Haw. Code R. § 16-12-5.5 - Benefit standards for 1990 standardized Medicare supplement benefit plan policies or certificates issued or delivered on or after September 3, 1992, and with an effective date for coverage prior to June 1, 2010
(a) The following standards are applicable to
all Medicare supplement policies or certificates delivered or issued for
delivery in this State on or after September 3, 1992, and with an effective
date for coverage prior to June 1, 2010 (Exhibit A (revised 2019)). 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)
The following are general standards that apply to Medicare supplement policies
and certificates and are in addition to all other requirements of this chapter
(Exhibit A (revised 2019)):
(1) A Medicare
supplement policy or certificate shall not exclude or limit benefits for losses
incurred more than six months from the effective date of coverage because it
involved a preexisting condition. The policy or certificate may not define a
preexisting condition more restrictively than a condition for which medical
advice was given or treatment was recommended by or received from a physician
within six months before the effective date of coverage.
(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 those 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
subparagraph (E), the issuer shall offer certificate holders an individual
Medicare supplement policy which (at the option of the certificate holder):
(i) Provides for continuation of the benefits
contained in the group policy; or
(ii) Provides for the 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:
(i) Offer the
certificate holder the conversion opportunity described in subparagraph (C); or
(ii) 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) 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 twenty-four 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 ninety days after the date the individual becomes
entitled to that assistance.
(B) If
the suspension occurs and if the policyholder or certificate holder loses
entitlement to the medical assistance, the policy or certificate shall be
automatically reinstituted (effective as of the date of termination of that
entitlement) if the policyholder or certificate holder provides notice of loss
of the entitlement within ninety days after the date of the loss and pays the
premium attributable to the period.
(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 ninety days after the date of the loss and pays the premium
attributable to the period, effective as of the date of termination of
entitlement in the group health plan.
(D) Reinstitution of the coverages as
provided in subparagraphs (B) and (C):
(i)
Shall not provide for any waiting period with respect to treatment of
preexisting conditions;
(ii) Shall
provide for resumption of coverage that is substantially equivalent to coverage
in effect before the date of the 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
(iii) 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.
(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 section
16-12-6) to a 2010 standardized plan (as described in section
16-12-6.05), 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 pre-funding
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 must be filed with the
commissioner.
(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 six months to any added
benefits contained in the new 2010 standardized policy or certificate not
contained in the exchanged policy.
(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) The
following are standards for basic ("core") benefits common to benefit Plans A-J
(Exhibit A (revised 2019)). Every issuer shall make available a policy or
certificate including only the following basic "core" package of benefits to
each prospective insured. An issuer may make available to prospective insureds
any of the other Medicare supplement insurance benefit plans in addition to the
basic "core" package, but not in lieu thereof.
(1) Coverage of Part A Medicare eligible
expenses for hospitalization to the extent not covered by Medicare from the
sixty-first day through the ninetieth 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 per cent 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 three hundred sixty-five 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
three 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) The following are standards for
additional benefits. The following additional benefits shall be included in
Medicare supplement benefit plans "B" through "J" only as provided by section
16-12-6 (Exhibit A (revised 2019)).
(1) Medicare Part
A deductible: coverage for all of the Medicare Part A inpatient hospital
deductible amount per benefit period;
(2) Skilled nursing facility care: coverage
for the actual billed charges up to the coinsurance amount from the
twenty-first day through the one hundredth day in a Medicare benefit period for
post-hospital skilled nursing facility care eligible under Medicare Part
A;
(3) Medicare Part B deductible:
coverage for all of the Medicare Part B deductible amount per calendar year
regardless of hospital confinement;
(4) Eighty (80) per cent of the Medicare Part
B excess charges: coverage for 80 per cent 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
(100) per cent of the Medicare Part B excess charges: 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 per cent 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 per cent 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 per cent
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 sixty 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) 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.
Reimbursement shall be for the actual charges up to 100 per cent 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 codes, to a maximum of $120 annually under this benefit. This benefit shall not include payment for any procedure covered by Medicare.
(10) The
following are at-home recovery benefits: 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:
"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.
"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.
"Home" means 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.
"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 four hours in a twenty-four hour period of services provided by a care provider is one visit.
(B) The following are coverage requirements
and limitations:
At-home recovery services provided must be primarily services which assist in activities of daily living. The insured's attending physician must 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. Coverage is 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) $1,600 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 this section;
(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 eight weeks after the service date of the last
Medicare-approved home health care visit.
(C) Coverage is excluded for:
(i) Home care visits paid for by Medicare or
other government programs; and
(ii)
Care provided by family members, unpaid volunteers, or providers who are not
care providers.
(e) The following are standards for Plans K
and L (Exhibit A (revised 2019)).
(1)
Standardized Medicare supplement benefit plan "K" shall consist of the
following:
(A) Coverage of 100 per cent of
the Part A hospital coinsurance amount for each day used from the sixty-first
through the ninetieth day in any Medicare benefit period;
(B) Coverage of 100 per cent of the Part A
hospital coinsurance amount for each Medicare lifetime inpatient reserve day
used from the ninety-first through the hundred-fiftieth day in any Medicare
benefit period;
(C) Upon exhaustion
of the Medicare hospital inpatient coverage, including the lifetime reserve
days, coverage of 100 per cent 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 three hundred sixty-five 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 per cent 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);
(E) Skilled nursing facility care: coverage
for 50 per cent of the coinsurance amount for each day used from the twenty
first day through the hundredth 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);
(F) Hospice care: coverage for 50
per cent 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);
(G) Coverage for 50 per cent
under Medicare Part A or B, of the reasonable cost of the first three pints of
blood (or equivalent quantities of packed red blood cells, as defined under
federal regulations) unless replaced in accordance with federal regulations
until the out-of-pocket limitation is met as described in subparagraph
(J);
(H) Except for coverage
provided in subparagraph (I) below, coverage for 50 per cent 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)
Coverage of 100 per cent of the cost sharing for Medicare Part B preventive
services after the policyholder pays the Part B deductible; and
(J) Coverage of 100 per cent 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.
(2) Standardized Medicare supplement benefit
plan "L" shall consist of the following:
(A)
The benefits described in subparagraphs (1)(A), (1)(B), (1)(C), and (1)(I) of
subsection (e);
(B) The benefits
described in subparagraphs (1)(D), (1)(E), (1)(F), (1)(G), and (1)(H) of
subsection (e), but substituting 75 per cent for 50 per cent; and
(C) The benefits described in subparagraph
(1)(J) of subsection (e), but substituting $2,000 for $4,000.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.