044-35 Wyo. Code R. §§ 35-8 - Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 30, 1992 and with an Effective Date for Coverage Prior to June 1, 2010
The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state on or after July 30, 1992 and with an effective date for coverage prior to June 1, 2010No 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 standards.
(a) General Standards. The following
standards apply to Medicare supplement policies and certificates and are in
addition to all other requirements of this regulation.
(i) A Medicare supplement policy or
certificate shall not exclude or limit benefits for losses incurred more than
ninety (90) days from the effective date of coverage because it involved a
preexisting condition. The policy or certificate may 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
ninety (90) days before the effective date of coverage.
(ii) A Medicare supplement policy or
certificate shall not indemnify against losses resulting from sickness on a
different basis than losses resulting from accidents.
(iii) 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.
(iv) No Medicare supplement policy or
certificate shall 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.
(v) Each Medicare supplement policy shall be
guaranteed renewable.
(A) The issuer shall not
cancel or non-renew the policy solely on the ground of health status of the
individual.
(B) The issuer shall
not cancel or non-renew the policy for any reason other than nonpayment of
premium or material misrepresentation.
(C) If the Medicare supplement policy is
terminated by the group policyholder and is not replaced as provided under
Section 8(a)(v)(E), the issuer shall offer certificate holders an individual
Medicare supplement policy which (at the option of the certificate holder):
(I) Provides for continuation of the benefits
contained in the group policy, or
(II) Provides for benefits that otherwise
meet the requirements of this subsection.
(D) If an individual is a certificate holder
in a group Medicare supplement policy and the individual terminates membership
in the group, the issuer shall:
(I) Offer the
certificate holder the conversion opportunity described in Section 8(a)(v)(C),
or
(II) At the option of the group
policyholder, offer the certificate holder continuation of coverage under the
group policy.
(E) 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 policy shall
not result in any exclusion for preexisting conditions that would have been
covered under the group policy being replaced.
(F) 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.
(vi) 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 conditioned upon the
continuous total disability of the insured, limited to the duration of the
policy benefit period, if any, or payment of the maximum benefits. Receipt of
Medicare Part D benefits will not be considered in determining a continuous
loss.
(vii) Suspension.
(A) A Medicare supplement policy or
certificate shall provide that benefits and premiums under the policy or
certificate shall be suspended at the request of the policyholder or
certificate holder for the period (not to exceed twenty-four (24) months) in
which the policyholder or certificate holder has applied for and is determined
to be entitled to medical assistance under Title XIX of the Social Security
Act, but only if the policyholder or certificate holder notifies the issuer of
the policy or certificate within ninety (90) days after the date the individual
becomes entitled to assistance.
(B)
If suspension occurs and if the policyholder or certificate holder loses
entitlement to medical assistance, the policy or certificate shall be
automatically reinstituted (effective as of the date of termination of
entitlement) as of the termination of entitlement if the policyholder or
certificate holder provides notice of loss of entitlement within ninety (90)
days after the date of loss and pays the premium attributable to the period,
effective as of the date of termination of entitlement.
(C) Each Medicare supplement policy shall
provide that benefits and premiums under the policy shall be suspended (for any
period that may be provided by federal regulation) at the request of the
policyholder if the policyholder is entitled to benefits under Section 226(b)
of the Social Security Act and is covered under a group health plan (as defined
in Section 1862(b)(1)(A)(v) of the Social Security Act). If suspension occurs
and if the policyholder or certificate holder loses coverage under the group
health plan, the policy shall be automatically reinstituted (effective as of
the date of loss of coverage) if the policyholder provides notice of loss of
coverage within ninety (90) days after the date of the loss.
(D) Reinstitution of coverages.
(I) Shall not provide for any waiting period
with respect to treatment of preexisting conditions;
(II) Shall provide for resumption of coverage
that is substantially equivalent to coverage in effect before the date of
suspension. If the suspended Medicare supplement policy provided coverage for
outpatient prescription drugs, reinstitution of the policy for Medicare Part D
enrollees shall be without coverage for outpatient prescription drugs and shall
otherwise provide substantially equivalent coverage to the coverage in effect
before the date of suspension; and
(III) Shall provide for classification of
premiums on terms at least as favorable to the policyholder or certificate
holder as the premium classification terms that would have applied to the
policyholder or certificate holder had the coverage not been
suspended.
(viii) If an issuer makes a written offer to
the Medicare Supplement policyholders or certificate holders of one or more of
its plans, to exchange during a specified period from his or her [1990
Standardized plan] (as described in Section
9 of this regulation) to a [2010
Standardized plan] (as described in Section 9.1 of this regulation), the offer
and subsequent exchange shall comply with the following requirements:
(A) An issuer need not provide justification
to the commissioner if the insured replaces a 1990 Standardized policy or
certificate with an issue age rated 2010 Standardized policy or certificate at
the insured's original issue age and duration. If an insured's policy or
certificate to be replaced is priced on an issue age rate schedule at the time
of such offer, the rate charged to the insured for the new exchanged policy
shall recognize the policy reserve buildup, due to the pre-funding inherent in
the use of an issue age rate basis, for the benefit of the insured. The method
proposed to be used by an issuer must be filed with the commissioner according
to Section
15(c).
(B) The rating class of the new policy or
certificate shall be the class closest to the insured's class of the replaced
coverage.
(C) An issuer may not
apply new pre-existing condition limitations or a new incontestability period
to the new policy for those benefits contained in the exchanged 1990
Standardized policy or certificate of the insured, but may apply pre-existing
condition limitations of no more than ninety (90) days to any added benefits
contained in the new 2010 Standardized policy or certificate not contained in
the exchanged policy.
(D) The new
policy or certificate shall be offered to all policyholders or certificate
holders within a given plan, except where the offer or issue would be in
violation of state or federal law.
(b) Standards for Basic (Core) Benefits
Common to Benefit Plans A to J. Every issuer shall make available a policy or
certificate including only the following basic "core" package of benefits to
each prospective insured. An issuer may make available to prospective insureds
any of the other Medicare Supplement Insurance Benefit Plans in addition to the
basic core package, but not in lieu of it.
(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 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 365 days. The provider shall accept the
issuer's payment as payment in full and may not bill the insured for any
balance;
(iv) Coverage under
Medicare Parts A and 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;
(v) 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 Part B regardless of hospital confinement, subject to
the Medicare Part B deductible;
(c) Standards for Additional Benefits. The
following additional benefits shall be included in Medicare Supplement Benefit
Plans "B" through "J" only as provided by Section
9 of this regulation.
(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) Eighty Percent (80%) of the Medicare
Part B Excess Charges: Coverage for eighty percent (80%) 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) One Hundred Percent (100%) 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 fifty percent (50%) 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 fifty percent (50%) 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 eighty percent (80%) 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 sixty (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.
(A) Coverage for the
following preventive health services is not covered by Medicare:
(I) An annual clinical preventive medical
history and physical examination that may include tests and services from
Subparagraph (B) and patient education to address preventive health care
measures;
(II) Preventive screening
tests or preventive services, the selection and frequency of which is
determined to be medically appropriate by the attending physician.
(B) Reimbursement shall be for the
actual charges up to one hundred percent (100%) 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 (AMA CPT) 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:
(I)
"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.
(II) "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.
(III) "Home" shall mean any place used by the
insured as a place of residence, provided that the 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.
(IV) "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 (4)
hours in a twenty-four-hour period of services provided by a care provider is
one visit.
(B) Coverage
Requirements and Limitations.
(I) At-home
recovery services provided must be primarily services which assist in
activities of daily living.
(II)
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.
(III) Coverage is limited to:
(1.) 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;
(2.)
The actual charges for each visit up to a maximum reimbursement of $40 per
visit;
(3.) $1,600 per calendar
year;
(4.) Seven (7) visits in any
one week;
(5.) Care furnished on a
visiting basis in the insured's home;
(6.) Services provided by a care provider as
defined in this section;
(7.)
At-home recovery visits while the insured is covered under the policy or
certificate and not otherwise excluded;
(8.) At-home recovery visits received during
the period the insured is receiving Medicare approved home care services or no
more than eight (8) weeks after the service date of the last Medicare approved
home health care visit.
(C) Coverage is excluded for:
(I) Home care visits paid for by Medicare or
other government programs; and
(II)
Care provided by family members, unpaid volunteers or providers who are not
care providers.
(d) Standards for Plans K and L.
(i) Standardized Medicare supplement benefit
plan "K" shall consist of the following:
(A)
Coverage of one hundred percent (100%) of the Part A hospital coinsurance
amount for each day used from the 61st through the 90th day in any Medicare
benefit period;
(B) Coverage of one
hundred percent (100%) 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;
(C) 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 365 days. The provider shall accept the
issuer's payment as payment in full and may not bill the insured for any
balance;
(D) 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 Subparagraph (J);
(E) Skilled Nursing Facility Care: Coverage
for fifty percent (50%) 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 (J);
(F) 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 Subparagraph
(j);
(G) 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
Subparagraph (J);
(H) Except for
coverage provided in Subparagraph (I) below, 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 Subparagraph (J) below;
(I) 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
(J)
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 $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.
(ii)
Standardized Medicare supplement benefit plan "L" shall consist of the
following:
(A) The benefits described in
Paragraphs (i)(A), (B), (C) and (I);
(B) The benefit described in Paragraphs
(i)(D), (E), (F), (G) and (H), but substituting seventy-five percent (75%) for
fifty percent (50%); and
(C) The
benefit described in Paragraph (i)(J), but substituting $2000 for
$4000.
Notes
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