Haw. Code R. § 16-12-6.05 - Standard Medicare supplement benefit plans for 2010 standardized Medicare supplement benefit plan policies or certificates issued or delivered with an effective date for coverage on or after June 1, 2010
(a) The following standards are applicable to
all Medicare supplement policies or certificates delivered or issued for
delivery in this State with an effective date for coverage 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
with an effective date for coverage before June 1, 2010, remain subject to the
requirements of sections
16-12-5.5 or
16-12-6.
(b)
(1) An
issuer shall make available to each prospective policyholder and certificate
holder a policy form or certificate form containing only the basic (core)
benefit, as defined in section
16-12-5.6(c).
(2) If an issuer makes available any of the
additional benefits described in section
16-12-5.6(d)
or offers standardized benefit Plans K or L (as described in paragraphs (f)(8)
or (f)(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 paragraph
(b)(1), a policy form or certificate form containing either standardized
benefit Plan C (as described in paragraph (f)(3)) or standardized benefit Plan
F (as described in paragraph (f)(5)).
(c) 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 subsection (g)
and in section
16-12-6.1.
(d) Benefit plans shall be uniform in
structure, language, designation, and format to the standard benefit plans
listed in this section and conform to the definitions in section
16-12-3.
Each benefit shall be structured in accordance with the format provided in
sections
16-12-5.6(c)
and
16-12-5.6(d);
or, in the case of Plans K or L, in paragraphs (f)(8) or (f)(9), and list the
benefits in the order shown (Exhibit A (revised 2019)). For purposes of this
section, "structure, language, and format" means style, arrangement, and
overall content of a benefit.
(e)
In addition to the benefit plan designations required in subsection (d), an
issuer may use other designations to the extent permitted by law.
(f) Make-up of 2010 standardized benefit
plans (Exhibit A (revised 2019)):
(1)
Standardized Medicare supplement benefit Plan A shall include only the
following: The basic (core) benefits as defined in subsection
16-12-5.6(c).
(2) Standardized Medicare supplement benefit
Plan B shall include only the following: The basic (core) benefit as defined in
subsection
16-12-5.6(c),
plus 100 per cent of the Medicare Part A deductible as defined in paragraph
16-12-5.6(d)(1).
(3) Standardized Medicare supplement benefit
Plan C shall include only the following: The basic (core) benefit as defined in
subsection
16-12-5.6(c),
plus 100 per cent of the Medicare Part A deductible, skilled nursing facility
care, 100 per cent of the Medicare Part B deductible, and medically necessary
emergency care in a foreign country as defined in paragraphs
16-12-5.6(d)(1),
16-12-5.6(d)(3),
16-12-5.6(d)(4),
and
16-12-5.6(d)(6),
respectively.
(4) Standardized
Medicare supplement benefit Plan D shall include only the following: The basic
(core) benefit as defined in subsection
16-12-5.6(c),
plus 100 per cent of the Medicare Part A deductible, skilled nursing facility
care, and medically necessary emergency care in a foreign country as defined in
paragraphs
16-12-5.6(d)(1),
16-12-5.6(d)(3),
and
16-12-5.6(d)(6),
respectively.
(5) Standardized
Medicare supplement (regular) Plan F shall include only the following: The
basic (core) benefit as defined in subsection
16-12-5.6(c),
plus 100 per cent of the Medicare Part A deductible, skilled nursing facility
care, 100 per cent of the Medicare Part B deductible, 100 per cent of the
Medicare Part B excess charges, and medically necessary emergency care in a
foreign country as defined in paragraphs
16-12-5.6(d)(1),
16-12-5.6(d)(3),
16-12-5.6(d)(4),
16-12-5.6(d)(5),
and
16-12-5.6(d)(6),
respectively.
(6) Standardized
Medicare supplement Plan F with high deductible shall include only the
following: 100 per cent of covered expenses following the payment of the annual
deductible set forth in subparagraph (B).
(A)
The basic (core) benefit as defined in subsection
16-12-5.6(c),
plus 100 per cent of the Medicare Part A deductible, skilled nursing facility
care, 100 per cent of the Medicare Part B deductible, 100 per cent of the
Medicare Part B excess charges, and medically necessary emergency care in a
foreign country as defined in paragraphs
16-12-5.6(d)(1),
16-12-5.6(d)(3),
16-12-5.6(d)(4),
16-12-5.6(d)(5),
and
16-12-5.6(d)(6),
respectively.
(B) 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 twelvemonth
period ending with August of the preceding year, and rounded to nearest
multiple of $10.
(7)
Standardized Medicare supplement benefit Plan G shall include only the
following: The basic (core) benefit as defined in subsection
16-12-5.6(c),
plus 100 per cent of the Medicare Part A deductible, skilled nursing facility
care, 100 per cent of the Medicare Part B excess charges, and medically
necessary emergency care in a foreign country as defined in paragraphs
16-12-5.6(d)(1),
16-12-5.6(d)(3),
16-12-5.6(d)(5),
and
16-12-5.6(d)(6),
respectively. Effective January 1, 2020, the standardized benefit plans
described in section
16-12-6.06(b)(4)
(redesignated Plan G with 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, sixty-first
through ninetieth days: 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) Part A hospital coinsurance, ninety-first
through one-hundred fiftieth days: 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 one-hundred fiftieth day in any Medicare
benefit period;
(C) Part A
hospitalization after one hundred fifty days: 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 one 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) Blood: 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) Part B cost
sharing: Except for coverage provided in subparagraph (I), 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);
(I) Part B preventive services: 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) Cost sharing after out-of-pocket limits:
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
(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
subparagraphs (f)(8)(A), (f)(8)(B), (f)(8)(C), and (f)(8)(I);
(B) The benefits described in subparagraphs
(f)(8)(D), (f)(8)(E), (f)(8)(F), (f)(8)(G), and (f)(8)(H) but substituting 75
per cent for 50 per cent; and
(C)
The benefit described in subparagraph (f)(8)(J), but substituting $2,000 for
$4,000.
(10) Standardized
Medicare supplement Plan M shall include only the following: The basic (core)
benefit as defined in subsection
16-12-5.6(c),
plus 50 per cent of the Medicare Part A deductible, skilled nursing facility
care, and medically necessary emergency care in a foreign country as defined in
paragraphs
16-12-5.6(d)(2),
16-12-5.6(d)(3),
and
16-12-5.6(d)(6).
(11) Standardized Medicare supplement Plan N
shall include only the following: The basic (core) benefit as defined in
subsection
16-12-5.6(c),
plus 100 per cent of the Medicare Part A deductible, skilled nursing facility
care, and medically necessary emergency care in a foreign country as defined in
paragraphs
16-12-5.6(d)(1),
16-12-5.6(d)(3),
and
16-12-5.6(d)(6)
with copayments in the following amounts:
(A)
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
(B) 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.
(g) 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 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 must 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.
Notes
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