Tenn. Comp. R. & Regs. 0780-01-58-.11 - STANDARD MEDICARE SUPPLEMENT BENEFIT PLANS FOR 2010 STANDARDIZED MEDICARE SUPPLEMENT BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED FOR DELIVERY WITH AN EFFECTIVE DATE OF COVERAGE ON OR AFTER JUNE 1, 2010
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 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 of coverage before June 1, 2010, remain subject to the requirements of T.C.A. Title 56, Chapter 7, Part 14 and all applicable benefit standards in Rules 0780-01-58-.07 and 0780-01-58-.08 of this Chapter.
(1)
(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 Rule
0780-01-58-.09(2)
of this Chapter.
(b) If an issuer makes available any of the
additional benefits described in Rule
0780-01-58-.09(3),
or offers standardized benefit Plans K or L as described in subparagraphs
(5)(h) and (i) of this Rule, 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
subparagraph (1)(a), a policy form or certificate form containing either
standardized benefit Plan C as described in subparagraph (5)(c), or
standardized benefit Plan F as described in subparagraph (5)(e).
(2) No groups, packages or
combinations of Medicare supplement benefits other than those listed in this
Rule shall be offered for sale in this state, except as may be permitted in
Paragraph (6) and in Rule
0780-01-58-.13 of this
Chapter.
(3) Benefit plans shall be
uniform in structure, language, designation and format to the standard benefit
plans listed in this Rule and conform to the definitions in Rule 0780-01-58-.04
of this Chapter. Each benefit shall be structured in accordance with the format
provided in Rules
0780-01-58-.09(2) and
(3) of this Chapter; or, in the case of plans
K or L, in subparagraphs (5)(h) or (i) and list the benefits in the order
shown. For purposes of this Rule, "structure, language, and format" means
style, arrangement and overall content of a benefit.
(4) In addition to the benefit plan
designations required in Paragraph (3), an issuer may use other designations to
the extent permitted by law.
(5)
Make-up of 2010 Standardized Benefit Plans:
(a) Standardized Medicare supplement benefit
Plan A shall include only the following: The basic (core) benefits as defined
in Rule 0780-01-58-.09(2)
of this Chapter.
(b) Standardized Medicare supplement benefit
Plan B shall include only the following: The basic (core) benefit as defined in
Rule 0780-01-58-.09(2)
of this Chapter, plus one hundred percent
(100%) of the Medicare Part A deductible as defined in Rule
0780-01-58-.09(3)(a)
of this Chapter.
(c) Standardized Medicare supplement benefit
Plan C shall include only the following: The basic (core) benefit as defined in
Rule 0780-01-58-.09(2)
of this Chapter, plus one hundred percent
(100%) of the Medicare Part A deductible, skilled nursing facility care, one
hundred percent (100%) of the Medicare Part B deductible, and medically
necessary emergency care in a foreign country as defined in Rules
0780-01-58-.09(3)(a), (c), (d), and
(f) of this Chapter, respectively.
(d) Standardized Medicare supplement benefit
Plan D shall include only the following: The basic (core) benefit as defined in
Rule 0780-01-58-.09(2)
of this Chapter, plus one hundred percent
(100%) of the Medicare Part A deductible, skilled nursing facility care, and
medically necessary emergency care in an foreign country as defined in Rules
0780-01-58-.09(3)(a), (c), and
(f) of this Chapter, respectively.
(e) Standardized Medicare supplement
[regular] Plan F shall include only the following: The basic (core) benefit as
defined in Rule
0780-01-58-.09(2)
of this Chapter, plus one hundred percent
(100%) of the Medicare Part A deductible, the skilled nursing facility care,
one hundred percent (100%) of the Medicare Part B deductible, one hundred
percent (100%) of the Medicare Part B excess charges, and medically necessary
emergency care in a foreign country as defined in Rules
0780-01-58-.09(3)(a), (c), (d), (e), and
(f), respectively.
(f) Standardized Medicare supplement Plan F
with High Deductible shall include only the following: one hundred percent
(100%) of covered expenses following the payment of the annual deductible set
forth in part 2. below.
1. The basic (core)
benefit as defined in Rule
0780-01-58-.09(2)
of this Chapter, plus one hundred percent
(100%) of the Medicare Part A deductible, skilled nursing facility care, one
hundred percent (100%) of the Medicare Part B deductible, one hundred percent
(100%) of the Medicare Part B excess charges, and medically necessary emergency
care in a foreign country as defined in Rules
0780-01-58-.09(3)(a), (c), (d), (e), and
(f) of this Chapter, respectively.
2. 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 one
thousand five hundred dollars ($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 twelve
(12) month period ending with August of the preceding year, and rounded to the
nearest multiple of ten dollars ($10).
(g) Standardized Medicare supplement benefit
Plan G shall include only the following: The basic (core) benefit as defined in
Rule 0780-01-58-.09(2)
of this Chapter, plus one hundred percent
(100%) of the Medicare Part A deductible, skilled nursing facility care, one
hundred percent (100%) of the Medicare Part B excess charges, and medically
necessary emergency care in a foreign country as defined in Rules
0780-01-58-.09(3)(a), (c), (e), and
(f) of this Chapter, respectively. Effective
January 1, 2020, the standardized benefit plans described in Rule
0780-01-58-.12(1)(d)
of this Chapter (Redesignated Plan G High
Deductible) may be offered to any individual who was eligible for Medicare
prior to January 1, 2020.
(h)
Standardized Medicare supplement Plan K is mandated by The Medicare
Prescription Drug, Improvement and Modernization Act of 2003, and shall include
only the following:
1. Part A Hospital
Coinsurance, sixty-first (61st) through ninetieth (90th) days: Coverage of one
hundred percent (100%) of the Part A hospital coinsurance amount for each day
used from the sixty-first (61st) through the ninetieth (90th) day in any
Medicare benefit period;
2. Part A
Hospital Coinsurance, ninety-first (91st) through one hundred fiftieth (150th)
days: 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 (91st) through the one hundred fiftieth (150th) day in any
Medicare benefit period;
3. Part A
Hospitalization After one hundred fifty (150) days: 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 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.
Medicare Part A Deductible: 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 part 10.;
5. Skilled Nursing Facility Care: Coverage
for fifty percent (50%) of the coinsurance amount for each day used from the
twenty-first (21st) day through the one hundredth (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 part
10.;
6. Hospice Care: Coverage for
fifty percent (50%) of cost sharing for all Part A Medicare eligible expenses
and respite care until the out-of-pocket limitation is met as described in part
10.;
7. Blood: Coverage for fifty
percent (50%), under Medicare Part A or B, of 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 until the out-of-pocket limitation is met as described in
part 10.;
8. Part B Cost Sharing:
Except for coverage provided in part 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 part 10.;
9.
Part B Preventive Services: Coverage of one hundred percent (100%) of the cost
sharing for Medicare Part B preventive services after the policyholder pays the
Part B deductible; and
10. Cost
Sharing After Out-of-Pocket Limits: Coverage of 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 ($4000) in
2006, indexed each year by the appropriate inflation adjustment specified by
the Secretary of the U.S. Department of Health and Human Services.
(i) Standardized Medicare
supplement Plan L is mandated by The Medicare Prescription Drug, Improvement
and Modernization Act of 2003, and shall include only the following:
1. The benefits described in subparagraph
(h), parts 1., 2., 3., and 9.;
2.
The benefit described in subparagraph (h), parts 4., 5., 6., 7., and 8., but
substituting seventy-five percent (75%) for fifty percent (50%); and
3. The benefit described in subparagraph (h),
part 10., but substituting two thousand dollars ($2,000) for four thousand
dollars ($4,000).
(j)
Standardized Medicare supplement Plan M shall include only the following: The
basic (core) benefit as defined in Rule
0780-01-58-.09(2)
of this Chapter, plus fifty percent (50%) of
the Medicare Part A deductible, skilled nursing facility care, and medically
necessary emergency care in a foreign country as defined in Rules
0780-01-58-.09(3)(b), (c), and
(f) of this Chapter, respectively.
(k) Standardized Medicare supplement Plan N
shall include only the following: The basic (core) benefit as defined in Rule
0780-01-58-.09(2)
of this Chapter, plus one hundred percent
(100%) of the Medicare Part A deductible, skilled nursing facility care, and
medically necessary emergency care in a foreign country as defined in Rules
0780-01-58-.09(3)(a), (c), and
(f) of this Chapter, respectively, with
co-payments in the following amounts:
1. the
lesser of twenty dollars ($20) or the Medicare Part B coinsurance or co-payment
for each covered health care provider office visit, including visits to medical
specialists; and
2. the lesser of
fifty dollars ($50) or the Medicare Part B coinsurance or co-payment for each
covered emergency room visit, however, this co-payment shall be waived if the
insured is admitted to any hospital and the emergency visit is subsequently
covered as a Medicare Part A expense.
(6) 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
Authority: T.C.A. ยงยง
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.
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