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
(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
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.