N.M. Admin. Code § 13.10.25.12 - 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 Subsection E of
13.10.25.11 NMAC.
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 Subsection G of
this section and in
13.10.25.16 NMAC.
C. Benefit plans shall be uniform in
structure, language, designation and format to the standard benefit
Plans A through L listed in this section and
conform to the definitions in
13.10.25.7 NMAC. Each benefit
shall be structured in accordance with the format provided in Subsection B, C
or D of 13.10.25.11 NMAC and list the
benefits in the order shown in this section. 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 Subsection C of this
section, other designations to the extent permitted by law.
E.
Make-up of benefit plans:
(1)
Plan A. Standardized
Medicare Supplement benefit Plan A shall be limited to the basic (core)
benefits common to all benefit plans, as defined in Subsection E of
13.10.25.11 NMAC.
(2)
Plan B. Standardized
Medicare Supplement benefit Plan B shall include only the following: The core
benefit as defined in Subsection E of
13.10.25.11 NMAC, plus the
Medicare Part A deductible as defined in Paragraph (1) of Subsection F of
13.10.25.11 NMAC.
(3)
Plan C. Standardized
Medicare Supplement benefit Plan C shall include only the following: The core
benefit as defined in Subsection E of
13.10.25.11 NMAC, plus the
Medicare Part A deductible, skilled nursing facility care, Medicare Part B
deductible and medically necessary emergency care in a foreign country as
defined in Paragraphs (1), (2), (3) and (8) respectively of Subsection F of
13.10.25.11 NMAC.
(4)
Plan D. Standardized
Medicare Supplement benefit Plan D shall include only the following: The core
benefit as defined in Subsection E of
13.10.25.11 NMAC, plus the
Medicare Part A deductible, skilled nursing facility care, medically necessary
emergency care in an foreign country and the at-home recovery benefit as
defined in Paragraphs (1), (2), (8) and (10) respectively of Subsection F of
13.10.25.11. NMAC.
(5)
Plan E. Standardized
Medicare Supplement benefit Plan E shall include only the following: The core
benefit as defined in Subsection E of
13.10.25.11 NMAC, plus the
Medicare Part A deductible, skilled nursing facility care, medically necessary
emergency care in a foreign country and preventive medical care as defined in
Paragraphs (1), (2), (8) and (9) respectively of Subsection F of
13.10.25.11. NMAC.
(6)
Plan F. Standardized
Medicare Supplement benefit Plan F shall include only the following: The core
benefit as defined Subsection E of
13.10.25.11 NMAC, plus the
Medicare Part A deductible, the skilled nursing facility care, the Medicare
Part B deductible, one-hundred percent of the Medicare Part B excess charges,
and medically necessary emergency care in a foreign country as defined in
Paragraphs (1), (2), (3), (5) and (8) respectively of Subsection F of
13.10.25.11 NMAC.
(7)
High deductible Plan F.
Standardized Medicare Supplement benefit High Deductible Plan F shall include
only the following: one-hundred percent of covered expenses following the
payment of the annual High Deductible Plan F deductible. The covered expenses
include the core benefit as defined in Subsection E of
13.10.25.11 NMAC, plus the
Medicare Part A deductible, skilled nursing facility care, the Medicare Part B
deductible, one-hundred percent of the Medicare Part B excess charges, and
medically necessary emergency care in a foreign country as defined in
Paragraphs (1), (2), (3), (5) and (8) respectively of Subsection F of
13.10.25.11 NMAC. 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. The annual
High Deductible Plan F deductible shall be $1500 for 1998 and 1999, and shall
be based on the calendar year. 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)
Plan G. Standardized
Medicare Supplement benefit Plan G shall include only the following: The core
benefit as defined in Subsection E of
13.10.25.11 NMAC, plus the
Medicare Part A deductible, skilled nursing facility care, eighty percent of
the Medicare Part B excess charges, medically necessary emergency care in a
foreign country, and the at-home recovery benefit as defined in Paragraphs (1),
(2), (4), (8) and (10) respectively of Subsection F of
13.10.25.11 NMAC.
(9)
Plan H. Standardized
Medicare Supplement benefit Plan H shall consist of only the following: The
core benefit as defined in Subsection E of
13.10.25.11 NMAC, plus the
Medicare Part A deductible, skilled nursing facility care, basic prescription
drug benefit and medically necessary emergency care in a foreign country as
defined in Paragraphs (1), (2), (6), and (8) respectively of Subsection F of
13.10.25.11 NMAC. The outpatient
prescription drug benefit shall not be included in a Medicare Supplement policy
sold after December 31, 2005.
(10)
Plan I. Standardized Medicare Supplement benefit Plan I shall
consist of only the following: The core benefit as defined in Subsection E of
13.10.25.11 NMAC, plus the
Medicare Part A deductible, skilled nursing facility care, one-hundred percent
of the Medicare Part B excess charges, basic prescription drug benefit,
medically necessary emergency care in a foreign country and at-home recovery
benefit as defined in Paragraphs (1), (2), (5), (6), (8) and (10) respectively
of Subsection F of
13.10.25.11 NMAC. The outpatient
prescription drug benefit shall not be included in a Medicare Supplement policy
sold after December 31, 2005.
(11)
Plan J. Standardized Medicare Supplement benefit Plan J shall
consist of only the following: The core benefit as defined in Subsection E of
13.10.25.11 NMAC, plus the
Medicare Part A deductible, skilled nursing facility care, Medicare Part B
deductible, one-hundred percent of the Medicare Part B excess charges, extended
prescription drug benefit, medically necessary emergency care in a foreign
country, preventive medical care and at-home recovery benefit as defined in
Paragraphs (1), (2), (3), (5), (7), (8), (9) and (10) respectively of
Subsection F of
13.10.25.11 NMAC. The outpatient
prescription drug benefit shall not be included in a Medicare Supplement policy
sold after December 31, 2005.
(12)
High deductible Plan J. Standardized Medicare Supplement benefit
High Deductible Plan J shall consist of only the following: one-hundred percent
of covered expenses following the payment of the annual High Deductible Plan J
deductible. The covered expenses include the core benefit as defined in
Subsection E of
13.10.25.11 NMAC, plus the
Medicare Part A deductible, skilled nursing facility care, Medicare Part B
deductible, one-hundred percent of the Medicare Part B excess charges, extended
outpatient prescription drug benefit, medically necessary emergency care in a
foreign country, preventive medical care benefit and at-home recovery benefit
as defined in Paragraphs (1), (2), (3), (5), (7), (8), (9) and (10)
respectively of Subsection F of
13.10.25.11 NMAC. 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. The annual
deductible shall be $1500 for 1998 and 1999, and shall be based on a calendar
year. 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. The outpatient prescription drug benefit shall not
be included in a Medicare Supplement policy sold after December 31,
2005.
(13)
Plan K and Plan
L. Make-up of two Medicare Supplement plans mandated by the
Medicare Prescription Drug, Improvement and Modernization Act of 2003
(MMA):
(a)
Plan K. Standardized
Medicare Supplement benefit Plan K shall consist of only those benefits
described in Paragraph (1) of Subsection G of 13.10.25.11 NMAC.
(b)
Plan L. Standardized
Medicare Supplement benefit Plan L shall consist of only those benefits
described in Paragraph (2) of Subsection G of 13.10.25.11
NMAC.
F.
New or innovative benefits: An issuer may, with the prior approval
of the superintendent, 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 that 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.
Notes
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