Tenn. Comp. R. & Regs. 0780-01-58-.07 - MINIMUM BENEFIT STANDARDS FOR MEDICARE SUPPLEMENT BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED FOR DELIVERY PRIOR TO JULY 1, 1992

No policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate unless it meets or exceeds the following minimum standards. These are minimum standards and do not preclude the inclusion of other provisions or benefits which are not inconsistent with these standards.

(1) General Standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this Chapter.

(a) A Medicare supplement policy or certificate 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. The policy or certificate shall 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.

(b) A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.

(c) 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, co-payment, or coinsurance amounts. Premiums may be modified to correspond with such changes.

(d) A "non-cancellable," "guaranteed renewable," or "non-cancellable and guaranteed renewable" Medicare supplement policy shall not:

1. 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; or

2. Be cancelled or non-renewed by the issuer solely on the grounds of deterioration of health.

(e)

1. Except as authorized by the commissioner of this state, an issuer shall neither cancel nor non-renew a Medicare supplement policy or certificate for any reason other than nonpayment of premium or material misrepresentation.

2. If a group Medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in part 4., the issuer shall offer certificate holders an individual Medicare supplement policy. The issuer shall offer the certificate holder at least the following choices:

(i) An individual Medicare supplement policy currently offered by the issuer having comparable benefits to those contained in the terminated group Medicare supplement policy; and

(ii) An individual Medicare supplement policy which provides only such benefits as are required to meet the minimum standards as defined in Rule 0780-01-58-.09(2) of this Chapter.

3. If membership in a group is terminated, the issuer shall:

(i) Offer the certificate holder the conversion opportunities described in part 2.; or

(ii) At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy.

4. 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 group policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced.

(f) 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 predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or to payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.

(g) 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.

(2) Minimum Benefit Standards.

(a) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the sixty-first (61st) day through the ninetieth (90th) day in any Medicare benefit period;

(b) Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount;

(c) Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days;

(d) Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of ninety percent (90%) of all Medicare Part A eligible expenses for hospitalization not covered by Medicare subject to a lifetime maximum benefit of an additional three hundred sixty-five (365) days;

(e) Coverage under Medicare Part A for the reasonable cost of the first three (3) pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations or already paid for under Medicare Part B;

(f) Coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the co-payment amount, of Medicare eligible expenses under Medicare Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount equal to the Medicare Part B deductible [$147];

(g) Effective January 1, 1990, coverage under Medicare Part B for the reasonable cost of the first three (3) pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations), unless replaced in accordance with federal regulations or already paid for under Medicare Part A, subject to the Medicare deductible amount.

Notes

Tenn. Comp. R. & Regs. 0780-01-58-.07

Original rule filed August 14, 1989; effective September 28, 1989. Repealed and new rule filed November 26, 1990; effective January 10, 1991. Repealed and new rule filed September 16, 1992; effective November 1, 1992. Amendment filed August 15, 1996; effective October 29, 1996. Public necessity rule filed September 1, 2005; effective through February 13, 2006. Public necessity rule filed September 1, 2005; expired on February 13, 2006. On February 14, 2006, reverted to rule in effect on August 31, 2005. Repeal and new rule filed October 13, 2006; effective December 27, 2006. Public necessity rule filed June 30, 2009; effective through December 12, 2009. Emergency rule filed December 9, 2009; effective through June 7, 2010. Amendment filed December 3, 2009; effective March 3, 2010. Administrative changes made to the authority of this chapter due to revisions in the 2016 Tennessee Code Annotated. Amendments filed November 20, 2018; effective 2/18/2019.

Authority: T.C.A. §§ 56-1-701; 56-2-301; 56-6-112; 56-6-124(a); 56-7-1401, et seq.; 56-7-1453; 56-7-1454; 56-7-1455; 56-7-1457; 56-7-1501, et seq.; 56-7-1503; 56-7-1504; 56-7-1505; 56-7-1507; and 56-32-118(a); Omnibus Budget Reconciliation Act of 1990, Pub. L. No. 101-508, (1990); Genetic Information Non Discrimination Act, Pub. L. No. 110-233 (2008); Medicare Improvements for Patients and Providers Act, Pub. L. No. 110-275 (2008); and Medicare Access and CHIP Reauthorization Act, Pub. L. No. 114-10 (2015).