Utah Admin. Code R590-146-9a - Standard Plans for 2010 Standardized Plans Issued for Delivery with an Effective Date for Coverage on or After June 1, 2010

The standards in this section are applicable to any 2010 plan delivered or issued for delivery in this state with an effective date for coverage on or after June 1, 2010. A policy or certificate may not be advertised, solicited, delivered, or issued for delivery unless it complies with the standards in this section.

(1)

(a) An issuer offering a 2010 plan shall offer to an applicant a policy or certificate that only contains the basic core benefits.

(b) If an issuer offers any of the additional benefits under Subsection R590-146-8a(2)(b), or offers Plans K or L under Subsection (5)(h) or (5)(i) of this section, the issuer shall also offer to an applicant either Plan C, under Subsection (5)(c) of this section, or Plan F, under Subsection (5)(e) of this section.

(2) A group, package, or combination of Medicare supplement insurance benefits, other than those listed in this section, may not be offered for sale except as permitted in Subsection (6) and in Section R590-146-10.

(3) A 2010 plan shall be:

(a) uniform in structure, language, designation, and format; and

(b) structured according to the format provided in Subsection R590-146-8a(2), or in the case of Plan K or L in Subsection (5)(h) or (5)(i) of this section, and list the benefits in the order shown.

(4) An issuer may use, in addition to the plan designations required under Subsection (3), other designations to the extent permitted by law.

(5) A 2010 plan shall only include the benefits listed in this subsection.

(a) Standardized Plan A shall only include the basic core benefits.

(b) Standardized Plan B shall only include:

(i) basic core benefits; and

(ii) 100% of the Medicare Part A deductible.

(c) Standardized Plan C shall only include:

(i) basic core benefits;

(ii) 100% of the Medicare Part A deductible;

(iii) skilled nursing facility care;

(iv) 100% of the Medicare Part B deductible; and

(v) medically necessary emergency care in a foreign country.

(d) Standardized Plan D shall only include:

(i) basic core benefits;

(ii) 100% of the Medicare Part A deductible;

(iii) skilled nursing facility care; and

(iv) medically necessary emergency care in a foreign country.

(e) Standardized Plan F shall only include:

(i) basic core benefits;

(ii) 100% of the Medicare Part A deductible;

(iii) skilled nursing facility care;

(iv) 100% of the Medicare Part B deductible;

(v) 100% of the Medicare Part B excess charges; and

(vi) medically necessary emergency care in a foreign country.

(f)

(i) Standardized Plan High Deductible F shall only include 100% of covered expenses following the payment of the annual Plan High Deductible F deductible. The covered expenses after payment of the deductible include:

(A) basic core benefits;

(B) 100% of the Medicare Part A deductible;

(C) skilled nursing facility care;

(D) 100% of the Medicare Part B deductible;

(E) 100% of the Medicare Part B excess charges; and

(F) medically necessary emergency care in a foreign country.

(ii) The annual Plan High Deductible F deductible shall:

(A) consist of out-of-pocket expenses, other than premiums, for services covered by Plan F; and

(B) be in addition to any other specific benefit deductibles.

(iii) The annual Plan High Deductible F deductible shall be based on the calendar year as adjusted annually by the Secretary.

(g)

(i) Standardized Plan G shall only include:

(A) basic core benefits;

(B) 100% of the Medicare Part A deductible;

(C) skilled nursing facility care;

(D) 100% of the Medicare Part B excess charges; and

(E) medically necessary emergency care in a foreign country.

(ii) Effective January 1, 2020, Plan High Deductible F under Subsection R590-146-9b(1)(d) is redesignated as Plan High Deductible G and may be offered to an individual eligible for Medicare before January 1, 2020.

(h) Standardized Plan K shall only include:

(i) 100% of the Medicare Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;

(ii) 100% of the Medicare 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% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days, which the provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance;

(iv) 50% of the Medicare Part A deductible until the out-of-pocket limitation is met;

(v) 50% of the skilled nursing facility care coinsurance amount until the out-of-pocket limitation in Subsection (3)(h)(x) is met;

(vi) 50% of the hospice care cost sharing for all Medicare Part A eligible expenses and respite care until the out-of-pocket limitation is met;

(vii) 50%, under Medicare Part A or B, of the reasonable cost of the first 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;

(viii) except for coverage provided in Subsection (5)(h)(ix), 50% of the cost-sharing otherwise applicable under Medicare Part B after the insured pays the Medicare Part B deductible until the out-of-pocket limitation is met;

(ix) 100% of the cost-sharing for Medicare Part B preventive services after the insured pays the Part B deductible; and

(x) 100% of all cost sharing under Medicare Part A and B for the balance of the calendar year after the insured has reached the out-of-pocket limitation on annual expenditures under Medicare Part A and B of $4,000 in 2006, indexed each year by the Secretary.

(i) Standardized Plan L shall only include:

(i) the benefits under Subsections (5)(h)(i), (5)(h)(ii), (5)(h)(iii), and (5)(h)(ix);

(ii) the benefits under Subsections (5)(h)(iv), (5)(h)(v), (5)(h)(vi), (5)(h)(vii), and (5)(h)(viii), but substituting 75% for 50%; and

(iii) the benefits under Subsection (5)(h)(x), substituting $2,000 for $4,000.

(j) Standardized Plan M shall only include:

(i) basic core benefits;

(ii) 50% of the Medicare Part A deductible;

(iii) skilled nursing facility care; and

(iv) medically necessary emergency care in a foreign country.

(k)

(i) Standardized Plan N shall only include:

(A) basic core benefits;

(B) 100% of the Medicare Part A deductible;

(C) skilled nursing facility care; and

(D) medically necessary care in a foreign country.

(ii) The copayments for the benefits in Subsection (5)(k)(i) are the lesser of:

(A) $20 or the Medicare Part B coinsurance or copayment for each covered health care provider office visit, including visits to medical specialists; and

(B) $50 or the Medicare Part B coinsurance or copayment for each covered emergency room visit, however, this copayment shall be waived if the insured is admitted to a hospital and the emergency visit is subsequently covered as a Medicare Part A expense.

(6)

(a) An issuer may, with the prior approval of the commissioner, offer a policy or certificate with a new or innovative benefit in addition to the standardized benefits provided in a policy or certificate.

(b) A new or innovative benefit shall only include a benefit that is appropriate to Medicare supplement insurance, new or innovative, not otherwise available, and cost effective.

(c) A new or innovative benefit may not:

(i) adversely impact the goal of Medicare supplement simplification;

(ii) include an outpatient prescription drug benefit; or

(iii) be used to change or reduce benefits, including a change of any cost sharing provision, in any standardized plan.

Notes

Utah Admin. Code R590-146-9a

Amended by Utah State Bulletin Number 2019-13, effective 6/7/2019 Adopted by Utah State Bulletin Number 2024-16, effective 8/7/2024