N.Y. Comp. Codes R. & Regs. Tit. 11 § 58.2 - Rules relating to the standard medicare supplement benefit plans and the make-up of medicare supplement benefit plans issued for an effective date of coverage prior to june 1, 2010
(a)
General applicability. The following shall be applicable to Medicare supplement
insurance and Medicare select as defined in sections 52.11 and
52.14 of this Title, respectively,
and shall be in addition to other requirements of this Part. Such rules shall
apply to all Medicare supplement and Medicare select policies and certificates
issued with an effective date for coverage prior to June 1, 2010 in this State.
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 on or after June 1, 2010 are subject to the requirements of
section 58.4 of this Part.
(b) Standard Medicare supplement benefit
plans issued with an effective date for coverage prior to June 1, 2010.
(1) 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 subparagraph
(6)(xi) of this subdivision.
(2)
Where a nonprofit health service, hospital service or medical expense indemnity
corporation issues a subscriber contract which does not include all of the
benefits required for a plan of Medicare supplement insurance, such contract
must, in order to qualify as Medicare supplement insurance, be issued in
conjunction with another contract including the remainder of the benefits
required for a plan of Medicare supplement insurance as prescribed in this
section. In the alternative, two or more of such corporations may act jointly
and issue a single contract which contains all of the benefits required for a
plan of Medicare supplement insurance.
(3) Benefit plans shall be uniform in
structure, language, designation and format to the standard benefit plans "A''
through "L'' listed in subdivision (c) of this section and conform to the
definitions in section
58.1(a) of this
Part. Each benefit plan shall be structured in accordance with the format
provided in paragraphs (5) and (6) of this subdivision and list the benefits in
the order shown in subdivision (c) of this section. For purposes of this
section, structure, language, and format means style, arrangement and overall
content of a benefit.
(4) An issuer
may use, in addition to the benefit plan designations required in paragraph (3)
of this subdivision, other designations to the extent permitted by law or
regulation.
(5) Benefit plans A-J
shall include the following basic "core'' benefits:
(i) coverage of Part A Medicare eligible
expenses for hospitalization to the extent not covered by Medicare from the
61st day through the 90th day in any Medicare benefit period;
(ii) 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;
(iii) upon exhaustion of Medicare hospital
inpatient coverage, including the lifetime reserve days, coverage of 100
percent of the costs incurred for hospitalization expenses of the kind covered
by Medicare and recognized as medically necessary by Medicare, subject to a
lifetime maximum benefit of an additional 365 days. The issuer may enter into
reimbursement contracts with provider hospitals to stand in the place of
Medicare and to make payment for the hospitalization expenses at the applicable
prospective payment system (PPS) rate or other appropriate Medicare standard of
payment, so long as there continues to be no cost to the insured
person;
(iv) 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
(v) 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.
(6) The following additional benefits shall
be included in Medicare supplement benefit plans "B'' through "J'' only, as
provided by subdivision (c) of this section.
(i) Medicare Part A deductible. Coverage for
all of the Medicare Part A inpatient hospital deductible amount per benefit
period.
(ii) Skilled nursing
facility care. 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.
(iii) Medicare Part B
deductible. Coverage for all of the Medicare Part B deductible amount per
calendar year regardless of hospital confinement.
(iv) 80 percent of the Medicare Part B excess
charges. Coverage for 80 percent 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.
(v) 100 percent 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.
(vi) Basic
outpatient prescription drug benefit. Coverage for 50 percent 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.
(vii) Extended outpatient
prescription drug benefit. Coverage for 50 percent 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.
(viii) Medically necessary emergency care in
a foreign country. 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, which care would have been covered by Medicare if provided in the
United States and which 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 shall mean care needed immediately because of an injury or an
illness of sudden and unexpected onset.
(ix) 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
clause (b) of this subparagraph 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 percent 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 (AMACPT) codes, to a maximum of $120 annually under this benefit. This benefit shall not include payment for any procedure covered by Medicare.
(x)
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.
(a) For purposes
of this benefit, the following definitions shall apply:
(1) 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.
(2) 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.
(3) Home shall mean any place used by the
insured as a place of residence, provided that such 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.
(4) 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 24-hour period of services provided by a care provider is one
visit.
(b) Coverage
requirements and limitations:
(1) At-home
recovery services provided must be primarily services which assist in
activities of daily living.
(2) 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.
(3) 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:
(1) home care visits paid for by Medicare or
other government programs; and
(2)
care provided by family members, unpaid volunteers or providers who are not
care providers.
(xi) 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. Such 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 which 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.
(7)
(i) Every issuer shall make available both
standardized Medicare supplement insurance benefit plans "A'' and "B,'' as
defined in paragraphs (c)(1) and (2) of this section, to each prospective
policyholder and certificateholder. An issuer may make available to prospective
policyholders and certificateholders any of the other Medicare supplement
insurance benefit plans permitted by this section in addition to benefit plans
"A" and "B,'' but not in lieu thereof.
(ii) Every issuer shall permit its
policyholders and certificateholders to terminate existing coverage and replace
it with any other Medicare supplement insurance benefit plan then being made
available to prospective policyholders and certificateholders by the issuer. An
issuer may limit changes in coverage initiated by a policyholder or
certificateholder to an anniversary date or other regular interval, so long as
the interval is not less than once every 12 months.
(c) Make-up of Medicare supplement
benefit plans issued with an effective date for coverage prior to June 1, 2010.
(1) Standardized Medicare supplement benefit
plan "A'' shall be limited to the basic ("core'') benefits common to all
benefit plans, as defined in paragraph (b)(5) of this section.
(2) Standardized Medicare supplement benefit
plan "B'' shall include only the following: the core benefits as defined in
paragraph (b)(5) of this section, plus the Medicare Part A deductible as
defined in subparagraph (b)(6)(i) of this section.
(3) Standardized Medicare supplement benefit
plan "C'' shall include only the following: the core benefits as defined in
paragraph (b)(5) of this section, 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 subparagraphs (b)(6)(i),
(ii), (iii) and (viii) of this section.
(4) Standardized Medicare supplement benefit
plan "D'' shall include only the following: the core benefit as defined in
paragraph (b)(5) of this section, plus the Medicare Part A deductible, skilled
nursing facility care, medically necessary emergency care in a foreign country
and the at-home recovery benefit as each is defined in subparagraphs (b)(6)(i),
(ii), (viii) and (x) of this section.
(5) Standardized Medicare supplement benefit
plan "E'' shall include only the following: the core benefit as defined in
paragraph (b)(5) of this section, 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 subparagraphs (b)(6)(i), (ii), (viii)
and (ix) of this section.
(6)
Standardized Medicare supplement benefit plan "F'' shall include only the
following: the core benefits as defined in paragraph (b)(5) of this section,
plus the Medicare Part A deductible, the skilled nursing facility care, the
Medicare Part B deductible, 100 percent of the Medicare Part B excess charges,
and medically necessary emergency care in a foreign country as defined in
subparagraphs (b)(6)(i), (ii), (iii), (v) and (viii) of this section.
(7) Standardized Medicare supplement benefit
high deductible plan "F" shall include only the following: 100 percent of
covered expenses following the payment of the annual high deductible plan "F"
deductible. The covered expenses include the core benefits as defined in
paragraph (b)(5) of this section, plus the Medicare Part A deductible, skilled
nursing facility care, the Medicare Part B deductible, 100 percent of the
Medicare Part B excess charges and medically necessary emergency care in a
foreign country as defined in subparagraphs (b)(6)(i) through (iii), (v) and
(viii) of this section. 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 $1,500 for 1998 and 1999, and shall be based on the calendar year.
Such deductible 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. For example, the annual deductible for Medicare
supplement benefit high deductible plan "F" for 2010 is $2,000.
(8) Standardized Medicare supplement benefit
plan "G" shall include only the following: the core benefit as defined in
paragraph (b)(5) of this section, plus the Medicare Part A deductible, skilled
nursing facility care, 80 percent of the Medicare Part B excess charges,
medically necessary emergency care in a foreign country, and the at-home
recovery benefit as each is defined in subparagraphs (b)(6)(i), (ii), (iv),
(viii) and (x) of this section.
(9)
Standardized Medicare supplement benefit plan "H" shall consist of only the
following: the core benefit as defined in paragraph (b)(5) of this section,
plus the Medicare Part A deductible, skilled nursing facility care, basic
outpatient prescription drug benefit and medically necessary emergency care in
a foreign country as each is defined in subparagraphs (b)(6)(i), (ii), (vi) and
(viii) of this section. The outpatient prescription drug benefit shall not be
included in a Medicare supplement policy sold after December 31,
2005.
(10) Standardized Medicare
supplement benefit plan "I" shall consist of only the following: the core
benefits as defined in paragraph (b)(5) of this section, plus the Medicare Part
A deductible, skilled nursing facility care, 100 percent of the Medicare Part B
excess charges, basic outpatient prescription drug benefit, medically necessary
emergency care in a foreign country and at-home recovery benefit as each is
defined in subparagraphs (b)(6)(i), (ii), (v), (vi), (viii) and (x) of this
section. The outpatient prescription drug benefit shall not be included in a
Medicare supplement policy sold after December 31, 2005.
(11) Standardized Medicare supplement benefit
plan "J" shall consist of only the following: the core benefit as defined in
paragraph (b)(5) of this section, plus the Medicare Part A deductible, skilled
nursing facility care, Medicare Part B deductible, 100 percent of the Medicare
Part B excess charges, extended outpatient prescription drug benefit, medically
necessary emergency care in a foreign country, preventive medical care and
at-home recovery benefit as each is defined in subparagraphs (b)(6)(i), (ii),
(iii), (v), (vii), (viii), (ix) and (x) of this section. The outpatient
prescription drug benefit shall not be included in a Medicare supplement policy
sold after December 31, 2005.
(12)
Standardized Medicare supplement benefit high deductible plan "J" shall consist
of only the following: 100 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 paragraph (b)(5) of this section, plus the
Medicare Part A deductible, skilled nursing facility care, Medicare Part B
deductible, 100 percent of the Medicare Part B excess charges, extended
outpatient prescription drug benefit, medically necessary emergency care in a
foreign country, preventive medical care and at-home recovery benefit as
defined in subparagraphs (b)(6)(i) through (iii), (v) and (vii) through (x) of
this section. 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 high deductible plan "J" deductible
shall be $1,500 for 1998 and 1999, and shall be based on a calendar year. Such
deductible 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. For example, the annual deductible for Medicare supplement
benefit high deductible plan "J" for 2010 is $2,000. The outpatient
prescription drug benefit shall not be included in a Medicare supplement policy
sold after December 31, 2005.
(13)
Standardized Medicare supplement benefit plan "K" shall include only the
following:
(i) coverage of 100 percent of the
Part A hospital coinsurance amount for each day used from the 61st through the
90th day in any Medicare benefit period;
(ii) coverage of 100 percent of the Part A
hospital coinsurance amount for each Medicare lifetime inpatient reserve day
used from the 91st through the 150th day in any Medicare benefit
period;
(iii) upon exhaustion of
the Medicare hospital inpatient coverage, including the lifetime reserve days,
coverage of 100 percent of the costs incurred for hospitalization expenses of
the kind covered by Medicare and recognized as medically necessary by Medicare,
subject to a lifetime maximum benefit of an additional 365 days. The issuer may
enter into reimbursement contracts with provider hospitals to stand in the
place of Medicare and to make payment for the hospitalization expenses at the
applicable prospective payment system (PPS) rate or other appropriate Medicare
standard of payment, so long as there continues to be no cost to the insured
person;
(iv) Medicare Part A
deductible. Coverage for 50 percent of the Medicare Part A inpatient hospital
deductible amount per benefit period until the out-of-pocket limitation is met
as described in subparagraph (x) of this paragraph;
(v) skilled nursing facility care. Coverage
for 50 percent of the coinsurance amount for each day used 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 until the out-of-pocket
limitation is met as described in subparagraph (x) of this paragraph;
(vi) hospice care. Coverage for 50 percent 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 (x) of this
paragraph;
(vii) coverage for 50
percent 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 (x) of this paragraph;
(viii) except for coverage provided in
subparagraph (ix) of this paragraph, coverage for 50 percent 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 (x) of this paragraph;
(ix) coverage of 100 percent of the cost
sharing for Medicare Part B preventive services after the policyholder pays the
Part B deductible; and
(x) coverage
of 100 percent 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 $4,620 in
2010, indexed each year by the appropriate inflation adjustment specified by
the secretary.
(14)
Standardized Medicare supplement benefit plan "L'' shall include only the
following:
(i) the benefits described in
subparagraphs (13)(i), (ii), (iii) and (ix) of this subdivision;
(ii) the benefit described in subparagraphs
(13)(iv), (v), (vi), (vii) and (viii) of this subdivision, but substituting 75
percent for 50 percent; and
(iii)
the benefit described in subparagraph (13)(x) of this subdivision, but
substituting $2,310 for $4,620.
Notes
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