760 IAC 3-6.1-1 - Benefit standards for 2010 Standardized Medicare supplement benefit plan policies or certificates issued for delivery with an effective date for coverage on or after June 1, 2010
Authority: IC 27-8-13
Affected: IC 27-8-13-1
Sec. 1.
(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 of coverage on or after June 1, 2010. No policy or certificate may be:
(1) advertised;
(2) solicited;
(3) delivered; or
(4) issued for delivery; in this state as a
Medicare supplement policy or certificate unless the policy or certificate
complies with the benefit standards in this section. Benefit plan standards
applicable to Medicare supplement policies and certificates with an effective
date of coverage before June 1, 2010, remain subject to the requirements of
760
IAC 3-6-1.
(b) The following standards apply to Medicare
supplement policies and certificates and are in addition to all other
requirements of this article:
(1) A Medicare
supplement policy or certificate:
(A) shall
not exclude or limit benefits for losses incurred more than six (6) months from
the effective date of coverage because it involved a preexisting
condition;
(B) 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 (6) months before the effective date of coverage; and
(C) shall not indemnify against losses
resulting from sickness on a different basis than losses resulting from
accidents.
(2) 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 copayment
percentage factors. Premiums may be modified to correspond with such
changes.
(3) 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.
(4) Each Medicare supplement policy shall be
guaranteed renewable and shall meet the following requirements:
(A) The issuer shall not cancel or nonrenew
the policy:
(i) solely on the ground of health
status of the individual; or
(ii)
for any reason other than nonpayment of premium or material
misrepresentation.
(B)
If the Medicare supplement policy is terminated by the group policyholder and
is not replaced as provided under clause (D), the issuer shall offer
certificate holders an individual Medicare supplement policy that, at the
option of the certificate holder, provides for:
(i) continuation of the benefits contained in
the group policy; or
(ii) such
benefits as otherwise meet the requirements of this subsection.
(C) If an individual is a
certificate holder in a group Medicare supplement policy and the individual
terminates membership in the group, the issuer shall offer the certificate
holder:
(i) the conversion opportunity
described in clause (B); or
(ii) at
the option of the group policyholder, continuation of coverage under the group
policy.
(D) 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.
(5) Termination of a Medicare supplement
policy or certificate shall be without prejudice to any continuous loss that
commenced while the policy was in force, but the extension of benefits beyond
the period during which the policy was in force may be conditioned upon the
continuous total disability of the insured, limited to:
(A) the duration of the policy benefit
period, if any; or
(B) payment of
the maximum benefits.
Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.
(6) Each Medicare supplement policy shall do
the following:
(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 (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 ninety (90) days after the date the individual
becomes entitled to the 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 the entitlement if the policyholder or certificate
holder:
(i) provides notice of loss of the
entitlement within ninety (90) days after the date of the loss; and
(ii) 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:
(i) is entitled to benefits under Section
226(b) of the Social Security Act; and
(ii) 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 (90) days after the date of the loss.
(D) Reinstitution of the coverages shall do
all of the following:
(i) Not provide for any
waiting period with respect to treatment of preexisting conditions.
(ii) Provide for resumption of coverage that
is substantially equivalent to coverage in effect before the date of the
suspension.
(iii) 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.
(c) 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. The
standards for basic core benefits common to all benefit plans are as follows:
(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 one hundred percent (100%) of the Medicare Part A eligible expenses
for hospitalization paid at the applicable prospective payment system (PPS)
rate, or other appropriate standard of payment, subject to a lifetime maximum
benefit of an additional three hundred sixty-five (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:
(A) the first three (3) pints of blood;
or
(B) 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 of
Medicare eligible expenses under Part B, regardless of hospital confinement,
subject to the Medicare Part B deductible.
(d) The following additional benefits shall
be included in Medicare supplement benefit Plans B, C, D, F, F with high
deductible, G, M, and N as provided by
760
IAC 3-7.1. The standard for additional benefits are as
follows:
(1) Medicare Part A deductible,
coverage for one hundred percent (100%) of the Medicare Part A inpatient
hospital deductible amount per benefit period.
(2) Medicare Part A deductible, coverage for
fifty percent (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 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.
(4)
Medicare Part B deductible, coverage for one hundred percent (100%) of the
Medicare Part B deductible amount per calendar year regardless of hospital
confinement.
(5) One hundred
percent (100%) 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.
(6) Medically necessary emergency care in a
foreign country, coverage to the extent not covered by Medicare for eighty
percent (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:
(A) would have
been covered by Medicare if provided in the United States; and
(B) began during the first sixty (60)
consecutive days of each trip outside the United States; subject to a calendar
year deductible of two hundred fifty dollars ($250) and a lifetime maximum
benefit of fifty thousand dollars ($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.
(7) Extended outpatient prescription drug
benefit, coverage for fifty percent (50%) of outpatient prescription drug
charges, after a two hundred fifty dollar ($250) calendar year deductible to a
maximum of three thousand dollars ($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) For policies written or issued prior to
June 30, 2010, 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 clause (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 one hundred percent (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 one hundred twenty dollars ($120) annually under this benefit. This benefit shall not include payment for any procedure covered by Medicare. This subdivision is only applicable to policies or certificates issued for delivery with an effective date for coverage before May 30, 2010.
(9) 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, including the
following requirements:
(A) For purposes of
this subdivision, the following definitions shall apply:
(i) "Activities of daily living" include, but
are not limited to, the following:
(AA)
Bathing.
(BB) Dressing.
(CC) Personal hygiene.
(DD) Transferring.
(EE) Eating.
(FF) Ambulating.
(GG) Assistance with drugs that are normally
self-administered.
(HH) Changing
bandages or other dressings.
(ii) "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 (4) hours in a
twenty-four (24) hour period of services provided by a care provider is one (1)
visit.
(iii) "Care provider" means
a duly qualified or licensed home health aide/homemaker, personal care aide, or
nurse:
(AA) provided through a licensed home
health care agency; or
(BB) referred
by a licensed referral agency or licensed nurses registry.
(iv) "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.
(B) Coverage
requirements and limitations are as follows:
(i) At-home recovery services provided must
be primarily services that assist in activities of daily living.
(ii) 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.
(iii)
Coverage is limited to the following:
(AA) Not
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.
(BB) The actual charges for each visit up to
a maximum reimbursement of forty dollars ($40) per visit. (CC) One thousand six
hundred dollars ($1,600) per calendar year.
(DD) Seven (7) visits in any one (1)
week.
(EE) Care furnished on a
visiting basis in the insured's home.
(FF) Services provided by a care provider as
defined in clause (A)(iii).
(GG)
At-home recovery visits while the insured is covered under the policy or
certificate and not otherwise excluded.
(HH) At-home recovery visits received during
the period the insured is receiving Medicare approved home care services or not
more than eight (8) weeks after the service date of the last Medicare approved
home health care visit.
(iv) Coverage is excluded for the following:
(AA) Home care visits paid for by Medicare or
other government programs.
(BB)
Care provided by family members, unpaid volunteers, or providers who are not
care providers. This subdivision is only applicable to policies or certificates
issued for delivery with an effective date for coverage before May 30,
2010.
(e) Standardized Medicare supplement benefit
plan "K" shall consist of the following:
(1)
Coverage of one hundred percent (100%) of the Part A hospital coinsurance
amount for each day used from the sixty-first day through the ninetieth day in
any Medicare benefit period.
(2)
Coverage of one hundred percent (100%) of the Part A hospital coinsurance
amount for each Medicare lifetime inpatient reserve day used from the
ninety-first day through the one hundred fiftieth day in any Medicare benefit
period.
(3) Upon exhaustion of the
Medicare hospital inpatient coverage, including the lifetime reserve days,
coverage of one hundred percent (100%) of the Medicare Part A eligible expenses
for hospitalization paid at the applicable prospective payment system rate, or
the appropriate Medicare standard of payment, subject to a lifetime maximum
benefit of an additional three hundred sixty-five (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 for fifty percent (50%) of the Medicare Part A inpatient hospital
deductible amount per benefit period until the out-of-pocket limitation is met
as described in subdivision (10).
(5) Coverage for fifty percent (50%) of the
coinsurance amount for each day used from the twenty-first day through the one
hundredth day in a Medicare benefit period for posthospital skilled nursing
facility care eligible under Medicare Part A until the out-of-pocket limitation
is met as described in subdivision (10).
(6) Coverage for fifty percent (50%) of the
cost sharing for all Part A Medicare eligible expenses and respite care until
the out-of-pocket limitation is met as described in subdivision (10).
(7) Coverage for fifty percent (50%) under
Medicare Part A or B of the reasonable cost of:
(A) the first three (3) pints of blood;
or
(B) 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 subdivision (10).
(8) Except for coverage provided in
subdivision (9), coverage for fifty percent (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
subdivision (10).
(9) Coverage of
one hundred percent (100%) of the cost sharing for Medicare Part B preventive
services after the policyholder pays the Part B deductible.
(10) Coverage for one hundred percent (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 four thousand dollars
($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.
(f)
Standardized Medicare supplement benefit plan "L" shall consist of the
following:
(1) The benefits described in
subsection (e)(1) through (e)(3) and (e)(9).
(2) The benefits described in subsection
(e)(4) through (e)(8), but substituting seventy-five percent (75%) for fifty
percent (50%).
(3) The benefit
described in subsection (e)(10), but substituting two thousand dollars ($2,000)
for four thousand dollars ($4,000).
(g) Notwithstanding the foregoing, insurers
are permitted to continue to use approved forms through December 31, 2005.
Insurers may offer any authorized plan upon approval of the commissioner.
Notes
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