MEDICARE
(PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once
you have been billed $[183] of Medicare-approved amounts for covered services
(which are noted with an asterisk), your Part B deductible will have been met
for the calendar year.
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
MEDICAL
EXPENSES – IN OR OUT OF THE HOSPITAL AND
OUTPATIENT HOSPITAL TREATMENT, such as
physician's services, inpatient and outpatient medical and surgical services
and supplies, physical and speech therapy, diagnostic tests, durable medical
equipment First
$[183] of Medicare Approved Amounts Remainder
of Medicare Approved Amounts |
$0 Generally
80% |
$0 Generally
20% |
$[183]
(Part B deductible) $0 |
Part
B Excess Charges (Above
Medicare Approved Amounts) |
$0 |
$0 |
All
costs |
BLOOD First
3 pints Next
$[183] of Medicare Approved Amounts* Remainder
of Medicare Approved Amounts |
$0 $0 80% |
All
costs $0 20% |
$0 $[183]
(Part B deductible) $0 |
CLINICAL
LABORATORY SERVICES
– TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN
M
PARTS
A & B
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
HOME
HEALTH CARE MEDICARE APPROVED SERVICES Medically
necessary skilled care services and medical supplies Durable
medical equipment First
$[183] of Medicare Approval Amounts* Remainder
of Medicare Approved Amounts |
100% $0 80% |
$0 $0 20% |
$0 $[183]
(Part B deductible) $0 |
OTHER
BENEFITS -- NOT COVERED BY MEDICARE
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
FOREIGN
TRAVEL -NOT COVERED BY MEDICARE Medically necessary emergency care services
beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of Charges |
$0 $0 |
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
PLAN
N
MEDICARE
(PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*
A benefit period begins on the first day you receive service as an inpatient in
a hospital and ends after you have been out of the hospital and have not
received skilled care in any other facility for 60 days in a row.
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
HOSPITALIZATION* Semiprivate
room and board, general nursing and miscellaneous services and supplies First
60 days 61st
thru 90th day 91day
and after: -
While using 60 lifetime reserve days -
Once lifetime reserve days are used: -- Additional 365 days -- Beyond the additional 365 days |
All
but $[1316] All
but $[329] a day All
but $[658] a day $0 $0 |
$[1316]
(Part A deductible) $[329]
a day $[658]
a day 100%
of Medicare eligible expenses $0 |
$0 $0 $0 $0** All
costs |
SKILLED
NURSING FACILITY CARE* You
must meet Medicare's requirements, including having been in a hospital for at
least 3 days and entered a Medicare-approved facility within 30 days after
leaving the hospital First
20 days 21st
thru 100th day 101st
day and after |
All
approved amounts All
but $[164.50] a day $0 |
$0 Up
to $[164.50] a day $0 |
$0 $0 All
costs |
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
BLOOD First
3 pints Additional
amounts |
$0 100% |
3
Pints $0 |
$0 $0 |
HOSPICE
CARE You
must meet Medicare's requirements, including a doctor's certification of
terminal illness |
All
but very limited co-payment/coinsurance for out-patient drugs and inpatient
respite care |
Medicare
co-payment/coinsurance |
$0 |
**NOTICE:
When your Medicare Part A hospital
benefits are exhausted, the insurer stands in the place of Medicare and will
pay whatever amount Medicare would have paid for up to an additional 365 days
as provided in the policy's "Core Benefits." During this time the hospital is prohibited
from billing you for the balance based on any difference between its billed
charges and the amount Medicare would have paid.
PLAN
N
MEDICARE
(PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once
you have been billed $[183] of Medicare-approved amounts for covered services
(which are noted with an asterisk), your Part B deductible will have been met
for the calendar year.
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
MEDICAL
EXPENSES - IN OR OUT OF THE HOSPITAL AND
OUTPATIENT HOSPITAL TREATMENT, such as
physician's services, inpatient and outpatient medical and surgical services
and supplies, physical and speech therapy, diagnostic tests, durable medical
equipment First
$[183] of Medicare Approved Amounts Remainder
of Medicare Approved Amounts |
$0 Generally
80% |
$0 Balance,
other than up to [$20] per office visit and up to [$50] per emergency room
visit. The co-payment of up to [$50]
is waived if the insured is admitted to any hospital and the emergency visit
is covered as a Medicare Part A expense. |
$[183]
(Part B deductible) Up
to [$20] per office visit and up to [$50] per emergency room visit. The co-payment of up to [$50] is waived if
the insured is admitted to any hospital and the emergency visit is covered as
a Medicare Part A expense. |
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY* |
Part
B Excess Charges (Above
Medicare Approved Amounts) |
$0 |
$0 |
All
costs |
BLOOD First
3 pints Next
$[183] of Medicare Approved Amounts* Remainder
of Medicare Approved Amounts |
$0 $0 80% |
All
costs $0 20% |
$0 $[183]
(Part B deductible) $0 |
CLINICAL
LABORATORY SERVICES
– TESTS FOR DIAGNOSTIC SERVICES |
100% |
$0 |
$0 |
PLAN
N
PARTS
A & B
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
HOME
HEALTH CARE MEDICARE APPROVED SERVICES Medically
necessary skilled care services and medical supplies Durable
medical equipment - First $[183] of Medicare Approval Amounts* - Remainder of Medicare Approved Amounts |
100% $0 80% |
$0 $0 20% |
$0 $[183]
(Part B deductible) $0 |
PLAN
N
OTHER
BENEFITS -- NOT COVERED BY MEDICARE
SERVICES |
MEDICARE
PAYS |
PLAN
PAYS |
YOU
PAY |
FOREIGN
TRAVEL -NOT COVERED BY MEDICARE Medically necessary emergency care services
beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of Charges |
$0 $0 |
$0 80% to a lifetime maximum benefit of $50,000 |
$250 20% and amounts over the $50,000 lifetime maximum |
(e)
Notice Regarding Policies or Certificates Which Are Not Medicare
Supplement Policies.
(1) Any accident and sickness insurance policy or
certificate, other than a Medicare supplement policy, a policy issued pursuant
to a contract under Section 1876 of the federal Social Security Act, 42 U.S.C.
§ 1395 et seq., disability income policy, or other policy identified in Ins
1905.02(b) issued for delivery in this state to persons eligible for Medicare
shall notify insureds under the policy that the policy is not a Medicare
supplement policy or certificate. The
notice shall either be printed or attached to the first page of the outline of
coverage delivered to insureds under the policy, or if no outline of coverage
is delivered, to the first page of the policy or certificate delivered to
insureds.
The notice shall be in no less than 12
point type and shall contain the following language:
"THIS
[POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT [POLICY OR CONTRACT]. If
you are eligible for Medicare, review the Guide to Health Insurance for People
with Medicare available from the company."
(2) Applications provided to persons eligible for
Medicare for the health insurance policies or certificates described in Ins
1905.19(d)(1) shall disclose, using the applicable statement in Appendix C, the
extent to which the policy duplicates Medicare.
The disclosure statement shall be provided as a part of, or together
with, the application for the policy or certificate.
Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93;
ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #7174, eff 12-22-99; ss by #8051, eff 3-1-04;
ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.16); ss by
#12370, eff 10-13-17 (from Ins 1905.18)
Ins
1905.20 Requirements for Application Forms
and Replacement Coverage.
(a)
Application forms shall
include the following questions designed to elicit information as to
whether, as of the date of the application, the applicant currently has
Medicare supplement, Medicare Advantage, Medicaid coverage, or another health insurance policy or
certificate in force or whether a Medicare supplement policy or certificate is
intended to replace any other accident and sickness policy or certificate
presently in force. A supplementary application or other form to be signed by
the applicant and agent containing such questions and statements may be used.
(1)
[Statements]:
a. You do not need more than one Medicare
supplement policy.
b. If you purchase this policy, you may want to
evaluate your existing health coverage and decide if you need multiple
coverages.
c. You may be eligible for benefits under
Medicaid and may not need a Medicare supplement policy.
d. If, after purchasing this policy, you become
eligible for Medicaid, the benefits and premiums under your Medicare supplement
policy can be suspended, if requested, during your entitlement to benefits
under Medicaid for 24 months. You must request this suspension within 90 days
of becoming eligible for Medicaid. If
you are no longer entitled to Medicaid, your suspended Medicare supplement
policy or, if that is no longer available, a substantially equivalent policy,
will be reinstituted if requested within 90 days of losing Medicaid
eligibility. If the Medicare supplement
policy provided coverage for outpatient prescription drugs and you enrolled in
Medicare Part D while your policy was suspended, the reinstituted policy will
not have outpatient prescription drug coverage, but will otherwise be
substantially equivalent to your coverage before the date of the suspension.
e. If you are eligible for, and have enrolled in
a Medicare supplement policy by reason of disability and you later become covered
by an employer or union-based group health plan, the benefits and premiums
under your Medicare supplement policy can be suspended, if requested, while you
are covered under the employer or union-based group health plan. If you suspend your Medicare supplement
policy under these circumstances, and later lose your employer or union-based
group health plan, your suspended Medicare supplement policy (or, if that is no
longer available, a substantially equivalent policy) will be reinstituted if
requested within 90 days of losing your employer or union-based group health
plan. If the Medicare supplement policy
provided coverage for outpatient prescription drugs and you enrolled in
Medicare Part D while your policy was suspended, the reinstituted policy will
not have outpatient prescription drug coverage, but will otherwise be
substantially equivalent to your coverage before the date of the suspension.
f. Counseling services may be available in your state
to provide advice concerning your purchase of Medicare supplement insurance and
concerning medical assistance through the state Medicaid program, including
benefits as a qualified Medicare beneficiary (QMB) and a specified low-income
Medicare beneficiary (SLMB).
(2) [Questions]:
a. If you lost or are losing other health
insurance coverage and received a notice from your prior insurer saying you
were eligible for guaranteed issue of a Medicare supplement insurance policy,
or that you had certain rights to buy such a policy, you may be guaranteed
acceptance in one or more of our Medicare supplement plans. Please include a copy of the notice from your
prior insurer with your application.
PLEASE ANSWER ALL QUESTIONS.
[Please
mark Yes or No below with an "X"]
To
the best of your knowledge,
1. Did you turn age 65 in the last 6 months?
Yes_____ No_____
2. Did you enroll in Medicare Part B in the last
6 months?
Yes_____ No_____
3. If yes, what is the effective date? ____________________
4. Are you covered for medical assistance
through the state Medicaid program?
[NOTE
TO APPLICANT: If you are participating
in a "Spend-Down Program" and have not met your "Share of
Cost," please answer NO to this question.]
Yes_____ No_____
5. Will Medicaid pay your premiums for this
Medicare supplement policy?
Yes_____ No_____
6. Do you receive any benefits from Medicaid
OTHER THAN payments toward your Medicare Part B premium?
Yes_____ No_____
7. If you had coverage from any Medicare plan
other than original Medicare within the past 63 days (for example, a Medicare
Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates
below. If you are still covered under
this plan, leave "END" blank.
START __/__/__ END __/__/__
8. If you are still covered under the Medicare
plan, do you intend to replace your current coverage with this new Medicare
supplement policy?
Yes_____ No_____
9. Was this your first time in this type of
Medicare plan?
Yes_____ No_____
10. Did you drop a Medicare supplement policy to
enroll in the Medicare plan?
Yes_____ No_____
11. Do you have another Medicare supplement
policy in force?
Yes_____ No_____
12. If so, with what company, and what plan do
you have [option for Direct Mailers]?
_____________________________________________________________________
13. If so, do you intend to replace your current
Medicare supplement policy with this policy?
Yes_____ No_____
14. Have you had coverage under any other health
insurance within the past 63 days? (For
example, an employer, union, or individual plan)
Yes_____ No_____
15. If so, with what company and what kind of
policy?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
16. What are you dates of coverage under the
other policy?
START __/__/__ END __/__/__
(If
you are still covered under the other policy, leave "END" blank.)
(b)
Agents shall list any other health insurance policies they have sold to
the applicant.
(1) List policies sold which are still in force.
(2) List policies sold in the past 5 years that
are no longer in force.
(c)
In the case of a direct response issuer, a copy of the application or
supplemental form, signed by the applicant, and acknowledged by the insurer,
shall be returned to the applicant by the insurer upon delivery of the policy.
(d)
Upon determining that a sale will involve replacement of Medicare
supplement coverage, any issuer, other than a direct response issuer, or its
agent, shall furnish the applicant, prior to issuance or delivery of the
Medicare supplement policy or certificate, a notice regarding replacement of
Medicare supplement coverage. One copy
of the notice signed by the applicant and the agent, except where the coverage
is sold without an agent, shall be provided to the applicant, and an additional
signed copy shall be retained by the issuer. A direct response issuer
shall deliver to the applicant at the time of the issuance of the policy the
notice regarding replacement of Medicare supplement coverage.
(e)
The notice required by (d) above for an issuer shall be provided in
substantially the following form in no less than 12-point type:
NOTICE
TO APPLICANT REGARDING REPLACEMENT
OF
MEDICARE SUPPLEMENT INSURANCE
OR
MEDICARE ADVANTAGE
[Insurance
company's name and address]
SAVE
THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.
According
to [your application] [information you have furnished], you intend to terminate
existing Medicare supplement or Medicare Advantage insurance and replace it
with a policy to be issued by [Company Name] Insurance Company. Your new policy
will provide thirty (30) days within which you may decide without cost whether
you desire to keep the policy.
You
should review this new coverage carefully. Compare it with all accident and
sickness coverage you now have. If, after due consideration, you find that
purchase of this Medicare supplement coverage is a wise decision, you should
terminate your present Medicare supplement or Medicare Advantage coverage. You
should evaluate the need for other accident and sickness coverage you have that
may duplicate this policy.
STATEMENT
TO APPLICANT BY ISSUER, AGENT [BROKER OR OTHER REPRESENTATIVE]:
I
have reviewed your current medical or health insurance coverage. To the best of
my knowledge, this Medicare supplement policy will not duplicate your existing
Medicare supplement or, if applicable, Medicare Advantage coverage because you
intend to terminate your existing Medicare supplement coverage or leave your
Medicare Advantage plan. The replacement
policy is being purchased for the following reason (check one):
____ Additional benefits.
____ No change in benefits, but lower premiums.
____ Fewer benefits and lower premiums.
____ My plan has outpatient prescription drug
coverage and I am enrolling in Part D.
____ Disenrollment from a Medicare Advantage
plan. Please explain reason for
disenrollment.
[optional only for Direct Mailers.]
_____________________________________________________________________________
_____________________________________________________________________________
____ Other. (please specify)___________________________________________________________
1. Note: If the issuer of the Medicare supplement
policy being applied for does not, or is otherwise prohibited from imposing
pre-existing condition limitations, please skip to statement 2 below. Health conditions which you may presently
have (preexisting conditions) may not be immediately or fully covered under the
new policy. This could result in denial
or delay of a claim for benefits under the new policy, whereas a similar claim
might have been payable under your present policy.
2. State law provides that your replacement
policy or certificate may not contain new preexisting conditions, waiting periods, elimination periods
or probationary periods. The insurer will waive any time periods applicable to
preexisting conditions, waiting periods, elimination periods, or probationary
periods in the new policy (or coverage) for similar benefits to the extent such
time was spent (depleted) under the original policy.
3. If, you still wish to terminate your
present policy and replace it with new coverage, be certain to truthfully and
completely answer all questions on the application concerning your medical and
health history. Failure to include all material medical information on an
application may provide a basis for the company to deny any future claims and
to refund your premium as though your policy had never been in force. After the
application has been completed and before you sign it, review it carefully to
be certain that all information has been properly recorded. [If the policy or
certificate is guaranteed issue, this paragraph need not appear.]
Do
not cancel your present policy until you have received your new policy and are
sure that you want to keep it.
______________________________________________________
(Signature of Agent, Broker or Other Representative)*
[Typed
Name and Address of Issuer, Agent or Broker]
______________________________________________________
(Applicant's Signature)
_______________________
(Date)
*Signature
not required for direct response sales.
(f)
Paragraphs 1 and 2 of the replacement notice (applicable to preexisting
conditions) may be deleted by an issuer if the replacement does not involve
application of a new preexisting condition limitation
Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93;
ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #7174, eff 12-22-99; ss by #8051, eff 3-1-04;
ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.17); ss by
#12370, eff 10-13-17 (from Ins 1905.19)
Ins
1905.21 Filing Requirement for
Advertising. An
issuer shall provide a copy of any Medicare supplement advertisement intended
for use in this state whether through written, radio or television medium to
the commissioner of insurance of this state for review or approval by the
commissioner to the extent it may be required under state law.
Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93;
ss by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss
by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.18); ss by
#12370, eff 10-13-17 (from Ins 1905.20)
Ins
1905.22 Standards for Marketing.
(a)
An issuer, directly or through its producers, shall:
(1) Establish marketing procedures to assure that
any comparison of policies by its agents or other producers will be fair and
accurate;
(2) Establish marketing procedures to assure
excessive insurance is not sold or issued;
(3) Display prominently by type, stamp or other
appropriate means, on the first page of the policy the following:
"Notice
to buyer: This policy may not cover all of your medical expenses."
(4) Inquire and otherwise make every reasonable effort
to identify whether a prospective applicant or enrollee for Medicare supplement
insurance already has accident and sickness insurance and the types and amounts
of any such insurance; and
(5) Establish auditable procedures for verifying
compliance with Ins 1905.22 (a).
(b)
In addition to the practices prohibited in RSA 417, the following acts and practices are prohibited:
(1) Twisting.
Knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance
policies or insurers for the purpose of inducing, or tending to induce, any
person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow
on, or convert any insurance policy or to take out a policy of insurance with
another insurer;
(2) High pressure tactics. Employing any method of marketing having the
effect of or tending to induce the purchase of insurance through force, fright,
threat, whether explicit or implied, or undue pressure to purchase or recommend
the purchase of insurance; and
(3) Cold lead advertising. Making use directly or indirectly of any
method of marketing which fails to disclose in a conspicuous manner that a purpose
of the method of marketing is solicitation of insurance and that contact will
be made by an insurance agent or insurance company.
(c) The terms “Medicare supplement,”
“Medigap,” “Medicare wrap around”, and words of similar import shall not be
used unless the policy is issued in compliance with this part.
Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93;
moved by #6406, eff 1-1-97 (from Ins 1905.20); ss by #7174, eff 12-22-99; ss by
#8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins
1905.19); ss by #12370, eff 10-13-17 (from Ins 1905.21)
Ins
1905.23 Appropriateness of Recommended Purchase and Excessive
Insurance.
(a)
In recommending the purchase or replacement of any Medicare supplement
policy or certificate an agent shall make reasonable efforts to determine the
appropriateness of a recommended purchase or replacement.
(b)
Any sale of a Medicare supplement policy or certificate that will
provide an individual more than one Medicare supplement policy or certificate
is prohibited.
(c)
An issuer shall not issue a Medicare supplement policy or certificate to
an individual enrolled in Medicare Part C unless the effective date of the
coverage is after the termination date of the individual's Part C coverage.
Source. #6406, eff 1-1-97 (from Ins 1905.21,
originally #5656, eff 7-1-93); ss by #7174, eff 12-22-99; ss by #8051, eff
3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.20);
ss by #12370, eff 10-13-17 (from Ins 1905.22)
Ins
1905.24 Reporting of Multiple Policies.
(a)
On or before March 1 of each year, an issuer shall report the
following information for every individual resident of this state for which the
issuer has in force more than one Medicare supplement policy or certificate:
(1) Policy and certificate number; and
(2) Date of issuance.
(b)
The items set forth above shall be grouped by individual policyholder.
Source. #6880, EMERGENCY, eff 11-5-98, EXPIRED:
3-5-99
New. #7174, eff 12-22-99; ss by #8363, eff 9-8-05;
ss by #9559, eff 10-13-09 (from Ins 1905.21); ss by #12370, eff 10-13-17 (from
Ins 1905.23)
Ins
1905.25 Prohibition Against
Preexisting Conditions, Waiting Periods, Elimination Periods, and Probationary
Periods in Replacement Policies or Certificates.
(a)
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 conditions,
waiting periods, elimination periods, and probationary periods in the new
Medicare supplement policy or certificate for similar benefits to the extent such time was spent under the
original policy.
(b)
If a Medicare supplement policy or certificate replaces another Medicare
supplement policy or certificate which has been in effect for at least 6
months, the replacing policy shall not provide any time
period
applicable to preexisting conditions, waiting periods, elimination periods, and
probationary periods for benefits similar to those contained in the original
policy or certificate.
Source. #8619, eff 5-1-06; ss by #9559, eff 10-13-09
(from Ins 1905.22); ss by #12370, eff 10-13-17 (from Ins
1905.24)
Ins 1905.26 Prohibition
Against Use of Genetic Information and Requests for Genetic Testing. This section applies to all policies with
policy years beginning on or after May 21, 2009.
(a) An issuer of a Medicare supplement policy or
certificate:
(1) Shall not deny or condition the issuance or
effectiveness of the policy or certificate, including the imposition of any
exclusion of benefits under the policy based on a preexisting condition, on the
basis of the genetic information with respect to such individual; and
(2) Shall not discriminate in the pricing of the
policy or certificate, including the adjustment of premium rates, of an
individual on the basis of the genetic information with respect to such
individual.
(b) Nothing in (a) shall be construed to limit
the ability of an issuer, to the extent otherwise permitted by law, from:
(1) Denying or conditioning the issuance or
effectiveness of the policy or certificate or increasing the premium for a
group based on the manifestation of a disease or disorder of an insured or
applicant; or
(2) Increasing the premium for any period issued
to an individual based on the manifestation of a disease or disorder of an
individual who is covered under the policy, in such case, the manifestation of
a disease or disorder in one individual cannot also be used as genetic
information about other group members and to further increase the premium for
the group.
(c)
An issuer of a Medicare supplement policy or certificate shall not
request or require an individual or a family member of such individual to
undergo a genetic test.
(d) Paragraph (c) shall not be construed to
preclude an issuer of a Medicare supplement policy or certificate from
obtaining and using the results of a genetic test in making a determination
regarding payment, as defined for the purposes of applying the regulations
promulgated under Part C of title XI and section 264 of the Health Insurance
Portability and Accountability Act of 1996, as may be revised from time to
time, and consistent with subsection (a).
(e)
For purposes of carrying out paragraph (d), an issuer of a Medicare
supplement policy or certificate may request only the minimum amount of
information necessary to accomplish the intended purpose.
(f)
Notwithstanding (c), an issuer of a Medicare supplement policy may
request, but not require, that an individual or a family member of such
individual undergo a genetic test if each of the following conditions is met:
(1) The request is made pursuant to research that
complies with Part 46 of Title 45, Code of Federal Regulations, or equivalent
Federal regulations, and any applicable state or local law or regulations for
the protection of human subjects in research;
(2) The issuer clearly indicates to each
individual, or in the case of a minor child, to the legal guardian of such
child, to whom the request is made that:
a. Compliance with the request is voluntary; and
b. Non-compliance will have no effect on
enrollment status or premium or contribution amounts;
(3) No genetic information collected or acquired
under this subsection shall be used for underwriting, determination of
eligibility to enroll or maintain enrollment status, premium rates, or the
issuance, renewal, or replacement of a policy or certificate;
(4) The issuer notifies the secretary in writing
that the issuer is conducting activities pursuant to the exception provided for
under this subsection, including a description of the activities conducted; and
(5) The issuer complies with such other
conditions as the secretary may by regulation require for activities conducted
under this subsection.
(g)
An issuer of a Medicare supplement policy or certificate shall not
request, require, or purchase genetic information for underwriting purposes.
(h)
An issuer of a Medicare supplement policy or certificate shall not
request, require, or purchase genetic information with respect to any
individual prior to such individual's enrollment under the policy in connection
with such enrollment.
(i)
If an issuer of a Medicare supplement policy or certificate obtains
genetic information incidental to the requesting, requiring, or purchasing of
other information concerning any individual, such request, requirement, or
purchase shall not be considered a violation of subsection (h) if such request,
requirement, or purchase is not in violation of subsection (g).
(j)
For the purpose of this section only:
(1) "Issuer of a Medicare supplement policy
or certificate" includes third-party administrator, or other person acting
for or on behalf of such issuer;
(2) "Family member" means, with respect
to an individual, any other individual who is a first-degree, second-degree,
third-degree, or fourth-degree relative of such individual;
(3) "Genetic information" means, with
respect to any individual, information about such individual's genetic tests,
the genetic tests of family members of such individual, and the manifestation
of a disease or disorder in family member of such individual. Such term includes, with respect to any
individual, any request for, or receipt of, genetic services, or participation
in clinical research which includes genetic services, by such individual or
family member of such individual. Any
reference to genetic information concerning an individual or family member of
an individual who is a pregnant woman, includes genetic information of any
fetus carried by such pregnant woman, or with respect to an individual or
family member utilizing reproductive technology, includes genetic information
of any embryo legally held by an individual or family member. The term "genetic information" does
not include information about the sex or age of any individual;
(4) "Genetic services" means a genetic
test, genetic counseling, including obtaining, interpreting, or assessing
genetic information, or genetic education;
(5) "Genetic test" means an analysis of
human DNA, RNA, chromosomes, proteins, or metabolites, that detect genotypes,
mutations, or chromosomal changes. The
term "genetic test" does not mean an analysis of proteins or
metabolites that does not detect genotypes, mutations, or chromosomal charges;
or an analysis of proteins or metabolites that is directly related to a
manifested disease, disorder, or pathological condition that could reasonably
be detected by a health care professional with appropriate training and
expertise if the field of medicine involved; and
(6)
"Underwriting purposes" means:
a. Rules for, or
determination of, eligibility, including enrollment and continued eligibility,
for benefits under the policy;
b. The computation of premium or contribution
amounts under the policy;
c. The application of any preexisting condition
exclusion under the policy; and
d. Other activities related to the creation,
renewal, or replacement of a contract of health insurance or health benefits.
Source. #9559, eff 10-13-09
ss by #12370, eff 10-13-17 (from Ins 1905.25)
Ins
1905.27 Waiver or
Suspension of Rules.
(a)
The commissioner, upon the commissioner’s own initiative or upon request
by an insurer, shall waive any requirement of this chapter if such waiver does
not contradict the objective or intent of the rule and:
(1) Applying the rule provision would result in a
form that is inaccurate, would cause confusion, or would be misleading to
consumers;
(2) The rule provision is in whole or in part
inapplicable to or inconsistent with the form of policy;
(3) There are specific circumstances unique to
the form such that strict compliance with the rule would be onerous without
promoting the objective or intent of the rule provision; or
(4) Any other similar extenuating circumstances
exist such that application of an alternative standard or procedure better
promotes the objective or intent of the rule provision.
(b)
No requirement prescribed by statute shall be waived unless expressly
authorized by law.
(c)
Any person making a form filing and seeking a waiver shall make a
request in writing.
(d)
A request for a waiver shall specify the basis for the waiver and
proposed alternative, if any.
Source. #12370, eff
10-13-17
Appendix
A.
MEDICARE
SUPPLEMENT REFUND CALCULATION FORM
FOR CALENDAR YEAR_________________
TYPE1__________________________________________________________ SMSBP2__________________________________________________
For the State
of______________________________ Company
Name__________________________
NAIC Group Code___________________________ NAIC
Company Code_____________________
Address____________________________________ Person
Completing Exhibit_________________
Title_______________________________________ Telephone
Number________________________
Line |
|
(a) |
(b) |
||
1. |
Current
Year's Experience |
|
|
||
|
a. Total
(all policy years) |
|
|
||
|
b. Current
year's issues5 |
|
|
||
|
c. Net
(for reporting purposes = 1a–1b |
|
|
||
2. |
Past
Years' Experience (all policy years) |
|
|
||
3. |
Total
Experience |
|
|
|
|
4. |
Refunds
Last Year (Excluding Interest) |
|
|||
5. |
Previous
Since Inception (Excluding Interest) |
|
|||
6. |
Refunds
Since Inception (Excluding Interest) |
|
|||
7. |
Benchmark
Ratio Since Inception (see worksheet for Ratio 1) |
|
|||
8. |
Experienced
Ratio Since Inception (Ratio 2) |
|
|||
9. |
Life
Years Exposed Since Inception |
|
|||
10. |
Tolerance
Permitted (obtained from credibility table) |
|
|||
Medicare
Supplement Credibility Table
Life
Years Exposed |
|
Since
Inception |
Tolerance |
10,000
+ |
0.0% |
5,000
-9,999 |
5.0% |
2,500
-4,999 |
7.5% |
1,000
-2,499 |
10.0% |
500
- 999 |
15.0% |
If
less than 500, no credibility. |
_______________________________________________________
1 Individual, Group, Individual Medicare
Select, or Group Medicare Select Only.
2 "SMSBP" = Standardized Medicare
Supplement Benefit Plan - Use "P" for pre-standardized plans.
3 Includes Modal Loadings and Fees Charged
4 Excludes Active Life Reserves
5 This is to be
used as "Issue Year Earned Premium" for Year 1 of next year's
"Worksheet for Calculation of Benchmark Ratios"
MEDICARE
SUPPLEMENT REFUND CALCULATION FORM
FOR
CALENDAR YEAR________________________________________________
TYPE1
___________________________________________________________________________________________________________________
SMSBP2_________________________________________________________________________________________________________________
For
the State of__________________________________________________________________
Company
Name ________________________________________________________________
NAIC
Group Code_______________________________________________________________
NAIC
Company Code_____________________________________________________________
Address________________________________________________________________________
Person
Completing Exhibit_________________________________________________________
Title___________________________________________________________________________
Telephone
Number_______________________________________________________________
11. |
Adjustment
to Incurred Claims for Credibility |
|
|
Ratio
3 = Ratio 2 + Tolerance |
|
If
Ratio 3 is more than Benchmark Ratio (Ratio 1), a refund or credit to premium
is not required.
If
Ratio 3 is less than the Benchmark Ratio, then proceed.
12. |
Adjusted
Incurred Claims |
|
|
[Total
Earned Premiums (line 3, col. a)–Refunds Since Inception (line 6)] x Ratio 3
(line 11) |
|
13. |
Refund
= |
|
|
Total
Earned Premiums (line 3, col. a)–Refunds Since Inception (line 6) |
|
If
the amount on line 13 is less than .005 times the annualized premium in force
as of December 31 of the reporting year, then no refund is made. Otherwise, the amount on line 13 is to be
refunded or credited, and a description of the refund or credit against
premiums to be used must be attached to this form.
I
certify that the above information and calculations are true and accurate to
the best of my knowledge and belief.
_______________________________________
Signature
________________________________________
Name - Please Type
________________________________________
Title - Please Type
________________________________________
Date
REPORTING FORM FOR
THE CALCULATION OF BENCHMARK
RATIO SINCE INCEPTION FOR GROUP POLICIES
FOR CALENDAR YEAR____________________
TYPE1_______________________________________________
SMSBP2_____________________________________________
For
the State of________________________________________
Company
Name_______________________________________
NAIC Group
Code_____________________________________
NAIC Company
Code__________________________________
Address_____________________________________________
Person Completing
Exhibit______________________________
Title________________________________________________
Telephone
Number____________________________________
(a)3 |
(b)4 |
(c) |
(d) |
(e) |
(f) |
(g) |
(h) |
(i) |
(j) |
(o)5 |
|
Earned |
|
|
Cumulative |
|
|
|
Cumulative |
|
Policy
Year |
Year |
Premium |
Factor |
(b)x(c) |
Loss
Ratio |
(d)x(e) |
Factor |
(b)x(g) |
Loss
Ratio |
(h)x(i) |
Loss
Ratio |
1 |
|
2.770 |
|
0.507 |
|
0.000 |
|
0.000 |
|
0.46 |
2 |
|
4.175 |
|
0.567 |
|
0.000 |
|
0.000 |
|
0.63 |
3 |
|
4.175 |
|
0.567 |
|
1.194 |
|
0.759 |
|
0.75 |
4 |
|
4.175 |
|
0.567 |
|
2.245 |
|
0.771 |
|
0.77 |
5 |
|
4.175 |
|
0.567 |
|
3.170 |
|
0.782 |
|
0.80 |
6 |
|
4.175 |
|
0.567 |
|
3.998 |
|
0.792 |
|
0.82 |
7 |
|
4.175 |
|
0.567 |
|
4.754 |
|
0.802 |
|
0.84 |
8 |
|
4.175 |
|
0.567 |
|
5.445 |
|
0.811 |
|
0.87 |
9 |
|
4.175 |
|
0.567 |
|
6.075 |
|
0.818 |
|
0.88 |
10 |
|
4.175 |
|
0.567 |
|
6.650 |
|
0.824 |
|
0.88 |
11 |
|
4.175 |
|
0.567 |
|
7.176 |
|
0.828 |
|
0.88 |
12 |
|
4.175 |
|
0.567 |
|
7.655 |
|
0.831 |
|
0.88 |
13 |
|
4.175 |
|
0.567 |
|
8.093 |
|
0.834 |
|
0.89 |
14 |
|
4.175 |
|
0.567 |
|
8.493 |
|
0.837 |
|
0.89 |
15+6 |
|
4.175 |
|
0.567 |
|
8.684 |
|
0.838 |
|
0.89 |
Total: |
|
|
(k): |
|
(l): |
|
(m): |
|
(n): |
|
Benchmark
Ratio Since Inception: (l + n)/(k + m): __________
___________________________________________
1 Individual,
Group, Individual Medicare Select, or Group Medicare Select Only.
2 "SMSBP"
= Standardized Medicare Supplement Benefit Plan - Use "P" for
pre-standardized plans
3 Year 1 is
the current calendar year - 1. Year 2 is
the current calendar year - 2 (etc.) (Example:
If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)
4 For the
calendar year on the appropriate line in column (a), the premium earned during
that year for policies issued in that year.
5 These
loss ratios are not explicitly used in computing the benchmark loss
ratios. They are the loss ratios, on a
policy year basis, which result in the cumulative loss ratios displayed on this
worksheet. They are shown here for
informational purposes only.
6 To include the earned premium for all years
prior to as well as the 15th year prior to the current year.
REPORTING FORM FOR
THE CALCULATION OF BENCHMARK
RATIO SINCE INCEPTION FOR INDIVIDUAL POLICIES
FOR CALENDAR YEAR____________________
TYPE1____________________________________________________________
SMSBP2__________________________________________________________
For
the State of_____________________________________________________
Company
Name____________________________________________________
NAIC
Group Code__________________________________________________
NAIC
Company Code_______________________________________________
Address__________________________________________________________
Person
Completing Exhibit___________________________________________
Title_____________________________________________________________
Telephone
Number_________________________________________________
(a)3 |
(b)4 |
(c) |
(d) |
(e) |
(f) |
(g) |
(h) |
(i) |
(j) |
(o)5 |
|
Earned |
|
|
Cumulative |
|
|
|
Cumulative |
|
Policy
Year |
Year |
Premium |
Factor |
(b)x(c) |
Loss
Ratio |
(d)x(e) |
Factor |
(b)x(g) |
Loss
Ratio |
(h)x(i) |
Loss
Ratio |
1 |
|
2.770 |
|
0.442 |
|
0.000 |
|
0.000 |
|
0.40 |
2 |
|
4.175 |
|
0.493 |
|
0.000 |
|
0.000 |
|
0.55 |
3 |
|
4.175 |
|
0.493 |
|
1.194 |
|
0.659 |
|
0.65 |
4 |
|
4.175 |
|
0.493 |
|
2.245 |
|
0.669 |
|
0.67 |
5 |
|
4.175 |
|
0.493 |
|
3.170 |
|
0.678 |
|
0.69 |
6 |
|
4.175 |
|
0.493 |
|
3.998 |
|
0.686 |
|
0.71 |
7 |
|
4.175 |
|
0.493 |
|
4.754 |
|
0.695 |
|
0.73 |
8 |
|
4.175 |
|
0.493 |
|
5.445 |
|
0.702 |
|
0.75 |
9 |
|
4.175 |
|
0.493 |
|
6.075 |
|
0.708 |
|
0.76 |
10 |
|
4.175 |
|
0.493 |
|
6.650 |
|
0.713 |
|
0.76 |
11 |
|
4.175 |
|
0.493 |
|
7.176 |
|
0.717 |
|
0.76 |
12 |
|
4.175 |
|
0.493 |
|
7.655 |
|
0.720 |
|
0.77 |
13 |
|
4.175 |
|
0.493 |
|
8.093 |
|
0.723 |
|
0.77 |
14 |
|
4.175 |
|
0.493 |
|
8.493 |
|
0.725 |
|
0.77 |
15+6 |
|
4.175 |
|
0.493 |
|
8.684 |
|
0.725 |
|
0.77 |
Total: |
|
|
(k): |
|
(l): |
|
(m): |
|
(n): |
|
Benchmark Ratio
Since Inception: (l + n)/(k + m): _______________
________________________________________________________
1 Individual, Group, Individual
Medicare Select, or Group Medicare Select Only.
2 "SMSBP" = Standardized Medicare
Supplement Benefit Plan - Use "P" for pre-standardized plans
3 Year 1 is the current calendar year
- 1. Year 2 is the current calendar year
- 2 (etc.) (Example: If the current year
is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)
4 For the calendar year on the
appropriate line in column (a), the premium earned during that year for
policies issued in that year.
5 These loss ratios are not explicitly
used in computing the benchmark loss ratios.
They are the loss ratios, on a policy year basis, which result in the
cumulative loss ratios displayed on this worksheet. They are shown here for informational
purposes only.
6 To include the earned premium for all
years prior to as well as the 15th year prior to the current year.
FORM
FOR REPORTING
MEDICARE SUPPLEMENT POLICIES
Company
Name: ________________________________________________
Address: ________________________________________________
________________________________________________
Phone
Number: ________________________________________________
Due March 1, annually
The
purpose of this form is to report the following information on each resident of
this state who has in force more than one Medicare supplement policy or
certificate. The information is to be
grouped by individual policyholder.
Policy and Date of
Certificate # Issuance
|
|
|
|
|
|
|
|
___________________________________
Signature
___________________________________
Name and Title (please type)
___________________________________
Date
Appendix
C.
DISCLOSURE
STATEMENTS
Instructions
for Use of the Disclosure Statements for
Health Insurance Policies Sold to Medicare Beneficiaries
that Duplicate Medicare
1. Section 1882 (d) of the federal Social
Security Act [42 U.S.C. 1395ss] prohibits the sale of a health insurance policy
(the term policy includes certificate) to Medicare beneficiaries that
duplicates Medicare benefits unless it will pay benefits without regard to a
beneficiary's other health coverage and it includes the prescribed disclosure
statement on or together with the application for the policy.
2. All types of health insurance policies that
duplicate Medicare shall include one of the attached disclosure statements, according
to the particular policy type involved, on the application or together with the
application. The disclosure statement
may not vary from the attached statements in terms of language or format (type
size, type proportional spacing, bold character, line spacing, and usage of
boxes around text).
3. State and federal law prohibits insurers from
selling a Medicare supplement policy to a person that already has a Medicare
supplement policy except as a replacement policy.
4. Property/casualty and life insurance policies
are not considered health insurance.
5. Disability income policies are not considered
to provide benefits that duplicate Medicare.
6. Long-term care insurance policies that
coordinate with Medicare and other health insurance are not considered to
provide benefits that duplicate Medicare.
7. The federal law does not preempt state laws
that are more stringent than the federal requirements.
8. The federal law does not preempt existing
state form filing requirements.
9. Section 1882 of the federal Social Security
Act was amended in Subsection (d)(3)(A) to allow for alternative disclosure
statements. The disclosure statements
already in Appendix C remain. Carriers
may use either disclosure statement with the requisite insurance product. However, carriers should use either the
original disclosure statements or the alternative disclosure statements and not
use both simultaneously.
[Original
disclosure statement for policies that provide benefits for expenses incurred
for an accidental injury only.]
Important
Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This
is not Medicare Supplement Insurance
This
insurance provides limited benefits, if you meet the policy conditions, for
hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or
coinsurance and is not a substitute for Medicare Supplement insurance.
This
insurance duplicates Medicare benefits when it pays:
hospital or medical expenses up to the maximum stated
in the policy
Medicare
generally pays for most or all of these expenses.
Medicare
pays extensive benefits for medically necessary services regardless of the
reason you need them. These include:
hospitalization
physician services
[outpatient prescription drugs if you are enrolled in
Medicare Part D]
other approved items and services
BEFORE
YOU BUY THIS INSURANCE
Ö Check the coverage in all health
insurance policies you already have.
Ö For more information about Medicare and
Medicare Supplement insurance, review the Guide to Health Insurance for
People with Medicare, available from the insurance company.
Ö For help in understanding your health
insurance, contact your state insurance department or state [health] insurance
[assistance] program [SHIP].
[Original
disclosure statement for policies that provide benefits for specified limited
services.]
Important
Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This
is not Medicare Supplement Insurance
This
insurance provides limited benefits, if you meet the policy conditions, for
expenses relating to the specific services listed in the policy. It does not pay your Medicare deductibles or
coinsurance and is not a substitute for Medicare Supplement insurance.
This
insurance duplicates Medicare benefits when:
any of the services covered by the policy are also
covered by Medicare
Medicare
pays extensive benefits for medically necessary services regardless of the
reason you need them. These include:
hospitalization
physician services
[outpatient prescription drugs if you are enrolled in
Medicare Part D]
other approved items and services
BEFORE
YOU BUY THIS INSURANCE
Ö Check the coverage in all health
insurance policies you already have.
Ö For more information about Medicare and
Medicare Supplement insurance, review the Guide to Health Insurance for
People with Medicare, available from the insurance company.
Ö For help in understanding your health
insurance, contact your state insurance department or state [health] insurance
[assistance] program [SHIP].
[Original
disclosure statement for policies that reimburse expenses incurred for
specified diseases or other specified impairments. This includes expense-incurred cancer,
specified disease and other types of health insurance policies that limit
reimbursement to named medical conditions.]
Important
Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This
is not Medicare Supplement Insurance
This
insurance provides limited benefits, if you meet the policy conditions, for hospital
or medical expenses only when you are treated for one of the specific diseases
or health conditions listed in the policy.
It does not pay your Medicare deductibles or coinsurance and is not a
substitute for Medicare Supplement insurance.
This
insurance duplicates Medicare benefits when it pays:
hospital or medical expenses up to the maximum stated
in the policy
Medicare
generally pays for most or all of these expenses.
Medicare
pays extensive benefits for medically necessary services regardless of the
reason you need them. These include:
hospitalization
physician services
hospice
[outpatient prescription drugs if you are enrolled in
Medicare Part D]
other approved items and services
BEFORE
YOU BUY THIS INSURANCE
Ö Check the coverage in all health
insurance policies you already have.
Ö For more information about Medicare and
Medicare Supplement insurance, review the Guide to Health Insurance for
People with Medicare, available from the insurance company.
Ö For help in understanding your health
insurance, contact your state insurance department or state [health] insurance
[assistance] program [SHIP].
[Original
disclosure statement for policies that pay fixed dollar amounts for specified
diseases or other specified impairments.
This includes cancer, specified disease, and other health insurance
policies that pay a scheduled benefit or specific payment based on diagnosis of
the conditions named in the policy.]
Important
Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This
is not Medicare Supplement Insurance
This
insurance pays a fixed amount, regardless of your expenses, if you meet the
policy conditions, for one of the specific diseases or health conditions named
in the policy. It does not pay your
Medicare deductibles or coinsurance and is not a substitute for Medicare
Supplement insurance.
This
insurance duplicates Medicare benefits because Medicare generally pays for most
of the expenses for the diagnosis and treatment of the specific conditions or
diagnoses named in the policy.
Medicare
pays extensive benefits for medically necessary services regardless of the
reason you need them. These include:
hospitalization
physician services
hospice
[outpatient prescription drugs if you are enrolled in
Medicare Part D]
other approved items and services
BEFORE
YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance
policies you already have.
Ö For more information about Medicare and
Medicare Supplement insurance, review the Guide to Health Insurance for
People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance,
contact your state insurance department or state [health] insurance
[assistance] program [SHIP].
[Original
disclosure statement for indemnity policies and other policies that pay a fixed
dollar amount per day, excluding long-term care policies.]
Important
Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This
is not Medicare Supplement Insurance
This
insurance pays a fixed dollar amount, regardless of your expenses, for each day
you meet the policy conditions. It does
not pay your Medicare deductibles or coinsurance and is not a substitute for
Medicare Supplement insurance.
This
insurance duplicates Medicare benefits when:
any expenses or services covered by the policy are
also covered by Medicare
Medicare
generally pays for most or all of these expenses.
Medicare
pays extensive benefits for medically necessary services regardless of the
reason you need them. These include:
hospitalization
physician services
[outpatient prescription drugs if you are enrolled in
Medicare Part D]
hospice
other approved items and services
BEFORE
YOU BUY THIS INSURANCE
Ö Check the coverage in all health
insurance policies you already have.
Ö For more information about Medicare and
Medicare Supplement insurance, review the Guide to Health Insurance for People
with Medicare, available from the insurance company.
Ö For help in understanding your health
insurance, contact your state insurance department or state [health] insurance
[assistance] program [SHIP].
[Original
disclosure statement for policies that provide benefits upon both an
expense-incurred and fixed indemnity basis.]
Important
Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This
is not Medicare Supplement Insurance
This
insurance pays limited reimbursement for expenses if you meet the conditions
listed in the policy. It also pays a fixed amount, regardless of your expenses,
if you meet other policy conditions. It does not pay your Medicare deductibles
or coinsurance and is not a substitute for Medicare Supplement insurance.
This
insurance duplicates Medicare benefits when:
any expenses or services covered by the policy are
also covered by Medicare; or
it pays the fixed dollar amount stated in the policy
and Medicare covers the same event
Medicare
generally pays for most or all of these expenses.
Medicare
pays extensive benefits for medically necessary services regardless of the
reason you need them. These include:
hospitalization
physician services
hospice care
[outpatient prescription drugs if you are enrolled in
Medicare Part D]
other approved items & services
BEFORE
YOU BUY THIS INSURANCE
Ö Check the coverage in all health
insurance policies you already have.
Ö For more information about Medicare and
Medicare Supplement insurance, review the Guide to Health Insurance for
People with Medicare, available from the insurance company.
Ö For help in understanding your health
insurance, contact your state insurance department or state [health] insurance
[assistance] program [SHIP].
[Original
disclosure statement for other health insurance policies not specifically identified
in the preceding statements.]
Important
Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This
is not Medicare Supplement Insurance
This
insurance provides limited benefits if you meet the conditions listed in the
policy. It does not pay your Medicare
deductibles or coinsurance and is not a substitute for Medicare Supplement
insurance.
This
insurance duplicates Medicare benefits when it pays:
the benefits stated in the policy and coverage for the
same event is provided by Medicare
Medicare
generally pays for most or all of these expenses.
Medicare
pays extensive benefits for medically necessary services regardless of the
reason you need them. These include:
hospitalization
physician services
hospice
[outpatient prescription drugs if you are enrolled in
Medicare Part D]
other approved items and services
BEFORE
YOU BUY THIS INSURANCE
Ö Check the coverage in all health
insurance policies you already have.
Ö For more information about Medicare and
Medicare Supplement insurance, review the Guide to Health Insurance for People
with Medicare, available from the insurance company.
Ö For help in understanding your health
insurance, contact your state insurance department or state [health] insurance
[assistance] program [SHIP].
[Alternative
disclosure statement for policies that provide benefits for expenses incurred
for an accidental injury only.]
Important
Notice to Persons on Medicare
This Is Not Medicare Supplement Insurance
Some
health care services paid for by Medicare may also trigger the payment of
benefits from this policy.
This
insurance provides limited benefits, if you meet the policy conditions, for
hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or
coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare
generally pays for most or all of these expenses.
Medicare
pays extensive benefits for medically necessary services regardless of the reason
you need them. These include:
hospitalization
physician services
[outpatient prescription drugs if you are enrolled in
Medicare Part D]
other approved items and services
This
policy must pay benefits without regard to other health benefit coverage to
which you may be entitled under Medicare or other insurance.
BEFORE
YOU BUY THIS INSURANCE
Ö Check the coverage in all health
insurance policies you already have.
Ö For more information about Medicare and
Medicare Supplement insurance, review the Guide to Health Insurance for
People with Medicare, available from the insurance company.
Ö For help in understanding your health
insurance, contact your state insurance department or state [health] insurance
[assistance] program [SHIP].
[Alternative
disclosure statement for policies that provide benefits for specified limited
services.]
Important Notice to Persons on
Medicare
This Is Not Medicare Supplement Insurance
Some
health care services paid for by Medicare may also trigger the payment of
benefits under this policy.
This
insurance provides limited benefits, if you meet the policy conditions, for
expenses relating to the specific services listed in the policy. It does not pay your Medicare deductibles or
coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare
pays extensive benefits for medically necessary services regardless of the
reason you need them. These include:
hospitalization
physician services
[outpatient prescription drugs if you are enrolled in
Medicare Part D]
other approved items and services
This
policy must pay benefits without regard to other health benefit coverage to
which you may be entitled under Medicare or other insurance.
BEFORE
YOU BUY THIS INSURANCE
Ö Check the coverage in all health
insurance policies you already have.
Ö For more information about Medicare and
Medicare Supplement insurance, review the Guide to Health Insurance for People
with Medicare, available from the insurance company.
Ö For help in understanding your health
insurance, contact your state insurance department or state [health] insurance
[assistance] program [SHIP].
[Alternative
disclosure statement for policies that reimburse expenses incurred for
specified diseases or other specified impairments. This includes expense-incurred cancer,
specified disease and other types of health insurance policies that limit
reimbursement to named medical conditions.]
Important
Notice to Persons
on Medicare
This Is Not Medicare Supplement Insurance
Some
health care services paid for by Medicare may also trigger the payment of
benefits from this policy. Medicare generally
pays for most or all of these expenses.
This
insurance provides limited benefits, if you meet the policy conditions, for
hospital or medical expenses only when you are treated for one of the specific
diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or
coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare
generally pays for most or all of these expenses.
Medicare
pays extensive benefits for medically necessary services regardless of the
reason you need them. These include:
hospitalization
physician services
hospice
[outpatient prescription drugs if you are enrolled in
Medicare Part D]
other approved items and services
This
policy must pay benefits without regard to other health benefit coverage to
which you may be entitled under Medicare or other insurance.
BEFORE
YOU BUY THIS INSURANCE
Ö Check the coverage in all health
insurance policies you already have.
Ö For more information about Medicare and
Medicare Supplement insurance, review the Guide to Health Insurance for People
with Medicare, available from the insurance company.
Ö For help in understanding your health
insurance, contact your state insurance department or state [health] insurance
[assistance] program [SHIP].
[Alternative
disclosure statement for policies that pay fixed dollar amounts for specified
diseases or other specified impairments.
This includes cancer, specified disease, and other health insurance
policies that pay a scheduled benefit or specific payment based on diagnosis of
the conditions named in the policy.]
Important
Notice to Persons on Medicare
This Is Not Medicare Supplement Insurance
Some
health care services paid for by Medicare may also trigger the payment of
benefits from this policy.
This
insurance pays a fixed amount, regardless of your expenses, if you meet the
policy conditions, for one of the specific diseases or health conditions named
in the policy. It does not pay your
Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement
insurance.
Medicare
pays extensive benefits for medically necessary services regardless of the
reason you need them. These include:
hospitalization
physician services
hospice
[outpatient prescription drugs if you are enrolled in
Medicare Part D]
other approved items and services
This
policy must pay benefits without regard to other health benefit coverage to
which you may be entitled under Medicare or other insurance.
BEFORE
YOU BUY THIS INSURANCE
Ö Check the coverage in all health
insurance policies you already have.
Ö For more information about Medicare and
Medicare Supplement insurance, review the Guide to Health Insurance for People
with Medicare, available from the insurance company.
Ö For help in understanding your health
insurance, contact your state insurance department or state [health] insurance
[assistance] program [SHIP].
[Alternative
disclosure statement for indemnity policies and other policies that pay a fixed
dollar amount per day, excluding long-term care policies.]
Important
Notice to Persons on Medicare
This Is Not Medicare Supplement Insurance
Some
health care services paid for by Medicare may also trigger the payment of
benefits from this policy.
This
insurance pays a fixed dollar amount, regardless of your expenses, for each day
you meet the policy conditions. It does
not pay your Medicare deductibles or coinsurance and is not a substitute for
Medicare Supplement insurance.
Medicare
generally pays for most or all of these expenses.
Medicare
pays extensive benefits for medically necessary services regardless of the
reason you need them. These include:
hospitalization
physician services
hospice
[outpatient prescription drugs if you are enrolled in
Medicare Part D]
other approved items and services
This
policy must pay benefits without regard to other health benefit coverage to
which you may be entitled under Medicare or other insurance.
BEFORE
YOU BUY THIS INSURANCE
Ö Check the coverage in all health
insurance policies you already have.
Ö For more information about Medicare and
Medicare Supplement insurance, review the Guide to Health Insurance for
People with Medicare, available from the insurance company.
Ö For help in understanding your health
insurance, contact your state insurance department or state [health] insurance
[assistance] program [SHIP].
[Alternative
disclosure statement for policies that provide benefits upon both an
expense-incurred and fixed indemnity basis.]
Important
Notice to Persons on Medicare
This Is Not Medicare Supplement Insurance
Some
health care services paid for by Medicare may also trigger the payment of
benefits from this policy.
This
insurance pays limited reimbursement for expenses if you meet the conditions
listed in the policy. It also pays a fixed amount, regardless of your expenses,
if you meet other policy conditions. It does not pay your Medicare deductibles
or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare
generally pays for most or all of these expenses.
Medicare
pays extensive benefits for medically necessary services regardless of the
reason you need them. These include:
hospitalization
physician services
hospice care
[outpatient prescription drugs if you are enrolled in
Medicare Part D]
other approved items & services
This
policy must pay benefits without regard to other health benefit coverage to
which you may be entitled under Medicare or other insurance.
BEFORE
YOU BUY THIS INSURANCE
Ö Check the coverage in all health
insurance policies you already have.
Ö For more information about Medicare and
Medicare Supplement insurance, review the Guide to Health Insurance for
People with Medicare, available from the insurance company.
Ö For help in understanding your health
insurance, contact your state insurance department or state [health] insurance
[assistance] program [SHIP].
[Alternative
disclosure statement for other health insurance policies not specifically
identified in the preceding statements.]
Important
Notice to Persons on Medicare
This Is Not Medicare Supplement Insurance
Some
health care services paid for by Medicare may also trigger the payment of
benefits from this policy.
This
insurance provides limited benefits if you meet the conditions listed in the
policy. It does not pay your Medicare
deductibles or coinsurance and is not a substitute for Medicare Supplement
insurance.
Medicare
generally pays for most or all of these expenses.
Medicare
pays extensive benefits for medically necessary services regardless of the
reason you need them. These include:
hospitalization
physician services
hospice
[outpatient prescription drugs if you are enrolled in
Medicare Part D]
other approved items and services
This
policy must pay benefits without regard to other health benefit coverage to
which you may be entitled under Medicare or other insurance.
BEFORE
YOU BUY THIS INSURANCE
Ö Check the coverage in all health
insurance policies you already have.
Ö For more information about Medicare and
Medicare Supplement insurance, review the Guide to Health Insurance for People
with Medicare, available from the insurance company.
Ö For help in understanding your health
insurance, contact your state insurance department or state [health] insurance
[assistance] program [SHIP].
PART Ins 1906
DISCONTINUANCE AND REPLACEMENT OF GROUP ACCIDENT AND HEALTH COVERAGE – EXPIRED
Source. (See Revision Note at chapter heading for Ins
6100)
PART Ins 1907
NONDISCRIMINATION IN HEALTH INSURANCE COVERAGE IN THE GROUP MARKET
Statutory
Authority: RSA 400-A:15, II.
Ins
1907.01 Purpose and Scope.
(a)
The purpose of this chapter is to incorporate the requirements set forth
in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and
federal regulations that prohibit carriers providing health insurance coverage under a health benefit plan in the group
market from discriminating against individual participants or beneficiaries in
these plans with respect to plan eligibility and in setting premium and
contribution rates based on any health factor of the participants or
beneficiaries.
(b)
This chapter shall apply to any carrier that
provides coverage under a health benefit plan in the group market.
Source. #8607, eff 4-17-06, EXPIRED: 4-17-14
Ins 1907.02 Definitions. As used in this chapter:
(a)
"Affiliation period" means a period of time that shall expire
before health insurance coverage provided by a carrier becomes effective, and during which the carrier is not required to
provide benefits.
(b)
"Beneficiary"
has the meaning stated in Section 3(8) of the Employee Retirement Income
Security Act of 1974 (ERISA).
(c)
"Carrier" means an entity subject to the insurance laws and
rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to provide, deliver,
arrange for, pay for or reimburse any of the costs of health care
services. For the purposes of this
chapter, carrier includes a sickness and accident insurance company, a
nonprofit hospital and health service corporation, a health maintenance
organization, and any other entity providing a plan of health insurance or
health benefits subject to state insurance regulation.
(d)
"Commissioner" means the insurance commissioner of this state.
(e)
"Creditable coverage" means:
(1) With respect to an individual, health
benefits or coverage provided under any of the following:
a. A group health plan;
b. A health benefit plan;
c. Part A or Part B of Title XVIII of the Social
Security Act (Medicare);
d. Title XIX of the Social Security Act
(Medicaid), other than coverage consisting solely of benefits under Section
1928 (the program for distribution of pediatric vaccines);
e. Chapter 55 of Title 10, United States Code
(medical and dental care for members and certain former members of the
uniformed services and for their dependents).
For purposes of Chapter 55 of Title 10, U.S.C., "uniformed
services" means the armed forces and the Commissioned Corps of the
National Oceanic and Atmospheric Administration and of the Public Health
Service);
f. A medical care program of the Indian Health
Service or of a tribal organization;
g. A state health benefits risk pool;
h. A health plan offered under Chapter 89 of Title
5, United States Code (Federal Employees Health Benefits Program (FEHBP));
i. A public health plan, which for purposes of
this chapter, means a plan established or maintained by a state, county, or
other political subdivision of a state that provides health insurance coverage
to individuals enrolled in the plan; or
j. A health benefit plan under Section 5 (e) of
the Peace Corps Act (22 U.S.C. 2504 (e)).
(2) A period of creditable coverage shall not be
counted, with respect to enrollment of an individual under a group health plan,
if, after such period and before the enrollment date, the individual
experiences a significant break in coverage.
(f)
"Dependent" means a spouse, an unmarried child under the age
of 19, an unmarried child who is a full-time student under the age of 25 and
who is financially dependent upon the participant, and an unmarried child of
any age who is medically certified as disabled and dependent upon the
participant.
(g)
"Enrollment date" means the first day of coverage or, if there
is a waiting period, the first day of the waiting period, whichever is earlier.
(h)
"Genetic information" means:
(1) Information about genes, gene products and
inherited characteristics that may derive from the individual or a family member;
(2) Information regarding an individual's carrier
status and information derived from laboratory tests that identify mutations in
specific genes or chromosomes, physical medical examinations, family histories
and direct analysis of genes or chromosomes.
(i)
"Group health plan" means:
(1) An employee welfare benefit plan, as defined
in Section 3(1) of ERISA, to the extent that the plan provides medical care and
including items and services paid for as medical care to employees or their
dependents as defined under the terms of the plan directly or through
insurance, reimbursement, or otherwise.
(2) For the purposes of this chapter:
a. Any plan, fund or program that would not be,
but for PHSA Section 2721(e), as added by Pub. L. No. 104-191, an employee
welfare benefit plan and that is established or maintained by a partnership, to
the extent that the plan, fund or program provides medical care, including items
and services paid for as medical care, to present or former partners in the
partnership, or to their dependents, as defined under the terms of the plan,
fund or program, directly or through insurance, reimbursement or otherwise,
shall be treated, subject to subparagraph b. of this paragraph, as an employee
welfare benefit plan that is a group health plan;
b. In the case of a group health plan, the term
"employer" also includes the partnership in relation to any partner;
and
c. In the case of a group health plan, the term
"participant," as defined in subsection (g) below, also includes an
individual who is, or may become, eligible to receive a benefit under the plan,
or the individual's beneficiary who is, or may become, eligible to receive a benefit
under the plan, if:
1. In connection with a group health plan
maintained by a partnership, the individual is a partner in relation to the
partnership; or
2. In connection with a group health plan
maintained by a self-employed individual, under which, one or more employees
are participants, the individual is the self-employed individual.
(j)
"Health benefit plan" means:
(1) A policy, contract, certificate or agreement
offered or issued by a carrier to provide, deliver, arrange for, pay for or
reimburse any of the costs of health care services.
(2) Short-term and catastrophic health insurance
policies, and a policy that pays on a cost-incurred basis, except as otherwise
specifically exempted in this definition.
(k) "Health benefit plan" shall not
include:
(1) One or more, or any combination of, the
following:
a. Coverage only for accident, or disability
income insurance, or any combination thereof;
b. Liability insurance, including general
liability insurance and automobile liability insurance;
c. Coverage issued as a supplement to liability
insurance;
d. Workers' compensation or similar insurance;
e. Automobile medical payment insurance;
f. Credit-only insurance;
g. Coverage for on-site medical clinics; and
h. Other similar insurance coverage, specified
in federal regulations issued pursuant to Pub. L. No. 104-191, under which
benefits for medical care are secondary or incidental to other insurance
benefits.
(2) The following benefits if they are provided
under a separate policy, certificate or contract of insurance or are otherwise
not an integral part of the plan:
a. Limited scope dental or vision benefits;
b. Benefits for long-term care, nursing home
care, home health care, community-based care, or any combination thereof; or
c. Other similar, limited benefits specified in
federal regulations issued pursuant to Pub. L. No. 104-191.
(3) The following benefits if the benefits are
provided under a separate policy, certificate or contract of insurance, there
is no coordination between the provision of the benefits and any exclusion of
benefits under a group health plan maintained by the same plan sponsor, and the
benefits are paid with respect to an event without regard to whether benefits
are provided with respect to such an event under a group health plan maintained
by the same plan sponsor:
a. Coverage only for a specified disease or
illness; or
b. Hospital indemnity or other fixed indemnity
insurance.
(4) The following if offered as a separate
policy, certificate or contract of insurance:
a. Medicare supplemental health insurance as
defined in Section 1882(g)(1) of the Social Security Act;
b. Coverage supplemental to the coverage
provided under Chapter 55 of Title 10, United States Code; or
c. Similar supplemental coverage provided to
coverage under a group health plan.
(l)
"Health care
services" means services for the diagnosis, prevention, treatment, cure or
relief of a medical condition,
illness, injury or disease.
(m)
"Health maintenance organization" means a person that
undertakes to provide or arrange for the delivery of health care services to
enrollees on a prepaid basis, except for enrollee responsibility for copayments
or deductibles or both.
(n)
"Health factor"
means:
(1) In relation to an individual, any of the
following health status-related factors:
a. Health status;
b. Medical condition, including both physical
and mental illnesses, as defined in subsection (p) below;
c. Claims experience;
d. Receipt of health care;
e. Medical history;
f. Genetic information;
g. Evidence of insurability, including:
1. Conditions arising out of acts of domestic
violence; or
2. Participation in activities, such as motorcycling,
snowmobiling, all-terrain vehicle riding, horseback riding, skiing, and other
similar activities; or
h. Disability.
(2) For purposes of this subsection, "health
factor" does not include the decision whether to elect health insurance
coverage, including the time chosen to enroll, such as under special enrollment
or late enrollment.
(o)
"Medical care"
means amounts paid for:
(1) The diagnosis, care, mitigation, treatment or
prevention of disease, or amounts paid for the purpose of affecting any
structure or function of the body;
(2) Transportation primarily for and essential to
medical care referred to in subparagraph (1); and
(3) Insurance covering medical care referred to
in subparagraphs (1) and (2).
(p)
"Medical
condition" means:
(1) Any condition, whether physical or mental,
including any condition resulting from illness, injury, accident, pregnancy or
congenital malformation;
(2) For the purposes of subparagraph (1), genetic
information is not a condition.
(q)
"Participant" has the meaning stated in Section 3(7) of ERISA.
(r)
"Preexisting condition" means a condition, regardless of the
cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during
the 3 months immediately preceding the enrollment date of the coverage.
(s)
"Preexisting condition"
shall not mean:
(1) A condition for which medical advice,
diagnosis, care or treatment was recommended or received for the first time
while the covered person held creditable coverage and that was a covered
benefit under the health benefit plan, provided that the prior creditable
coverage was continuous to a date not more than 90 days prior to the enrollment
date of the new coverage; or
(2) Genetic information which shall not be
treated as a condition under paragraph (r) for which a preexisting condition
exclusion may be imposed in the absence of a diagnosis of the condition related
to the information.
(t)
"Significant break in coverage" means a period of 90
consecutive days during all of which the individual does not have any creditable coverage, except that
neither a waiting period nor an affiliation period is taken into account in
determining a significant break in coverage.
(u)
"Waiting period" means, with respect to a health benefit plan
and an individual, who is a potential enrollee in the plan, the period that shall pass with respect to
the individual before the individual is eligible to be covered for benefits under
the terms of the plan. For purposes of
calculating periods of creditable coverage pursuant to (e)(2) above, a waiting
period shall not be considered a gap in coverage.
Source. #8607, eff 4-17-06, EXPIRED: 4-17-14
Ins 1907.03 Prohibited
Discrimination in Rules for Eligibility.
(a)
A carrier subject to this chapter shall not establish a rule for
eligibility, including continued eligibility, of an individual to enroll for benefits under the plan that
discriminates based on any health factor that relates to the individual or
dependent of the individual.
(b)
For purposes of this section, rules of eligibility includes rules
relating to:
(1) Enrollment;
(2)
The effective date of coverage;
(3) Waiting or affiliation periods;
(4) Late and special enrollment;
(5) Eligibility for benefit packages, including
rules for individuals to change their selection among benefit packages;
(6) Benefits, including rules relating to covered
benefits, benefit restrictions, and cost-sharing mechanisms, such as
coinsurance, copayments and deductibles as described in Ins 1907.05 (a) and (b)
of this chapter;
(7) Continued eligibility; and
(8) Terminating coverage, including
disenrollment, of an individual under the plan.
(c)
Nothing in this section prohibits a carrier subject to this chapter
from:
(1) Establishing more favorable rules of eligibility
for individuals with an adverse health factor, such as disability, than for
individuals without the adverse health factor; or
(2) Subject to state law, charging a higher
premium or contribution with respect to an individual with an adverse health
factor if the individual would not be eligible for coverage, but for the
adverse health factor.
Source. #8607, eff 4-17-06, EXPIRED: 4-17-14
Ins 1907.04 Prohibited Discrimination in Premium and Contribution
Rates.
(a)
A carrier subject to this
chapter shall:
(1) Not require an individual, as a condition of
enrollment or continued enrollment under the plan, to pay a premium or
contribution rate that is greater than the premium or contribution rate for a
similarly situated individual enrolled in the plan based on any health factor
that relates to the individual or a dependent of the individual.
(2) Take into account, in determining an
individual's premium or contribution rate, discounts, rebates, payments-in-kind
and any other premium differential mechanisms.
(b)
Nothing in this section restricts the aggregate amount that a carrier
subject to this chapter may charge an employer for coverage under a plan. However, a carrier subject to this chapter
shall not quote or charge an employer or an individual participant or
beneficiary a different premium than that quoted or charged an individual in a
group of similarly situated individuals based on a health factor unless
permitted under Ins 1907.03 (c) or (d) below.
(d)
Notwithstanding (a) and (b) above, a carrier subject to this chapter may
establish a premium or contribution differential
based on whether an individual has complied with the requirements of a bona
fide wellness program.
(e)
Nothing in this section prohibits a carrier subject to this chapter from
charging an individual a premium or contribution
rate that is less than the premium or contribution rate for similarly situated
individuals if the lower charge is based on an adverse health factor of the
individual, such as a disability.
Source. #8607, eff 4-17-06, EXPIRED: 4-17-14
Ins 1907.05 Application of Ins 1907.03 to Plan Benefits;
Preexisting Condition Exclusions; Similarly Situated Individuals.
(a)
Subject to (b) and (c) below, Ins 1907.03 does not require a carrier
subject to this chapter to provide coverage for any particular benefit to any
group of similarly situated individuals.
(1) A carrier subject to this chapter shall make
the benefits provided under a plan available uniformly to all similarly
situated individuals, as those groups are determined under (c) below.
a. For any restriction on a benefit or benefits
provided under a plan, a carrier subject to this chapter:
1. Shall apply the restriction uniformly to all
similarly situated individuals; and
2. Shall not direct the restriction, as
determined based on all of the relevant facts and circumstances, at individual
participants or beneficiaries based on any health factor of the participants or
beneficiaries.
b. A carrier subject to this chapter may impose
annual, lifetime or other limits on benefits and may require a deductible,
copayment, coinsurance or other cost-sharing requirement in order to obtain a
benefit under the plan if the limit or cost-sharing requirement:
1. Applies uniformly to all similarly situated
individuals; and
2. Is not directed at individual participants or
beneficiaries based on any health factor of the participants or beneficiaries.
c. For purposes of (a), a plan amendment
applicable to all individuals in one or more groups of similarly situated
individuals under the plan and made effective no earlier than the first day of
the first plan year after the amendment is adopted is not considered to be
directed at any individual participants or beneficiaries.
(2) If a carrier subject to this chapter
generally provides benefits for a type of injury, the plan or carrier shall not
deny an individual participant or beneficiary benefits otherwise provided under
the plan for treatment of the injury if the injury results from an act of
domestic violence or a medical condition.
(3) A carrier subject to this chapter with a
cost-sharing mechanism, such as a deductible, copayment or coinsurance, that
requires a higher payment from an individual, based on a health factor of that
individual or dependent of that individual, than for a similarly situated
individual under the plan, does not violate this section if the payment
differential is based on whether the individual has complied with the
requirements of a bona fide wellness program.
(b)
Ins 1907.03 does not prohibit a carrier subject to this chapter from
imposing a preexisting condition exclusion period if:
(1) The preexisting exclusion period:
a. Complies with the requirements for imposing a
preexisting condition exclusion period established by federal regulation;
b. Is applied uniformly to all similarly
situated individuals, as those groups are determine under (d) below; and
c. Is not directed at individual participants or
beneficiaries based on any health factor of the participants or beneficiaries.
(2) For purposes of this subsection, a plan
amendment relating to a preexisting condition exclusion that is applicable to
all individuals in one or more groups of similarly situated individuals under
the plan and made effective no earlier than the first day of the first plan
year after the amendment is adopted is not considered to be directed at any
individual participants or beneficiaries.
(c)
This subsection applies only within a group of individuals who are
treated as similarly situated individuals, so that:
(1) Subject to (4) below of this subsection, Ins
1907.03 does not prohibit a carrier subject to this chapter from treating
participants as 2 or more distinct groups of similarly situated individuals if
the distinction made between or among groups of participants is based on a bona
fide employment-based classification that is consistent with the employer's
usual business practice.
a. Whether an employment-based classification is
bona fide shall be determined based on all of the relevant facts and circumstances.
b. For purposes of 1. a. above, relevant facts
and circumstances include whether the employer uses the classification for
purposes independent of qualification for health coverage, such classifications
may include:
1. Full-time versus part-time status;
2. Geographic location;
3. Membership in a collective bargaining unit;
4. Date of hire;
5. Length of service;
6. Current employee versus former employee
status; and
7. Occupation.
c. A classification based on a health factor
shall not be determined to be a bona fide employment-based classification for
purposes of this subjection unless the requirements of Ins 1907.03 (c) and Ins
1907.04 (e) are satisfied.
(2) Subject to subparagraph (4) of this
subsection, Ins 1907.03 does not prohibit a carrier subject to this chapter
from treating beneficiaries as 2 or more distinct groups of similarly situated
individuals if the distinction is made between or among the groups of
beneficiaries is based on any of the following factors:
a. A bona fide employment-based classification
of the participant through whom the beneficiary is receiving coverage;
b. Relationship to the participant (e.g., as a spouse
or as a dependent child);
c. Marital status;
d. With respect to a child of the participant,
age or student status; or
e. Any other factor, if the factor is not a
health factor.
(3) Subparagraph (1) above shall not be
construed to prevent a carrier subject to this chapter from providing more
favorable treatment of individuals under the plan with adverse health factors
in accordance with Ins 1907.03 (c) and Ins 1907.04 (e).
(4) Notwithstanding subparagraphs (1) and (2) of this subsection,
unless permitted under Ins 1907.03 (c) and Ins 1907.04 (e), if the creation
or modification of an employment or coverage classification is directed at
individual participants or beneficiaries based on a health factor of the
participants or beneficiaries, the classification is not permitted under this
subsection.
Source. #8607, eff 4-17-06, EXPIRED: 4-17-14
Ins 1907.06 Application of Ins 1907.03 and Ins 1907.04 to
Nonconfinement and Actively-at-Work Provisions.
(a)
Except to the extent permitted under (b)(2) or (c) below, in accordance
with Ins 1907.03 and Ins 1907.04, a carrier subject to this chapter shall not
establish a rule of eligibility or set an individual's premium or contribution
rate based on:
(1) Whether the individual is confined in a
hospital or other health care institution; or
(2) The individual's ability to engage in normal
life activities.
(b)
In accordance with Ins
1907.03 and Ins 1907.04:
(1) A carrier subject to this chapter shall not
establish a rule for eligibility or set an individual's premium or contribution
rate based on whether the individual is actively-at-work, including whether an
individual is continuously employed, unless absence from work due to any health
factor is treated, for purposes of the plan, as being actively-at-work.
(2) Notwithstanding subparagraph (1) above, a
carrier subject to this chapter may establish a rule for eligibility that
requires an individual to begin work for the employer sponsoring the plan
before coverage under the plan becomes effective if the rule for eligibility
applies regardless of the reasons for the absence.
(c)
Notwithstanding paragraphs (a) and (b) above, a carrier subject to this
chapter may establish a rule of eligibility or set an individual's premium or
contribution rate with respect to similarly situated individuals, as those
groups are determined under Ins 1907.05 (d).
Source. #8607, eff 4-17-06, EXPIRED: 4-17-14
Ins 1907.07 Enforcement.
(a)
The commissioner shall conduct a reasonable investigation based on a
complaint received by the commissioner and issue a prompt determination as to
whether a violation of this chapter may have occurred.
(b)
If the commissioner finds from the investigation that a violation of
this chapter may have occurred, the commissioner shall promptly begin an
adjudicatory proceeding.
(c) The commissioner may address a violation of
this chapter through means appropriate to the nature and extent of the
violation, which may include suspension or revocation of certificates of
authority or licenses, imposition of civil penalties, issuance of cease and
desist orders, injunctive relief, a requirement for restitution, referral to
prosecutorial authorities or any combination of these.
(d)
The powers and duties set forth in this section are in addition to all
other authority of the commissioner.
Source. #8607, eff 4-17-06, EXPIRED: 4-17-14
Part Ins 1908
Coverage for Individuals Under the Age of 19
Authority: RSA 400-A:15
Ins 1908.01 Purpose. The purpose of this part is to authorize the
New Hampshire Individual Health Plan Benefit Association, an existing entity
established pursuant to RSA 404-G, to operate a new mechanism for risk
adjustment and subsidization to assist health carriers who have issued
individual health insurance policies on or after September 23, 2010 to children
under the age of 19, as required by federal law.
Source. #10023, eff 11-14-11
Ins 1908.02 Scope and Applicability. The requirements of this part shall apply to
writers of individual health insurance that are subject to the association's
plan of operation under RSA 404-G:5.
Source. #10023, eff 11-14-11
Ins 1908.03 Definitions. The definitions in RSA 404-G:2 shall be
applicable to this part, except insofar as a defined term is clarified below:
(a)
"Association" means the New Hampshire Individual Health Plan
Benefit Association, established under RSA 404-G:4.
(b)
"Board" means the association's board of directors.
(c)
"Carrier" means any entity licensed to provide health
insurance in this state, including an insurance company, a group hospital or
medical service corporation, a fraternal benefit society, a health maintenance
organization, an organized delivery system, or any other entity providing
health insurance subject to state insurance regulation.
(d)
"Child-only policies" means individual health insurance
policies issued to persons under 19 years of age.
Source. #10023, eff 11-14-11
Ins 1908.04 Risk Adjustment and Subsidization.
(a)
Risks shall be shared as follows:
(1) Sharing shall be implemented through a risk
adjustment and subsidization mechanism whereby all carriers will subsidize
losses of certain carriers issuing individual health insurance policies to
persons under 19 years old;
(2) Only individual policies with an age rating
factor equal to or lower than the lowest applicable age factor for ages 19 and
over, and issued directly to persons under
19 years old, shall be eligible for subsidy.
For example, persons under 19
years old provided coverage under a family policy issued in the individual
market shall not be eligible for subsidy.
(3) Only individual policies issued with the
maximum allowable health status factor shall be eligible for subsidy; and
(4) Only policies issued on or after September
23, 2010, the date on which carriers were required under federal law to issue
individual policies to persons under 19 years old, shall be eligible for
subsidy.
(b)
The subsidy eligibility calculation shall be performed as follows:
(1) Except as provided in Ins 1908.06, subsidy calculation shall be for
experience incurred during a calendar year;
(2) For purposes of the subsidy calculation, the
following additional definitions shall apply:
a. "Subsidizable incurred claims"
means claims incurred on subsidy eligible policies during the experience period
and paid through the reporting date;
b. "Subsidizable gross earned premium"
means earned premium accrued during the experience period from subsidy eligible
policies; and
c. "Experience period net premium" means
subsidizable earned premium times 0.90 less the smaller of:
1. 0.06
times subsidizable incurred claims; or
2. 0.09
times subsidizable gross earned premium;
(3) The subsidy shall be based on the amount by
which subsidizable incurred claims (SIC) exceed the experience period net
premium (EPNP);
(4) The subsidy shall be calculated by adding the
following:
a. 97 percent of SIC above 100 percent of EPNP
up to 140 percent of EPNP;
b. 93 percent of SIC above 140 percent of EPNP
up to 170 percent of EPNP;
c. 85 percent of SIC above 170 percent of EPNP
up to 190 percent of EPNP; and
d. 75 percent of SIC above 190 percent of EPNP;
(5) Carriers eligible for risk sharing as
described in (a) above shall be eligible for a subsidy based upon experience of
the prior calendar year provided that such carrier was actively marketing
individual health insurance child-only policies during the experience period.
(c)
Applications for a subsidy
shall be made as follows:
(1) On or before July 1 of each year, each
eligible carrier wishing to apply for a subsidy with respect to the prior
year's experience shall make application to the association, including in the
application all data required under Ins 1908.04(b) and a calculation of the
anticipated amount of the subsidy; and
(2) A carrier that has made application, while an
eligible carrier pursuant to (1) above, for a subsidy with respect to the prior
calendar year's experience, may submit a corrective application for a
corrective subsidy determination and payment based upon additional experience
for that calendar year. Such corrective
application may be submitted only once, shall be filed not later than 12 months
after the July 1 date for initial application, and shall be completed and
contain data with respect to its
experience in this market during the current calendar year. A carrier shall not need to be an eligible
carrier at the time of such corrective application or at the time of receipt of
any corrective subsidy payment.
(3) Any errors in the subsidy application shall
be reported to the board immediately upon discovery.
Source. #10023, eff 11-14-11
Ins 1908.05 Assessment and Disbursement Plans.
(a)
Each year, the board shall specify its assessment and disbursement plans
for eligible subsidies under this part.
The assessment and disbursement plans shall each be considered
amendments to the association's plan of operations pursuant to RSA 404-G:5 and
shall conform to all applicable requirements of RSA 404-G.
(b)
The board's assessment plan shall apply to all association members and
shall be calculated to provide sufficient revenue to cover actuarial
projections of anticipated subsidies, calculated in accordance with this part.
(c)
The board's disbursement plan shall:
(1) Add available funds remaining from the prior
year to anticipated current year assessments, investment income and experience
period subsidies;
(2) Subtract anticipated expenses, including
windup expenses; and
(3) From the remaining funds, calculate subsidies
in accordance with Ins 1908.04(b) for eligible carriers, including prior
unfunded experience period subsidies, based on the applications and experience
data submitted by carriers.
(d)
The board shall notify subsidy eligible carriers of the disbursement
plan no later than November 1 of each year.
(e)
The board shall collect assessments in accordance with its assessment
plan and make payments in accordance with its disbursement plan.
Source. #10023, eff 11-14-11
Ins 1908.06 Initial Subsidy Period.
(a)
The initial subsidy period shall be for claims incurred during the
experience period from September 23, 2010 through December 31, 2011 for
individual health insurance child-only policies that meet the requirements of
Ins 1908.04.
(b)
Applications for the initial subsidy period shall be due July 1, 2012.
(c)
Payment of initial subsidies shall be made in the second year in the
event sufficient funds are not available in the first year of the subsidy.
Source. #10023, eff 11-14-11
APPENDIX 1
RULE |
STATUTE |
|
|
Ins
1901.01 |
RSA
400-A:15, I; 415-A:2, I |
Ins
1901.02 |
RSA
400-A:15, I; 415-A:2, I |
Ins
1901.03 |
RSA
400-A:15, I; 415-A:2,I (n); 415:6; 415:18 |
Ins
1901.04 |
RSA
400-A:15, I; 402:8; 417:4, IX; 402:39-42; 76-83; 415-A:2; 415-A:5; 415:2;
415:3; 420-G:6, III; 415:6; 415:18 |
Ins
1901.05 |
RSA
400-A:15, I; 415-A:2, I; 415-A:3; 415:6; 415:18 |
Ins
1901.06 |
RSA
400-A:15, I; 415:5; 415:6; 415:18 |
Ins
1901.07 |
RSA
400-A:15, I; 415-A:2; 415:6; 415:18 |
Ins
1901.08 |
RSA
400-A:15, I; 415:20 |
Ins 1901.09 |
RSA 400-A:15-c |
|
|
Ins 1902.01 |
RSA 415:5, I. |
Ins 1902.02 |
RSA 415:1; RSA
415-F:2 |
Ins 1902.03 |
RSA 400-A:15, |
Ins 1902.04 |
RSA 400-A:15, |
Ins 1902.05 |
RSA 415:15, |
Ins 1902.06 |
RSA 400-A:15, |
Ins 1902.07 |
RSA 415:15, |
Ins 1902.08 |
RSA 400-A:15, |
Ins 1902.09 |
RSA 400-A:15, |
Ins 1902.10 |
RSA 400-A:15, I. |
Ins 1902.11 |
RSA 400-A:15, I. |
Ins 1902.12 |
RSA 415:15, I. |
Ins 1902.13 |
RSA 400-A:15, I. |
Ins 1902.14 |
RSA 400-A:15, I. |
Ins 1902.15 |
RSA 400-A:15, .I |
|
|
Ins 1903.01 |
RSA 415:5 I |
Ins 1903.02 |
RSA 415:1 |
Ins 1903.03 |
RSA 400-A:15 I |
Ins 1903.04 |
RSA 400-A:15 I |
Ins 1903.05 |
RSA 400-A:15 I |
Ins 1903.06 |
RSA 400-A:15 I |
|
|
Ins
1904.01 |
400-A:15,
I; 415-A:1; 415-A:2 |
Ins
1904.02 |
400-A:15,
I; 415-A:1; 415-A:2, I (c) |
Ins
1904.03 |
400-A:15,
I; 415-A:2, I (n) |
Ins
1904.05 |
400-A:15,
I; 415-A:2, I (c) |
Ins
1904.06 |
400-A:15,
I; 415-A:2 |
Ins
1904.07 |
400-A:15,
I; 415-A:2 |
Ins
1904.08 |
400-A:15,
I; 415-A:2 |
Ins
1904.09 |
400-A:15,
I; 415-A:2 |
Ins 1904.10 |
400-A:15,
I |
Ins
1905.01 |
RSA
415-F:3, III |
Ins 1905.02 |
RSA 415-F:2 |
Ins 1905.03 |
RSA 415-F:3, III |
Ins 1905.04 |
RSA 415-F:3, III |
Ins 1905.05 |
RSA 415-F:3, III |
Ins 1905.06 |
RSA 415-F:3,
III, IV, V |
Ins 1905.07 |
RSA 415-F:3,
III, IV, V |
Ins 1905.08 |
RSA 415-F:3,
III, IV, V |
Ins 1905.09 |
RSA 415-F:3,
III, IV, V |
Ins 1905.10 |
RSA 415-F:3,
III, IV, V |
Ins 1905.11 |
RSA 415-F:3,
III, IV, V |
Ins 1905.12 |
RSA 415-F:3,
III, V |
Ins 1905.13 |
RSA 415-F:3,
III, IV |
Ins 1905.14 |
RSA 415-F:3, III,
IV, V |
Ins 1905.15 |
RSA 415-F:3,
III, IV |
Ins 1905.16 |
RSA 415-F:3, V;
RSA 415-F:4 |
Ins 1905.17 |
RSA 415-F:3,
III, IV, V |
Ins 1905.18 |
RSA 415-F:3, IV |
Ins 1905.19 |
RSA 415-F:3,
III, IV, V; RSA 415-F:6 |
Ins 1905.20 |
RSA 415-F:3,
III, IV |
Ins 1905.21 |
RSA 415-F:3, IV;
RSA 415-F:7 |
Ins 1905.22 |
RSA 415-F:5 IV,
V |
Ins
1905.23 |
RSA
415-F:3 IV; RSA 415-F:5 V |
Ins
1905.24 |
RSA
415-F:3 III |
Ins
1905.25 |
RSA
415-F:3 III, V |
Ins 1905.22 |
RSA 415-F:3, IV;
RSA 415-F:7 |
Ins 1905.23 |
RSA 415-F:5, IV,
V |
Ins 1905.24 |
RSA 415-F:3, IV |
Ins 1905.25 |
RSA 415-F:3,
III, IV, V |
Ins 1905.26 |
RSA 415-F:3,
III, V |
Ins 1905.27 |
RSA 400-A:15, I |
Appendix A |
RSA 400-A:15, I |
Appendix B |
RSA 400-A:15, I |
Appendix C |
RSA 400-A:15, I |
|
|
Ins
1906.05 |
RSA
415-A:2 I (f) |
Ins 1906.06 |
RSA 415:18-a |
|
|
Ins
1907.01 |
RSA
400-A:15, I |
Ins
1907.02 |
RSA
415-A:2 |
Ins
1907.03 |
RSA
415-A:2 I (b) |
Ins
1907.04 |
RSA
415-A:2, II |
Ins
1907.05 |
RSA
415-A:2, I (e) |
Ins
1907.06 |
RSA
415-A:2 I (b) & II |
Ins
1907.07 |
RSA
400-A:15, III |
|
|
Ins
1908.01 |
RSA
400-A:15, |
Ins
1908.02 |
RSA
400-A:15, |
Ins
1908.03 |
RSA
400-A:15, |
Ins
1908.04 |
RSA
400-A:15, |
Ins
1908.05 |
RSA
400-A:15, |
Ins
1908.06 |
RSA
400-A:15, |
|
|
APPENDIX 2
Rule |
Title |
Obtain at: |
|
|
|
Ins
1905.16(c)(5) |
The NAIC
Medicare Supplement Insurance Compliance Manual, March 25, 2010; published by
the NAIC |
Available
for no cost on-line at: http://www.naic.org/documents/prod_serv _supplementary_med_lm.pdf |