3 AAC 28.459 - Minimum beneflt standards for 2020 standardized Medicare supplement benefit policies or certificates issued with an effective date of coverage on or after January 1, 2020

Current through September 28, 2021

(a) A Medicare supplement policy or certificate issued with an effective date of coverage on or after January 1, 2020 may not be advertised, solicited, or issued for delivery in this state, unless it meets the requirements in this section and all other applicable requirements of 3 AAC 28.410 - 3 AAC 28.510.
(b) A Medicare supplement policy or certificate issued under this section may not exclude or limit coverage for a loss due to a preexisting condition, if the loss was incurred more than six months after the effective date of coverage. The policy or certificate may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage.
(c) A Medicare supplement policy or certificate issued under this section may not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.
(d) A Medicare supplement policy or certificate issued under this section may 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 the changes.
(e) A Medicare supplement policy or certificate issued under this section may 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.
(f) A Medicare supplement policy or certificate issued under this section must be guaranteed renewable and
(1) the issuer may not cancel or nonrenew the policy solely on the ground of health status of the individual;
(2) the insurer may not cancel or nonrenew the policy for any reason other than nonpayment of premium or material misrepresentation by the individual;
(3) if the Medicare supplement policy or certificate is terminated by the group policyholder and is not replaced under (5) of this subsection, the issuer shall offer each certificate holder an individual Medicare supplement policy that, at the option of the certificate holder provides for
(A) continuation of the benefits contained in the group policy; or
(B) benefits that otherwise meet the requirements of (a) - (/) of this section;
(4) if an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall
(A) offer the certificate holder an opportunity to convert the group policy under (3) of this subsection; or
(B) at the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy; and
(5) 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 individuals covered under the old group policy on its date of termination; coverage under the new group policy may not result in any exclusion for preexisting conditions that would have been covered under the group policy that is being replaced.
(g) The termination of a Medicare supplement policy or certificate issued under this section must be without prejudice to a continuous loss that commenced while that 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 the payment of the maximum benefits. Receipt of Medicare Part D benefits may not be considered in determining a continuous loss.
(h) A Medicare supplement policy or certificate issued under this section must provide that benefits and premiums under the policy or certificate will be suspended at the request of the policyholder or certificate holder for the period, not to exceed 24 months, in which the policyholder or certificate holder has applied for and is determined to be entitled to Medicaid under 42 U.S.C. 1396- 1396w-2, but only if that policyholder or certificate holder notifies the issuer of the policy or certificate within 90 days after the date that the policyholder or certificate holder becomes entitled to the assistance.
(i) If a suspension occurs under (h) of this section and if the policyholder or certificate holder loses entitlement to Medicaid, the policy or certificate must be automatically reinstated as of the date of the termination of that entitlement if the policyholder or certificate holder provides notice of loss of that entitlement within 90 days after the date of the loss and pays the premium attributable to the period, calculated from the date of termination of the entitlement to Medicaid.
(j) A Medicare supplement policy or certificate issued under this section must provide that benefits and premiums under the policy or certificate will be suspended at the request of the policyholder or certificate holder if the policyholder or certificate holder is entitled to benefits under 42 U.S.C. 426(b) and is covered under a group health plan as defined in 42 U.S.C. 1395y(b)(l)(A)(v).
(k) If an issuer suspends a policy under (j) of this section and if the policyholder or certificate holder subsequently loses coverage under the group health plan, the policy or certificate must be automatically reinstated as of the date of loss of group coverage if the policyholder provides notice of loss of coverage within 90 days after the date of the loss and pays the premium attributable to the period starting from the effective date of the termination of enrollment in the group health plan.
(l) Reinstatement of the coverage described in (i) and (k) of this section
(1) may not provide for any waiting period with respect to the treatment of preexisting conditions;
(2) must provide for the resumption of coverage that is substantially equivalent to coverage in effect before the date of the suspension; and
(3) must provide for classification of premiums on terms at least as favorable to the policyholder or certificate holder as the premium classification terms that would have applied to the policyholder or certificate holder had the coverage not been suspended.
(m) An issuer shall make available a policy or certificate including only the basic core benefits to a prospective insured. An issuer may make available to a prospective insured Medicare supplement insurance benefit plans "A" - "D," plan "F," high deductible plan "F," plan "G," high deductible plan "G", and plans "M," and "N" in addition to the basic core benefits, but not instead of them. The basic core benefits must contain
(1) coverage of Medicare Part A 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 Medicare Part A 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 percent of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days;
(4) coverage under Medicare Parts A and B for the reasonable cost of the first three pints of blood, or equivalent quantities of packed red blood cells, as provided 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 eUgible expenses under Medicare Part B regardless of hospital confinement, subject to the Medicare Part B deductible; and
(6) coverage of cost sharing for all Medicare Part A eligible hospice care and respite care expenses.
(n) The following additional benefits must be included in Medicare supplement insurance benefit plans "B" - "D," plan "F," high deductible plan "F," plan "G," high deductible plan "G," and plans "M," and "N," as set out in 3 AAC 28.461:
(1) coverage for 100 percent of the Medicare Part A inpatient hospital deductible amount per benefit period;
(2) coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period;
(3) 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) coverage for 100 percent of the Medicare Part B deductible amount per calendar year regardless of hospital confinement;
(5) coverage for 100 percent 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;
(6) coverage to the extent not covered by Medicare for 80 percent of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician, and medical care received in a foreign country, if the care would have been covered by Medicare if provided in the United States and if the care began during the first 60 consecutive days of each trip outside the United States, subject to a calendar year deductible of $250 and a lifetime maximum benefit of $50,000; for purposes of this benefit, "emergency care" means care needed immediately because of an injury or an illness of sudden and unexpected onset.

Notes

3 AAC 28.459
Eff. 3/28/2019,Register 229, April 2019

Authority:AS 21.06.090

AS 21.42.130

AS 21.96.060

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